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BIOGRAPHIC CLINICS

GOULD

Lhe Seorye Could
BIOGRAPHIC CLINICS

VOLUME III

ESSAYS CONCERNING THE INFLUENCE OF
VISUAL FUNCTION PATHOLOGIC AND PHYSIOLOGIC

UPON THE HEALTH OF PATIENTS

BY

GEORGE M. GOULD, M.D.

Editor of AMERICAN Mepicingz, Author of “‘ An I}lustrated Dictionary of Medicine,
Biology, etc.,’’ ‘‘ Borderland Studies,”’ ‘‘ The Meaning
and the Method of Life,’’ etc.

PHILADELPHIA :

P, BLAKISTON’S SON & CO.
1012 WALNUT STREET

1905
 

ese Pe.

COPYRIGHT 1905

By GEORGE M. GOULD, M.D.

 

Go?

PRESS OF
Tar New Era PrintTING COMPANY,
Lancaster, PA.
TABLE OF CONTENTS.

PAGE

INTRODUCTION ‘ : I
CHAPTER I. Tue New OputTHALMOLOGY AND ITS
RELATION TO GENERAL MeEpIcINE,

BroLocy AND SocioLocy 25
CHAPTER II. Tue Lire Tracepy or Joun Appinc-

TON SYMONDS % : 75
CHAPTER III. Tarine’s Itt-Heattu ‘i . 97

CHAPTER IV. Evestrarn as A Cause oF HEADACHE
AND OTHER NEUROSES, BY SIMEON
SNELL, F.R.C.S.Ep. ; é . <Ts

CHAPTER V. SiicHT Errors oF REFRACTION AND
THEIR INFLUENCE ON THE NERVOUS
System, By C. Ernest PRONGER,

F.R.C.S. 2 . 155
CHAPTER VI. Tue History anno Ettotocy or “ M1-
GRAINE ” ; 199

CHAPTER VII. THe Optic ann Ocutar Factors IN
THE ETIOLOGY OF THE SCOLIOSIS OF
ScHOOL CHILDREN 249

CHAPTER VIII. Visuat Function THE CAUSE OF
SLANTED HANDWRITING; Its RELA-
TION TO SCHOOL HYGIENE, SCHOOL
Desxs, MALposturE, SPINAL CuR-
VATURE, AND Myopia. 295

vil
vill

CHAPTER IX.
CHAPTER X.

CHAPTER XI.

CHAPTER XII.

CHAPTER XIII.
APPENDIX A.

APPENDIX B.

CONTENTS.

DEXTRALITY AND SINISTRALITY

Tue PatHotocic RESULTS oF DEXTROC-
ULARITY AND SINISTROCULARITY

SuBNORMAL ACCOMMODATION AND
PREMATURE PRESBYOPIA

Tue Reception oF MepicaL Dts-
COVERIES

Some ProBLEMS OF PRESBYOPIA

SUGGESTIONS AS TO POSTMYDRIATIC
REFRACTION TESTS

A Case or “ MATHEMATICALLY PrEr-
FECT Eyes”

339

361

375

413
469

483

491
INTRODUCTION.

The examination of 7,166 school children in New
York City in 1905 showed that 1,273, or more than 17
percent, were suffering from defective eyesight of the
worst or most evident kinds. A much larger propor-
tion have smaller defects, and these added to the more
manifest ones make a total of over 33 percent which
had defects interfering with the pursuit of their stud-
ies. But these examinations took note only of the
manifest errors of refraction or disease, and the kinds
of eyestrain which have the worst reflex effects upon
the general health are those caused by the low errors
not manifest and which may be temporarily overcome
by morbid effort. It is therefore abundantly demon-
strated that almost everything urged by refractionists
as to the pernicious influence of eyestrain is more than
true. This is also suggested by further items of the
report which state that of the 7,166 there were also
the following cases:

Bad: nutrition: sewa cs ansiedaeds <yaseansas ceeee cam 032
INEDVOUS diSedSES Mss sede ines mr oekis were n ens 85
CardiaG CISeases.  euis ni agacks Revie wis enon ted Kerem 133
Pulmonary diseases ..¢ccc0css ssesetow es oe be eee 127
Skit GiseaseS ssw cecesweese wes as eeu se sees Sais 126
Deformity of spine. ..... 0... cece eee eee eens 63

2 I
2 INTRODUCTION.

Deformity Of CHeSt. ...cicsuwawcr sees acetadeeesess 100
Bad iWentanty s.cacsc oss suede eases saan yess 650
Total cases requiring medical attention......... 3,132

I have long and often urged the influence of eye-
strain as a cause of truancy, and hence of crime. It
is gratifying to find Dr. Cronin, the Chief of the Di-
vision of School Inspection of the New York Depart-
ment of Health, thus summarize his conclusions:

“Physical defects of one sort or another are the cause of
bad habits, truancy, and moral obliquity in later life. It is the
physically defective who leave school early or become hopeless
truants. Truancy is the first stage of a criminal career, and
by improving the physical condition of children we save many
of them from the downward path. If some of the unhallowed
money which is now causing so much useless talk with refer-
ence to its acceptance for the purpose of civilizing savages
were directed toward the poor people from whom it came, that
money would be sufficiently purified to satisfy all consciences.
The poor children of the tenements should be able to have
glasses when they need them. The city, too, should appro-
priate funds to pursue the work so well begun and so as to
improve as much as possible the physical status of the school
child of the present.”

All preexisting evils of eyestrain and ill-health are
tremendously exaggerated by the morbid writing pos-
ture taught or allowed in our schools. That 27 per-
cent of European, and undoubtedly of American,
school children, have lateral curvature of the spine
by the time they are 14 years old is, literally, an awful
charge against our blundering, both pedagogic and
INTRODUCTION. a

professional. If, as I am firmly convinced, this ter-
rible disease of one-fourth of the coming generation
is, with all its secondary morbidity, due to a neglect
of the demands and diseases of the visual function,
the crime of the neglecters, indifferentists and con-
temners is one that demands a summary ending. Sev-
eral orthopedists have written me letters upon the sub-
ject. Ihave pleasure in quoting one such:

“T have read your article ‘The Optic and Ocular Factors
in the Etiology of the Scoliosis of School Children’ with
profound interest and benefit. As I have examined so many
patients in whom you have found peculiar etiological factors
of astigmatism and have satisfactorily confirmed the relations
that you have discovered I find great profit from studying your
elaborate article. I cannot refrain from expressing to you my
appreciation of your courtesy in permitting me to be associated
with you in this unique discovery in so far as to examine the
spines of your patients. I am convinced that your discovery
will remove the ‘idiopathic’ from use in connection with
Scoliosis. Because we did not know we said idiopathic, but
now we will know and try to prevent the deformity of Scoliosis.

“T heartily congratulate you upon adding to our knowledge
a definite scientific truth. Knowing the adverse criticism that
is always heaped upon original investigators I take pleasure in
asking you to accept my favorable comments in the spirit in
which they are offered. Very cordially yours,

H. Aucustus WIzson.”

One of the greatest of American public school
teachers thus writes:

“Dr. brought me the copy of the Medical Record in
which your article on the evil consequences of the condition

 
4 INTRODUCTION.

under which we compel children to write is published. We are
both tremendously interested in it, and we could cite more
proofs of the truth of your argument if it needed them. Now
I know why I have wanted young children to be allowed to
use the blackboard and the sand-table more when learning to
write. Some of these days I shall become frank and write an
energetic and (for a teacher) ill-advised philippic which I
shall entitle ‘The Curse of Literacy.” How does the idea
strike you? You should have seen the fine children I met in
my journey among the Pueblo Indians of New Mexico and
Arizona. Keen eyes, straight bodies, magnificent lungs, steady
nerves—and not an alphabet among them all! However, let
the good work go on, and one of these days people may come
to understand that it profits a man mighty little (and a woman
still less) to gain the world of book-learning and lose health.”

A majority of the citizens of the United States are
so educated or conditioned that they cannot procure
a little optical device necessary for their health, their
happiness, and their intellectual progress. Either they
are so ignorant that they do not know the nature of
their need and the obstacles which prevent relief, or,
if knowing, they are so circumstanced that proper
spectacles cannot be obtained. Of this majority one-
half, by the ignorance and unskillfulness of opticians,
are not able to secure such an adjustment of scientifi-
cally-made lenses to the eyes as to give the requisite
relief of eyestrain. Only a few city opticians are
sufficiently expert to adjust glasses, when rightly pre-
scribed and ground, the majority of the vendors, even
in cities, being incapables. These incapables, of
INTRODUCTION. 5

course, are moving heaven and earth, and especially
legislatures, to give them powers to do the physicians’
work of prescribing the glasses which they as artisans
cannot even place properly before the patient’s eyes.
But the majority of patients needing scientific advice
cannot consult the city oculists. They live in the
country and are too poor or too far removed, or too
ignorant, to find the capable city oculist. They are
therefore the prey of the traveling spectacle-vendor,
who should often be jailed, the quack optician and
oculist, the “ jeweler” who knows nothing of optics
or of ophthalmology. Al! of this constitutes a severe
indictment of the medical profession and of the public
for dereliction of duty. The generation-long neglect
of the profound influence of small errors of refraction
upon the general health, a neglect which is still fos-
tered by the so-called leaders of the profession, gives
warrant to school-boards, trustees and teachers, and
hygienists generally, to continue the sources of a large
part of the ills which occupy physicians and delay
social progress. It seems not altogether impossible
that the already alarming disrespect towards us of the
lay-world will be increased by the failure of the med-
ical men and their organizations to take up the work
of which a more enlightened public sentiment is fast
realizing the immense importance. That ophthalmol-
ogists themselves should so often be the leaders in this
cynical and blameworthy indifference is one of the
6 INTRODUCTION.

mysteries and disgraces of our time. Probably a hun-
dred articles are being published every week in the
medical journals of the world treating of diseases that
are or may be the result of eyestrain, and yet there
is not a line in them which alludes to this cause. Text-
books of course are still further behind the serial lit-
erature. Great ophthalmologic societies meet monthly
or annually with scarcely an allusion or a title showing
interest in the subject. Some recent happenings
would seem to indicate that the ideal of medical men
must be one whose interest in the patient is limited
to naming his disease; who believes little in, and cares
less for, curing; whose pathology is solely anatomic.
To heal and to learn the causes and prevention of dis-
ease would seem worthier and more professional aims,
even if not fashionable ones.

Concerning the two previous volumes of Biographic
Clinics, there have appeared in medical literature few
or no destructive criticisms of the positions taken
which are worth answering. The voice of ignorance
and prejudice was expected and could not surprise.
The oculists who could not refract correctly and who
therefore had never seen in their patients such results
as I have described, were and remain openly oppos-
ing or secretly scorning. Another class, half con-
vinced, have preferred to keep a discreet silence for
fear of allying themselves with the “ extremists and
exaggerators,” and of losing referred cases sent by
INTRODUCTION. 7

the general practitioner, the surgeon, or the neurolo-
gist. The tenotomists have of course risen as a man
to claim all, and to reemphasize their old exploded
theory, and have thus frightened a few timid ones
away from assent to any similar “ hobby-riding.”
Over the heads of these, “ gentlemen all,” has softly
waved the banner of that delightful egotism which
pities us, the narrow-minded ones, because we have
not the broad general medical knowledge and philo-
sophic aplomb to guard against the self-interest, the
puerile enthusiasms, and the limitations of specialism.

Anatomic pathology, having ended in the blind alley
of non possumus, has yet to turn and ask as to the
nature and methods of production of the morbid func-
tion which caused the special organic disease which
caused the patient’s death. The pathologic slide is
the scientific House that Jack Built, When one asks
about the rat that ate the malt, the cat that killed the
rat, the dog that worried the cat, and all the rest, the
impertinent is frequently met by an amazed stare end-
ing ina stupid sneer. But after all our pathology the
intolerable question recurs as to any explanation of
structure except by precedent function. After all our
slide-making, indeed, as a result of it, has it not been
more and more manifest that prevention of disease is
the true work of the conscientious physician, and that
“the soil” is as responsible for the end-products of
disease as is “the seed”? ‘The contention that in
8 INTRODUCTION.

biology the function and malfunction of vision has
been a large conditioning factor of organic evolution,
the truth that in all our sociology and pathology the
same factor is increasingly a controlling and crippling
source of evil and failure——this must be acknowl-
edged, and in its past attitude the profession is stulti-
fying itself and preventing its possible magnificent
progress,

An unwise councilor has recently advised young
men against the investigations of medical problems
which are not popular and fashionable. He should
have lent his authority to the truth, which is the oppo-
site of this cheap notoriety-seeking. The true thinker
and discoverer chooses to “ waste his life,’ as the
after-dinner orator termed it, in experimentation and
thought upon that which, even in medicine, is not the
fad of the day. Of course if the young medical man
is seeking after leadership, honorary degrees, pro-
fessorships, he must as a popularity-hunter and a
success-seeker follow the cunning advice to watch and
pursue the Zeitgeist with deft assiduity. But he will
find that truth shuns the trickster.

But the tide is turning. A well-trained oculist, Dr.
F. C. Hotz, of Chicago, in the April, -1905, number
of the Annals of Ophthalmology writes thus:

“c

“Although there are seventy-eight reasons why glasses may
not give relief, the truth of the doctrine that refraction errors
play a very prominent réle in the etiology of headaches and
INTRODUCTION. 9

neuroses, is universally recognized and accepted by the oculists
of this country, and has also begun to percolate into the ranks
of the general practitioners. Neither the fact that the correc-
tion of abnormal refraction does not give relief in every case,
nor the fact that many ametropes go through life without ex-
periencing any discomfort from their uncorrected ametropia,
is regarded as a valid argument against the overwhelming
clinical evidence recorded in favor of this doctrine.”

As to the method whereby eyestrain induces its
effects, Dr. Robert T. Edes (Boston Medical and Sur-
gical Journal, March 3, 1904) says:

“Certainly no local draft of energy could be more ingeni-
ously adapted to bring out the earlier symptoms of neuras-
thenia and to develop them to the full in cases of lesser resist-
ance than a pair of eyes incapable of perfect function sepa-
rately or together, and yet not so thoroughly unfit as to com-
pletely prohibit their use for near vision. The constant and
constantly unsuccessful attempt, from which there is no nat-
ural relief but disuse, and with necessity or ambition con-
stantly pushing the imperfect organ to its never satisfactorily
accomplished function, and then, too, this organ, the one upon
which so much of useful activity in the higher walks of life
depends, together with the psychic strain under feelings of
failure and disappointment, make the ideal combination to
develop nervous exhaustion under the highest tension possible.”

The Continent of Europe still lingers in pitiful bar-
barism upon this subject. When my patients return
from these benighted countries they tell tales that
should be gathered for the amusement of coming and
humor-loving generations. ‘‘ American humbug”!
—is the answer of protest that eyestrain may cause
fe INTRODUCTION.

any extraocular disease, or that it needs accurate or
scientific diagnosis and treatment. In England the
light is breaking. The courtesy of Mr. Pronger and
of Mr. Snell allows me to reproduce two capital illus-
trations. I have found it impossible to gather or even
epitomize a wealth of American articles.

To those numerous objectors who have asked for
clinical proofs in my own practice of what they call
the unproved theories of Biographic Clinics, 1 might
say that a thousand could readily be given, but they
would scarcely convince those who do not wish to
be convinced. If I should follow out the suggestion
it would give an added opportunity for slur and
innuendo ; however kindly disposed, I hesitate. Many
indeed, as well as myself, have published reports
of such cases, but these were as neglected as those
of Dr. William Thomson twenty-five years ago. My
first attempt at such reporting was made in 1888; I
was the first, I think, to direct attention to the fact
that errors of refraction exercise a great role in the
psychologic development of the young. In part I
wrote as follows:

“Tt is now a matter of common knowledge that the patho-
logical relations of the eye and the rest of the system are of
the most intimate nature; that refractive errors or muscular
insufficiencies are the great prolific sources of headache, and
that gastric troubles, and numerous forms of reflex neurosis,

even chorea and more profound derangements of the nervous
system, may be due to eyestrain. But no one seems to have
INTRODUCTION. II

thought what a tremendous influence upon the character and
life may be exerted by an uncorrected eyestrain. The micro-
scopic size of the defect has served to keep it ignored, and its
influence also minimized by the general ignorance of the extent
and exceeding intimacy of relation of the organ of sight and
the organ of mind. Indeed so thorough-going and wide-
spread and causal are these relations that the effect of the
other senses combined is but a fraction of that of vision in
the creation of intellect. In the light of evolution and psy-
chology, reason and mind may almost be said to be products
of the visual mechanism. Language itself, the sine qua non
of intellect and civilization, is but the record of things seen;
the letters of the alphabet are each and all but conventional-
ized pictographs, and mental pictures, or signs of pictures,
are the counters used by the mind in all the processes of logic
or thought. The ocular mechanism is like a bank at which
mental counters are tested and cashed with the coin of reality
and truth. What more natural, therefore, than that a dis-
organized and faulty bank should disarrange the processes
dependent upon it. Ifa false image, or one that is distorted,
or one that is only reached by an exhausting expenditure of
energy is the means of comparison, the action of the mind is
disturbed, heredity is at war with reality, and the mental
mechanism undergoes a subtile but profound change. It is,
of course, in the young that this unfortunate process goes on
at the most rapid rate, but is not noticed by parent or teacher.
The most frequent methods in which an uncorrected eye-
strain acts disastrously upon the developing mind is in making
study and literary labor so irksome that the mind is slowly
but irrevocably turned from intellectual pursuits and directed
to physical activities for an outlet of its energy. This, in the
formative period of the child and youth, is of the most abso-
lute and tragical importance.

“ A year ago a boy of nine was brought to me for examina-
tion of the eyes. He was a child of large brain, active mind,
and fine character, whose parents were educated, intelligent
12 INTRODUCTION.

people. But this boy had never learned his letters. It
had been utterly impossible for him to exercise his accommo-
dation long enough upon a printed page to learn the alphabet.
I corrected his hyperopic astigmatism, and within the past year
he has more than made up for lost time; in reading, arith-
metic, writing, and such studies being well ahead of the chil-
dren of his age. The gist of the matter consists in the ques-
tion, what would have been the result if this boy’s parents
had not been keen-witted enough to suspect ocular trouble?
Plainly, the boy would have grown up with the poorest
interests in intellectual pursuits, and more and more uncon-
sciously driven to physical ones; a professional life would not
have been chosen, and the position for which, by all the laws
of heredity and endowment, he was fitted to take in life would,
if thought of at all, have been only as a matter of regretful
wonder on the part of parent or friend that it had not been
adopted. I have had many similar examples in my practice.
For instance, a woman 22 years old, came to me suspecting
that her daily headaches, persisting for many years, might be
connected with eye troubles. It was, indeed, so. Her head-
aches disappeared, and other nervous derangements and cho-
reic affections, and her general deterioration of health was
changed as if by magic from the day her hyperopic astig-
matism and insufficiency were relieved. But I also was inter-
ested to learn that in the past ten years one by one the intel-
lectual and esthetic occupations she had heroically undertaken
had been laid aside, and everything dependent upon near
vision, such as study, languages, painting, needle-work, music,
etc., had been found so tiresome that her life had been
wrenched from its natural order, and her whole mind had
been regretfully turned to other exercises and uses.

“Still another somewhat pathetic case came to me last
week. Parents and teachers had for years stupidly scolded
and punished a bright little girl ten years old, because of her
inattention to studies and because of her petulance, nervous-
ness, and insubordination. In fact, the child was quite choreic,
INTRODUCTION. 13

and the pinched eyes and bent head told of eyestrain at once.
Both eyes were astigmatic to the fearful degree of 5.50 D.—
one of the highest astigmatic errors I ever have met with.
Who can doubt that her spectacles will have the most happy
effect in changing the child’s disposition, character, and the
trend of her whole life, not only physically but in a psycho-
logical sense? There can be no doubt that this subtle and
far-reaching cause—eyestrain—is at work everywhere to balk
and blight. How many vocations and careers—intellectual,
professional, or esthetic—have been left unfilled, the natural
aptitudes of character and endowment failing to reach their
predestined fruition, because this subtle but effective enemy
rendered it impossible? It is easy to poohpooh, and to talk
glibly about the ridiculous conceits and exaggerations of the
medical specialist. The question remains, Is it so or not so?
If my contention is true to the extent of the one-hundredth
part of what I believe, it is a matter of the most profound
significance for every parent, guardian, or general physician.
Exactly their particular child or patient or friend may be
undergoing an experience that is molding the whole course of
its future life, character, and influence upon the world. We
cannot doubt that many a promising life has been switched,
permanently crippled, into the side-tracks or lumber-yards
of mercantile or humdrum life, that might have swept across
continents, bearing its messages of intellectual honor and
humanitarian service.”

In 1889 I reported (Medical and Surgical Reporter,
February 9, March 9) a case of chorea of several
years’ standing, one of flatulent dyspepsia of twenty
years’ continuance, one of cardiac palpitation, and a
number of similar cases, cured at once and perma-
nently by glasses. In the American Journal of the
Medical Sciences for January, 1890, I gave the details
14 INTRODUCTION.

of a case of stammering due to hyperopia. One of a
peculiar paralysis and anesthesia from eyestrain, one
of chorea, one of aphonia, a number of dyspepsia and
other gastric disorders. I have reported seven cases
of nocturnal enuresis and as many of epilepsy cured
immediately by spectacles. An important fallacy of
the Rest-Cure Treatment, due to neglect of eyestrain,
was published in the Journal of the American Medical
Association, September 9, 1899. I have analyzed
1,500 consecutive cases of refraction-error showing
that 19.3 percent of these had noteworthy morbid
digestional effects, 58 percent headaches, and 81 per-
cent some morbid reflex result. In 1892 (Medical
News) I showed how the common occurrence of a dis-
used and neglected eye, suffering from lack of glasses,
produced disastrous results, and how it could often
be brought back to life and usefulness. Some of the
other papers bearing on the subject I reproduce in this
volume. I regret that some writer does not collect
and republish the many demonstrations contained in
the articles of a multitude of American authors. Since
the appearance of the first two volumes of Biographic
Clinics one critic of marked ability has hagtened to
publish cautionary articles as to “ pseudo-eyestrain ”
and “simulations of eyestrain,” and more than one
has kept up a persisting emphasis on the supposed fact
that many sufferers from migraine and other eyestrain
reflexes have no errors of refraction. The fallacy of
INTRODUCTION. 15

this logic is evident to those who know ophthalmic
literature. There are at least seventy-eight reasons
why such a statement may be untrue, as we all now
recognize. The so-called “ slight error of refraction ”
is precisely that which produces the worst and most
far-away morbid results, as is shown in an article I
published in the British Medical Journal in 1894.
Two critics of this truth had said that a hopeless and
incurable patient was possessed of “mathematically
and optically perfect eyes.” Gout, gout, and again
gout, was their pronounciamento. But gout was in-
curable. The patient for eight years has had no
“gout of the eyes,” and may be consulted as to his
opinion of the glasses worn during these years for
“mathematically perfect eyes.” The report of his
case is included in the forelying volume as a corollary
to seventy-eight reasons why glasses and no glasses
failed to cure. An editorial in the Journal of the
Michigan State Medical Society of July, 1905, states
a truth of such importance that I feel compelled to
quote the following passage:

The practice of refraction is one of the most laborious,
complicated, and difficult fields of medical practice; and that
competence in ophthalmology demands as a foundation the
broadest knowledge of medicine and surgery, and a super-
structure, of long training in delicacy of perception of slight
variations from physiological function, in minute structures;.
a quickening of sound judgment, and a fineness of manipula-
tion, only attained by actual experience with clinical material
16 INTRODUCTION.

under the guidance of a competent instructor. He who can-
not unravel the relation of damaged, or deformed eye struc-
ture to the general nervous system, or who cannot read in
the eye evidence of disease in distant organs, is quite unworthy
the name of ophthalmologist. It cannot be too strongly urged
that as druggists are for the compounding and sale of physi-
cians’ prescriptions, so opticians are for the adjustment of
spectacle frames, and fitting therein the lenses which ophthal-
mologists have prescribed.

In another part of this volume I have said that those
who should have been the wise judges and acceptors
of new truth, have as a rule been its rejectors and
enemies. In a recent number of Science I find a
curious instance that the law is still operative, and
not only in medicine and science, but in pedagogics,—
of all fields that in which one would least expect to
find it: :

Mr. Frank A. Vanderlip, ex-assistant secretary of the
Treasury, and now vice-president of the National City Bank,
addressed the students of Girard College on May 20, on the
general subject of educational benefactions. He is reported
to have said:

“The professional educator is quite as likely to become nar-
row and provincial as is any other specialist. The president
of one of our great eastern universities told me a few days
ago that he had been making an exhaustive examination of
the history of his institution, and he had discovered that the
great progressive steps which the university had taken in 150
years had been against the protest and the opposition of the
faculty. The trustees from time to time brought forward new
plans of organization, and broader ideas regarding the cur-
riculum. The faculty had in every case voted adversely, and
INTRODUCTION. 17

when the changes were made, they were made only by the
trustees taking the responsibility upon themselves. Alexander
Hamilton, with his consummate wisdom, once worked out a
plan of reorganization for the university, only to have it meet
with the usual vote of emphatic protest from the faculty, but
final adoption by the trustees. Now, in the light of years of
experience, these changes have been seen to be wise in the
main. The unavailing protests of the learned men who made
up the institution’s faculty are discovered sometimes to have
been based on narrow grounds lacking the impersonal view
and judgment that should have been brought to bear upon the
question.”

Far from acknowledging their. error these gentle-
men are probably now claiming that they have been
and are the helpers in the new education—of the past
and now established—but it is also quite sure that
they are as unitedly and blindly opposing the new
education of the future yet to be established. It is
still true that in proportion to the progress evidenced
in the acceptance of the truth of reflex ocular neu-
roses the reactionary spirit becomes more reckless
and fatuous. In Germany the whole subject is dis-
missed as “American humbug.” In England it
elicits that characteristic reply of attempted irony
which exhibits self-satisfied prejudice rather than zeal
for investigation. Under compulsion writers may be
forced to allude to the subject, but only as an evi-
dence of unjustified hobby-riding, “ possessed by a
theory,” etc., and deftly passed over as unworthy of
a true scientist. Thus Berry says, ‘ While in some

3
18 INTRODUCTION.

way or other astigmatism may give rise to headaches,
it is equally certain that its influence in this respect
has been greatly exaggerated.” Far from a wise and
humane desire to learn if it may not also give rise to
other troubles than headache, there is evidently in
such authors not the least curiosity to learn how astig-
matism “may cause” headaches, how many it may
cause, nor how they may be relieved. Despite the
amazing amount of testimony to the role of eyestrain
in general pathogenesis in our country a multitude of
text-books are being issued by our medical writers
and publishers which ignore the matter entirely, or
worse, flippantly. In 1905 ophthalmologists (Howe,
Casey Wood) get up “collective investigations ”’
which neither collect nor investigate, but which are
designed to throw all possible obloquy upon the theory.
The counting of noses is a poor way to establish truth
and would not change the facts if the ballots were
to be obtained nor if they were all yes or all no.
Luckily the balloting proved a sorry blunder and a
disastrous failure.

Besides the demonstrations of progress in the ac-
ceptance of the theory I have already set down, others
are rapidly appearing. As examples may be cited the
opinion of Dr. Ellis in his monumental Life of
Wagner. In his fourth volume the theory I have
offered as to the cause of Wagner’s ill-health is re-
peatedly and continuously accepted and emphasized.
Dr. Ellis is an accomplished physician and musician.
INTRODUCTION. 19

It seems that he is also a good logician. From pri-
vate sources of information we have discovered per-
fect proofs that Wagner had astigmatism and that
his personal sufferings and tragedy could largely if
not entirely have been relieved if ‘ American ophthal-
mic humbug ” or that of any other national type could
have been allowed to give him proper glasses. Dr.
Ellis, in a private letter, points out a source of injury
that I had overlooked: Each of several of Wagner's
operas have over a million notes, the stems being of
course at axis go”, and the five ruled lines of the music
paper at axis 180°. These notes were placed there
by his hand governed by his astigmatic eyes!

One endeavor to solve the mysteries of the nervous
and nutritional disorders generally classed as the par-
oxysmal neuroses (migraine, angina pectoris, asthma,
bilious attacks, gout, epilepsy, dyspepsia, etc.) is a
two-volume treatise about to be issued (by Longmans
& Co.) by Dr. Francis Hare. Dr. Hare has sent me
a copy issued for private circulation ; the more complete
work will have the title, The Food Factor in Disease.
The work was nearly complete when the eyestrain
theory of the source of these diseases was called to the
author’s attention. That theory, I think, largely trans-
forms if not revolutionizes Dr. Hare’s philosophy.
There is hardly a page which it not flooded with new
light by the fact that ametropia often or generally is
the source of the evils and conditions he describes.
With noble frankness Dr. Hare says:
ah INTRODUCTION.

“The adoption of the humoral (hyperpyremic) hypothesis
does not by any means involve the abandonment of the hy-
pothesis of Gould. Many of the illustrious patients of whom
he writes may well have suffered from ametropia; and the
eyestrain so induced may quite possibly have been responsible
for a state of increased vaso-motor irritability, and so for
conditions of pathological prepotency. In this event, much of
the relief from symptoms, which in their case followed phys-
ical exercise in the open air, would have been due to the inci-
dental relief from eyestrain, and the abolition of eyestrain
by properly correcting spectacles might have done much, if
not all, to relieve their almost lifelong miseries. Many ob-
servations directly support the view that eyestrain is capable
of causing increased vaso-motor irritability, and so of leading
to exaggerated or disordered vaso-motor action.

“Tn the following case, the exaggerated vaso-dilation of the
internal genitalia, responsible for dysmenorrhea, was clearly
shown to be due to eyestrain. Mr. Alban Doran, in dwelling
upon the necessity for following up the after-history of opera-
tion cases in order to verify reported recoveries, refers to a
case of severe dysmenorrhea in which it was proposed to
remove the ovaries. The symptoms, however, were relieved by
the patient wearing spectacles suitable for the correction of
her hypermetropia.

“Tt must, I think, be admitted that, in many cases, typical
recurrent migraine has been abolished by the correction of
ametropia by appropriate glasses, the necessary inference being
that eye-strain was an essential factor of the migraine.

“Consequently, there is reason to anticipate that recurrent
anorexia, dyspepsia, and biliousness will be found in some cases
to own an essential factor in eyestrain from uncorrected
ametropia. This anticipation is strongly supported by an
increasing accumulation of clinical evidence at my disposal,
most of which I have collected since the publication of Gould’s
‘Biographic Clinics.” This subject is of immense importance
and deserves the fullest consideration.
INTRODUCTION. 21

“The subjoined history, given in Dr. Turner’s own words,
fully demonstrated, to me at least, the indispensability of both
the humoral or supply factor and the neuro-vascular or func-
tional factor (in this case grossly exaggerated by unconscious
eyestrain) in the causation of what may be termed recurrent
hepatic anorexia. Therein is fully emphasized, not only the
influence on the attacks of those conditions, namely, external
temperature, exercise, and diet, which, as already argued, influ-
ence the pyremic state, but also the influence on the attacks,
of eyestrain, which, I am now arguing, influence the respon-
siveness of the vaso-motor system to the pyremic state.

“ Such exalted irritability of the vaso-motor system depended
very largely, if not mainly, upon unconscious eyestrain, chiefly
from prolonged lens work.

“That the deficiency of fat-formation in this case depended,
in great part at least, upon deficiency of supply, that is, of
carbonaceous material in the blood-stream available for fat-
construction capacity—is shown, I think, somewhat clearly
by one of the carefully observed experiences of the patient.
In order to add to his store of fat, it was only necessary to
eliminate the peripheral irritation, eyestrain, upon which ap-
parently depended most of the exaggerated responsiveness of
the vaso-motor system to pyremic conditions. This he
achieved by keeping his eyes closed for many hours of the day
and avoiding all near work at other times. The results of this
manceuvre may be tabulated as follows:

“1, Cessation of the exaggerated responsiveness of the vaso-
motor system to pyremic conditions.

“2. Cessation of exaggerated hepatic glycogenesis.

"3, Increased delivery of sugar by the liver to the general
blood-stream.

“4. Cessation of recurrent glycogenic distension.

“5, Increased digestion in, and absorption from, the ali-
mentary canal, through removal of the constantly recurring
hepatic block.

“6. Increased supply of nutritive material of all kinds to the
general circulation. .
22 INTRODUCTION.

“>. General increase of nutrition.

“We have now seen that urticaria, certain catarrhs, dys-
menorrhea, recurrent hepatic anorexia, and migraine, all affec-
tions in which a pathological degree of vaso-dilation in dif-
ferent localities is an essential factor, may depend upon eye-
strain from uncorrected ametropia; and there seems a possi-
bility that some cases of epilepsy may arise from this cause.
It would not be surprising, therefore, if there should be found
cases of asthma and angina pectoris owing a similar causation.”

Interesting recent testimony to the truth contended
for is given in the report of a meeting of the Boston
Society for Medical Improvement held December 5,
1904. The papers are published in the Boston Med-
ical and Surgical Journal, February 23, 1905. Dr.
Myles Standish demonstrates effectually that the ‘“ ex-
aggerations ” of those opposed to the theory of reflex
ocular neuroses are fully equal to those who support
the theory. He assents so far as one could wish to
the truth that dyspepsia, general weakness, migraine,
epilepsy in the young, etc., are often due to ametropia
and curable by glasses. Dr. Allen Greenwood em-
phasizes the truth that mental feebleness and back-
wardness in children are often due to the same cause.
Dr. Edwin E. Jack’s experience teaches him that nau-
sea, dizziness, dyspepsia, “ the blues,’ nervousness and
irritability, insomnia, brainfag, neurasthenia, and a
general inability to take up the burdens of life may
all be due to this cause. ‘‘ To one who has seen many
times the mental wreck which, eyes can cause, such a
INTRODUCTION. 23

correction is far from incredible, and indeed does not
seem unusual.”

In the Boston Medical and Surgical Journal of June
22, 1905, Dr. G. L. Walton admits most that the ma-
jority of “extremists” desire as to the influence of
eyestrain on the general nervous system. Coming
from a neurologist the article is peculiarly noteworthy.
I had often urged that the testimony of the blind
would be of value as to the ocular origin of many
nervous and systemic disease and Dr. Walton proves
it. There is far more to be learned in that way than
Dr. Walton brings out. Speaking generally, his val-
uable confession is, however, a forced one, and far
from ingenuous. It is indeed a most curious fact of
human nature which we see in so many who are now
hastening to accept the theory of eyestrain ignored
for thirty years. Their great zeal is for the limita-
tions of the truth. They care far less for what is
positive and helpful than for the negatives and fail-
ings of the theory. They have greater solicitude in
pointing out the “ constitutionality ” of headache than
in recognizing its ocular origin. It would seem that
in confessing that these diseases may be cured by
glasses, they are really afraid that one too many
patients may be cured. Instead of delight in a new
found therapeutic agency of admittedly vast power,
there is a downright morbid fear it may really prove
too great. And far from any gratitude for those
24 INTRODUCTION.

who have extorted the confession there is poorly con-
cealed contempt which proceeds to amusing lengths.
The worst of it all is that the question is treated as if
it were a scientific or professional one, without in-
fluence upon the world’s health and progress. The
patient is forgotten in the endeavor to square one’s
prejudices and past errors with the coming truth.
But professionally we exist only for the patients’ good.

It may also seem trivial and unnecessary to call to
the mind an axiomatic statement that as spectacles
will not bring the dead to life, nor even arrest impend-
ing death from organic disease, neither will they, at
least immediately, cure in all chronic cases of neuras-
thenia, hysteria, abused and broken-down nervous and
digestional systems, ruined by twenty, thirty, or forty
years of suffering. The eyestrain which frequently
begot the later conditions could have been extin-
guished in the young and the neurologist should at
least take to heart his own failure ir such cases.

My thanks are due the editors and publishers of the
Popular Science Monthly, of the Journal of the Amer-
ican Medical Association, the Medical Record, the
Maryland Medical Journal, the Annals of Ophthal-
mology, American Medicine, etc., for courteous per-
mission to republish articles appearing in their
columns.

Greorce M. Govutp,
PHILADELPHIA,

June, 1905.
THE NEW OPHTHALMOLOGY
AND ITS RELATION TO
GENERAL MEDICINE,
BIOLOGY AND
SOCIOLOGY.
CHAPTER I.

THE NEW OPHTHALMOLOGY AND ITS RELA-
TION TO GENERAL MEDICINE, BIOLOGY,
AND SOCIOLOGY.*

THE distinction between what may be called the old
ophthalmology and the new is one of almost unique
clearness, as compared with other departments of med-
icine or science. Especially in medical practice the
modern status has usually grown out of the older and
oldest by infinitesimal increments and gradual modi-
fications. In ophthalmology it is not so, and this fact
explains why there are such profound differences of
opinion as regards the claims of the new. Although
both are usually practiced by the same men, they may
be, and often are, as distinct in origin, theory and prac-
tice as, e. g., are otology and ophthalmology.

The “old ophthalmology’ was, and is concerned
with inflammatory and surgical diseases alone, remain-
ing ignorant of and indifferent to such relations as
might exist between the eye and the general system,

1Read before the Section on Ophthalmology, International
Congress of Arts and Science, Universal Exposition, St. Louis,
September 24, 1904, and reprinted from the Journal of the
American Medical Association, November 26 and December
3, 1904.
27
28 BIOGRAPHIC CLINICS.

except as regards those minor and few diseases which
arise in the body and then affect the eye. Ocular in-
flammations, ocular operations, and the ocular results
of systemic disease—these were the limits of its in-
terests. Even in recent text-books on medical ophthal-
mology, there is no thought of any other relations of
general medicine and ophthalmology than those mor-
bid ocular ones originating outside. That the eye is
the starting point of systemic disease was unsus-
pected. In the latest, greatest, best and most official
text-book on medical practice, that of Allbutt, there is
not a word from the first page to the last which hints
at the ocular origin of any systemic disease, not even
of headache. In the text-books of general medicine
by continental authors, there is the same official ignor-
ing of the claims of the new ophthalmology. In
America also most of the text-books either ignore
entirely, or, what is worse, list the remote causes of
one or two systemic symptoms as possibly due to the
eye, but so mechanically and inattentively as to turn
the student aside more effectively than the silence of
the utter ignorers. The “praise” is very “ faint,”
indeed, with which they condemn.

The new ophthalmology finds its objects of study
and interest precisely in those systemic results of oc-
ular conditions. I do not mean in such ways as the
circulatory or metastatic transfer of inflammatory or
infectious diseases from the eye to other organs, nor to
THE NEW OPHTHALMOLOGY. 29

the extension of localized inflammations to adjacent or
even distant ones. That is another matter, and of it
the old ophthalmology took sufficient cognizance. The
field of study of the new ophthalmology is topograph-
ically well defined, its title clear, its methods, instru-
ments of culture, the seed, and the crop itself, distinct,
both genetically and evolutionally.

The abnormal conditions of the eye which set up
morbid systemic results may, in strictness, scarcely be
called abnormal, except by a strain put on the word.
At least they are per se not morbid. They might bet-
ter be called physiologically aberrant or variant. They
do not originate in inflammatory or pathologic condi-
tions, but simply in optical ones. But for us all phys-
ical optics leads to physiologic optics; primarily and
fundamentally it pertains to the eye as an optical in-
strument, but as a living one, a physiologic camera ob-
scura. If the photographer’s camera had an elastic lens
instead of a rigid one, and if its refractive power were
spontaneously governed by the desire of the camera for
an accurate focus of the picture, the analogy would be
almost perfect. But the photographer’s camera can
neither direct itself nor renew its own sensitive plate,
so that in spontaneous choice of scene, change of focus,
and renewal of sensitive plate, the living camera is su-
perior to the dead one. The natural difficulties of the
choice of scene and of the resensitization of the plate
have been beautifully overcome in the eye by the God
30 BIOGRAPHIC CLINICS.

of evolution, but other obstacles have not been over-
come. The ocular camera, for instance, is double and
stereoscopic, and accurately to superpose the images of
both cameras is frequently impossible even after ages
of workmanship. As all physiology leads to pathology,
so, for physicians, all physiologic optics ends in patho-
logic optics. The twelve ocular muscles have a highly
complex and skilled task; hence heterophoria and stra-
bismus. Moreover, the spontaneously elastic lens
grows inelastic in forty-five years, and presbyopia, at
least before the days of spectacles, was a frightful
tragedy. Lastly, the transparent lens could not, for-
merly, retain its transparency in old age, and the
blindness from cataract at the end of life has not yet
been entirely prevented.

The chief difficulties of the mechanic of the living
camera were to secure to 1,500,000,000 human beings
and to their successors in each generation, eyeballs
which did not vary more than about 1/300 of an inch
trom a given diameter, and to make all corneas of the
same radii of curvature in all meridians. These diffi-
culties have been so great that there has probably never
been such a mathematically perfect and optically exact
pair of eyes in the world. Those chosen by natural se-
lection, the elimination of the unfit and the mystery of
heredity, to survive and to repeople the earth have been
such as were not so widely variant as to disqualify
their possessors for work and service; and the major-
THE NEW OPHTHALMOLOGY. 31

ity of their children, those now living in the world,
have eyes so near accuracy in optical dimensions as
to render their owners at least partly functional in
the process of evolution.

This almost infinitesimal variant of 1/300 of an inch,
the thickness of a sheet of paper, in eyeball measure-
ments, may throw the unfortunate possessor out of the
struggle for existence, so far as perpetuation of the
race goes, at least in civilized life, and for some occu-
pations, or it may render him a most pathetic, sufferer.
I say it may do so, not that it does do this invariably
or generally. The simple law is that the greater the
ametropia the greater the certainty that it will do so,
and the more limited the range and choice of occupa-
tions. The lower, not the positively lowest, errors of
refraction, however, in civilization are they which in
moral persons cause the greatest personal pain and
suffering. The high errors brutalize, immoralize and
exclude the owner from most occupations, the lower
cause pain and illness.

Eyestrain is the unfortunate and inexpressive term
that has come into use for the results that follow the
attempt of the eyes, brain and correlated organs, to
neutralize the defective function of the optically imper-
fect eyeballs and mechanisms. The optical defect is
not morbid and has no relation to morbidity. It is at
best pathogenic, secondarily or indirectly, not primar-
ily. Its secondary effect—the straining of physiologic
32 BIOGRAPHIC CLINICS.

muscles and nerve centers—is not in itself pathologic,
but it illustrates, and best illustrates, the great truth
which text-books, teachers and medical science itself
are sadly prone to forget, that abnormal physiology is
the origin of most pathology. Unnatural action and
overaction start the morbid function which finally lands
the physiologic on the postmortem table. To ignore
this truth is itself pathologic pathology; to scorn it is
to add unscientific sin to the symptom-complex of the
scientist’s disease.

It should be noted that as eyestrain is itself simply
functional, not organic, so its results are at least pri-
marily the same. Headache, the paroxysmal neuroses,
many nervous and psychic disorders, epilepsy, chorea,
migraine, sick-headache, gastric, digestional, and pelvic
disorders, influenza, anemia, denutrition, etc., when due
to eyestrain, are at first and essentially purely func-
tional. Even those more severe diseases, such as spinal
curvature, appendicitis and pulmonary and renal dis-
eases, which are sometimes directly and indirectly the
results of eyestrain, are at first characterized by a
peculiar stage of functional and remediable disorder,
preceding the organic, inflammatory and incurable one.

There are valuable lessons to be gleaned from the
fact of the origin of eyestrain in optics, at once historic,
physical and physiologic. There is the observation that
medical science and pathology did not discover it. The
science of physiologic and pathologic optics came to
THE NEW OPHTHALMOLOGY. 33

medicine almost entirely from without. It is the gift
of students of physics. Even when physicians busied
themselves with it they did so purely from their inter-
est in vision and clear-seeing, not from that of path-
ology. Astronomers, physicists, and opticians pre-
sented their gift to medicine. Even Donders had little
or no thought of the extension of the practical science
made by the practical American ophthalmologist. The
earliest refractionists—we must use the word—more or
less accidentally and incidentally discovered the facts
of the relief of systemic diseases by their spectacles.
The patients made the discovery that their headaches
and nervous symptoms disappeared when they wore
astigmatic lenses, and they came back and told the as-
tonished and delighted oculists about it. Mitchell, not
an oculist, heard the story from Thomson, and he told
the profession about a little of it. The profession would
not listen and utterly ignored it. For several hundred
years the official profession would not even have any-
thing to do with the spectacles which the non-profes-
sional invented. It allowed Franklin to invent the
bifocal lens, and failed to adopt it for a hundred years.
There are to-day neurologists, diagnosticians, and phy-
sicians of international renown who wholly deny that
eyestrain causes reflex diseases of any kind. A special
meeting of the New York Academy of Medicine was
recently held in which great neurologists and ophthal-
mologists vied with each other in ridiculing the ab-

4
34 BIOGRAPHIC CLINICS.

surdity. It is no wonder, therefore, if the stone which
the medical builders refused should become the corner-
stone of the temple of the opticians. These gentlemen
naturally think they have a right to practice the art
and science of refraction. Those who scorn the new
ophthalmology would, in fact, reduce the refractionist
to an optician. It is a costly blunder which the pro-
fession will resent and must unlearn, because refraction
is a medical art and science in the strictest sense of the
term, one requiring the highest intellectual qualities.
Hence their claim can never be allowed, and the pro-
fession must, therefore, now wage a hundred-year war,
which it might have prevented, against an enemy which
it might have made a friend and ally.

What are the relations of the new and the old oph-
thalmology? They are most intimate, sociologically
and clinically. In a word, the scientific correction of
ametropia prevents almost all inflammatory and sur-
gical diseases of the eyes—I should say about nine-
tenths of them. It will not, of course, prevent the few
ocular results of systemic disease, such as albuminuric
and diabetic retinitis, optic neuritis, toxic amblyopias,
etc., but such things are uncommon, and not seldom
the systemic trouble had its individual grounding in
morbid ocular function. The far greater proportion
of all ocular diseases are those of the extrinsic mus-
cles ; inflammations of the conjunctiva, cornea, and iris;
glaucoma; high and increasing myopia, and cataract.
THE NEW OPHTHALMOLOGY. 35

As to the external muscles, there is now an almost
unanimous agreement that heterophoria is due to un-
corrected or miscorrected refraction anomalies, and
that the plunge made into tenotomies, graduate, under-
graduate, or post-graduate, was into a blind alley of
error and waste which has done irreparable harm to
true ophthalmology by making the professional and
lay world suspicious and even contemptuous. The
heterophoric trouble is innervational in nature and
refractional in origin.

As to strabismus, the same truth is at last becoming
manifest and admitted. A recent English book,
Browne and Stevenson, on the “ Squint of Children,”
is a striking proof. Get glasses on the child early
enough and there will be no squint. Even when the
fatal delay has been negligently permitted, the opera-
tion does not do away with the necessity for the spec-
tacles, and there are some of us “ extremists” who
contend that the operation is of little or no good even
at the late date.

With the exception of relatively few cases, due to
trauma, infections, malnutrition, etc., conjunctivitis
and keratitis are of eyestrain origin. When one sees
a few thousand cases of spontaneous recovery after the
patients get proper glasses the truth needs no further
mention.

As to iritis and glaucoma, did any skilled refraction-
ist ever see the disease appear in eyes which for years
36 BIOGRAPHIC CLINICS.

previously had been fitted with right correcting lenses?
It may be that such cases occur, but observation shows
that the eye which is morbidized by eyestrain has such
low resisting power that only a slight inciting cause is
needed to develop the otherwise powerless hint.

Concerning retinal and choroidal diseases, it is also
a truism that they are usually caused by the ciliary
strain of uncorrected ametropia. The “ woolly,”
hyperemic and suffering retinas, the ‘ pepper-and-
salt,” unhealthy macules, the abnormal pigmentations,
noted ophthalmoscopically as the result of long-con-
tinued eyestrain, are suggestive and characteristic.

There is one refraction-anomaly, high or malignant
myopia, which is the direct consequence of disease of
the eyeball. Does anyone now doubt that this, the
stretching or stretched eyeball, is the result of ametro-
pia? If so, he should go to Germany to live. And
why does the lens so often grow opaque in the old?
Why, it would be better asked, does it grow opaque
toward the end of presbyopic failure? The sugges-
tion comes that it is at least partly because of the
denutritive conditions set up by the severe strain of
presbyopia added to that of preexisting ametropia.
This theory derives clinical support from the fact that
cataract does not arise when the eye has been kept in
an optically correct, healthy and physiologic condition
for twenty years before the cataract-age.

And thus the good American motto, e pluribus
THE NEW OPHTHALMOLOGY. 34

unum, applies to ophthalmology as well as to states-
manship. In the many diseases of the eye there is at
last but one disease. There was plainly an overhasty
recourse to surgery when the surgical disease could
have been prevented. As has been well said, an an-
cient hunger for the miraculous has come down to
our times and to our medical science, and operation is
the modern medical miracle.

At last we have begun to see that prevention is better
than cure, and the ophthalmic surgeon is becoming the
refractionist. In the same way the ophthalmic thera-
peutist is disappearing to return immediately as the
preventor of disease, the keeper of good eyes good.
Therapeutics is fast merging itself into prophylaxis,
and the practitioner of medicine is becoming the hy-
gienist. It is a sort of benevolent suicide of the old
ophthalmologist for the benefit of his heir, the well-
insured new young man. It is fortunate that the new
and the old science are in reality carried on in Amer-
ica by the same practitioners so that no rivalry nor ill-
will can take place. For a time, to be sure, the dual
ophthalmologist may privately discuss with his con-
science the question as to whether he will undertake
to prevent the strabismus of the little one, and the
cataract of the presbyope, or operate later, etc., but in
this and many other similar instances I do not contend
that the old ophthalmologist is Mr. Hyde,'although I
am sure that the new one is Dr. Jekyll.
38 BIOGRAPHIC CLINICS.

The unity of the organism and the interdependence
of all functions is the dominating and moulding truth
of medicine, the monism of physiology, the evolution
principle of medical science and practice. No organ
lives to itself alone; there is no function that does not
influence every other. This is the truth which disal-
lows a narrow specialism, prevents the exaggerator
from becoming an extremist, and forbids the extremist
to become a hobby-rider. In obedience to it the
specialist must always be on the sharp lookout for all
the lines of cause and effect which may subtly run back
and forth, either way, between the diseases of his
chosen field of study, and that of all the other special-
ists. We are, in truth, all of us, specialists nowadays,
the general physician fully as much so as any other.
While knowing profoundly one specialty, as willy-
nilly we now must do, it is our common duty to main-
tain a keen outlook over the work of others and pre-
serve a large sanity of mind, and a genuine sympathy
of feeling with our colaborers in all other fields. The
direction to speakers at this meeting is to choose out
and emphasize the relations running between their
specialties and those of others, between one science
and the other sciences. Weare to bind into unity, or
preferably discover the number and nature of the
existing bonds, which make the organism one and its
parts interdependent, and which resolve all organisms
into a universe.
THE NEW OPHTHALMOLOGY. 39

The relations which exist between refraction anom-
alies and general medicine are almost solely of one
kind—those, namely, in which the ocular condition is
causal. There are few bodily conditions or diseases
that influence the ametropia.1 Large changes in gen-
eral body weight, I have demonstrated, do so, a de-
cided increase of fat tending to lessen the anteropos-
terior diameter of the globes; an extensive decrease
of fat, conversely, lengthening the eyeballs. I have
also noticed that after a severe illness refraction
changes will probably be found. Other illustrations
may be omitted.

When one turns to observe the number of organs and
ways in which eyestrain results in extraocular disease,
there is at once, of course, a recognition that, com-
pared with direct ocular reflexes, they are few. The
eye and ear have extremely few, if any, interdepen-
dencies, and they are relatively unimportant. And yet
an expert might write an interesting monograph on
“the subject. One would say that the dentist and ocu-
list had little in common, and yet I have had more
than one patient who had violent toothache in sound
teeth whenever he read or wrote five minutes.

The specialist in diseases of the upper air passages

2 Although one well-known neurologist and one orthopedist
have said that eyestrain is a result of the systemic disease,
rather than the reverse—an amusing betrayal of a lack of
knowledge of what ametropia is!
40 BIOGRAPHIC CLINICS.

must never forget the oculist. It is a significant fact
that eyestrain patients locate their headaches directly
in or behind the frontal sinuses. We list them as
frontal, but understand thereby that the forehead is the
location of the pain. For many years I had noticed
that there was a suspicious relation between eyestrain
and frontal-sinus disease, and in several patients I
had definitely traced it. Dr. Phillips of Buffalo has
made a close study of ten such cases in which the sinus
disease was clearly due to eyestrain.1 Reflex conges-
tion of the upper air passages, pharyngitis, laryngitis,
aphonia, common colds and influenza, may be due, and
more frequently than is supposed, to eyestrain.

In general surgery nothing, a short time ago, would
have seemed more absurd than to say that eyestrain
could at least prevent appendicitis, surgical diseases
and operations. Yet Dr. Robert T. Morris, of New
York,” whose character and professional standing need
no setting forth, writes as follows:

“A very large group of cases of intestinal fermentation is
dependent on eyestrain. These cases are perhaps quite as often
overlooked as any others, but as soon as we have all become
familiar with the external signs of eyestrain fewer cases will
get to the surgeon with the diagnosis of abdominal disorder.
Those that I see are sent to the office most often with the
request to have the appendix examined, because the distension
of the cecum is apt to cause more pain than distension of other

* American Medicine, 1904.
* Medical Record, December 26, 1903.
THE NEW OPHTHALMOLOGY. 4I

parts of the bowel! and attention is attracted to this region.
If there are external evidences of eyestrain these cases are
referred to the ophthalmologist, along with my cases of ‘ner-
vous dyspepsia’ and ‘ gastric neuralgia,’ and some of the most
brilliant results that I have observed in any kind of medical
practice have come out of the treatment that was instituted.”

If an oculist had first made such a statement the
grin of derision would have extended across the face
of the continent. Because the general surgeon thus
annually turns away from his office thousands of dol-
lars’ worth of operations, it derives at least the merit
of unselfishness. _

There is no truth in medicine more certain and
demonstrable, although the gastrologist has not heard
of it, than that eyestrain produces anorexia, denutri-
tion, intestinal fermentation, constipation, and many
disorders of the digestive organs, including, especially,
the liver. If so, it is, of course, admitted that the
surgical diseases secondary to such disorders may be
ocular in remote origin, and the warning may not in the
future be safely unobserved by the appendicitis special-
ist, the gastrologist, the gynecologist, etc. Within a
year a famous medical journal has editorially stated
that all obscure gastric symptoms demand operation to
discover and excise a possible gastric ulcer. That is,

‘surely, surgery gone mad.

In orthopedic surgery a new causal relation has most
recently been discovered between eyestrain and spinal
curvature. Scoliosis begins in childhood and adoles-
42 BIOGRAPHIC CLINICS.

cence as spinal curvature, and in thousands of patients
the spinal disease is unsuspected by child, parent, and
doctor. Within a few months I have discovered thirty
or forty cases of tilted heads, most of which caused or
might cause secondary or compensatory scoliosis, and
all due to an axis of astigmatism (about fifteen degrees
unsymmetric, and to one side of go degrees or 180
degrees in the dominant, that is, the dextral eye in the
dextromanual), which compelled a habitual lateral in-
clination of the head in order to see plainly. And
the compensatory curvature of the spine induces a
score of other systemic diseases. We formerly allowed
our patients to tilt the head while making refraction
tests, and so missed locating the astigmatic axis cor-
rectly. By keeping the head vertical during the test-
ing we now apply glasses that keep it straight after-
ward, and when the spinal curve is still functional we
likewise straighten it by glasses alone.

No pediatrist henceforth may forget the eyes in all
of his patients over eighteen months old. The chances
are high that, without other definite and easily ascer-
tained cause exists, eyestrain is the source of the mis-
chief in the child which suffers from night-terrors,
breakfast anorexia, tics, chorea, nervousness, disorders

*An excellent rule of ophthalmic office practice is that when
we fail to cure eyestrain results by our glasses, it is perhaps
because we have allowed the head-tilters to hold their heads
as they pleased during the tests.
THE NEW OPHTHALMOLOGY. 43

of digestion and nutrition, irritability, headache, etc.
I have cured nocturnal enuresis in children by spec-
tacles alone. Alert-minded pedagogs are fast becom-
ing aware of the tremendous role of eyestrain in the
health and success of their pupils. As every year of
school life passes the proportion of diseased pupils
increases, until in the upper grades it may rise to 60
percent; it is 40 percent on the average in Columbus,
Ohio. The diseases are precisely those which every
capable oculist knows are often due to eyestrain. The
rule is so certain that discerning teachers know that
those pupils who are one, two or three years behind
their classes, have severe eyestrain, and without
further inquiry they are sent to the oculist. There is
hardly a page of that magnificent book on “ Adoles-
cence,’ by Dr. G. Stanley Hall, that does not need
rewriting with this new knowledge—unfortunately
and strangely ignored—in the mind of the writer. Its
splendid power and truthfulness could have been
doubled had its gifted author looked into the vast
existing literature, written by capable and scientific
minds, confirmatory of the role of eyestrain in school
life.

In neurology there is almost no limit to what the
refractionist may justly claim. And posterity will
allow it, although the neurologist of to-day is uncon-
scious and contemptuous of the truth. Neurasthenia
and hysteria he claims as his exclusive possession.
44 BIOGRAPHIC CLINICS.

Private sanitariums or rest-cure establishments may
be of limited and infrequent service for chronic pa-
tients whose vitality and resisting powers have been
worn to a thread by a half-life of torture for which no
therapeutics availed. But even the ordered rest-cure
could often be avoided by correction of eyestrain, and
in perhaps 75 percent of cases the neurasthenic break-
downs and chronic hysterias could have been prevented
by attention to the matter in adolescence. Not infre-
quently it is plain that the resting is curative because
the eyes are rested. With reading and writing inter-
dicted there are often astonishing cures; with resump-
tion of reading and writing, relapses and returns to
the sanitarium are required.

Every sensation and its every correlated motion is
an example of reflex action, and yet there are those
who airily scoff at the very possibility of reflex neu-
roses, and other diseases due to reflex action. There
are those who speak scornfully of mysticism and mys-
tery in medicine, while satisfied with a practice which
reduces itself to diagnosis and naming unknown mys-
teries as migraine, neurasthenia, hysteria, psychosis, etc.

Psychiatry seems to have reached the goal of its am-
bition. Diagnosing and naming a morbid mental con-
dition as “a katatonic state,” “major psychosis,”
“melancholia of involution,” “ psychical tonus or con-
tracture,” “ dementia precox,” “forme fruste,” “manic
depressive insanity,” “

33 66

confusional psychosis,” “ pseu-
THE NEW OPHTHALMOLOGY. 45

3d 66 as tk dy 66

mysophobia, topoalgia, neu-
rasthenical syndrome,” etc., all of which terms are
culled from one short article, seems to end in the air
so far as bettering conditions. Logomachy does not
help. Who has examined the refraction of the in-
sane? What patient with extreme eyestrain or mi-
graine has not feared insanity? The sanest of men,
Parkman, was pronounced insane, and so was Wagner
and others, by great authorities, at the climax of their
sufferings. Was not Nietzsche’s “atypical paralysis ”
intimately connected with his most evident eyestrain?
A competent oculist finds the majority of the young
criminals of the Elmira Reformatory afflicted with so
high a degree of ametropia as to make study, reading
and writing and ordinary handicrafts impossible.
What else could many of the poor boys do but play
truant and steal? The statistics showing the relation
of crime to truancy indicate that some of both may
be due to bad eyes.

In 252 cases of suicide, 187 were due to ill health.
About 50 percent of chronic epileptics have unsym-
metric astigmatism and anisometropia—a surprising
ratio of a defect especially prone to upset the cerebral
health and balance. The peculiarity of the diseases of
eyestrain is their tendency to produce psychic and emo-
tional disorder, despair, melancholy, etc.

There is scarcely any disease which the general phy-
sician or internist is called on to treat that may not

doneurasthenia,
46 BIOGRAPHIC CLINICS.

be and that frequently is not due to or influenced by
eyestrain. The commonest is designated by that silly
and meaningless word, migraine. The term has little
or no significance nowadays. It is, in fact, the vul-
garization of a misnaming and meaningless designa-
tion of a malobserved and trivial symptom, which in
the majority of cases is not present, of a widely preva-
lent and ingravescent disease, with indescribable symp-
toms, which may, in extreme cases, wreck life and
morbidize the mind, the etiology and pathology of
which are unknown, the location or organs affected
being also unknown, and of which no treatment avails.
It is made to cover the conditions indiscriminatingly
called scotoma scintillans, headache, sick-headache,
gastric and intestinal disorders, insomnia, melancholy,
etc.; in a few severe cases such patients have all of
the symptoms. It is almost always due to eyestrain,
and, except in the rarest worn-out chronic cases, it is
almost immediately curable by relieving the eye-
strain. It is the commonest of all affections, the great
manurer of the ground for other and terminal diseases,
the supporter of quacks and patent-medicine syndi-
cates. From 10 to 20 percent of Americans suffer
from it, under one alias or another, recognized or
unrecognized. The larger number of these, taught by
sad experience, have given up the hope of cure,and they
are neighbors of the person who says migraine has
no relation to eyestrain, and who does not know that
THE NEW OPHTHALMOLOGY. 47

thousands are now being cured by two little pieces of
glass. Eyestrain effects have a peculiar tendency to
periodicities and waves of better or worse. The ner-
vous centers can endure for a time the burdens and
irritations laid on them, but at last give way. This
is so of mental states and diseases, and the eye as psy-
chologists know is the chief creator of intellect.
Hence those diseases or symptoms when not depen-
dent on organic disease, like headache, sick-headache,
fickle appetite, the paroxysmal neuroses, cardiac pal-
pitation or irregularity, chorea, epilepsy, neuralgias,
insomnias and colds, which exhibit such waves of
exacerbations and depression, may be due to ocular
irritation.

A key to many mysteries of disease might be found
in a careful classification of such as have increased
with civilization as compared with those conditions
outside which have been changed during the progress
of civilization. Among these changed conditions none
can be more noteworthy than the new kind of labor,
and the tremendous addition of the amount of it
thrown on the eye by the printing press, schools, sew-
ing, clerical and urban life. No other organ has been
subjected to such a change of work and stimulus, and
in all other functions the same kind of work is now
demanded as before. The eye, however, was brought
into function to use in distant vision, and if for near,
for but an instant. Osler says that dyspepsia is the
48 BIOGRAPHIC CLINICS.

besetting malady of this country, due to improper diet,
etc., although modern food is many times more certain
in amount and good in quality than ever before. It is
certain that stomachic and nutritional diseases seem to
have increased inordinately. What is the cause of this
contradiction? One, surely, is eyestrain, which is ex-
tremely prone to upset the digestive function. See
several thousand cases of nausea, “ dyspepsia,” loss of
appetite, constipation, etc., relieved at once by glasses,
see the disease return at once when the glasses are
broken, a lens reversed in a frame, or when the re-
fraction changes, and one recognizes the fact of the
interrelation. Allied to this class of cases are those
in which the keen ophthalmologist detects more than
hints that renal affections, hepatic ones surely, includ-
ing gall-bladder diseases, may possibly be set up or
aggravated by severe reflexes from the eyes to the
secretory and eliminative organs. Some day it will
be established that eyestrain is a large factor in the
production of diseases of the kidney.

One of the more subtle but still easily recognizable
methods in which eyestrain works perniciously is by a
slow and general denutrition and reduction of mental
and physical vitality. whereby the resisting powers of
the system are reduced to such a degree that it becomes
the easy prey of infections, and of general and term-
inal diseases. This makes eyestrain a factor in the
tuberculosis and pneumonia crusade. The life study
THE NEW OPHTHALMOLOGY. 49

of patients and their diseases—the biographic clinic—
will make such a connection more often manifest.
The sad story of the life of John Addington Symonds
is in this way suggestive.

The age-long superstition whereby almost all the
diseases of women were traced to the sexual organs
and functions,’ is fast giving way to a new view more
in correspondence with facts. That puberty and men-
struation should inaugurate a host of terrible evils,
and the menopause another legion, is at the least con-
tradictory. The proper name for the cause of many
supposed disorders of menophania and puberty is study
with astigmatic eyes; that for supposed menopausal
woes is presbyopia. In a large number of instances
ég0aives may replace Setépa as the organ primarily at
fault. The oculist and gynecologist should be good
friends. The connection between the eye and sexual-
ism is known of old, and is a deep and profound one.
Love of any and all kinds dilates the pupil, the des-
ignation of the grand sympathetic system itself arising
from the fact. A certain profound relation of vision
and sexualism will sometime be established which as
yet is unsuspected.

Justly motived, therefore, is the question: Why has
this great truth been so long ignored, and why now
do so many reject it? Some of the answers are these:

1A sad error that much mars the large sanity and lessens

the benefits of Dr. G. Stanley Hall’s great book.
5 e
50 BIOGRAPHIC CLINICS.

1. The progress of science has not yet reached the
stage that will enable certain minds to see its truth.

2. The conditions of life and professional evolution
have made surgery of supreme importance.

3. Organic diseases had first to be studied.

4. The laws and status of infectious diseases had
first to be made definite.

5. A mere habit of neglecting the eye and its all-
important function and diseases has with some grown
into a blind dogmatism.

6. The theory of optics, and the elaboration of math-
ematical formulas, satisfied too many minds, and there
was no proceeding to the practical application in clin-
ical work.

7. Specialists in medicine, other than ophthalmolo-
gists, have overstated the effects of the diseases of
special organs.

8. The ophthalmic tenotomist has made unwarranted
claims and so made the profession blind and deaf to
the warranted claims of the refractionist.

9. The commercial medical journal plays to the gal-
leries, and flatters the prejudices of its readers.

10. Patent medicine vendors, drug-sellers and quack-
ery within the profession carry on the irrational ten-
dency.

11. Suffering and pain are positive, relief and cure
negative. The patient, therefore, is prone to forget
the primary misery, nor does the physician recognize

.
THE NEW OPHTHALMOLOGY. 51

the cause of the cure by glasses, which is ascribed to
fate, gale répercutée, the doctor and his drugs, ete.

12. The method of eliciting symptoms and of clin-
ical note-taking is so faulty that the very existence of
the chief symptoms of eyestrain is not recognized.
The patient thinks the vomiting, abdominal symptoms,
migraine, headache, dyspepsia, insomnia, loss of en-
ergy, etc., have no possible connection with the eyes,
does not allude to them, and they are thus wholly
ignored. Thousands of such have been cured by
glasses, and the fact unsuspected by either physician
or patient. In another, less large, number of cures
the method of cure is known or suspected by the
oculist, who is silent concerning it because of the desire
to “‘ stand well with the profession,” or to secure refer-
ence cases from those physicians and neurologists who
disbelieve in the “ extremist’ and all his work.

13. The desire for consultation practice, referred
cases, professorships, hospital positions, and “ suc-
cess” make the cunning silent or conservative. ‘“ Fad-
dism” and ‘“hobby-riding”’ charged to a budding
reputation are ruinous.

14. Poor refraction work on the part of oculists is
the greatest cause of scepticism. Those who do accu-
rate refraction know perfectly well that, broadly speak-
ing, the ophthalmologists of the world have done their
refraction work badly. The logical and pathologic
conclusions of the labors of Donders, Helmholtz and
52 BIOGRAPHIC CLINICS.

others have been practically made only by some Amer-
ican and one or two English refractionists. “I sent
my patient to the oculist and glasses had no effect on
the disease,” means utterly nothing. “Is not my ocu-
list a man of the highest renown and ability ?’”—may
mean as little. Does this man of renown and ability
teach, and in the persons of his patients demonstrate
that so-called “migraine,” headache, sick-headache,
dyspepsia, spinal curvature, insomnia, neurasthenia,
anemia, the blues, and the rest of the list, are often,
very often, due to eyestrain? Belief in the truth is a
prerequisite of ability to cure; and is absolutely essen-
tial to a rigid attention to at least “ seventy-eight rea-
sons why glasses failed to give relief.” From 50 to
75 percent of glasses prescribed in the world are inac-
curate and can not relieve eyestrain. Then it is also
true that fully 90 percent of the adjusting of opticians
is so bad that any possible therapeutic result is not
obtained.

To be entirely frank one should add an argument
which is, indeed, a two-edged sword, but which needs
occasional use to keep it from rusting. It is this:
Those who deny that migraine and the many other dis-
eases mentioned may be due to eyestrain have not of
course cured such patients in their own private prac-
tice. That is a self-judgment which is most severe.
Those on the other hand who claim that such diseases
are curable by ametropic correction, unless utterly un-
THE NEW OPHTHALMOLOGY. 53

professional, must have cured such patients. If they
do not cure they would surely be soon found out and
their reputations and practices ruined. They seem to
prosper! I heard one astute oculist say that if this
absurd scepticism continued a few years longer his for-
tune would be made. He is very “ successful ” and is
conducting his work in an honorable manner. The
enthusiasm and gratitude of a patient permanently
relieved of the tragedy of “migraine” or “ neuras-
thenia ”’ is irrepressible.

A corollary is that refraction is not taught, there is
not a single adequate and thorough-going school
wherein may be taught, or wherein there is any out-
fitting, or attempt to teach, this most skilled, most
infinitely subtle and difficult art and science. Two
years at least of study, daily, exclusive study and prac-
tice, after the general course in medicine, under expert
teachers, and on the part of the best type of student
minds, is a too short period to introduce a man to the
work, and to legally justify him in entering on such
specialist practice. An endower and maker of such a
school would do the world a greater service than either
Carnegie or Rockefeller have so far dreamed of doing.

Again the critic may justly ask: ‘“ Have none, then,
recognized and spoken out this much unrecognized
truth?” Oh, yes, many and good men have done so.
There is a vast quantity of literature produced by clin-
jcians of the best character and professional standing,
54 BIOGRAPHIC CLINICS.

and it is astonishingly convincing and cogent. It is
unfortunately scattered, and hence, in part ignored by
too many physicians. The last weighty utterances are
Dr. Zimmerman’s study,’ and especially since they are
from England, the excellent reports of Dr. Snell,’ and
Dr. Pronger.? Hundred of others might be cited, the
testimonies, e. g., of such good professional journals as
the Cleveland Afedical Journal, the St. Paul Medical
Journal, the Lancet, the Pacific Medical Journal,
American Medicine, the Maryland Medical Journal,
Colorado Medicine, Science, Mind, the Harvard Grad-
uates’ Magazine, Bulletin of the American Academy of
Medicine, Canadian Journal of Medicine and Surgery,
Dublin Medical Journal, Medical Press and Circular,
Bulletin Chicago Health Department, The Practi-
tioner, The Nation, Wisconsin Medical Recorder,
Quarterly Medical Journal, Treatment, California
Medical Journal, Medical Bulletin, Medical Council,
The General Practitioner, etc.

Of individual opinions a page of names could be
easily cited, of men with good professional reputations,
acquired and to be preserved, such as, for instance,
Drs. Jackson and Bates of Denver, Edes of Boston,
Southard of San Francisco, Hurd, Reik, Murdock,

‘New York Medical Journal, November 21, 28, 1903.

* The Lancet, April 30, 1904.

°“ Slight Errors of Refraction and Their Influence on the
Nervous System,” Harrogate, R. Ackrill, 1903.
THE NEW OPHTHALMOLOGY. 55

Welch and Halsted of Baltimore, Senn, Westcott and
Walker (J. W.) of Chicago, Baker and Sherman of
Cleveland, Cheney of Boston, Alleman and Prout of
Brooklyn, Carmalt and Swain of New Haven, Coggin
of Salem, Mass., Bennett, Starr, Pohlman and Phillips
of Buffalo, Risley, Pyle, Thorington, Hansell, Reber,
Zimmerman, Solis-Cohen (S.), Thomson, Fenton,
Murphy, Talcott Williams, Hollopeter, etc., of Phila-
delphia, Callan, Ramsey, Carhart, etc., of New York,
Van Duyn and Marlow of Syracuse, Taylor of Wilkes-
barre, Wiirdemann and Black of Milwaukee, Roberts
of Pasadena, Ellis and McBride of Los Angeles, Hale
of Nashville, Matas and Souchon of New Orleans,
and especially the dean of American ophthalmologists,
Dr. Green of St. Louis, who for nearly fifty years has
been refracting patients and observing the results. I
append in a footnote+ extracts from a personal letter

*Dear Dr. Gould:

I have read your two volumes of “ Biographic Clinics ” with
great interest, and have gained much instruction from them.
I regard them as a very important contribution to a just appre-
ciation of the distinguished men and women whose lives you
have so sympathetically studied.

The fact that the commonest ocular defects may give rise to
morbid states, such as you have depicted, has impressed itself
on ophthalmic specialists before it was recognized, and urged
on the medical profession in the classical essay of Dr. S. Weir
Mitchell, American Journal of the Medical Sciences, April,
1876. In the nine illustrative cases reported in that paper the
trains of distressing and disabling reflex symptoms clearly

2
56 BIOGRAPHIC CLINICS.

written by Dr. Green because of its peculiar appo-
siteness.

As optics grow into physiology, and physiology into
pathology, so must our pathology merge into biology.
How is eyestrain related to the evolution process of
living things? The test of the validity of all medical
truth, and distinctively of that we have been empha-

parallel those analyzed by you in the fourteen biographic
clinics, but with this difference: In his cases the dominant
etiologic factor was discovered before irreparable damage had
been done, and relief followed the timely prescription of appro-
priate glasses; in the lives which you have discussed, relief
came only in advanced age, when accommodation ceases from
troubling.

To me the central and very significant fact is that the pros-
trated sufferings, always alleviated by rest from eye work and
always recurring with the resumption of studious pursuits, as
portrayed in the several biographies from which you have
culled, are such as ophthalmic practitioners recognize as de-
pendent, in many persons, on common ocular defects, and as
preventable or curable by properly directed optical treatment.

It cannot be too strongly impressed on all intelligent per-
sons, whether physicians or workers in other fields, that the
demands made on the eyes in modern life are much greater
than the visual apparatus, when of only average structural
perfection, can meet effectively and safely. The lesson which
I have learned from forty years of continuous study of the
anomalies of accommodation and refraction is precisely in the
line of your teaching, namely that no degree of anisometropia
or of astigmatism can be regarded as too small to demand
accurate correction in persons compelled to use the eyes con-
tinuously, or in patients suffering either from so-called asthen-
opic symptoms or from headache or other reflex disorders
induced or aggravated by eye work. Neither can I accord any
THE NEW OPHTHALMOLOGY. 57

sizing, is its function in the great incarnation process
summed up in the Bible, verity, “ The Word became
flesh,” and in the consensus of doctrine in the term,
Darwinism.

A truth none can deny, but one which all biologists
have ignored, is this: Vision is the dominant condition
of self-motility. Wherever there is an animal that

measure of assent to the notion that a short term of attendance
at a post-graduate school, or any period of apprenticeship in
selling eye-glasses and spectacles, can qualify an uneducated
or, at best, a crudely educated man to do work which often
taxes my own powers to the utmost, and in which I find that
the continued cooperation of the patient, by returning promptly
for further advice when anything goes wrong and by permit-
ting the necessary periodical revision of his optical correction,
is indispensable.

It is surely not an extravagant contention that eyes which
do not perform their function perfectly in all respects and
under all conditions, or whose use’ is attended or followed
either by local disturbances or by headache, nausea, insomnia
or other reflex manifestations, ought, without exception, to be
promptly and critically examined. That such examination will
very often bring to light a previously unrecognized ocular
defect, and so point the way to urgently needed relief through
wearing properly chosen and properly adjusted spectacles,
needs only to be stated to command assent. The knowledge
that relief from headache may come through wearing glasses
is becoming more and more widely diffused; but comparatively
few physicians have learned, as yet, to recognize the protean
forms which reflex disorders of ocular origin may take on,
or to estimate at its true value the service which a wise and
conscientious ophthalmic specialist may be able to render.

The investigation and treatment of functional disorders de-
pendent on structural imperfections of the visual organs call
58 BIOGRAPHIC CLINICS.

moves, in the light, there are eyes. Ubi motus ibi
visus. There could not have come into being any ex-
cept the very lowest animalian organisms unless
through the visual function. All nutrition, all safety,
all attack and escape, all free-moving and effectual
doing, was utterly and wholly by means of seeing.
Thus the evolution process was dependent on and made
possible only through the evolution of the eye, both as
a precedent and conditioning sine qua non.

for the exercise of the minutest care, and often of almost in-
finite tact and patience. That three essential qualifications are
sometimes conspicuously lacking in men eminent for their
achievements along other lines is also true. Careless or per-
functory refractive work by an ophthalmic specialist will yield
no better results than similarly defective work done by persons
of inferior scientific attainments and of vastly less reputation.
The intelligent and painstaking pioneer work of Ezra Dyer;
the invention and employment of new aids to diagnosis by
William Thomson; the frank recognition and just appreciation
by S. Weir Mitchell, of the far-reaching benefits rendered, in
his reported cases, by William Thomson, William F. Norris
and George C. Harlan; and lastly, the continued devotion to
the cultivation of accurate methods by a long line of careful
investigators down to the present day, make up a sum of
achievement by Philadelphia men which may be regarded as
more than sufficient to justify the recognition of a distinctive
Philadelphia school.

The personal sufferings of Ambrose Paré and of Percival
Pott were the means of enriching surgical literature by two
illuminating chapters on compound fracture. Your early ex-
perience of the torments and disabilities incident to a too long
delayed diagnosis and connection of a complicated ametropiz
gives you, also, the right to speak forcibly and with authority.

Were not the Hebrew prophets decried, in their day, as en-
thusiasts ? JoHN GREEN.
THE NEW OPHTHALMOLOGY. 59

And few have the most dim notion of the complex-
ity of the organ of vision in man, or of the amazing
difficulties of “ Biologos ” in fashioning and perfecting
it. Millions of finger tips are bunched together in the
one-inch cup of the eyeball, from whence run about
425,000 nerve fibrils to a topographic mechanism of
sensation in the occipital lobe. The eye can see an
object 1/1000 of an inch in diameter. The cones and
rods are only I1/10,000 or 1/14,000 of an inch in diam-
eter, and a million cones at the macula occupy a space
of only 1/10 of an inch square. These crowded finger
tips perceive the shape of the picture and the intensities
of the light stimuli of all illuminated objects of a
millionth of a millionth of the kinetic energy of any
other physiologic force, and of so short a duration as
the 0.00144 of a second. And out of these infinites-
imal waves the sensations called light and color are
created. The mechanism which creates them must
be in intimate and instant connection with the centers
initiating and controlling every other sensation, of
every motion, of every muscle of the body. Imagine
for an instant what takes place in every animal and
human being every day of its existence. A traveler
tells of a monkey pursued by another, and running
over and through the tops of the trees of an African
forest faster than a deer could run on open ground.
The flashing repetitive momentary glances of the eyes,
before, back, and all about a hundred objects must be
60 BIOGRAPHIC CLINICS.

coordinated with a mathematical precision to accurate
unity and brilliant action of every muscle of the body.
Similar perfection of eye and motion has been evolved
in every higher animal of the world, and in every
savage, and in every child. Your horse avoids all
stones and knows, unconsciously, every inequality of
the ground before and beneath him by the like mech-
anismal unity. Watch little children in play barely
missing obstacles and dangers which would mean in-
juries and perhaps death with swift unconscious-
ness. The history of savagery and of civilization is
all there and is of the same nature. See with unbe-
lievable accuracy if you would succeed, is the first
verse of the biologic decalog. That is the physiologic
Logos which became the biologic flesh.

But see inaccurately and you die, is the antithesis,
and the animal which failed to obey perished, inevita-
bly and quickly. The savage did the same, your horse
that stumbles is useless, your playing child that hits its
leg or trips becomes, at least, a very different child,
and a very different man or woman from the others
who do not make these visual and coordinating blun-
ders. Such are the backward scholars in school and,
in large part, they are your failures in life, society’s
expensive degenerates, defectives and dependants.
They are rapidly increasing in number with every
step in civilization, because every such step means the
entangling difficulty of added near vision,
THE NEW OPHTHALMOLOGY. 61

All of which—and this is the heart of the matter—
Darwin, a martyr to bad eyes himself, failed to see,
and all of which no evolutionist has since caught sight
of. And yet it has been one of the large controlling
conditions of the evolution process. For not only has
this unity of mathematic optics and physiologic func-
tion been the inescapable method of success in the
struggle for existence, but it has been the chief mech-
anism whereby the so-called unfit have been thrown
out of the count. Visual imperfection has been and is
increasingly becoming one of the dominating causes
of the exclusion of the ontogeny from the propagating
phylum. This is the fundamental distinction which
differentiates the laws of biologic evolution and sur-
vival of those with and those without vision. It is
the key which will unlock and reveal many of the pro-
found mysteries of heredity and descent which to-day
are tormenting the different schools of evolutionists
and biologists. Open the door and walk into the long-
closed ancestral hall and the mystery of forbear and
after-comer is revealed. How and why we are here
is at once plain. None could have been, and we
could not now be the link between the phylum of the
past and that of the future, except on the condition of
seeing well. Those not allowed to become such paren-
tal links were largely those who saw too inaccurately
to compete in the beneficent but summary process.

Note well, however, two things: The most perfect
62 BIOGRAPHIC CLINICS.

organism in the past world of animal and man was
useless without, first, this perfection of visual function,
cerebral coordination, and muscular response; and,
second, the attainment of this optical mechanism was
far more transcendently difficult than any other phys-
iologic task. To attain transparency and nourishment
of cornea, lens, vitreous humor and retinal end-organs,
to superpose the images of the two eyeballs, to respond
to the almost nothing of stimulus, to transmit to brain,
to manufacture sensation, to dominate all other cere-
bral function, instigate and direct all motion—where is
the end of the marvellous task! The end is in failure
to do any one of these things, and to make that inch-
in-diameter eyeball of a spheric perfection which shall
not vary by 1/300 of an inch from the normal. The
end is not to have prevented conjunctivitis, trauma-
tism, keratitis, iritis, glaucoma, cataract, retinitis and
other multiform diseases, prone especially to occur in
the astoundingly complex and refined organism. The
pathology of animalian evolution has therefore been
in large part the pathology of vision. The organism
otherwise perfect except as to an infinitesimal visual
part is thrown out by this optical necessity. The
mechanism per excellence of the exclusion of the unfit
is thus made clear.

To this now add the consummating and crowning
function of vision—the creation of intellect. Psychol-
ogy, history, and biology unite to demonstrate that the
THE NEW OPHTHALMOLOGY. 63

objectivation of the ¢vz% of civilization is almost
uniquely by means of vision. The greatest task of
all human history was the creation of the letters of
the alphabet. It was so difficult that only one race did
it, and within one of two millenniums all others have
come to a knowledge and use of civilization only
through the adoption of the invention. No writing
and printing, no civilization. But the letters of the
alphabet are conventionalized symbols of pictures, or
things seen. Add to this that language itself is of
identic origin. There has been no speech except to
express the result of ocular function. Almost all psy-
chology is summarized as handlings, coordinations and
deductions of visual images, of these and of the
motions made possible by sight. Thus every cerebral
function, perception, apperception, feeling, most of it,
and willing, that which is effective, surely reasoning
and judgment—all spring originally and constantly,
are bound up with, dependent on, and interdependent
with vision.

There is something more than mere imagery and
fancy which analogizes the course and phases of these
developmental stages to the way of water-flow in the
world. Decidedly optical are the sun, cloud, rainfall
and snowfall on the uplands and mountains whence
spring the crystal streams and rivulets of physiology.
In them optics become function and action, physics
become physiologics. The lower falling brooks be-
64 BIOGRAPHIC CLINICS.

come discolored and morbid when they reach the homes
and degradations of man—physiology becomes path-
ology. But the stream broadens into the large river
of biology with the commerce, the health and unhealth
of a continent, until finally the Mississippi sweeps to
the mothering ocean of sociology where sail and steam
the navies of the world.

Thus all routes and efforts lead to man, all biology
ends in sociology. Our striving is for human better-
ment; because all medicine is preeminently philan-
thropic. The beclouded or befogged mariner orients
himself by means of an optical instrument, and as
the sun and the sun’s winds bear the sun-made clouds
back to the faraway mountains again, so vision and
optical eyes and instruments again complete the morbid
and therapeutic circle, the cure which is always begin-
ning and never complete.

My contention is that here is a great means of civi-
lization. It is a profoundly important thing that the
hopeful Carlyle of the “ Characteristics ” should have
become the pessimist of ‘‘ Shooting Niagara and
After.” It is civilization’s tragedy that Nietzsche
should have had havoc played with his mind by eye-
strain; that Huxley should have been driven from
work at the height of his powers; that DeQuincey
should have been an opium eater; that Darwin should
have been able to work but two hours a day with his
eyes, and Parkman but a few minutes; is it not a sad
THE NEW OPHTHALMOLOGY. 65

thing that George Eliot and her books, Symonds and
his great opportunity, Twain and his great scholar-
ship should have suffered as they did? Is it not a
pathetic source of social misery that 10 or 20 percent
of eyes are incapable of sewing, typewriting, book-
keeping, lathe-work, studying, draughting, and a still
sadder thing that their owners have no knowledge
of the fact, and that they should suffer until “ break
down’ comes? Is it not an awful thing that from
40 to 60 percent of all school children are sickly?
That suicide is increasing, insanity and epilepsy in-
curable, hospitals multiplying—and taxes, and prisons,
and war, and want? A certain, perhaps a large, per-
cent of all these backward school children, epileptics,
prisoners, insane, hysterics, neurasthenics, dyspeptics,
have such eyes that glasses correcting their optical
defects would bring them much relief, would often
have prevented much or all of their tragedy. And the
proof is this: Put any pair of such spectacles on any
one of us, and within an hour there would be head-
ache, giddiness, vomiting or intense suffering. The
cynics and skeptics of “ eyestrain exaggeration ” can
be speedily converted whenever they are earnest
enough to try a simple experiment on themselves. It
is a truth awful in its significance that in civilized
countries there are millions of people who are good
products of the evolutionary mill, who have sound
minds and good bodies, but who are partial or com-
6
66 BIOGRAPHIC CLINICS.

plete failures, always with intense personal suffering,
simply because of an infinitesimal malcurvature of the
cornea, a too long, or a too short eyeball, no greater
than the thickness of a sheet of thin paper. It is the
little thing that, overlooked by others, makes or mars
all undertakings, all sciences, and all cosmic proceed-
ing. The compass guides the ship, and without it
there would be no civilization as we see it. Without
vaccine virus there would be a different world, there
could hardly be civilization, and yet it was a genera-
tion after farmer Jesty inoculated his family from the
teats of the cows in the field before even Jenner dared
do the same, and before the best of the profession
would have anything to do with it; and to-day there
are perhaps a million antivaccinationists in America!
When Pasteur had demonstrated what Villemin and
Davaine had before said was true, the bacterial origin
of some diseases, history records that “ the doctors, in
the great majority, were violently opposed to the germ
theory of diseases. They answered experimental
proof with oratory. The less excited among them
urged temporizing. The surgeon Chassaignac warned
Pasteur that laboratory results should be brought out
in a circumspect, modest and reserved manner, etc.”
In 1843 Dr. O. W. Holmes conclusively showed that
puerperal fever was contagious. We ignored the fact.
In 1846 Semmelweiss of Vienna independently pro-
claimed that puerperal fever was due to inoculation by
THE NEW OPHTHALMOLOGY. 67

nurse, midwife or doctor, and that this contagion
could be prevented. For this bravery and clinical
acumen Semmelweiss was persecuted by his medical
brethren, turned out of his professorship and ruined.
In the Paris Maternité Hospital in 1856, 64 women
died of the disease out of 347 admitted. In 1864, out
of 1,350 cases, 310 died. At last in 1874 Fornier and
Budin introduced the “new” views of Pasteur and
Lister, and in spite of what Dr. Roux calls the “ tyr-
-anny of medical education,” they were accepted, and
puerperal fever disappeared. Would it not have been
an inestimable gain not to have persecuted Semmel-
weiss and instead to have examined and tested his
theory? In 1888 Dr. G. Martin stated that “ mi-
graine ” was due to astigmatism and published proofs.
In 1903 and 1904 the Medical News likens those who
say the same thing to Dowie and Mrs. Eddy, and the
leaders of the New York Academy of Medicine call a
special meeting in order to snuff out of existence the
advocate of such a senseless theory. And yet migraine
is due to eyestrain as any one can prove whenever
he wishes, and as thousands of patients will testify
whenever asked. Migraine is peculiarly a disease of
civilization, increased with every added hour of near-
work with the eyes; and civilization is enormously in-
creasing that constant strain of near-work with eyes
evoluted during millions of years for a different
function.
68 BIOGRAPHIC CLINICS.

There is hardly an instance in all history of a great
and beneficent medical discovery that was not either
ignored or hated and scorned by the official leaders,
and by the great part of the entire profession. It was
so with vaccination, with anesthesia, the germ-theory
of disease, Mendelism, thoracic percussion, ovari-
otomy, antisepsis in surgery, the etiology of yellow
fever and malaria, the serum treatment of diphtheria,
Pasteur’s antirabies inoculations, the huimnane treat-
ment of the insane, etc.

Now the amazing fact about all of this is its ease
of proof or disproof, the passionate hatred with which
was rejected a possible source of relief of human suf-
fering, the harmlessness of the trial, the utter forget-
ting of the patient, the supreme interest in the preju-
dice. Vaccination is harmless and its protective effect
easily demonstrated. To tap the chest with the finger
is a very simple proceeding and the sounds elicited are
easily recognized. It is not difficult, if so minded, for
the nurse, midwife and doctor to be clean, and thus test
if puerperal fever is contagious. The physicians who
clamored against railway travel because it would make
passengers sick, giddy or insane, and said if the foolish
would build railways board fences must be built above
the height of the cars—these physicians could have got
on the cars and disproved their theory. The opposers
of the theory of circulation of the blood might at least
have tested the theory by pricking their finger. The
THE NEW OPHTHALMOLOGY. 69

prejudice against rabies inoculation, the diphtheria
antitoxin, the mosquito-theory of malaria, and yellow
fever, etc., which resulted in untold deaths and delay
of scientific progress, could have been easily tested.
It is childishly simple to test the power of astigmatism
to produce or cure migraine, and yet many prefer not
to make the test.

There are probably not a half dozen hospitals or
ophthalmic clinics in the world outfitted with a trial-
frame or set of test lenses that would enable even an
expert refractionist to diagnose ametropia with the
perfect accuracy which is necessary to cure morbid
ocular reflexes. But those set to do refraction work
in the public clinics are not expert. They are the
students and learners. Hence nine-tenths of the
glasses prescribed in these institutions are not correct.
Ophthalmic surgery and inflammatory diseases are all
that interest, and these would be largely preventable
by the refraction that is neglected and misdone.

Even in the institutions for the blind it has been
found that some of the inmates are not blind, and that
their remnant of vision may be so vastly improved as
to make these dependents self-supporting. In every
school of the world at least 20 percent of the pupils are
suffering from ill-health due to imperfect eyes, and yet
pedagogics, except infinitesimally and incipiently, does
not know and does not care. The teachers and pro-
fessors in preparatory schools, colleges, universities,
7O BIOGRAPHIC CLINICS.

technical and other schools, pay little or no attention
to the ventilation of the rooms, or to the refraction of
the eyes of their students. These are constantly
breaking down in health, or in study, from migraine,
etc., and the general scholarship is vastly depreciated
because of the neglect of the eyes. An official and
resident expert refractionist would make a university
outdistance its rivals more than does all its “ athletics.”

In every asylum for the insane some patients are
there because of bad eyes—and if only a few are cura-
ble of the chronic disease, many could be relieved of
the headaches, gastric and other nutritional diseases
which burden the attending physicians and the tax-
payer. In one great institution for epileptics, a little
experiment with glasses, imperfectly executed in many
ways, showed a greater percentage of cures, a greater
reduction in the number of seizures, than by all other
methods of cure combined that had been tried in the
institution. And yet the official report characterized
the experiments as “ disappointing,” and sneered and
misrepresented it. Epilepsy, it has been demonstrated,
is in many cases due to ametropia; many cases could
be prevented by proper glasses in the child, or during
the early history of the case. In the chronic, severe
and hopeless cases it may not be always or even fre-
quently curable. The conditions of the glass-treatment
are exceptionally difficult to carry out, and often can
not be done at all, especially if conscience and sym-
THE NEW OPHTHALMOLOGY. 71

pathy are absent. The improved general health, free-
dom from headaches, etc., would make it at least a
saving of money for the state to pay an expert resident
oculist. This, apart from the humane consideration.
Nobody can rightly estimate the number of degen-
erates, paupers, defectives and dependents loaded on
the producers and taxpayers because reading, writing,
sewing, study, handicrafts, etc., are impossible to a
person with disqualifying astigmatism. Neglect of
the fact greatly increases the tax rate, and makes the
philanthropic miserable.

Why does the truant school boy exist, and why does
he so often develop into the young criminal? If the
majority of these, as Dr. Case of the Elmira Reform-
atory finds, have an ocular defect that makes vision
impossible for any continued reading, writing, or hand-
work, does not the fact modify all penology? If the
sewing-girl can not possibly sew, or do any such kind
of eye-work, what alternative is often left her except
crime? Sociology is very frequently another name for
ophthalmology.

And if even to-day in the city the poor can not be
fitted with a simple device to make their lives happy
and independent, how is it with the other half or three-
quarters of the people who live in small towns and in
the country supplied only with the itinerant criminal
spectacle-peddler? The farmers and their families
now waste most of their evenings and their winters,
q2 BIOGRAPHIC CLINICS.

and then the sociologist blames them for their vile
country newspaper and their unprogressiveness.

Philosophers and thoughtless critics bewail the lit-
erary pessimism of the age. It is indeed a pitiable and
a pitiful fact. In a time when comfort and possibility
of education and of enjoyment have suddenly increased
a hundredfold, why the strange phenomenon of vastly
increased skepticism, mental suffering, hopelessness
and melancholy? Who have set the fashion? Cer-
tain powerful, but in some respects morbid, literary
geniuses. Who were they? Those almost without
exception who were great sufferers from physical dis-
ease. Of what disease? Simply of “ migraine.”
Without a thought of the class to which they may
belong, make a list of the literary pessimists of the last
century, and another list of the optimists. The pes-
simistic or gloomy writers and artists were almost en-
tirely great sufferers from eyestrain and from its result,
migraine. They were, for instance, Nietzsche, the
two Carlyles, de Maupassant, George Eliot, Wagner,
Tchaikowsky, Chopin, Symonds, Tolstoi, Heine, Leo-
pardi, Schopenhauer, Turner, Obermann, Thomson
(the younger), Poe, and many others. Others that
partially or wholly conquered the “ migraine ” of eye-
strain by opium, or by renouncing ocular near-work,
by walking, etc., are Mrs. Browning, DeQuincey, Cole-
ridge, Beethoven, Parkman, Whittier, Margaret
Fuller, Browning, Huxley, Spencer, Taine, Darwin,
Lewes, Hugh Miller, Southey.
THE NEW OPHTHALMOLOGY. 73

The optimists, the cheerful, hopeful, encouraging,
loving and helpful ones, were, a few and at random,
Goethe, Mozart, Verdi, Ruskin, Wordsworth, St.
Beuve, George Sand, Emerson, Lowell, Longfellow,
Hawthorne, Kant, Scott, Bronti, Dumas, Voltaire,
Gibbon, Macauley, Mommsen, and a host of others.

In not one of the lives or writings of these last will
you find a hint of eyestrain or migraine, hardly even
of ill-health. Note also that the pessimists are mostly
atheistic and materialistic, while hardly one of the
healthy optimists is so. One may also remember the
tendency to despair and even suicide in those who suf-
fered the most from migraine. It is exactly so in pri-
vate practice to-day. Pessimism and atheism are an
expensive tax on the natural vitality, a danger to the
public health, a brake on the wheels of the progress of
civilization. If we care naught for the personal and
preventible sufferings of these great workers in hu-
manity’s cause, nothing for those of the literary and
other laborers tremendously increased by the very
nature of their tasks, we at least should consider the
welfare of the generations that follow us. As the
creation and perfection of vision has been the condition
of past biologic evolution, so its normalization and the
avoidance of its pathogenic results is one of our
highest professional duties and ideals.
THE LIFE TRAGEDY OF JOHN
ADDINGTON SYMONDS.
CHAPTER II.

THE LIFE TRAGEDY OF JOHN ADDINGTON
SYMONDS.

THE reader of Brown’s “ Life of Symonds” must
be strangely insensitive who is not sympathetically
grieved by the peculiar and profound pathos of the
man’s life and suffering. One of the sharp appeals
to the attention, coming almost as a shuddering jar,
which so often halts one in reading Symonds’ own
words is shown in this challenge of his of “ the injus-
tice of the world”:

“T felt at Venice, and I feel sure, very deeply, the injustice
of the world, that a man like myself, who has no merits to
distinguish him from the rest, should be, through luck of birth
and money merely, enabled to play upon the lyre of life so
largely to his satisfaction—sea, city, islands, pictures, palaces,
there; here, mountains, fine air, forests, homely houses, flowers
—and in both situations intellectual enjoyment, responsive
human beings, energies of heart and hand.”

There are few men so highly endowed with both
the internal and external gifts of good fortune who
have quarreled thus with Fate for its “ injustice.”
There are fewer still who would have believed so
naively in the momentary happiness which he caught

1Reprinted from Maryland Medical Journal, August, 1904.
77
78 BIOGRAPHIC CLINICS.

out of the monotonous drag of wretchedness which
made up his days and nights, his years and his life.
The man who could think and feel as this one did may
teach the reader the best lessons which come only from
the intimate living with another through biographic
study. One who loves the swift, clean sword of intel-
lect, polished by knowledge and culture and handled
by art and power, cannot pass by this duel between
fate and personality. One who himself feels the
tragedy that such swordsmanship may bring must have
waited for this sad, bright hero. The physician who
can see the pathogenic source of the sufferer’s hurt
should find a double pathos in the sad tale.

As in Beethoven’s great symphony, the knocking of
fate is at the very beginning. Not even in childhood
was the boy allowed the usual boyhood plays and joys.
From his earliest years and during youth he was tor-
mented with frightful dreams, night terrors or night-
mare, visions, etc., and from eight to twenty-eight he
was struck as with a semiparalysis, and had daytime
states of trance, self-absorption, times when space,
time, sensation itself, seemed obliterated. He took no
interest in athletic sports, and was wanting in mus-
cular vigor. He preferred rambling alone and wan-
dering over the downs or through the woods. He
was afflicted with diarrhea, which at about twelve
became severe and chronic. Somnambulism began at
about this time to complicate the tormenting dreams.
THE LIFE TRAGEDY OF SYMONDS. 79

From fourteen to eighteen he had a number of de-
pressing ailments—colds lasting all winter, lack of
energy, etc. His father, who was a successful physi-
cian, tried all sorts of drugs; but, as the autobiog-
rapher says, “these things did not touch the root of
evil.” All through Symonds’ life he sets down the
fact of the “root of evil,’ but, as usual, with the
astonishingly repetited failure to recognize the cause
and effect. So now he writes of “close study,” the
poring stupidly and mechanically over books, imme-
diately preceding the sickness and the drugs. He is
“tired and lamentably dismal about his study,” forgets
everything he reads, etc., and headache is “ bitterly
resented.” He is “very ill, his memory weak, his
head heavy, his limbs dragging, his whole being low,”
etc., until his father telegraphs him to give up all study,
and then begins the walking, “ much of it and every
day.”

But stopping reading was, of course, an impossibility
with such a mind, although “to read as much as he
intended he could and might not,” and there continued
the “ bad, depressed headache, painful reveries, weary
dreams, weakness, melancholy, nervousness at night,
and inability to do literary work in the morning.” He
then “took to riding again, with much benefit to his
health,” for “rides take away the headaches and de-
pression. I got sleepy and read less than I might.”
He was now twenty-one.
80 BIOGRAPHIC CLINICS.

His return to Oxford was followed by a return of
all the old symptoms—the persisting repetition of bad
nights, sick-headaches, insomnia, weakness, nervous-
ness, pain in the trapezoid muscles, depression, weak-
ness of memory, etc. Study confuses him, and
strychnin is resorted to. He is unable to read, and
the steady complaints are reiterated of headache, cloud-
over-brain, return of the “ old cramped-head feeling,”
amounting at last to “ doubts, questionings, mad sui-
cidal fancies,” etc. When coming up for examinations
he has to use “ sleeping draughts ” and “ pick-me-ups.”

Travel is, of course, commanded—(I am aware of
the scurrilous clubman’s nonsense as to the reason
given for his leaving Oxford; no word of correction
is needed), and one should note the formidable list of
books he took with him and devoured on trains, in
hotels, etc., followed immediately by headache, sleep-
lessness, soreness of the scalp, neuralgic pains in the
head, his eyes feeling “as if boiled, and regular cen-
ters of agony to move which is to set two instruments
in motion.” These and many such ever-varying symp-
toms are entered many times a day in the case histories
of their patients by the modern oculist. Here are
others, set down by Symonds’ writing of three years:

“Strained feeling in the head.”
“Chills and rheumatism.”

“Pain, weakness, and aching eyes.”
“Brain so troubled; headache.”
THE LIFE TRAGEDY OF SYMONDS. 81

“ My eyes got worse at Oxford.”

“Cannot read or look out of the window when on train,
nor can I read or write during the evenings at hotels.”

“Terrible physical and mental weakness. An oppression
under which I hope you may never grow has weighted me to
earth, and neuralgia has gnawed me until I am very feeble.”

“Being unable to use my eyes for study, I read very little.
But I was able to walk as much as I liked.”

“TllIness and ennui.”

“Deeply wounded in heart, brain, and nerves.”

“The physical illness, that obscure failure of nerve-force,
which probably caused a subacute and chronic congestion of
small blood-vessels in the brain, the eyes, the stomach perhaps,
and other organs.”

“Enforced leisure—periods of unemployed solitude more
frequent and trying, owing to the weakness of my eyes and
head.”

“Hard to bear both blindness and weakness of brain in soli-
tude, for thought and reading are rendered equally injurious
to the chance of future strength.”

“ Head and eyes fail.”

“Theater and lecture-rooms are bad for head and eyes.”

“Sleepless nights.”

“ Weakness of head and eyes.”

“Eyes for more than two years useless.”

“ Sinews, strong nerves, strong eyes, are needful for action.
I have none of these.”

“My brain refused to work; then my eyes were blinded.”

“ Wasted idleness of existence—that is what I suffer from.”

“Not able to read much, owing to weakness of eyes and
other ailments.”

To lessen the ennui of the long periods in which he
could not read and write, as also unconsciously to get
physiologic relief from the reflex ocular irritation

7
82 BIOGRAPHIC CLINICS.

«

aroused by reading, he now spent much of his days in
rowing, riding, in social calls, entertainments, etc.
He had now reached the age of 25, and the outcome
of all the sufferings he had endured, the direct result,
as it seems, was the development of “ mischief at the
apex of the left lung,” diagnosed by his father. The
significant fact needing emphasis is that “ the appear-
ance of this trouble began almost immediately, though
very slightly at first, to relieve the brain trouble from
which he had suffered so acutely.” At once blisters,
morphin, etc., produce a “head-weariness and eye-
weakness ” of which there had long been constant and
bitter complaints. Now also begin “the long series
of journeys in search of health,” the cause of the
ill-health always taken with the traveler as his most
precious possession. Of course, there was the ever
old, ever new “ depression, thwarting of aspirations
through ill-health,” colds, and again bad colds, and
still others, with records of ‘“ feebler, chronic trouble
in the head,” “‘ permanent malaise and nervous sensi-
bility, which made me incapable of steady work,” etc.
“Tf I produce, my thoughts tear me like vultures; I
have to leave the lines unfinished.”

This connection between writing and _ suffering,
always recognized, becomes more vivid, but no sug-
gestion of its true causal nature ever occurred either
to Symonds or his physicians, except, of course, the
THE LIFE TRAGEDY OF SYMONDS. 83

old fallacy that it was due to intellectual labor per se.
Other jottings showing it are as follows:

“The daily ennui of my tired brain and eyes. Nervous irri-
tation amounted at times to insanity. A sprained ankle made
matters worse” [because it confined him to his room].

“Not able to use my eyes for continuous study.”

“Why I have not written is simply a letter costs me a
good deal.”

“Translation was intolerably irksome. It retarded the re-
covery of my eyesight.”

“Tt was only by tours abroad that I kept myself from phys-
ical collapse.” [Travel was the only way to keep him from
study.]

“How my blood burned while I sat scribbling until the
manuscript was finished!”

“The irritability of my brain rendered me peculiarly intol-
erant of sustained labor.” [A natural, ancient, and ever-living
example of post hoc logic.]

“T worked recklessly.”

“In the winter my health, as usual, began to fail.” [“As
usual” also with all eye-workers.]

What an unintentional illumination the actual facts
receive from such entries as these:

“T attribute my gradual recovery in no small measure to the
fact that I resolutely refused to give up study.”

“To write vigorously only ends in irritation of the nerves
by night and day.”

“Whatever you do, don’t go and lose your health.”

“ Sudden and inexplainable collapses.”

He read 16 books [in Italian] within a fortnight.

“When the eyes and brain are both disturbed there is no
happiness.” :
84 BIOGRAPHIC CLINICS.

“T have worked out the thread of ennui which made me
take this paper to write.”

All bad weather [keeping him indoors, etc.] are depressing
to his health and spirits.

“ Wandering again, partly for my eyes’ sake.”

He now dictated much of his work to his wife.

“Brain tired with correspondence.”

The wet summer had a decidedly bad effect on his health
and spirits.

“T was falling ill with too much writing.”

“T£ I could have taken walks, I should have kept my health.”

He worked 10 hours a day at proofreading, and was on the
brink of actual collapse all winter.

He had continuous fever. There was only an hour or two
in the morning when he could “use his head.”

“The day’s headache has begun, and I must stop.”

“Tired and worn with writing.”

The life of Michael Angelo caused “ fainting and falling
fits.” “TI have been very ill.”

Another hundred quotations might be added to illus-
trate the thought now familiar to all ophthalmologists.
These may serve as samples:

“JT felt that my incessant brainwork and amusements at
Davos are in a true sense occasioned by the total lack there
of free sensuous beauty and delight inflowing from the outer
world. Most of us who are not born mountaineers have been
bred to the enjoyment of such things as the pyrus and cherry
symbolize. Without, perhaps, being aware of it, they are
driven too much in upon themselves by the monotony of snow
through seven months of winter and the austerity of that brief
summer of the mountains. The tension becomes at last too
great. They react against it by debauches of brainwork, stim-
ulation, company.” (49.)
THE LIFE TRAGEDY OF SYMONDS. 85

“Then came the goddess Drudgery I had invoked, and spoke
to me, and I replied as follows: ‘It is my particular source
of misery that I cannot labor; I am forced to be inactive by
my health. If I could study for six or seven hours a day, the
intervals might be devoted to a well-earned relaxation. But
now the whole day has to be devoted to encouraging a cheer-
fulness and peace that rarely comes. Relaxation is labor, and
the untamable soul frets under its restrictions.’ A little ner-
vous strength might make all the difference—a loosing of the
bands about my forehead, a soothing of the aching eyes. (28.)

“Ever since you left us in the summer I have been suffering
from a chronic inflammation of the eyes. This made my liter-
ary work painful. And I was under obligation to do a heavy
bit before the end of the year. I translated Cellini’s ‘Memoirs’
into English. Under this pressure I broke down, and I have
been seriously ill for more than two months with a very ex-
hausting fever. It is of the nature of ague, I think, and has
implicated the lungs. The result is that now I spend wretched
days of helpless prostration without brain, suffering in every
joint, alternately icy cold and burning hot, sleepless at night
or pursued by tedious dreams, incapable of moving beyond my
house and its wooden shed outside, the mere shadow and
vision of a man.”

Whether ill or not there was no respite of literary
work:

“T have managed in this illness to write a long poem in
ottava rima on an Italian story, another in terza rima of a
ghastly kind, an elaborate essay on Heywood’s plays, a notice
of Brome’s dramatic works, and a portion of an essay on the
{talian republics of the Renaissance. But it is killing work.
I say to myself, like Macbeth, ‘At least we’ll die with harness
on our back.’” (33.)

And the curious and long well-recognized sudden
86 BIOGRAPHIC CLINICS.

alternations of seeming health and profound suffering
in migraine are often met, as, e. g.:

“What I suffer I only know. And when this emotion be-
comes blunt I shall know, not that I am freed, but that I am
dying, for these intense pains are a condition of vitality in me.
It is all this which makes me alternate between feverish and
voracious work and exhausted idleness. I have intervals of
clairvoyance and intervals of stagnant blindness.” (33.)

“Violent revolutions of subjective tone from extreme
quiescence to febrile excitement, and back again.”

As from the beginning up to his death there break
forth the constant and painful iteration of the afflic-
tion of colds and draughts—chest colds, heavy colds,
severe colds “ which left me exhausted,’ bad colds,
bronchitis, long and tedious illness; “I catch cold
then,” severe colds, bronchitis, influenza, etc. The
intimate and causal connection of eyestrain and colds,
influenza, and diseases of the respiratory tract is grow-
ing clearer to the profession nowadays. Patients long
ago found it out:

“The way in which my nerves as well as lungs have been
attacked looks like influenza.” [And he thinks it a result of
his writing.]

Just before his death (at 51) his cold was worse,
his “throat very bad—almost a form of diphtheria.”

So far as concerns the biographic clinic upon
Symonds’ life the greatest medical interest may lie in
the development of his pulmonary tuberculosis. The
diagnosis of any lung disease was made when he was
THE LIFE TRAGEDY OF SYMONDS. 87

twenty-five, following close upon the years of intense
suffering, denutrition and weakness, all, as seems clear,
the reflexes of eyestrain. Careful observations of the
histories and morbid conditions of many such patients
have convinced me that the severe migraine of eye-
strain is a potent and frequent source of tuberculotic
infection. It is of less concern whether one accepts
as the method of pathogenesis—

1. The chronic denutrition and physical weakness
which supplies a prepared soil for the infection;

2. The psychical depression, hopelessness, or melan-
choly, which reduces the energizing power of a healthy
and active will; or,

3. The direct action of the morbid ocular reflex
upon the pulmonary tissues.

In the case of Symonds all three causes were in syn-
chronous and constant action. He himself recognized
somewhat vaguely, but still definitely, the influence of
a direct reflex when he says, fifteen years after mis-
chief at the apex of the left lung has been diagnosed :
“The subsequent lung disease from which I am now
suffering is no doubt the result of the strain of those
years.” More clearly it came out in the statements :

“ Curiously enough, the lung troubles, which now threatened
my very existence, seemed to relieve the misery of my brain.
Gradually that organ regained tone, although I suffered fre-
quently from attacks which proved that the disorder had not
been lived down. Sustained mental labor was out of the ques-
tion. I worked by fits and snatches.” (31.)
88 BIOGRAPHIC CLINICS.

“T always find that to organize a big book drills the holes
in my lung. The other part of the business bores the body out,
but does not destroy tissue.”

“The friction of setting down to work has stirred my lungs
up, and I am again far from well.”

Pulmonary disease began at 25. Blisters were ap-
plied to the chest at 28; his “chest was so weak” at
31; his first hemorrhage was at 37, when he was “ face
to face with death and weakness’; Quain and Jenner
give a poor report of his health at 4o; Clark and
Williams detect beginning disease of the right lung
at 42; Davos makes a nervous man of him, pulls him
together, and ‘“‘cures the old lung trouble” at 48;
there are always bronchitis and colds; he has “ three
months of illness, continued fever, and general dis-
turbance of the whole system, including brain, lungs,
and stomach.” The symptoms immediately preceding
his death at 53 remind one of those of Lewes and
George Eliot. As a case of tuberculosis the general
practitioner must find the clinical history highly anom-
alous, and the existence of other pathogenic factors
than the simple tuberculotic process is clear. The
chief was undoubtedly eyestrain and its migrainous
reflexes. These were clearly active every day of his
life.

The character of the man and of his fundamental
disease is further illustrated by the interest he took,
the time and money given to the social, urban, and
THE LIFE TRAGEDY OF SYMONDS. 89

economic welfare of his fellow-citizens at Davos, by
the marvellous energy—physical and mental—shown
in his walks, sports, mountain-climbing, tobogganing,
etc., almost up to the day of his death. The account
of a day’s sport a year or more before his death given
by his biographer (p. 459) and of his dancing the
pizzica “as vigorously as any of the vigorous natiyes ”
less than a month before his death are facts that put
a caution in the thought of the wary diagnostician.
His biographer writes of him at the age of 44:

“ Symonds’ great physical energy was certainly one of the
most remarkable and surprising things about him. No one
who shared one of those expeditions with him would ever have
suspected the invalid in that lithe, elastic figure, which breasted
the hills with such apparent ease and left many a sounder man
behind him. It was his intense spiritual vitality, his nervous
energy, his keen enjoyment of lovely sights which supplied the
motive power. These walking expeditions, of which he took
several in the autumn of the year 1884, would have proved no
slight tax on the resources of most men. A few days before
the ascent of this Schwartzhorn, which is 10,300 feet high, he
had enjoyed what he calls ‘three splendid days’ on the hills.”

It seems clear that the disease from which he suf-
fered was a preceding, causing, and always compli-
cating condition which, had it been recognized, as it
should have been, even from his thirty-fifth year on-
ward, would have given him sound lungs and a long
life of usefulness and power.

A parenthetic word may not be amiss as to an
go BIOGRAPHIC CLINICS.

always recurrent phase of the clinical history of eye-
strain sufferers—that is, the influence of the added
strain of presbyopia. This, when unrelieved, brings
the lifework to a crisis of impotence and breakdown,
and end, even of the life itself, as in the cases of
Nietszche, George Eliot, Lewes, and others. With
the entrance upon the presbyopic period new elements
and added intensities of old ones are added. For
instance, see the paragraph on a preceding page. At
the beginning of this period (age 39) he writes:

“T have got up today for the first time since last Friday.
I have had a strange attack, quite unlike anything I experi-
enced before. From 2 p. M. on Friday to 4 p. M. on Tuesday I
suffered from intermittent pain of a really horrible kind. I
thought I must die or become insensible. And yet my mind
was lucid” It was a long hurricane of torture, with short
respites got by triple doses of chloral, lasting an hour and
a-half, I live in dread, for the whole theatre of my former
misery throbs with a dull menace. It is not over, and I am so
weak that I can hardly form these words. I never felt pain on
so august, so colossal’a scale. There was something grand in
it. Most pain has an element of the nasty. This was like
hell. It is worth the misery to have registered the sensation.”

“T have suffered for more than a year from unrest, mortal
fatigue, and from strange morbid irritabilities. The will to
maintain feeble health at its maximum is broken down.” (45.)

The most active of ‘his literary years, age 46, was
followed by great vital depression.

* Compare the noteworthy likeness. as to this lucidity in the
case of Nietszche—a long recognized fact in migraine. .
THE LIFE’ TRAGEDY OF ‘SYMONDS. gi

Tormented by his own suffering and the unfathom-
able mystery of it, he despaired almost of his own
sanity, as so many other migrainous patients have
done, and at the crisis of presbyopic wretchedness he
writes:

“How can a writer escape from being neurotic? He has
such tremendous changes of mental climate and revulsions of
emotion. He is always vehemently growing or being violently
amputated, and he is not a vine to suffer these alternatives in
the due course of natural seasons. If genius is connected with
insanity, this must be due in many cases not merely to a con-
genital diathesis, but also to the abnormal vibrations set up in
the nervous system of an author by the conditions of his labor.
A pendulum has rhythmic action so long as the motive force
lasts, but here the creative rhythm is suddenly suspended just
when the nervous energy is overstimulated to its utmost. I
feel the fact acutely at the present moment, and am tingling,
jumping.”

And at 53 he died, a hero of erudition and literature,
a martyr of medical indifference and ignorance. The
principles had been scientifically stated for thirty years
which, if put into practice, would have given him com-
plete relief. Although many thousands have found
that relief during the last twenty-five years, many
other thousands are to-day needlessly suffering ex-
actly as did Symonds.

At the age of twenty-five Symonds wrote in his
diary:

“And for what work am I fitted? Jowett said, some time
ago, for law or literature. I say, after some months’ trial, not
92 BIOGRAPHIC CLINICS.

for law. And for literature, with these eyes and brain? What
can I do? What learn? How teach? How acquire ma-
terials? How think? How write calmly, equably, judicially,
vigorously, eloquently for years, until a mighty work stands up
to say: ‘This man has lived. Take notice, men; this man had
nerves unstrung, blear eyes, a faltering gait, a stammering
tongue, and yet he added day by day labor to labor and
achieved his end!’ Shall it, can it be?”

At 33 he describes himself as—

“Working very hard in my study at Clifton Hill House and
filling four or five thick books of manuscripts with fervid
declamations. But the strain was severe. I fear the whole
horizon is changed for me as usual. Almost from the date I
saw you in London I have been ill. I had to give up my visit
to Eton, and on arriving here to take to bed. Bronchitis
began the mischief, and the last three days have been one pro-
tracted torment. I sometimes wonder whether there are many
men thwarted as much as I am by a series of protean small
ailments; then I wonder with a sort of vanity how many of
the kind do as much as I do.”

At 51 his working day is thus described:

“T begin work at 9:30, and go on till 12:30; after lunch, at
2:30, I go to bed and sleep two hours; have tea in bed and
talk to my wife; dine at 6:30; begin work again at 8 Pp. m.,
and go on with it till r or 2 A. M.; then to bed and sleep
again.”

The result was one natural to the depressing effect
of severe migraine, but doubled in Symonds’ case by
the piteous crippling of his splendid scholarship and
noble aims in life. Few men are born with wealth,
intellect, the esthetic temperament, and a burning love
THE LIFE TRAGEDY OF SYMONDS. 93

of truth, who desire only to work unselfishly for the
best interests of civilization and their fellow-men.
When one such appears it is a genuine tragedy both
for the man himself and for the world if ill-health
prevents the rare conspiracy of the benevolent fates.
And the pity of it is all the greater if the tragedy was
wholly unnecessary and obviable. For the patient it
is, as Symonds himself wrote, “the final sense of
impotence to be effectual, most poignant, most crush-
ing, most persuasive, and yet unutterable.” The heart-
rending outbreaks of sorrow and disappointment at his
destiny (see pages 214, 230, 238, etc., of the biog-
raphy) are almost too poignant to reproduce. More
than once he thought of suicide, and once, at 28—note
the age—he seriously contemplated it. He had
thought deeply, perhaps too deeply, of his life-problem,
but his nonmedical mind could reach no nearer the
simple, little-great truth than “
soul that ails.” Intellect, one must keep repeating, is
the product of vision—physical, or rather physiologic

it is the center of the

vision.
Even before this, a youth of 25, he approached the
problem in this way:

“What happens to me is that one tide of physical depression
after another sweeps over me, and not one leaves me as I was
before. Each weakens me. I feel my strength of mind, and
power of action and fancy, and sense of beauty, and capacity
of loving and delight in life gradually sucked out of me. At
the present moment I do not know what to do. Life is long
94 BIOGRAPHIC CLINICS.

for unnerved limbs and brains which started with fresh
powers, now withered and regretful only of the past, without
a hope for the future. I do not write this because I am not
happy in my home. Far from that. But happiness, domestic
felicity and friends, good as they are cannot make up for a
vie manqué. Ifa man has in his youth dreamed of being able
to do something, or has rashly promised himself. . if setting
forth thus, he has failed upon the threshold, . . then he re-
sembles those for whom the poet wrote ‘Virtutem videant
intabescantque relicta. But I am not in despair. No one
should give over hope. I am only disappointed at the failure
of anticipation, and sorrowfully convinced that the weakness
of which I have been conscious is inherent and invincible.”

There is no doubt whatever as to the correctness of
his diagnosis. There failed only one little logical
nexus and conclusion:

“T sometimes imagine that if I had force enough to work
over and over again at expression I might produce some satis-
factory results. But I dare not apply such ‘improbus labor.’
My brain will not stand it. I lose my sleep. I am perplexed
with obscure pressure on the top and front of the head. And
this Umarbeitung cannot well be deferred until I have regained
force. It is most effectual when the iron is yet hot and the
enthusiasm of the first conception remains plastic. Thus I
am thrust by my physical debility into the petty style. Yet
even as it is, in this imperfect work, I derive the greatest
pleasure from the contemplation of the great thoughts and
splendid images presented to me, which I do not try to put
into my own language, and for the moment feel assimilated to
them.” (27.)

And despite this glimpse of vague therapeutics:

“What I managed to do was done under great difficulties
and in a desultory, fragmentary manner. Moving from one
THE LIFE TRAGEDY OF SYMONDS. 95

place to another, without access to libraries, and always in
depressed health, I could not undertake any important work
or engage in any regular scheme of study. Intellectually, I
lived from hand to mouth. The weakness of my eyes rendered
systematic reading impossible, and I depended, in a great
measure, upon my wife’s unfailing kindness. She read aloud
to me for hours together.”

“No one who has not suffered in the same way can ade-
quately feel how great is the sapping, corroding power of my
debility—eyes for more than two years useless; brain for more
than two years nearly paralyzed—never acutely tortured, but
failing under the least strain and vibrating to the least excite-
ment. To feel as little as possible, to think and work as
slightly as I could, to avoid strong enjoyments when they rarely
offered themselves, has been my aim. I have done nothing in
this period by a steady effort. Everything has come by fits
and starts of energy, febrile at the moment, and prostrating me
for days when they are over. Sometimes for weeks together I
have not seen a ray of sunlight. At Florence, at Rome, in
London, at Clifton I have risen with horror of these nights,
have walked through the day beneath the burden of dull-aching
nerves, and have gone to bed in hopelessness, dry with despair,
and longing for death. Suddenly, in the midst of this despair,
a ray of my old capacity for happiness has burst upon me.
For a few hours my heart has beat, my senses have received
impressions, my brain has coined from them vigorous ideas.
But vengeance follows after this rejoicing. Crack go nerves
and brain, and thought and sense and fancy die. The leaden
atmosphere of despair closes around me, and 1 see no hope.
Many are the men, no doubt, who have suffered as I have
suffered. Last summer I spent six days in London, in Half-
Moon Street. I had just been subjected to treatment which
gave me great pain and made me very weak. If it succeeded,
it was to do wonders. In the midst of my weakness I hoped.
I sat upon one chair, with my legs upon another. I could not
read. I could not bear the light upon my eyes, I was too
96 BIOGRAPHIC CLINICS.

desolate and broken to see friends. I scarcely slept, and heard
all night London roar, with the canopy of flame in the hot sky
above those reeking thoroughfares. At three or four day
broke. In the evening I sat idle, and it was dark. All the
while I hoped. This cure shall do wonders. God, give me
strength.... Cast me not utterly away as a weed. Have
I not longed and yearned and striven in my soul to see Thee,
and to have power over what is beautiful? Why do I say
‘Lord, Lord, and do not? Here is my essential weakness.
I wish and cannot will. I feel intensely, I perceive quickly,
sympathize with all I see or hear or read. To emulate things
nobler than myself is my desire. But I cannot get beyond—
create, originate, win heaven by prayers and faith, have trust
in God, and concentrate myself upon an end of action. Skepti-
cism is my spirit. In my sorest needs I have had no actual
faith, and have said to destruction, ‘Thou are my sister.’ To
the skirts of human love 1 have clung, and I cling blindly.
But all else is chaos—a mountain chasm filled with tumbling
mists; and whether there be Alps, with flowers and streams
below and snows above, with stars or sunlight in the sky, I
do not see. The mists sway hither and thither, showing me
now a crag and now a pine—nothing else. Others see, and
rest, and do. But I am broken, bootless, out of tune.”
TAINE’S ILL HEALTH.
CHAPTER III.

TAINE’S ILL-HEALTH?

His teacher, Vacherot, said of Taine at the age of
22, that he was the hatdest worker and the most re-
markable student he had ever known at the Ecole
Normale ; that he was prodigiously learned for his age;
that he had an ardor and an avidity for knowledge
such as his teacher had never before known. Those
who have read Taine’s works must have been struck
by his marvelous power of absorbing and digesting
knowledge, and his ability—he was philosopher, his-
torian and critic, all in one—to present the systema-
tized results of his erudition with a thoroughness, sym-
pathy, succinctness and brilliancy rarely, if ever,
equaled. Few, however, are aware of the difficulties
this great litterateur encountered in carrying out his
scholarly ideals, his poverty, the opposition of the
church and of those envious of his remarkable talents
and industry, and particularly the ill-health, which
like a vindictive fate pursued him so relentlessly.
Even those who may have learned something of these
things have probably not an adequate conception of

Reprinted from American Medicine, Vol. VIII., No. 19,
pages 805-808, November 5, 1904.

99
100 BIOGRAPHIC CLINICS.

the exact nature and origin of the man’s sufferings
and of how they prevented the realization of his aims
in literature, which, without the crippled executive
ability, would have resulted in wonders.

Taine was born in 1828, and at the age of 11 “he
had devoured everything in the way of books that
came into his hands, especially the classic authors of
the seventeenth and eighteenth centuries.” This pre-
cocious ripening of his mind and enormous amount of
reading seems not to have produced serious evil results
to his health during adolescence. He was “ somewhat
fragile” at 12, and needed to pick up health and
strength at 20. At 21 his troubles began. The fol-
lowing excerpts from his letters and from his biog-
rapher’s notes are sufficiently self-explanatory and
illuminative of the nature of his disorder, so that thev
may be given without the interruptions of annotations:

“It often happens to me to fall into a state of languid de-
pression, during which I spend hours on my bed or in an
arm-chair, in that sort of mental prostration so dreary and
oppressive, which you know.” (21.)

“T have a bad headache at this moment, and am incapable
of serious thought—I am even going to take a few days’
rest.” (21.)

“Cholera, or a sort of mild imitation of it, seized hold of
me, and laid me low those few days.” (21.)

“When my head aches with work (study).” (23.)

“Tf my head aches.” (23.)

“Hegel makes my head ache.” (23.)

“Studies so fatiguing that I feel I never really appreciated
rest before.” (23.)
TAINE’S ILL-HEALTH. IoL

“T am in the dumps. It happens to me when my head
aches, and I have no resource but to laugh at myself and
others.” (23.)

“Sometimes I have headaches, moments of weakness, when
my solitude palls upon me.” (23.)

“ Struggling in the most marshy depths of the bog of mel-
ancholy.” (24.) : =

“This last resource—writing—is failing. I am not well,
and in such depressed spirits that I find it impossible to string
two ideas together. My last refuge against myself has failed.”
(24.) :

“There are days when I am so sick of myself that I should
like to throw myself away.” (24.)

“My aching brain prevents me from finding a relief in
work.” (24.)

“The country is an opiate for troubled brains.” (24.)

“When my head aches.” (25.)

“This horrible scribbling- dazzles me, and my head seems
full of pages, letters, lines, corrections, etc.” (25.)

“Bored when my head aches.” (25.)

The immoderate labor of those years began to exhaust his
powers. In October he was seized with a granular laryngitis,
from which he suffered for several years. (Biography, 25.)

The bad state of his health lasted during the winter. His
physician advised spending his vacation at St. Sauveur.
(Biography, 26.) /

He was obliged to limit his work hours and _ lectures.
(Biography, 27.) wi

“For a month I have not spoken six sentences aloud.”
(25.)

“The cure of the throat is slow.” (26.)

“Impossible to study with the least appreciation; imme-
diate head symptoms. My winter is being lost. May the
beautiful, lovely spring be medicine for me.” (26.)

“T am doing everything to be cured, without much success.”

(26.)
102 BIOGRAPHIC CLINICS.

“My throat does not better. I shall probably be compelled
to go to some watering place and pass the winter in the
South.” (26.)

“The worst is that my head is so bad that I am unable to
apply myself for an hour, beside having an increase of fever-
ishness.”’—

“Tf I had not this fever and a head so ailing.” (26.)

“My throat is better, the homeopath prescribing phos-
phorus, which perhaps will cure me.” (26.)

“T am an old man, used up, tired of everything, hopeless.”
(26.)

“ Sick to-day.” (26.)

“When I do not have headache I write.” (26.)

“To what watering place I do not know, the physician will
decide.” (26.)

“T have left the homeopath, who was tiresome. The good
I thought he was doing to me was really the summer season
and the company of my mother. Many physicians are sceptics
in medicine. Some believe only in quinin and surgery.” (26.)

“Worse for several days. I leave in July.” (26.)

“The necessity of doing nothing, six weeks of it under a
burning sun, without distraction, except to drink rotten-egg
water, etc.” (26.)

“A poor machine out of repair.” (26.)

“The waters of Eaux-Bonnes are as valueless as those of
Saint-Sauveur.” (26.)

“Not cured, not curable.” (26.)

“Since I have been ill I think everybody is ill, or should
be.” (26.)

“Tf I may believe the medical men, a race little to be
trusted, I shall be better in a month, the waters acting only
at a distance.” (26.)

“When I do not have headache.” (26.)

re more frequently it creates headache; I stick in my
room, badly cured, working seldom.” (26.)

“T continue extracting descriptions from my sick head.”

(26.)
TAINE’S ILL-HEALTH. 103

“Tam no better. Take care of your health; if it goes you
can’t tell when it will come back again.” (26.)

“Three months in the Pyrenees in complete idleness, trying
to cure my sick head and.throat.” (29.)

“Try never to be sick.” (26.)

He returned from his trip to the Springs suffering severely.
Lecturing tired his voice. (Biography, 27.)

“T was sick and could not visit you. Neuralgias, conges-
tions, huge nails in the nerves of my neck—for a month
utterly crippled.” (27.) ©

“JT am studying the influence of the body upon the mind,
and I ask myself what is the use of sensory nerves scattered
so abundantly in our physical machine, unless to make us
suffer uselessly, for the glory of God.” (27.)

“The Eaux-Bonnes waters left me statu quo. I failed in
faith, in that as in other things, and am punished.” (27.)

“T have swallowed a cargo of books.” (27.)

“What woes of the eyes and of the head? How many hours
of mechanical reading? I am only a machine disgusted with
itself.” (27.)

If Eaux-Bonnes cured his laryngitis (sic) he had to pay
dearly the ransom for his excess of work. . . . He was
halted by a crisis of cerebral fatigue and nervous depression
lasting for two years. He had to suspend entirely his work in
philosophy, and was able to resume it only ten years later.
He had also to renounce literary work in part; he wrote less
and less frequently, condemned to long months of complete
inaction during which he was unable to read much. (Biog-
raphy, 27.)

For long hours, lying in his room, the eyes closed to avoid
the light of day, which wounded his suffering head, he was
read to by a little secretary helper. (Biography, 27.)

At times, in order to get sleep which had disappeared, he
undertook fatiguing exercise, splitting wood, etc. (Biography,
27.)

After a year of this rusting he was able for a few months
104 BIOGRAPHIC CLINICS.

to work (study) for two or three hours a day. (Biography,
27.)

Finding himself again suffering, he undertook voyages for
the sake of diversion and to revive his intellect. But the
threatening crisis was not conjured away by these journeys.
He became more ill than before, and 1859 was the year the
most saddening and sterile of his life. He believed seriously
that his intellectual powers were entirely broken. He tried to
take up his work, but the pen or the book soon slipped from
his hands, and he fell back into his old cruel inactivity. Only
at the end of the year with infinite devices did he begin to
write. He has had since then frequent periods of forced
leisure, but never one so persistent and intense. (Biographer,
31.)

“Sick for four months, unable to write and even to read,
having a cap of lead on my head and frequent neuralgias.
Nothing did any good, neither hydrotherapy, iron pills, or
dieting. My physicians tell me to have patience and to keep
still. I have renounced all work.” (28.)

“Pardon me that I write so little; I am no longer a man,
only an inferior sort of mollusc, and I feel my head no more
except to suffer with it.” (28.)

““A sick man who plants cabbages and walks five miles a
day.” (28.)

“Against orders I have lately made use of my poor head.”
(28.)

“Far from cured. I work two or three hours a day, in the
morning, with the greatest precautions; the rest of the time I
rub myself with cold water, sleep, digest, ete.—I go to bed at
9. This is why I do not write.” (30.)

“One has to adapt one’s self to his readers, if he would
have his book sell at the newsstands.” (30.)

“T accustom myself to live even though suffering. I am
becoming patient. I bend my back. I am 30. I am going
into the country to better my health.” (30.)

“My voyage is delightful. Flanders has beautiful land-
scapes, and it encourages ideas.” (30.)
TAINE’S ILL-HEALTH. 105

“Especially I, who have bad eyes, and have abused them.”
(30.)

“T am suffering very much, always from my head. I read
or write scarcely two hours in the morning, and the rest of
the day I am idle and kill time sadly.” (30.)

“Not cured, although it was the chief object. I am forced
to pass my life in walking the streets—what can one learn
when he has to go to bed at 9 o’clock?” = (30.)

“T am entirely down, commanded neither to write nor read.”
(31.)

“A little better, not much. I read one hour a day.” (31.)

“T wander sadly through the woods. I am a steam engine
without fire, rusting, and rotting.” (31.)

He did not dare to undertake his great work in his state of
weariness. (Biography, 32.)

He had entirely given up private teaching, but he knew how
study, pushed to an extreme, exhausted his forces. (Biog-
raphy, 32.)

Appointed examiner. It had the advantage of demanding
only three months work a year, and compelled him to stop his
studies during the summer, which had been an affliction to
him. (Biography, 32.)

“T have headache. It is my vicious habit.” (33.)

“My excuse for not writing for three months is my head-
ache; it is only half well now; I have done nothing for several
weeks and even now I work at the most only three hours a
day, so that I am cross when it comes to writing even to my
excellent friend.” (33.)

“Head as usual. I have reading done aloud to me; go to
bed at 9, walk the quays.” (33.)

“Keep your health, it is the substratum of the essence of
substance.” (33.)

“ The literary life here, the necessity of earning one’s bread
by black lines drawn out of the head is too hard.” (34.)

“Shall I be able to work? For a month I have not written
a line; I had too great headache. I should have had to erase
it all. I do not know when I can recommence my book, and
106 BIOGRAPHIC CLINICS.

the undesired inaction and empty revery ends in eating away
my life.” (34.)

“T tried to occupy my forced leisure. I made notes in Lon-
don, went up the Thames, to the Derby, to balls, to the slums,
to the docks, to country houses. I copied, at the British
Museum, an English Medieval author, etc.” (34.)

“On my return to England I had to blot out a month, and
that made two which were lost.” (34.)

“T have exhausted my brain; I am obliged to stop and
remain idle several times a year, sometimes for three or four
months; I have #emained for two whole years incapable of
writing, and even of reading. Writing requires a tremendous
effort on my part, and after two or three hours, sometimes one
hour only, I am obliged to leave off, having become quite
unable to string two ideas together. My manner of writing
must be contrary to nature, since it is so laborious. Several
people, friends, have told me that it is strained, wearisome,
and difficult to read.” (34.)

“T have much more difficulty in writing, to order facts or.
ideas, than formerly. A school-boy’s task is an enormous
weight which I lift only with effort.” (34.)

“ . constant efforts and very little result. If I succeed
in reaching the necessary state of mind, it only lasts an hour
or half an hour, and it kills me. It is probable that I have
tried to unite two irreconcilable faculties; one must choose
and be either an artist or an orator.”

“T think I have found the root of my complaint, for my
fundamental idea has been that the particular passion or
emotion of the man who is described should be reproduced,
and all the degrees of logical generation stated. In fact, that
a character should be painted after the manner of artists and
constructed at the same time after the manner of reasoners.
It is a true idea productive of powerful results when it can
be applied, but it is unhinging to the brain and we have no
right to destroy ourselves.” (34.)

“Tf all this is correct, I must change my style, which is a
TAINE’S ILL-HEALTH. 107

serious undertaking. A rest, and an extensive one, is first
necessary, then a search among my remaining faculties, such
as I may put to use. I shall finish my ‘History of English
Literature’ in accordance with the former method. . But
after this work is finished I must change. But what is left of
me? What ability?” (34.)

During his long periods of forced idleness and suffering he
had dreamed, etc. (Biography, 34.)

He set out for Naples and a softer climate. (Biography, 36.)

“There is so much emptiness, physical lassitude, and spleen,
etc.” (36.)

“J shall return next month and study—study is the proper
word; I have already bought some books, but I have too bad
eyes, and also a hurrying imagination, which spoils every-
thing in advance. I admit that I have found things in the
engravings more beautiful than the reality itself.” (36.)

“Tt was well to go. I had to shake myself up, I was be-
coming sick.” (34.)

“My pleasure was not great as I was too used up. Yester-
day curled up in bed or in my chair, and all this morning.”
(34.)

“Tt was even an effort to write a letter. My eyes are pain-
ful, attention is immediately exhausted, anxiety supervenes,
and with that, spleen.” (34.)

“T am 36 years old. My life which is in the past is the
healthy and strong part. The second part now commencing
will soon be a descent; but through work I may make some-
thing of it.” (36.)

“Sightseeing for four or five hours (at Padua) produces
not only pain in the neck, back, etc., but attention is also
exhausted; I am incapable of a single idea, and I have to close
my eyes while I sit.” (36.)

“Your poor Marcelain (himself) is exhausted; 'he works
to excess, has a suffering head, is too sleepless. I am much
troubled that he is using up his forces. His mother (he is
writing to her) is much tormented. His affairs otherwise go
108 BIOGRAPHIC CLINICS.

well—subscribers, announcements, esteem, success, are here.
Let us hope that, like Woepke, he will not fall on arriving.
The day is filled with public duties, and it is only toward mid-
night, on the return home, that he becomes an artist. He can
then not resist the need of noting down his ideas and sys-
tematizing them. And the waking causes so much suffering!”

(36.)

If the intelligent reader has looked over the fore-
going excerpts attentively, the cause of this life tragedy
and the harm done to literature will be plain. Espe-
cially if the similar histories gathered in the two
volumes “ Biographic Clinics” are known. The case-
histories of all patients with the same morbidity-pro-
ducing cause at work seem to a careless eye to differ
from each other in marked degrees. To the physi-
cian’s discrimination, however, the differences are
either in the external circumstances of the patient, or
in his peculiar or individual differences of inheritance,
resisting powers, tasks, etc. In the case of the reflexes
of eyestrain the clinical histories are likely to vary
astonishingly according to the organs that bear the
brunt of the derouted nerve discharges. This is a
fact now familiar to modern oculists. But even in the
most aberrant types there are certain facts and phases
common to all: The suffering, of whatever kind, is
directly consequent upon the use of the eyes; it in-
creases in intensity with the lessening of the accom-
modative power; the sole method of stopping the suf-
fering is by nonuse of the eyes; the depressing effect
TAINE’S ILL-HEALTH. Iog

upon the mind and feelings is always present; the dis-
ease being functional, and not organic, the essential
health and vitality are not at first, nor for a long time,
and usually never, irremediably affected. After the
crisis the mental and physical energies suddenly re-
turn with astonishing promptness and energy.t

In the fifteen biographic clinical cases I have studied,
these and a number of other characteristics, such as
insomnia, depression, limited power of working, etc.,
usually present, have been found, and the notes from
Taine show them also present in his life.,

When an otherwise healthy young person has head-
ache upon near use of the eyes the capable physician
nowadays knows what is the cause of it. When melan-
choly, physical and mental weariness, inability to use
the eyes, insomnia, etc., become marked, when an ex-
cessive amount of reading and writing makes old
symptoms more intense and produces others, there is
no doubt as to what a scientific correction of the exist-
ing ametropia will do. No patient of the sixteen
studied saw this simple relation of effect and cause,
nor did any of their physicians. Each and all traced
it to the peculiar character of the intellectual work
done, or to the excessive amount of it. The popular
brain fag” shows the

“ce

newspaper nonsense about

*His letters often speak of being in “good health” during
the very weeks when he was temporarily suffering from
migraine—a well-known clinica] fact,
110 BIOGRAPHIC CLINICS.

old error much alive among us now, although the
simplest observation would make it manifest that
where there is one who has “ brain exhaustion ” from
overwork, there are a hundred who have no such
symptoms from an equal or a greater amount of
intellectual labor. This brilliant genius was a cynic
in philosophy, but in real life pitiful and charitable, a
determinist in scientific ethics, but at the end he con-
fessed, as applied to the French Revolution, that such
a creed could not explain. How much his unneces-
sary suffering molded his character would be impos-
sible to decide, but it is certain that it hardened it to
an appreciable degree.

Taine was forced to go through the hydropathy
and water cures, the dieting, etc., just as all the other
migraine sufferers of the last century did—those who
were financially able to do so. The vast majority had
not the money for such vagaries. Taine was one; he
was so poor that he had to undertake guidebook com-
pilation and all sorts of pedagogic and literary potboil-
ing tasks in order to carry out the cult of these super-
stitions. Travel, open-air walking, “change of scene,”
etc., gave the others some relief, at least temporarily,
except those who, like Taine, were doomed by an
insatiable hunger and a driving necessity to carry
books with them or find great numbers of them wher-
ever they went. When the eyes were really rested
there was the inevitable relief,
TAINE’S ILL-HEALTH. III

Taine’s “ granular laryngitis,” “ cured by the waters
at a distance,” shows the possible reflex of eyestrain
to the upper air passages, a fact noted by observant
oculists. When it was cured his head symptoms grew
worse.

The dip into homeopathy is not so amusing as that
of the Carlyles, but shows the clear-headedness of
Taine, who had a not inconsiderable medical education.

My notes stop at the age of 36 with the two columns
of the Life and Correspondence that have been issued.
He lived for twenty-eight years after this till 1893,
and died at 64. It is comparatively useless to continue
the study for the rest of the life, even if the remaining
volumes had been published. Either the patient got
some glasses several years before he died, which in
some measure lessened his evident eyestrain, or his
sufferings continued, probably increased, until the end
of the presbyopic period, or until his myopia lessened
the usual reflexes of this time of life. That he was
myopic even in middle manhood is plain from some of
the sentences quoted. It is the old story repeated—
the production or increase of myopia by uncorrected
ametropia. That he was also astigmatic and aniso-
metropic is beyond question from the fact of his most
severe reflexes caused by the use of his eyes, both to
the eyes themselves and to the brain. Only Professor
Mobius of Germany still believes that there is no eye-
strain, nor any migraine due to it, in myopia—by
112 BIOGRAPHIC CLINICS.

 

 

 

 

 

PHoroGRarPH OF TAINE SHOWING STRABISMUS AND PTosis,
TAINE’S ILL-HEALTH. 113

which term he means what.is unknown to him, com-
pound myopic astigmatism. All of these inferences
would be sufficiently clear without the demonstration
given by a late photograph of M. Taine, which I re-
produce. This picture shows that toward the end of
life there was paretic, almost paralytic, ptosis or droop-
ing of the lids, a somewhat frequent result of long-
continued eyestrain. In the right it is greater than in
the left, showing the longer and more severe, but at
last ineffectual, effort to keep the right eye in function.
The entire expression of the eyes and neighboring
structures speaks plainly of the struggle. “ His eyes
showed a cast behind their spectacles,” says one who
knew him in later life. The date at which the right
eye gave up the attempt at binocular vision is not
suggested in the life and letters. In the picture it is
plainly strabismic, or turned in. Its exclusion from
use marked the end of long and painful period of
effort, which, while it lasted, produced great suffering,
and when completed would probably bring a decided,
possibly an entire, measure of relief. How easy it is
at present to prevent in modern patients the entire
list of evils which is evident in the case of Taine! And
yet there are still many thousands in the civilized world
enduring them as he did only thirty or forty years ago.
EYESTRAIN AS A CAUSE OF
HEADACHE AND OTHER
NEUROSES.
CHAPTER IV.

EYESTRAIN AS A CAUSE OF HEADACHE AND
OTHER NEUROSES.*

By Simron Swett, F.R.C.S.ED.,

Ophthalmic Surgeon to the Royal Infirmary, Sheffield,
England; Professor of Ophthalmology,
University College, Sheffield.

OF all painful affections probably headache causes
the most distress and misery. The individual who
never experiences headache is much to be envied, and
many persons fortunately enjoy more or less complete
immunity from the affection in its more severe forms.
On the other hand, there are many who are afflicted
with headache which causes constant or recurring
suffering, and which frequently so disables its victims
that life becomes a burden. In many cases the occu-
pation of the sufferer is seriously interfered with. A
consideration of some of the causes of this suffering

*In his preface, Mr. Snell says: “The address here printed
in book form was delivered in the first instance before the
York Medical Society and was published in the Lancet. It is
now reprinted with a few alterations, and the addition of
illustrations.” By Mr. Snell’s kind permission it is included
in the present volume.

117
118 BIOGRAPHIC CLINICS.

and the measures which may be adopted for its relief
is well worthy of our attention.

Historical.—It has, of course, for some time been
known that certain instances of headache bear some
relation to eye defects. But the far-reaching effects
of eyestrain and the relief afforded by the proper cor-
rection of refraction errors are not by any means as
widely recognized as they demand. It is a matter
that, in my opinion, admits of no question. The evi-
dence is continually before one. Again and again is
the same story told, first of the suffering and then of
the relief afforded by optical aid. In my last eight hun-
dred refraction cases in private practice I find that one
hundred and sixty-two suffered from headaches. I do
not include in this number those making the usual com-
plaint of discomfort for which hypermetropes and
early presbyopes so frequently solicit assistance. In
the cases to which I refer the patients have at once
volunteered that they suffered from severe headaches,
or have stated on inquiry that they do so. In the
great majority this constituted the cause for seeking
advice. In most, also, in varying degrees, were asso-
ciated some or all of the train of symptoms to be
described later.

Perhaps no more important work has been accom-
plished in the whole range of medicine and surgery
than that of placing anomalies of refraction on a firm
scientific basis. This we owe in the greatest measure
EYESTRAIN CAUSE OF HEADACHE. 119

to Donders, and it brought to him undying fame. It
is well-known, too, that astigmatism, which has such
a close bearing on our subject, was discovered by
Thomas Young, the physician as well as the physicist.
Sir George Airy, the astronomer royal, described astig-
matism in his own case. It was of the compound
myopic variety and was monocular. Here it is of
interest to note that Airy was the subject of migraine,
and he described his own case in a paper in the Philo-
sophical Magazine for 1865.1 It may be remarked
in passing that a proper correction of his refraction
error, with the knowledge which we now possess,
would in all probability have relieved him of his mi-
graine, for he had both astigmatism and asymmetry
in the refraction of the eyes, two very potent causes of
headache, as will be shown farther on. Ajiry’s son,
Dr. Hubert Airy, also published a very graphic de-
scription of migraine and the ocular symptoms in his
own person,? and it appears not unlikely from the
account which he gives that he, too, would have been
relieved, as has so often been the case in my experience
in similar instances, if attention had been given to his
eyes. He speaks of his attacks coming on after close
eye-work, and says, “Usually after two or three
hours’ close reading, especially if I had insufficient

1 Philosophical Magazine, July, 1865, Vol. XXX., p. 19.
2 Transactions of the Royal Society, 1870.
120 BIOGRAPHIC CLINICS.

exercise, I become aware that part of the letter I am
looking at, or a word at some little distance from the
sight point, is eclipsed by a dim cloud spot,”

“ Want of exercise, sedentary employment, close read-
ing and writing, are the usual antecedents. It gener-
ally comes on while the eyes are engaged with toilsome
reading.”

The interest that Young and Airy had in astig-
matism was physiological and not pathological. And
even Donders lays stress always on the normal and
abnormal astigmatism, the latter being astigmatism
which interfered with the acuteness of vision. Our
interest here, however, is in the pathological signifi-
cance of astigmatism and the subtle and powerful in-
fluences of eyestrain, and not necessarily on its inter-
ference with visual acuteness. Frequently no com-
plaint of vision is made and the error of refraction
is only discovered after a careful and complete exami-
nation of the eyes.

As far as I am aware the first to recognize clearly
the close connection existing between headaches and
other neuroses with eyestrain was the distinguished
physician and writer, Weir-Mitchell, of Philadelphia.
In a series of articles he urged the importance of a
proper understanding of this relation. The views
which he set forth are so well expressed and have such
a practical bearing that they may still be read with
EYESTRAIN CAUSE OF HEADACHE. 121°

profit* by those interested in the subject. He recog-
nized that the distant symptoms may be the indica-
tion of eyestrain when no complaint is made of any
defect of sight, and this is a point of the greatest prac-
tical moment. He cites several cases from his expe-
rience and says of them “that the cases just told
seem to me enough to prove that the eyes may long
rest unsuspected as the cause.” I make here the fol-
lowing quotations:

“My conclusions have plainly enough taught me
that hardly any men in the general profession are fully
alive to the need of interrogating the eye for answers
to some of the hard questions which are put to us by
certain head symptoms, since many of the patients
treated successfully by the correction of optical defects
never so much as suspected that their eyes were im-
perfect. What I desire, therefore, to make clear to
the profession at large is: (1) That there are many
headaches which are due indirectly to disorders of
the refractive or accommodative apparatus of the eye ;

*The references and titles of the articles are: (a) Medical
and Surgical Reporter, July 25 and August 1, 1874: “ Head-
aches from Heat-Strokes, from Fevers, after Meningitis, from
Over-use of the Brain, from Eyestrain.” (b) Ibid., February
6, 1875: “Notes on Headaches.” (c) American Journal of
the Medical Sctences, April, 1876, pp. 363-73: “ Headaches
from Eyestrain.” For these references I am indebted to Dr.
George M. Gould’s able and instructive volume entitled
“ Biographic Clinics.” He there gives copious extracts from
Weir-Mitchell’s articles,
122 BIOGRAPHIC CLINICS.

(2) that in these instances the brain symptom is often
the most prominent and sometimes the sole promi-
nent symptom of the eye troubles, so that, while there
may be no pain or sense of fatigue in the eye, the
strain with which it is used may be interpreted solely
by occipital: or frontal headache; (3) that the long
continuance of eye troubles may be the unsuspected
source of insomnia, vertigo, nausea and general failure
of health; (4) that in many cases the eye trouble
becomes suddenly mischievous owing to some failure
of the general health or to increased sensitiveness of
brain from moral or mental causes.”

Lauder Brunton some years ago? also very forcibly
pointed out that the cause in many cases of headache
must be sought in some irritation of the sensory
nerves. It was to be found in the teeth, eye, throat
and nose. He makes references to the teeth as start-
ing irritation of sensory nerves and does so with excel-
lent illustrations. He then says:

“Perhaps a more frequent source of headache than
even decayed teeth are abnormal conditions of the
eyes. The headache which comes on after working
with the microscope or after straining the eyes in a
picture gallery is only too well known. It is usually
frontal, often extending over the whole breadth of
the forehead, but_sometimes limited to the forehead

* St. Bartholomew's Hospital Reports, Vol. XIX., 1883, p.
336, etc.
EYESTRAIN CAUSE OF HEADACHE. 123

above one orbit. It would be going too far to say
that frontal headache is always due to an abnormal
condition of the eyes, but I believe it is so much more
frequently than one would at all suspect. .. . But
frontal headache is not the only one which may arise
from abnormal conditions of the eyes, for megrim,
or sick headache, is very frequently associated with,
and probably dependent on, inequality of the eyes,
either in the way of astigmatism, myopia or hyper-
metropia.”

Since this time others in this country have written
on the subject, notably the late Mr. H. B. Hewetson,
of Leeds. But in America it has received much more
careful notice than in this country. Recently Dr.
George M. Gould, of Philadelphia, in able articles in
The Lancet? and the British Medical Journal,? has
called attention to the effects resulting from eyestrain
and the treatment which they demand.

Migraine.—Before going on to the consideration of
the class of cases with which this paper is chiefly con-
cerned, a few words may be said about migraine, for
many instances of this disorder in which the classical
symptoms are present will be relieved by giving atten-
tion to ocular errors. Two medical friends who have

1The Lancet, August 1, 1903, p. 306: “The Ill-health of
Richard Wagner.”

2 British Medical Journal, Vol. II., 1903, pp. 663 and 757:
“The Role of Eyestrain in Civilization.”
124 BIOGRAPHIC CLINICS.

been closely associated with me have experienced an
almost entire absence of the disorder since their as-
tigmatism was corrected. One of these had several
attacks of typical migraine. The last attack, which
brought him to me for examination, he thus describes:

“T went to the ward to do a sugar determination.
I then found I could see only the right half of the
meniscus at the top of the fluid. In ten minutes (1
noted the time) a black star appeared in the center
of the field. It lasted about thirty seconds and then
enlarged; the vision in the center of the field cleared,
and towards the left side of the field there appeared
the fortification spectrum. It lasted like this for
twenty minutes, flickering all the time and moving
away from the center. For an hour after this there
was some headache on the right side. This was inten-
sified by lowering the head to use the stethoscope,
coughing and contracting the scalp muscles. There
was no tenderness of scalp. For several hours after-
wards there was dull pain in the right occipital region
on coughing or lowering the head.”

In May, 1902, he came to me and I found myopic
astigmatism (—1 D. with —o0.25 D. cyl.) in the left,
and myopia (—1.5 D.) in the right eye. He wore
the correcting glasses constantly and had no further
attack of migraine until a year later. Then an attack
followed his leaving off the glasses for reading in the
EYESTRAIN CAUSE OF HEADACHE. 125

evening. He again took to the use of the glasses con-
stantly and no further attack has occurred.

The other case was the following. A youth, aged
14, began to have typical attacks of migraine which
were always precipitated by reading. At the age of
22 he was ordered convex spherical lenses which gave
practically no relief. At the age of 25 I carefully
estimated his refraction under a mydriatic. In the
right with + 1.5 D. sph. and + 0.5 D. cyl. vert. V.
==: in the left with + 1.25 D. sph. and + 0.5 D.
cyl. vert. V.= 8. Cylindrical in combination with
spherical lenses were prescribed and gave the greatest
relief. He still continues to have migraine, but the
attacks are transient and at much longer intervals.
He can now read and write for hours at a time without
fear of precipitating an attack. The correction of the
astigmatism has been most marked in relieving the
nausea and dyspepsia.

Headache—its Situation, Characteristics, etc-—The
headaches, however, which we have now to consider
belong to a different category. It will be well, there-
fore, to specify in some detail the situation and char-
acter of the headache met with, together with other
associated symptoms. The pain may be frontal, across
the forehead, or just above the eyes, limited to the
supraorbital region or reaching to the hair. This
frontal situation is perhaps the most common. It
may also be in the temples. It may be between the
126 BIOGRAPHIC CLINICS.

eyes and at the root of the nose (fronto-nasal). The
pain is frequently paroxysmal and called neuralgic,
or it may be a more dull continuous pain. Usually
it is bilateral, but it may affect chiefly one side, one
eye, one temple, or one side of the forehead. When
this is the case it is often described as neuralgia, espe-
cially when affecting the eye. Unilateral headache
is often associated with astigmatism on that particular
side, whilst the other eye may be normal in refraction
or have ametropia of less consequence. Pain may be
at the vertex, and this is a frequent seat. It may bea
dull continuous pain or it may be of a dragging char-
acter. One lady described it as if an “iron claw was
gripping her head.’ The occiput is another situa-
tion where pain is localized. It may extend down the
nape of the neck to the spine. A lady referred to the
pain as if a large crab had seized her by the nape of
the neck, whilst another said the feeling was as if thou-
sands of strings were in the back of the neck and as
if someone was pulling them. In some the pain is
confined to the neighborhood of the eyes, forehead or
temple, whilst in others it may be associated also with
vertical or occipital pain. It may, moreover, be con-
tinuous, lasting for long periods, or it may be inter-
mittent. Some speak of never passing a day without
suffering, whilst others may have a headache daily or
be free for portions of the day; others suffer once or
twice a week, and others again only at longer inter-
EYESTRAIN CAUSE OF HEADACHE. 127

vals. The pain is sometimes relieved by pressure over
the most painful part.

Giddiness, Sleeplessness—Giddiness is a frequent
complaint in these cases, causing often such a ten-
dency to fall that it necessitates keeping very quiet
and is a reason for seeking advice. Associated with
headache not infrequently is a feeling of misery or
apathy, a dulling of interest in things. One gentle-
man mentioned his “ inability to think,” but cylinders
of + 0.25 D. aided him greatly in this respect. Irri-
tability of temper, too, is mentioned. Insomnia is a
frequent complaint and it is interesting to notice how
speedily natural sleep returns after relief has been
afforded by correcting glasses. Sleep is spoken of
as not restful, as being often disturbed by dreams and
nightmare. The general effect on the nervous system
is such that a “ nervous breakdown” is spoken of. A
lady wrote to me respecting her cook who, she feared,
was getting her brain affected, and yet this, together
with constant headache, yielded to attention to the
eyes.

Blinking and winking are, it is well-known, not in-
frequently met with, especially in children with eye-
strain, and these symptoms disappear when the ocular
defects are corrected. Less frequent are choreiform-
like movements affecting not only the eyelids but the
muscles of the face and even the occipito-frontalis.
A young patient suffering in: this manner, recently
128 BIOGRAPHIC CLINICS.

under my care, yielded at once when his hypermetropia
and astigmatism (R. + 2 D., L.+ 1.5 D. with +1 D.
cyl. vert.) were corrected, whereas several months of
medical treatment had failed to benefit.

Gastric Symptoms.—Vomiting and nausea are com-
mon symptoms. The former may be severe and last-
ing and attended with much retching. It may render
a patient prostrate and necessitate confinement to
bed. More frequently nausea is complained of, a
sickly feeling after using the eyes. Indigestion is
often mentioned or ascertained on inquiry. These pa-
tients frequently present an anxious, worn look, and
the difference, when relief has been afforded to the
distressing symptoms, is evidenced often very clearly
in the facial expression. The symptoms differ often
considerably in each patient.

It has been mentioned that nausea and vomiting
are met with not infrequently in these cases. This is
of considerable interest, for it is well-known that they
are prominent and well-recognized symptoms of some
eye diseases. An attack of acute glaucoma is ushered
in with severe pain in the eye and the head and at-
tended with violent vomiting. The bilious attack is
such a prominent symptom that it masks the eye con-
dition. It therefore receives attention; the eye is un-
heeded and treatment of the glaucoma is frequently
deferred until sight is lost. If the reverse plan had
been adopted and an iridectomy performed or even
EYESTRAIN CAUSE OF HEADACHE. 129

eserine instilled a clearing up of the general symptoms
would have followed and the eye would have recov-
ered its sight. Vomiting and the so-called “ bilious
attack ” would have ceased on the relief to the in-
creased tension of the globe which the measures men-
tioned would have brought about. Another example
may be given. Increased tension of the eyeball is indi-
cated in injuries to the crystalline lens or when a
needling operation for cataract has been performed,
not merely by pain in the eye but often by vomiting.
Here, again, removal of the swollen lens is followed
by immediate relief to the stomach symptoms. The
disturbance of the pneumogastric nerve by these con-
ditions is well recognized. It is not difficult to under-
stand that the attempts of the ciliary muscle to over-
come defects should similarly influence the pneumo-
gastric nerve. It must be borne in mind that the
ciliary muscle is perhaps the only muscle the action of
which is continuous. Sleep is the only time for
recuperation.

Attention to the Eyes the Remedy.—The remedy
for the condition met with in these cases is attention
to the eyes. Over and over again in my experience
relief has been afforded by the correction of anomalies
of refraction. Frequently a patient expresses regret
at not having obtained relief before instead of wasting
time upon other measures. Usually no other treat-
ment is necessary. A faulty state of the eyes is

10
130 BIOGRAPHIC CLINICS.

ascertained; it is corrected, the proper glasses are
worn, and relief follows, whilst the other conditions
of life have been unaltered. This is proof sufficient.
It has been well said:

“Tf use of the eyes produces any of these results
it is almost surely the cause; if disuse of the eyes
relieves, it is doubly sure; if without the disuse of the
eyes wearing of proper glasses does the same, the dem-
onstration is beyond question ’” (Gould).

In many cases which come before one, however,
the symptoms have already existed for a long period
and immediate relief from the wearing of the cor-
recting glasses cannot be expected any more than that
a chronic disease should at once yield to any treatment
which may be adopted for it.

The Effects of Astigmatism.—If anyone wishes to
learn what the astigmatic eye has through the ciliary
muscle to overcome, he can do so by placing + or —
cylinders before his eyes. Let him wear these glasses
and they will produce the symptoms of ametropia. To
illustrate, though imperfectly, the indistinctness of type
which a low degree of astigmatism occasions if uncor-
rected by the action of the ciliary muscle, I have had a
series of photographs taken of a portion of a Times
leader. First, the leader was photographed in the usual
way and appeared sharp and clear. Then under precisely
similar conditions, the same was again photographed,
but close to the lens of the camera a cylindrical glass
 

 

fof the Russian Government to the last Japanese |
Note has reached: Tokio, or that its tenor hes
reduced to an almost. vanishing quantity’ the
Lslender hopes which copld still be entertained for
the maintenance of peace in the Far East.
Though the. Russian Government and its mouth-
pieces on the Continent. may, choose: still to
describe the,.reply to..the Japanese Note as
i conciliatory,” and' though in form it doubtless
is so, we have reason.to believe ‘that. in substance
it fails entirely to.meet the views of the,
Japanese Government. “From. the moment when
the Mrxavo’s!, Ministers ‘requested the Russian,
Government’ to reconsider the térms— of, its
previons reply. it was obvious that they would,
not he ‘satisfied with any mere forpral “OF |
superficial aniendments. I

 

Fig.1z. Normal photograph.

 

 

of the Russian Government to the last Japanese
‘Note has reached Tokio, or that its tenor has
reduced to an almost vanishing quantity the
slender hopes which could still be entertained for
the mainvenonce of peace in the Far East,
Though’ the Russian Government and its mouth-
pieces on tke Continent may ‘choose still to
describe. the reply to the. Japanese Note as
* eonciliatory,”’ and though in form it doubtless
is s0, we have reason to believe that in substance
it fails entirely to meet the -views of the
Japanese Government. From the moment when
the Mirapo’s Ministers requested the Russian
Government ta reconsider the terms of its
previous reply it wis obvious that they would
not ‘be satisled srith any mere formal or
superficial amendmetis. - 4

 

 

Fig. 2. With + 25 D. cyl in front of lens.

 
 

 
 
 

 
 
    
   
 
  
  
  
 
 
 
 
  
 

mh a
roan. aon vant

   
  

ie Pints Suntinont | alt “abastiea
toi nie Mie tespy Leo eaak tinea
Manat alary and Aboagsh JL ‘fortis,

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We filly anid (eedy bane "the
planino: Warvernnieatitee > ren the mamatl whan
NAb A pilnbien Heqenlend the Numalan!
wreestet te eeennider fle hein ooh sia
: fuspely 40 wes abvtenn (bab Mog ‘avin
i “aut deatien Ls, wikde saniy  tuneskey ‘Forsunt ur,
a peaihaliak anneanbnenbt Psic07 Bs

 

Fig. 3. With +5 D. cyl. in front of lens.

 

Geers Ge tbe Camtieess mey choos <cT on:
ee
coma,” a chee Se See Se Saco
Ss see Ee ome oe Bete ae Se orien
k its eT Ti Rees tae Tiwe af die.

 

ze cei Ge eee FF te
eens eS 8 ee Se ee ee

eee ee

 

 

 

 

Fig 4. With +:75 D. cyl in froat of lens.
 

of the Russian Government to the last Japanese
Note has reached Tokio, or that its tenor has
reduced to an almost vanishing quantity the
slender hopes which could still be entertained for
the maintenance of peace in the Far East.
Though the Russian Government and its mouth-
pieves on the Continent may, choose still to
‘describe the: reply te the Japanese Note as
“ eonciliatory,”’ and though in form it doubtless
is so, we have reason to believe that in.substance
it fails entirely to -meet' the views -of the
Japanese Government. From the moment when
the Mrxapo’s’ Ministers requested the Russian
Government to’ reconsider the terms of its
previous reply. it was obvious that they would
nob he satisfied with any mere formal or
superficial amendments. /

 

 

 

Fig. ra. Normal photograph.

 

of the Rossiun Government to the last Japanese
Note hax reached Tokio, or that its tenor has
xedueed to an almost voninhing quantity tho
slondor hupes which could still be entertained for
the malntenanes of peaco in the For Enat.
Though tho Itussian Government, and its mouth-
ploces’ 6p the .Continont may choose stilt -to
denerihe ‘the: reply to the Japanoso Note. as
“ conciliatory,” and though in form it doabtless
fs wo, wo have reagon to believe that in. substance
1b fails entirely .to meet the viowa of the
Japanese Government. From the,moment when
the Mikapo's Ministers requested the Ruaslan
Governmont to reconsider’ the terms of its
Lprevioun reply if was obvious that they would
‘nob bo- sntisficd with any mere formal or}
guporticink amendments, | ; |

 

 

 

 

 

Fig 2a. With—-‘25 D. cyl in front of iens.
 

lez tee Bassin Goverment to the iam ispamene|
[Sete “hes reacbed Tokio, ce that its terres
: an aipost wauishing qramizy the
hopes Whick cowld cul be emtermined fie
ie mainsemamce ef yee in the Far Bet
Thowgh the Rosen Govermaest ond ie monk
Hietes ca cee Comtimex: sesy choose sill’ wo
deseribe . the. rents tothe Fapamese Nece, 25)
| cametiower,”* and thcxss im down i dowkciess
isso, we Lave roan w believe thar hb sabecampe,

 

 

 

 

 

 

Fig. 3a. With —‘s5 D. cyl in front of lens.

 

 
  

VU thes Beattie herbed ator bec Hlaee Mate: daguannegsae!
Petter Wie vem ad Debt, 9 Ctiek tee beat hin
pean Gor ec adieciak ae elie “dheg
nf wie Iype sovrtibsh onthte (ith far bern tiead ‘tye
‘Ue! vee mbas ait ieee, fe tin fn Haw,
eta lie Mitiayay Cie ettiniedit aut Hee ynetibh 4

itn “Hit iy Higthane: ait “acdtinuseas wt ‘(ar
Patan iy Nive £44 ye fey OMe © “shaquennany Nidic Wh
ae ein ntisinee Maal Chive h i Fagen He cdenate fice
ta my HE Tvteee beaten Ee Cet CHE de tifa ligennn:

We fbb vedbroty dv spe Hine Cette whe (hes
AUynpactee ee Cr E canpet S Pee, (een ayberigade Yebiin
fear ke verre Abeta wp As ap tieed seal tho Tenia
Hleveae ttre for ver eal lie Hite fivgna gif tba
ee hath ‘pla Wows ve AS Vesthan (had Moy, wuld
vide ot al athe ttt Hoe ivtanal
Lan aiidl “ar gellig ak on fats

 

 
 
 
  

 

 

 

      
   

 

 
 

be Teh iby

 

 

Fig. 4a. With—-75 D. cyl. in front of lens.
EYESTRAIN CAUSE OF HEADACHE. 131

was placed. In this way a series of photographs was
taken with + 0.25 D. cyl.; +0.5 D. cyl., and +0.75
D. cyl., respectively, before the lens of the camera.
A second series with similar minus cylinders was
taken. In each case the cylinder was so placed to
occasion the effects of an astigmatism “ according to
rule.” The eye naturally strives after a clear and
sharp image, and as this can only be accomplished by
the action of the ciliary muscle the photographs will
be understood as illustrating the strain which the astig-
matic eye must undergo to accomplish this result.

Illustrative Cases—The following cases may be
given as illustrations of the class we have under con-
sideration. The first is that of a lady who had suf-
fered for a considerable time. She is the wife of a
medical practitioner at a seaport on the East Coast,
and he has very kindly written the following account
for me:

“The patient, aged 32, had studied music until she
was 21 years of age, spending five years in hard study
in Germany. There were no eye symptoms then ex-
cept headache occasionally. When working for a
concert five years ago she began to have attacks of
giddiness and occipital headache. These ceased after
the concert, but returned with increased force twelve
months later when she was again working up for a
concert. On this occasion she had one or two attacks
of sickness. Improvement again took place. A few
132 BIOGRAPHIC CLINICS.

months afterwards she had some lessons in London
and practiced hard, ultimately having a complete
breakdown from headache, giddiness and nervous at-
tacks. Then she gave up playing, but for a long time
her general health was poor. She was thin, did not
sleep well and was very nervous. She developed a
cough and consulted a well-known physician nearly
two years ago. He found no organic disease, but
ordered her to feed up. Her general health improved
somewhat, and then she began to have the typical
attacks which brought her to you. The attacks came
at first once a fortnight and gradually increased in
frequency until she had one every week. They came
on quite suddenly, sometimes when she had been feel-
ing particularly well. She first felt giddy as if she
would fall, and at the same time felt sick and faint;
vomiting soon followed and lasted for several hours,
with severe straining and retching. After an attack
she was prostrate and confined to bed for twenty-four
hours. Occipital headache was frequent and severe,
as if a large crab had seized her by the nape of the
neck. Occasionally an attack would come on with
startling rapidity, almost like an epileptic attack. On
one occasion I remember she was sitting at lunch
chatting and quite cheerful. Suddenly she became
giddy and nearly fell off the chair. She was pale and
faint, and had to be assisted to a couch. In a quarter
of an hour she was vomiting. The worst attack she
EYESTRAIN CAUSE OF HEADACHE. 133

ever had came on during the night when in bed. The
slightest attempt to lift her head from the pillow
brought on frightful nausea and giddiness. After
consulting you and wearing the glasses you prescribed
she had several attacks during the first four weeks,
but they did not culminate in vomiting, and she has
not had an attack of vomiting since (excepting once
she had a bilious attack from eating some indigestible
food; on this occasion there was no giddiness and she
was ‘comfortably sick’; in an hour or two she was
well). The attacks of headache and giddiness grad-
ually disappeared, and she is now free from any trouble
of this kind. Her general health is good and she is
stouter. In every way there has been a marked im-
provement. For a time attendance at a theatre was
invariably followed by headache and giddiness, or a
long carriage drive would induce an attack, but now
they simply produce a slight tired feeling. Hearing
has always been acute and there has been no ear
trouble. During the worst attacks the nausea was so
severe that the headache was unnoticed; there was,
however, a feeling as if thousands of strings were in
the back of the neck and as if someone were pulling
at them. The giddiness always commenced in the
occipital region.”

The refraction ascertained after using a mydriatic
was as follows: R.—0.75 D. cyl. ==$; L.—1 D. cyl.
=, axes vert.
134 BIOGRAPHIC CLINICS.

The next is a more acute case and is one of con-
siderable interest apart from the question of his head-
aches, for five years ago, when studying at the
Sheffield Technical College, the patient was struck in
the right eye by a splinter of steel which penetrated
the globe and became imbedded in the retina near the
optic disc. I was successful in removing this particle
of steel with the electro-magnet ; he recovered perfect
sight which, as the record now shows, has been per-
manent. The patient, aged 27, is an engineer and
lecturer on electrical engineering at a technical school
in a great Midland city. He has always been a hard
worker and the following is an account of his work
during the last few years:

“From September, 1900, to May, 1901, he studied
and lectured in the evenings. Considerable organ
playing (music reading). August to October, 19o1,
engaged in engineer’s drawing office (eight and a half
hours a day). October, 1901, to September, 1903,
two years’ research work involving accurate reading
of moving spot of light on mm. scale; fifty readings
in one and a half hours, two or three times a day for
several weeks. Plotting results on fine mm. squared
paper, etc. Nearly whole time spent in artificial
light (electric arc), most of work being done in the
evenings. September to Christmas, 1903, reading and
lecturing. There was no serious difficulty experienced
with eyes during the whole of this time, except that
EYESTRAIN CAUSE OF HEADACHE. 135

there was sensitiveness to strong light, which was con-
siderable on waking and when the eyes were tired
with reading. The eyes also watered on changing to
a colder atmosphere, and there were slight headaches,
and except just before Christmas, 1903, slight occa-
sional sickness necessitating careful dieting. He had
a fortnight’s holiday last Christmas (1903), during
which time he did no reading whatever, nor other
eye work. This rest did not altogether give relief,
so that when he returned to work he was worse than
he had ever been before. For the last two or three
years he noticed that his head felt ‘ muzzy’ and it was
not even recovered by the morning. The eyes would
be sensitive after a hard evening’s work and watered
a good deal. Even when interested in his subject he
was disinclined to go on with reading owing to feeling
sick, and had to go out for a walk for an hour or more.
He has been in the habit of giving his eyes complete
rest whenever possible, and always so on Sunday, on
which day no reading has been done for three years.

“ After the holidays he resumed work on January
4, 1904, and read hard for five hours. On the 5th he
read hard for seven or eight hours and lectured in
the evening. The following day, after breakfast, he
began to feel dizzy and could eat but little (not to be
accounted for by the system being out of order, nor
improper food). On the 7th everything appeared to
be in a state of vibration. He kept his bed all dav.
136 BIOGRAPHIC CLINICS.

Much vomiting. He had no food. On the 8th he
was about the same; had no food, but got up for an
hour. On the 9th he was able to eat a small piece
of fish. On the 1oth he came downstairs at noon and
had light diet. His medical adviser prescribed a tonic.
He had to be assisted upstairs on account of dizziness.
On the 11th, 12th and 13th he came down about noon
daily. On the 14th, diet about normal; went out of
doors for the first time, but was dizzy, otherwise felt
well. On the 15th and 16th the dizziness slowly de-
creased. On the 16th he came to Sheffield and con-
sulted me. On the 17th dizziness was still less. The
eyes were absolutely at rest from January 7th to 17th.
He has not complained so much of headache. The
feeling in his head was more of general muzziness,
with occasionally acute pain in the eyes and forehead.
The dizziness, he mentions, is that he feels about to fall
and everything around seems to be swimming.”

The refraction in this case was R.+ 0.75 D. cyl.
60° =£; L.+o0.75 D. sph.-=$. Subsequently he
gave this report:

“Tam glad to say that I am now in normal condi-
tion, having worn the glasses continuously as you
advised. The dizziness gradually disappeared, and
during the last few days I have felt quite free from
any indications of weakness, although I am doing a
considerable amount of extra work owing to the illness
of one of the lecturers here. Am doing a third of his
EYESTRAIN CAUSE OF HEADACHE. 137

work (lectures, etc.) in addition to my own. Once
or twice I have tried the effect of not using the
glasses for an hour or two, but this gave rise to head-
ache and acute pain at times in the right eye, not pro-
longed. Also the dizziness began to return.”

Analysis of Cases—lIt has already been mentioned
that of the last eight hundred refraction cases in my
private practice, one hundred and sixty-two sought
advice in consequence of headaches more or less con-
forming to the types which have been described—that
is to say, about one in every five. Dr. A. E. Barnes,
a late clinical assistant of mine, has very kindly col-
lected from my private case-books three hundred and
eighteen consecutive cases of headache and has pre-
pared for me the following analysis. (See table,
p. 139.)

Sex.—Females predominated largely. This was
especially the case in hypermetropia and hyperme-
tropic astigmatism. In myopic astigmatism the pre-
ponderance was much less. The following figures
illustrate this point. Of the total cases, 84 percent
were females; of cases of hypermetropia, 89.4 percent
were females; of cases of hypermetropic astigmatism,
89.4 percent were females; of cases of myopic astig-
matism, 64 percent were females. The preponder-
ance of females is hardly to be wondered at. Women
are more subject to neurotic conditions than men.
The mental or nervous stress more rapidly affects
138 BIOGRAPHIC CLINICS.

them. Their nervous system is less stable. Women
have more constant close eye work than men, and
their lives are passed more indoors than men. They
have more leisure for reading and spend much of their
time in sewing and fancy work—the latter and “ bazaar
work” often being responsible for a breakdown and
a visit to the ophthalmologist. It is the eye-workers,
whether male or female, that are prone to headaches
and the train of other neuroses which have been men-
tioned. These have been illustrated in the cases which
have been related.

Age.—tThe youngest case was that of a boy, aged
63. His refraction was R.+ 1.5 D.; L.—o.75 D.,
axis vert. Some time previously he had undergone
tenotomy for convergent squint. There were two
girls, aged 7, one had H. + 1.5 D. and the other H. +
1 D. in each eye. The oldest was a woman, aged 60,
with one available eye. L.—1 D. with cyl. — 0.75 D.,
vert. approx.t The next in age was a man, aged 52,
with simple hypermetropic astigmatism + 0.75 D. cyl.
in each eye according to rule (approximately). In
males the ages at which eye-strain headaches are most
prevalent correspond to three periods of life, i. e.,
puberty, from 10 to 15 years; age of greatest stress,

*“ Approximately ” vertical or horizontal is used as indi-
cating that the axis approaches one or other of these meridi-
ans. This suffices for our purpose here, but in testing, the
axis must be determined very exactly if relief is to be afforded.
139

EYESTRAIN CAUSE OF HEADACHE.

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140 BIOGRAPHIC CLINICS.

from 20 to 25 years; age when accommodation is fail-
ing, from 45 to 50 years. Myopic astigmatism is
again different to the other errors, for five out of
eleven cases were over 35 years of age, corresponding
to the last period. In females the prevalence belongs
to the period of sexual activity, for they begin to be
common at I5 years, reach a maximum at from 25 to
30 years, and finally disappear at 50 years.

The Frequency of Different Varieties of Ametropia.
—As to the relative frequency of the different kinds of
ametropia, it was found that the kind of error most
associated with headache was hypermetropic astigma-
tism. Pure hypermetropia was nearly as common,
myopic astigmatism much less common, mixed astig-
matism still less common, whilst myopia was only
present in four cases, and in three of these there was
also anisometropia. The analysis of 300 cases gave
the following results: hypermetropic astigmatism,
49.3 percent ; hypermetropia, 34.3 percent ; myopic
astigmatism, 11.3 percent ; mixed astigmatism, 3.6
percent ; and myopia (three of which were unequal in
the two eyes), 1.3 percent.

The Importance of Low Degrees of Astigmatism.—
Of particular interest in this analysis of cases of head-
ache and errors of refraction associated with them is
the large number of cases in which the degree of astig-
matism is a low one and the cylinder prescribed corre-
spondingly weak. There is in some quarters a failure
EYESTRAIN CAUSE OF HEADACHE. I41

to recognize the importance of estimating these low
degrees of astigmatism and the value derived from the
use of weak cylinders. A careful study of the subject,
however, will easily demonstrate that the low degrees
of astigmatism play a very important réle in the causa-
tion of the neuroses we have under consideration.
They will be found in patients complaining little, if at
all, of their sight, and can only be detected and the
exact axis ascertained after a careful examination
when the eye is under the action of a mydriatic. I
refer especially to astigmatism of 0.25 D. and 0.5 D.
Included in my series were 144 cases of hypermetropic
astigmatism, simple and compound. I find that
+ 0.25 D. cyl. was prescribed in 18 cases of simple and
5 of compound hypermetropic astigmatism, or 23 cases
altogether; -+ 0.5 D. cyl. was prescribed in 38 and 9
respectively, or 47 cases; and + 0.75 D. cyl. was pre-
scribed in 22 and 8 respectively, or 30 cases, thus
making a total number of 100 out of the 144 cases in
which cylinders of +0.75 D. and under were pre-
scribed. The benefit of these weak + cylinders was
undoubted. There were also 34 cases of myopic astig-
matism, simple and compound. For these cylinders
of — 0.75 D. and lower were ordered in 20 cases—viz.,
—o.25 D. cyl. in 3 simple and 1 compound, or in 4
cases; —o.5 D. cyl. in 4 simple and 2 compound, or in
6 cases; and—o.75 D. cyl. in 9 simple and 1 com-
pound, or 10 cases. The percentage for these weak
142 BIOGRAPHIC CLINICS.

cylinders works out as 66.8 percent for hypermetropic
and 58.8 percent for myopic astigmatism. The fol-
lowing is a case illustrative of the value of weak cylin-
drical lenses. It has been related before* and is epi-
tomized here.

Illustrative Case.—In consequence of long-continued
and severe headaches a gentleman, a missionary in the
East, consulted me in October, 1901. The headaches
had commenced about February, 1899, after consider-
able stress of work. They began on the left side, to
which they were chiefly confined, sometimes beginning
about the eye and at other times about the teeth. At
first there was a sort of hot feeling which, after a time,
gave place to a more acute pain, apparently like neu-
ralgia. When pain was absent there was a numb feel-
ing reaching from the left side and top of the head to
the occipital region. The feeling was as if one side of
the head was boiling hot or in flames, and he lost all
energy. His sight was tested by a medical man and
declared to be above normal, and the complaint was
designated “ hemicrania,”’ ‘* cause undiscovered ” being
put in the certificate. It was suggested at this time
that his teeth might be responsible and he consequently
had two extracted from the upper jaw. As a result of
this examination he was invalided to another part of
the country for six months, but he was able to do some
work. The change and comparative rest were bene-

*The Lancet, Vol. IL., p. 1667, 190r.
EYESTRAIN CAUSE OF HEADACHE. 143

ficial and he was able to resume regular work in the
autumn of 1899, continuing it until the beginning of
1901, when the headaches recurred. He was treated
without avail by another medical man who regarded
the headaches as rheumatic. In February, 1901, he
left for England, arriving in this country in the middle
of April. He was then brought before the medical
board who ordered six months’ rest, at the expiration
of which time he was reexamined. The headaches
still remained at that time, but were somewhat modified
in severity. The principal medical officer could not
diagnose the cause, and advised him to see an ophthal-
mic surgeon. He therefore came to me. At his visit
I found that, though suffering from headache, it was
not so bad as previously. The numb feeling was con-
stant and there were exacerbations of more acute pain.
He was of opinion that the headaches were made
worse by exertion, but as he was unable to use his eyes
with comfort he believed they had a good deal to do
with his suffering. Vision in each eye was normal (#)
and glasses rendered it worse. After being under the
action of homatropine and cocaine in each eye V. =,
or with + 0.5 D. cyl. axis horizontal, $. The muscle
balance appeared to be normal. These cylinders were
ordered and a week later he reported himself as im-
proved and better than he had been for a very long
time. He also added that the numb feeling in the
144 BIOGRAPHIC CLINICS.

head disappeared when wearing the glasses, but re-
turned on leaving them off.

He mentioned an interesting fact that two days
previously after a bicycle ride the pain in the head re-
turned, and he wished to know if cycling would be
injurious. He had cycled a good deal when in the
East and thought the pain had been aggravated
thereby. I explained the way in which it might be so
and was informed that he had been in the habit of
leaning forward, and consequently, on looking straight
in front of him he would have to use and strain the
elevator muscles and discomfort would be caused in
the same way that “academy” or “ sightseers’ ” head-
ache is occasioned by looking at pictures hung above
the line. At a later call he stated that he had received
considerable relief and was anxious to return to work
and desired my permission for him to accept a curacy
in the south of England. He was able to read with
much greater comfort than formerly. He also said
that he was satisfied as to the cause of the strain to the
eyes when cycling, as he had put himself in the position
I had explained, and he found the eyes to tire very
soon.

On November 22 I again saw the patient who ex-
pressed himself as better and more fit for work than
he had been since he first commenced his labors in the
East. He was able to read with comfort for long
periods and felt confident of being able to fulfil his
EYESTRAIN CAUSE OF HEADACHE. 145

clerical duties, which he was to enter upon the next
day. Later he obtained permission to marry and to
return to his work in the East.

The Importance of Inequality of the Eyes—Ani-
sometropia, or an inequality in the refraction of the
two eyes, is another feature to be noticed and it is
important. One eye may be myopic and the other
hypermetropic, or both may be myopic or hypermetro-
pic, but the degree may be higher in one of the eyes or
the degree of astigmatism may be unequal in each eye.
Moreover, one eye may be normal and the other may
have some form of ametropia. A consideration of my
cases shows that inequality of the two eyes was present
in nearly half (45.6 percent). It was most frequent
in mixed astigmatism (81 percent). Myopia came
next with 75 percent, and myopic astigmatism with
74 percent. In hypermetropic astigmatism it was
present in 55 percent; in hypermetropia only in 21
percent. In compound astigmatism, both hyperme-
tropic and myopic, it was relatively more common than
in the simple varieties.

The Axis in Astigmatism According to the “ Rule.”
—In hypermetropic astigmatism the axis according to
the “rule” should be horizontal, and in myopic astig-
matism it should be vertical. There is but little evi-
dence from my cases to show that astigmatism against
the rule is especially potent in causing headaches. In
hypermetropic astigmatism there were only nine cases

Il
146 BIOGRAPHIC CLINICS.

against, or approximately against, the rule (i. ¢., about
6 percent). There were also fourteen cases in which
there was astigmatism against the rule combined with
inequality of degree, but as anisometropia is such a
powerful factor in the production of headache these
cases can hardly be used to show that departure from
the rule is also a factor. In myopic astigmatism there
were no symmetrical cases against the rule where there
was not also inequality of degree, but there were nine
cases in which there was also this inequality of degree.

Asymmetry of Axes in Astigmatism.—lIf we do not
take account of those cases in which one eye only was
astigmatic we find that there were thirteen cases of
hypermetropic astigmatism in which the axes were not
symmetrical. This is not quite 10 percent. In myopic
astigmatism there were nine cases, or nearly 25 percent.

The correction of these conditions without glasses
could only be brought about by an effort of accommo-
dation differing in the two eyes, and this, it is thought,
the eyes are hardly capable of doing to any great
extent. Where the difference is considerable the
inconvenience is not always great and persons often
only become aware of the fact that they do not see
equally well with each eye when the tests for vision are
applied.

Tn a case like that of Mrs. O., in which there was
myopia with amblyopia (V.— 10 D. with 1.5 D. cyl.
gz) in the right, and hypermetropic astigmatism
EYESTRAIN CAUSE OF HEADACHE. 147

(+ 0.75 D. cyl.) in the left, the chief factor in
giving relief to her headaches probably was the correc-
tion of the astigmatism in the left, though a minus
spherical glass with a cylinder was at the time pre-
scribed for the right. In a letter she says: ‘“‘ Before
wearing glasses I used to suffer constantly from head-
aches and often felt nervous and irritable, with occa-
sional shooting pains in the head and a sensation of
being thoroughly run down. The use of glasses has
given me quite a restful feeling, and I have had but
very little headache since wearing them. I feel very
grateful for the good they have done me and my
general health has considerably improved.”

In other cases the effort to accommodate with each
eye will be made, especially in the low degrees of
asymmetry, and this endeavor is often attended with
considerable discomfort and headache, etc., and is an
important factor in occasioning the distressing condi-
tions which we are discussing.

The Use of a Mydriatic Essential.—lIf relief is to be
afforded in these cases it is of the utmost importance
that the refraction should be carefully and thoroughly
worked out. To accomplish this the use of a mydriatic
is essential. It has been pointed out that many of the
greatest sufferers make no complaint of their eyesight,
and unless, therefore, the accommodation is paralyzed
and the exact refraction ascertained relief will not be
afforded. For this purpose homatropine, especially in
148 BIOGRAPHIC CLINICS.

combination with cocaine, is usually sufficient. I gen-
erally employ it made up in gelatine discs. If these
are used two or three times at intervals of ten or fifteen
minutes a patient is ready for examination at the lapse
of from one and a quarter to one and a half hours.
The next day the effect has passed off sufficiently for
the patient to be able to read with his correcting
glasses. A mydriatic will reveal a latent hypermetro-
pia of one, two, or even three dioptres not infrequently
even in patients aged 35 and over, and the low degrees
of astigmatism will not be discovered without it.
Homatropine used in the way already mentioned usu-
ally suffices, but its employment has in some cases to
be repeated daily.

Careful Testing Essential—Retinoscopy is the one
objective method that is of real value. Its discovery
has rendered immense service to refraction work. For
young children it must often be relied on for ascertain-
ing the degree of the error, and it may often be neces-
sary to prescribe spectacles from its findings. For all
others, however, the final examination must be made
with the trial glasses and test-type cards. No objec-
live method can be permitted to dispense with these.
Ascertain carefully the best correcting glasses and be
very exact as to the axes of the cylinders. Attention
to these matters is essential if our treatment is to be
successful.

*Homatropine and cocaine, ziyth of a grain of each.
EYESTRAIN CAUSE OF HEADACHE. 149

Faulty Muscle-Balance——It must not be forgotten
that whilst an error in the refraction is responsible in
the main for the headaches and other conditions in
these cases, there nevertheless is in some added thereto
a faulty condition of the muscle balance of the eyes.
This, though secondary, is still an important factor,
and the latent deviation must be carefully ascertained
by the use of Maddox’s rod and tangent scale. The
close relation between the external ocular muscles and
the accommodation is such that it suffices not infre-
quently, after careful testing, to relieve the ciliary
strain by the appropriate glasses. The muscle balance
becomes rectified or of less account. This is not, how-
ever, true of all cases, and the adaptation of prisms
must then be combined with such correction as the
refraction error requires. Exophoria, or latent diver-
gence, is the condition most commonly met with. It
occurs much more frequently than the opposite condi-
tion, or esophoria. It is often present in myopia, and
in the comparatively few instances that headache is
associated with myopia, apart from astigmatism and
anisometropia, it may be regarded as the cause. Tenot-
omy of the external recti is sometimes indicated and is
of service. The following case illustrates well the
benefit of taking into account the muscle balance as
well as correcting the ametropia.

Illustrative Case-—Twelve months ago a medical
student came to me from Scotland. His headaches
150 BIOGRAPHIC CLINICS.

were so intense and so constant that study was almost
impossible; his examination had been postponed in
consequence and he was considering relinquishing his
medical career, at all events for a time. He had pre-
viously consulted two ophthalmic surgeons; each had
prescribed glasses, but neither had ascertained the re-
fraction as revealed by a mydriatic. He had accord-
ingly received no benefit. Homatropine and cocaine
were used by me for two days. The refraction then
was R.+ 0.75 D. sph., with + 0.25 D. cyl., axis vert. ;
L. sph.+ 0.75 D. These were ordered for general
use, and later for the exophoria which was present
prisms 1°, base in, for each eye was prescribed. These
gave complete relief; he soon wrote that he was able
to do a normal amount of work, and that he was pre-
paring with confidence for his final examination. This
he was successful in passing. The following is an ex-
tract from one of his letters:

“The prisms seem to have worked almost a miracle.
I do not, of course, wish to depreciate the other factors,
yet the most marked difference occurred after the
prisms were worn. I am now able to read the whole
day and about two or three hours in the night, a pleas-
ure which has been denied me for more than three
and a half years. The terrible photophobia, conjunc-
tivitis, constant headaches, and utter mental depression
have all disappeared. I feel quite a different person.
While not expecting to have the eyes I had five years
EYESTRAIN CAUSE OF HEADACHE, I51

ago, it is quite an unspeakable felicity to be able to read
as much as I do now and cover the work of the exami-
nation which lies before me. It is impossible to realize
that for periods of three months at a time I was hardly
ever free from severe headaches, that I was unable to
look at a book for six weeks at a time, and that this
state of sublimated mental and physical torture lasted
for some years.”

At the close of last year he wrote saying he had
ceased for a time to use the prisms, wearing the cor-
recting glasses alone, but as he felt the old symptoms
returning he was taking to the prisms and again find-
ing the same relief.

Vertical deviations are less frequent than lateral,
but in my experience they have been associated with
severe headache. One case was that of a nurse who
was frequently laid up and who had been obliged for a
time to give up her occupation. I found in the right
eye mixed astigmatism (+ 0.75 D. vert.,—o.25 D.
horizontal) and in the left simple hypermetropic astig-
matism (0.75 D. vert.). Glasses were ordered com-
bined with prisms correcting the vertical deviation.
Very considerable relief was experienced.

Academy Headache.—A word now as to “academy”
or “sightseers’” headache, or, as it is called in
America, “theatre headache.” There is no doubt that
astigmatism or some other form of ametropia is a
factor in its production. But a proper correction of
152 BIOGRAPHIC CLINICS.

such defects will not always prevent this kind of head-
ache, and I feel certain that there are other important
influencing conditions." A lady mentioned that she
suffered so much from headache after attending a play
that she ceased to think a visit to the theatre was
worth the after-suffering. It was also ascertained
that she visited the pit and it was the effect of looking
up at the stage that she found distressing in the after-
effects. When sitting in the dress circle and looking
on to, or down to, the stage she experienced less ill
results. My investigations into the conditions causing
the nystagmus, or rolling of the eyes, met with in
miners, showed that it was due to the weariness induced
in the elevator muscles of the eyeball by the constrained
position in which the miner had for long periods to-
gether to cast his eyes when engaged in working the
coal. My observations in compositors, plate-layers,
and many other occupations, indicated, moreover, that
prolonged use of the elevators tended in them also to
produce nystagmus, but that in many instances only
discomfort and aching of eyes were complained of. I
believe also the cause of academy headache is in many
cases to be found in this throwing the gaze above the
horizontal line, especially without a corresponding up-
lifting of the head. Watch the visitors to a picture

*“ Acquired Nystagmus in Occupations other than Coal

Mining,” Transactions of the Ophthalmological Society, Vol.
XVI, and “ Miners’ Nystagmus” (J. Wright & Co.).
EYESTRAIN CAUSE OF HEADACHE. 153

gallery and it will be observed how often this turning
upwards of the eyes is required, especially when the
paintings are hung above the line, and careful observa-
tion will show that many of the same visitors will com-
pensate for this movement above the horizontal by a
backward motion of the head. Anyone may try this
for himself and observe the tiring effects occasioned”
by looking at pictures more or less “ skied,” and then
notice the difference of looking at the same objects,
but relieving the elevators by at the same time throw-
ing the head backwards. The collier with nystagmus
learns to steady his eyes by turning them downwards.
And it will have been noticed that the lady before re-
ferred to had herself observed the difference in looking
up at the stage from the pit and looking down from the
dress circle.

Cycling a Cause of Headache.—Cyclists suffer from
this kind of headache, particularly those who lean on
the handle-bars with the head lowered, when if they
look forward the gaze is necessarily directed above the
horizontal line. I have already related a case in which
a return of the headache resulted from a rather long
cycle ride. As previously stated, on questioning the
patient it was found that he was in the habit of looking
in the direction I have suggested as occasioning weari-
ness of the elevators and consequent headache. The
accuracy of this observation he was able to endorse
from tests which he made himself. I mention this par-
154 BIOGRAPHIC CLINICS.

ticularly because I think that it is an explanation of the
headache or eyeache sometimes complained of by
cyclists, and the cause once recognized admits of easy
remedy.

Conclusions—We may summarize what has been
written under the following conclusions:

(1) That eye-strain is the cause of a large propor-
tion of headaches, often of a very aggravated character.

(2) That various other neuroses are met with in
association with headache, and among these may be
mentioned the following: Mental depression, nausea,
indigestion, vomiting, insomnia, giddiness, choreiform
movements of the eyelids and face, etc.

(3) That relief is afforded to these conditions by
correcting the error of refraction, which can be ascer-
tained only after careful examination.

(4) That for such examination a mydriatic is abso-
lutely essential.

(5) That frequently no complaint is made of defect
of vision.

(6) That the ametropia is frequently of low degree,
61.2 percent of my cases needing 0.75 D. cyl. and
weaker.

(7) That a cylinder of 0.25 D. is of great value.

(8) That anisometropia is frequently present and
requires proper adjustment.

(9) That in a certain number of cases the muscle
balance is faulty and necessitates the prescribing of
prisms.
SLIGHT ERRORS OF REFRAC-
TION AND THEIR INFLU-
ENCE ON THE NERV-
OUS SYSTEM.
CHAPTER V.

SLIGHT ERRORS OF REFRACTION AND THEIR
INFLUENCE ON THE NERVOUS SYSTEM.’

By C. Ernest Proncer, F.R.C.S.,
Ophthalmic Surgeon to the Harrogate Infirmary, England.

Havinc been asked to read a paper to the members
of this Society, my first thought was to select a subject
which would be of interest to all of us in our every-day
practice, and the discussion of which might be of some
real practical use.

The subject which has suggested itself to my mind
is the consideration of some of the results of uncor-
rected errors of refraction, more especially those con-
nected with the nervous system, and the association of
errors of refraction with some of the nervous diseases
you are so constantly called upon to treat.

I do not wish to speak to-night of the higher degrees
of refractive errors, the effects of which are usually
obvious and at once attract notice, but rather of those
slight degrees which I find are so constantly over-

2A paper read before the Harrogate Medical Society, and
reprinted in the present volume by the kind permission of
Mr. Pronger.

157
158 BIOGRAPHIC CLINICS.

looked, and yet whose influence upon the nervous sys-
tem may be so far-reaching and disastrous.

The cases which I would have you consider are
those which in themselves have little or nothing to
draw attention to the eyes, and unless you have had
previous experience of them, it is little to be wondered
at if, in many instances, the real cause of the malady
and in others a very important element is entirely
unrecognized. I say this because the text-books on
medicine seem to attach so little importance to the sub-
ject of refractive errors, and, so far as I know, the
attention of the student is but little drawn to it during
his hospital career.

The most important of these nervous ailments is,
probably, headache, on account of the vast numbers
who suffer from it, occurring as it does at all ages from
six or seven years of age to sixty or more. It is very
common during school life, and how much of the
suffering we see in after-years might have been obvi-
ated had the real cause been detected at that period.

There is no special characteristic by which eye-head-
aches can be diagnosed. They vary in intensity from
the dull aching across the brows, not much more than
a sense of weariness, to the intense pain in the head,
often with retching and vomiting, which completely
prostrates the patient, and the effects of which some-
times last for days. The pain may be a dull aching or
of sharp neuralgic character, and the situation of it is
SLIGHT ERRORS OF REFRACTION. 159

very varied. It is often in the mastoid or occipital
region, or it may be either across the top of the head
or the brows, or limited to one side, and I have some-
times had cases in which the pain has been between the
eyes, just at the root of the nose, in which glasses have
given complete relief. In a large number of cases of
headache there is no suspicion, either on the part of the
patient or the doctor, that the eyes have anything to do
with it, for the reason already given, and from the fact
that nausea, retching, or vomiting is present in many
cases, these are almost invariably attributed by the in-
experienced to some disorder of the liver or digestive
organs, forgetting that vomiting is also frequently
associated with nervous disturbance.

But if the doctor be fully alive to the fact of eye-
trouble being a very frequent cause of headache, and
make inquiries as to the sight, many obstacles may be
put in his way; for instance, he may be told that the
sight is perfectly good, and truly, for the vision often
comes up to the normal standard in each eye; that the
sight has been tested, and that the glasses are quite
satisfactory, for so they may be to the patient, from
a visual point of view. Then again, the patient is
often very sceptical, and may pooh-pooh the idea
altogether.

I would strongly advise you in all cases of persistent
or frequently recurring headaches to have the sight
tested, and the testing, to be effectual, should be very
160 BIOGRAPHIC CLINICS.

carefully and thoroughly done, and if the symptoms
still persist, repeated, for these cases of slight refrac-
tive error are much more difficult to diagnose and cor-
rect than is generally supposed. One other point—if
you decide to send your patient to an ophthalmic sur-
geon, be emphatic and convey to the patient that it is
a matter of some moment, or your advice will often be
disregarded.

In selecting cases, in illustration of some points
which I wish to impress upon you, I have chosen those
which have been under some member of this Society or
of some well-known medical man in this district, and
the first is that of a daughter of a medical man, who
brought her to me in April of last year.

Case I—Her age was 16 years, and she had been suffering
severely from headaches for five years, so much so that her
school career had been quite spoiled by the frequent interrup-
tions in her studies.

She had had a good deal of treatment by drugs, rest, and
frequent changes of air. Her father told me that all the pos-
sible causes of headache had been carefully gone into, and she
had been taken on several occasions to an ophthalmic surgeon,
but, unfortunately, without success. I need hardly tell you
that with such a history I exercised the greatest care in deal-
ing with her case, and I had the satisfaction shortly after of
finding that, as a result of making a slight alteration in her
glasses, which were for the correction of myopic astigmatism,
her headaches became less severe and less frequent, and she
has now been for six months almost entirely free. Having
extended over five years, this illustrates not only the difficulty
(and no trouble seems to have been spared) of finding the
SLIGHT ERRORS OF REFRACTION. 161

cause, but also how difficult some of these slight astigmatic
errors are to correct accurately.

Case II.—A medical man consulted me, some years ago, on
account of a small meibomian cyst, and I mentioned that in
my experience these cysts were almost invariably associated
with errors of refraction. (As these cysts are very common,
you will do well to bear that in mind.) He at once said that
he must then be an exception to my rule, for he had had his
sight tested by an eminent oculist and that it was quite normal.
Acting upon a principle which experience has taught me,
never to accept anybody’s estimate of refraction without veri-
fying it, I tested his sight, and soon convinced him that he
had astigmatism.

He now told me that he suffered much from headaches,
brain weariness, and exhaustion when at his work. On wear-
ing glasses for the correction of his astigmatism he soon
obtained complete relief.

Another point in his case, although not very uncommon in
astigmatic patients may be new to some of you, was that if
he travelled any considerable distance by rail, say to a medical
dinner, he would suffer so much from nausea at the end of
the journey that he would be unable to eat a thing.

With his glasses on he can now travel to town and eat as
big a dinner at the end of the journey as at any other time.

This was to me a very interesting case. That tiny mei-
bomian cyst brought the patient to me; it told me that there
was sonie error of refraction; that error of refraction was so
slight that it had escaped the observation of an ophthalmic
surgeon; so slight that it had caused no appreciable impair-
ment of vision, and yet so powerful as to cause a great deal
of headache in a strong, healthy man, and undue weariness and
exhaustion when at his work; to render railway travelling to
him a thing to be dreaded, and lastly, if my theory be correct,
to play an important part in causing that tiny cyst.

The cure of ordinary headaches by glasses is now so
12
162 BIOGRAPHIC CLINICS.

well known to the general public, that patients fre-
quently come to me, both at the Infirmary and in pri-
vate practice, telling me that they can see perfectly
well, but that they have heard of a friend whose head-
aches had been cured by wearing glasses, and that they
would like to have their eyes examined.

That being so, I do not wish to enlarge unduly upon
this subject, when speaking to a body of medical prac-
titioners, but would like to devote a few minutes to
the more severe forms of headache which I often have
to treat, and which have almost invariably passed
through several hands before coming to me, showing
that there are some at any rate who do not readily
recognize the cause of the trouble in these patients.

This type seems to be commoner in women than in
men, and the attacks of severe pain in the head, with,
usually retching or vomiting, come on at intervals of a
day or two, to two or three or more weeks. The
patient is quite prostrate during an attack, and in ex-
treme cases the after-effects have barely passed off
when a fresh one occurs. The nervous system be-
comes shattered by such severe suffering, and life
becomes a misery. Patients have sometimes told me
they have often wished themselves dead.

 

Case III.—Mrs. B , at 56, a sufferer from these attacks,
came to me in October, 1901. The doctor who sent her wrote
that she had been a terrible neurotic or rather neurasthenic
sufferer for many years, and that for ten or fifteen years,
SLIGHT ERRORS OF REFRACTION. 163

frightful. attacks of sick-headache had prostrated her over
and over again. She had never worn glasses, for, being short-
sighted, she had been able to read small print until quite
recently, but as her sight for reading had now rather failed,
he wished me to prescribe glasses “for that purpose.”

This proved to be a case of astigmatism of different degree
in the two eyes, and I prescribed glasses for constant use,
with suitable correction in addition for reading. I told her
doctor what I had prescribed, and expressed the opinion that
the attacks from which she suffered were caused by the astig-
matism, and that they would be much benefited if she per-
severed with her spectacles. He told me I had no conception
of the severity of her attacks, and scouted the idea that attacks
such as hers could be due to so simple a cause or cured by so
simple a remedy. Twelve months later this patient came again
to Harrogate, and meeting her doctor one day I inquired after
her. He reported that she was wonderfully better—he had
not seen her looking so well for years, and he then went on
to say that on leaving Harrogate his patient had gone to stay
at Malvern, and that “ Malvern had so completely set her up
that she had had hardly an attack since.” I inquired about
the spectacles, and was pleased to find that she had worn them
constantly.

Case IV.—A photographer, age 57, consulted me in October,
1901, stating that he had had frequently recurring severe head-
aches, attended by vomiting, for some months, and that his
family doctor had attended him for several weeks without
benefit. (This doctor told me afterwards that he had asked
about the eyes and had been told that the sight had been
tested, and that the glasses were quite satisfactory.) Finding
that he got no better, he went to another doctor, who advised
him to consult me, but he was sceptical, and thought it rather
a far-fetched idea that the eyes could have anything to do
with, what he looked upon as, his attacks of indigestion. He
therefore ignored this advice, and tried a third, who expressed
to him the same opinion. He thought now that there must be
something in it and came to me.
164 BIOGRAPHIC CLINICS.

I found simple hypermetropia in the right and myopic astig-
matism in the left eye, and prescribed glasses to be worn con-
stantly. He met me in the street eighteen months after this,
and told me he had had only one attack since the change in
his glasses—that that one followed a “special occasion” in
his family, and could be accounted for on other grounds.

I see a great many sufferers from this severe form
of headache, and the usual history is one of many
years’ duration, and of consultations with many doc-
tors, but that until now no one had suggested testing
the sight.

Another condition which we hear a good deal of
now-a-days is insomnia, and the frequency with which
it is met with as a symptom among my patients has led
me to consider whether some error of refraction may
not in some cases be an important contributory cause
of this trouble—in fact, I would go further and suggest
that in some cases, at any rate, it is the primary cause.
I believe insomnia is generally attributed to overwork,
worry, and anxiety, and the treatment prescribed is
rest, change, and the use of sundry drugs.

But insomnia sometimes occurs in those who do not
work hard, and have no special worries or anxieties;
and insomnia is sometimes cured in those who are hard
workers without any change or diminution of their
labors. There must, then, be room for another cause,
and another method of cure, for some of the sufferers
from this troublesome malady, and I would suggest
that, in any case of insomnia you may have to treat,
SLIGHT ERRORS OF REFRACTION. 165

you bear in mind that possibly error of refraction may
be the cause, and glasses the cure.

Case V.—In July last a young man of twenty came to me
complaining of sleeplessness. He was reading for an examina-
tion for the army. He had slight hypermetropic astigmatism,
the correction of which at once gave relief, without any relax-
ation of his studies. This was a simple case, and readily
cured, but it was a very important one, for it would have
been a very serious matter to him if he had. been ordered to
give up his work and go away for a change.

Hewetson, writing in 1888, says this symptom
(insomnia) I observed in many cases of astigmatism,
and he mentioned the case of a University student who
was astigmatic in whom the insomnia was cured when
the astigmatism was corrected, although he continued
to do the same amount of work.

 

Case VI—I have just received a letter from Mr. B ;
aged 50, who consulted me not long ago for headaches, and
who told me that he had been for fifteen years a great sufferer
from insomnia. He had myopic astigmatism, for which he
has since worn glasses, and he writes to say that he now
sleeps “ splendidly.”

Vertigo is another of the troubles often due to error
of refraction, and I will relate just one case:

Case VII.—Mrs. A. , aged 48, was sent to me in August
last by her doctor, who reported that she had suffered for a
considerable time from frequent attacks of giddiness, for
which he had been unable to assign a cause. I found hyper-
metropic astigmatism of different degree in the two eyes,
which I corrected, and she has since written me that the wear-

 
166 BIOGRAPHIC CLINICS.

ing of spectacles at first caused some embarrassment and
difficulty in estimating distances, but the attacks of giddiness
had, as she expressed it, reached “the vanishing point.”

Slight errors of refraction, dating as many of them
do from birth, seem to have a very gradial injurious
influence upon the nervous system, similar to the
dropping of water upon a stone, and those who are the
subjects of them are usually of the highly-strung,
sensitive temperament.

We frequently see nervous disturbances in children
speedily relieved by the correction of these slight
defects. Later on we have the satisfaction of seeing
many serious nervous phenomena entirely disappear
on wearing suitable glasses. Unless these slight
errors of refraction are corrected, sooner or later they
make themselves felt, and appear to gradually under-
mine the nervous sytem.

Owing to this slow action, and to the fact that in
many cases there is little or no impairment of vision,
their injurious influence often goes on for years, and
the cause of the troubles to which they give rise is
quite unsuspected.

I want to suggest for your consideration the possi-
bility of some of the neurasthenic conditions being
brought about in this way.

I have seen patients in whom I have thought this to
be the actual cause of the neurasthenia, and I have
seen others in whom I have thought that the soil, as
SLIGHT ERRORS OF REFRACTION. 167

it were, had been prepared in this way, and that stress
of work, worry, and anxiety had brought matters to
a crisis. —

Undoubtedly errors of refraction are very common
in neurasthenia, in fact I should be interested if any
of you could send me a case in which the refraction is
normal in the two eyes.

Some of these neurasthenic cases, in which the cause
has, for instance, been ascribed to overwork, worry and
anxiety, seem to drift on with no permanent benefit
long after these conditions have been done away with,
and often, in spite of rest, travel, Weir Mitchell treat-
ment, and many other remedies.

Does not this make one think that there must be
some subtle influence at work in the background? and
as I so constantly find astigmatism present, it strikes
me as very strange, when patients tell me that of all
the many doctors whom they have consulted, no one
till now had ever suggested that the eyes should be
examined.

I should like to mention a few cases of a neuras-
thenic type, in which the eye defect has appeared to
have an important influence, and in which the correc-
tion of it has undoubtedly been helpful in the treat-
ment.

 

Case VIII.—Mr. N. , aged 57, consulted me in Feb-
ruary, 1895, with the usual train of nervous symptoms, ex-
treme depression, headaches, nervousness, etc. I found he
168 BIOGRAPHIC CLINICS.

had hypermetropia of different degree in the two eyes—he
had worn glasses for reading only, and these were of the same
strength for each eye. His vision was quite good. He had
been constantly under treatment of one sort or another for
many years, but he now quite despaired of ever being any
better. When eight years had elapsed since his visit I wrote
to him and asked him to report, and will read you his own
account :

“About twenty years ago I gradually broke down in my
nervous system, and could not attend to business, as my
nerves were so shattered, and for years I was often completely
prostrate with nervous exhaustion. During that time I con-
sulted about a dozen doctors in different parts of the country,
but without relief. The only relief I could find was in change.
Ultimately I broke up my home and travelled from place to
place, and often was able to stay only a short time in one
place, as the sameness seemed to play upon my nerves to such
an extent that I was miserable until I changed again. During
those years I lost, very gradually, about five stones in weight;
in fact, I had no idea whether I should live or die. About
eight years ago, when I came to you in the condition I have
described, I had not worn glasses except for reading, in fact-
I never thought of doing so, because I could see splendidly
and practically any distance. You advised me to wear glasses
always, and I have done so ever since, and very gradually,
but very surely, I began to gain weight and to be better in
every sense of the word; so much so that my friends are
surprised to see me as I am.”

In September last, when he came to Harrogate to bring his
wife to see me, I was struck with his greatly improved ap-
pearance and cheery expression, and jokingly asked him how
much doctoring he had done since he last came to me. He
told me he had had influenza and erysipelas about two years
ago, for which he was medically attended, but that that was
the only occasion since his visit to me. Certainly, a great
improvement took place in this patient, and has been main-
SLIGHT ERRORS OF REFRACTION. 169

tained, and there was no change in his circumstances or sur-
roundings to account for it except the wearing of glasses.

Case IX.—Mrs. P. . aged 36, consulted me on July to,
1896. Very ‘neurotic, always short-sighted, but had not worn
glasses. Last few years had suffered much from headache,
sleeplessness, great depression, and extreme irritability. She
had tried several of the Continental health resorts, and had
just returned from a voyage round the world, attended by a
trained nurse, which had been prescribed for her by a nerve
specialist, but from which she had derived little benefit.

I found she had myopic astigmatism of different degree in
the two eyes, and prescribed spectacles, but had the greatest
difficulty in getting her to wear them. She resented them on
account of the appearance, and would not understand that
they could have anything to do with her general health. I
think, too, that she felt that a pair of spectacles was a great
come-down, after the more elaborate prescriptions to which
she had been accustomed, especially as she had been sent to
Harrogate for a course of waters and baths. After a great
deal of talking, she got a pair of spectacles, but in two days
the nurse came to me and said she had taken them off and
pitched them across the room. You see how very irritable
she was; most patients would have laid them on the table.
I again reasoned with her, and eventually she wore them con-
tinuously, and in three weeks found she was getting benefit
from them—she began to sleep better, and the sleeping
draughts which she had been taking were dispensed with.

After she had worn her glasses five weeks, she had an
accident and broke them, and sent an urgent message to the
optician to have them repaired immediately, as she could not
get on without them.

I saw her on August 25th, before leaving Harrogate, and
found her better in every respect, and four months later she
reported herself as being very much better, and with care,
very free from nerve troubie.

 
170 BIOGRAPHIC CLINICS.

This was a very wealthy patient, who had sought
advice from many sources, and any treatment sug-
gested could be carried out, but no one seemed to
have paid any attention to the eyes until the doctor to
whom she had been sent in Harrogate advised her to
consult me. My difficulties in adapting glasses in this
case were much increased by the fact that the patient
was very sceptical, very sensitive, and so irritable that
the process of testing the sight was a great tax upon
my patience as well as upon hers.

Case X.—The next was a much simpler case—more recent,
less severe, and the patient very amenable to treatment. She
was married, aged about forty, very energetic, and highly-
strung temperament. She was a great reader, and got through
a good deal of needlework as well.

Two years ago, she had quite a breakdown of her nervous
system. She had no headaches, but great depression, felt
utterly incapable of attending to her household duties, was
sleeping badly, and as she expressed it, felt that she was not
herself at all. As tonics, etc., seemed to have no effect her
doctor sent her into a nursing home, where she had five weeks
of Weir Mitchell treatment, from which she derived much
benefit and kept fairly well until the spring of last year, when
the same symptoms as in the preceding spring all began again,
and I was asked to examine her eyes. I found slight hyper-
metropic astigmatism, for which I prescribed. She had just
returned from a week at Scarborough, but with this exception
no other special treatment was adopted. She gradually re-
covered her nerve tone, and I saw her last month, looking,
and expressing herself as feeling quite well.

The simplicity of the treatment and the expense on
this occasion were in strong contrast to the experience
of the preceding year.
SLIGHT ERRORS OF REFRACTION. 171

Case XI.—The next case, which I saw in October of last
year, is so graphically portrayed by the patient herself that
I cannot do better than read to you her reply to my inquiry
as to her present condition. In this case there was hyper-
metropic astigmatism of different degree in the two eyes, but
with quite good vision. I ordered glasses for constant use.
She writes as follows:

“T have had severe neuralgia for more than twenty years,
but for the last four or five years the pain has been increasing,
both in intensity and frequency. About two years ago I col-
lapsed, and was treated for ‘nervous prostration.’ I had always
been very sick with every attack, but the sickness got much
worse, and I was quite an invalid. I had no memory, and
was in a miserably nervous state, and worst of all, I think, I
was morbid. When I went to see you in October last I was
having about three attacks of violent pain and sickness almost
every week. I could only crawl along, and was never trusted
out alone. I daren’t cross a road, and could not bear to look
at anything painful. You may perhaps remember that when I
saw you again in December, I was alone, and had gone to
Harrogate from Manchester by myself. The attacks had
quickly diminished to about five or six in the two months,
and I had been only slightly sick. I have gone improving at
the same quick rate, and it is more than a month since J was
sick at all. I have within the last month nursed my two girls
through influenza, and have not had a bad attack of pain.
I can walk quite well and am not afraid to cross a road. I
feel alive and happy, and can trust my own judgment of things
once more. We had all made up our minds to my being a
helpless sufferer for the rest of my life, and I am now more
active than I have been for years, more cheerful, and sane
altogether.”

As no other mode of treatment was being tried in
this case, there is, I think, little room for any miscon-
ception as to the cause of the truly distressing state
172 BIOGRAPHIC CLINICS.

this patient was in, and so well described by her, nor
as to what this great improvement is due.

Just one other case, which I saw in 1894, shows, I
think, that the eye-defect was unmistakably the start-
ing point of the nervous troubles, and that the glasses
were as assuredly the cure.

 

Case XII.—Miss P— , aged 30, had suffered much dur-
ing school life from sick-headache, being often absent on that
account, but her sight was not tested. As she grew older,
other symptoms developed, giddiness, and extreme depression,
and she became so nervous that she could hardly bear to sit
in a room if many others were present. At twenty her condi-
tion became so serious that she was under medical treatment
for three months, and a grave view was taken of her case.
It then occurred to her doctor that it would be desirable to
have her eyes examined. She was sent to an oculist, astig-
matism was diagnosed and glasses ordered. She soon began
to mend, and eventually got quite well. She came to me in
1894, complaining that all the old symptoms which she had
entirely lost for ten years were returning.

I examined the eyes, and my results exactly coincided with
the glasses she had, so there could be no change in her refrac-
tion to account for her relapse. I then asked her to put on
her pince-nez, and found that the horizontal spring was worn
out, so that the axis of the lenses was quite altered, and the
glasses were not fulfilling the purpose for which they were
intended. I advised the repair of her pince-nez, which was
carried out. She soon got quite well again, and has had no
trouble since.

This case speaks for itself.

I will now pass on to true epilepsy and petit mal,
but do not propose to read any cases, for in these
SLIGHT ERRORS OF REFRACTION. 173

ailments other methods of treatment, notably by bro-
mides, are invariably being used, so that one’s results
are always open to doubt. I will therefore confine
myself to the statement that some error of refraction
is very commonly present and that the correction of
it tends unmistakably in my opinion to mitigate both
the intensity and frequency of the attacks.

I will allude to one other type of nervous trouble—
that in which the hysterical element predominates.
This class has, I believe, become more restricted now
than in the days of my earlier experiences, when my
labors were not confined entirely to eye work, but
when I had to examine patients from the general
practitioner's point of view and not only through the
spectacles of the specialist. For instance, some of the
cases which are now called neurasthenia would have
probably been included in this category.

What is it that causes in the first instance that per-
version of nerve force which gives rise to the con-
dition we speak of as hysteria? The very fact of so
many causes of the initial irritation of the nervous
system having been suggested and the difficulty of
giving any actual demonstration of the presence and
mode of action of such suggested causes, make one
feel that this is still a question that has to be solved.

I should like now, briefly, to relate two or three
cases which seem to me to be of interest, and which
174 BIOGRAPHIC CLINICS.

supply some suggestive material for reflection in con-
nection with this abstruse subject.

Case XIII—I was asked to see the following case on Oc-
tober 4, 1894. Miss M . aged 32, was in bed, and com-
plained of being unable to open the eyes as she could not bear
the light. She had kept the eyes tightly closed for a fortnight
in a darkened room. Having made up my mind, from such
examination as I was able to make, as to the nature of the
case, I put some cocain drops into the eyes and told her to
keep them firmly closed and to make no attempt to open them
for five minutes, and that she would then be able to open them
as well as ever. During this interval I listened to further
details of her history, and will now read you an abstract of a
very long written account which she had sent me of her ex-
periences from sixteen to thirty-two years of age:

“ Fairly strong until 16 years of age (1878), when ‘nervous
debility’ came on—grew weaker and lost the use of her legs
and could not sit up, and for ten years was always either car-
ried or wheeled about in a chair, and for six years after this
could only move about the house with the aid of a crutch. In
1881 her spine was cauterized, causing terrible pain and in-
creased sensitiveness. In 1882 confined to the couch for sev-
eral months, and had the first attack in the eyes, inability to
open them and could not bear the light. These attacks re-
curred every November or December for 12 years, lasting on
each occasion three or four weeks. After this she was sent
to a nursing home for electricity and massage, and to be
separated from her friends, and remained seven months ‘with
little benefit. Residence in the country and at the seaside were
both tried, sometimes gaining a little, and then relapsing.
In 1885 and 1886 tried electricity, but derived no permanent
good. Continued much in the same state until 1894, when T
first saw her.”

At the end of five 11inutes she was able to look about the

 
SLIGHT ERRORS OF REFRACTION. 175

room quite comfortably, and there was nothing abnormal to
be seen in the eyes. I ordered cocain drops and said the eyes
would be quite well in two days, and she was then to come
to my house that I might test her sight.

She arrived, and with the aid of a crutch under one arm,
a stick in her hand, and supported by her sister (a trained
nurse), came into my consulting-room. I found myopic astig-
matism in the right and simple myopia in the left eye, and
ordered spectacles for constant use.

Three months later she came to me unattended. She had
discarded the crutch entirely, but told me she carried a stick
out of doors as she did not yet feel quite confident of her
walking powers.

I saw her again in 1895, in November, and found her greatly
improved in every respect, and able to walk about by herself.

It is now more than eight years since I first saw her—the
improvement which took place has been maintained, and a
point which I wish to emphasize is that there has been no
fresh development of any hysterical symptom.

Case XIV.—In July, 1898, Miss H . a healthy-looking
girl of eighteen years of age, was sent to me by her doctor
with a history of attacks of inflammation in both eyes which
had defied all treatment for seventeen weeks—frequent, sud-
den attacks of great congestion and much watering of the
eyes, and lasting for a few hours only. There was nothing
abnormal to be. seen at her first visit to me, but on testing
the sight, I found myopic astigmatism, and ordered glasses to
be worn constantly, and some boric acid lotion to be used for
three weeks. At her next visit an attack came on very op-
portunely in my waiting room. On carefully examining the
eyes I found a minute foreign body inside the lower lid, which
on examination with the lens looked like vegetable matter. I
put this aside for further examination—had the eyes fastened
up with compress and strapping so that she could not get at
them for three days, during which time no attack occurred. In
the meantime I came to the conclusion that there was some-

 
176 BIOGRAPHIC CLINICS.

thing of the nature of the onion about that foreign body; so
I spoke to the girl alone, told her I now knew the cause of
the attacks, and that she must not have any more of them or
her parents and her doctor would have to be told. The cure
was complete, and again in this case there has been no fresh
development of a hysterical nature after five years of observa-
tion. It is also noteworthy that in this case, as in the last,
astigmatism was present, and that in both instances the eye
was selected for the hysterical manifestation.

Case XV.—My last case is described by the doctor who sent
her to me, and who writes as follows:

“Mrs. S . who is over the climacteric, has for the last
twenty years been subject to peculiar attacks of unconscious-
ness, coming on without warning or apparent cause. I found
her in one in my waiting-room to-day—the first J have seen.
She had just come in, asked the servant for a drink of water,
but before it could be fetched, lapsed into unconsciousness.
Color good, pulse regular, breathing regular, but very faint,
twitching of eyelids, conjunctival reflex almost absent, pupils
equal, slightly contracted, but reacting to light. She remained
in that condition for nearly two hours. The attacks seem to me
to be of an epileptic nature, but without any convulsive action.
She is a neurotic subject, but on looking for a peripheral irri-
tant to the nervous system I could only find it probable in the
eyes, and a history of headache (occipital more than frontal),
so send her to you to see if you can find any cause in the eyes,
and if suitable glasses will do anything to avert the attacks.”

I found hypermetropic astigmatism in the right and simple
hypermetropia in the left eye, and on the correction of this no
more attacks occurred, and after five years’ observation no
fresh developments of a nervous character have arisen.

 

Many matters of the greatest importance often have
very trifling beginnings, and yet when we reflect upon
the picture of suffering and misery presented to us by
SLIGHT ERRORS OF REFRACTION. 177

some of the cases I have quoted it seems almost incred-
ible that it could have been brought about by so small
and apparently trivial a cause as a slight error of
refraction.

But as we have seen it, beginning in early life,
slowly and obscurely, but surely, bringing its perni-
cious influence to bear upon the nerves more and more
energetically as age advances.

Finally, if undetected and untreated, we have seen
it gradually undermining the whole nervous system,
and we find the sufferer in a state of hopeless despair.

When I think of the incalculable amount of suffer-
ing which might be averted if, by careful and pains-
taking observation, the earliest indications of nerve
trouble were noted, I feel that I cannot be too emphatic
in urging you always to bear in mind the vast pos-
sibilities and far-reaching effects of these apparently
trifling errors of refraction. Sil

Mr. Proncer’s SECOND PAPER.*

Two years ago I read at a meeting of this Society
-a paper on the influence of slight errors of refraction
as a starting point of many functional nerve troubles,
quite apart from any impairment of vision or local
discomfort to suggest eye trouble. I mentioned some
of the commoner remote effects of eyestrain, such
as migraine and the various forms of headache, in-

*March, 1905.

13
178 BIOGRAPHIC CLINICS.

somnia, vertigo, depression, irritability, choreic move-
ments of facial muscles, and various troubles usually
treated as disorders of the liver or stomach.

Having referred briefly to epilepsy, petit mal, chorea
and hysteria, the question was submitted, for your
observation and consideration as to whether the real
starting point of those various symptoms to which the
name neurasthenia has been given might not be slight
error of refraction; that the soil being prepared, as it
were, by its insidious harmful effects, the supervention
of shock or any one or more of the long list of causes
of neurasthenia which have been suggested might not
bring about the crisis or breakdown which at first
sight would be looked upon as the beginning of the
condition of neurasthenia.

Your reception of my paper was most gratifying to
me, and it has been still more gratifying to note that
the large majority of you have put to a practical test
the propositions submitted to you. Some, of course,
were sceptical and a few scoffed, and it was remarked
that “ Pronger was going to cure everything with
spectacles”; and, in reply, I ventured to predict that
we should in time hear much more of this subject.
My paper, read and printed in March, 1903, was fol-
lowed in September by a long article in the British
Medical Journal on a book on “ Biographic Clinics,”
brought out by Gould of Philadelphia; and it was very
pleasing to me to find that many of the main points
SLIGHT ERRORS OF REFRACTION. 179

advocated in that book were identically the same as
in my own paper.

From the dates given in some of the cases in my
paper it will be seen that this special subject has en-
gaged my careful attention for more than ten years—
my first paper on this subject was in 1895—and Gould,
in a letter recently received from him, tells me he has
long been urging this subject upon the profession.?

Now, when two men, working upon the same lines
and quite independently for some years, arrive at prac-
tically the same results, it would seem probable that
their conclusion would be fairly accurate. More espe-
cially should it be the case in regard to these slight
errors of refraction, seeing that many of the remote
effects of the higher degrees have been recognized and
recorded.

In continuation of my paper of two years ago, I
want to say something about neurasthenia, if I may
venture to discuss a subject which has hitherto been
generally looked upon as quite outside my department
and belonging almost exclusively to the province of
medicine.

Now, if we consider for a moment the many sug-
gested causes of neurasthenia, and let us take, for

*I read a paper before the British Medical Association in
1894, published in British Medical Journal September 15, 1894,
upon “Low Degrees of Ametropia and Their Results as Sys-
temic Diseases.”—G. M. G. °
180 BIOGRAPHIC CLINICS.

example, a very common one, worry, we are at once
struck by the fact that out of large numbers subject
to this influence, only one here and there actually
breaks down under it. Is it that the worries and
anxieties of these few are so much greater than those
of the others? or is it that the nervous system is less
stable, that there is some predisposing cause which
renders it less able to resist the tax put upon it?

We might go further, for in many cases of neuras-
thenia one of the earliest symptoms observed is a dis-
position to worry about the merest trifles, and in such
cases, if really great worries or anxieties were to crop
up, a breakdown would readily occur. Is the worry-
ing cause or effect?

It behooves us, therefore, to search for such a cause
as would be likely to so affect the nervous system as to
predispose it to break down under the influences which
have been suggested as the causes of neurasthenia.

We have such a cause in refractive error; and this
is not merely a theoretical suggestion on my part, but
the conviction which has resulted from actual observa-
tion of large numbers of cases during many years, and
the careful following up of the results of treatment.
A rather striking instance occurs to me which illus-
trates the point I wish to impress upon you. A few
years ago I prescribed glasses for a medical man well
known to you all for the correction of astigmatism,
in spite of the fact that up to that time he had consid-
SLIGHT ERRORS OF REFRACTION. 181

ered that his eyes were normal; in fact, they had been
tested and he had been told so. Some time after this
he had occasion to go over to Ireland, as he had fre-
quently done before, but had always dreaded the jour-
ney, as he was invariably violently sick. On his return
he came to me and told me that he had had a very
rough passage both ways, but he had not been in the
least sea-sick, and that he attributed this to the glasses.
In this particular instance the motion of the sea was
not by itself sufficient to upset him, the additional in-
fluence of that slight error of refraction having been
removed. The scepticism with which this incident
would be received by many, and the ready explanation
given that it was merely a coincidence, suggest that I
should pursue the case a little further. The same pa-
tient was also a great sufferer from train-sickness, a
not uncommon result of astigmatism. With his glasses
on he can now take a long journey without incon-
venience. Here again the train journey would be the
obvious cause of his trouble, the more important, but
less apparent, cause being slight error of refraction.

It seems to me not unreasonable to suppose that the
same thing might happen in other functional nervous
derangements, and why not in some of those conditions
called neurasthenia?

I will now take two cases of neurasthenia having
many points in common, in which this contention ap-
pears to be borne out.
182 BIOGRAPHIC CLINICS.

J. L. B., zt. 51, married, consulted me May 8, 1903.
Led an outdoor life, learning farming until 24 years
of age, and enjoyed good health. He then began to
study for the ministry, but his studies were much
hampered by severe headaches. He persevered, be-
came a minister, and eventually occupied a posi-
tion of great responsibility, and which involved much
hard work and anxiety. He began to suffer severely
from insomnia, vertigo and extreme depression and
finally his nervous system broke down completely. He
was treated as these cases usually are: first, by his
family doctor and afterwards by another, both per-
sonal friends, who took the greatest interest in his case.
He also saw an ophthalmic surgeon in town, who pre-
scribed glasses which might be used for reading, but
the patient seldom used them, as he could see well
enough both for distance and near work for all visual
purposes. A London consultant then advised a pro-
longed stay in Switzerland, and this was carried out,
but with a most disappointing result. A course of
treatment at Woodhall Spa was next tried, but being
no better he was afterwards sent to Harrogate. The
doctor whom he consulted sent him at once to me, and
abstained from any other treatment, as he wished to
see if spectacles would have any effect. The patient
told me he could see quite well and did not believe
the eyes could have anything to do with it, but was
willing to try anything, although he quite despaired of
SLIGHT ERRORS OF REFRACTION, 183

ever being any better. Six months later he wrote:
“After ten weeks of hard and anxious work I am still
holding my own. This is such a joy to me that I am
preaching this new treatment wherever I go. After
the little confusion which the glasses caused—the per-
spective of everything being altered—I began to im-
prove in health, and for six months have never had any
setback. Refreshing sleep became habitual after a
long period of insomnia, during which I was quite a
wreck, and with sleep strength began to return, and
life, which had been a burden, is now a delight.”

The next case—J. M., married, et. 53, consulted me
in August, 1902. He had suffered much in the same
way as the last, occasional severe headaches, great
mental depression and insomnia. He had been obliged
to give up his occupation (a ship-builder), and had
been treated by twelve different medical men before
consulting the one who sent him to me. He did not
then believe that glasses could be of any use, but con-
sented to wear them. Having no faith in them, he
consulted two nerve specialists, one of whom pre-
scribed the common remedy, a prolonged stay in Swit-
zerland. His letter, received on January 2, 1905,
shows that he has grasped the very point which I wish
you to more fully recognize. He writes “that his
health is vastly improved since first consulting me;
that, after taking to glasses, he had, as the result of
consulting two nerve specialists, carried out a treat-
184 BIOGRAPHIC CLINICS.

ment—prolonged stay in Switzerland—which had not
been previously tried; this his first long journey after
taking to glasses was accomplished without a headache
(although worn and tired in other respects), a thing
which had not happened for many years, and showing
that he was getting benefit ; that he is fully of opinion
that had he not worn glasses the treatment would not
have had such good and permanent effect.” These
two cases suggest that, however helpful the change of
air and scene may be in these cases, they are not
enough by themselves to cure if there be a slight uncor-
rected error of refraction in the background; but first
correct this, and the combination will effect the cure.
In my experience error of refraction is almost in-
variably present in neurasthenia, and I do not mean
the infinitesimal amount which physiologists tell us is
present in all eyes, but an appreciable quantity such
as can be detected and corrected by glasses, a quarter
of a dioptre upwards. I have often wondered how it
was that this association had not been observed; or,
if so, that greater importance had not been attached to
it. One reason now occurs to me. Having read a
long and able article on neurasthenia in the Journal,
I was struck by the fact that refractive errors were not
mentioned, and asked the author what his experience
had been in this direction. He told me that the cases
he sent to the ophthalmic surgeon were nearly always
returned as “ normal, or practically so.” The last two
SLIGHT ERRORS OF REFRACTION. 185

words, “practically so,” suggest a great deal. The
ophthalmic surgeon—and I speak generally, not of in-
dividuals—finds the patient can see & with each eye,
and can read J1 without difficulty, and makes no com-
plaint of aching or of trouble of any kind connected
with the eyes; even headaches may not be a symptom.
He not having had a large experience as a physician,
or knowing much of neurasthenia, is satisfied with the
patient from a visual point of view, and reports “ nor-
mal, or practically so.” He may or may not have
observed slight astigmatism; but if so, why saddle a
patient with spectacles under such conditions?

It is necessary that both the physician and the oculist
should understand the principle which I suggest to
you if good is to result.

The following is a case in point:—A physician in a
neighboring town suspected the presence of astig-
matism in a boy of 14 suffering from nerve troubles,
and sent him to an ophthalmic surgeon, but the report
came back as “normal.” Not being satisfied, the phy-
sician asked me to examine the boy,and I found a quar-
ter of a dioptre of hypermetropic astigmatism in each
eye, axis oblique, and ordered glasses to be worn con-
stantly. The boy got quite well and kept so for twelve
months, when the mother brought him to me again,
saying the symptoms had suddenly all come back again.
As the result of a fall one of the lenses had dropped
out of his spectacles and had been replaced, but with
186 BIOGRAPHIC CLINICS.

the axis in the opposite direction to that prescribed.
Some of you have said that my results are due to sug-
gestion and how well this case would have fitted in
with that view but for that little accident. One can-
not, of course, say what this boy’s future might be if
the astigmatism were uncorrected, but it is quite pos-
-sible that it might be not unlike that of a patient whom
I saw in August last, whose error of refraction was
very similar. This patient described his experiences
in somewhat emphatic language in a letter four months
after his visit to me. He says: “ Personally, I can
say that life has been much more enjoyable since I
visited you. Previously I was intensely irritable and
frequently ‘cursed myself in my despair.’ Latterly I
have arrived home from business with a slight surplus
of energy and power of concentration which previously
was a rare thing for me to do. I have changed my
residence frequently, fled to poultry farming once, and
generally behaved in a manner which caused my
friends to have serious doubts regarding the stability
of my mental gear. I now begin to appreciate Car-
lyle on ‘ Permanency,’ and can form a plan of life
where previously chaos reigned. It is impossible, of
course, to say or conceive what might have been, but
my own personal conviction is that I should have been
less of an ass if my eyes had not troubled me so per-
sistently. My internal and secret profanity must have
at times satiated the devil himself, assuming such a
SLIGHT ERRORS OF REFRACTION. 187

personage to still exist. I sincerely hope that this
happier frame of mind will become chronic, and that
you may long be spared to alleviate the suffering which
-can only be understood by those who have had to en-
dure it for years as I have done. I have endeavored
to represent to you as nearly as possible my actual feel-
ings on this subject, and trust you will excuse my
departure from conventional expressions in my effort
to truthfully convey my ideas.”

One meets with constant variety in the cases sent to
one as neurasthenia, and it is sometimes very difficult
to tell how much is due to functional disturbances,
and whether there may not be some organic lesion
present.

A patient was sent to me in May of last year, in
whom no organic lesion had been detected, although
she had been seen by several medical men, and yet that
patient died in the following November, and the
autopsy revealed chronic Bright’s disease. This pa-
tient derived very great benefit from the use of glasses
in the relief of her neurasthenic symptoms, and the
case is instructive in that it shows how necessary it is
to bear in mind the possibility of refractive error being
present as a complication in cases of organic disease.
Had the Bright’s disease been recognized, her neuras-
thenic symptoms would, no doubt, have been attributed
to that, and the patient would not have been sent to me.

Especially would I suggest this point to you in con-
188 BIOGRAPHIC CLINICS.

nection with gout, for when once that word has been
used there is a great disposition both on the part of
doctors and patients to attribute all symptoms to that
special cause, and but for this complication being over-
looked, many cases of headaches, insomnia, etc., might
be speedily relieved.

Perhaps it more frequently happens that serious
brain or other lesions are supposed to exist, in which
the results show that the troubles are entirely func-
tional. The following is an illustration: J. S., et. 44,
had suffered for some years from nervousness, dizzi-
ness and headaches, and for the last six months had
been obliged to give up his occupation. From the
severity of his symptoms generally, his medical atten-
dant wrote that he feared some serious brain trouble.
The doctor who saw the case here asked me to ex-
amine him, and I prescribed glasses for constant use.
The medical attendant at home was at first somewhat
annoyed, as he had already sent the patient to an
oculist, who had found slight astigmatism, but had con-
sidered it so slight as to be of no special importance.
The patient got rapidly better, returned to his occupa-
tion, and has since been to Harrogate for a holiday,
but feels that he does not now require any treatment.
This case shows how dangerous it is to ignore slight
errors of refraction, and how misleading it may be to
the physician.

It is always interesting to watch the effects of treat-
SLIGHT ERRORS OF REFRACTION. 189

ment in cases in which the conditions are similar, and
in that respect the three following instances are of use:

In the spring of 1903 three patients came under
observation, all married, all about the same age, sim-
ilar conditions of life, one being a solicitor, one a
doctor,and one a manufacturer, with similar symptoms,
headaches, irritability, depression and feeling unfit to
continue the ordinary duties of daily life. They had
all tried the usual remedies advocated in these cases,
special attention having been paid to the functions of
the liver. In spite of treatment they had all arrived
at that stage in which something must be done, as they
could not go on as they were. In all three cases a
sea voyage had been prescribed. In all the cases the
vision was quite good and there was no complaint of
any kind directly connected with the eyes. The doctor
came to see me and I ordered glasses for slight astig-
matism to be worn constantly, and he started for a
voyage. The solicitor also went by the same ship, but
knew nothing of his fellow passenger, and he did not
consult me before leaving. The manufacturer, after
hearing my opinion of his case, decided not to take the
voyage, but returned to his duties. The doctor tells
me that the long rest and change of the voyage un-
doubtedly did him a great deal of good, and he also
noticed that he could read in the train without head-
ache since wearing the glasses, which he could not do
previously. I, too, have observed that although the
Igo BIOGRAPHIC CLINICS.

glasses are not in any way a necessity from a visual
point of view, he is now never seen without them; in
fact, on three occasions he tells me that he has got into
bed with them on. The manufacturer has taken no
voyage, but steadily improved in health, and in six
weeks reported himself as much better. The improve-
ment continued, and I saw him recently in his usual
good health and enjoying life again as of old. He
was rather indignant at being sent to me, as he had
been told previously that his eyes were normal, but
he tells me he now wears his glasses constantly and
has done so ever since I first saw him. The solicitor
returned from the voyage greatly disappointed, as he
was little, if any, better. A few weeks later, being as
bad as ever, he consulted me, and I prescribed glasses
for constant use. In a letter received six months later
his wife writes: “ My husband is now very well in-
deed,” the “very well” being underlined.

It is my lot to frequently see instances in which the
whole career of an individual has been blighted and
changed as the result of a cause which might have been
easily remedied had it been detected and its importance
recognized. This nearly happened to the writer of the
following letter, who was considering the question of
giving up his post, when he was advised to consult me.
This advice was a surprise to him, as he had always
attributed his symptoms to digestive disturbances, and
had had no discomfort in the eyes, and was not con-
SLIGHT ERRORS OF REFRACTION. Ig!

scious of any defect. He wrote me four months after
his visit as follows: “I must tell you of the great
benefit I have received from the constant use of the
glasses you prescribed for me on July ist last (1903).
I had suffered from headaches for many years, the
pain being chiefly frontal, and at times so acute that
the whole of my head felt as though it had been burnt.
About three years ago I was subjected to a very pecu-
liar attack, a sudden dizziness overtook me when just
awaking from sleep and I fell into an unconscious con-
dition which lasted for about fifteen minutes. On
recovering I was left with one of those violent head-
aches. ‘These attacks I suffered from repeatedly, and
when up and about it required a very great effort to
prevent oneself from becoming unconscious. I saw a
London specialist, who advised the use of bromides,
but with no definite result. Towards the end of June
last Dr.
worn the glasses ordered ever since. About ten days
after this I had another of those attacks, perhaps the
most violent I have had, this occurring early in the
afternoon. Previous to this attack I had occasionally
discarded my glasses, but since then I am never with-
out them. Four months have now elapsed and, so far
as these attacks are concerned, there seems no proba-
bility of their return. Before my visit to you lapses
of memory were almost a daily occurrence; now they
are practically unknown, and when in evidence are but

 

advised me to consult you, and I have
192 BIOGRAPHIC CLINICS.

momentary. The periods of dizziness have quite dis-
appeared. I feel better in health, my brain is clearer,
the headaches have never returned since I wore the
glasses, and the state of depression into which I was
sinking has entirely passed away.”

Were I to assert that error of refraction is respon-
sible for a large proportion of the suicides occurring
daily, and that it is a potent factor as a cause of
insanity, that assertion would probably be held up to
ridicule and dismissed as absurd. Many things appear
at first sight improbable, but on reflection much less
so, and I will ask you to reflect for a few minutes on
this subject. When you have seen, as I have done in
a very large number of cases, the effect of uncorrected
errors of refraction on the nervous system, you will
be struck by the great frequency of the occurrence of
such symptoms as insomnia, great irritability, extreme
depression, impaired memory, difficulty of concentra-
tion of thought, lack of self-confidence, apprehension,
weariness and exhaustion, and a general want of sta-
bility of the nervous system. I have tried to illustrate
error of refraction as the cause, and the correction of
it the cure for these troubles. How often the patients
have told me they have been on the verge of suicide,
and have used the expression that they were afraid
they were going out of their minds. It is quite con-
ceivable that suicide would be more likely to occur in
those who had been for a long time enduring the
SLIGHT ERRORS OF REFRACTION. 193

mental torture which results from the conditions I
have enumerated and which has rendered life a burden.
I will read one or two extracts from actual reports of
suicide.

“The deceased had been very low-spirited and had
been under medical treatment for six months ; she com-
plained of pains in the head.”

Another case: “ The deceased had been afflicted with
nervous debility about four years.”

Again: “The deceased had suffered latterly from
insomnia, and had been much depressed.”

Again: “ The deceased had suffered from influenza,
later insomnia, and had been taking narcotics to induce
sleep.”

If alongside of these extracts you read some of the
cases I have already quoted, or the following letter, it
certainly provides suggestive material for considera-
ation.

The writer says: “ I must tell you how grateful I am
for what you have done for me. I should have written
long ago, but wished to give the glasses a thorough
test, and to see if the attacks of terrible depression
returned which I have suffered from previous to seeing
you. I am glad now to tell you I find the glasses a
great comfort, and have never once had a return of
those particular attacks of depression which had hith-
erto made life a misery to me.”

Many of you will be able to recall instances of suf-

14
194 BIOGRAPHIC CLINICS.

ferers such as I have described flying to narcotics or
alcohol for temporary relief from their distress, and no
doubt this leads to much of the secret drinking which
prevails to so great an extent. In view of the large
number of suicides attributed to alcoholic excess, ought.
we not to look upon intemperance as a disease, and
always try to find out the circumstances attendant upon
its commencement as to whether or not it might be due
to a remediable cause? We should often be able to
trace it to conditions of suffering such as I have de-
scribed, and on examining the patient, the presence or
absence of error of refraction would be a most impor-
tant point.

Errors of refraction are largely on the increase, and
for two reasons-—firstly, as a result of the great de-
mands made upon very young children by the educa-
tional system of the present day, and secondly, from
the fact that they are hereditary. Insanity is also
largely on the increase, not only numerically, but pro-
portionately. May there not be a connecting link
between these two facts? Much that I have said in
regard to suicide might also be applied to the question
of insanity. To those of you who have had much ex-
perience of cases similar to those I have represented,
it would not, I think, require a great stretch of the
imagination to suppose that some of them might lose
their mental balance and become insane or gradually
drift into a condition of melancholia. Insanity is
SLIGHT ERRORS OF REFRACTION. 195

sometimes attributed to shock, but it would be an
alarming thought to feel that any one of us, if exposed
to a severe shock, might suddenly become insane. We
could more readily understand such an effect being
produced in one who has been a long sufferer from
neurasthenia, and this reminds me of a case sent to me
for neurasthenia. The doctor told me she had on two
occasions been out of her mind, the cause being attrib-
uted to shock at the loss of her sister, who had sud-
denly disappeared when on board ship and had not
been seen since. This patient had for a long time
suffered from neurasthenic symptoms, and had always
been of a highly-strung nervous temperament. She
had slight astigmatism in both eyes, but of different
degree. She had previously been sent to two eminent
ophthalmic surgeons, but they had, apparently, not
attached sufficient importance to the refractive error
to insist upon its constant correction. Again, what a
very important position is always assigned to alcohol
in the list of causes of insanity. If alcohol by itself
were the cause of insanity, we should expect even a
larger number of cases to result, seeing the vast extent
of its use and abuse, and also more frequent and more
rapid cure on its complete withdrawal. In a typhoid
epidemic you would not be content to trace the cause
to the milk only, but would pursue your investigations
to the source of contamination. Would it not be more
reasonable in this case also to investigate the condition
196 BIOGRAPHIC CLINICS.

of the nervous system which led up to the excessive
use of alcohol? and this would often take us back to
that starting point which would suggest a very careful
examination of the patient’s eyes. The truly distress-
ing condition of some of these neurasthenic cases sug-
gests strongly to my mind that as there so frequently
is a complete nervous breakdown, so, if unrelieved,
there might be eventually a mental breakdown. I can-
not help thinking that a thorough investigation of the
previous history and a very careful examination of the
refraction would result in some of the forms of insanity
being traced back to these early manifestations of nerve
troubles which have been shown to be due to eyestrain.

We have heard lately of pre-cancerous conditions,
and my suggestion is that we have also a premonitory
stage in some of the forms of mental breakdown, and
that it is during this stage that so much might be done
to avert disaster.

The following is a suggestive and instructive case
in regard to this point: Mrs. C., et. 36. Extremely
neurotic, had suffered intensely in her head for some
years, especially the last four years. Not so much
actual pain, but distressing sensations and a constant
dread of going out of her mind. Great depression and
nervousness and could not be prevailed upon to go
out by herself. Could not go to a theatre without
much suffering after it, and, in fact, was practically
debarred from all social functions, and quite unfit to
SLIGHT ERRORS OF REFRACTION. 197

attend to domestic duties. She had been variously and
greatly treated, had changed her place of abode several
times, had had a course of Weir Mitchell treatment ;
she had consulted five different medical men in Har-
rogate, a consultant in Leeds and nearly all the doctors
in Scarborough. She could see quite well without
glasses, but promised to wear them, as she would do
anything to get better. She persevered and very grad-
ually, but very surely, improvement took place. In
eighteen months after I first saw her she was much
better in every way, came over from Scarborough un-
attended by her husband; could go to theatres and
attend to domestic matters, and life was now to her
worth living. J have recently had a further report
from her husband, who writes: “ When my wife first
called upon you she was in such a state of nervous
prostration that she was totally unfit to perform or go
through the ordinary duties of life, and I feel confident
that the wearing of spectacles enabled her to battle
against her feelings and saved her from a mental
breakdown. For the past two years she has never
been without her glasses and now her health is nearly
restored. May she now leave off the glasses out of
doors ?”

This was a very long-standing and severe case, and
some months elapsed before very marked improvement
was observed. Bearing in mind her condition when I
first saw her, I can only endorse the opinion expressed
in her husband’s letter.
198 BIOGRAPEHIC CLINICS.

I would suggest that in all cases of neurasthenia in
which error of refraction is present, it should become
the routine practice to have that error corrected. If
this be skilfully done and the correction perseveringly
worn by the patient, I am quite convinced that those
measures which may be prescibed by the physician for
the restoration of nerve tone will be not only more
rapidly successful, but more permanently so.

I must ask you to receive these remarks as far as
possible with an open mind, not with the idea of criti-
cising my feeble attempts at the elucidation of such
intricate and difficult problems, but rather to try to
find in them some hints, some suggestions to help you
in your efforts to throw more light upon these obscure
subjects.
THE HISTORY AND ETIOLOGY
OF “MIGRAINE.”
CHAPTER VI.
THE HISTORY AND ETIOLOGY OF “MIGRAINE.”?

THE word migraine (megrim, the megrims, etc.) is
the vulgarization of a misnaming and meaningless
term for a malobserved and trivial symptom, which in
the majority of cases is not present, of a widely prev-
alent and ingravescent disease with indescribable symp-
toms which wrecks life and morbidizes the mind, the
etiology and pathology of which are unknown, the
location or organs affected being also unknown, and of
which no treatment avails.

The term is a corruption of the Greek ‘Hpzpavia and
the Latin, Hemicranion or Hemicrania, taken to mean
a pain in one side of the head. The word is, of
course, an absurdity, because it denotes not pain, but
only half-headedness, the idea of pain having no part in
the construction of the word. One may perhaps spec-
ulate in vain as to the reasons of the Greeks for making
half-headedness a synonym of pain in or on one side of
the head. The fact itself seems to imply that when the
word was born there must have been many patients
who were so greatly tormented with this unilateral pain
of the head that it was at once understood when such a

1From the Journal of the American Medical Association,

January 16 and 23, 1904.
201
202 BIOGRAFHIC CLINICS.

patient was spoken of as “ half-header ’—“ the man
(or, more probably, woman) with half a head.” The
term was used in this way by Hippocrates, Galen and
other Greek physicians with the same indiscrimination
to express all headache, until Alexander Trallianus in
the sixth century recognized that there were two forms
of headache, and he urged that hemicrania or migraine
was that which resulted from gastric disease or suf-
fering.

In the seventeenth century the kinds of headache be-
gan to multiply and. they have continued to do so until
now they are almost innumerable. The more cool-
headed, at least not half-headed, English of one or two
hundred years ago, began to recognize that “ half-
head” did not imply pain, and that pains in the head
were by no means one-sided. Migraine, they saw, was
not etymologically a pain and the pain that existed in
patients was not migrainous. Thence began the use of
the good old English word head-ach. In his excellent
dictionary published in 1809, Parr refers migraine or
megrim to cephalalgia, and treats of the whole subject
of headache, migrainous or not, under this heading. It
was a sensible thing to do. It followed that the head-
ache accompanied by gastric disorder, nausea, vomit-
ing, indigestion, etc., naturally and rightly received the
name sickhead-ach, or as we now say, sick-headache.
With so-called “ scientific” medicine (which in so far
as pertains to this disease is absolutely as unscientific
as was that of classic or medieval times) there was a
HISTORY AND ETIOLOGY OF MIGRAINE. 203

relapse to the absurd term migraine, and under that
caption are now published hundreds of erudite mono-
graphs that throw little or no light of knowledge on
the ludicrous tangle. The word is now applied to a
symptom-complex of infinite variability to indicate a
very common and violent disease, the cause of which
is wholly unknown and for which there is no cure.

The old term “sun-pain ” applied to the disease is
of illuminative significance. It was so called because
it ‘lasted, in the olden times when the theory was
formed, only so long as the sun shone, and ceased with
darkness. Now in those times all reading and writing
was done by daylight; at night the absence of artificial
lights compelled cessation of literary, sewing,and hand-
craft occupations. With this ocular rest, as always,
came immediate relief of the ocular reflexes called
“head-ach ” and “ megrim.”

In literature and in history the disease itself has
played a tremendous role, and it is not surprising that
writers should have busied themselves with it. To
attempt any culling or epitome of the literary allusions
to headache would fill volumes. There is hardly an
observant author who does not give intimations of the
fact that must have been either before his eyes, or in
them, or behind them, almost every day in his life. For
as a source of pain and suffering, as a molder or de-
stroyer of literature, as well as of lives, headache has
been, I doubt not, one of the greatest producers of evil.
204 BIOGRAPHIC CLINICS.

In any city, village or community of the civilized world,
if one will ask any woman and every second man, he
will be told that all know of relatives, friends and even
whole families constantly suffering from headache,
sick-headache and other eyestrain affections. Willis,
an ancient writer, already said of this affection:

“There is none but is sometimes obnoxious, so that it has
become a proverb as a sign of a most rare and admirable
thing ‘that his head did never ake.’”

Other diseases, the plagues, poxes, and punishments
of evil and unsanitary living, came and went, but head-
ache always remained with men and women, at least
since civilization came to them.

An old English chronicler speaks of one:

“A fervent mygreyn was in the right syde of hurr hedde.”

Other references are:

“Heyera hermetis purgeth the hemicran.”—Lloyd, Treas.
Health, 1585.

“Oyle of fystikes healeth the hemicrane and watchynges.”
—Ibid.

“Here hence springs the head-ache . which last we call
the Hemicrany or Megrim, possessing but the one side of the
head.”—Vaughan, 1600.

“The bones help the Hemicrania.”’—Lovell, 1661.

“Subject to the sickness called Megrim or Hemicrain.”—
Blount, 1656.

The opinion of the writer in that monument of
French erudition—Larousse’s “ Grand Dictionnaire
Universel ”—is plainly implied in the opening sentence
of the article on Migraine: “ The disease which physi-
HISTORY AND ETIOLOGY OF MIGRAINE. 205

cians have baptized with the fine name of Hemicrania,
without, for all that, feeling themselves under any
obligation to cure it.” “ The shame of medicine,” the
writer calls it later.

Méry says that migraine is “a wonderful invention
which will last until there are no more women.”

Samuel Johnson quotes Bacon’s Natural History,
which says that “in every megrim or vertigo there is
an obtenebration joined with a semblance of turning
around.” Both of these chief symptoms, it should be
noted, are visual.

Pope wroté:

“There, screened in shades from day’s detested glare,
Spleen sighs forever on her pensive bed,
Pain at her side and megrim at her head.”

“The sole thing that brings me relief,” still say
many patients, ‘is absolute darkness.”

In his “ Physiology of Marriage” the Frenchman,
Balzac, best fitted to give expression to the national
opinion, gives a vivid picture of the disease as illus-
trated in upper-class families. It is always the wife
who is afflicted. He pictures it as the queen of dis-
eases, the most pleasant and at the same time the most
terrible weapon which a woman can use against the
husband. “I have the migraine ” ends all controversy.
But while ridiculing the disease as a makeshift of these
cunning ones to deceive, Balzac gives an admirable de-
scription of the attack, and lets us see that the assumed
206 BIOGRAPHIC CLINICS.

disease is certainly an imitation of the real, and per-
haps the idea of trickery was read into the real expe-
rience by the husbands and the romancer. Her book,
he says of the patient, is at her feet; the least noise is
unbearable; her voice is weak ; she silences her husband
and all his reproaches with a look. The doctor is called
in; he advises exercise and madam recovers. But she
gets her way, good or bad, and beats all plots or plans
by means of her migraine—the protector of illicit loves
and the confounder of virtuous husbands.

For a thousand years in Greece not even the fathers
of medicine noticed that the aches of the head were not
unilateral. Alexander of Tralles made one distinction,
namely, that the stomach was implicated in some head-
aches. Even this was forgotten and for another thou-
sand years there was no observation that resulted in
distinctions. Then began a luxury of growth in no-
menclature which has increased until to-day all that
one can say is that “there are as many kinds of mi-
graine as there are heads that suffer.” Even a few
years ago Nietzsche had to protest to his scientific phy-
sicians that his disease was not migraine, because it
was not on one side of his head. The spell or hyp-
notism of a badly-formed, meaningless word thus con-
tinues to-day to dominate observation and facts. And
all this despite the truth that so many physicians
(being students)—Lepois, Airy, Parry, DuBois-Rey-
mond, Travers, Fothergill, etc-—were sufferers from
the disease.
HISTORY AND ETIOLOGY OF MIGRAINE. 207

Anthropologists have pretty nearly come to an agree-
ment that prehistoric and savage trephining, so general
in all races and times, was probably done for the pur-
pose of relieving headache. The location of the hole
made in the savage skull, in order to let out the evil
spirit, does not warrant the conclusion that the head-
ache was particularly on one side. It may have been
so, but the arrow-makers, basket-weavers, etc.,in whom
it probably chiefly occurred, were not so discriminating
as to point it out to the medicine men. Both probably
thought of the living cranium as a more or less hollow
organ, such as they found it in their ancient dead. The
Greeks, and after them the Romans, and then the medi-
eval nations, thought of the headache as a hemicranous
ache, although many patients, and most of them in the
crisis of the attack, found the ache as much on one
side as the other.

Classification and Etiology.—Sauvages gives ten
forms: ocular, dental, sinus, coryzal, hemorrhoidal, hys-
teric, purulent, insectal, nephralgic and lunatic. The
great French Dictionary of Medicine finds it best to
limit the varieties to two chief classes, the simple and
the constitutional. Many authors recognize (1) the
idiopathic, (2) the sympathetic (diseases of the vis-
cera), (3) the symptomatic, i. e., from lesions of the
encephalon or its envelopes. In Parr’s Dictionary
(1809) cephalalgia is divided into:

1. The mild, i. e., cephalalgia.
208 BIOGRAPHIC CLINICS.

2. The inveterate, or cephalza.

3. The one-sided—hemicrania, migraine, etc.
4. In one temple, crotaphos.

5. In the crown, 7. ¢., clavus hystericus.

But he says it may be symptomatic and idiopathic,
adding that it is often impossible to ascertain the dis-
ease of which it is a symptom, and that in some it is
unconnected with any other complaint.

The cause of migraine, if known, would dictate the
classification. The fruitlessness and self-contradictions
reached by all the classifications that have been devised
shows only what is frankly confessed, that none has
had the hint of a suspicion of the true etiology. The
primitive trephiners of prehistoric and present-day
savage times were as sure of their pathology as of their
therapeutics. Areteus described migraine under the
name of “heterocrania”’ and with considerable accu-
racy—better, in fact, than Galen. Aurelianus finds
that women are more subject to it than men. Serapion
thought the disease sprang from the digestive organs.

Alexander Traillianus continued the great blunder
that has reigned supreme almost to our own day, and
still rules many minds, that in the symptom-complex
we now call sick-headache the stomach is primarily at
fault.

Charles Lepois, 1618, taught that migraine was
caused by fermentation of the biliary matter which dis-
tended the membranes of the brain, Thus began the
HISTORY AND ETIOLOGY OF MIGRAINE. 209

fashion of using those sacred mumbo-jumbo words,
“bile,” “biliousness,” “ bilious headache,” “liver,”
etc., which have been of such potent-impotent service
in the literary and social history of the last two hun-
dred years.

Wepfer ascribed the disease to stagnation of the
exudated blood serum in one half of the head. Theo-
ries as metaphysical ruled the minds of Hoffman, Wil-
lis, Fordyce and others, who credited the disease to
animal spirits. Tissot, in 1813, returned to the gastric
theory. Devilliers and Deschamps attribute it to dis-
ease of the frontal sinus. No one could for long get
far away from the ocular idea or location. Schodnlein
called the disease cephalic hysteria; its seat in the
nerves of the forehead and temple. Romberg called it
cerebral neuralgia. Chaussier and Pinel charged the
disease to neuritis of the seventh and especially the fifth
nerve. Professor Brouillard thought the third nerve
was the sinner. Auzias-Turenne thought compression
of the trigeminus in the cavernous sinus was the cause.
Calmeil said that sick-headache was a double lesion;
the flow of blood to the central and to the peripheral
system. Piorry held it to be due to an ascending neu-
ralgia, starting from the nerves of the iris and patho-
logically reflected from the sensitive centers to other
organs. Charcot insists on an intimate relation with
rheumatism, gout, hemorrhoids, and gravel. Of thirty

15
210 BIOGRAPHIC CLINICS.

women with nodular joint affections, twelve had pre-
viously had intense migraine.

The number of primary or secondary causes of the
disease that have been noted by physicians’ reports is
astonishing. In DuBois-Reymond’s own case the at-
tacks usually followed fasting or lack of food, and
many have alluded to this. On the other hand, scarcely
less frequently it is caused by the presence of food.
Fothergill, with a hundred others, is sure that diet,
“the kind or quantity, or both,” is at the root of the
mischief. He says that butter is the greatest cause, as
“nothing more speedily and effectually gives the sick-
headache, and sometimes within a few hours.” The
next most important articles are “ melted butter, fat
meats, spices, meat pies, hot buttered toast and malt
liquors.” English authors generally incline to the
“bilious,” gastric, or intestinal cause of the disease.
Fothergill’s philosophy of the disease was that an acid
or bitter bile in the empty stomach or duodenum, fa-
vored by certain foods, was the cause.

If fasting will not produce the disease, overeating
will do it. Hunger and satiety are equally effective.
DuBois-Reymond again says his attacks were generally
preceded by constipation. Wine, even sacramental
wine, the least fragment of burnt pastry, are the great
causes testified to by a physician as producing the
attacks in himself for thirty years. The role of “ bil-
iousness,” the “ bile,” “liver,” ‘“ stomach,” “ dyspep-
HISTORY AND ETIOLOGY OF MIGRAINE. 211

sia,” “ disorder of the bowels,” etc., is a big one in the
great tragicomedy during the last several hundred
years. Dr. Parry’s own attacks were caused by the
state of the stomach, “ although they occurred without
any feeling of indisposition at the time, either there or
elsewhere. They generally went off with a movement
in the stomach producing eructation.” “ Anything
disagreeing with the stomach ”—a hearty meal, meats,
lack of meats, and every possible article of diet or lack
of it—these ad infinitum have filled the accounts of
patients and physicians. All of which is, of course,
post hoc logic.

Perhaps next in emphasis and number of mentions
after the digestional cause is the sexual. One physi-
cian has devoted a whole treatise to ‘‘ catamenial me-
grim.” Liveing at once stumbles on the fact that men
have monthly attacks as well as women, but that does
not deter him nor others from the hypnotism of coin-
cidental and succedant disease viewed as cause. Pu-
berty is a great disposer, but why it is so none can say,
and the exceptions to the rule are far more numerous
than the hits. The greatest reliance is placed on the
supposed fact that the menopause brings cessation of
migraine. Here again the inaccurate observation and
domination of theory is noticed, because in the major-
ity of cases the attacks increase in severity for ten or
more years after the menopause, and in men the meno-
212 BIOGRAPHIC CLINICS.

pausal factor is not present and they also suffer up
to about sixty.

Cephalalgia Spasmodica, the sick-headache, Parr de-
scribes in a separate paragraph, but his first sentence
is that he considers it separately only out of respect
to Fothergill, for “this afflictive malady scarcely dif-
fers from the symptomatic headache arising from the
stomach.”

Loud noises, foul air, smoke, drums, military music,
review-days, etc.,also, it seems, determine attacks. But
especially smelling strong odors, particularly of drugs
(turpentine, musk, valerian), even roses and flowers,
are also effective. The smell of an autopsy room, of
a hospital ward, always caused migraine in a great
hospital physician, “ one of the most brilliant writers,”
etc. He missed it but once, and that was when the
wards had been watered with chlorinated water!

Meteorology is the great comfort of certain physi-
cians in explaining migraine. In 1903 a great one
has sought refuge in it when frightened by the ocular
theory. Dr. Lepois was attacked “on every change
of the weather.” Tissot and Labarraque are sure
about atmospheric states, changes of season, or of
weather. A large number of Symonds’ patients blamed
their attacks to weather, or no weather, to thunder-
storms, etc. Dr. Airy’s attacks were favored by windy
weather—several of his family synchronously and un-
known to each other. Direction of the wind is another
HISTORY AND ETIOLOGY OF MIGRAINE. 213

cause, frequent in Libert’s cases. The southwesterly
wind is effective at Zurich. Wagner, Nietzsche, and
others note the power of Féhn to cause the disease.

Mental excitement, emotion, vexation, distress,
fright, passion, sexual emotion, etc., have been noted
by Tissot, Symonds and many others as influential
causes. “ Nursing the mother through a long illness,”
“prolonged lactation,” “poverty,” “marriage ten
years previously,” frequent child-bearing, etc.,are men-
tioned. On the other hand, freedom from the habitual
attacks is noted during pregnancy.

Violent exertion, gymnastics, and just as frequently,
fatigue, are charged with producing the disease. Lift-
ing heavy weights, sudden effort, straining, running,
a hard day’s washing, skating, traveling, riding, are
among other causes of the disease.

“Prolonged discharges,” “ prolonged indigestion,”
“ disordered bowels,” “ impaired general health,” “ de-
bility,” “ leucorrhea,” are recorded observations. The
cart is before the horse often, and often there is no
horse or no cart.

“ The state of sleep, or rather, perhaps, of waking,”
also causes the attacks, according to Liveing. One
wonders if the neither-waking-or-sleeping state would
not also do the same. To wake up from sleep seems
to have been a frequent cause, and to be awakened °
before time. Prolonged watching, resistance to sleep,
etc., are also listed.
214 BIOGRAPHIC CLINICS.

The thousand causes that have been given remind
one of the symptoms of the homeopathists in the
“proving” of their drugs. However foolish scien-
tifically they are also pathetic and confessions of impo-
tence in the face of a great mystery.

In Symonds’ ninety cases the causes are thus clas-
sified :

Emotional disturbance ............0. 02. eee recone 53
Indiscretions of diet........ 0.00.0 cece cee eee eee 19
Denial of diét as cats, ccese vee verteca gas eracvas 62
Action of the bowels............. cee cece eee ee ee 12
Denial of this cause... ..... 0... cece eee eee eee eee 54
FHATIB UG: pdicead ian clei es actminalan died aas's saeanetanuns 289 32
Catamenia (out Of 76)...... 0... ccc ce eee eee 35
Atmospheric states ......... 0g cee cece ee ee eens 48
ATTN OR cites cc pS 00ed sana sass eS aH ReaKa eR at 25

Analysis of these figures is at once edifying and
mystifying and amusing.

DuBois-Reymond held to the theory of a tetanization
of the cervical sympathetic, and the great modern
French “ Dictionnaire des Sciences Médicales ” agrees
that this is the best theory.

The bibliography of the subject would occupy a vol-
ume. The Index-Catalogue and the Monographs of
Liveing, Spitzer, Cornu, and Mébius may be consulted
for references. All text-books on general medicine
and nervous diseases, of course, add to the literature,
without adding any clarification of the subject.

Hooper’s Medical Dictionary says migraine “ arises
HISTORY AND ETIOLOGY OF MIGRAINE. 215

from a state of the stomach,” and Parr’s Dictionary
traces causes to bony fragments, exostoses, tumors,
worms in the brain, etc. Parr finally breaks down,
however, and in despair says: “ Authors have endeav-
ored to distinguish by the particular kinds of pain
which of these causes may have produced it, but lan-
guage fails in describing the different feelings and
their variety.” One of the reasons for the despair of
Parr and of all others is that the whole life of the
patient was not observed. The clinic was of the day,
not biographic. This disease is one of the whole life.

Airy and Forster think cerebral anemia is the cause.
Sarda says: “ How many dyspeptics have hemicrania!
How many migrainics have no dyspepsia?” Liveing’s
view is that the disease is of the nature of a nerve
storm from the sensory centers, and is related to
epilepsy.

As for definitions, one modern one may serve for
many: “ A complex neuralgia of the nervous centers,
of the nerves of sensation and of vasomotor nerves,
characterized by direct or reflex modifications of the
intellect, of sensibility and of local circulation, also of
general circulation and of great functions.” Almost
all authors emphasize the role of “heredity ’—“ the
unknown god ignorantly worshipped.” Osler’s sum-
mary is “the nature of the disease is unknown.”

In a general way all theories may be grouped into
four large classes:
216 BIOGRAPHIC CLINICS.

1. The cause is central. The authors upholding this
view are Liveing, Romberg, Anstie, Leubuscher, Jack-
son, Gowers, Mobins, and others.

2. The vasomotor system is at fault. The advocat-
ing authors according to Spitzer are DuBois-Reymond,
Mollendorf, Eulenberg, Mauthner, Siegrist, Oppen-
heim, Whytt, Latham, Lauder-Brunton, Hammond,
Wilks, Pemberton, Peake, Handford, Charcot, Gale-
zowski, Féré, Thomayer, Lyon, Antonelli, d’Astros, etc.

3. Toxins are the etiologic factors—held by Galen,
Serapion, Brunton, Hecker, Haig, Navarre, Wallace,
Claus, Rachford, Steckel, Strtimpell, etc.

4. Reflexes are the causes, supported by Tissot,
Hack, Schaffer, Schech, Sommerbrodt, Zien, Dobisch,
Martin, Seguin, Greenwood, Terrien, etc.

Each one of these may be and are combined with
either one, two, or three of the others, until only the
most patient of experts can distinguish the divisional
distinctions. To all others confusion soon becomes
ever worse confounded with each hour’s study. When
one has become migrainous with attempts even to
understand the theories he will agree with Osler and
others that the nature of the disease is unknown.
“ dutant de tetes, autant de migraines.”

Prodromal Symptoms.—tThe typical attack is said to
be usually ushered in by pain over, in, behind or above
one eye, or in one temple, or by vague symptoms of
gastric malaise, anorexia, lassitude, sleeplessness, or,
HISTORY AND ETIOLOGY OF MIGRAINE. 217

conversely, on reading or writing, with sleepiness.
The prodromes that have been noted are many. With
or without the pain in the forehead, eyes or temple (or
in all three), scotoma scintillans may precede the at-
tack, and a number of authors and many practitioners
still think this is a necessary part or prodrome of “ true
migraine.” (This symptom has itself been called
“ophthalmic migraine.”) But if this is so, we can
then have migraine without unilateralism, without
pain and without implication of the digestive organs,
for I am sure that close observation of many clinical
cases will demonstrate that the majority of attacks of
sick-headache are not preceded by scotoma scintillans ;
and that in fully a half of cases of scotoma this symp-
tom is followed by no headache or other symptom
whatever.

I have scrutinized the facts in not less than a thou-
sand private cases of typical sick-headache, and myself
and assistant are sure that at least half do not have the
prodrome. On the other hand, questioning all patients
who have had this symptom, shows that the same pro-
portion do not have any headache following. Until I
secured a perfect correction of my own ametropia I had
frequent attacks of scotoma scintillans—numbering
several hundred in twenty-five years—and I never had
a headache in my life. Hippus and hemianopsia are
also other ocular prodromes.

“ The Typical Attack.” —The most common, and es-
218 BIOGRAPHIC CLINICS.

pecially the initial symptom, is that supposed to be ex-
pressed by the name—a pain in one side of the head.
This pain is almost always described as over one eye, in
it, or behind it, or in one temple. One after another
there are or maybe additional symptoms until the whole
encephalon becomes unendurably painful and sensitive,
and nausea and indescribable wretchedness follows;
violent emesis then ensues, lasting for a few minutes, or
for days; there is then a sudden clearing, and, in other-
wise healthy and strong natures, a quick return to
health. The recovery may be slower in the weak or
otherwise unhealthy. Despite the fact that the diges-
tive disorder is a late or last and infrequent symptom
of the disease the gastric origin is still the favorite
theory today. But it must not be forgotten that the
testimony of all writers agrees with that of personal
clinical experience: the number of atypical cases is
many times greater than that of the so-called typical.
The so-called typical disease is the severe one, that in
which there will be at least the two chief symptoms of
headache and nausea. Hence the applicability of the
term sick-headache to this condition. But, again, the
vast majority of cases of what is evidently the same
disease do not reach the extreme of nausea or even of
vomiting.

One may with truth say that there is no typical dis-
ease. The vast majority of cases have no aura. This
pathologic house has no portico or front door. Almost
HISTORY AND ETIOLOGY OF MIGRAINE. 219

as many cases have the aura only, without other symp-
toms. The house, then, consists solely of front door.
Parkman and Spencer and others avoided what the
writers would call migraine by most careful and deft
avoidance of the causes of it, and yet their disease
was essentially the same as that of George Eliot and
Nietzsche. Hemicrania is often not hemicrania, i. e.,
it is bilateral instead of unilateral. All pain in the head
may be absent and the disease have the same cause as
in headache cases. The digestional reflexes are in the
great majority of cases entirely absent, or they may
be of a hundred types. What shall, therefore, be said
of a disease that has no true typical symptoms, which
hardly ever has all of those called so, which usually
has only one, which may consist solely of a prodrome,
or without one of the usually recognized symptoms?
It is time that it were reborn, renamed, rechristened
and reeducated.

The recognition of the essential morbid condition is
further rendered more difficult by the intermixture of
an infinite variety of symptoms that often mask or com-
plicate the clinical course, complaints and diagnosis be-
yond recognition. Thus has been completed the utter
chaos which today characterizes the whole subject.
There is no agreement among a multitude of theorists ;
there is the most ridiculous weedy growth of contra-
dictions and inconsequence concerning etiology ; and of
course there is no therapeutics whatever. Migraine is
220 BIOGRAPHIC CLINICS.

the puzzle and the opprobrium of medicine. The con-
clusion of the article in the greatest medical encyclo-
pedia is: Autaut de tetes autaut de migraines, which
translated into scientific language means that the
almost unique cause of migraine, astigmatism, etc.,
differs in each case; the exciting cause, occupation and
use at near-range of the eyes, differs no less; the soil,
1. ée., the nervous and digestive systems, into which this
infinitely varying seed falls, are also never alike in two
cases. How certain, therefore, must it be that the
morbid results are so lawless and seemingly illogical.

The terminal stages of the attacks also illustrate the
death-and-life struggle of the organism with the excru-
ciating disease. The one-day, two-day, or three-day
vomiting and retching described in the cases of Mrs.
Carlyle, Nietzsche, etc., is suggestive. There is some-
times a flow of tears, sometimes abundant secretion of
urine, a mucus flux from the nose, lavish sweating of
the feet, hands, or half of the face; there may be nose-
bleeding or even arterial hemorrhage.

A large clinical experience with migrainous patients
shows that their headaches are of an apparently amaz-
ing variety of kinds, and seemingly, of causes. An
examination of the literature also illustrates the same
fact, each of these kinds by one or by others being
called or described as migrainous. The mere index or
enumeration of these kinds of headache would fill many
pages. In the first place there is a long list of head-
HISTORY AND ETIOLOGY OF MIGRAINE. 2ar

aches plainly due to organic and systemic diseases,
such as tumor and traumatism of the brain, menin-
gitis, fevers, infectious diseases, etc. These are of
course excluded. They are few in number compared
to the nonsymptomatic and functional cases, but in
many treatises they fill most if not all of the field of
vision. Of the functional kinds one may likewise con-
struct a huge list: the nervous sick, periodic, heredi-
tary, constitutional, dietary, hemicranic, menstrual,
ocular, nasal, dental, constipational, bilious, indiges-
tional; those from intellectual overwork, physical ex-
haustion, worry, lack of food, from study, bad light,
bad ventilation; from coryza, influenza, rheumatism,
uterine disease, pregnancy, hysteria, anemia, diseases
of the spinal cord, of syphilis, and so on, and so on.
And, finally, there is a very large class that can not
be ascribed even to the vaguest and most far-off cause.
Any one, two, or dozen of the kinds may be mixed in
all proportions in any one case, and only omniscience—
not possessed at least by young practitioners—could
discern the explanation and dissolve the mystery.

Lastly, the location, character and degree of the
ache in, about, on and below the head, in spots, in
halves, or of the whole, make confusion worse con-
founded.

The Eye and Migraine.—For several thousand years
the observation has been unconsciously persisted in
that the cephalalgia is not a head-pain, but an eye-pain.
222 BIOGRAPHIC CLINICS.

Few or none in any definite way noticed that it was
produced by near-use of the eyes, and none that the
various extensions to other parts and organs, the inten-
sifications of the pain, and the masking under a hun-
dred other protean disguises, were also products of
continued and increased eyestrain. But there was
never any failure of the necessity to notice the impli-
cation of the ocular factor. The most noteworthy
after the eye-pain was, of course, scintillating scotoma.
The seat of this strange disorder has been placed in
every part of the visual apparatus from the retina to
the ultimate of the visual center.1_ Piorry’s theories of
“ monophthalmalgia ” or “ iralgia,” or of an affection
of peripheral nerves of the eye, was followed by
Brewster’s thought that the retina is the organ
affected. Airy, Forster, and Liveing placed it within
the cranium, the latter, with Wollaston, locating it
in the thalamus. Mauthner argues against the cor-
tical localization. Dianoux thinks the source is in
the optic nerve, the chiasm, the optic tracts or
the geniculate bodies. Baralt returned to the retinal
theory and Féré defended the cortical localization.
Possibly the mixture of phosphene symptoms helped

*This has been elevated into an independent disease, espe-
cially by Galezowski and Féré. Charcot, Airy, Latham, List-
ing, Forster, Mannhardt, Ruete, etc. have especially com-
mended or emphasized the special treatment of this form of
migraine. The results are naturally nil.
HISTORY AND ETIOLOGY OF MIGRAINE. 223

to create the diversity of opinions. It has also been
noticed that the typical fortification spectra is of great
variety ; that often it is not colored or quivering, etc. ;
that it does not have any uniformity of location or
appearance; and finally that it is often not a positive
phenomenon at all, but merely a negative one—
“aphose,” “

30 66

anopsia,” “ vision nulle,” etc. There may
be a failure to perceive the image in varying degrees,
in various parts of the field, and for varying lapses of
time. “Blind headaches” the patients speak of in
such cases, Spitzer is in error when he says all sco-
tomas are positive, the products of irritation. I have
had many patients who, on being narrowly questioned,
bear witness to the negativity of the visual difficulties.
Neither is it always binocular, as he contends. Theory
is abundantly contradicted by observation when he says
that ‘the visual aura of migraine is an irritation-
symptom, a binocular homogeneous hemiscotoma.”
Siegrist contends for the purely negative character of
all migrainous scotomas, and believes they are of cor-
tical origin. And such beyond question they are.

But wherever may be the location of these disturb-
ances, they are visual in character. Thus what is rec-
ognized as the most frequent aura or initial symptom
should have pointed to the visual function as the source
of the mischief which it ushers in. In other diseases
such a symptom dictates the location of the trephining
224 BIOGRAPHIC CLINICS.

of the skull. In migraine it is held as without sug-
gestive value.

Some three hundred years ago Lepois, in beginning
the study of medicine, found that he was greatly
afflicted with migraine. He endured the attacks for
four years and then, as thousands have done since, he
fled to Italy. With cessation of study and with the
out-of-door life he led, he soon recovered, and thought
himself rid of the disease. But when he went back
to his home and literary work the attacks returned as
bad as ever. He naturally sought an explanation of
the mysterious affection and found it to consist of a
serous exudation produced by vomiting. Since his
day the same persistent cause has inevitably produced
the infinitely multiplied result, but to the fact all have
been blind and all have multiplied theories as mis-
leading and groundless as that of Lepois. And yet
medicine is said to be purely empiric. The cause has
been ever before and in their eyes and empiricism has
failed. And yet medicine is said to be a science,
although none has observed the simple fact always
present that near-use of astigmatic eyes is absolutely
required to produce migraine. In the last century
arose a so-called “ cure’ for migraine or for suffering
eyes, atropin in the eyes, when, rarely, the eyes hap-
pened to suffer in migrainous attacks. Nietzsche was
put through this cure. It acted as successfully as the
other prescriptions, “Italy,” or “ Switzerland,” or
HISTORY AND ETIOLOGY OF MIGRAINE. 225

“walking the moors.” But the cure did not last. The
patient's ills returned when the mydriatic or the
“change of climate” had ended and there was return
to literary work. Later, Brewster reports three cases
of cure that really cured. He credits it to atropin,
but ends the reports of each case with the incidental
remark that glasses correcting the ametropia were also
prescribed !

Migraine or hemicrania, when we inquire with ac-
curacy either of the literature or of private patients,
is almost always not cranial in any common acceptation
of the term, but is ocular. The fact that gave origin to
the word is that not the skull, so much as the eyebrow,
temple, eye, and orbit, is the small portion where begins
the headache, and whence with ingravescence, radiates
or extends the disease to all parts of the head, with ner-
vous and digestive symptoms. <A large proportion of
all so-called and recognized “ ocular headaches ” per-
haps have the same initial symptom and location. A
great theory of the nature of the disease, migraine,
was that of Piorry, which supposed that the neuralgia
started from the nerves of the iris and was patholog-
ically reflected from the cerebral sensitive center to
other organs, from which reflex came all the symptoms
and results of the subsequent disease. When the time
and the state of medical science are considered, this
showed a remarkably close observation and a near
guess at the truth.

16
226 BIOGRAPHIC CLINICS.

Other references to the eyes are “ anxiety about col-
lege examinations,” “ troublesome letter writing,” “a
rapid succession of visual impressions (in traveling)
in upsetting the sensorium and producing a vertiginous
state allied to sea-sickness.”’ Glaring lights, “ sight-
seeing,” “an evening entertainment ” have, of course,
been noted. “ Reading on a full stomach ” caused the
attacks in a great physician, and he could thus pro-
duce an attack instantly. Two young ladies always
brought on the attacks by reading late at night. Inci-
dence of strong light, a reflected light from snow, ice,
a tablecloth, are also put as causes. In Dr. Airy’s
case the attacks generally came on ‘“ while the eyes
are engaged with troublesome reading.” It was so
with Dr. Piorry, who could produce the disease exper-
imentally “by strongly fixing the sight on reading.”
Looking at striped wall-paper, or a striped dress, a
trellis, etc., are other causes, but it aroused no attention
to astigmatism or the eyes in the physicians who chron-
icle the fact. Liveing’s comments on these causes of
and the “habit” of migraine are

I

the “ nerve-storm,’
most instructive—at least for us to-day. Pity they
were not more so to him. Liveing notes that dress-
makers and others compelled to work far into the
night, often for weeks together, complain of migraine.
He does not fail to explain it by the “close and con-
fined rooms.”
HISTORY AND ETIOLOGY OF MIGRAINE. 227

It is set down that “mental exertion ”—it is not
called study—especially in lads at school and young
men at college often causes the first development, or at
least the increase, of the malady. ‘Close application
to books,” “and those modern instruments of torture,
competitive examinations,” are emphasized—“ espe-
cially if coupled with deficiency of out-door life.”
“The same thing,” says Liveing, “happens in later

d

years to literary and professional men,” especially be-
tween 30 and 40 years of age. But “ overwork and
over-anxiety in business ” are in these cases the causes.
“ Students’ life and intellectual competition,” not eyes,
are the supposed factors. “In Mr. A’s son the early
strain of school life caused the ‘ day-nightmare,’ which
preceded his megrim, and his subsequent attacks of the
latter complaint were always multiplied by close appli-
cation and almost ceased with an out-door life. It was
much the same, though commencing at a somewhat
later period, with his father and uncle.” DuBois-Rey-
mond found his own attacks subsided when he had
leisure to stop severe intellectual work. In one of
Liveing’s cases, “a child of nine had been overworking
at school, and on returning home early with a head-
ache, etc.” Another boy was thirteen or fourteen, and
to overapplication at school was ascribed his attacks.
Of thousands of boys the same might now be

chronicled,
228 BIOGRAPHIC CLINICS.

But among many other things pertaining to the eye
the most striking and convincing demonstration of the
ocular cause of migraine, and at the same time one of
the most remarkable instances of scientific error, is that
of Dr. Alexander Spitzer. In 1go1 he published a most
erudite and critical monograph on the disease, the con-
clusion of which is that stenosis of the foramen of
Munro is its unique and universal pathologic basis!
This bizarre theory, the latest result of critical science,
does not need a word to demonstrate its absurdity.
One can only ask, why the inveterate disinclination to
ignore the eye itself?

In his great work, Allbutt, like many others, notes
that migraine is of exceptional frequency among those
pursuing sedentary or in-door occupations, and rarely
in those living an out-of-door life. The treatment is,
therefore, advised to live much out of doors. But
Allbutt and his departmental writer, Mackenzie, has
no allusion whatever to eyes in the article.

In 1888 Dr. G. Martin (Ann. d’oc., 1888, xcix, pp.
24 and 205), a French oculist, published an article
which some time will be recognized as truly epoch-
making. But two writers, so far as I have noticed,
have even mentioned Martin’s magnificent and daring
attempt to bring the medical world to its senses. One
of these, Spitzer, passes Martin by with a one-word
mention of his name. The second, Schmidt-Rimpler,
HISTORY AND ETIOLOGY OF MIGRAINE. 229

himself also an oculist, scorns Martin’s theory with
genuine unscience.?

One day Martin happened to get one of the astig-
matic lenses of his own spectacles reversed, or “ hind-
side-before,” as patients often do, and he had a violent
attack of sick-headache. This has frequently occurred
with my patients, with the same sudden appearance of
“the disease whose nature is unknown.” Martin hap-
pened to possess the power of observation and to be a
scientific scientist. From his own experience he was
led to study that of his patients, and it was soon evi-
dent that their migraines were due to astigmatism, i. e.,
to partial and too continuous contraction of the ciliary
muscle. When a single eye was astigmatic, and the
other not so or less so, the pain (hemicrania) was
over the astigmatic eye. With loss of one eye the
bilateral migraine (if one may be excused the absurd
term) became unilateral. When only one eye is used
in vision, if it is the less astigmatic, the migraine is
on that side. With cataract operations on both eyes
the whole migrainous troubles disappear instantly, be-
cause there was then no function or malfunction of the
ciliary muscle. (Surgeons and scientists should not,

*This distinguished specialist rightly finds * glasses do not
cure,” because he fails to see that he has never prescribed
proper glasses for his patients. The astigmatism, ametropia,
etc., must be corrected in order to cure, and such correction
is beneath the dignity of the German oculists. Patients so
report and books and articles frankly confess the fact.
230 BIOGRAPHIC CLINICS.

therefore, advise extraction!) Martin reports many
cases of cure by spectacles correcting the ametropia.
As to heredity, he counters capitally that the corneal
abnormality (astigmatism) is as often hereditary as
the incriminating diathesis. Of course, a headache
can not be inherited, but only the anatomic, or other
conditioning, cause of headache. The diathesis or
constitutional factor determines whether existing astig-
matism will produce migraine, and just what its nature
will be. Martin reports 352 cases. Low astigma-
tisms, of course, are the rule—just such as the inatten-
tive European oculist frankly ignores and _ scorns.
There were, for example, in one series: 66 cases with
0.25 D.; 121 cases with 0.50 D.; 77 cases with 0.75
D.; 18 cases with 1.00 D.; 2 cases with 1.25 D.; 1 case
with 1.50 D.

In higher degrees, as we know, there is no attempt
to neutralize the corneal asymmetry and so no reflex
disease. Near-work occupation is renounced, study
interdicted, the eyes ruined, or a criminal life con-
firmed, but there is no migraine.

The morbid science which made the profession ut-
terly ignore the testimony of S. Weir Mitchell pub-

1“ A man bored a hole in a tree and a woodpecker came
and lived in it. ‘The tree has conceived’ said the man, ‘and
has brought forth a bird.’ Next year the woodpecker went
away and two flying squirrels lived in the tree. ‘ What a curi-
ous thing,’ said the man, ‘is heredity.’ ”
HISTORY AND ETIOLOGY OF MIGRAINE. 231

lished thirty years ago, made it overlook Martin’s most
valuable and scientific contribution. The great mass
of medical men smiled and passed on after the manner
of the leaders who knew so much and yet who knew
so little. But the quiet protests and reports of other
oculists began to appear, especially in America, and
better still, thousands of patients began to tell thou-
sands of their friends that “ glasses cured my sick-
headache.” The doctors kept on with that wonderful
smile, but it is now becoming more concealed and if
exposed to public view, more sneery and much more
sickly. The professional leaders, the text-book makers,
the monograph-writers, especially if of European
origin or tradition, have the smile thoroughly out of
sight. In fact, they never smiled. Their books know
nothing of eyes. In our country the bookmakers, as a
concession to popular superstition and in order to be on
the safe side and to show they do know about all this
sort of thing, make a lofty allusion to the ocular factor
and treatment, but in a given case in their office they
would no more think of directing the patient to an
oculist than to a corn-doctor. Osler goes so far as to
say that many headaches are from eyestrain ; that many
of these are hemicranial; and that in migraine the eyes
should be examined. Tyson barely alludes to eyestrain.
Anders also notes it, but in treatment he ignores
it. French and Monro say eyestrain is a cause. The
“ New International Encyclopedia,” volume of 1903,
232 BIOGRAPHIC CLINICS.

gives eyestrain as one of the causes of migraine, but
fails to mention the fact under treatment. At present,
all over the United States, there are quiet, almost un-
known oculists who are curing thousands of patients
of the afflictions described in the fourteen historic in-
stances of the two volumes called “ Biographic Clin-
ics.” Hardly a week passes that noteworthy testi-
monies are not printed in medical journals by honor-
able oculists, that the eyes are a powerful factor in
producing sick-headache and various morbid reflexes.
Many other oculists do not publicly testify, and are
afraid to acknowledge either their belief or the facts
privately, for reasons which all consultants and re-
ferers of cases well know. There is an old disease
called “being between the devil and the deep sea.”
Thousands of American patients have learned that
good refraction cures and prevents sick-headaches and
many other miserable diseases. But their official med-
ical advisers derisively smile that old-time, tired, sneer-
ing, sickly smile. The young and timid physicians,
specialists or generalists—the great mass of the half-
convinced or well-frightened—find themselves on a
very narrow strip of an island or peninsula. On one
side is water, deep, cold and far-reaching ; on the other
is what the polite little girl in her prayers called “ the
gentleman from hell.”

The Relation to Age, Sex and Occupation.—From
of old it has been noticed that migraine rarely appears
HISTORY AND ETIOLOGY OF MIGRAINE. 233

before the age of puberty, and that with old age it dis-
appears. But I am sure that it occurs more often in
childhood than is supposed. Gowers goes so far as to
say that one-third of all cases begin from the fifth to
the tenth yéar. It all depends on the existence of
ametropia and the amount of study, reading, etc., car-
ried on. I have had a large number of school children
afflicted with the malady in variant and typical forms.
One little boy I particularly remember whose astigma-
tism for years increased about 0.5 D. every few months
was each time relieved of his intense vomiting by a
change of glasses until the compensation of the higher
astigmatism again became impossible. Puberty has
nothing to do with the existence of the disease in
either girls or boys. In the same way one of the
superstitions of the ages appears in physicians’ offices,
both in patients and physicians, that with the meno-
pause there is a sudden rising or exacerbation of many
diseases, chief among which is migraine. The meno-
pause has nothing whatever to do with this, which is
wholly due to the increase of the ocular reflexes caused
by presbyopia. The blunder should long ago have been
manifest to the crudest observation.

There is no causal relation between the sexual his-
tory and organs and migraine. The old observation
that women are more subject to the disease than men
is also explained by the fact that women have always
in the past done more near-work with the eyes than
234 BIOGRAPHIC CLINICS.

men—sewing, house-life, cooking, weaving, reading,
etc. Whenever men pursue such occupations the dis-
ease is proportionally as frequent, modified slightly by
their greater neurologic and temperamental resisting
power.

The books and monographs also speak of the great
incidence of the affection among the upper classes, the
liberal professions, men and women of letters, etc. As
the French say, La migraine est le mal des beaux esprit.
This means only that such people read and write more
than others. I have never heard of a case of sick-head-
ache among farmers, policemen, firemen, soldiers,
ranchmen, trainmen, cattle dealers and drivers, sailors,
etc. But among seamstresses, typewriters, typesetters,
lathe-workers, watchmakers, book-keepers, copyists,
sewing-machine girls, weavers, etc., the disease is as
common as among students, literary workers, educated
people, etc.

An amusing and long-drawn out correspondence and
discussion occurred in one of the London papers in
November and December, 1903, on “ brain-fag.”
Almost every line showed that “ brain-fag ” was caused
by use of ametropic eyes, not by use of the intellect.

As to periodicity, when the life has been forced into
regularity and routine there is sometimes an approach
to regularity of rhythm in the attacks. But in another
case, and in the same one if ocular rest is secured even
for a day, the return of the attack is replaced by health
HISTORY AND ETIOLOGY OF MIGRAINE. 235

and happiness. The length of the attack may thus
vary from a few hours to almost any number of days.
The interim of freedom varies with each patient and
with the ocular labor of each patient, from a day or
two, to once in a lifetime.

The Gastric Crisis—Inaccuracy of observation is
shown in the descriptions of gastric symptoms by
many writers. In the first place there should be a
distinction drawn between nausea and vomiting.
Many patients will have nausea only, not followed by
actual vomiting, and it is the testimony of most patients
that this nausea is far more agonizing than vomiting
would be—that emesis would bring relief. On the
other hand, there is not seldom intense retching without
any or but little vomitus. This is worse than either
of the other two kinds of sickness. The difficulty of
understanding what actually takes place in a given
case is enhanced by the disinclination, especially in
literature, of patients to state that actual vomiting took
place. They use euphemisms, “ malaise,” “
“sickness ” and many indefinite or misleading terms.
One’s doubt is heightened by the difference in different
countries and even in one country in the significance
of the word “sick” and “sickness.” Many writers
state that the gastric complication comes on and ends
suddenly, and with the vomiting there is immediate
return to the normal state of health. But constant

nausea,”
236 BIOGRAPHIC CLINICS.

retching and digestive misery sometimes persists for
one, two, and even three days.

Then there is the failure to notice that the nausea
and vomiting are but the latest and severest stages of
the one disease, brought on by continuous application
of the eyes, regardless of the prodromal and cephalgic
warnings. Parkman, Huxley, Browning, Spencer,
Carlyle, heeded the warnings and avoided the results ;
Nietzsche, Mrs. Carlyle, Margaret Fuller, George
Eliot, and Wagner did not heed, and their lives were
tragedies. There is also wanting in reports the recog-
nition of the striking fact that patients with the severe
gastric disease, sick-headache, which produces vom-
iting, indigestion, anorexia and anemia, are able and
are irresistibly compelled to walk five, ten, or fifteen
miles a day, or take some other form of exercise; and
they are able to do it with ease and with the most mani-
fest relief of all symptoms. In what other organic or
severe stomachal disease is this possible?

Colds, Rheumatism, and Gout.—In private practice
the careful and scrutinizing oculist finds that common
colds and influenzas have a strange connection with
eyestrain, and the relief of these conditions often fol-
lows the wearing of glasses. A misplaced or wrong
lens strangely results in “a cold.” In the cases studied
in “ Biographic Clinics ” there are many confirmations
of the fact. Mrs. Carlyle’s “eight influenzas an-
nually ” is an instance, and all through the biographies
HISTORY AND ETIOLOGY OF MIGRAINE. 237

of several of these cases colds and influenzas are mys-
teriously present. It is exactly the same with rheu-
matism and gout. I have found no accident or cause
ascribed for Parkman’s life-long arthritis. The ac-
counts of Nietzsche’s “rheumatism” and that of the
other patients are likewise both mystifying and sug-
gestive. Sir Henry Holland is the great advocate of
the theory of the gouty origin of migraine. To excess
of uric acid in the system he and many others ascribe
the disease. Because migraine as an “ independent
disease ’’ is in reality due to eyestrain, the only conclu-
sion to be drawn is that eyestrain often causes gout,
rheumatism and the “uric acid diathesis.’ To that
conclusion medical science may sometime come.
Pareses, Paralyses, Anesthesias, etc., are most con-
stant, frequently reported, and remarkably peculiar
symptoms, concurrent or resultant, in the history of
migraine. The following are the words of some of
the reports: “The right arm becomes numb in the
paroxysm, and in consequence so useless that she will
let things drop from the hand.’’ ‘“ Numbness and a
sense of tingling (like that in a foot or hand ‘asleep,’
as we say, and ‘pins and needles’) commence in the
fingers of the right hand and gradually extend up that
arm and side, until the throat is reached. The in-
terior of the throat, the tongue, and the lips seems to
share in the sensation, which is no longer confined to
the right side, but affects these parts bilaterally. The
238 BIOGRAPHIC CLINICS.

speech is next implicated.” “It is utterly impossible
for me to speak.” “This disorder of speech is like
that of some other highly educated patients.” “An
arm or a leg of the same side, one time one side and.
one another, go to sleep.” “I feel a tingling as if
ants were on them. I have the same feeling in the
mouth and tongue, and, further, during this period, I
have the greatest difficulty in speaking.” Disorders
of sensation and touch were present in twenty-one out
of sixty cases in one series, sometimes alternating with
disorders of sight. A distinguished physician, Travers,
describes in his own case the numbness in fingers and
tongue, so that touch and taste were muffled, etc.
Piorry speaks of “ painful thrilling,” vibratory in na-
ture, “uselessness of the hands, transient hemi-
plegia.” The description of Nietzsche’s ‘“ rheuma-
tism ” creeping up the arm, etc., and others may be
construed as the explanation of popular and permitted
pathology. In private practice I have often noted these
disorders of motility and sensation as dependent on
eyestrain, and if, as I am convinced, migraine is
caused by eyestrain, there can be but one conclusion
of the matter. The overlooked little and contemptible
cause, just as in daily life, is also the secret of path-

xy 66

ology and practical medicine.

Ocular Paralysis.—Transient paralyses and pareses
of the ocular muscles are well-recognized effects in
migrainous histories. “ Of the internal rectus of the
HISTORY AND ETIOLOGY OF MIGRAINE. 239

right,” “partial of the oblique,’ ptosis, etc., are ex-
plained as inhibitory phenomena. Double vision, of
course, is the result of these ocular paralyses.
Psychic Disorders, not alone those naturally result-
ing from long and intense suffering, but such as tem-
porarily and directly are the immediate consequences
of the disease, are frequent in all the literature of
migraine. Confusion of intellect, temporary loss of
memory, inability to speak, or to speak intelligibly,
embarrassment, etc., are frequent expressions. It is
noteworthy that these are usually concurrent with
anesthesias, paralyses, pareses, etc. “ Confused and
tumultuous mental and emotional conditions ” are the
most frequent effects. Hallucination is rare. Pro-
fessor Lebert’s severe seizures began with “ incoher-
ence of ideas and difficulty in finding words.” “Strange
and wandering in his mind,” “unable to collect his
thoughts,” “ mind affected,” “ mentally incapacitated,”
“whatever he read left no impression,” “ disorder of
ideation,” “ double consciousness,” “ the past and pres-
ent confounded,” “ feeling silly,’’ “ losing their senses,”
“confusion in the head,” “ uneasiness,” “ irritability,”
“mental incapacity,” “‘ sick-giddiness,” “ vertigo,”
“ determinations of blood to the head,” ‘ threatened
apoplexy,” “tumultuary disorder,” etc., are a few of
the hundreds of expressions that might be gathered
in the literature. The description given by Crichton
(Vol. I., p. 237) of the case of Dr. Spalding of Berlin
240 BIOGRAPHIC CLINICS.

is most suggestive. When the patient tried to write
he was unable either to think or to make sensible sen-
tences. A multitude of excerpts might be gathered
from literary history bearing witness to the same men-

“ce

tal paralysis. Parkman’s “ stirred-up head’ when he
wrote a few minutes told him to stop; Wagner,
Nietzsche, and indeed all eyestrain sufferers, had the
same or similar disorders.

But the profoundest evil is the dejection and disgust
with life that follows persistent use of astigmatic eyes.
It is noticed in all the best literature of migraine, ill-
humor, petulance, morbid introspection, irritability, pro-
ceed to melancholy and pessimism in the extreme cases.
““Inexpressible fear’? is recorded by Dr. Reynolds;
“vague dread,” “a sense of apprehension and inse-
curity,” “dread,” “ apprehension,” “something about
to happen,” “ shuddering at the thought of an attack,”
“horror,” are some of many expressions that have
been recorded. Sir John Forbes says: “ There seems
to be some peculiarity in the pain, whatever be its
degree, unlike the pains of other parts of the body,
and as if it were combined with something of a mental
quality. There is a feeling and a fear of impending
death and the primary symptoms of corporeal disorder,
etc.” This intellectual disorder and morbidity of the
emotions is painfully evident in many great literary
men who suffered from migraine or from eyestrain.
In Parkman it was so evident, and yet so under control,
HISTORY AND ETIOLOGY OF MIGRAINE. 241

that his friends (not himself) and the greatest physi-
cians believed in his insanity. Wagner was also
thought to be insane by physicians who knew nothing
of migraine and less of eyestrain. Two of Nietzsche’s
oculists recognized the ocular origin of his malady,
but that did not prevent the terrible tragedy of his
paralysis. Even Professor Mobius, in 1903, says that
“myopia can not produce migraine”; and this great
clinician has not heard of astigmatism, or if he has
heard of it, cares nothing for it. And if he cared much
for it, he could not, in all Germany, get it corrected in
his patients. Wagner resolved to commit suicide many
times when driven to desperation by his awful suffer-
ing. The effect of this mental torture and gloom in
great literary workers is the almost single cause of the
“literary pessimism ” in an age of rugged vigor, lux-
ury and national expansion.

The lessening of the amount of literary work that
would otherwise have been done is exactly in propor-
tion to the severity of the reflexes, or in the skill
whereby they are avoided. In private practice one
finds whole lives made futile, painful and invalid.
Doctors are consulted, travel undertaken, spas visited,
hydropathy pursued, quackery multiplied, patent med-
icines guzzled, narcomania encouraged, alcoholism
made chronic. In biography one sees literary labor
avoided, made impossible, reduced to an hour or two
a day or to a life average of production of a few lines

17
242 BIOGRAPHIC CLINICS.

a day. To avoid this Parkman is compelled to write
his own name by means of his gridiron and Nietzsche
is paralyzed at 44. Moreover, the literary work done
is abnormal in character and is produced “in a white
heat,” the “nerves ablaze,” in “a shivering precipi-
tancy,” etc., as Wagner, Nietzsche, Carlyle, and others
testify.

Treatment.—The chapters on the treatment of mi-
graine are longer than that famous one concerning
snakes in Ireland, but are less convincing and satis-
factory. The systematic books and articles give pages
of drugs to be tried. The profession at one time set-
tled down to hydropathy and diet, until the amusing
and yet warning resultlessness lessened the enthusiasm.
And then the quacks took up these scientific methods.
How both treated the fourteen sufferers of “ Bio-
graphic Clinics’ may be read in those volumes. The
present-day treatment of such patients is as ineffective
and scarcely less irrational than in the time of Parr,
who advises:

1. Keep the bowels open, 7%. e., give cathartics,
purges, etc.

2. Drain from the head by a perpetual blister on
vertex, etc.

3. Emetics. “ The tyro, without a suspicion of the
difficulty, by the exhibition of an emetic has succeeded.”

4. The fetid gums, especially if “ joined with aloes.”

5. Camphor, nitre.
HISTORY AND ETIOLOGY OF MIGRAINE. 243-

6. He advises against the too common practice of
cutting off the hair, because it is supposed to keep the
head warm, and also in order that cold applications
may be more conveniently applied. The author him-
self says that he long had headaches and that they
returned frequently after shaving the head, and after
he let the hair grow he suffered less in violence, fre-
quency and duration of his paroxysms. (When Parr
published his dictionary he was 59 years old!)

7. Bleedings, leeches, cupping-glasses, opening the
temporal artery, diet, etc.

8. The suppression of the hemorrhoidal discharge.
Parr doesn’t believe much in this, but says that “in
the whole circle of practical medicine no question is
so difficultly explained as the connection of the hem-
orrhoidal discharge with the general health; or rather
the supposed connection as stated by the German phy-
sicians. The experience of ages must not be over-
looked. The hemorrhoids were considered at a certain
period of life as essential to the male as the catamenia
to the female.”

g. Mental causes, anxiety, etc., are to be lessened.

Sequels of Migraine-—Martin and others have no-
ticed that migraine often ends in a period of herpetism.
One is reminded of Wagner’s life-long and inexplica-
ble attacks of “erysipelas.” Blanching of the hair has
been noticed. The disappearance of migraine, says
the “ Dictionnaire des Sciences Médicales,” is often
244 BIOGRAPHIC CLINICS.

followed by gout, asthma, hemorrhoids and cutaneous
affections. Trousseau says the same of gout. Tissot,
Wepfer, Schobelt, Laurent, Percy, etc., cite cases in
which migraine disappeared and was at once replaced
by an unconquerable diarrhea, to which the original
disease was preferred. The relation to hemorrhoids
noticed by Parr gives a glimpse into clinical medicine,
at least of the middle and later ages, which seems to
have been overlooked or outlived in our time.

Use of the Eyes at Near-range is the Cause of Mi-
graine.—I have never had or read of a case of migraine
or of sick-headache in which it was not strikingly man-
ifest that near-use of the eyes was the cause of the
disease. Fifty pages of quotations from Nietzsche,
Wagner, George Eliot, etc., could easily be gathered
testifying with complete unanimity and intensity to this
fact.t The records of private cases show the same
thing. In the extreme cases, and especially during
the ages from forty to sixty years, this inability to
write and read reaches such a height that it is possible

only for an hour or two or a few minutes a day, and
then only with cries of pain. Letters are replaced by

postal cards, near-work with the eyes is renounced,

*The cephalalgia of students, says Parr, is often a nervous
affection merely. “ Whatever be the action of the nervous
fibers in intellectual operations its excess is often a cause of
pain; though, in many instances, the cephalalgia of students
is connected with obstruction of the bowels, and very often
with increased determination to the head.”
HISTORY AND ETIOLOGY OF MIGRAINE. 245

and a trip is taken, wet-packs endured, walking or
mountain-climbing begun, etc. To such a degree was
this recognized, both by patient and physician, that it
became in the last few centuries an established practice
to spend most of one’s time in “ walking the moors,”
journeys to Switzerland or Italy, trips to the seashore,
etc. “A change of climate” became the universal
prescription for all “ brain-workers ” who had symp-
toms of “brain-fag” or of “migraine.” The great
vogue of hydropathy arose largely from the suffering
that followed near-use of the eyes, and spas, cures,
mineral springs, health resorts of a hundred kinds and
in a hundred places sprang up largely to meet the
demand for ocular rest and the relief of other ills that
came with it? The world and the profession ascribed
the cures to the stopping of intellectual work, and to
the waters, packs, mountains and sunshine. But the
ills returned always when the eyes were used. Thou-
sands of other persons used brain and eyes without
these ills, that made no difference in faulty observa-
tion, and the domination of theory and preconception.

Almost all observers find it impossible to draw any
distinction between headache and megrim. What
causes one causes the other. What cures one cures
the other. Asa matter of theory, they draw fine and
infinite distinctions between the two, but they are ter-

1This cause has been operative, one may believe, in estab-
lishing the English custom of country houses and homes.
246 BIOGRAPHIC CLINICS.

ribly puzzled, contradictory and_ self-contradictory
when it comes to observation of cases and to treat-
ment.’ The lighter forms of migraine, the unclassi-
fiable thousand types of headaches and “ masked mi-
graine” are, says a late writer, “essentially of the
same stock—merely feebly developed forms or the
vanishing inheritance of previous generations.” To
such a pass have the theorists come! Driven by des-
peration and a sound observational instinct, the excel-
lent Liveing, after excluding certain types, justly and
“one independent affec-
tion, constituting a malady per se—all varieties of
migraine.”

Liveing is right in finding the riotous multiplicity
of symptoms classed under headache, sick-headache,
etc., to be the expression of one independent morbidity
or malady per se, erroneously called migraine or the
megrims. But Liveing, as well as every other writer
on the subject (except Martin), missed the open secret.
The appalling mystery of thousands of years, especially
of the last three hundred, the explanation of the one
disease whose cause and nature and cure are unknown,
is now clear to all who wish to know, and whose minds

rightly, crowds them all into

1An old astute observer wrote: “It may be doubted whether
causes do not sometimes produce pain in the head, which are
still less easily traced... . On a review of these causes of
idiopathic headache we must regret that the source of so few
cases is discoverable and that we have scarcely appropriate
remedies for any of those which we can ascertain.”
HiSTORY AND ETIOLOGY OF MIGRAINE. 247

are capable of receiving the truth. Migraine, in its
so-called typical or in its multitude of atypical forms,
is but one of the manifestations and results of eye-
strain. Eyestrain produces almost an infinity of ~
morbid results, and migraine, typical or not, is, if not
absolutely, almost always, one of the products of the
malfunction of astigmatic eyes. Any one can test the
theory who wishes. The disease may be caused ex-
perimentally (on the skeptics, if they will!) by wrong
glasses or by maladjusted right glasses. It may be
cured by lenses correcting the astigmatism on which
the disease depends.1 The profession has for many
years scorned the truth, until now the patients them-
selves are fast becoming aware of it without the
doctor’s advice. For many years to come they will
probably have to teach physicians the etiology and
therapeutics of their ailment.

1Very rarely it is not curable, as in the cases of George
Eliot and Lewes, because a life of suffering has killed all reac-

tion even when the cause is extinguished. In the young it is
always curable—if the careful and scientific oculist is found.
 
THE OPTIC AND OCULAR FAC-
TORS IN THE ETIOLOGY OF
THE SCOLIOSIS OF SCHOOL

CHILDREN.
CHAPTER VII.

THE OPTIC AND OCULAR FACTORS IN THE
ETIOLOGY OF THE SCOLIOSIS OF
SCHOOL CHILDREN.

The Theses in General_—There seems no reason to
doubt the accuracy of the statistics of Guillaume,
Krug, Hagman, Kallbach, and Scholder, which dem-
onstrate that in five European cities over 25 percent
of the school children have lateral curvature of the
spine. The fact is astonishing and even appalling.
The manifold and indirect production of morbidity is
incalculable, and the neglect of this pathogenic factor
in preventive and practical medicine is of terrible sig-
nificance. We give absorbed attention to a score of:
morbific agencies of vastly less importance than sco-
liosis. Many of these are doubtless the direct and
unrecognized results of the deformity, but of this no
question is asked. The terminal diseases seize upon
the anemic, morbid, and devitalized scoliotic, and the
terminal diseases occupy the minds of the pathologists
and hygienists to the entire exclusion of the early, real
and hidden cause.

1From American Medicine, April 8, 1905. Previous papers
on this subject were published in American Medicine of March
26, 1904, and May 21, 1904.

251
252 BIOGRAPHIC CLINICS.

Many experts admit that malposture, especially in
writing, is the principal cause of so-called idiopathic
lateral curvature of the spine. School desks and
slanted handwriting are constantly emphasized as the
chief factors in bringing about the malposture, and all
are emphatic in advising an erect posture in writing,
reading and study. As to study, when not writing,
the contention is just and pertinent and the advice
easily and usually followed. But as to writing, their
advice, as it is given, is impossible of being carried
out, and none has seen the reason of the impossibility,
because none has recognized that the writing postures
heretofore commended are absolutely interdicted by a
peculiarity of the visual function, namely, the neces-
sity of seeing the writing field, 7. e., the space about
the pen-point, with both eyes, but especially with the
right eye. The simple observation has been over-
looked that the eyes must see clearly and freely what
is being done. The command of George Sand, ecri-
ture droite, sur papier droit, corps droit, “ vertical
writing on vertical paper, the body also vertical,’’ is
the fitting demand or attitudinizing of the theorist
who cannot see that obedience is impossible, and that
no child and no theorist ever did actually write in
that way.

The entire history of scoliosis investigation, of
school hygiene and of vertical and slanted hand-
writing is dominated by the strange ignoring of the
SCOLIOSIS OF SCHOOL CHILDREN. 253

function chiefly concerned in the mechanisms—. e.,
the visual function. All motion and activity of the
higher animals in the history of evolution has been
dependent upon visual function, the finest, most deli-
cate, most difficult of physiologic functions. Even
Spencer was proud of his scorn of optics, of his own
wilful ignoring of his eyestrain, proud of his pride in
ignoring the source of his own ill-health and that of
many others.

An analysis of the optic problem, therefore, explains
the malposture of writing, and so far as this mal-
posture is responsible for spinal
curvature, so far is this deformity
due to ocular function. Ortho-
pedic surgeons have taken the
curves of the back as the primary
ones, and have sought to explain
their origin from the facts pre-
sented in this region. I suggest
that another, the cervical curve,
precedes, and by compensation
causes those of the dorsal, lum-  %1:——“ Supposed mal-

posture in writing, often

bar, or dorsolumbar spine. In ___ pictured but never prac-
tised, because the pupil
other words the surgeons have auld oe ‘see the: ‘pens
neglected the primary functional Point or writing field.
and habit curves of the neck, which are caused by
morbid writing postures and by eyestrain, and which

later induce most of those of the lower spine. The

 
254 BIOGRAPHIC CLINICS.

malpostures of writing are caused by the demands of
physiologic optics, the necessity that both eyes, and
especially the right, shall have as unobstructed a view
of the writing field as is possible. According to in-
structions given the right-handed pupil, this clear view
is usually impossible without bending the head to the
left. There is also another factor, likewise purely
ocular, which accounts for the malposture which en-
genders curvature of a different kind and in an entirely
different way. These are theses, which I think are
easily demonstrable.

Age When Spinal Curvature is First Noticed.—
Roth, in tabulating the reports of 1,000 cases in his
practice, finds that when first noticed the numbers
steadily increased from infancy to the age of 13, the
highest number being 107 at 12, 117 at 13, 103 at 14,
and then steadily declining. The average was 12.32
for the noticed beginning of the deformity, but 15.65
when the patients came under treatment. Eulenburg’s
1,000 cases are listed as follows:

Before the sixth year............ cece eee cee wees 78
Between the sixth and seventh years............ 216
Between the seventh and tenth years............ 564
Between the tenth and fourteenth years......... 107
After the fourteenth year..................005. 35

Whitman's figures are of 3,252 patients, 1,299 (39.9
percent) of whom were under 14 years of age, and
1,576 (48.4 percent) between 14 and 21. The reports
SCOLIOSIS OF SCHOOL CHILDREN. 255

of some other specialists are in essential agreement
with those quoted. More definite data are found in
the report of Scholder,t whose figures are as follows:

7th grade, about 8 years, 218, 19 scoliotics= 8.7%

6th 9 “ 257, 47 18.1%
sth “ “to “ 408, 81 ~ 19.8%
4th “ “ir “ 404, IIo 8 27.2%
3d “12 “ = 370, 105 a 28.3%
2d “13 “ 354, 115 32.4%
Ist “ “14 “ 304, 94 “ 31. %

Frequency.—As to the percentages among school
children, the following are the most trustworthy
reports:

Guillaume, Neuchatel, in 731 found..... 218 = 29%
Krug, Dresden, in 1,418 found.......... 357 = 25%
Hagman, Moscow, in 1,664 found....... 20%
Kallbach, St. Petersburg, in 2,333 found.. 26%

Scholder, Lausanne, in 2,314 found... 571 = 24.67%

The average is thus about 27 percent. Probably
but a small proportion of all scoliotics are ever exam-
ined by the orthopedist. The general physician does
not examine the back in the vast majority of his
patients.

Sex.—The disease is mistakenly said to be more
than three times as common among girls, although in
cases developing in early childhood, sex seems to exer-
cise little influence. Eulenberg puts the proportion as

1 Archiv fiir Orthopddie, 1903.
256 BIOGRAPHIC CLINICS.

high as to girls to 1 boy; Kolliker, 5 to 1; Tubby, 17
boys in 69 cases, although he thinks the number of
severe cases greater in boys than girls. In orthopedic
institutions, the average of nine tables is 85.8 percent
girls, and 14.2 percent boys. A number of reasons
for the greater incidence of the disease in girls have
been given, but they do not appear to be very convinc-
ing ones. One at least wonders how puberty can have
much influence. The old propter ovarium est mulier
idol has to be redressed, solemnly bowed, prayed, and
sacrificed to, even in scoliotic deformity. It is evident
that the numbers reported by orthopedists are without
value, so far as indicating the absolute relativity.
Thus, under five years of age, Rédard found the sex
numbers equal, and in Dresden among 1,418 school
children, Krug found scoliotic boys 181 = 26 percent.
and girls 163 = 22.5 percent. In Lausanne, Scholder
found among 2,314 pupils of the primary grades, 571
scoliotic, of whom 23 percent were boys and 26.7 per-
cent girls.

Statistics of the Kind of Curves.—The figures re-
ported by the older writers as to numbers of the differ-
ent kinds of curves are wholly untrustworthy. It is
perhaps impossible to explain the errors of these reports
satisfactorily. The latest and most accurate observers,
in fact, reverse the relative numbers of right and left
curves, as given by Roth, Kolliker, Drachmann,

* See especially Tubby, p. 108, and also other writers.
SCOLIOSIS OF SCHOOL CHILDREN. 257

Adams and Lonsdale, and the Royal Orthopedic Hos-
pital. The institutional figures differ decidedly from
those of school children in the primary grades, and
as it is in the school or young children that the begin-

 

Fic. 2. — Another impossible posture, similar to that of Fig. 1, and unconsciously
and unintentionally showing the cervical curve with convexity to the right,
which is common in dextral writers.

nings of the evil are found, it is upon these that atten-

tion should be exclusively directed. It is the very

earliest stages which must be studied, as the later com-

plications are merely the results of compensation.
18
258 BIOGRAPHIC CLINICS.

Of the 571 Lausanne school children examined by
Scholder and his assistants, the curves were single left-
sided in 401, or 70.3 percent ; 121, or 21.1 percent, were
right-sided, and 49, or 8.6 percent, were combined.
Krug’s figures are 67 percent left, 21 percent right,
and 12 percent combined. In the report of Schulthess,
the proportion of left curves is higher—approximately
go percent left as against 10 percent right.

Causes of Lateral Curvature—Many writers, after
listing a number of causes, such as inequality of the
length of the legs, paralysis, thoracic disease, trauma-
tism, organic disease of the spine, sacroiliac disease,
rachitis, occupation, heredity, etc., confess that in the
greater number there is no certainty as to etiology.
This mystery has taken shape in the designation “ idio-
pathic,” which is, of course, a frank confession of lack
of knowledge. As to occupation and posture, the
“confession ” appears in another phasing in Whit-
man's table:

Occupation.
SCHOO] axncnivge d a eacea iy EO aae cee DAA Ch Baas 285
NO: GCChPAtiOn: o00c¢-neancordvesactatiadsde sexes (50
FaGtOny g:a%cs'e vsiiaie an ava wae a eee ae GRE IAS ese 19
Gletk> 5 e¥4caxgeas aude Bidigale Sas boumuaaiealnida es 13
Domestic, millinety, les Qacteanseiaaueciaursroa Wd
400
Posture.
Weight on right foot...................20002.. 48

Weight om. left) 100t ii. civ ada cas gtanicdeteecen 48
SCOLIOSIS OF SCHOOL CHILDREN. 259

Carrying weight on right arm.................. 38
Carrying weight on left arm................... 36
Faulty attitude at desk ............... 00 cee aes 57
SUNndHYy ay gan Mane Aetnanae tance a ae nem oeeeieays 5

232

And again in Roth’s table of causes:

Heéteditary sccxcoivas ada’ doaws oleae ses 207 cases
Rapid growth .<sasees ees siaee ehedsaaicae 203 “
Del Cate ass ee 045 Fama Ged Ai epeoe IWAN 176 “
After acute fevers ............ 0.0 cece eens so
Lung affections: saeceascie cosas denen eee ns Ain
Born in the tropics. ....... 0.00.00 eee eee es 27
Nerve diseases ......... cc. c cece cece e eee 24“
Education (violin, piano, etc.)............. 14 “
Premature birth .............. cc ce ee ee eee 1 “
Eye afeCtronmsy. vec. i0.6o.05.54 Bee oi eee Revue io. *
ONE. GE EWATS Saye 5 acccee via raver vea cee Se es Si
Eldetly: parents: sececssscceeinbesneaes BRAS ot
Vety tall) i aacgsdeecetavs esenvancetsaeaes 30
Sundry diseases ....... 0.0... cece eee eens 8 “

Scientifically these awkward gropings after an ex-
planation would be provocative of a very unscientific
kind. of laughter were it not that the subject and its
suggestions are of a profoundly serious and pathetic
nature. The most striking physical characteristic of
the human animal is his erect posture; all his dignity
is in that and his health; and there is no misfortune
so great and no suffering so poignant, both physically
and mentally, as that inseparable from spinal disease.
Every consideration, professional and humane thus
demands that a solution of the appalling mystery of
260 BIOGRAPHIC CLINICS.

spinal curvature shall be sought with all the zeal, in-
genuity and knowledge at the command of men of
science and benevolence. I believe that it is demon-

 

Fic 3.—The hand in the writing posture as usually ordered, but not practised,
because to the writer the writing-field is hidden by the thumb, finger, and
holder A view of the hand, as seen by the writer, with the head displaced in
photographing.

strable that the great majority of so-called cases of
“idiopathic ” spinal curvature are directly and indi-
SCOLIOSIS OF SCHOOL CHILDREN. 201

rectly the consequences of visual function and chiefly
of binocularity, dextrocularity and astigmatism.
Ruprecht holds that ordinary lateral curvature is
rachitic and Deutschlander goes so far as to say that
all scoliosis begins in bone-disease, and that there is
no such a thing as a habit type, all being constitutional.
(Sutter’s report is of 1,140. institutional children and
suggests nothing ‘new as regards etiology.) Such
opinions need only to be glanced at and passed with a
smile. They illustrate the too common tendency of
specialists and particularly of pathologists, to “go to
seed,” and the seed without any germinating power.
Even Scholder’s institutional cases were not always
rachitic, and of the school children cases up to the
fourteenth year, only 21 percent showed any rachitic
symptoms. Too often the modern pathologist is appar-
ently wholly oblivious of the axiom of physiology and
of pathogenesis that function precedes structure.
Liebreich! does not make this mistake, saying, e. g.,
“How these curvatures arise in children, notwith-
standing their healthy bone structure, I have first illus-
trated, etc.” As to constitutional diseases, Drachmann
found but a small proportion of scoliotics among
28,000 children examined and which were anemic or
scrofulous. According to Adams, lateral curvature
rarely exists with pulmonary tuberculosis—in marked

1 Klin. Monatsbl. f. Augenheilk, 1904, and Annals of Ophth.,
January, 1905.
202 BIOGRAPHIC CLINICS.

contradiction of Eulenberg, who found that 25 percent
of scoliotics showed a tuberculous tendency, and to
Vogt who reported it in half. Lorenz thinks that
weakly children have ipso facto a disposition to the
disease. Lorenz also thinks symptoms of general dis-
turbance accompany the development of the deformity.

As regards all such statements it may be urged that
they are rendered valueless by the simple observation
that the general or systemic symptoms of eyestrain,
such as headache, anemia, anorexia, etc., now recog-
nized by all competent American oculists as frequently
due to the eyes, are not recognized as due to astigma-
tism, etc., by the orthopedists and hygienists, especially
of Europe, but are charged to general constitutional
diseases, supposedly present. Another similar instance
of post hoc, propter hoc reasoning is to credit to the
constitutional disease the balance of the anemias, weak-
nesses, etc., which may be due directly to the abnor-
malism of the curvature and the desperate efforts of
the system to overcome or resist it.

It is admitted that all attempts to prove the origin of
lateral curvature in supporting the weight of the body
have proved in vain; and that the carrying of weights,
unless habitually and unsymmetrically, is also of little
or no influence.

Resist the Beginnings of Evil_—If it should be estab-
lished that the functions of vision and of eyestrain are
responsible for most spinal curves, the fact will throw
SCOLIOSIS OF SCHOOL CHILDREN. 263

added light on the symptomatology as well as etiology.
I shall allude to but one or two aspects and first in a
quotation from Tubby:

“For my part I think that if 1,000 presumably normal chil-
dren were examined, the proportion of them showing some
deviation of the spine would be large, but I should not include
these as cases of scoliosis, inasmuch as they do not develop
rotation.» And it is always a serious matter to disturb the
domestic peace by pronouncing a child to be afflicted with
spinal deformity; rather every effort should be made to mini-
mize than magnify the possibilities of a slight case, both to the
parents and in the hearing of the child. A slight spinal de-
formity is often ‘treasure-trove’ to a hysteric lad or girl.”

Was there ever more unscientific and inhumane
advice? How discover the cause when the beginnings
are minimized as unimportant? In no type of disease
is the advice, principiis obsta, more zealously de-
manded. To lull to inconsideration with the hypnotic
of pooh-pooh is surely as bad therapeutics as it is per-
nicious sociology. Almost all scolioses begin in the
slight functional curves. The gravity of such begin-
nings can hardly be overestimated. There remains
also the glaring question, Whence the “hysteria” of
these “lads or girls”? Lastly also arises the question
why so many of these scoliotic children have headache,
poor appetite and digestion, are “nervous,” pale,
anemic, “ delicate,” have so many intercurrent dis-

1 There is always an element of twisting or rotation in lateral
curvature.
264 BIOGRAPHIC CLINICS.

eases, are backward in their classes and all the rest?
The answer will be found in the fact that eyestrain,
which causes many of the malpostures, also causes a

Liem 4

 

 

Fic. 4.— Changes of posture of body and head, the paper skewed, and the pen-
holder angled, in order to bring the writing field into view. In practice different
pupils modify or emphasize one or more of the factors, all of which are some-
what exaggerated in the picture.

certain large proportion of these systemic and cerebral

disorders.
The Writing Posture-—Almost all authors, in fact,
proceed to blame the school desks and the postures in
SCOLIOSIS OF SCHOOL CHILDREN. 265

writing supposedly engendered by them. Thus Roth
says:

 

 

Fic. 5. — The usual malposture of writing. The skewed paper and head and body
bent to the left producing a cervical curve with convexity to the right, with
inclination and torsion. The astigmatic axes, d, d, are at right angles approxi-
mately with a, a, the upright lines of the paper and of the letters formed. The
inclination ur torsion of the head is lessened by slanting the written Jetters,
making variations in approximate parallelism of the lines c and b, with a, a,
This is the reason for slanted handwriting.
266 BIOGRAPHIC CLINICS.

“The position in writing, as generally practiced, is, more
frequently than anything else, an initial cause of most cases of

 

 

 

 

Fic. 6. — More hygienic posture gained by placing the paper vertically opposite the
right shoulder. Some constraint is still necessitated by the level desk or table.

lateral and other curvatures not due to diseased bone or in-
fantile paralysis.”
SCOLIOSIS OF SCHOOL CHILDREN. 267,

But Roth then goes on to make some highly erro-
neous statements:

 

 

 

 

 

Fic. 7.— Normality of posture by placing the paper vertically, opposite the right
shoulder, and with the desk-top well inclined. The pitch here shown is about
45°. Atleast one of 30° is demanded, although when greater the ink will still
flow.

“For many years I have made it a rule, when examining
for lateral curvature, to let the patient sit down and write his
268 BIOGRAPHIC CLINICS.

or her name, and to observe the posture then assumed; nine
times out of ten the patient will have placed himself or herself
in a posture corresponding with the form of the curvature,
except that usually it is highly exaggerated. In most early
cases, where, as we shall see later on, the whole spine is
usually convex to the left, this is found to be exactly the
posture in writing; in severer (i. e., more advanced) cases,
where the usual type is to have the dorsal (upper) curve with
convexity to the right, the patient in writing generally raises
the right shoulder, and this to a far greater degree than in
the ordinary posture of the lateral curvature. This vicious
posture during writing is due to the unfortunate custom of
teaching a slanting handwriting from left to right upward
obliquely, whereas the natural direction of the handwriting
ought to be really in the opposite direction, as anyone will
recognize by sitting perfectly erect with his hands symmetric-
ally placed upon the desk and then attempting to write with-
out screwing the right hand round or twisting the body. I
have therefore been glad to see that in the so-called ‘ reformed’
handwriting children are taught to make the letters vertical,
or even sloping the other way.”

I am utterly incapable of understanding how such a
statement could be made by anyone who had observed
any school child, any adult even, or himself indeed,
during the act of writing. No right-handed two-eyed
person actually writes with the head or body bent to the
right, and the spine with the convexity to the left. Such
a supposed position is often pictured in books, and I
reproduce one as illustrative of the mistakes of this
kind (Fig. 1). In such a posture the pen and writing
space are more or less hidden from view. Every per-
son so placed at once changes about and cants the head
SCOLIOSIS OF SCHOOL CHILDREN. 269

to the left, the neck presenting a convexity to the
right, the body also probably adding other malpostures,
such as turning the right side toward the desk, skewing
the paper, holding the pen unnaturally, etc. All of

 

 

 

Fic. 8. — The unobstructed view of the writing field gained by the writer in Fig. 7.
The head is bent out of sight in photographing.

which is in obedience to the demand, unconscious by
the writer, and unobserved by the physician and
teacher, that the writing space about the pen-point shall
be seen by the right eye. The error of these authors
may possibly be explained as arising from their desire
270 BIOGRAPHIC CLINICS.

to find the posture of the child in writing such as will
explain the dominant type of initial single curves to
the left, and coupled with the false supposition that
the bending of the body slightly to the right can be the
only possible cause of the left scoliotic curve. Uncon-
sciously, however, they may picture the head bent to
the left while the body is bent to the right (Fig. 2),
and at all events they completely ignore the initial,
dominating and supreme etiologic factor, the head bent
to the left and forming a right cervical curve. The
suggestion I have to make is that this right cervical
curve, without exception functionally present in all
right-handed writers, is the primary pathogenic factor,
and the simple left curve of the spine below is merely
secondary and compensatory. ‘The still later com-
pound curve most frequently right dorsal, left lumbar,
is the third or compensatory stage following the second
single curve.*

*The opinion of Tubby also seems to point to a similar
finding of the facts in accord with a false theory. He says:
That the dorsal convexity to the right is more frequent, ad-
mits of no dispute. The statistics quoted by Mr. Adams
fully support the generally received opinion; of 569 cases
in the dorsal region, 470 were convex to the right, and ¢9 to
the left. As to the reason of the excessive preponderance of
right-sided dorsal curves, I believe it is due to excessive use
of the right arm in faulty positions involved in occupations
and employments, these being such as to elevate the right
shoulder and depress the left. Occupations of this nature are,
clerking among men, painting and sewing among women, and
SCOLIOSIS OF SCHOOL CHILDREN. 271

The importance of rotation of the vertebras as a
deforming factor has been brought out by Dr. Lovett.
Anything which causes a rotation of the spine or
head is a powerful influence in causing lateral curva-
ture. “Any lateral yielding of the spine,” says Lovett,
“at any part must be accompanied by a twist of the
spine. As the lateral curve increases, the twist will
tend to increase.’ Dr. Lovett emphasizes that the
torsion or rotation of the head alone causes rotation of
the spine, and that in all spinal curvature there is rota-
tion. This, he says, may be easily demonstrated by
placing the patient in front of the physician, with the
back exposed, and have the patient turn the head or
shoulders sharply to the right or left. We may there-
fore accept as true that any cause which compels too
continuous abnormal postures of the head will probably
produce scoliosis. The cervical vertebras are part of
the spinal column and the mechanism whereby a per-
sistent curvature or rotation of one part of the spine
results by compensation in curvature of the other parts,
while not perhaps well understood by orthopedic sur-
geons is still admitted. So far as this paper is con-
cerned, the demonstration of the mechanism must, of
in school children the very absurd position they are forced to
assume in learning to write the “Italian hand.” The desk is
often too low, and the child is compelled to stoop over it, with
the right arm raised and rigid to insure correct and fine up

strokes, while the left arm is depressed, so that the hand may
fix the copybook,
272 BIOGRAPHIC CLINICS.

course, be left to orthopedic surgeons and the future
progress of science. There are possibly some occupa-
tions besides writing which may compel these abnor-
mal head postures, but at least in school children they
are few and inconsiderable. Among occidental peoples
the habitual writing posture is always with the head
bent to the left, the cervix presenting a convexity to
the right. In addition to this the chest or trunk is
commonly more or less bent to the left, and there is
also another morbid factor added in the torsion of the
head whereby the chin is turned to the right. (In
the I percent or 2 percent of left-handed the inclina-
tions and torsion are, of course, all reversed.) The
reasons for the assumption of this malposture in writ-
ing, together with the related questions of vertical and
slanted handwriting, unhygienic school-desks, etc., I
shall discuss more in detail in another article now writ-
ten, to be published in the Afedical Record, and I may
here only briefly epitomize the conclusions reached:

1. The school desks and seats, imperfect and unhy-
gienic as they may be, are not the primary or chief
factors in the production of the morbid writing pos-
tures, and hence do not per se cause spinal curvatures.

2. They are not the cause of slant handwriting.

3. The two really important needs in school desks,
space to the right so that the paper may be placed
opposite the right shoulder or elbow and a pitch of 30°
or more have not been suggested or demanded.
SCOLIOSIS OF SCHOOL CHILDREN. 273

4. Hygienists and the advocates of vertical as against
slanted handwriting have persistently demanded a po-
sition absolutely impossible to be taken by the writing
child, and have never seen that the child neither takes
such a position when actually writing, nor that he can-
not take such a position, nor the reason therefor.
Slanted handwriting, so far as the writing child him-
self is concerned, has no relation, as a cause, to disease,
nor to the malposture, but is solely a result of the
malposture—is in reality a method of lessening the
malposture and of its consequences.

5. With the head and body erect, the paper straight
before the median line of the body and the penholder
held as commanded, no person can or will write, for
the simple reason that the writing and the writing field
about the pen-point are hidden by the writing hand,
and the penholder (Fig. 3). Immediately the pupil
skews the paper, tilts the head to the left, and grasps
the holder differently—all in order to bring the writing
field and letters being made into clear view, and espe-
cially of the right or “ dominant” eye (Fig. 4). Be-
side the bending of the head (and usually also the
body) to the left, there is a synchronous rotation or
torsion of the head to the right in order to bring the
predominant 90° and 180° axes of astigmatism (in-
stinctive desire for verticality and horizontality) into
alignment with the upright strokes and lateral lines of
the pen and paper (Fig. 5). The cervical vertebras

19)
274 BIOGRAPHIC CLINICS.

are thus forced into a combination of three morbid
positions caused by: (1) Bending the head forward;
(2) canting it to the left; (3) rotating it so that the
chin is turned to the right. There is thus produced a
threefold increase of the scoliosis-producing agency

 

Fic. 9. — Suggested angling of the penholder in order to bring the writing field into
view without morbid posture of the body, head, hand, or paper. (Flanges are
fixed to the holder — hidden in the cut by the fingers — to insure ease of holding,
steadiness, etc. )

which is transmitted to the dorsal and lumbar regions
of the spine in the effort at compensation. There is
always a tendency to hump-back in patients with lat-
eral curvature.
SCOLIOSIS OF SCHOOL CHILDREN. 275

6. The slanted handwriting is due merely to the fact
that less torsion or rotation of the head to the right is
rendered necessary and a slight easing is secured by
slanting the letters to the right. This is illustrated
in Fig. 5. The attempt to make the pupil write ver-
tically, without correcting the malposition demanded
in order to see the writing at all is futile and is an
unconscious fanaticism preferring 27 percent of sco-
liotic children to an unesthetic and mildly criticizable
slanted handwriting.

7. The cure of the false position and of slanted hand-
writing consists in: (a) Placing the paper vertically
and opposite the right shoulder and upon a desk leaf
pitched at an angle of 30° and 12 to 14 inches from
the eye, the body normally erect and hygienically posed
(Figs. 6, 7, 8). (b) Or by the use of angled pen-
“holders as pictured, leaving the paper straight in front
of the body (Fig. 9). (c) The grasping the old
straight holder between the first and second fingers,
or as the Japanese and Chinese do their brushes, from
two to three inches from the point, and the upper end
held vertically or somewhat slanted to the right. This
would require that our common steel pens should be
made somewhat differently.

The last two suggestions are, I think, less ideally
perfect, are in fact somewhat of the nature of expe-
dients, in the lack of properly constructed desks.
Something, anything, must be done to prevent the hor-
276 BIOGRAPHIC CLINICS.

rible production of scoliosis in over a fourth of all
school children.

 

 

 

 

 

Fic, ro,—- Picture of patient taken 35 years ago, showing tilting of head, due to
astigmatism of a peculiar variety, and producing spinal deformity.
SCOLIOSIS OF SCHOOL CHILDREN. 277

Head Tilting from Astigmatism.—Except in the few
left-handed, therefore, the malposture due to the writ-
ing act and caused by visual function and peculiarity,
results in a tilting of the head to the left and a func-
tional right convex cervical curvature. There is
another class of cases, also due to the eyes, which in
the large majority affected produces a canting of the
head to the right and resulting in a functional left cur-
vature of the cervical portion of the spine. The first
class of cases was in large part caused by the need
of participation in vision of the right or dominant eye.
The second class is also ocular in origin and depends
upon astigmatic peculiarity of the dominant eye.

It is perhaps necessary to explain more fully what
is meant by the dominant eye; I refer for a more
extended statement to “ Dextrality and Sinistrality,”?
and “The Pathologic results of Dextrocularity and
Sinistrocularity.”* From one of the articles I quote:

“A little observation and a few tests will show that, with
few exceptions, the right-handed or dextromanual person is
also right-eyed, or dextrocular; and the left-handed is left-
eyed. That is to say, there is, in the dextromanual, the same
habitual and unconscious choice of the image of the right eye
for the more expert and important tasks, just as the right
hand is chosen for those functions in skilled work. A dextro-
manual hunter places his gun against the right shoulder, be-

cause he can sight it with the right eye better than the left
eye. The right-handed person, in playing the violin, violon-

* Popular Science Monthly, August, 1904.
* Ophthalmology, October, 1904.
278 BIOGRAPHIC CLINICS.

cello, etc. is forced to use the left hand for the more expert
task, because he thus sees the fingers and the neck of the in-
strument without fore-shortening and better than he could if
the fingering were done with the right hand. All actions, in
fact, are determined by the fundamental necessity that accurate
vision shall precede all action, and vision is more accurate
with the habitually exercised eye, just as manual function is
more expert and reliable with the hand most exercised in a
special kind of work. But the domination of one eye does not
throw the other out of all function, and especially in artistic
work where stereoscopic vision is of high importance. Du
Maurier had but one eye, and his drawings have a peculiarity
explained by this fact.

“A little closer observation soon demonstrates that not only
is the dextromanual also dextrocular, but that he is likewise
right-footed, and usually right-eared; he is dextropedal and
dextraural. This is equivalent to saying that a person is either
dextral, generally, as to ear, eye, hand, and foot, or else he is
sinistral. There must manifestly be a unity in the coordina-
tions of all acts, and such coordinations would evidently be
better with a habitual one-sided similarity of execution run-
ning through all kinds of action, so that there would be no
indecision in rapid and dangerous acts. The unity and the
resultant promptness and accuracy of all motions is thus en-
hanced by a synchronous dextrality and sinistrality. The
mixed type, illustrated by the so-called ambidextrous, would
place the organism at a wretched disadvantage in the struggle
for existence, and in the social struggle of the highest types
of civilized life.

“The underlying and long forerunning cause, however, of
the coordination of dextral acts, or of sinistral ones, lies in
the necessity of the localization of the organ of speech in one
or in the other side of the cerebrum. As it is a single and
not a dual function, its organ can be only in one place.
Pathology has proved what physiology pointed out, that in
the dextral the speech center is in the left side of the brain,
SCOLIOSIS OF SCHOOL CHILDREN. 279

and in the sinistral it is in the right side. Moreover, the in-
tellectual act of writing develops the speech center on the side
opposite to the writing hand. The history of cases with tumors
and paralyses has settled this question beyond controversy.

“The speech center may be looked on as the organ through
which intellectual judgment and decision issues in determina-
tion and act. The spoken and written word is the most in-
timate act of the mind, its irrevocable and immediate exponent.
Prior to all judgment and decision, vision must give the data.
Intellect is, in fact, the product of vision, and all mental sym-
bols, the letters of the alphabet themselves, are but modified
visual images. The thing seen is thus worked into judgment,
and by the third component of human action, motion is
wrought into completed function. Vision, judgment, act, are
thus the unexceptional conditions of human activity and
validity. It is at once plain that if the centers which inter-
mediate these three functions are on one side of the brain, in
contiguity, and closely united by many intercentral fibers, the
resultant act will be more accurate and rapid than if one or
two of the centers are in the opposite side of the brain. The
commissural fibers between the two cerebral hemispheres
would be fewer and longer, and the coordination less clear,
sharp, and certain. This is the neurologic basis for a common
dextrality or a common sinistrality of function in one indi-
vidual, and it completely demolishes the foolish contention of
those who would vainly educate the two percent of left-handed
children to be ambidextrous.” *

*One thing has been much impressed upon me, and that is
that those who are normally left-handed, and are taught to
write with their right hand, suffer from writer’s cramp much
more readily than normally right-handed individuals. It would
seem as though nature were taking her revenge for an inter-
ference with her original plan, for the man is right-brained
and should not be compelled to use his right hand for a work
requiring so much coordination as does writing—From “ So-
called Rheumatisms,” J. J. Walsh, Medical News, February
18, 1905.
280 BIOGRAPHIC CLINICS.

In a small proportion of the oculist’s patients he
finds a peculiar asymmetric axis of astigmatism in
the dominant eye which compels the child and youth
to hold the head inclined or tilted, usually to the right,
and almost all the time, in order to bring the abnormal
axis of astigmatism to 90°. At the worst, school ses-
sions last for but a part of the day, writing for but a
part of the school hours, the school term for but a part
of the year, the school years for only a part of the
youth and adult life. A cause that keeps the head
tilted to one side all the waking hours of youth will
inevitably result in lateral spinal curvature. Such a
cause is a certain axis of astigmatism in the dominant
eye not compensated for by that of the other eye.

An axis of astigmatism in the dominant eye from
10° to 20° to either side of 90° or 180°, while the axis
in the fellow eye remains normal or unsymmetric, pro-
duces head tilting; symmetric axes produce no head
tilting. Ina year after I discovered this law I found
in the ordinary run of office practice over fifty cases
of head tilting. The stupid error I made all my life
was to allow these patients to cant the head during the
refraction testing. In this way I failed to find how
large is the number of right-handed patients who have
axes of astigmatism of the right eye from 10° to 20°
to one side of 90° or 180°. And never before this
had I thought of the necessity of inquiring as to dex-
tromanuality in patients having these slightly unsym-
SCOLIOSIS OF SCHOOL CHILDREN. 281

metric axes of astigmatism. It is evident that an axis
in the dominant eye only 5° to one side of 90° or 180°
would hardly produce a noticeable tilt of the head, or
might possibly be compensated for by the rotation of
the eyeball itself. It is possible that some types of
heterophoria, and especially cyclophoria, may be ex-
plained as arising from this compensation of the ocular
structures, instead of producing the tilt or cant of the
head. It also seems possible that this compensatory
twist of the eyeball in the orbit may possibly cause a
compensatory twist of the optic nerve, and perhaps
certain other diseases of the papilla and retina. After
prescription of proper correcting glasses it would be
natural to find before long a secondary change of axis
resulting from the rectification of the abnormal head
tilt or ocular twist. Such patients must be kept under
continuous and repeated observation. If the axis of
astigmatism of the dominant eye is about 75° or 165°,
it is evident that if the nondominant eye is unsym-
metric, the head must be tilted to the right in order to
bring the false axis into line with the vertical lines of
print, trees, houses, wall paper, doors, etc. (Figs. 10,
11). If the axis of astigmatism of the dominant eye
is about 105° or 115°, compensatory tilt of the head
must be to the left. Greater variations of the axis
than 20° would hardly be compensated for by head
tilting, but would either produce amblyopia, a transfer
of dominancy to the other eye, or else some other path-
282 BIOGRAPHIC CLINICS.

ologic consequence equally harmful to action and life.
The axis of the largest number of head tilters is about
75° in the right eye, and thus the majority tilt the head
to the right.

 

 

 

 

Fic. rr — Present habitual pose of head of patient shown in Fig. 10.

Among my cases of head tilters the majority had
resultant spinal curvature or scoliosis or otherwise mal-
formed backs. The fact was usually unsuspected by
SCOLIOSIS OF SCHOOL CHILDREN. 283

the patient, the parent, and the attending general phy-
sician. I sometimes had difficulty in getting consent
that an expert orthopedic surgeon should verify the
diagnosis. A report of these cases will be published
later.

Of course there are other cases of functional head
tilting, wry or twisted necks and spasmodic or rigid
conditions of the head. A person who has one blind
or nearly blind eye, or one deaf ear, will turn the func-
tional eye or ear forward and bring about habitual
abnormal head postures with the same disastrous re-
sults to the spine.

Other Organic Results of Head Tilting—In the
Journal of Medical Research of July, 1904, Dr. Thomas
Dwight writes of the anatomic anomalies causing mal-
position of the head and distortion of the face. These
he classes as follows:

1. Diminution of the cervical vertebras.

2. Fusion of the cervical vertebras.

3. Union of the atlas and occiput by fusion or by a
paramastoid process with or without fusion.

A question as to the origin of some of these anoma-
lies, especially those in which fusions have taken place,
is suggested: May they not in part or often be due to
the habitual malposture of tilted head or wrenched and
rigid attitudes, themselves the products of the postures
compelled by astigmatism and other optic defects?

Illumination of the School Room.—Many writers
284 BIOGRAPHIC CLINICS.

have ascribed the malposture of pupils in writing to
the fact of the wrong direction of the incident illumi-
nation upon the desk. However necessary good illu-
mination may be it scarcely influences the posture.
Bad light is bad, but not for a bad reason. It is
remarkable how indifferent children and indeed almost
all others are to the direction of the light. Scholder
places insufficient light as the first of the evil school
influences which begets scoliosis, by forcing the child
to bend forward. To get relief he says unsymmetric
postures sideways are assumed and the curvature
begins. This begs the question and ascribes to the
assumption results which leave the mystery greater,
because there will be lateral postures to both sides and
neutralization of any tendency to one curvature solely.
This wrong explanation of malposture is another in-
stance of grasping at a hoped-for elucidation of the
fact deplored, in the absence of an exact recognition
of the real cause. Scholder even claims that in the
new school buildings with better light there are fewer
scoliotics.

The Sitting Posture-——The second cause listed by
Scholder as the cause of scoliosis in school children is
the prolonged sitting posture. Long hours, he says,
tire the muscles, and to rest the child assumes lateral
postures. This also, although of some influence is
only indirect, vague and most unsatisfactory. The
beating about for an explanation in default of the
SCOLIOSIS OF SCHOOL CHILDREN, 285

genuine one, is also illustrated by the peculiar causes
ascribed in the case of girls, the supposed fact of their
sitting with their dresses and skirts more thickly
bunched under one of the hips than under the other.
His third reason, that the desks are not adapted to

 

Fic. 12, — Japanese and Chinese method of holding the writing-brush,

the size of the children approaches closer, but still
leaves the mystery untouched.

Placing of the Writing Paper.—His fourth reason is
the wrong position of the writing paper, copy book,
etc., and “this,” he says, “is of the greater signifi-
286 BIOGRAPHIC CLINICS.

cance in etiology.” With the paper placed to the right,
he adds, it is skewed, and the written letters slant to
the right. ‘“ The left eye is thereby brought nearer the
paper than the right and therefore there are more left-
eyed myopes than right-eyed myopes in our schools.”
To remedy this faulty placing of the eyes, “ the body is
turned to the left, producing torsion ; the right forearm
is turned from the body, the left supports it, the left
shoulder is raised, the right depressed, and the spine is
curved to the left. Hence the eyes suffer from myopia
and scoliosis is produced. The largest portion of our
pupils assume this position and it should be forbid-
den.” Now unless 98 percent of the Lausanne chil-
dren are left-handed or differ from other mundaners
as much as the Martian children may differ, not a
word of this is true. It is all exactly the reverse with
any righthanded child. One cannot understand how
such statements can be made, nor what meanings can
have been attached to the terms “left” and “ right,”
etc.; and malposture has little or nothing to do with
the etiology of myopia.

He says further that if the paper is placed in the
median position, straight or skewed, “ the Grundlinien
of the eyes instinctively seek parallelism with the
lines.” The more the paper is skewed to the left the
more the head and body are depressed to the left and
the greater the torsion, and thus are produced the
right curvatures. This observation of the instinctive
SCOLIOSIS OF SCHOCL CHILDREN. 287

seeking for parallelism of the Grundlinien of the eyes
with the lines of the paper (the horizontal rulings, or
the vertical written one?) constitutes a dim and inac-
curate perception of one of the most important and
real factors at work. But why this skewing of the
paper? is a question not asked nor answered. And
what the Grundlinien of the eyes may be, and why the
instinctive search for parallelism exists, are sugges-
tions, not answers, of the deeper question and fact.
Scholder thus explains the origin of the right curva-
ture by the skewing of the paper to the left and the
bending of the head and body to the left. These cur-
vatures, however, according to him, constitute only
something like 30 percent of the total of initial ones,
and so the 7o percent of left curves must, it would
seem, be explained by the placing and skewing of the
paper to the right and the resulting bending of the
head and body to the right. But there are no such
positions of the paper, the head and body, assumed
by any right-handed child! And for the simple reason
that in such a supposed position the hand utterly pre-
vents vision of the writing field and even of the pen.
To emphasize the necessity of teaching vertical writing
Scholder says that of children with curvatures the fol-
lowing were the proportions:

Slant Writers. Vertical Writers.
Niirnberg ................2.4. 24% 15%
ZiTiCh gc astactem sa beanie weeds 32% 12%
288 BIOGRAPHIC CLINICS.

Slant Writers. Vertical Writers
Munich’ ;.jauss sasicvaraeien sae Bah 15%
Pirth. ajacieee cede ote ease alent OG 314%
Wirz bie! csccsaad a aegre aces 28% 8%

The average of the first column is about 30 percent,
of the second, 16 percent. Taking the figures at their
“face value,” it would appear that the slanted writing
produces less than twice the number of scolioses that
the vertical style causes, but that the vertical style is
responsible for 7o’5 of the chosen examples. The figures
still leave over 50 percent of the total number of cases
of scoliosis to be caused by some style of writing other
than the slanted or vertical. The logic and the obser-
vation seem equally strange and inconclusive.

The Sense of Equilibrium and Adjustment—The
mechanism which controls the establishment of equi-
librium and adjustment dominating the development
of scoliotic malfunction, is also largely the result of
a visual necessity. The vertical and horizontal posi-
tions of the head, 7. e., the go° and 180° axes of astig-
matism, must be preserved in order to render bodily
action or motion skilled, certain and safe, and vision
clear. The prevalent axes of astigmatism serve a func-
tion not unlike the hair lines of a transit or theodolite,
1. e., they guide all judgments of horizontality and
verticality. I suspect that the semicircular canals of
the ear are less the organ of equilibrium than are the
eyes, and that seasickness in swinging or on board ship
SCOLIOSIS OF SCHOOL CHILDREN. 289

is a visual rather than an aural phenomenon. The
astigmatism lines are negative, and variation from
them of head-poising is the warning and danger signal.
The necessity is so great of aligning the dominant axis
with upright objects, printing, etc., that head tilting
results when the dominant axis is, say, 75°, and not
neutralized by a symmetric axis in the fellow eye. In
these head tilters the pathologic results in the spine,
etc., are different from those in which the head pre-
serves its verticality; and they differ also in this that
the mental and psychic troubles are greater in the
head tilters.

The Relations of Occidental and Oriental Writing
Postures and Methods to Spinal Curvature —In China
and Japan the habits and methods of writing present
throughout the most noteworthy contrasts to those cus-
tomary with us. The particulars may be briefly
epitomized as follows:

1. The writing begins at the upper right-hand corner
of the paper, giving an evident advantage in seeing the
writing field or the letters which are being formed and
especially with the right or dominant eye.

2. The lines of writing are from the top to the bot-
tom of the page, thus again securing increased visi-
bility of the writing field.

3. There is thus no need and no practice of skewing
the paper to secure unimpeded vision of the writing
field. The writing is naturally vertical.

20
290 BIOGRAPHIC CLINICS.

4. The writing brush (corresponding to our pen and
holder) is grasped from two to three inches from the
brush-tip (corresponding to our pen) ; it is held usually
between the second and third fingers (instead of be-
tween the thumb and first finger, as with us), and
either upright or slanting away from the writing space,
to the right, and not, as our children are instructed,
with the holder pointing over or to the right shoulder.
Each one of the methods of holding the brush aids
decidedly and collectively very powerfully in keeping
the writing space clearly in view of the vision of both
eyes. It seems almost as if all these methods were
consciously designed that the writing field might be
seen (Fig. 12).

5. In addition, native Japanese and Chinese tell me
it is a habit of many to hold the paper with the left
hand, in the air, and pitched at an agle of from 30° to
50°. I did not know of this custom until months after
I had written, advising a pitch of the leaf of the writ-
ing desk of 30° A greater pitch than this would
sometimes not permit the ink to flow freely from our
steel pens. The medieval copyists used a pitch of 50°
or over, and our modern draughtsmen and artists often
do the same. Modern artists in painting and sketching
secure the clear view of the field of work by setting
their canvasses nearly horizontal and by holding the
brush or pencil from three to ten inches from the point.
There are more modern writers than we suspect who
SCOLIOSIS OF SCHOOL CHILDREN. 291

increase the extent of visibility of the writing field by
holding the pen between the first and second fingers, or
by grasping the holder two or three inches from the.
pen-point, by turning the hand upward, or by slanting
the pen-holder to the right. But these are devices for-
bidden by teachers (and writing books) who have no
perception of the simple reason why the so-called
“incorrect habits and postures” are unconsciously
chosen.

6. Whether we should imitate the Oriental methods
described above, either in part or not, is at present not
my concern. Their result is our one great desideratum
—the preservation of the erect and hygienic posture
during the writing act. There is little or no bending
of the head to the left. If this functional right cer-
vical curve, habitual in the Occidental writing posture,
is the cause of the incipient spinal left curve of our
school children, it follows that there will be far less
than 27 percent of Japanese and Chinese children

showing such curves between the ages of 7 and 14
‘ years. An orthopedic examination of the backs of a
large number of the children of Oriental schools would
yield interesting and critical results. A minor query
would be as to the proportion of scoliotics among
Occidental children blind from infancy.
VISUAL FUNCTION THE CAUSE
OF SLANTED HANDWRITING;
ITS RELATION TO SCHOOL-—
HYGIENE, SCHOOL DESKS,

MALPOSTURE, SPINAL
CURVATURE AND
MYOPIA.
CHAPTER VIII.

VISUAL FUNCTION THE CAUSE OF SLANTED
HANDWRITING; ITS RELATION TO SCHOOL-
HYGIENE, SCHOOL DESKS, MALPOSTURE,
SPINAL CURVATURE, AND MYOPIA.

Slanted Handwriting is Bad, but not because of
Bad Reasons.—Careful and trustworthy statistics show
that on the average 27 percent of the pupils in the
primary grades of the schools of Europe have lat-
eral spinal curvature. The fact is as terrifying as
the greatest in pathology, as bad, for instance, as the
prevalence of tuberculosis. There is no reason to
doubt that American children are less scoliotic than
those of Lausanne, Dresden, etc. If not actually cry-
ing out against slanted handwriting and school desks
as the causes of this appalling disease, almost all or-
thopedists and school hygienists admit or suggest it.
And yet slant handwriting is not only not the cause
of the writing malposture and of scoliosis, it is only a
-minor effect of the writing malposture. It is not only
an effect, but, bad as it is, it is a method of avoiding
worse malposture. To no one could such a style of
writing be more repulsive than to me, and yet, as one
must so often emphasize, the bad reason does not

1From the Medical Record, April 22, 1905.
295
296 BIOGRAPHIC CLINICS.

make it bad. The reasons for vertical vs. slanted
handwriting must be scientific and true or the slant-

 

 

 

 

Fic, 13. — Habitual posture of head and shoulders of a patient with an axis of astig-
matism in the dominant eye that compelled the head-tilting, depression of the
right shoulder, etc., and caused curvature of the spine.
CAUSE OF SLANTED HANDWRITING. 207

ing will never be done away with. There are consid-
erations very different, and of infinitely more impor-
tance than the slanting itself, why such writing must
be abolished.

 

 

 

 

 

 

 

 

 

 

 

 

 

Fic. 14. — Habitual reading posture of a boy with beginning lateral curvature of the
spine caused by a peculiar axis of astigmatism,
298 BIOGRAPHIC CLINICS.

Factors of the Writing Malposture—All acts or
habits are wrong some of the time, and some acts or
habits are partly wrong all of the time. Only the act
of writing, as commonly carried out, is wholly wrong
all the time.

1. In a state of rest every object illustrates and
obeys the law of gravity, equilibrium, or architecture,
which demands that its center of gravity must be
vertically above its base or point of support. A feel-
ing of strain or irritation arises in the mind when
natural objects do not conform to this law. Tum-
bling-down chirography does not obey this law.

2. The letters of the alphabet are conventionalized
pictures or ideograms of the pictograms or pictures
of natural objects—the ox, horse, camel, door, win-
dow, hook, serpent, hand, fish, water, eye, mouth,
head, etc. These prototypes, of course, obeyed the
law of verticality in Phoenician and Semitic times as
they do now. The modern written letters of the
alphabet should do the same.

3. All printed and type-written letters and musical
notes preserve the erect position. The handmade let-
ters should conform to the rule.

4. The slant method of writing is a result of the
writer’s personal difficulties, but the character of the
writing is, or should be, dictated by the consideration
of the reader’s sake, not because of the writer’s per-
sonal or pathologic trouble.
CAUSE OF SLANTED HANDWRITING. 299

5. More important than all the foregoing is the fact
that the vast majority of all persons have some astig-
matism, and about 95 percent of all astigmatisms are
at or about the axes 90° and 180°’, and such eyes
demand the prevailing lines of things seen at 90° or
180°.

Even if no astigmatism is present, or if that which
is present is not in the neighborhood of go° or 180°,
the habit of equilibrium, and the inheritance from all
ancestors of the habit of holding the head erect and
of seeing with the eyes coincident with the usual 90°
and 180° axes, would compel the customary position.

The secondary factors, which determine the pos-
ture and malposture of the body and the character
of the handwriting, vertical, slanted, or otherwise im-
proper, are:

1. The position or posture of the head.

2. The position or posture of the body.

3. The location of the paper upon the desk.

4. The angling or skewing of the paper as regards
the right angles of the desk-top or writing-board.

5. The flatness or inclination of the desk-top or
writing-board.

6. The relative height and distance apart of the
desk and seat.

7. The position of the hand, method of holding the
penholder, etc.

8. The necessity of parallelism between the vertical
300 BIOGRAPHIC CLINICS.

axis of the head, or what is the same thing, of the 9o°
axes of astigmatism of the eyes, and the vertical lines,
real, supposed or presented by the formed lines of the
written letters.

 

Fic. 15.— The hand in the writing posture as usually ordered, but not practised
because to the writer the writing-field is hidden by the thumb, finger, and holder.
An actual view of the hand with the writer’s head displaced.
g. The relative position of the right or dominant
eye, and the unhindered meeting of the visual axes of
CAUSE OF SLANTED HANDWRITING. — 301

both eyes upon what may be called the writing field,
1. é., the space at and about the pen-point.

In other articles (Popular Science Monthly, Au-
gust, 1904: Ophthalmology, October, 1904) I have
explained the terms dominant eye and dextrocularity.
The relation of the writing malposture to the produc-
tion of lateral spinal curvature I have set forth in
American Medicine, April 8, 1905.

Briefly epitomized, this etiologic factor arises from
a bending of the head to the left, skewing of the
paper, etc., in writing, in order that both eyes of the
writer may have a clear view of the writing-field or
space about the pen-point. And especially by the
right or dominant eye, the one corresponding in
function, and particularly in writing, with the right-
handedness (expertness) of the right-handed person.
This canting of the head to the left produces a func-
tional cervical curve with the convexity to the right,
which I suggest is the primary factor in the forma-
tion of subsequent compensation curves of the spine
below. Orthopedists seem to have forgotten that the
cervical vertebras are part of the spinal column; any
lateral bending of any part of the column produces
twisting or rotation, with the production of reverse
or secondary curves later, in the effort at compensa-
tion. (Figs. 13, 14.) George Sand and all the advo-
cates of vertical handwriting have persistently de-
manded écriture droite, sur papier droit, corps drott
302 BIOGRAPHIC CLINICS.

—vertical handwriting, on vertical paper, the body
also vertical. Knowing what was and is intended by
the words, not what literally is said, we may add that
even this intended advice is impossible of execution.

 

 

 

 

Fic. 16.--The common but in the picture somewhat exaggerated, writing malpos-
ture, method of holding the pen, skewing the paper, bending of Lody, torsion of
head, etc., in order to gain a clearer view of the writing-field.

No right-handed person ever writes so, or could write
so, 1. ¢., if the paper (as supposed) is horizontal, placed
squarely (not skewed) before the median line of the
CAUSE OF SLANTED HANDWRITING. 303

body, and the penholder held as instructed in the “ cor-
rect position,” 7. e., with the upper end pointing toward
the shoulder. No one ever wrote a line in this posi-
tion, and simply because he could not see the letters
he was making. And to write we must see the letters
which are being formed. (Fig. 15.)

Details as to the Nine Factors of Malposture in
Writing —

1. The position of the head may be:

a. Perfectly erect, its long or vertical axis corre-
sponding with the vertebral axis when the body is
erect and accurately and squarely in front of the desk.

b. Canted or tilted to one side, to the left in the
dextral, and in varying degrees.

c. Twisted on the vertical axis of the head and neck,
to the right in writing, by the dextral.

d. Positions a and c, combined or mixed.

e. Positions b and c, combined or mixed.

2. The posture of the body may be:

f. Erect, the lateral axis parallel with the front line
of the desk.

g. Bent to the left (in the dextral) in varying de-
grees, the vertebral column being either straight or
curved.

h. The spinal column twisted in varying degrees.

i. The right side of the body turned toward the desk
or approximated to it more or less.

j. Varying combinations of the positions g, h, and i.
304 BIOGRAPHIC CLINICS.

In practical and unconscious writing the positions
of the head and postures of the body above enumer-
ated under 1 and 2 may be and usually are mixed and
interdependent, thus resulting in many modifications
and variations.

 

 

 

 

 

 

 

 

 

Fic. 17. — The medieval copyists wrote with the paper pitched at a sharp angle.

3 and 4. The location and angling of the paper upon
the desk may be:

k. In front of the face and squarely placed, i. ¢., its
lower border parallel with the front of the desk.
CAUSE OF SLANTED HANDWRITING. 305

1. Askew, at varying angles to the left, but usually
at an angle of about 35° with the desk front.

mt. With the left hand border parallel with the desk
front.

i. Opposite the right shoulder in head and body
postures a and f, the lower border parallel with the
desk front.

With the ordinary straight penholder and pen held
as universally ordered and the head and body in pos-
tures a and f, no ordinary human being can write,
because the index finger and the pen necessarily
come between the right eye and the pen-point. (Fig.
15.) Therefore, every writer immediately disobeys
the teacher and varies one or all of the positions, pos-
tures, etc., so that the dominant eye has an unob-
structed view of the writing field. (Fig. 16.) The
most extreme position of the body and head I have
ever seen was in a patient who had an enormous as-
tigmatism, and who was compelled to bring the eyes
almost to a level of the table, with extreme rotation
of the head in order to bring the astigmatic axes
into parallelism with the lines of the writing being
executed. Position 1 of the paper is the only one that
permits of the perfectly erect or hygienic postures of
the head and body designated as a and f, because only
under such conditions can the dominant eye have a
clear view of the writing field.

5. But the difficulty of writing in these postures

21
306 BIOGRAPHIC CLINICS.

 

 

 

Fic. 18 — The usual(writing posture. The{body andghead are bent to the left, the
head in addition, rotated so that the chin is to the right; there is a cervical
curve with the convexity to the right; the right side of the body is turned
toward the desk; the paper is skewed to the left; the predominant go® axes of
astigmatism, dd, are at approximate right angles to the vertical lines of the
Paper, aa; to lessen the strain upon the body, neck and eyes, the approximate
parailelism of the lines cd, with the lines aa, of the skewed paper is varied,
causing the obliquity of the written letters to the right, or the slanted style of
handwriting.
CAUSE OF SLANTED HANDWRITING. 307

and conditions is greatly increased by the flat desk,
and is almost done away with by an inclination of the
desk leaf or writing board at an angle of 30°. The ink
will still flow from the pen with the leaf at this angle,
the position of the head and body made most comfor-
table and hygienic, and the unconscious tendency to
bend the head and body is neutralized. The copyists
and monks of medieval and Latin times learned this, as
is illustrated by the annexed cut. (Fig.17.) Anadded
and highly important consideration is that by the 30°
or 40° sloped desk leaf, the eyes are enabled to look
off at the book or writing at nearly a horizontal line,
instead of down upon it with the eyes nearly verti-
cally over the letters. The traction on the inferior
recti muscles of the eyes with the resultant unnatural
position of the eyes, is a prolific source of eyestrain.
It also compresses the chest, humps the back, inter-
feres with the circulation of the neck, the supply of
‘blood to the brain, and the flow of air in and out of
the lungs in breathing. The inclination of the desk
may be more pitched in reading than in writing.

o. The child’s feet must rest lightly and naturally
upon the floor, with the knees bent at about a right
angle, the body at the proper distance from the edge
of the desk. This can be effected only by means of a
seat that may be raised or depressed, and not attached
to the floor.

6. The organizers, teachers, trustees, furniture
308 BIOGRAPHIC CLINICS.

makers and parents have too often failed to notice
that children differ in height from adults, differ from
each other and that they have a habit of growing.
Even the most progressive in very recent years have
not come to a thoroughgoing knowledge of these
simple facts, and have not made the school desks and
seats to conform accurately to them. What is now
needed is mechanical constructions which will meet
the differences of each child in an easy and perfect
manner.

p. The leaf of the desk, in addition to being inclined
at an angle of about 30°, must be of a height which
brings the printed book and writing paper at a dis-
tance of about fourteen inches from the eyes.

g. The pedagogs have also usually failed to notice
that in reading a book it may be placed opposite the
median line of the body or face (in erect position),
but that in writing the paper cannot be thus placed.
Hence the frequent permission in writing to turn the
right side of the body toward the desk. When the
paper is placed opposite the right shoulder upon a
sharply-inclined desk leaf of the proper height, the
eyes can see the writing field without unnatural posi-
tions of the body and head.

7. Everyone has probably wondered why, when the
school and writing teacher are ignored or forgotten,
the pen and holder are either slanted differently ; held
between the first and second fingers ; not seldom angled
 

 

Fic. 19 Styles of angled holders which permit of an unobstructed view of the writing-fleld without malposture of body, head, paper, or hand
CAUSE OF SLANTED HANDWRITING. 309

parallel with the lateral lines of the paper, even nearly
vertical, or toward the upright lines of the paper;
drawn inward and toward the chest, the eyes above
and looking down vertically upon the sheet; and the
head in various other unnatural and cramping posi-
tions. (Fig. 18.) Such anomalies are too frequent to
be called anomalies and are simply the unconscious
morbid methods whereby the dominant eye gets a free
view of the writing field. The types of this unhygienic
pen-holding are too numerous and anomalous to be
classified.

Artists, by means of long-handled brushes, etc.,
are able to gain a clear view of large spaces about
the point of the brush, pencil, etc, by grasping
the handle several inches from the point. They are
thus under no necessity of inclining the head and
body. Also their canvases, easels, etc., are either ver-
tical or nearly so, and this does away with the visual
difficulty encountered when the surface is horizontal
or only slightly inclined. There is a simple method
whereby the writing field or space about the pen-
point may be seen without canting the head and body
to the left and with the paper placed squarely in front
of the body. This is by means of angled penholders
which I have devised and of which I show cuts of
some styles. (Figs. 19,20.) The difficulty in holding
these without the depression of the angled parts is
obviated by flanges or supports for the fingers. Of
310 BIOGRAPHIC CLINICS.

course they seem odd and “awkward” at first, but
one soon writes with them easily and unconsciously.
And with them one finds himself writing vertically
without effort or intention. Any lateral or unhygienic
posture is unnecessary in their use.

 

 

 

Fic. 20. —The writing-field is clearly seen with an angled holder, the body, head,
and hand being hygienically posed and the paper vertical and opposite the
median line of the body, upon a flat desk or table,

8. Some authors describe postures in which the
body is leaned to the right, but they are not practiced
because the writing-field is thus hidden to a greater
degree. (Figs. 21, 22, 23, 24,25, 26.) In all the mul-
CAUSE OF SLANTED HANDWRITING. 311

titude of improper postures, positions, pen-holdings,
etc., the teacher of writing, hygiene and physiology
have failed to notice that by some device nature will
bring it about that the 90° axes of the eyes and astig-
matism will be forced into parallelism with the verti-
cal or slanted lines of the long letters being written.
Hence the multiplicity of morbid postures begotten
by the failure to place the paper properly before the
right shoulder and with the head and body erect,
with the inclined desk leaf and the penholder properly
seized.

g. Only when these conditions last named are as-
sured has the dominant eye an unobstructed view of
‘the writing-field at the proper distances, etc. To
secure this clear view of the writing-field with the
paper placed according to universal instruction, the
head and body are forced into unnatural positions.
The unnaturalness and weariness of these morbid pos-
tures are lessened a little by the slanting of the letters
to the right and the tendency of the line of writing to
slant upward. This any one can demonstrate by a
few thoughtful tests or observations. And this is the
source of slanted handwriting. (Fig. 18.) It is in
fact a method of avoiding still more extreme torsion
of the head or neck—a greater morbid slant of the
patient by a slant of the writing.

J cannot find that anyone who has written of hand-
writing or of school hygiene, or who has constructed
312 BIOGRAPHIC CLINICS.

or advised as to the making of school desks and seats,
has ever dreamed of the patent and easily recognized
fact that every one of the nine factors are verities,
and that they are bound together into a coordinate
unity. None of them can be much changed without
changing all of the others, and unconsciously every
pupil and writer has solved the problem of carrying
out the writing act by a special and personal adap-
tation and modification of each of the factors men-
tioned. The one all-dominating necessity which every-
one discussing the subject seems to have overlooked,
is that the writing-field (the space about the pen-
point) shall be seen, seen with both eyes, but espe-
cially seen with the right eye. I speak of right-
handed and right-eyed persons. All is reversed as
to the left-handed and left-eyed. The essence of the
matter is the necessity of binocularity and especially
the existence of dextrocularity, a hitherto unrecog-
nized thing, and the most intimate coordination of
the right eye and right hand in the most mental and
intellectual of all acts, except speech—that is, writ-
ing. The positions usually taught by school-teachers,
writing-teachers and copy-books are next to impos-
sible, certainly not practised by the child or man
when writing much or unconsciously. Then nature
modifies all the nine factors mentioned, solely and
simply in order that the hand, fingers and pen shall
not come between the right eye and the writing-field.
CAUSE OF SLANTED HANDWRITING. 313

The pathology of school life in a multitude of symp-
toms and diseases consists for the greater part in the
unhygienic attempts to see the writing-field with the
dominant eye. And the two great blunders of all the
teachers and desk-makers are that the penholders and
pens are not shaped so that the writing space or field
about the pen-point can be seen with both eyes when
the body and head are erect; or that the desk is not
inclined at an angle of about 30°, and the writing
paper is not placed squarely and opposite the right
shoulder, with the body and head erect and squarely
postured before the desk. With the paper so placed,
the desk top so inclined, the body and head thus erect,
the right eye sees the paper at twelve inches or fourteen
inches and the writing is vertical. (Figs. 27, 28.)

Probably as many as two hundred distinct styles of
school desks and chairs have been proposed, tried and
rejected or in use. The reader may find some of these
described in works on school hygiene, such as those
of Kotelmann, .Meyer, Staffel, Fahrner, Rettig, Her-
mann, Bendzula, Schildback, Schenk, Hippauf, Prausek,
Wallraff, Barnard, Priestley Smith, Stone, Shaw,? and
especially Risley.*

So far as these relate to reading of a single book,
the results reached by students of pedagogy are of

* American Physical Education Review, June, 1900.

* Tbid., June, 1901.
* Norris and Oliver: “ System of Diseases of the Eye,” Vol. II.
316 BIOGRAPHIC CLINICS.

varying the pitch from the minimum of 30° to a max-
imum of 45° and thus adapted to reading or writing at
pleasure. Thus made, the right-hand leaf would be

 

 

 

Fic, 22.--Some hygienists describe a form of malposture consisting in skewing the
paper to the right and bending the body and head to the right; it is never prac-

tised because the writing-field is still more hidden than in the posture of Fig, 15
ordered as ‘‘ correct ”’

the only one used for writing. All pupils, should, of
course, have desk and chair so adapted to their height
CAUSE OF SLANTED HANDWRITING. 317

that the book or paper would be at fourteen inches
from the eye when looking down upon it with a visual
axis at an angle or inclination not greater than 150°
oris5°. The visual axis at about 150° should approx-
imately form a right angle with the inclination of the
desk leaf at about 30°. (According to the oculist’s
trial frame and as figured in illustration, the desk top
should be at 145° and the visual axis at 35°.)

The Relation of Occidental and Oriental Writing
Postures and Methods to Spinal Curvature.—In China
and Japan the habits and methods of writing present
throughout most noteworthy contrasts to those cus-
tomary with us. The particulars may be briefly epi-
tomized as follows:

1. The writing begins at the upper right-hand cor-
ner of the paper, giving an evident advantage in seeing
the writing field or letters which are being formed, and
especially with the right or dominant eye.

2. The lines of writing are from the top to the bot-
tom of the page, thus again securing increased visi-
bility of the writing-field.

3. There is thus no need and no practice of skewing
the paper to secure unimpeded vision of the writing-
field. The writing is naturally vertical.

4. The writing brush (corresponding to our pen
and holder) is grasped from two to four inches from
the brush tip (corresponding to our pen) ; it is held
usually between the second and third fingers (instead
318 BIOGRAPHIC CLINICS.

of between the thumb and first finger as with us),
and either upright or slanting away from the writing
space, to the right, and not, as our children are in-
structed, with the holder pointing toward the right
shoulder. (Fig. 29.) Each one of the methods of
holding the brush aids decidedly, and collectively very
powerfully, in keeping the writing space clearly in
view of the vision of both eyes. It seems almost as
if all these methods were consciously designed that
the writing-field might be seen.

5. In addition, Japanese and Chinese friends tell
me it is a habit of many to hold the paper with the
left hand, in the air, and pitched at an angle of from
30° to 50°. I did not know of this custom until
months after I had written advising a pitch of the
leaf of the writing desk of 30°. A greater pitch than
this would sometimes not permit the ink to flow freely
from our steel pens. The medieval copyists used a
pitch of 50° or over, and our modern draughtsmen and
artists often do the same. Modern artists in painting
and sketching secure the clear view of the field of work
by setting their canvas nearly vertical and by holding
the brush or pencil from three to ten inches from the
point. There are more modern writers than we sus-
pect who increase the extent of visibility of the writing-
field by holding the pen between the first and second
fingers, or by grasping the holder two or three inches
from the pen-point, by turning the hand half upward,
CAUSE OF SLANTED HANDWRITING. 319

or by slanting the penholder to the right. But these
are devices forbidden by teachers (and writing books),
who have no perception of the simple reason why the

 

 

Fic, 23. — View of the writing-field as seen by the writer with skewed paper, and
body and head turned to the left.

so-called “incorrect” habits and postures are uncon-
sciously chosen.

6. Whether we should imitate the Oriental methods
described above, either in part or not, is at present
320 BIOGRAPHIC CLINICS.

not my concern. Their result is our one great desid-
eratum—the preservation of the erect and hygienic
posture during the writing act. There is little or no

 

 

 

 

 

Fic. 24.—To gain a better view of the writing-field the pupil instead of leaning to
the left, sometimes bends forward until the eyes are directly above or even in
advauce, of the writing, lateral curvature and rotation being thus avoided.

bending of the head to the left. If this functional
right cervical curve, habitual in the Occidental posture,
is the cause of the incipient spinal curves of our school
CAUSE OF SLANTED HANDWRITING. — 321

children, it follows that there will be far less than 27
percent of Japanese and Chinese children showing such
curves between the ages of seven and fourteen years.
An orthopedic examination of the backs of a large
number of the children of Oriental schools would yield
interesting and critical results. A minor query would
be as to the proportion of scoliotics among Occidental
children blind from infancy.

That the approximation to the upright posture (not
its absolute practice) lessens scoliosis is apparently
shown by the following statistics of examinations of
school children:

Slant Writers. Vertical Writers.
NUGHbeRe aveie ee sa oe eee eck 24% 15%
ZATION: 2. on have wwnddandensenera 32h 12%
INMUHICH:» csncaliaeeagepana aaa 2a 15%
Tat: ae igneaenoeienen ve piaake sinietian: 65% Bs
Wurzburg 2.0.0.0... cece eee 28% 8%

The first column averages 30 percent, the second
16. But if the slanted style is accountable for twice
as many scoliotics as the vertical, the vertical is still,
apparently, responsible for one-half as many as the
.slant. It is, therefore, evident that the vertical style
did not insure the vertical position of the head and
body, or that some other cause is at work. If the
true reason of malposition in writing had been under-
stood, and the conception of its cure realized, the
results and their suggestions would have differed and

Qa
322 BIOGRAPHIC CLINICS.

been of greater value. The above great differences
found in different cities also exhibit an inexactitude
which makes one doubt the value of the methods
smployed.

The School Desk.—There is probably not a pupil’s
desk in the world constructed upon correct physio-
logic principles. Many approximate, but fail in one
or more important particulars. This is because, with
all of the interest, study and invention which have
been put into the work, with all that has been written
concerning the vertical and slanted handwriting,
there has been no understanding of the physiology
of dextrality and dextrocularity, no comprehension
of the optic problem which controls every posture
and act. The wrong to the child began with the be-
ginnings of pedagogy. Prior to this handwriting was
usually vertical, because without a powerfully domi-
nating necessity no adults, much less the shrewd
monks, would have bent themselves to the left and
skewed their vellum, tablet or paper at the absurd
angle now common with all writers. But when
school teaching began it was, of course, in the houses
or rooms of adults, and with their tables, benches,
forms or stools. No one then dreamed of the peculiar
child nature, not even the size of the child’s body.
Hence, he sat upon a bench or seat too low, or what
amounts to the same thing, at a table too high for the
height of his body, and at about the level of his ster-
CAUSE OF SLANTED HANDWRITING. — 323

num, neck or chin. When compelled to write he could
do nothing at the desk, except by placing his forearm,
and even his elbow, upon the table. Let an adult try
to write sitting at a flat table the height of his neck

 

 

 

 

Fic. 25.— The writing-field brought into clear view by holding the penholder be-
tween the first and second finger, thus lessening the need of bending the body or
head to the left. The view is as the writer sees it, his head being out of the field
in order to photograph the hand.

and he will realize the child’s predicament. With the
arm upon the table there can be no writing accom-
plished unless the head is canted to the left, the body
also, the paper placed askew, the feet or one foot
324 BIOGRAPHIC CLINICS.

thrust out to lessen the strain and wrenching of the
spine, the pen held at a related abnormal angle, and
the hand gripping the holder in a distorted way. (Fig.
16.) All this, that the right eye may have an unim-
peded view of the space in which the letters are being

 

 

Fic 26.—To secure a better view of the writing-field the hand is held in a straining

and unnatural position, the holder directed go® to the right of the right shoulder.
formed. Think of the millions of morbidly raised
right shoulders, the millions of necks and backs thus
wrenched, with all the resultant disease, and during
the last 4oo years! And still going on!
CAUSE OF SLANTED HANDWRITING. 325

Most school-desks are without lateral space to the
right in which the paper may be placed opposite
the right shoulder when the body and head are erect
and squarely placed in front of the desk, and not
as now in front of the face or chest. This lack of
lateral space to the right has always been the un-
realized need, and upon securing it the complete es-
tablishing of the vertical style of handwriting will
depend, as also the rescue of the child from the bad
postures and ill-health caused by the diabolic head-
tilting, right-shoulder-elevating, eye-ruining, body-
bending, pelvis-cramping, spine-twisting, scoliosis-
provoking postures, which have come down to our
time. It will be useless to demand of the child that
he shall write vertically, sit vertically, place the paper
squarely and not askew, and opposite the median line
of the body. No human being can write in that way
unless the pen holder is held with the tip directed
toward the northeast, or upper right corner of the
paper (Fig. 26), or even toward the north, all sure
to produce writer’s cramp, or other evil results in a
short time.t In former times, as we know, the chil-

*Some time after these words were in type, a striking con-
firmation was found in an article published without any knowl-
edge of my work. I quote the paragraph:

“One thing, however, has been much impressed upon me,
and that is that those who are normally left-handed and are
taught to write with their right hand, suffer from writer’s
cramp much more readily than normally right-handed indi-
326 BIOGRAPHIC CLINICS.

dren were crowded together side by side so that it was
impossible to place the paper opposite the right hand
side of the body and keep the body and head erect.
The high desk united to compel the arm to be rested
upon the desk, the right side to be turned toward it,
the left side away from it, the head and body bent to
the left in order to gain a clear view of the writing
space of the pen-point with the dominant eye. Even
the flat desk or table cooperated to produce the result-
ant bad posture and the slanted chirography.

In all left-handed writers the foregoing factors and
results are reversed, and the writing is back-handed,
or slanted to the left. (Fig. 30.)

There has also been much error in the statements
made as to the history of slanted handwriting. The
superb History of the Art of Writing, by Dr. Henry
Smith Williams, gives an illuminating series of ex-
amples which show that the slanted handwriting
appeared much earlier than has .been supposed. De-
spite the high-pitched slope of the desks of the pro-
fessional and more learned scribes, and also not-
withstanding the dictation of the original vertical
engraved, etched, or painted patterns, the slanted
viduals. It would seem as though nature were taking her
revenge for an interference with her original plan, for the man
is right-brained and should not be compelled to use his right
hand for a work requiring so much coordination as does

writing.” (“Some So-called Rheumatisms,” J. J. Walsh, Med-
ical News, February 18, 1905.)
CAUSE OF SLANTED HANDWRITING. = 327

style appears throughout the Middle Ages, as the
necessary result of the writing posture consequent
upon.the flat table, etc. Even in A. D. 93, the letters
of a Greek MS. plainly lean to the right, and in a
cursive Latin imperial rescript of the fifth century
the slope is 15°. In a grant to the Church of Ra-
venna of the seventh century, the right oblique slant
is 10° or more, and even in Magna Charta all ietters
lean to the right somewhat. Examples of similar
slanting are found in the handwriting of Michael
Angelo, Macchiavelli, Ariosto, Tasso, Luther, Shakes-
peare, Bacon, Lope de Vega, Milton, Locke, Leibnitz,
Johnson, etc. Montaigne, Spencer, Galileo, Corneille,
Addison, Pope, Newton, Voltaire slanted their letters
to about the same extent as is now customary. Dante,
Piers Plowman, and others wrote the vertical hand.
Goethe leaned his letters extremely, Schiller less so,
while Tennyson’s were nearly vertical. Thackeray’s
were absolutely upright. Of the signers of the Amer-
ican Declaration, only one is in vertical letters. Long-
fellow wrote a “ backhand,” and in a MS. of the tenth
century the letters also lean to the left, as do MSS.
of Henry II and Richard I. In King John’s Charter
the letters are generally upright, although many let-
ters slant to the left, especially lower case d, and
capital D. Of course the best writers and penmen
were usually intelligent, and wrote more nearly cor-
rectly, i. e., vertically, while the writers of the lower
328 BIOGRAPHIC CLINICS.

 

 

 

 

Fic. 27.--The normal or hygienic posture of the body and head with the paper
placed vertically and opposite the right shoulder. The arm and head thus have
free motion. There is some constraint, due to the flat desk, a too great distance
of the writing, and the fact that the visual axes, falling at an angle of about 45°,
demand a bending of the head forwards, or too great traction on the depressor
muscles of the eyes. '
CAUSE OF SLANTED HANDWRITING. 329

and commercial classes illustrate the degeneracy which
quickly overcame the cursive style of writing. In
general, the older and more important styles of head-
ings, those in capitals, etc., were upright, while the
less important and the body of the writing showed the
inevitable leaning that came with crowding and cursive
writing. An instance of this is our own Declaration
of Independence, a few lines of which next to each
other I reproduce. (Fig. 31.)

Malposture Not the Cause of Myopia.—In almost
all the discussion as to school desks, especially that
originating in Europe, there is much said about the
influence of malposture in producing myopia, and it
is largely twaddle. The tremendous gathering of
statistics and the thoughtless ascription of the truly
tragic increase of myopia to malposture in study and
writing are essentially wide of the mark. Some acci-
dental, incidental and subordinate influence is, indeed,
to be ascribed to the malposture criticised. Kotel-
mann’s pages concerning myopia are, for instance,
wholly misleading, and utterly ignore the real cause—
which is the noncorrection of ametropia, and especially
of astigmatism. In Germany, the motherland of
myopia, there is no scientific correction of ametropia.
The very simplest and most fundamental conditions
of accuracy are wilfully or ignorantly unnoticed, and
the ocular, nervous and nutritional systems are hope-
lessly ruined and by wholesale. With one splendid
330 BIOGRAPHIC CLINICS.

exception our American students of the subject have
usually adopted the European blunder, and for a hun-
dred years we shall doubtless have the empty echoings

 

 

 

 

 

Fic. 28. With the desk-leaf pitched at an angle of 30° or 40°, the posture is hygieni_
cally perfect and the faults of Fig. 18 are entirely avoided

of the European nonsense as to school desks and
myopia.
CAUSE OF SLANTED HANDWRITING. 331

In an article (published in the Klin. Monatsbl. f.
Augenheilkunde, July, 1904, and translated in the
Annals of Ophthalmology, January, 1905), Dr. Lieb-
reich lends his authority to the error that myopia is
caused by the combined action of too strong conver-
gence and too great an accommodation tension, quoting
the investigations of Cohen, Hersing, Seggel, and
others. This inversion of cause and effect does not
prevent the true statement that “through the too near
approach of the head to the table the normal curvature
of the spinal column is increased and by simultaneous
rotation of the head and body lateral curvature ensues.”
Of course, all such statements and explanations miss
the causes of the cause which are the action of astig-
matism in producing myopia, its effect in compelling
parallelism of the axes of the astigmatism and of the
written lines on the paper, and the more fundamental
necessity of binocular vision of the writing-field.
Scholder also says that myopia is produced by getting
the eyes too near the paper, because, he says, the more
the head and body are depressed and thus myopia is
produced. But what is the causa causans he never
asks. Why the skewing of the paper? In Scholder’s
table of the increase of scoliotics in the grades of the
Lausanne schools he notes in an added column the
increase of myopia, as follows:
332 BIOGRAPHIC CLINICS.

Scoliotics. Myopes.
First grade. a: easceaay ceevegaus 8.7% 8.95
Second grade .........-.00.42.. 18.2% 4.5%
Third @rade..ccccctecdeecseessee TOBA 5.2%
POuUrthy Stade wageaa cvotenre anne 27.2%, 6. %
Fifth tadé, < scccswage oveeca say 28.3% 8.5%
Sisctly orades un udaievytesexes ses 32.4%, 137 %
Séveth grade .ccwseugeciee as ar, Z 19.4%

If the author had scrutinizingly asked himself why the
increase of scoliosis is suddenly stopped and decreased
at about 14 years of age, and why the rate of myopia
at the same time is suddenly increased, he might have
seen a stiggestion of the cause of myopia. In Dr. S.
D. Risley’s magnificent article (Norris and Oliver:
“System of Diseases of the Eye,” Vol. II.) there is a
clear understanding and statement of the problem of
myopia. Myopia is not due to the bad desk and bad
posture, but to the bad or absent spectacles. (I differ
from Dr. Risley on one minor point—the astigmatism
is not only “ the turnstile,” but the path, road, and con-
tinuance of the road itself, which leads to the bog of
myopia.) If every school trustee, pedagog, physician,
and hygienist would read every word of Dr. Risley’s
article five times a year, one of the greatest ‘afflictions
of mankind might be obviated. Unfortunately, it is
buried from all but ophthalmologists, and the majority
of these care too little for this revolutionizing truth.
The remarkable success of all the European in-
vestigations in not seeing the cause of myopia is a
CAUSE OF SLANTED HANDWRITING. 333

painful illustration of the difficulties in the way of
scientific and medical progress. Jaeger, Ely, and
Horstmann were approaching the true explanation
in their work leading to the measurements of the
anteroposterior diameter of hyperopic and myopic
eyes; by Arlt and Donders, the latter emphasizing
the role of predisposition—that easy, old and _ still
popular word to cover ignorance of the real and
active pathogenic factor. Dobrowoesky and Erisman
charged the accommodation with the production of
myopia, while Forster thought it was due to conver-
gence. Mauthner ascribes the leading role to spasm
of the ciliary muscles, while Stilling threw the respon-
sibility upon the obliques and the shape of the orbit—
a’ view opposed by Schmidt-Rimpler and Seggel.
Hasner and Weiss contended that myopia is caused
by a too short optic nerve, and Schnabel and Herrn-
heiser by a lessened resistance of the sclerotic. It
remained for an American oculist to discover the true
etiology which is to-day as much ignored by European
oculists and school hygienists as if it had been made
this morning instead of thirty-eight years ago. In
1867, and again in 1871, Dr. John Green of St. Louis
set forth the explanation, and a few years later Dr. S.
D. Risley of Philadelphia demonstrated it by studies
of school children’s eyes in epoch-making papers,
which, within the next generation or two may begin to
make the epoch.
334 BIOGRAPHIC CLINICS.

The Evils of Eyestrain.—In all of the foregoing
there have been considered only the children, stu-
dents and writers who had eyes so near normality
as regards ametropia that they had no severe eye-
strain or morbid reflexes from use of the eyes in a

'

 

Fic. 29.— Oriental method of holding the writing brush, giving an unobstructed
view of the writing-field.

natural way, or even in the unnatural ways begotten
by morbid postures; but unnatural posture produces
unnatural ocular function, and besides this, from 25
percent to 50 percent of all civilized persons have
eyestrain or hurtful use of ametropic eyes. The
CAUSE OF SLANTED HANDWRITING. 335

 

 

 

Fic. 30 — All malpostures are reversed by left-handed writers and this particular
patient gained a better view in his habitual writing by holding the penholder as
pictured.
336 BIOGRAPHIC CLINICS.

amount of harm done the eyes, the neurologic mech-
anism, the digestive and assimilative systems depends
upon three things: the kind and the degree of the
ametropia; the amount of reading and especially of
writing done; the susceptibility of the patient, the gen-
eral vitality, intercurrent diseases, etc. It has been
found that from 50 percent to 64 percent of school

CKho mrartarons Dec
eee og

flowers from the concen 2 he Peak wherove oon
Fic. 3c.—‘Lhe older the style of writing, the more perpendicular or vertical the

letters; the later and more cursive, the more slanted become the letters, even
in the same document, ¢. g., the Declaration of Independence.

children are sickly or below a desirable norm of health.
I do not think it is an exaggeration to say that the
ills of 50 percent of these hygienically subnormal chil-
dren and students are due to the morbid postures com-
pelled by the present false methods of writing and
reading. Of the remaining 50 percent, a full half are
directly caused by the eyestrain of ametropic eyes.
CAUSE OF SLANTED HANDWRITING. 337

Headache, “ weak eyes,” migraine, anorexia, dyspepsia
and many types of denutrition, spinal curvature, in-
somnia, “ nervousness,” many cases of chorea and
epilepsy, despondency and frequent psychic disorders,
truancy, immorality, etc., almost any form or kind of
functional disease—all these, and the denutrition that
fallows the ground for the incoming of infectious and
terminal diseases—all of these are, or may be, the clear
consequences of eyestrain. Only proper and scientific
spectacles can extinguish these evils. But without
glasses they are tremendously increased and intensified
by the morbidities of posture engendered by the pres-
ent school-desks and methods of writing and reading.
A revolution is demanded by an enlightened hygiene
in school furniture and methods of writing and study.
It is the most profound and crying reform of the day,
a matter of national and evolutional importance almost
overtopping all others.

Read the clinical biographies of the great sufferers
from eyestrain and note how intolerable and impossible
writing becomes. A thousand quotations from their
biographies and letters might be made showing that
suffering of the most varied and subtle kinds follows
directly upon use of the eyes especially in writing, and
is at once relieved with cessation of writing and read-
ing. The abnormal and morbid postures caused by
nonunderstanding of the optic problems in writing add
enormously to the preexisting and attendant eyestrain.

23
DEXTRALITY AND SINIS-
TRALITY.
CHAPTER IX.

DEXTRALITY AND SINISTRALITY.*

Tue theories that have been advanced as to the
origin of dextrality and sinistrality are:

1. A natural provision. (Sir Charles Bell and
others.)

2. The left-sided location of the heart. (Referred
to by Wilson.)

3. A greater supply of nerve-force to the muscles
because of an earlier and greater development of the
brain upon one side. (Professor Gratiolet.)

4. Obstruction to the flow of blood in the vena
cava by the pulsation of the aorta. (Dr. Barclay.)

5. Inspiration produces mechanically a superior
efficacy of the muscles of the right side. (Professor
Buchanan.) This theory is based upon the observa-
tion of the anatomic peculiarities of the liver, lungs,
etc., and their supposed influence upon the center of
gravity of the body. (So far as pertains to the center
of gravity, the theory has been adopted by Dr. Struthers
and by Dr. Allis.)

6. The center of gravity theory. The influence of
the weight of the viscera of the two sides of the body

*From The Popular Science Monthly, August, 1904.
341
342 BIOGRAPHIC CLINICS.

upon the position of the center of gravity. (Dr.
Struthers, accepted by Buchanan, Allis, etc.)

7. The origin of the subclavian arteries, the left
before the right in the left-handed, with superiority of
blood-supply to certain structures. (Professor Hyrtl.)

8. The development of one cerebral hemisphere
more than the other. (Wilson.)

g. The Topsy theory— just growed.”

These theories merit little argument in rebuttal.
No.3 and No.8 are essentially the same, and, of course,
are mere avoidances of an explanation. No. 2, No.
4, No. 5, No. 6 and No. 7 are not based upon facts,
and contain fallacies of observation, rendering them at
least of insufficient reach and validity. No. 9 is almost
as good as any or all of the rest, and we are left with
the frank confession of Dr. Struthers, that the mystery
“has baffled satisfactory explanation.” Carlyle said it
was “a question not to be settled, not worth asking
except as a kind of riddle.” It is, however, of great
and practical importance in medicine and in social life.

In a large way and notwithstanding a certain num-
ber of exceptions, it is an illuminating truth of biology
that “the ontogeny repeats the phylogeny.” We can,
therefore, never explain the phases of development
through which an organism passes except by knowing
the corresponding stages of evolution of the line of its
ancestral forms. If, therefore, we ever solve the mys-
tery of dextrality and sinistrality, it will be by the
DEXTRALITY AND SINISTRALITY. 343

study of the conditions, habits, necessities, etc., of the
ancestral types when dextrality and sinistrality arose.
The infant of a few months shows no signs of pref-
erence in the use of the hands; it is not yet dextro-
manual, nor ambidextral; it is simply nondextrous,
or ambisinistrous. Almost as soon as it exhibits any
conscious effort toward skillful use of the hands it
begins to show signs of dextromanuality. Before it
walks, before it is one year old, dextrality is clearly
pronounced. Baldwin (Popular Monthly Science,
Vol. XLIV.) has demonstrated experimentally that it
is plainly established as early as the seventh or eighth
month. The period in phylogenous savage life to
which this of the infant corresponds must, therefore,
be that of the earliest phase of humanization. The
animals, even the anthropoid apes, do not, so far as I
have observed, exhibit it. Vierordt says that parrots
grasp food with the left foot, by preference, and that
lions strike with the left paw. Livingston is quoted
as thinking “all animals are left-handed.” I suspect
this is all error, because, as a rule, it would disadvan-
tage rather than help in the animalian struggle.t

*In the comparative absence of interest in these subjects
there is a resultant dearth and awkwardness of words describ-
ing the conditions. It seems necessary to coin a few in order
at least to avoid more cacophanous ones. The following, some
of them already listed in the dictionaries, may be found useful
in future discussions :

Dextral, pertaining to the right side of the body.
344 BIOGRAPHIC CLINICS.

Since any sort of consciousness of the facts has
existed the wisdom of dextromanuality has been em-
phatically exhibited: (1) In the word dexterity, which
is the prized and honored quality of savage and civil-
ized man; (2) in the secondary meaning of the word
sinister—unlucky, ill-omened, evil; (3) in the persis-
tent training of all left-handed children, by parents,
teachers, etc., to make them like the rest of the right-
handed world. These three facts, the residue of the
psychologic habits of ages, persistent in all history,
crystallized and embedded in the very language itself
which chronicles all mentality, help to give us the clue
to the solution of the riddle.

Skillfulness, ‘“ handiness,’ expertness of sense and

Sinistral, pertaining to the left side.

Dextrality, Sinistrality, the corresponding abstract qualities.

Dextrad, Sinistrad, toward the right, or left, respectively.

Dextromanual, Sinistromanual, dextrality and_ sinistrality,
respectively, as relating to the hands.

Dextropedal, Sinistropedal, as relating to the feet.

Dextrocular, Sinistrocular, as relating to the eyes.

Dextraural, Sinistraural, as relating to the ears.

Dextrocardial, Sinistrocardial, as relating to the heart.

Dextrohepatal, Dextrosplenic, etc., may be formed.

Dextrocerebral, located in the right cerebral hemisphere.

Sinstrocerebral, located in the left cerebral hemisphere.

Dextrorse, turned, turning, or moving to the right.

Sinistrorse, turned, turning or moving to the left.

Sinistrous, awkward, unskilled.

Desxtrous, skilled, expert.

Ambidextrous, equally skilled with both hands.
DEXTRALITY AND SINISTRALITY. 345

act, were the sole means whereby the savage could win
his place in the world, domesticate animals, conquer in
all sorts of conflicts, supply himself with food, clothing,
house, etc. It was necessary that one hand should be
chosen to do the dextrous or more skilled tasks, for the
simple reason that exercise develops and perfects func-
tion, and one would learn to be more skilled and
“handy ’’ with one hand than with both. The savage
required no treatise on logic nor even any conscious
reasoning to teach him this primary lesson. His food
and life depended upon his learning it.

But that it was an acquirement, that the law and
necessity were not exceptionless, that it was due to no
absolute fatalism of anatomy or physiology, is evident
from the fact that so large a proportion of left-handed
children and adults exist in all races and times. The
education of left-handed children, whereby their writ-
ing center, naturally dextrocerebral, is by forced train-
ing and long habit transferred to the left cerebral
hemisphere, is another demonstration that no inherent
neurologic or psychologic law governs the location of
the cerebral center or its peripheral outworking. When
the occasion arose in the humanization process, and
the demand for the differentiation of cerebral mechan-
isms was made, the plastic brain on either side could
take up the work. And pure, or untrained, left-
handed persons are to-day as expert as their right-
handed fellows. All that is needed to explain dex-
346 BIOGRAPHIC CLINICS.

trality in 98 percent of children is some ancestral
savage custom, habit, or necessity, widely prevalent,
which inclined to the use of the right hand and eye for
one or two exceptionally intellectual tasks. The in-
heritance of aptitude, the force of custom, and the
necessities of the struggle for existence would certainly
fix the persistence of dextrality.

We must not forget that the somewhat sudden and
clear preference of dextrality and sinistrality of the
child of to-day was in the far-away ancestral line
spread out over long periods of time. A year or two
of the child’s life represents thousands of years of slow
acquirement arid habit.

Again, it should be remembered that even in our
preferences and habits it is only in a few things that
one hand, etc., has a greater expertness, accuracy and
rapidity. It is often rather a division of functions, a
differentiation of ability, than a unique one. In the
dextral the left hand does many tasks of as great or
greater importance, and with equal or superior skill,
as the right. In eating, the fork is now more used
than the knife; in gunning, the left hand is given the
vastly more important, difficult and onerous task; in
chopping, hoeing, shoveling, picking, lathe-work, rail-
way locomotive engineering and other tasks the left
arm and hand often execute the chief and more expert
tasks. Especially noteworthy is the playing of the
violin, ’cello and bass viol. The “ fingering” is done
DEXTRALITY AND SINISTRALITY. 347

with the left hand, and forms a striking reversal of
dextrality, because it is by all odds the function requir-
ing more manipulative skill, accuracy and rapidity. I
do not know that the fact itself has ever been observed
and stated, but certainly the reason of this strange con-
tradictory practise has hitherto escaped the attention.
It is, I think, due to dextrocularity. With few and
easily explained exceptions dextromanuality is a result,
or a concomitant, of dextrocularity. If the violin,
‘cello and viol were fingered with the right hand the
learner would be greatly handicapped by the fore-
shortening which would exist as his dextral eye
glanced along the neck of the instrument straight in
front or below this eye. The learner must see his
fingers and gain precision in placing them by careful
visual estimates. But when placed sinistrad the right
eye sees the neck of these instruments and the fingers
at an angle which permits more accurate observation,
estimates of distances, etc., than would be possible if
the instrument were fingered with the right hand. In
those instruments necessarily held in the median line,
some wind-instruments, the flagolet, hautboy, etc., the
right hand asserts its selective and more difficult task.
When the hands are not seen at all, as in the flute, fife,
etc., the right again has its choice. No pupil with
sinistromanuality established can learn piano-playing
easily. I know of one who was a great lover of
music who failed utterly after long perseverance.
348 BIOGRAPHIC CLINICS.

There are other cautions to be emphasized relating
to the acquirement of dextrality by the savage: Nearly
all the actions which we now call right-handed were in
primeval times to him unknown. This is especially
true of three things. Knives and forks have only been
used in eating for a few hundred years. He ate with
his fingers, and one may suspect he used the left as
much as the right in this way. The Mussulman cus-
tom and its reason are, of course, both modern. Sec-
ondly, the modern gun and revolver had not been
devised. The bow and arrow, the spear, boomerang,
club, etc., could be used as well with the left hand by
the sinistromanual. Thirdly, writing was unknown,
or relatively so, and, as we have now learned, that
locates the speech center in the cerebral hemisphere
opposite the writing hand. It is thus evident that dex-
trality in the savage, at the time when it began to
become habitual, must have been at best only partial,
incomplete, and for a very few acts. The left-handed
arrow-chippers, basket-weavers, club-wielders, sewing-
women, etc., even if more numerous relatively than in
civilized life, would perhaps attract little or at least
less attention than now, and would be less discouraged,
surely less taught to reverse the natural inclination.

In default of systematic banding and military train-
ing, also, the left-handed spearmen, bowmen, swords-
men and clubmen might not have much attention
directed to themselves and sometimes might have an
DEXTRALITY AND SINISTRALITY. 349

advantage over their single and dextral adversaries,
e. g., in tilting. The preference in heraldry for dextral
quarterings, etc., is by no means uniform.

But there was one overlooked factor which was
doubtless decisive in setting up the trend toward dex-
trality. This was the development of sign-language
synchronously, and even preceding that of spoken lan-
guage. The ineffaceable relics of this long and ar-
duous period exist in present day language, plainly in
many savage tribes and customs, but the most striking
proof is displayed in our so-called Roman numerals.
The fingers of the hand held up, or counted off, were
beyond question the beginnings of arithmetic, the
means of barter, the method of stating the fundamental
fact of number requisite in all thinking and doing.
Military and intertribal dealings, especially made the
custom powerful and even sacred. One finger was
the origin of our figure owe, the second equaling to,
etc., up to five, or V, which fork was made by the
thumb stuck up opposite the first I. When the count-
ing was more than five, the other hand was made to
represent the first five, the digits being added up to
ten, when two forks were used, or the crossed thumbs,
which constituted X, or ten.1 The impressive cere-

*It does not matter with which hand the first numbering, in
some cases, was done; the intelligent attention must have been
directed to the action with the dextral or spear side. Homer

and the earliest Greek vases show the right was dépv éri , the
spear side, and én’ dorida the shield side.
350 BIOGRAPHIC CLINICS.

monies of warring and bartering tribes would stamp
with distinctive approval the hand used in the sign-
language, and henceforth it would become the honored
one, the stamping and writing hand, and in time the
sword-hand. The right was chosen as the sign and
numbering hand because the left was naturally used
for the highly important task of guarding the sinis-
trally-placed heart with the shield. War is the sub-
stance of all early history and of the savage eons
which preceded all history. Dr. Flint (The Sun,
April 17, 1904) says that deaf-mutes may have an
aphasia that prevents the use of the right hand in the
sign-language.

Speech is the sole example of the higher functions,
sensational or motor, which is single. Feet, legs, arms,
hands, vision, hearing, all are dual in nature, requiring
dual centers of coordination and innervation in the
two halves of the brain. But speech, being a single
function, can have but one center, and that, of course,
must be located, not in any median place, because there
is no such place, but in one or the other side. We also
know by physiology and pathology that in the dextral
it is in the third left frontal convolution, and in the
sinistral it is in the corresponding position of the right
side. We know, furthermore, that it is the intellectual
act of writing, rather than the grosser acts and func-
tions, which localizes the speech center. A man may
be left-handed for everything but writing and the
DEXTRALITY AND SINISTRALITY. 351

judgments issuing in the correlations of spoken words
are formed and innervated from Broca’s convolution.
Or vice versa in the case of the sinistromanual writer
who is dextromanual for all other acts.

The reason why dextromanuality, dextrocularity,
etc., must coexist with sinistrocerebrality becomes
manifest. The function of speech or writing is the
method whereby judgment or volition passes into
action. The initial, dominating and guiding motility
to vocal organs, to hand, and even to foot, springing
from closely contiguous, and hence more quickly and
accurately acting, cerebral centers, will be better corre-
lated and certain than if the centers were in opposite
cerebral hemispheres. The indicator of all action, the
very creator of intellect, is vision. Hence all right-
handed people are also right-eyed.1 The centers for

*One of the best tests of predominant dextrality or sinis-
trality is the ‘sighting’ of a stick to see if it is straight, or
the sighting of a gun or pistol. Dextrocularity is largely a
dictator of general dextrality. And of dextropedality also, for
the dextral is right-footed also. Errors of judgment, however,
have been frequent as to the function of the feet. The ‘ spade-
foot’ is the left, naturally, because the right leg and foot are
the directing ones, in the dextral, who also, as the masonic
ritual directs, steps off with the left foot first. The dextral
must spring from the right foot. It has been said that the
oblique line of the body of the dog in trotting is due to in-
cipient right-'or left-footedness. But all soft-footed animals
avoid ‘interfering’ by this obliquity of progression. The much
discussed knockout blow of the pugilist with the left is, I
suspect, because of the better spring from the firmer right foot.
352 BIOGRAPHIC CLINICS.

right vision, right motion, and for speech are thus in
close relationship and upon the same side of the brain.
As I have said (Science, April 8, 1904) :

“The unification and perfection of innervation and cerebra-
tion must be better if initiated and executed with the cerebral
centers mainly upon one side of the brain, than if the unity is
gained by means of the longer and more distant commissural
fibers extending between the two sides of the: brain. In the
right-handed the speech center is in the left side of the brain,
as is also the motor center for the right hand, and the optical
center of the right eye. The dependence of all motion upon a
perfect correlation of vision and judgment needs only to be
mentioned. That all intellect is psychologically the product of
vision is less recognized, but is not less absolute truth. The
right hand writes, possibly because the right eye looks down
upon the writing more accurately than would the left; both
depend upon the synchronous and closely interrelated guidance
of the speech-making function. All three are in closer unity
and contiguity than if either were in the opposite side of the
skull.”

This furnishes the physiologic reason why all at-
tempts at ambidexterity are failures, and unwise.

“The chief centers most closely interrelated in writing and
thinking are thus demonstrably better harmonized when in one
side of the brain. The mechanics of neurology are plainly less
difficult than could be achieved by any foolish and unsuccess-
ful ambidexterity. I have never seen anything but bad results
from the attempt to train children to use the right hand instead
of the left, when there is a decided tendency or habit to be
left-handed. Moreover, the attempt is never successful. The
best consequences are poor, and are only awkward mixtures of
the two forms, which yield confusions and indecisions during
the entire subsequent life. I could cite many instances in
DEXTRALITY AND SINISTRALITY. 353

proof, some of them most pathetic, in which disease and life-
failure resulted. One that plainly illustrated the neurologic
troubles was that of a naturally left-handed friend, A. V. P.,
who by arduous and continuous training during his childhood
was compelled to write with his right hand. For all other acts
he is left-handed, but he cannot use his left hand for writing.
Although now past fifty, he has always hated any writing, the
mere act of doing so, and he cannot do any original thinking
while writing. He is for this purpose compelled to rely on a
stenographer, and then his ideas flow freely and rapidly. If
he tries to think, plan, or devise and to write at the same
time there is a positive inhibition of thought and he must make
sketches, epitomes, several efforts, copyings, etc., in a painful
and most unsatisfactory manner. The attempt at ambidex-
terity has been a lifelong obstacle to him in his professional
progress. The ambidexterity of surgeons, artists, etc., is over-
praised, exaggerated, and fallacious. It is of course advisable
in exceptional callings and actions to cultivate skill in the
more awkward hand, but that is a very different matter from
“ambidexterity.’ ”

All agree that perfect ambidexterity has never ex-
isted, despite all training. It is neither possible nor
desirable.t Sinistrality is no defect and of no disad-
vantage. That said to exist in criminals, idiots, etc.,
like many things ‘“ Lombrosal,” is not true, or it is
post hoe, etc.

It seems that there is an ‘“ Ambidextral Culture So-
ciety ” in England which, in default of something to
do of use and in accord with nature’s indications,
wishes to insure that every child at school shall be so

+See the case of Morse, reported by Wilson; especially his
own, and that cited on p. 146.

24
354 BIOGRAPHIC CLINICS.

drilled in both separate and simultaneous use of the
two hands that he shall have the two equally strong,
sensitive and skillful. The pitiable victims! The
organization might better call itself the society for
nullifying the law of the differentiation of function
necessary to all progress, for returning to barbarism
in the handicrafts, and for life-long cruelty to the
left-handed.

The essential and clarifying thought of the fore-
going explanation is that as the writing act now locates
the speech-center, although all other acts may be oppo-
site-handed, so the right-hand sign-language and num-
bering would necessarily have had the same effect in
barbarous times. That this sign-language of primitive
man was dextral is not to be questioned, as about 98
percent of babies are now clearly right-handed before
they are one year old. The protection of the heart by
the shield would constitute sufficient reason for the
institution of dextrality in counting and sign-making,
and custom and uniformity of habit-especially in early
times, would result in almost a universality. But not
an absolute one, for one or two percent are now Sinis-
tral. And the Bible story of the Benjamite tribe illus-
trates how the habit would not be absolute. There
is in all this one noteworthy neurologic fact: In view
of the long continuance and vast preponderance of
dextrality it seems strange that the brain preserves
all the preformed mechanisms, plastic and ready to
DEXTRALITY AND SINISTRALITY. 355

make a sinistral child, and the outworking of sinis-
trality is as prompt, the result as dextrous, as if dex-
trality had been chosen. The wonder at this is, how-
ever, lessened when one notes that all the functions of
completed dextrality are at the same time and in the
same person now possible to the sinistral; there is a
mere difference in the degree not in the kind of expert-
ness. Besides this a number of left-handed acts in
the dextral, e. g., those of the violinist, gunner, etc.,
are far more expertly and finely coordinated than those
of the right, etc.

If the foregoing explanation of the origin and per-
petuation of dextrality is adequate, it remains to ex-
plain the origin of sinistrality. Why are there about
two out of a hundred naturally left-eyed and left-
handed? Fundamentally, of course, because the
speech-center is located in the right cerebral hemis-
phere, and the contributing and executing centers of
vision and motion act in better unity if they are in
close connection and contiguity than if connected by
long commissural fibers to and from the opposite sides
of the brain. The dextrocerebrality of two percent of

‘There is thus no danger and no need of a greater weight
of the half brain initiating dextrality in the dextral, and all
the discussion and labor of comparative weighing the two
halves is relatively useless. Moreover the cerebral mechanisms
must be equally perfect even if not equally exercised. Taken
in the average the two sets of organs, central and peripheral,
do about the same amount of work.
356 BIOGRAPHIC CLINICS.

sinistral exceptions to the usual law appears explain-
able, perhaps in part by persistence of original sinistral
types, but more certainly they are due to accident,
injury, disease, etc., of dextral organs, in the young of
our ancestors. Especially in savage life would these
accidents be more numerous than now. The loss of
even one dextral finger might compel the education
of the undeveloped speech center on the right side.
Injury to the right hand and arm, even of the right
foot or leg would do the same. Deafness of the right
ear would compel a turning of the left ear forward
and might work out complete sinistrality. But more
important than all these causes combined would be the
more frequent greater ametropia, amblyopia, disease,
leukoma, etc., of the right eye, compelling the use of
the left, and thus transferring all centers of dextrous-
ness to the right side. I have repeatedly demonstrated
the persistence of dextrocularity even with visual
acuteness considerably less than that of the left. But

‘

there is a limit to this “ accommodation,” and if the
amblyopia of the right is greater than double that of
the left, the patient becomes left-eyed. In savage and
in semicivilized life these accidents, diseases, ame-
tropias, heterophorias and strabismuses of the right eye
would again be far more numerous than in our day and
civilized peoples. Our two percent of sinistral chil-
dren seem for the greater part to be the descendants,

by the laws of heredity, of ancestors who in childhood
DEXTRALITY AND SINISTRALITY. 357

and youth have been compelled to become sinistral by
the causes enumerated.

Is it possible that there are proportionally more left-
handed among Oriental nations who read from right
to left, than in those who read from left to right? A
writer in the Cornhill Magazine (1889) says that the
‘change in writing whereby the proceeding from right
to left was reversed was due to the use of ink and pig-
ments in writing, and the avoidance of smearing the
fresh-writing by tracing the letters from left to right.
But individual writers would not do this, and, if they
did, they could not get their writing accepted! It is
difficult to see how there would be less smudge and
smear by the reversal.

The arguments for upright writing are incontestably
strengthened by some facts I have lately discovered
as to the frequent influence of an axis of astigmatism
in the dominant eye varying by about 15° from go’,
in producing a habitual canting or sideways inclination
of the head. This habitual cant of the head is often
followed by spinal curvature. Undoubtedly many

*This writer says that artists paint from left to right, that
the spectator views the painting of a real landscape in the same
way, etc. Even corkscrews, buckles, buttons on clothing—
men’s he says, not women’s—are for the right-handed, and
asks, why? The figures on the faces of our clocks and watches
are traced to the same cause; but he forgot that the clock face
is the modified sun-dial made round, the location of the
shadow of the meridional instant line, dictating the placing
of the figure 12, and of all the related ones of the day.
358 BIOGRAPHIC CLINICS.

spinal curvatures are produced in this way, and the
number of cases is much greater than is supposed.
Such a patient can see upright lines, which predomi-
nate over all others in civilized life, especially in those
who read much only by holding the head to one side.
When the axis of astigmatism is about 75° the head
must be canted to the right to see plainly. When it is
105° it must be canted to the left. Slanted hand-
writing is itself pathologic, or produces pathologic
results of many kinds. The printed letters of the
alphabet should be refashioned to avoid all lines except
the vertical and horizontal. This would greatly con-
duce to lessening of ocular and neurologic labor, and
would increase ease and celerity of reading. Almost
the only letters that could not be thus remodeled and
bettered are V, Z, X, which are little used. K and R
also require some slanted strokes. The others could
all be made up of vertical and horizontal lines. The
vast majority of astigmatisms cluster about axes 90°
or 180°, and those which are anomalous and unsym-
metric produce disease unless corrected, as they may
be by proper spectacles.

The summary of the foregoing theory of the origin
of dextrality and sinistrality is:

Modern pathology has demonstrated that the intel-
lectual acts of writing and reading locate the speech
center upon the cerebral side opposite the writing hand.

The centers for vision, audition and motion of the
DEXTRALITY AND SINISTRALITY. 359

hand and foot for correlated dextral or sinistral actions
and sensations, are in the same side of the brain.

Coordination of sensation, perception, judgment and
act are rendered more accurate, expert and quick by
this close contiguity and inter-relationship than if made
by commissural fibers from the other cerebral hemis-
phere.

The original location of the speech center in the
dextral was caused by the almost universal employment
of the right or spear-hand in sign-language preferred
to the left or shield-hand, because this was more re-
stricted in movement by holding the shield over the
heart.

The origin of left-handedness was in large measure
due to the location or education of the speech center
in the right brain because of the injury to dextral
organs, but chiefly to disease or deficient vision of the
right eye.

Ambidexterity of any general or thoroughgoing
kind is neither possible nor desirable, and the attempt
to bring it about results in suffering and disease.

Vertical handwriting and printed letters made up of
vertical and horizontal lines, should be encouraged.
THE PATHOLOGIC RESULTS OF
DEXTROCULARITY AND
SINISTROCULARITY.
CHAPTER X.

THE PATHOLOGIC RESULTS OF DEXTRO-
CULARITY AND SINISTROCULARITY}

A LITTLE observation and a few tests will show that,
with some exceptions, to be noted later, the right-
handed or dextromanual person is also right-eyed, or
dextrocular ; and the left-handed is left-eyed. That is
to say, there is, in the dextromanual, the same habitual
and unconscious choice of the image of the right eye
for the more expert and important tasks, just as the
right hand is chosen for those functions in skilled
work. A dextromanual hunter places his gun against
the right shoulder because he can sight it with the
right better than the left eye. The right-handed per-
son, in playing the violin, violoncello, etc., is forced to
use the left hand for the more expert task, because he
thus sees the fingers and the neck of the instrument
without foreshortening and better than he could if the
fingering were done with the right hand. All actions,
in fact, are determined by the fundamental necessity

*Read at the meeting of the American Ophthalmological
Society, held in Atlantic City, July 13-14, 1904, and reprinted
from its Transactions, and from Ophthalmology, October, 1904.

A previous paper on the subject was published in Science,
April 8, 1904.

363
364 BIOGRAPHIC CLINICS.

that accurate vision shall precede all action, and vision
is more accurate with the habitually exercised eye,
just as manual function is more expert and reliable
with the hand most exercised in a special kind of work.

A little closer observation soon demonstrates that
not only is the dextromanual also dextrocular, but that
he is likewise right-footed, and usually right-eared ; he
is dextropedal and dextraural. This is equivalent to
saying that a person is either dextral, generally, as to
ear, eye, hand and foot, or else he is sinistral. There
must manifestly be a unity in the coordinations of all
acts, and such coordinations would evidently be better
with a habitual one-sided similarity of execution run-
ning through all kinds of action, so that there would
be no indecision in rapid and dangerous acts. The
unity and the resultant promptness and accuracy of
all motions is thus enhanced by a synchronous dex-
trality or sinistrality. The mixed type, illustrated by
the so-called ambidextrous, would place the organism
at a wretched disadvantage in the struggle for exist-
ence, and in the social struggle of the highest types of
civilized life.

The underlying and long forerunning cause, how-
ever, of the coordination of dextral acts, or of sinistral
ones, lies in the necessity of the localization of the
organ of speech in one or in the other side of the
cerebrum. As it is a single and not a dual function,
its organ can be only in one place. Pathology has-
PATHOLOGIC RESULTS. 365

proved what physiology pointed out, that in the dextral
the speech center is in the left side of the brain, and
in the sinistral it is in the right side. Moreover, the
intellectual act of writing develops the speech center
on the side opposite to the writing hand. The history
of cases with tumors and paralyses has settled this
question beyond controversy.

The speech center may be looked on as the organ
through which intellectual judgment and decision
issues in determination and act. The spoken and
written word is the most intimate act of the mind, its
irrevocable and immediate exponent. Prior to all
judgment and decision, vision must give the data. In-
tellect is, in fact, the product of vision, and all mental
symbols, the letters of the alphabet themselves, are but
modified visual images. The thing seen is thus worked
into judgment, and by the third component of human
action, motion, is wrought into completed function.
Vision, judgment, act, are thus the unexceptional con-
ditions of human activity and validity. It is at once
plain that if the centers which intermediate these three
functions are on one side of the brain, in contiguity,
and closely united by many intercentral fibers, the re-
sultant act will be more accurate and rapid than if one
or two of the centers are in the opposite side of the
brain. The commissural fibers between the two cere-
bral hemispheres would be fewer and longer, and the
coordination less clear, sharp and certain. This is the
366 BIOGRAPHIC CLINICS.

neurologic basis for a common dextrality or a common
sinistrality of function-in one individual, and it com-
pletely demolishes the foolish contention of those who
would vainly educate the two percent of left-handed
children to be ambidextrous. There never was an
ambidextrous person, but there has been produced
much misery by the foolish attempt to create ambi-
dexterity.*

If by ocular disease, ametropia, accident, etc., the
dextromanual are compelled to be sinistrocular, the
pathologic results which may flow from this inter-
ference, or reversal, of the natural order, become of
exceptional interest to the ophthalmologist. That these
pathologic results exist I have no doubt, and have
repeatedly demonstrated in the persons of actual pa-
tients. I suspect that they exist in at least 10 percent
of all patients, and no case whatever can be treated
wholly irrespective of the fact of dextrocular or sinis-
trocular function.

For purposes of naming and clarifying the ideas to
be presented, let us call the right eye of right-handed
persons, and the left eye of left-handed persons, the
dominant eye. The caution must be emphasized that
the hand which does the writing unconsciously or
preferentially dictates the location of the speech center,

*This subject is treated more extensively in an article pub-
lished in Popular Science Monthly, August, 1904.
PATHOLOGIC RESULTS. 367

and the true condition of dextromanuality or sinistro-
manuality.

It hardly needs the saying that the accidents of
ocular diseases, keratitis, fundus lesions, cataract, high
ametropia, heterophoria, amblyopia, etc., may put out
of function, or threaten to do so, the primary—that
is, the naturally, logically and neurologically—domi-
nant eye, and thus the eye of the other side must be
used as a makeshift and educated to become the sec-
ondarily dominant one. The older the age at which
this occurs the greater the difficulty, the more of a
tragedy will it be to the patient. There arise a hun-
dred problems. I shall here allude, and most briefly,
to but a few of these:

1. In all operative procedures there should be an
exceptional striving to save the dominant eye. I do
not believe in operations for this purpose, but if only
one eye can be straightened and made functional in
strabismus, by all odds let it be the dominant one.
The strabismus of a naturally dominant eye will be
more easily cured than that of the non-dominant one.
In double convergent squint the dominant eye should
be the one first chosen to save. In certain cases of
cataract extraction a similar rule should be followed.

2. In inflammatory diseases there should be the
same solicitude, when choice, as frequently, is possible,
to preserve the best function in the dominant eye.

3. The supreme value of the dominant eye makes it
368 BIOGRAPHIC CLINICS.

highly important that ametropia shall be corrected at
the earliest day and year possible. Every month that
amblyopia, heterophoria or strabismus increases in that
eve, makes the life history and struggle of that child
a different and a more difficult one. Dextromanuality,
or its opposite, is pronounced in children of less than
a year, and the location of the speech center is being
fixed rapidly, and often unchangeably, at two and
three years of age.

4. If saving of the naturally dominant eye is impos-
sible in the young child, and its fellow must be sec-
ondarily educated into dominancy, it becomes a ques-
tion if the child should not also be taught to write,
eat, etc., with the corresponding hand.

5. In the adult the dominant eye I have found will
preserve its dominancy despite a considerably higher
degree of amblyopia, ametropia, etc., than that of its
fellow. But it is evident that there must be a limit. I
doubt if the naturally dominant eye would retain its
dominancy if it had, say, an acuteness of only 20/50
while the vision of the other was normal. This fact
arouses a number of queries in the mind of the refrac-
tionist. One of these would refer to the inadvisability
of giving the non-dominant eye a greatly superior
acuteness of vision by means of glasses. In an adult
such a sudden change, even reversal, in the habits of
part of a lifetime might be brought about that the
spectacles would not be tolerated, and failures of varied
PATHOLOGIC RESULTS. 369

kinds ensue. The patient would then have a life
handicap that would greatly lessen his personal validity
and happiness.

6. An axis of astigmatism in the dominant eye from
10° to 20° to either side of 90° or 180°, while the axis
in the fellow eye remains normal or unsymmetric, pro-
duces head-tilting ; symmetric axes produce no head-
tilting. In the few months after I discovered this
law I found in the ordinary run of office practice over
thirty cases of head-tilting. The stupid error I had
made all my life was to allow these patients to cant
the head during the refraction testing. In this way I
had failed to find how large is the number of right-
handed patients who have axes of astigmatism of the
right eye from 10° to 20° to one side of go” or 180°.
And never before this had I thought of the necessity
of inquiring as to dextromanuality in patients having
these slightly unsymmetric axes of astigmatism. It is
evident that an axis in the dominant eye only 5° to
one side of g0° or 180° would hardly produce a notice-
able tilt of the head, or might possibly be compensated
for by the rotation of the eyeball itself. It is possible
that some types of heterophoria, and especially cyclo-
phoria, may be explained as arising from this compen-
sation of the ocular structures instead of producing the
tilt or cant of the head. It also seems possible that
this compensatory twist of the eyeball in the orbit may
possibly cause a compensatory twist of the optic nerve,

25
370 BIOGRAPHIC CLINICS.

and perhaps certain other diseases of the papilla and
retina. After prescription of proper correcting glasses
it would be natural to find before long a secondary .
change of axis resulting from the rectification of the
abnormal head tilt, or ocular twist. Such patients
niust be kept under continuous and repeated obser-
vation.

If the axis of astigmatism of the dominant eye is
about 75° or 165”, it is evident that, if the non-domi-
nant eye is unsymmetric, the head must be tilted to the
right in order to bring the false axis into line with
the vertical lines of print, trees, houses, wall paper,-
doors, etc.

If the axis of astigmatism of the dominant eye is
about 105° or 15°, compensatory tilt of the head must
be to the left. Greater variations of the axis than 20°
would hardly be compensated for by head-tilting, but
would either produce amblyopia, a transfer of domi-
nancy to the other eye, or else some other pathologic
consequence equally harmful to action and life. The
axis of the largest number of head-tilters is 75° in
the right eye, and thus the majority tilt the head to
the right.

7. Among the thirty or more head-tilters I have
found, in the few months mentioned, about a dozen
with resultant spinal curvature or scoliosis. The fact
was usually unsuspected by the patient, the parent and
the attending general physician. I sometimes had
PATHOLOGIC RESULTS. 371

difficulty in getting consent that an expert orthopedic
surgeon should verify the diagnosis. A report of these
cases, the nature of the compensatory spinal curva-
ture, and the cure by glasses alone, or by glasses and
orthopedic help, will be published later. It is needless
to add that the method of production of scoliosis re-
sulting from an enforced and habitual abnormal posi-
tion of the head is well understood by orthopedic sur-
geons. Habitual carrying forward, for instance, of
the hearing ear in case of unilateral deafness will result
in scoliosis. There are undoubtedly thousands of. chil-
dren with curved spinal columns in the United States
whose spinal disease is due to a slightly aberrant axis
of astigmatism.

8. An ametropia in the non-dominant eye which
tends to throw it out of function is much more likely
to result in malfunction, non-function and disease of
that eye than would be the case in the dominant eye.
Many practical suggestions and rules result from this
fact both in refraction work and in the management
of inflammatory diseases. In amblyopiatrics, for in-
stance, it is perhaps as well not to strive to give the
non-dominant eye an exceptional, or even an equal,
acuteness of vision. Nature will not respond to the
attempt so willingly as in a similar attempt with the
dominant eye.

g. The failure to diagnose the unsymmetric varia-
tion of axis of the dominant eye will, of course, result
372 BIOGRAPHIC CLINICS.

in the non-cure of the reflexes which are caused by
eyestrain. This is so well established that it may serve
as a reason for reexamination of the cases in which,
in the past, there has not been perfect relief of patients
with general ill-health, migraine, dyspepsia, headache,
neurasthenia, insomnia, melancholy, etc., probably due
to eyestrain. Not seldom the change of axis found
to exist when the refraction test is made with the head
accurately erect will at once bring astonishing and
brilliant relief in many forms of inveterate systemic
functional disease.*

POSTSCRIPT.

After the foregoing paper had been read at Atlantic
City, Dr. Peter N. Callan said to me that the sugges-
tion of right-eyedness had also come to him, and he
had asked the question in the Medical Record of April

* A corollary of the discovery of the cause of so many cases
of tilted heads is suggested. Beside the thousand vertical and
horizontal objects that demand relief of astigmatism, or its
placing at axes 90° or 180°, the predominant cause in civiliza-
tion is the shape of the letters of the printed page. As a rule,
these are made up chiefly of lines at axis 90°, supplemented by
a few at 180°, and a less number of curves and of oblique axes,
at about 60° or 70°, or, conversely, at 120° or 130°. It is these
last which should be eliminated when it is possible, and in all
but a few letters this is possible, the exceptions (K, V, X, Z)
being relatively unimportant. The lower case of small letters
could be modified in shape to correspond to these. The lesson
as to vertical and slanted handwriting at school is equally
plain.
PATHOLOGIC RESULTS. 373

2, 1881. Confirmation of the fact has been found in
the examination of the records of more than 1,000 of
the private patients of Dr. H. D. Noyes in whom each
eye had been carefully examined and the vision and
refraction noted. The general results were that when
myopia existed there was a higher degree in the right
than in the left eye, and when hyperopia was present
there was a less degree in the right than in the left.
In the hyperopic cases the vision was more acute in
the right than in the left, and in the myopic the vision
was almost the same in each eye, taking all degrees
into consideration. Dr. Callan drew the conclusion
“that with binocular vision we use one eye more than
its fellow—that one being generally the right eye.”
This quick confirmation of the theory of dextrocularity
was unexpected, and suggests a number of valuable
and practical rules in refraction work, in the care of
the eyes of school children, students, etc.

There are indirectly further proofs of the theory to
be found in the ingenious and instructive paper of Dr.
Wheelock Rider, on “ Unilateral Winking,” published
in Transactions of the American Ophthalmological
Society, 1898, to which my attention was kindly di-
rected by the author, in the discussion of my paper,
and which had also escaped my notice.
 

 

 

 
SUBNORMAL ACCOMMODATION
AND PREMATURE
PRESBYOPIA.
CHAPTER XI.

SUBNORMAL ACCOMMODATION AND
PREMATURE PRESBYOPIA+

Art least 99 percent of “ migraine” is caused by eye-
strain and smaller percentages of other types of head-
ache, dyspepsia, malnutrition, etc. Many nervous and
psychic disorders have the same origin, and the major-
ity of cases of “idiopathic” lateral spinal curvature.
When due to eyestrain, the failure to cure these trou-
bles by ocular treatmént is either due to the failure
in preventing them by the same treatment, to the fact
that the individual case is not chargeable to eyestrain
or to the oculist’s fault. We are constantly and rap-
idly learning that our faults as refractionists explain
our failures to cure. There is a vast realm of unsolved
puzzles and mysteries in ophthalmic practice, but every
advance we make shows that it was to our ignorance
‘or carelessness that we should ascribe most of our fail-
ures. It is astonishing to perceive upon what slight
and seemingly negligible things success depends. A
whole art and science of therapeutics is being built up
upon these nothings, heretofore and even now, gener-
ally neglected by the great body of oculists and physi-

*From American Medicine, Vol. 1X., No. 3, pages 103-108,
January 21, 1905.

377
378 BIOGRAPHIC CLINICS.

cians of the world. That, of course, is the history of
discovery and progress in every branch of knowledge.
We pass at our peril the tiny thing, the trivial consid-
eration, fact, or suggestion, upon which all great things
depend.

A good, round three-fourths of our failures as ocu-
lists are due to our poor refraction work. In all
Continental Europe it is a disgraceful farce, with
the possible exception of that of one or two men. In
England two or three men are doing work equal to
that of a hundred in America. But it is simply amaz-
ing to find men in our own country who are “ leading
oculists ” in their communities and members of great
ophthalmologic societies, utterly ignoring the condi-
tions of accurate ametropia measurement, spurning
cycloplegiacs, disdaining astigmatism and anisome-
tropia, and, of course, heaping ridicule upon the
“hobby-rider.”

Of the remaining fourth of our failure to cure eye-
strain diseases, a large proportion is due to neglect of
head-tilting, with the result that we do not locate accu-
rately the slight unsymmetric axes of astigmatism.
The ordinary and common symptoms, such as head-
ache, gastric, nutritional, and nervous disorders, are
consequently not relieved, and one of the great causes
of spinal curvature is not discovered or prevented.

Many of our puzzling nonsuccesses are due to failure
to recognize insufficient or paretic accommodation, or
SUBNORMAL ACCOMMODATION. 379

premature presbyopia. The books do not know of it,
and the lecturers do not speak of it. Such case are pe-
culiarly tormenting, because the symptoms are plainly
those caused by eyestrain, which the perplexed and
desperate oculist cannot lessen. There is no test by
which the fact may be learned, because for the time
required in the ordinary tests there is almost always
the ability to hold the vision perfect, or seemingly so,
by an effort which exhausts with long-continued read-
ing, writing and sewing. Then the cases are so rare
that the hundred normal accommodations following the
last example of the abnormality make the oculist care-
less and likely to forget. Failure and ill-success is the
penalty of routine. Moreover, the paresis of accom-
modation may occur in the most unlikely people, and
as it is so peculiar, masked and variable, it requires
great alertness and conscientiousness to keep the dan-
ger in mind. But when subnormal accommodation in
the young does exist, it means so much to the patient,
and to the oculist also, to become aware of it! The
relief by glasses is usually great, instantaneous, almost
magical. Most of the twenty-seven patients whose
clinical histories are here epitomized had been treated
by many other oculists, and all had failed to find the
source of the evil. This makes me feel that, like
myself, most of my colleagues have not recognized
this pathogenic factor in a certain number of their
patients. Some of these case histories date back from
380 BIOGRAFPHIC CLINICS.

six to fourteen years, but the fact of accommodational
paresis has become clear to me only during the last
few years. I have no doubt that I have missed recog-
nizing it many times even during this time.

This is because we have neglected to notice that the
function of accommodation is the only important one
of the male human being that gives out in middle and
advanced life, a fact that demonstrates biologically the
recentness and difficulty of its acquirement, the tem-
porariness of its easy action, and consequently the
variableness of its quality or power in heredity and
exercise. The lens is its organ, and all depends upon
the endowment and preservation of its inherent elas-
ticity or refracting power. The ciliary muscle does
not lose its power, and hence the strain of effort of
this muscle acting upon a paretic or subnormally elastic
lens makes all the greater the reflexes of eyestrain.
Without nervous connection with the brain and body,
nourished only by blood-serum without blood-corpus-
cles, it is not surprising that the lens loses its elasticity,
and thus gives the refractionist added and difficult
problems. But with their solution the explanation is
guaranteed of many of our most distressing failures to
cure, and the opprobrium of our inability to relieve
many diseases and cases is removed. The critics and
ignorers of “the eyestrain hobby-rider,” as they care
more for the preservation of their prejudices than they
do for the relief of the sufferings of their patients,
SUBNORMAL ACCOMMODATION. 381

will not at once welcome this new power in thera-
peutics. This, of course, will not long postpone the
recognition of the fact.

Case 476 offers an interesting example of the ever-varying
conditions of accommodation anomalies. A man at the present
time 46 years old has a static error of:

R. — Sph. 0.25 + Cyl. 1.00 ax. 115° = 20/20
L. + Cyl. 1.00 ax. 75° = 20/20

But for distance he has an accommodation so strong that
— Sph. 1.00 is required to give him normal distant acuteness.
Even — Sph. 0.50 added to his static correction will give him
only about 20/40 vision, and this is annoying. But he also
presents the contradiction of insufficient accommodation for
near, and + Sph. 1.75 must be added to his distance glasses,
in bifocals, to enable him to read without intense pain in the
neck, a sore and swollen spot on the occipital bone, insomnia,
etc. I have tried for years to reduce the accommodation
power for distance, but without great success.

Case 626 is that of a young woman who came to me soon
after I entered upon practice, and who long had more faith in
me than I had understanding of her disease. She had almost
every symptom which has been charged to eyestrain and
hysteria, but I preserve a clear conviction that few or none of
her troubles were imaginary, and that if I had known what I
discovered years later, I might have lessened her sufferings, if
not cured them entirely. For about seven years, during which
she clung to me with pathetic trust, I tried everything, ocular
and systemic, to give her relief, but succeeded only for a little
while or but partially. At last it entered my head that although
she saw clearly at near range with her distance correction, she
might need more help of a paretic accommodation, and rapid
increases were made in her near lenses, until, at the age of 37,
she is now wearing + Sph. 1.50 D. as presbyopic segments in
382 BIOGRAPHIC CLINICS.

bifocal glasses, and with a satisfaction and freedom from
sufferings, which she has never before experienced. Her static
error is:

R.+ Sph. 2.75 + Cyl. 1.50 ax. 45° = 20/60
L. + Sph. 0.37'++ Cyl. 1.25 ax. 180° = 20/30

The amblyopia has improved somewhat, but a high exophoria
has wholly disappeared, and there is now almost perfect
muscle-balance.

Case 1958 is that of a woman now 38, whom I failed to give
perfect relief for several years. Her static error was:

R.+ Sph. 3.25 + Cyl. 0.50 ax. 75° = 20/20
L. + Sph. 2.50 + Cyl. 0.37 ax. 105° = 20/20

After a time complaints and experiments led me to order
bifocal spectacles:

R.+ Sph. 3.37 + Cyl.0.50 ax. 75° oo

L. + Sph. 2.62 + Cyl. 0.37 ax. 105° { Digtainee
R.+ Sph. 4.00 and Cyl. |

L. + Sph. 3.25 and Cyl. } Near

The small degree of premature presbyopia or accommoda-
tion failure could not be discovered by any tests, and only the
experiment brought the fact to light.

Case 3417 is that of a young woman of 20 years of age, in
1894, who gave me at that time a history of severe sick-head-
aches, the crises recurring every two weeks for the last twelve
years. There was a leukomatous cornea in the right eye from
keratitis as a child. I found her static refraction:

R.+ Cyl. 3.00 ax. 180° = 20/100 +
L.+ Sph. 0.62+ Cyl. 0.50 ax. 90° = 20/20?
with 14° of exophoria.
SUBNORMAL ACCOMMODATION. 383

I ordered the best correction I could give, and did not see
her again until 1901, when I again refracted her eyes and gave
her somewhat different lenses. The sick-headaches had been, in
part, replaced during these years by a severe pain in the left
side of the chest, extending to the left arm, brought on by read-
ing, writing, or sewing, even for a few minutes. This com-
pelled her to give up her position as a school teacher. In 1903
I again retested her eyes. She reported that during the last
two years reading any length of time would cause pain under
the left shoulder-blade, extending to the breast, to the base of
the brain and down the left arm to the middle fingers. Think-
ing the struggle of the maimed right eye to retain its share in
binocular vision might be the cause of her eyestrain reflexes, I
asked her to try the use of a blinder over the right eye when
reading. She reported in six weeks that she could not do this.
There was no relief from the device. The sick-headache, how-
ever, had been better of late and more rare, although they still
clung to her, as they had done more or less during the years
since I first saw her. She is now entirely relieved of the
peculiar, indescribable and unendurable suffering which used
to accompany the attacks, and the pain in her arm and side is
not so intense, and she can use the arm more in sewing. In
1904 I had learned my lesson as to subnormal accommodation,
and was not thrown off my guard so easily by the leukoma of
the cornea of the right eye. I now found her refraction
error to be:

R. + Sph. 0.62 + Cyl. 3.00 ax. 180° = 20/50?
° L. + Sph. 1.12 + Cyl. 0.25 ax. 180° = 20/20

But there was exophoria of 15°, and hyperphoria of 15°,
showing, of course, the complete loss of binocular fusion. Then
came to light the reason of my failure to give her complete
relief during all these years and the reason for the partial func-
tional exclusion of the right eye, by means of the enormous
heterophoria. (But the doubling of visual acuity proved the
384 BIOGRAPHIC CLINICS.

benefit of the glass.) This was a failure of accommodation
power measured, in the right, by + Sph. 1.62, and in the left by
1.00. The difference in the loss is highly suggestive. Bifocal
glasses were ordered and the last report was gratifying.

Case 3812 is that of a woman who, when she came to me in
1895, was 35 years of age; her static error was:

R.+ Sph. 1.62 + Cyl. 0.37 ax. 45° = 20/20
L. + Sph. 1.50 + Cyl. 0.25 ax. 45° = 20/20

For nine months she was relieved entirely of her headaches
and other reflex symptoms, but with their recurrence, I found
little or no change to account for them. I gave a stronger
correction for neir-work, but in two months there was still
trouble. The symptoms were surely due to eyestrain, and I
had failed to give relief. There was but one recourse. She
could temporarily overcome the weakness and see to read
plainly, or at least she contended that she could do so. By
experiments J found that there was an accommodational weak-
ness, measured by + Sph. 2.75 over her distance correction.
With this, in bifocals, all the symptoms disappeared in a day,
and have never returned. The woman had been a great suf-
ferer all her life—was, in fact, an invalid under the care of
many physicians and oculists. She now has good health.

Case 4144.—For several years prior to 1902 I had been able
to give this patient, aged 4o at that time, fairly good satisfac-
tion by her distant correction worn all the time. Complaints
now became insistent. She had but one useful eye, the left; the
right having become practically blind from strabismus, unsuc-
cessful operation and disuse. The left required + Cyl. 0.50 ax.
go° to give her perfect acuteness of vision. Her symptoms
were plainly due to eyestrain, and the solution only came when
I found premature presbyopia, which was neutralized by + Sph.
1.37 added to her cylinder. In 1904, at the age of 42, this loss
of accommodation power is measured by + Sph. 2.25 D.
SUBNORMAL ACCOMMODATION. 385

Case 4748.—This patient is a woman, now 30 years of age,
who for many years has done an enormous amount of reading
and writing. I had during several years prescribed glasses for
constant use, but although she was generally physically strong
and healthy, they were never satisfactory. Her static defect
was the same in both eyes, + Sph. 0.75 + C. 0.25 ax. 90°, with
perfect vision. She had had conjunctival hemorrhages after
severe study, photophobia, pain and burning in the eyes, asthe-
nopia and headache. After a term of abuse of the eyes, she
had an attack of hemiplegia, the right side of the body being
without power or sensation. The right pupil was contracted to
a pin-point, the left widely dilated and responding but little to
light. Rest in bed and cessation of all reading were followed
by a return to normal, the hemiplegia disappearing entirely.
This was seven years ago, and there has been no return of such
symptoms. Two years later there was an attack of herpetic
conjunctivitis, photophobia, and pain in the temples. The axes
of astigmatism were now found to be 70° and 110°. Now be-
gan attacks of typical migraine, followed by intense dermatitis.
These I did not at first dream were connected with eyestrain,
because, like the rest of the profession, I had never known or
had forgotten what the science of 100 years ago had clearly
recognized. The old clinicians, of course, had no idea that
migraine was due to eyestrain, but they saw that “herpetisms ”
were not seldom the sequels of migraine. Wagner’s was a clear
case of eyestrain, and he had repeated attacks ofa “ cutaneous
malady” and “continuous attacks of erysipelas,’ which tor-
mented him much of his life. My patient had most distressing
attacks of “hives” and various other eruptions, pronounced
by the best dermatologists atypic, and which were puzzling to
them and intractable. These attacks were sometimes called
acute urticaria, psoriasis, generalized eczema, pityriasis
rosacea, etc. In looking back over her life, this very intelligent
patient now remembers that the eruptions were always con-
nected with extreme use of the eyes, headache, and especially
sick-headache. All of these symptoms in her case have since

26
386 BIOGRAPHIC CLINICS.

been repeatedly demonstrated to be due to eyestrain. They
recur with leaving off the glasses, and are relieved at once by
proper correction of the eye defect. A most carefully observed
and excellently reported case of a similar nature has been
called to my attention. It was in the practice of Dr. Charles A.
Oliver, and published in The Philadelphia Medical Journal.
The repeated demonstrations that the urticaria was absolutely
caused by eyestrain is most convincing. Observations would
doubtless prove the sequel more frequent than is supposed.
Other cases which I had seen of these skin affections connected
with migraine and the growing conviction that migraine itself
is entirely a product of eyestrain finally landed me in the
puzzle that here was a patient of 38 with an almost inconsider-
able error of refraction, and yet with the most glaring diseases
due to eyestrain. The solution of the mystery came with the
thought of premature presbyopia, and the enormous amount of
reading and writing done by the woman. A moderate amount
of near-work left her free from attacks; with 10 or 15 hours a
day of application there was the sick-headache and the terrible
eruptions all over the body, which confined her to bed or the
bath-tub for a week or two at a time. There was not the least
sign of recession of the near-point, and reading produced no
trouble if not exceeding several hours a day. At first I gave
her reading glasses + Sph. 0.62 stronger than her distant cor-
rection. These gave complete relief except when they were
forgotten for two days, followed by a typic attack of migraine
and urticaria, subsiding in twenty-four hours after the reading
glasses were resumed. With a still stronger correction (1.25),
and put in bifocals and worn all the time, this woman, now
39 years old, has had no attacks unless the glasses are broken
or forgotten.

Case 5489 is that of a woman of 23 with a static error as
follows:
R.+ Sph. 2.50 + Cyl. 1.00. ax. 90° = 20/20
L, + Sph. 3.50 + Cyl. 0.75 ax. 90° + 20/20
SUBNORMAL ACCOMMODATION. 387

She had suffered much from frontal headache, asthenopia
and indigestion. There was at first a high accommodation
power and a low correction was followed by some relief, but a
speedy return of headache, sleepiness, etc., and also by a dental
reflex symptom somewhat more frequent than is suspected.
Intense neuralgia came on in the jaw and teeth of one side. The
teeth were demonstrated sound and healthy. One tooth finally
became the seat of the toothache. The tooth was killed. The
pain at once transferred itself to the corresponding tooth on the
opposite side. The nerve was likewise killed in this tooth by
the obliging dentist. Another tooth seemed to die sponta-
neously. There was now another visit to my office and I found
the accommodation reduced to normal, but with my former
low correction there was, of course, much eyestrain with con-
tinuous near-work. Full correction for reading, writing and
sewing brought considerable but not complete relief, and at the
last visit one diopter added to the distance glasses for near-
work has brought entire satisfaction. She is now 29; if there
is a return of the symptoms I shall advise bifocals.

Case 6316 is that of a woman of 35, whose static error is:

R.— Sph. 2.50 — Cyl. 0.50 ax. 50° = 20/20
L. — Cyl. 0.25 ax. 140° = 20/20
with an exophoria of about 20°.

She had passed through the hands of able oculists, but they
had failed to notice that in such a defect the right eye would
be used only for near-work, and the left only for distance, and
that this would necessarily destroy the accommodation of both
eyes. Their glasses, ordered only for distance or constant use,
would naturally increase the patient’s difficulties and symp-
toms instead of relieve them. By prescribing:

Distance { R.— Sph. 2.50 — Cyl. 0.50 ax. 50°
L. — Cyl. 0.25 ax. 140
288 BIOGRAPHIC CLINICS.

{ R.— Cyl. 0.50 ax. 50°

ok
cad | 1" 4 Sph. 2.00— Cyl. 0.25 ax. 140”

this patient’s problem was solved and binocular vision estab-
lished.

Case 6324 is that of a woman of 39, complaining four years
ago of frontal and occipital headache, sleepiness on use of the
eyes for near-work. At that time I was not aware of the fact
that subnormal accommodation might be the explanation of my
failure to relieve symptoms by the use of the ametropic correc-
tion alone. Here was a woman with a low degree regular com-
pound hyperopic astigmatism (B. E. + Sph. 0.62 + Cyl. 0.50 ax.
go°), and who got little relief from evident eyestrain by the
glasses ordered. For a year I tried all methods, general exam-
ination, urinalyses, with indicated hygienic and systemic thera-
peutics—all in vain. The woman was doing a great deal of
writing and reading, and was finally compelled to give up her
position, and take another with less pay and work. She
returned to me recently, after an absence of two years and a
half. She had a severe headache or neuralgia, a few weeks
ago, above the eyes, and was abed several days, the pain so
intense that morphin was given. She has long recognized that
her symptoms are caused by the use of the eyes. I had now
learned my lesson, and at this visit I recognized that the
symptoms indicated premature presbyopia. Her static refrac-
tion I found to be:

R.+ Sph. 1.00 + Cyl. 0.62 ax. 90° = 20/40?
L. + Sph. 0.87 + Cyl. 0.62 ax. 90° = 20/20

When the mydriatic wore off I found the subnormality of
accommodation I had expected and ordered:

R.+ 5.0.75 + Cyl. 0.62 ax. 90°
L. + S. 0.62 + Cyl. 0.62 ax. 90°
R.+ S. 2.25 and Cyl.
L. + S. 2.12 and Cyl.

\ Distance
Bifocals
\ Reading
SUBNORMAL ACCOMMODATION. 389

There has not been sufficient time since to give the results
of this correction, but I have little doubt that they will be good.
The amblyopia in the right eye had not bettered in four years,
a natural consequence of the noncorrection of the accommo-
dation weakness. I am curious to see if it will not now im-
prove somewhat, despite her age.

Case 7005.—This patient, a woman of 32, had had temporary
and partial relief of her headaches and sick-headaches for
eleven years by the glasses of other oculists. Recently the ap-
petite had grown bad. She had quite a high degree of compound
hyperopic astigmatism with perfect acuity of vision. For
eighteen months I also was able to give her considerable com-
fort, but in November, 1904, there was much nausea, ill-health
and “nervousness.” I again changed her glasses, finding a
decided increase of astigmatism in one eye. I ordered:

R. + Sph. 1.25 + Cyl. 1.62 ax. 90°
L. + Sph. 1.37 + Cyl. 0.50 ax. go°

There was again a temporary and noticeable bettering, but
in reading, writing, etc., the symptoms tended to recur. I
ordered for near-work:

R.+ Sph. 1.87 and Cyl.
L. + Sph. 2.00 and Cyl.

and success was attained.
Case 7127 is that of a man of 42, with a static correction of:

R.+ Sph. 0.87 + Cyl. 0.37 ax. 90° = 20/30
L. + Sph. 1.00 -+ Cyl. 0.87 ax. 180° = 20/30
and without muscular imbalance.

I gave him weak presbyopic segments in bifocals, but he
was soon dissatisfied with them, and I was puzzled to under-
stand why until I found he was depressing his head and read-
ing at a great and abnormal distance through the upper or dis-
390 BIOGRAPHIC CLINICS.

tance lenses. At the same time I discovered that my presbyopic
correction was entirely too weak to allow him to read at the
proper distance and for but a little while. I increased this cor-
rection first to 1.25 D., and soon was forced to carry it to 2.00
D. added to his distance lenses. During his early life the
reversed astigmatism without correction could not be over-
come, and the accommodation was thus highly paretic from
disuse, and the odd compensation plan became habitual of
reading and writing almost at arm’s length.

Case 7353 is that of a busy physician, aged 27. All the
glasses that had been ordered for him before he came to me
gave at best only temporary and partial relief. Thirty min-
utes’ reading would bring on a headache and if persisted in
there would be sick-headache, indescribable suffering and
depression. He was sick in bed, three years ago, for a week
with “congestion of the retina.” His static error was found
to be:

R.+ Sph. 1.00 + Cyl. 1.00 ax. 80° = 20/20
L.+.Sph. 3.50'+ Cyl. 0.62 ax. 115° = 20/20

His adduction power was only equal to the abduction; I
gave him 64° of adduction power by prism gymnastics, with
some relief and added reading ability, but neither this nor my
correction of his refraction error gave him ability to study or
read long, and the muscle imbalance was highly variable. He
persistently tilts his head to the right, but has no spinal curva-
ture. I at last discovered subnormal accommodation, and gave
him glasses for near-use, stronger by 1.00 D. than his static
correction. He discovered that his symptoms were lessened,
and without any decrease of distant visual acuteness, by wear-
ing these all the time. This led me to strengthen his reading
correction, the total being as follows:

R.+ Sph. 2.50 + Cyl. 1.12 ax. 80°
L.+ Sph. 5.25 + Cyl. 0.37 ax. 105°
SUBNORMAL ACCOMMODATION. 391

But there still remained the inability to read as he desired
without bringing on suffering, and the demands of his life are
that he shall keep posted in medical literature and progress.
At last I learned that during childhood a table fell and struck
him on the forehead, cutting the scalp open the entire width of
the forehead and also vertically into the hair on one side. One
cannot know what results may have been caused by such an
extensive injury. Two things lead one to suspect that there
was cerebral or meningeal traumatism and inflammation: He
has always been somnambulistic, walking all about the house,
talking and doing strange things in his sleep; he also has a
persistent subnormal temperature, ranging from 96° to nearly
normal, but never over 98.4°, generally about 97° His case is
as much a puzzle to neurologists as it is to me, and I am not at
all sure how far his eyes have been the cause of his troubles, or
if his subnormal accommodation is the consequence of the
traumatism. It is certain that his anisometropia and intense
eyestrain during youth and college days would work havoc
with any nervous system, but that does not imply that the
head injury has not been at least a contributing cause of the
man’s misfortune.

Case 7530 is that of a woman of 38, wearing atrocious opti-
cian’s glasses, with much epiphoria, some frontal and temporal
headache, constipation, “nervousness,” or restlessness, irrita-
bility, excitability, depression of spirits and dizziness. Her
static error is:

Both eyes + Sph. 6.50 + C. 0.80 ax. 90° = 20/60
and some exophoria.

This huge error, of course, was not to be overcome; there
had been renunciation of the attempt, with almost complete
resultant lack of accommodation power. She subsequently
required full correction for distance, and 2.50 D. added for near
in bifocals, with perfect relief of all her symptoms and a great
improvement, in six months, of visual acuteness.
392 BIOGRAPHIC CLINICS.

Case 7554 is that of a man of 27, who has worn incorrect
glasses since the age of 13. He works for twelve hours a day
by artificial light at reading and writing. His eyes tire, and he
has a feeling as if they were turning toward the nose, and “as
if being pulled back in his head.” There is temporal headache
and pain in the eyes. He does not feel rested after the night’s
sleep. He has nausea when feeling the worst. He is very
depressed and “nervous.” He was wearing:

R.+ Sph. 1.75 — Cyl. 3.50 ax. 15°
L. + Sph. 1.75 — Cyl. 3.50 ax. 165°

His static refraction is:

R.-+ Sph. 1.25 — Cyl. 5.00 ax. 5° = 20/20?
L. + Sph. 2.00 — Cyl. 4.75 ax. 160° = 20/40

Although only 27, I found that his correction for distance
did not give him clear near vision, and I ordered + Sph. 1.75 as
presbyopic segments in bifocal glasses. But this did not give
relief, and two months later I increased the power of the seg-
ments to 2.25 D., when there was a disappearance of the symp-
toms mentioned. He returned in six weeks with slight com-
plaints, when I discovered plain evidences of an increase of
accommodation power, and I at once gave him comfort by a
reduction of the segments to 1.25 D. In two weeks more his
accommodation power had become normal, and the distance
glasses (remaining all the time as originally ordered), are now
worn with satisfaction for all purposes.

It seems from this history that the accommodation paresis
was probably due to a direct inhibition reflex.

Case 7575 is that of a woman of 50 whose left eye has been
practically blind from childhood. The static refraction of the
right is + Sph. 1.75 + Cyl. 0.50 ax. 30°. She was wearing a
cylinder axis 90°. She had been a great sufferer from sick-
headache, car-sickness, etc., up to four years ago when glasses
SUBNORMAL ACCOMMODATION. 393

gave her relief. Her chief complaints now are pain in the
temple, extending over the head, “ congestive stomach trouble,”
eructations and constipation. I found almost total paralysis
of the accommodation, and ordered:

R. + Sph. 1.75 + Cyl. 0.50 ax. 30° eee
L. Plano

R.-+ Sph. 4.12 and Cyl. i :
L. Plano Reading

She has now none of the symptoms complained of, is healthy
and most grateful.

Case 7703 is that of a woman of 29 who has suffered much
from headache, the pain being throbbing and extending to the
neck, and made worse by sewing. She frowns or scowls, is
always sleepy, has chronic constipation, is “nervous,” irrita-
ble, depressed, worries much, etc. There is complaint of lac-
rimation and photophobia. I ordered:

R.+ Sph. 0.25 + Cyl. 0.50 ax. 90°
L. + Cyl. 0.50 ax. 90°

In six months all symptoms were better and her improved
health was shown in a gain in weight of fifteen pounds, her
former weight having been 115, and now 130. But her eyes
tire with near-work and in one hour get “bloodshot.” These
symptoms were relieved by a second pair of glasses for near-
work as follows:

R.+ Sph. 1.62 and Cyl.
L. + Sph. 1.37 and Cyl.

Case 7716 is that of a professor in a large university, who
three years ago was compelled to resign because of ill-health;
since then he has been wandering over the world from one
physician to another in the hope of finding relief from “ ner-
vous depression,” headache, intense photophobia from artificial
light (not from daylight), and an awful feeling as if the head
394 BIOGRAPHIC CLINICS.

would burst. He had a nervous breakdown ten years ago after
studying hard. Great neurologists and oculists have not been
able to do him any good, or to understand his case. In 1gor
the right pupil suddenly dilated with a reported paralysis of
the accommodation of this eye. Pilocarpin ordered by a
famous European oculist brought the pupil down to normal,
but resulted in no permanent good. I found the right pupil
wider than normal, but not reacting to stimulus either of
light or accommodation. His static error is:

R.+ Sph. 2.75 + Cyl. 2.25 ax. 45° = 20/20?
L. + Sph. 3.75 + Cyl. 2.25 ax. 135° = 20/50 +

The man is 34 years of age, but I found he demanded full
correction for distance and a somewhat stronger correction for
near-work, which was ordered in bifocals. At the time of his
first visit he was sailing for Europe the same day, and I could
not keep him under observation and for continuous testing.
There was some relief following the use of these glasses, an
ability to read from one to two hours daily and sometimes for
quite a number of hours; but this would not be satisfying.
Upon his return from Europe I found an anomalous condition
of the muscular imbalance. The tests did not show any con-
stancy of innervation, the cover tests and rod tests contradict-
ing each other. There was sometimes an exophoria of enor-
mous degree. There was plainly no binocular fusion. I now
discovered a great weakness of the accommodation for contin-
uous use, although by the momentary tests and those for a
half-hour’s reading, it was not at all detectible. And this was
the secret of the man’s tragedy. Moreover, there was a dif-
ference in the accommodative weakness of the two eyes, the
right eye showing a greater loss of power than the left. In
addition to his distance correction, I ordered in bifocals for
near-work :

R.+ Sph. 4.75 and Cyl. as above
L.+ Sph. 5.50 and Cyl. as above
SUBNORMAL ACCOMMODATION. 395

That is, 2.25 were added to the right and 1.75 to the left. In
a day or two he was reading much more, and without symp-
toms, visual acuity had greatly improved, and at all distances
under six feet there was no motion of the eyes under cover. I
judge that the entire history of the man’s misfortunes was
caused by unrecognized accommodation weakness. The his-
tory is to be completed.

Case 7724.—A healthy actor, now 50 years of age, who has
acted almost every night for some thirty years, has during the
past two years been much troubled with objective vertigo, the
first attack preceded by nausea. Many great physicians and
specialists have pronounced him free from all organic disease,
except possibly insidious brain disease. He was engaged in
severe literary labor two years ago, in addition to his eyestrain
from the footlights. He sometimes read all night. He has
always been strong and possessed good health, never has used
stimulants, not even tea or coffee, and has never had any
infectious disease. Whenever he does much reading the ver-
tigo returns. No physician has ever suggested ocular cause of
his vertigo. Great oculists told him he needed no glasses and
gave him an eye lotion. He was wearing optician’s glasses, of
course, and incorrect ones, it goes without saying. His static
refraction was:

R.-+ Cyl. 0.25 ax. 45° = 20/20 +
L. + Sph. 0.25 + Cyl. 0.37 ax. 60° = 20/20 +

When the effects of the mydriatic passed off I found that he
had no accommodation power whatsoever. There was the com-
plete paralysis of a man of 65 or 7o years of age. Bifocal glasses
have given him perfect relief of his symptoms, but there re-
mains a sensitiveness to long periods of reading and a tendency
to pain in the back of the head. A few hours of reading at a time
is all he can do; by resting, walking, etc., and doing his reading
by daylight, he is very happy. He cannot work by artificial
396 BIOGRAPHIC CLINICS.

light. In other patients who are actors or actresses I have also
found this inability to endure artificial light, and the influence
of the footlights to paralyze the accommodation. It is the
secret of the ill-health of many actors and actresses.

Case 7847 is that of a single woman of 37 years of age in
1904. She has been a great sufferer from headache, starting in
the forehead, extending to the vertex, occiput, and the pain
thence going down the spine. She has occasional “ bilious
headaches” with vomiting and violent pain in the epigastrium.
These attacks last for four days in which no food is taken or
retained. The vision was extremely poor preceding the last
attack. She has been greatly troubled by flatulence. She has
worried much about her eyes, and keeps up a constant fight
against despondency. She has terrible nightmare dreams
which awaken her with fright, so that she does not sleep well
at night; and yet she is drowsy and dull during much of the
day. She has worn glasses, incorrect ones, for sixteen years.
She was for many years an engraver on gold, using a mag-
nifying glass for this purpose, and she can now read only by
the aid of this glass. Deafness began coming on while work-
ing at gold engraving, between the ages of 17 and 21, and
without glasses. It became much worse about twelve years
ago from an adhesive or sclerotic inflammation of the middle-
ears. The static refractive error was:

R.+ Sph. 2.00 D. + Cyl. 0.37 ax. 45° = 20/30
L.+Sph. 2.25 + Cyl. 0.37 ax. 135° =20/30?

Although this patient was only 37 years of age the correc-
tion gave her no ability to read at fourteen inches, and the his-
tory of the use of the magnifying glass in engraving, and the
need of it now to read with, at once suggested paralysis of the
accommodation. Bifocal spectacles were ordered with the
addition of + Sph. 2.25 as a presbyopic segment. In three
weeks she returned to report her hearing better than for
SUBNORMAL ACCOMMODATION. 397

years. She now heard church bells she had not heard for
many years, and there was less tinnitus. She feels buoyant,
younger and was profuse in her gratitude. At her last visit
she stated that she reads and writes with ease and comfort.
She had long been unable to work,-but with the relief from
her glasses she at once secured a position as dressmaker, and
despite this kind of work she has no headache, does not use
a magnifying or hand glass to read, sleeps better, etc. The old
hopelessness and despondency have disappeared, and the im-
provement in hearing is permanent. :

Case 7851 is that of a woman of 35, whose chief complaints
are of “nervous dyspepsia,” “ general weakness of the nerves,”
depression, apprehensiveness, irritability, etc. She “has always
to be on the go.” She has “much gas and discomfort after
eating.” For the last year and a half she has had “a gurgling
of gas and a pressure below the heart,” whenever she reads or
sews too long. Her physician has been treating her for this,
and “his medicine cures it if she stops reading and writing and
sewing.’ She has never had much headache, but has often a
throbbing in the temples. She feels a nervous shock in the
pelvis as acutely as in the head. Some misplacement of the
uterus has been corrected. She has worn glasses for eight
years prescribed by good oculists, but has had no relief from
them, and the last ones ordered made her symptoms worse.
This will be understood by the record:

R.-+ Sph. 1.00 + Cyl. 0.50 ax. 75°
L. + Sph. 1.00 + Cyl. 0.62 ax. 105°

Her static correction I found to be:

R.-+ Sph. 2.75 + Cyl. 0.50 ax. 75° = 20/25
L. + Sph. 2.75 + Cyl. 0.62 ax. 130° = 20/25
with 60° of hyperphoria.

Plus spheric 2.25 and cylinders were ordered with a partial
398 BIOGRAPHIC CLINICS.

correction of her hyperphoria. With these she found so
much relief that she at once began to disobey orders and
sewed immoderately, “on black,” and in six weeks she
returned with a recurrence of her old symptoms, especially the
digestive reflexes, which ‘she herself traces directly to use of
her eyes. I was now prepared to find that I had blundered six
weeks before, which I found was true. I had failed to think of
a deficient accommodative power. The clearest hints were an
increase of the hyperphoria, showing the inability to preserve
binocular fusion and the “breaking down” under a great
strain of “sewing on black,” By adding plus 1.25 spherical to
her distance glasses in bifocals her problem was at once solved.

Case 7892 is that of a woman 30 years old, who has been
under treatment by general physicians for a long time for gas-
tric symptoms, dyspepsia, etc. She has had pain and nausea
after eating, with flatulence and constipation. She is intensely
“nervous,” cannot go out alone, “trembles” a good deal, is
depressed, excitable, and “a worrier.” She has had all her life
daytime drowsiness and frontal headache nearly every day,
culminating in sick-headaches with “ awful nausea” and “ rush
of blood to the head.” I found her static error:

R. + Sph. 0.62 + Cyl. 0.62 ax. 100° = 20/20
L. + Sph. 0.62 + Cyl. 0.62 ax. 90° = 20/20
with slight exophoria.

There was good accommodation for distance and I could
only order the cylindric correction; I also gave her + Sph.
0.25 and cylinders for reading. These glasses gave her much
relief and there was a betterment in all ways, although reading
seven weeks later still produced considerable trouble. Then
+ Sph. 1.00 and cylinders was now ordered for near-work.

Case 7951 was that of a strong, healthy, fine specimen of
young womanhood of 21. Ever since the age of 10 she has had
occipital headache, and especially following any reading and
SUBNORMAL ACCOMMODATION. 399

study since the age of 15. She has been compelled to forego all
near-work, as a half-hour of such strain at once causes the
pain. When she gets very tired from any cause the headache
is likely to come on. At about the age of ten it was noticed by
her mother that one shoulder was higher than the other, and
the spine somewhat curved. She was put under the charge of
a physical culture teacher and after several years of training
the spine became straight. For several months before meno-
phania, at about the age of 14, she had severe sick-headaches
with vomiting. There has been none of these attacks for sev-
eral years. She is sleepy during the day. The consciousness
of her headache persists more or less clearly during her sleep
at night. About five years ago she had “nervous exhaustion”
and was in bed most of the time for a long period. She has
worn glasses most of the time during the last five years, but
for reading only. I found her wearing, both eyes + Cyl. 0.50
ax. 90°, prescribed by an oculist—a correction which was adding
to eyestrain instead of neutralizing it. Her static refraction is:

R.-+ Sph. 0.25'+ Cyl. 0.25 ax. 70° = 20/20
L. + Cyl. 0.25 ax. 110° = 20/20

She has an exophoria of 1°, but an abduction power of 7°,
and an adduction of 24°.

The patient had been sent to me from a long distance and
after many failures of other oculists and physicians to cure her
headaches. I was therefore greatly worried to find an error of
refraction almost impossible alone to cause the severe symp-
toms, which were most plainly chargeable to eyestrain. In
such cases every possible proving of the tests must be gone
over and the mistake or the mystery exposed. Retesting only
reproved the correctness of the diagnosis, and I was forced to
order:

R. + Cyl. 0.25 ax. 70°
L. — Sph. 0.12 + Cyl. 0.25 ax. 110°

This was done in the faint hope that, as sometimes happens,
400 BIOGRAPHIC CLINICS.

an irritated and hypersensitive system might be morbidly
acted upon by as slight an ametropia as this. Possibly, one
knows, a higher degree and an unsymmetric one may have
previously existed, and the habit-reflex persist with the slight
eyestrain. True to my rule, I hung to the mystery and would
not let the patient return home. When the mydriasis should
have passed off I noticed that the pupils were still abnormally
wide, although the accommodation had returned so that the
finest type could be read at near range. This suggestion put
me on the track of a solution, as I had several times found that
subnormal power of accommodation for persistent use was indi-
cated by physiologically wide pupils. The girl had always had
these remarkably wide pupils. All became clear when I found
that, although she could see to read even fine print for a little
while, and for all ordinary testing, yet she took with great
delight from 1.50 to 2.00 diopters plus spheric, and had “ never
seen printing look like that before.” J ordered reading glasses
+ Sph. 1.50 D. added to her distant correction. If I find the
accommodational paresis uniform and continuous, I shall ask
this patient of 21 to wear bifocal spectacles, at least for house
use. Whereas, before she read for only fifteen or thirty min-
utes without headache, the report of her physician is as
follows: “ Not a headache since she began using the glasses.
You have not only given her new eyes, but new life. She now
says she has never seen like other people, or really ever
enjoyed life. Her family are deeply grateful and jubilant
over it.”

Case 7953 is that of a woman of 34, who has long been
afflicted with temporal and occipital headache, culminating in
natsea, but not vomiting. The attacks are frequent, and espe-
cially so when doing reading or sewing. ‘“ When her eyes are
bad she has more nausea.” She has worn glasses for ten years,
generally with some temporary relief of headache with each
change in glasses. The last change, made during the last
summer, gave no relief. There are daytime drowsiness, chills
SUBNORMAL ACCOMMODATION. 401

with the nausea, a nervous shaking or tremulousness. She is
despondent, irritable, easily excited. She was wearing:

R.+ Sph. 1.50-+ Cyl. 1.00 ax. 80°
L. + Sph. 1.25 + Cyl. 1.50 ax. 90°

By comparing this with her static error, and especially
with that I ordered, given below, it will be understood why
she got no relief from these glasses. Her mydriatic error I
found to be:

R. + Sph. 1.37 + Cyl. 1.62 ax. 85° = 20/20
L. + Sph. 1.00 + Cyl. 2.25 ax. 105° = 20/20

While testing her I noticed that she persistently tilted her
head about 10° to the left, and when I found that with the
average of her axes of astigmatism there still remained 10° of
asymmetry in the left eye which could be rectified only by tilt-
ing the head toward the left side, I said to her: “ Oh, you are
left-handed?” She was surprised that I should have inferred
the fact. She was forced to learn to write during childhood
with the right hand, is a “ very poor writer now,” but does all
other usually dextromanual acts with her left hand. When she
told me that seven years ago her pastor had jokingly spoken to
her as the member of his congregation who always looked up
at him with her head to one side, I said to her: “ You have
curvature of the spine.” She had never suspected it. Exami-
nation of the naked back showed the right shoulder much
lower and longer than the other, an upper dorsal curvature of
the spine, the convexity to the left, with a compensating curve
to the right in the lower dorsal and lumbar regions. The mus-
cular developments and anomalies of the back were those
common in such cases. At the postmydriatic examination of
the eyes I found that she took a high correction for distance,
and this, with other suggestions, led me to suspect subnormal
accommodation. I found that + Sph. 1.25 was needed to give
her clear and satisfying vision at fourteen inches, and an

27
402 BIOGRAPHIC CLINICS.

ability to carry on near-work without the migraine with which
she had so long been tormented. There has been relief of all
other symptoms complained of.

Case 7959 is that of a physician of 39, who has consulted
the most famous oculists of half a dozen cities, but up to last
year has been unable to use the glasses ordered with any relief
of his symptoms. The last prescribed gave him comfort, ex-
cept for reading and writing. Even as a small boy he was pro-
nounced “neurasthenic,’ and had frontal headaches almost
constantly and could study but little. He has always been
troubled with insomnia, and of late years he cannot read with-
out intense sleepiness. He is “nervous,” depressed, easily
worried. Both external recti muscles have been scissored with-
out any relief. His most bitter complaint is of confusion or
obfuscation whenever he reads, and is usually unable to under-
stand what he is reading without the most intense effort, and
by rereading it several times. He was wearing glasses that
corrected his error of refraction with fair accuracy. His
static error I found to be:

R. + Sph. 0.75 + Cyl. 0.37 ax. 90° = 20/20
L. + Sph. 0.75 + Cyl. 0.25 ax. 90° = 20/20
with perfect muscular balance.

In such a case there was but one solution: If he had good
adduction and accommodation power, eyestrain could not be
the cause of his symptoms. And yet his symptoms were
beyond all question due to eyestrain. For twenty or more
years his professional work had been handicapped, and he had
spent much of his life consulting oculists and trying experi-
ments, for he never doubted that it was his eyes which were at
fault. I found paresis of the accommodation measured by
+ Sph. 1.25 D., and ordered bifocals. He at once was able to
read and write at pleasure, and with unbounded pleasure, and
without a symptom of discomfort or confusion. The first day
he wore his spectacles he read two and a half hours, and the
SUBNORMAL ACCOMMODATION. 403

second day one and a half hours on a train—a thing he had
never before been able to do. Even in a few minutes, pre-
viously, reading or writing brought on the symptoms, which
increased with every minute of continuance.

Case 7961 is that of a physician and professor, aged 32, who
was wearing, both eyes, + Sph. 1.00, prescribed by an oculist in
Germany, after a nonmydriatic examination. His chief symp-
toms have been aching of the eyes, sleepiness on reading, rest-
lessness, “bloodshot” eyes, blepharitis after reading, and lac-
rimation. He is completely left-handed, the attempt to force
him to write with his right hand in childhood and youth having
been a failure, although his left hand was tied behind him. It
is fortunate for the man that the foolish attempt was not suc-
cessful. I ordered for him:

L. + Sph. 0.75 + Cyl. 0.25 ax. 105°
R.+ Sph. 0.75 + Cyl. 0.25 ax. 125°
L. + Sph. 1.37 and Cyl.

R.+ Sph. 1.37 and Cyl. \ For near-work.

| For distance

This patient’s troubles were henceforth ended.

Case 7964, one of peculiar interest, is that of a young man
of 21 who has always had a weak and ailing left eye. He has
long been in the habit of convulsively closing and winking it,
especially during reading. Great sleepiness is his chief com-
plaint, whenever he is not in the open air. He has been
troubled with “biliousness” and constipation. He is always
“nervous” and had a “nervous breakdown” in July and
August, 1904. He is easily worried and excited, much de-
pressed, and imagines that he has all the diseases described by
others. He never feels rested by going to bed or sleep. After
his “ breakdown,” long rest from work and seeming recovery
last year, his old symptoms returned when he went back to his
office work as clerk. I found his static refraction to be:

y
404 BIOGRAPHIC CLINICS.

R.+ Sph. 0.37 + Cyl. 0.62 ax. 90° = 20/20 +
L. + Cyl. 2.75 ax. 90° = 20/200

There was no disease of the media or fundus of the left and
his amblyopia was therefore from disuse. But something told
me not to be satisfied with this diagnosis of the error of the
left eye and I persisted, long in vain, until I found the fol-
lowing:

L. + Sph. 0.50 + Cyl. 2.75 ax. 90° — Cyl. 1.12 ax. 60° = 20/60

I am unable to explain the origin of this irregular astigma-
tism. But I was still unsatisfied, and after a time I was able
to demonstrate a remarkable subnormality of accommodation

differing in degree in the two eyes. His presbyopic correction
ordered was:

R.+ Sph., 1.50 with cylinders
L. + Sph. 2.50 with the two cylinders

In twenty-four hours the visual acuity of the left eye had
risen to 20/50, with an immediate disappearance of all symp-
toms, and a satisfaction in distant and near vision of the most
gratifying kind.

These data suggest that:

1. Subnormal, paretic, or insufficient accommoda-
tion, or premature presbyopia, even paralysis of the
accommodation, of a functional or reflex nature, not
dependent upon organic disease, exists in a certain,
probably much larger than suspected, proportion of
young or middle-aged persons.

2. The youngest of my patients was 20, the oldest
50. Several cases show that the subnormal accommo-
dation existed during adolescence. That eighteen were
SUBNORMAL ACCOMMODATION. 405

women and nine men has only the significance that
women are more subject to eyestrain than men because
they do more near-work with the eyes, are less resist-
ant, etc.

3. It is usually permanent or ingravescent, although
there was complete recovery in one of my cases.

4. It may be caused by such degrees and kinds of
ametropia as compel the renunciation of the accommo-
dative function, especially high hyperopia or astigma-
tism, etc., monocularity, glare of footlights, the use of
magnifying glasses in engraving, etc., long-continued
abuse of the eyes, a direct inhibiting reflex to the
accommodational mechanism. It will be noticed that
seventeen of my patients had unsymmetric astigma-
tism, and most of the others an ametropia or anisome-
tropia unconquerable by the visual mechanism. In
many cases there may be no discoverable or patho-
logic cause, the determining factor being a personal
and physiologic peculiarity. We are prone to forget
that presbyopia really begins with the beginning of
life, as the recession of the near-point commences in
infancy, and is continuous throughout life up to the
age of sixty or more. In the normal progress, and
when uncomplicated by ametropia, this recession, at
about forty-five, reaches a degree which makes reading
wearying at fourteen inches with ordinary-sized type,
because the book and writing cannot.be held further
away ; because the letters are so small, and because the
406 BIOGRAPHIC CLINICS.

macular image is too minute. If our arms were five
feet long and our printers used type about a third
inch in height, all might get on without presbyopic
glasses. The crystalline lens of the eye loses its inher-
ited and high elasticity with each year of life. As it
has no neurologic connection with the brain, and is not
nourished by red blood-corpuscles, this loss of elasticity
is most natural. It is consequently as natural and
inevitable that its inherited and primary elasticity
should differ in different individuals and that local
ocular and also systemic disease and denutrition, eye-
strain, etc., should still further make the ingravescent
inelasticity of varying degrees of progress. The re-
sultant symptoms will depend upon the amount and
morbidity of the near-work demanded of the accom-
modation. The number of those under forty-five with
subnormal accommodation is thus probably much
higher than supposed and this fact gives us the sug-
gestion to be constantly upon our guard as to, its
presence.

5. It is of all degrees and varieties, and may even
differ in amount in the two eyes.

6. It may complicate the condition of head-tilting,
torticollis, etc., with secondary spinal curvature, due to
a peculiar axis of astigmatism in the dominant eye.
The pathogenic results of dextrocularity and sinistro-
cularity should not be forgotten.

7. The pathognomonic symptoms are the persistence
SUBNORMAL ACCOMMODATION. 407

of common eyestrain reflexes (such as migraine, head-
ache, indigestion, intestinal fermentation, constipation,
nervous disorders, dermatoses, etc.) after proper cor-
rection of the ametropia and muscle imbalance, and
especially an inability to carry on continuous near-
work.

8. The diagnosis is impossible by any of the ordi-
nary tests. The loss of power has come on so slowly
or has been so long present that the patients have no
suspicion that the print is not clear, and it is usually
possible for them to read even the finest letters with
ease, and for a short time. The comparative rarity of
the cases also throws the oculist off his guard, and
routine begets carelessness. Abnormally wide pupils
of one or both eyes, the demand of high corrections for
distant vision, certain occupations, certain forms of
ametropia and anisometropia, high heterophoria, unre-
lieved reflexes, photophobia, etc., are suggestions that
there may be accommodation weakness.

g. It is an active cause of heterophoria, adding to
the proof of the common dependence of muscle im-
balance upon ametropic and optical causes. It is
therefore an added demonstration, if it were needed,
of the mistake of the tenotomists who operate for
heterophoria. In the vast majority of cases, hetero-
phoria is ametropic in origin, innervational in nature,
and is an effort of nature to lessen eyestrain. The
408 BIOGRAPHIC CLINICS.

results of operation are therefore evil, and make the
cure more difficult by physiologic methods.

10. The treatment is by means of bifocal spectacles
which accurately neutralize the error of refraction for
distant, and the deficiency in accommodational power
for near vision. As in all treatment whatsoever, suc-
cess here also depends upon the amount of irreparable
damage done before the appropriate therapeutic meas-
ure is found. Usually relief is sudden and striking.
Whatever of usefulness there is in the nonsensical
“ fogging system ” is explained by the fact of incorrect
refraction and subnormal or paretic accommodation.

POSTSCRIPT.

THE DISCOVERY OF SUBNORMAL ACCOMMO-
DATION IN THE YOUNG:

To the Editor of American Medicine:—It has now
become a common observation that “there is nothing
new under the sun.” Old discoveries are being con-
stantly rediscovered, often several times, and with no
knowledge of the existence of the previous ones. This
is largely due to the insufferable amount of medical
literature whereby it becomes impossible for late stu-
dents, especially if busy practitioners, to “read up”
and to find the references to previous work. Much of

*Reprinted from American Medicine, Vol. IX., No. 5, page
180, February 4, 1905.
SUBNORMAL ACCOMMODATION. 409

our literature has misleading titles, much is not prop-
erly indexed in catalogues and epitomes, and worse
than all is the neglect of literary research work on the
part of the authors of text-books. It is astonishing to
find how far behind even these most authoritative text-
books are in the matter of summarizing the literature
and discoveries of previous workers. Important mat-
ters are wholly neglected, the echoings of older books
repeated as if by rote, and in many respects the book
is a generation old before it is issued from the press as
an epitome of the latest science. And all this despite
the existence of year-books and periodical summaries
of progress of a score of kinds and publishing firms.
Thus the individual discoverer, in almost unavoidable
ignorance of what has already been done, goes on
working out anew the old problems and rediscovering
old truths. But there are some compensations, of
course, for this unfortunate tendency. Each rediscov-
erer approaches the subject from a somewhat new, or
at least individual point of view, and there is thus a
peculiar emphasis and light thrown upon the problem.
There is also the satisfaction of a confirmation of the
truth in value far outweighing all the personal aspects,
the claims for “ priority,’ etc. Those whose minds
are fervently interested in the scientific or therapeutic
truths are glad of the confirmation by previous delvers
and happy to give credit to earlier students.

There is still another aspect which may not be for-
410 BIOGRAPHIC CLINICS.

gotten: All early discoveries are usually in the begin-
ning partial, and have been led up to by hints, sugges-
tions, incidental phasings of yet earlier workers, so
that a too exclusive or decided claim of priority on the
part of one may not be valid. Not only, for instance,
should Wallace also be honored for the discovery of
the principles now called Darwinian, but Lamarck’s
dues are daily gaining recognition, and many others
had previously suggested and dimly recognized or
stated the fundamental verities of the evolution or
developmental processes of nature.

And lastly should be noted the truth that the method
of presentation, the confirmatory evidence, the proper
placing, the significance as regards practise and future
correlations and extensions may warrant the giving to
a later discoverer as much honor as to an earlier one.
One illustration of all this has lately come to my
knowledge: In 1869 was published an article by Dr.
H. Kaiser, in the Archives of Ophthalmology, on
“ Binocular Vision,” in which incidentally he advanced
the theory of dextrocularity, offering some excellent
proofs of it, and giving the name of “ the prevailing
eye’ to what later I called “the dominant eye.” In
Ophthalmology, for January, 1905, there is an abstract
of an article by Majewsky, published in 1903, in which
Kaiser’s theory is independently restated, and his argu-
ment and illustrations essentially repeated. Neither
SUBNORMAL ACCOMMODATION. 411

Majewsky, his abstractor, or the editor of Ophthal-
mology were evidently aware of Kaiser’s work of
thirty-four or more years ago. I have published sev-
eral articles on the subject in 1904, also ignorant of the
studies of Kaiser and of Majewsky. Kaiser’s article
could only be indexed and catalogued under a title
which would not suggest the thought of dextrocularity,
and Majewsky’s work was published in an obscure
Polish periodical.

A second illustration occurs in reference to my arti-
cle published in American Medicine, January 21, 1905,
concerning “ Subnormal Accommodation and Prema-
ture Presbyopia.” So far as I can learn the credit of
the first clear statement of the principle is due to Dr.
Samuel Theobald, of Baltimore, Md., published in the
Transactions of the American Ophthalmological So-
ciety, in 1891. But in the Ophthalmic Record of April,
1899, Dr. J. G. Huizinga, of Grand Rapids, Mich.,
under the title “ Necessity for Knowing the Range of
Accommodation,” not aware of Dr. Theobald’s study,
published an article which shows from a somewhat
different point of view the essential truth of Dr. Theo-
bald’s contention. So far as I can judge, the road-
opening labor of Dr. Theobald and the excellent paper
of Dr. Huizinga have had little or no practical results
in the actual clinical work of most oculists. When I
think of the numerous patients under my own care in
412 BIOGRAPHIC CLINICS.

the past whom my ignorance of this relief-bringing
measure has not cured of their grievous sufferings, I
am heartily ashamed of myself.

Respectfully,

GeorcE M. GouLp.
PHILADELPHIA, January 28, I905.
dae RECEPTION OF MEDICAL
DISCOVERIES.
CHAPTER XII.

THE RECEPTION OF MEDICAL DISCOVERIES.

READERS of history are repeatedly struck with the
fact that discoveries and new truths which, if accepted
and acted upon, would have made for progress and the
good of the world, would have saved numberless lives
and inestimable suffering, would have been at first re-
jected; and by the very leaders and judges whose
function and duty it was to judge wisely of such
things! Instead of discriminating these have almost
always shown an utter lack of discrimination, and
have condemned the truth to death and its discoverer
to silence. After many years the dead discovery is
disinterred, and, as it was only a case of suspended
animation, it is brought to life and welcomed to a
beneficent activity. But probably the discoverer him-
self was really dead, often of the contumely heaped
upon him. The new truth finally accepted, again be-
comes old dogmatism in the minds of late and belated
receivers, and in their turn these resume the old work
of rejecting with scorn the new truths which may be
discovered in their time. And thus the combination
of farce and tragedy is repeated by every generation

1From Annals of Ophthalmology, October, 1904.
415
416 BIOGRAPHIC CLINICS.

with every discovery. One of the reasons for its
pathetic recurrence is that the perpetrators are igno-
rant both of psychology and history, and therefore
have no suspicion that they are recommitting the same
old blunders of their forefathers. Religious history is
full of capital illustrations of this law, admirably epi-
tomized by White in his “ Warfare Between Science
and Theology.” The history of metaphysics and phi-
losophy offers as striking and as numerous demonstra-
tions of the truth. In science I may cite a few of the
many illustrations occurring in recent times:

Galvani, the professor of physics in the University
of Bologna, discovered galvanism, as we now term it,
and afterward wrote: “I am attacked by two opposite
parties—the learned and the ignorant. Both laugh at
me and call me the frog’s dancing master. But yet
I know that I have discovered one of the forces of
nature.”

The great chemist Lavoisier demonstrated to the
Academy that meteorites cou/d not fall from the skies,
and would not believe, even when he had touched and
examined an aerolite.

The possibility of fossil man was denied by the great
scientific authorities, Cuvier, the master, pitching the
bones out of the window in disgust, and burying the
discovery in ridicule for thirty years.

In 1776 Jouffroy invented steamboats and ruined
himself financially in demonstrating the feasibility of
RECEPTION OF MEDICAL DISCOVERIES. 417

his invention. The French Academy of Sciences re-
ported unfavorably, and the inventor was thoroughly
lampooned. Fulton, in 1804, was no more successful
with the English government, and only succeeded in
the United States in 1807. Lardner’s famous essay
showing the impossibility of the steamship was brought
over on its first trip.

Lebon, a Frenchman, discovered how to use gas for
illuminating purposes in 1797; he died in 1804 without
seeing his invention accepted, and it was only in 1818
that the Parisians would believe in “a lamp without
a wick.” The English adopted the invention in 1804
in Birmingham, and in 1813 in London.

Franklin’s paper on lightning-conductors was
laughed at by the Royal Society, which would not
publish it in the Transactions.

Ohm was treated as a madman by his fellow Ger-
mans. The Dutch senators refused the inventor a
patent on glasses because they were only adapted to
one eye.

A committee of the most eminent engineers of
England opposed the use of locomotives on the first
complete railroad. Arago in the Paris Chamber of
Deputies exposed the fallacy and the folly of those
who would use locomotive engines on railroads, and
the Bavarian Royal College of Physicians declared that
if railroads were constructed the health of the public

would be ruined, as the rapid movement of the train
28
418 BIOGRAPHIC CLINICS.

would cause brain trouble, vertigo, etc., in the trav-
elers. It recommended that if used the tracks should
be enclosed by high board fences, raised above the
level of the cars and engines.

In 1855, when the submarine cable was advocated, a
ereat authority in physics, Babinet, a member of the
Institute and an examiner in the polytechnic school,
demonstrated the impossibility of the plan in the Revue
des deux Mondes. Our own Professor Lovering, of
Harvard College (afterward President of the Amer-
ican Association for the Advancement of Science),
when Field was preparing to lay the first Atlantic
cable, demonstrated to his classes the utter impossi-
bility of telegraphing under an ocean 3000 miles wide.

The opposition DaGuerre had in discovering pho-
tography is well known. He was put in an asylum
because he said he could transfer his likeness to a tin
plate.

The abuse heaped on Newton for substituting blind
gravitation for an intelligent Deity is another instance.

A practising physician, Young, as early as 1801,
hit upon the true theory of the luminiferous ether, and
of light and color, which nearly a century before had
been discovered by Robert Hooke. But his scientific
contemporaries would not see it, and to avoid persecu-
tion and deprivation of practice, Dr. Young was com-
pelled to publish his grand discoveries and papers
anonymously. Published finally by the Royal Society
RECEPTION OF MEDICAL DISCOVERIES. 419

(one can imagine the editor’s smile of superior wis-
dom over such trash), they were as utterly ignored
as were those of Mitchell, Thomson and Martin as to
eyestrain two or three generations later. Arago finally
championed Dr. Young’s theory in the French Acad-
emy, but the leaders, LaPlace, Poisson, Biot, etc.,
denounced and conquered, and not until 1823 would
the Academy allow the publication of Fresnel’s papers
on the subject ; in about twenty-five years the silencers
were themselves silenced. But Young had been si-
lenced, too, his disgust so great that he resigned from
the Royal Society, devoted himself to his poor medical
practice and to deciphering Egyptian hieroglyphics.
The all-comprehending generalization of the conser-
vation of energy has an equally sorry history. In 1806
Davy first, in a way, introduced the thought and Fara-
day in 1831 and 1840 developed it a little more ex-
plicitly ; in 1842 Carnot caught the truth. A German,
Mohr, in 1837, uttered it most clearly, and although
his article was published in the official magazine it
was ignored by his countrymen. Another physician,
Mayer, in 1842, noticed that a tropical patient’s venous
blood was redder than was usual in temperate cli-
mates. He followed up the question, why? and this
time blood-letting resulted in good, and unknown to
the world, Dr. Mayer independently thought out the
true doctrine of the sun’s persistent light and heat.
The world did not hear; the contumely he met caused
420 BIOGRAPHIC CLINICS.

Mayer, it is said, to throw himself out of a window.
In the fifties a Manchester manufacturer read a paper
before the British Association, and no one heeded it
in the least. Two years later he tried to read another,
but the chairman would permit only a brief verbal
synopsis. The leaders were again not leading, and
even Faraday, Brewster, and Herschel could not accept
and all the official judges of the world were silent.
Whewell in his “ History of Inductive Sciences ” does
not mention the theory of Mayer and Joule. It was
only rising, young and unknown men that finally
brought the work and its value to recognition. It is,
indeed, usually the young ones that made, and that
still make the discoveries. Davy, Young, Fresnel,
Arago, Forbes, Joule, Mayer, Helmholtz, Sir Wm.
Thomson, Clausius, Rankine and others were in their
twenties when they made their greatest discoveries.
The whole thinking world, says Williams, repu-
diated Lamarck’s epoch-making philosophy of the
transformation of species, as it had done with that of
Erasmus Darwin—repudiated with acclaim. The
official judges, and especially the great Cuvier, denied
and opposed, and Lamarck died in 1829 without seeing
any recognition of his truth; it lay dead for a genera-

d

tion. “ Heresy” and “impious visionary” were the
verdicts of theology and of science. “The whole

conservative majority of mankind recoiled with hor-
RECEPTION OF MEDICAL DISCOVERIES. 421

a9

ror,” is also the statement of the historian concerning
Darwin’s contribution.

In 1865 an Austrian monk published the report of
some experiments in heredity. No scientist looked at
his article or saw its purport for thirty-five years,
although his paper was sent to all scientific journals
and societies. Mendel’s law is now acknowledged to
be one of the most profound and illuminating in
modern developmental science, and his name will go
down to posterity with those of Darwin and Lamarck.
Darwin, prevented by his eyes from knowing well the
world’s scientific literature, published his “ Animals
and Plants” in 1868, without having seen Mendel’s
article.

In medicine it is particularly unfortunate to reject
offered truth and discovery, because medicine is at
heart both science and philanthropy, and the nonac-
ceptance means at once lack of knowledge, and the
nonrelief of patients at the instant under the care of
the skeptic. Rejection of a medical truth becomes
immediately condemnation of the patients to death or
to a continuance of their suffering. The history of
the discovery, the reception and the rejection of vacci-
nation is a perennial illustration.

Inoculation of cowpox as a protection against small-
pox was known by many nations in past ages. Hum-
boldt says it was understood and practised by Mexican
shepherds. The dairy folk of Europe knew of it, and
422 BIOGRAPHIC CLINICS.

especially those of England, long before the brave
Dorsetshire farmer, Benjamin Jesty, inoculated his
wife and two children from the teats of the cows.
The experiment was successful, but not even Jenner
dared to repeat it on the Phipps boy until twenty-two
years had passed. It was still a long time before the
profession and the world accepted the measure, and
the opposition was so great that it was passed down to
the ignorant of our own time. Only Germany and Japan
have become civilized enough to accept it fully, and
they have no smallpox. The rest of the world is still
paying the penalty for its sad disbelief. For instance,
in 1885, during nine months, 3,164 Canadians died
from neglect of vaccination, and all the patients caught
it from one case of the disease imported from Chicago.
The extent of the anti-vaccination movement to-day
among the ignorant is an indication of the bitterness
and length of the struggle of the supposedly enlight-
ened. For the law of heredity applies to medical
prejudice and superstition. The longer in forming,

i;

the more enduring is the “cake of custom.” Hence,
Mrs. Eddyism and medical magic generally are pow-
erful, and will long remain.

In 1760 Auenbrugger had discovered the principle
of thoracic percussion and published a book making it
known to the world. He wrote in his preface to this
work:

“My discoveries in this subject are not committed to paper
RECEPTION OF MEDICAL DISCOVERIES. 423

because of an itch for writing, nor an inordinate desire for
theorizing. Seven years of observation have put the subject
in order and have clarified it for myself and now I feel that
it should be published.

“T forsee very well that I shall encounter no little opposi-
tion to my views and I put my invention before the public
with that anticipation. I realize, however, that envy and
blame and even hatred and calumny have never failed to
come to men who have illuminated art or science by their
discoveries or have added to their perfection. I expect to
have to submit to this danger myself, but I think that no
one will be able to call any of my observations to account.
I have written only what I have myself learned by personal
observation over and over again, and what my senses have
taught me during long hours of work and toil. I have never
permitted myself to add or subtract anything from my obser-
vations because of the seductions of preconceived theory.”

In 1774 Van Swieten, a distinguished writer on
medicine, published a learned work on medicine, and
in 1779 appeared De Haan’s eighteen-volume ‘‘ System
of Medicine’; neither had heard anything of Auen-
brugger or of percussion. In France Corvisart prac-
ticed percussion fifteen years without convincing his
colleagues of its value. Auenbrugger’s book had been
published in 1770, but not till 1808 did French physi-
cians accept the device. Napoleon made Corvisart his
personal physician, because attracted by his progres-
siveness illustrated in practising percussion. His
other physicians had told Napoleon that his trouble
was gale répercutée, i. e., itch struck in. That was
the official science of the day, which Hahnemann
424 BIOGRAPHIC CLINICS.

“potentized ” and consecrated. The peasant women
of Poland knew more about the itch than Hahnemann
and all the medical men of Europe. The poor girls
had found out that the acarus scabei could be dislodged
from beneath their skin with their sewing needles.
When the unscientific Parisians heard of this pro-
cedure there was an end forever of the scientific gale
répercutée.

In Boston a dentist, Dr. Morton, had demonstrated
that a surgical operation could be performed, the pa-
tient being unconscious from administration of sul-
furic ether. Before this the surgeons of Europe had
despaired of such a discovery, and while the news of
Morton’s discovery was on its way to Europe, the
leader of English surgeons, Sir Benjamin Brodie, said
anesthesia was impossible. Following Morton’s dis-
covery there was incredulity and outcry; the shock of
pain was beneficial to the patient, said some surgeons;
the pulpit said pain was God-given, etc. Morton had
great difficulty in getting the profession to recognize
the value of the discovery, and when this had been
effected, disgraceful attempts were made to rob him
of the honor. Sir James Y. Simpson only conquered
the prejudice against the use of chloroform in child-
birth, by quoting the biblical story of the Lord throw-
ing Adam into a deep sleep before Eve’s creation.

Every student of the history of medicine knows of
the fight made against the theory of microorganisms
RECEPTION OF MEDICAL DISCOVERIES. 425

as the cause of fermentation and of certain diseases.
In 1762, Pleinez, of Vienna, a scientific mind, had
stated that the phenomena of disease and of decom-
position of animal fluids were wholly caused by these
minute organisms. Later the great authority, Liebig,
withstood the doctrine so persistently and successfully
that for twenty-five years, until Pasteur came, the
“ vitalistic theory ” was compelled to keep silent; and
even when Devaine showed that anthrax was due to
one variety, the world would not be convinced, until
in 1876 Pasteur ended the bitter controversy by the
famous anthrax test on sixty animals, in which the
thirty that had been protected lived, and the thirty
that had not been protected died.

The two greatest authorities on the subject signed
the adverse report against Dr. John Snow’s findings
as to the pollution of the famous Broad Street well,
thus postponing the knowledge of the true nature of
water-borne diseases.

How bitterly for about twenty years the discovery
of Pasteur and Lister was fought and scorned by phy-
sicians is well known. For ten and even twenty years
after the demonstration, hospital gangrene killed as of
old. The surgeon, Chassaignac, warned Pasteur that
“laboratory results should be brought out in a cir-
cumspect, modest, and reserved manner, etc.”

We are still living in the end of the professional
426 BIOGRAPHIC CLINICS.

struggle against Behring’s antitoxin serum for diph-
theria. Others are to come.

When the great brave McDowell published his work
in 1809, all who knew of it condemned it. It was
forty or fifty years before it was at all appreciated,
and even then Atlee and the followers of Tait met
with bitter opposition before ovariotomy was recog-
nized as a justifiable procedure.

In his great essay our own O. W. Holmes in 1843
showed himself the true John the Baptist of antisepsis,
because he contended, long before the germ theory of
disease was recognized, that puerperal fever was a
contagious affection. Of course he met the bit-
terest opposition from all the leaders of the profes-
sion, Hodge, Meigs, etc. In Vienna two years later,
not knowing of Holmes’ book, Semmelweiss tried to
convince his fellow practitioners of the same self-
evident fact. He taught the use of a chlorin solution
as a disinfectant. The’ violence of the hatred aroused
in the hearts of his professional brethren was so great,
that Semmelweiss was driven from his professorate
and ruined professionally and financially. Even in
1856, in the Paris Maternité 64 women died out of 347
admitted, and in 1864, 310 out of 1,350. At last, in
1874, Fornier and Budin succeeded in introducing the
new views of Pasteur and Lister in spite of what Dr.
Roux calls “the tyranny of medical education,’’ and
puerperal fever forever disappeared.
RECEPTION OF MEDICAL DISCOVERIES. 427

The autobiography of J. Marion Sims gives another
chapter of this world-wide stupid malevolence, or ma-
levolent stupidity. His struggle against the fierce
opposition of those whose office it was to know sci-
ence and to do right was most pathetic. He nearly
starved to death during many years in which his pro-
fessional colleagues utterly ignored him; then their
hatred and opposition gave him some encouragement,
until finally the denouncers themselves became silent,
or “always had recognized the real value of the truths
advocated.”

In the closing years of the eighteenth century Tuke
in England, Pinel in France, and Rush in America,
contended that chaining maniacs with riveted iron
bands in dungeons, often in darkness, and always in
filth, was neither medicine nor humanity. It took a
life-time to effect partly their reform, and even to-day
it is not entirely completed.

The French Academy ridiculed the discovery of
Desmoulins as to senile atrophy of the brain, and for-
bade the iconoclast the privilege of further hearings.

Bell’s great discovery as to the functions of the
anterior and posterior roots of the spinal nerves, made
in 1811, was ignored by the court of final appeal in
Paris, and not until 1823 was it in part accepted.

“The fundamental law of psychophysics,” formu-
lated by Weber, was ignored and denounced for over
428 BIOGRAPHIC CLINICS.

twenty years by the scientific associates, until Fechner
made them listen.

In 1825 Dr. Boillard had located the speech-center
in the brain, but despite his pertinacitv the world
would not listen, and the cerebral localization of func-
tion waited until about fifty years later it was in great
part threshed out, though even great masters, as Goltz,
still denied within the last generation.

It is doubtful if there is a single important dis-
covery in all the history of medicine which was not
at first either ignored or opposed. If a man is himself
an authority and power, the ignoring and hatred of
him will find vent in both ways. If he can be snuffed
out by silence alone, that is the plan pursued. Whata
combination of thick-witted blundering and malignity!

For, what at last has the light-bringer to gain by his
temerity? What crime against religion and the simple
law of kindness, to treat him and his announcement,
even if not true, with anything but a careful hearing
and respectful testing! These few men with minds
capable of discovering and benefiting mankind are the
most precious products of the groaning and travailing
ages. They are the prerequisites of progress, martyrs,
sufficiently, of their own sensitiveness and unselfish-
ness, without the added and heaped sorrow of cold
‘neglect, of colder disdain, and of an immeasurably
inhuman cruelty. Men will help raise a monument to
one of their martyrs, go home with their throats still
RECEPTION OF MEDICAL DISCOVERIES. 429

hoarse from praising and hurrahing, and at once re-
sume the making of new martyrs, as their grandfathers
did of the dead one of the monument! As Pope said:
“ They help to bury whom they helped to starve.”

The principal methods of killing new truths,- as
shown in historical examples are, therefore, these:

1. By silence and ignoring.

2. By opposition on supposed scientific grounds.

3. By opposition and denial per se, without giving
reasons.

4. By ridicule and sneers, also without reasons.

5. By the cry of exaggeration and hobby-riding,
without explanation or instance.

6. By pointing out real or partial errors and exag-
gerations, emphasizing them, and saying nothing as to
the truth admitted or not admitted.

7. By saying that the theory is old, long admitted,
or long ago refuted.

8. By “insinuendos”’ that the author is advertising
himself from the motives of vanity or the desire for
practice, etc.; that he has, as Dr. Sachs charges, “ pri-
vate axes to grind.”

All of these methods of preventing the acceptance
of discoveries, and their practical applications are
psychologicly devices of the balking mind to obviate
troublesome changes in mental attitude, undesired
activity in new ways, etc., and in reality are motived
430 BIOGRAPHIC CLINICS.

upon one or another, or several of the following com-
bined conditions:

1. Mental laziness. The ordinary mind (and there-
fore the pseudoscientific one) desires certainty, set-
tledness of habit, rest in the known, ease in the Zion of
the acquired and satisfying. New thought and new
truth is an affliction, a spur to new activities and
change of life.

2. Wounded vanity. “I did not make this dis-
covery or think of it,” one seems to hear, “and every
method (in practising medicine, e. g.) of future action
must be changed, and the confession thus made every
day that I was before in the wrong and that my knowl-
edge was error. It is too humiliating.”

3. Prejudice. A position once taken, an opinion
once accepted, a party once publicly espoused, gives a
seeming warrant for continuance of the old and trusted
belief.

4. The authority of leaders. ‘“ The great authority

2

so and so,” one hears again, “is unconvinced, and he
knows better than I, or the upstart, and I will wait
until he changes his opinion,” the motive being cun-
ning safety.

5. Influence of societies. The greater the power
and attendance of governing and authoritative societies
the more certain are they to oppose new truth and dis-
covery. The old leaders never lead. The crowd-

instinct tends to sweep its members to a unity of
RECEPTION OF MEDICAL DISCOVERIES. 431

indulgence in tradition and the sacredness of the truth
heretofore established. For the same reason the
official journals of powerful or large medical societies
are always likely to be on the wrong side as to medical
discoveries.

6. True and confessed ignorance and inability to
decide. The vast mass of men, ora class of men, must
be incapable of deciding upon a matter about which
they have no first-hand knowledge, and for which
special as well as general culture is demanded. Some,
or indeed many of these, must recognize this fact con-
cerning themselves, and thus wisely wait for the tide
of opinion to change.

7. The financial cost. This is an increasingly domi-
nant motive. In making the greatest discoveries of
modern times a poor practising physician, Dr. Young,
had to publish his articles anonymously because of the
danger to his practice from being scientific. The his-
torian records that patients demand of their doctor
“sophistry rather than philosophy.’ Nothing blights
a modern young practitioner's reputation quicker, pre-
vents his “success”? more assuredly, kills his hopes
of professorships and offices and hospital positions
speedier, than so-called “ exaggeration” and ‘ hobby-
riding.” Add to this that those who already have
private sanitariums and consultation practices to sus-
tain, must be extremely wary in avoiding the calumny
432 BIOGRAPHIC CLINICS.

that comes from “extremism.” Lastly, many medical
journals are purely commercial undertakings, and
have the publishers’ profit always in mind, or the
editor’s interest in some patent or secret nostrum, or
institution. The editorial position and salary are pow-
erful arguments.

8. True and genuine conservatism, both good and
bad. It is indeed well to get out of the old truth all
its good before renouncing it. Many too hastily ac-
cepted theories and discoveries have proved to be will-
o’-the-wisps leading to bogs and disappointments. As
to this, however, the obvious answer is that it proves
at best a lack of discriminating ability on the part of
the too lenient acceptors; and finally their condemna-
tion is complete in the fact that testing is the needed
thing both of the new false and of the new true propo-
sition. False conservatism is that which does not test,
either in its acceptances or in its rejections, and true
conservatism is that which neither denying nor assent-
ing, tests and weighs.

Turning from general scientific and past medical
illustrations of the opposition to new truths, it may be
more illuminating to give one striking instance which
is taking place in our own time. The data are at hand,
which is not always so, at least specifically, of others;
and to catch our contemporaries and colleagues, our
very acquaintances, in flagrante delicto, is more in-
RECEPTION OF MEDICAL DISCOVERIES. 433

structive than when we read only of those who are
dead and gone.

The first word, so far as I am aware, publicly
uttered, which announced that ametropia had path-
ologic or morbid systemic consequences was that of
the dean of the American ophthalmologic profession,
Dr. John Green, of St. Louis. In 1867* he had con-
cluded that astigmatism was an active cause of myopia.
Soon after 1861 Dyer, of Philadelphia, had begun to
prescribe astigmatic lenses, but there is nothing, so
far as I can learn, to show that he had any belief or
proof that ametropia caused ocular or systemic disease.
This honor, therefore, belongs to Dr. Green, so far as
the relation to the eye is concerned. To Thomson, of
Philadelphia, and secondarily to Norris, of Philadel-
phia, belongs the equal and in its consequences, greater
honor of suggesting that the evil effects of eyestrain
extended also to the brain and nervous system, and
thence to the functions of other systemic organs. In
conscientiously and ingeniously correcting the astig-
matism, etc., of his patients, Dr. Thomson found that
they came back and reported relief of headache and
other distressing symptoms and with the discerning
eye of the true clinician he noted, retested and re-
proved the reports. This was just prior to 1874. Dr.
Thomson spoke to Dr. S. Weir Mitchell, a neutologist
of Philadelphia, of his new findings, and Mitchell at

* Arch. Ophthal. and Otol., 1869, I., No. 1, pp. 17-21.

29
434 BIOGRAPHIC CLINICS.

once seconded them and published three articles? con-
cerning Dr. Thomson’s cases, in which it was shown
headaches, insomnia, vertigo, nausea and failure in
general health were consequences of refractive and
accommodative anomalies of the eyes. Two of the
cases reported in these articles of Mitchell were of
patients of Dr. Norris. The facts were discovered by
Thomson and Norris; Mitchell, adding nothing orig-
inal, simply made them public. Dr. Thomson followed
up his early observations and in 1879 published a note-
worthy and confirmatory article? on “ Astigmatism
as a cause for persistent headache and other nervous
symptoms.”

In the first case, to ametropia was ascribed “ some
forms of chorioidal disease, fatigue and pain in the
eyes, congestion, inflammation of the lids and con-
junctiva, nutritional changes in the fundus, neuralgic
pains over the frontal region, throughout the head,
and even vertigo and nausea.” These were entirely
cured by glasses.

In the second case reported, supposed “ disease of
the brain and spinal cord”’ had been treated for many
years by distinguished men in the chief American and
European cities. The least use of this patient’s eyes

* Medical and Surgical Reporter, July 25, 1874, and August I.
Ibid., February 6, 1875, and American Journal Medical Science,
April, 1876.

* Medical News and Library, June, 1879.
RECEPTION OF MEDICAL DISCOVERIES. 435

produced a long list of mental and neurologic symp-
toms, ending in “a fit of some kind,” and recovery
was by renouncing his pen, walking in the open air,
etc. Immediate and complete relief for nine years fol-
lowed the use of Dr. Thomson’s lenses. Then pres-
byopia was at hand, and Dr. Thomson prescribed for
the complication, but the Parisian optician who filled
the prescription thought he knew better and gave the
patient the wrong glasses. All of the old symptoms
returned, until correct lenses were ordered and the
symptoms disappeared.

The third case was that of a naval officer with pain
at the base of the brain, tinnitus, mental restlessness,
inability to do mental work, pain over the left brow,
extending to the occiput, severe tension of the head,
failure of mental vigor, etc. He resigned, lived in
open air a year, thought himself recovered and re-
turned to work, with immediate resumption of all the
old symptoms.

“ Cerebal congestion ” was now diagnosticated by a
great authority in the diseases of the nervous system.
(They are still making the same diagnosis, sometimes
calling it “ psychosis,” or “neurasthenia,” etc.) Life
in the open air-was again ordered. “ Migraine ” de-
veloped, “nervous headaches,” scotoma scintillans,
hemicrania, hemianopsia, and nausea. Proper glasses
ordered by Thomson gave almost complete relief.

The fourth case was one of sick headache on near

a
436 BIOGRAPHIC CLINICS.

use of the eyes. Spherical glasses alone gave no relief,
but cylinders did so. A sudden recurrence of the old
severe symptoms resulted in the discovery of a blun-
der, which is still frequently being made: An optician
(probably an “ eyes-examined free”? man, or “a re-
fracting optician”) had repaired the accidentally
broken frames and reversed the lenses so that the
woman “ had now two astigmatic eyes instead of one.”
Almost complete relief followed Dr. Thomson’s cor-
rection.

The fifth case reported by Dr. Thomson was of a
school girl who had been obliged to quit school because
of severe pain in the back of the eye, twitching of
muscles, etc. Mother and grandmother had been suf-
fering from neuralgic headache and ill-health. All
three were found to be astigmatic and all were cured

‘

by Dr. Thomson’s glasses.

I have epitomized these admirably reported cases,
because, together with those summarized in “ Bio-
graphic Clinics,” Vol. I., they form the earliest demon-
stration of what has been taking place in every com-
petent oculist’s office every day since.

But, note well, these reports and others that fol-
lowed, were absolutely and utterly ignored by the
whole world. There is not, I believe, a line in medical
literature, European or American, showing that they
were read, certainly none that suggests that they in-
stigated any practitioner having patients with such
RECEPTION OF MEDICAL DISCOVERIES. 437

diseases to try the experiment of accurate correction
of ametropia. How many thousands, should one not
say millions, have gone on suffering as before, with
these symptoms, treated as cases of “ brain conges-
tion,’ “brain disease,” ‘“‘ dyspepsia,” “ neurasthenia,”
“hysteria,” “gastric disease, psychosis,” and all
the rest? Hundreds of testimonies have since been
added by intelligent and honorable physicians, and
thousands of such cases have been reported; and yet
there are great physicians, neurologists, “ distin-
guished authorities,” psychiatrists and diagnosticans,
who are as silent as they have been on this subject for
twenty-five years, or who break that silence only to
ridicule and scoff. To-day in every oculist’s office
there appear patients who for years, few or many, or
for a lifetime, have vainly sought relief from one after
another of these authorities, of just such sufferings.
And to-day they are cured by the careful oculist just
as quickly and permanently as they were by Dr.
Thomson. To-day if an “ optician” misplaces a lens
of their spectacles they have the same recurrence of
symptoms which Dr. Thomson’s patient had. There
are great and famous neurologists who have contempt
and loathing for the mere suggestion of a morbid
reflex, although their epiglottis unconsciously and re-
flexly saves them from suffocation by its reflex action
with every swallow taken; although every motion and
function of the body is reflex; and although pathology

+d 66

,
438 BIOGRAPHIC CLINICS. i

is only morbid physiology. It is, indeed, pertinent to
inquire as to the reasons for and methods of this
amazing fact.

When an author issues a scholastic and learned text-
book, or encyclopedia upon a general subject, it is a
point of pride with him to show thoroughgoing ac-
quaintance with the literature of the subject. The
most recent and the most scientific text-book on the
subject of medicine is that of Allbutt. It does not con-
tain a word about the eyestrain origin of any disease.
Probably there is no European text-book on general
medicine, gastric diseases, nervous and mental dis-
eases, which mentions eyestrain as a cause. Indeed
those on ophthalmology are as indifferent to the mat-
ter, or their mention of the fact is incidental, and cal-
culated to make the reader ignore it rather than follow
it up. In our country Osler gives the subject a gen-
eral and vague allusion in a sentence or two. Tyson
and Anders are less generous. Anders does not allude
to it in the treatment of migraine, nor does the New
International Encyclopedia. The only work on gen-
eral medicine of which I know that has acknowledged
the ocular origin of migraine is “ Essentials of Diag-
nosis,’ Cohen & Eshner, 1892. Einhorn, Hemmeter,
and others on stomachal diseases make no mention of
the eye as a cause.

As to “the psychoses ” the opinion of the authorities
is approvingly quoted by Dana in a paper read before
RECEPTION OF MEDICAL DISCOVERIES. 439

a special meeting of the New York Academy of
Medicine,* instigated to demolish the eyestrain theory.
“T cannot find,” he says, “any systematic writer who
even refers to it.”

Dana sums up his experience in saying that he has
“found hardly any case in which eyestrain is an im-
portant and direct factor in establishing even a minor
psychosis.” Accuracy in refraction is not necessary
in treatment, because ‘
without treating the eyes,” and “ glassing has become
something of a minor psychosis.” The acme of the
ludicrous is, of course, added:—‘“‘I heartily believe
that eyestrain should be carefully looked after.”

At the same meeting referred to, Dr. Sachs said
that very few cases indeed of epilepsy, chorea and the
convulsive tics, are due to eyestrain, and cures by
ocular treatment are fewer indeed. ‘“ The relation
may be a close one,” he says, “in the minds of some
faddists, but is remote in the minds of those who have
no axes to grind, etc.” This is charming and highly
characteristic! Dr. Sachs also incorrectly epitomized
the incorrect statements of Dr. Spratling as regards
the tests upon a number of epileptics at Craig Colony,
concerning the influence of glasses. The same gloat-
ing delight at the “disappointing” results is echoed
in many medical journal editorials and abstracts. The
least desire to be truthful would have stated what has

“success is generally obtained

* Medical News, July 30, 1904.
440 BIOGRAPHIC CLINICS.

been published in connection with Dr. Spratling’s re-
port, that by all the other methods of treatment pur-
sued at Craig Colony, according to its official figures,
the cures amounted to one in eighty, while in “ glass-
ing ” the cures were one in fifty-seven!

The reduction in the total number of seizures in
three months following the test with glasses in fifty-
seven cases was 44 percent. And yet, Dr. Sachs says,
“there is no good excuse for attempting to argue
with ” the foolish faddist—and he is perfectly right.
The repeater of false statistics does not, indeed,
“argue” with any one.

At the meeting referred to at which the sentence,
death, burial, and chanting of the Requiescat was car-
ried out upon poor Eyestrain, Dr. Collins said that no
case of migraine had been cured, remedied, or bene-
fited by glasses; and that was bravely done, without
a single anchor cast in any direction. He should have
quoted the saying of the great and distinguished neu-
rologist, Professor Mobius, still living and writing,
that “ the tendency to headache is a part of the degen-
eration which is inseparable from civilization.’ Or,
better still, he might have proceeded to the logical con-
clusion of Dr. Seguin and advised abandoning all
medical treatment in epilepsy, and thus encouraging
the recurrence of the convulsions. “ Knowledge to

*But not acknowledged or referred to by him—See Amer-
tcan Mcdicine, April 9, 1904.
RECEPTION OF MEDICAL DISCOVERIES. 441

one is a goddess, to another an excellent cow,” sang
Schiller long ago.

Two of the helpers drummed up for the occasion,
alas, must have been sadly “ disappointing” to the
generals. One proved an alibi and the other proved
a traitor. Both happened to be physicians as well as
neurologists. Dr. Holden, in about ten thousand words
concerning hysteria, neurasthenia, etc., wisely refrained
from saying a word for or against the ocular origin of
these diseases. Dr. Cutler actually said that “ many
cases of sick-headache are relieved by treating the eyes
or other peripheral organs,” and “sick-headache having
all the clinical features of migraine is often a reflex
neurosis of ocular origin.” How bitter must have
been that medicine for the distinguished gentlemen
responsible for the meeting!

It needed only the hearty baritones of two famous
oculists to pronounce the benediction of the burial ser-
vice with fitting conclusiveness. Dr. Knapp is cred-
ited with the profoundly ludicrous remark that “ eye-
strain is due to over-exertion of the eye,” and Dr. de
Schweinitz returned to Philadelphia after having said
that he was “glad of the firm stand taken by the
Academy on the conservative side.” The report does
not add that the corpse of the criminal came to life
and also returned to Philadelphia, where it is still
laughing cheerily at the fun he had, though sorry for
the fate of the migrainous patients in and about New
442 BIOGRAPHIC CLINICS.

York. His was simply a case of suspended animation
due to severe attack of migraine, because he had for-
gotten his Philadelphia spectacles.

Those medical journals which have shown the most
unqualified disgust and bitterness against the eyestrain
theory and theorists are, in the order of their violence,
The Medical News, The Medical Brief, Modern Med-
ical Science (an anti-vaccination and pro-bovinine pub-
lication), the Homeopathic Recorder and The Post-
graduate. Others preserve some trace at least of good
manners and caution, but with these neither is to be
found. The first mentioned periodical goes out of its
way with rage and most impolitic compliment, to de-
molish and rend, in three long, over-long, editorials.
In neither does it tell its readers anything about the
arguments or intention of the writer so heartily de-
spised. A gathering of the scurrilous epithets indulged
in by the hasty editor would fill a page, and would
prove uninteresting except to makers of slang diction-
aries and to yellow newspaper reporters. However,
one is at least capable of understanding this excerpt:

“We are content to leave these papers to the judgment
to which the scientific world will undoubtedly subject them,
and to the oblivion to which it will eventually consign them.
Writing them down would be a work of supererogation in the
case of literary products which are foreordained to perish.
The author’s screed should have been consigned to the waste-
basket. We live in just the age for these things. The times
are prolific in all sorts of ‘healers’ who play their antics,
RECEPTION OF MEDICAL DISCOVERIES. 443

literary or oratorical, before the public in their own ways.
Dowie and‘Mrs. Eddy are, of course, outside the pale of
rational criticism, but unfortunately there are spectacular
prophets within the ranks of the medical profession itself, and
these do not scruple to distort facts, to originate fantastic
theories, to use exaggerated language, and to indulge in coarse
invective, Dowie-like, etc.’—Medical News, November 14, 1903.

“An epidemic of fantastic belief,” is the character-
ization of the Postgraduate, and it is a sufficient self-
characterization of its writer. Cynical persiflage was
expected of the Medical Record of that day, but its
usual good wit was rendered bitter by too serious a
desire to hit hard the “ furious rider of this hobby.”
“It cannot be productive of good” of the New York
Medical Journal, fails to suggest any possible harm
that could come of trying glasses on a patient who has
“a functional disease whose nature is unknown,” and
which is confessedly incurable by any other method.

The Boston Medical and Surgical Journal admits
all that any one but an “extremist” and “ exaggera-
tor ’’ could desire, at least all that I desire, but still
charges extremism, and reiterates its expression, “an
overworked theory.” This is the burden of so many
reviews that a word or two may be replied. All who
take this position are so strangely and furiously set
upon the denunciation of the exaggeration that they
quite forget the admissions they have made of “ essen-
tially right,” “fundamentally true,” “eyestrain is in-
deed a cause of many distressing ailments,” “the eyes

2) 66
aaa BIOGRAPHIC CLINICS.

are, it is true, the source of much cerebral and systemic
disease,” etc. Why does the truth at the foundation
concern them so little, and the ‘‘ over-emphasis ” con-
cern them so much? If there is a great truth “ over-
estimated ’’ and “ over-worked,”’ why not bring to the
absolute deniers and ignorers the knowledge of the
truth in the “ hobby-rider’s”” contention and not en-
courage them in their delusion by exaggeration of the
oculist’s exaggeration? This class of critics forget
the patient who, through the local physician, is in
reality counselled to be neglected and to be continued
in his suffering. This favorite expression is “it will
do harm,” but what conceivable harm it could pos-
sibly do to let the oculist try, they never explain. If
there are only a dozen instead of thousands or mil-
lions of pati€nts needlessly suffering from migraine
and other eyestrain effects, then the many cases in
which the oculist fails are not “harmed” much or
any, and the dozen cured are no longer an “ oppro-
brium of medicine.” Is it not worth while to cure the
twelve? How could they be cured except by making
the test? There is, indeed, a negative exaggeration,
a minus enthusiasm operating “ inversely as the square
of distance,” which far more than counteracts the plus
exaggerator. This sort of conservatism is active
against every discovery and is a great brake on the
wheels of progress.

But when the exaggerator is finally found to be
RECEPTION OF MEDICAL DISCOVERIES. 445

right the grudging admissions previously muttered in
parenthesis and aside permit the man at the brake to
cry, “I always said so! I pulled the wagon!”

From the mouth of the discriminating scientist the
counsel of perfection against misstatement and exag-
geration comes with grace and must be received with
graciousness. But from the editor of a house-organ
“medical” journal one naturally gives it scant cour-
tesy. The sale of one’s professional service as a
figure-head to enable mercantile firms to make money
out of the profession’s disorganization and affliction
does not encourage confidence in the editorial science
or ethics. When medical men become organized they
will not donate forever out of their control their litera-
ture to commercial firms which by the gifts make im-
mense wealth, while the writers remain as poor as
ever. It is precisely these editors of these journals
who misquote and lie about those of whom they do
not approve.

If you do not “train with the crowd,” if you do
and not buy the special brand of secret nostrums, or of
books, etc., advocated by the editor, or by his manu-
facturers and publishers, it will be impossible to get
any sort of justice done or errors and misrepresenta-
tions corrected. The most glaring and wide-of-the-
mark misstatements and misquotations, instead of
being corrected, will be repeated and added to. Point
out to the rabid editor these “ errors” and he will not
446 BIOGRAPHIC CLINICS.

publish your statement and certainly not acknowledge
his “ mistakes.” You have never implied that more
than a small percent of insanity or epilepsy is due to
eyestrain, you may have only suggested that crimi-
nality may be due to that cause, and yet these editorial
and review writers will unblushingly tell their readers
that you say all crime, all epilepsy, all insanity, etc.,
are caused by lack of a pince-nez. The book reviewed
may contain the clearest cautions against exaggera-
tion, may expressly state the “ mays,” “the small pro-
portion,” “the minority of diseases so caused, etc.,”
it matters not. “Any club to hit a mad dog!” I
never yet succeeded in getting but one editor to ac-
knowledge a misstatement of this kind. He had said
I claimed that eyestrain was the cause of cancer. He
finally confessed that this error was entirely a product
of his imagination. But this model man was not the
editor of a “ house-organ.”

When the real question reaches conscience, as to
“exaggeration” it must of course be scrutinizingly
considered, even though the questioner is interested
not in the patient’s sufferings, or in the fundamental
truth of the matter. Accuracy of statement is so im-
portant that its want will excuse neither tu quoque
nor over-enthusiasm. But it is evident that it can be
decided only by testing and by the verdict of posterity.
Neither asseverations of the enthusiastic nor denials
of the conservative settle the doubt. All that the
RECEPTION OF MEDICAL DISCOVERIES. 447

affirmer wishes is to get the denier to put the matter
to the test. The clinical test is the only one in medi-
cine. Have these patients been carefully tested by a
believer in the eyestrain theory, one who has his repu-
tation to lose if he fails? Only then will the truth or
error of the theory be demonstrated.

The critic who answers all argument by charges of
“ exaggeration ” and “ hobby-riding ” relies usually on
“the consensus of opinion of the leading authorities,”
in other words, appeals to established belief, prejudice,
in short, to back up his charge of “overworked theory.”
And it is precisely authority which the truth-discoverer
disallows. He looks into the history of every dis-
covery of medicine and science and finds the estab-
lished opinions have been erroneous or incomplete.
How could it be otherwise? If the existing doctrine
were true, what need or right would he have to sup-
plant it with anything else? ‘“ Established opinion to
the dogs!’’—one almost says. The existing ‘“ author-
ity’ must be wrong if new truth is to be discovered,
if progress is to be achieved, and unless all truth has
been attained, and all error annulled. Huxley admir-
ably stated this position when he wrote:

“The improver of natural knowledge absolutely refuses to
acknowledge authority as such. For him skepticism is the
highest of duties; blind faith the one unpardonable sin. And
it cannot be otherwise, for every great advance in natural
knowledge has involved the absolute rejection of authority,
the cherishing of the keenest skepticism, the annihilation of
448 BIOGRAPHIC CLINICS.

the spirit of blind faith; and the most ardent votary of science
holds his firmest convictions, because his experience teaches
him that whenever he chooses to bring these convictions into
contact with their primary source, Nature—whenever he thinks
fit to test them by appealing to experiment and to observation—
Nature will confirm them. The man of science has learned to
believe in justification, not by faith, but by verification.”

Personally I may differ from many who believe in
varying degrees in the theory as regards the extent to
which migraine, headache, digestional and assimilation
diseases, etc., are due to ametropia. Unless those
disagreeing have had an oculist’s personal experience
with something like ten thousand such cases, they are
not so well fitted to judge as I. If they rely on the
authority of neurologists and psychiatrists, their re-
liance is upon nonexperts and is misplaced. If they
rely on the authority of old-fashioned ophthalmologists
there are several answers, among which are these:

1. There are at least seventy-eight reasons why
glasses fail to cure—the first being that the dis-
ease in question may not be caused by eyestrain. But
there are seventy-seven others which pertain to the
demonstrated and admitted carelessness in making
refraction tests and in prescribing glasses and in
watching the patient afterward. Most of the seventy-
seven requisites are habitually disregarded by the ma-
jority of the oculists of the world. Most of them are
openly scorned by the criers of exaggeration. It will
not do to say, as does Dr. Shrady and Dr. Sachs, that
RECEPTION OF MEDICAL DISCOVERIES. 449

the seventy-eight reasons are evidence of a “ hedge,”
of being “ driven into a corner,” etc., for these seventy-
eight reasons are the conditions of accurate refraction,
the sine qua non of the tests, without which the glasses
might as well be worn before the mouth as before the
eyes.

2. Chief among the reasons is the neglect of the
principal condition causing eyestrain on the part of
the great majority of oculists of the world. This is
the small error of refraction, and the methods and
carefulness necessary to diagnose it with that accuracy
which alone can cure. Good oculists well know that
it is precisely these low and unsymmetric astigmatisms
which are the most certain provokers of such systemic
reflexes as headache, sick-headache, denutrition, dys-
pepsia, morbid nervous phenomena, etc. Donders
taught the neglect of these low errors of refraction,
and the ophthalmologic world has strangely persisted
in an error which accurate physiologic and optical
knowledge, as well as closely observed clinical facts,
would have detected. In a recent number of the
Lancet the editor acknowledges that the English oph-
thalmologists still usually continue their indifference
to the low error. A noteworthy illustration was given
at the last meeting of the British Medical Association.
Dr. Clarke, of London, epitomized his experience of
twenty years in the treatment of myopia. He fully
corrects the myopia; he does not correct astigmatism

30
450° BIOGRAPHIC CLINICS.

of less than one D., unless it would improve vision;
he allows no reduction for near work from the “ fully
corrected’ myopia; he thinks that excessive conver-
gence is the main factor in increasing myopia. A
more perfect combination of malobservation, poor
logic, wrong views, and bad practice could hardly be
found.

3. The oculists who contend, for instance, that mi-
graine is not due to eyestrain, speak, of course, from
their own clinical experience. A greater number of
good oculists say that migraine is, in their experience,
frequently cured by glasses. The first class are thereby
convicted, and self-convicted, of unskilled work.
Negative testimony, alibis, etc., counts for little in law
and for nothing in medicine. What sort of a physi-
cian is he who says migraine is generally, or even
always, curable, and then when thousands of migrain-
ous patients come to him he cannot cure them? How
long would such an oculist have any professional repu-
tation or practice left? The patient-world of repu-
table oculists is not so stupidly foolish as that.

A great physician famous in America and Europe
writes criticising nothing else except the advice that all
children should have their eyes tested by a competent
oculist. And yet he advises that whether they have
toothache or not their teeth should be examined by
the dentist! The ocular examinations are now ad-
vised by most physicians. The diseases due to the eyes
RECEPTION OF MEDICAL DISCOVERIES. 451

are so subtle, so varying, so multiform in expression,
and the organs affected are so remote from the eyes,
that it is of the highest importance that the evils should
be prevented by this simple method.

Another reviewer says the ametropia is due to the
same cause as the neurasthenia, migraine, etc—an
error which could only arise from an ignorance as to
what astigmatism really is, and a return to the old
fetiches of the neurologists,—a “neuropathic ten-
dency,” a “ morbid predisposition,” “ degeneracy,” etc.
Even admitting the fun and nonsense of the view that
corneal curves and ocular measurements are produced
by headache and vomiting, that does not lessen the
duty of attempting to discover the cause of “ that dis-
ease (migraine) whose nature is unknown” (Osler).
The “neuropathic predisposition ” is the ultimate re-
liance of the hard-pressed neurologist. Upon that die
his whole scientific fortune is staked. Well, then, he
is certainly doomed to bankruptcy! For a capable
refractionist could make a great reputation and income
if he could be allowed his way with the neurologist’s
patients before they consult him, or even afterward.
There would certainly be an end of many rest-cure
establishments, private hospitals, and sanitariums.

Two reviewers have affected to speak as defenders
of the sacred medical profession against the criticism
that some of its members have been in the wrong in
opposing new medical truth. These self-appointed
452 BIOGRAPHIC CLINICS.

defenders of the faith jauntily mounted their Rosi-
nantes and cantered forth to what they thought an
easy victory. The truth of the matter did not con-
cern them. Theirs was the cheap bravado of men
with a disciplined army behind them and a supposed
poor Falstaffian rabble in front of them. But they
faced the wrong direction. It was wrongly thought
to be war, and it was very far from magnificence. It
was mock-heroism and pseudoprofessionalism. There
proved to be no Falstaff, no enemy in fact, and Rosi-
nante was put back in the stable, while badges com-
memorating the Defenders of the Faith were being
made. The medical profession, I admit, is the best
of all, and there are more noble-minded and clean-
hearted men in it than in any other. But there are
others of very different character. And all of us are
human, quite prone to occasional error and sometimes
even to sin. It is a sacred calling, but those who
think it so must avow and disown its sycophantic para-
sites who flatter its vices and perpettate its errors;
who encourage the seekers after offices and consulta-
tion practices, and who care far less for medical truth
than they do for personal success.

As I write an excellent illustration comes to my hand
of a certain condition of mind and of the methods of
expressing it.t I had just been treating a patient who

“In the spring of 1904 were published articles showing the
origin of probably the larger proportion of all cases of spinal
RECEPTION OF MEDICAL DISCOVERIES. 453

had been under the care of an orthopedic surgeon of
national fame. When I tested the eyes, I found the
girl’s astigmatism in the dominant eye was 15° and
in the nondominant it was 180°. I called the parents
to one side and told them that in the vast majority of
cases with such axes of astigmatism there was gener-
ally found a tilting of the head to one side, an elevation
of one shoulder, etc., from childhood, with resultant
spinal curvature. I asked if this girl (of 18) had not
inclined her head to the left, elevated the right shoulder
and if she had any spinal curvature. Then came the
family tragedy! The child had done as described
from the age of eight, and had been under the care
of the great Dr. , and of others, with
daily devotion to physical culture methods, for many
years. Spinal curvature was also said to have been
inherited by her, several ancestors and relatives having”
had it. I at once wrote to the orthopedic authority,
saying that I had discovered, I thought, the cause of
his patient’s scoliosis; I set forth the details, and sup-
posed that he would be glad to learn of the, at least,
possible new truth. The following was his reply:

 

 

“I have your letter and clipping and thank you. Yes, I
read your paper when it was published and I have a vague

curvature in a peculiar axis of astigmatism which forces the
child to hold the head to one side. Many months later great
“medical journals” had not thought best to tell their readers
a word about this highly important fact.
454 BIOGRAPHIC CLINICS.

memory of some previous one. At the time I was tempted
to write on scoliosis as a cause of unsymmetric astygmatism,
but I feared to touch a sore place on your back, and out of
pure love held my pen.

“As to my patient, of which you speak, the parents have
not done everything they could for the scoliosis. The child’s
Latin was far more important to them than her scoliosis.
And I am quite sure that the cause of the unsymmetric as-
tygmatism is the cause of the scoliosis, and not the astygma-
tism the cause of the scoliosis, or the scoliosis the cause of
the astygmatism. With a bald father, who is a clergyman,
and who has sufficient money for unnecessary charity and
insufficient to pay half rates for treatment of his child; who
does not pay what he has promised to pay. With a fat
mother who talks your arm off, and whose parents were
mentally and physically defective, one may naturally expect
in an only child very marked evidence of degeneracy. And
you have the eye defect, the scoliosis, weak feet and fat.

“Why do we find such a large percentage of scoliosis among
the children of clergymen and Jews? I believe it is degen-
eracy. What percentage of your cases of unsymmetric astyg-
matism have scoliosis ?

“Tf there is an eye man that you can interest in your theory
I will send him abundant scoliotics for examination if he will
send me an equal number of unsymmetric astygmatics for
special examination.

“Yours truly,

“ ”

This is delightfully naive! It reminds one of
Lincoln’s saying about fooling some of the people all
of the time, etc. Some “ scientists ’’ can not be fooled
any of the time.

1. Here is a man who stands at the head of his
RECEPTION OF MEDICAL DISCOVERIES. 455

specialty and yet who knows so little of astigmatism
that he does not know how to spell the word itself, in a
hand-written letter.

2. He misreports another orthopedic surgeon atro-
ciously (in a subjoined abstract) as an ignoramus in
his specialty, and then abuses him, saying that “he
knows very little about lateral curvature of the spine.”

3. He has not the faintest idea of what I have sug-
gested as the.cause of many of these cases of scoliosis.
He traces it to “ unsymmetric astygmatism,” but it is
in fact due to only one rare variety of unsymmetric
astigmatism. The vastly greater number of cases of
unsymmetric astigmatism could not possibly produce
tilting of the head, and he does not know that the eye-
strain of others, previously suggested as a cause of
scoliosis, is an utterly different thing from that I have
described.

4. He has not the least conception of what astigma-
tism optically and anatomically really consists. The
idea that scoliosis or “degeneracy” could produce
malcurvature of the cornea, would make the whole
ophthalmic world break into derisive laughter.

5. When a crude mind cannot remedy a fault of
temper or discover the cause of an obstinate disease,
it tends to blame some one else. The attitude of scorn
and contumely for a patient who persists in not being
cured is, of course, highly justifiable, but it does not
help matters “at all, at all.” This hauteur is as ridic-
456 BIOGRAPHIC CLINICS.

ulous as it is unscientific; as self-stultifying as it is
unkind. There are few patients who really “ enjoy
bad health,” and who are- contemptible “hysterics ”
and despicable “ degenerates.” They usually wish to
be cured, and would be cured if we physicians were
able to find the cause of their diseases. The physi-
cians who thus speak contemptuously of patients—in
the “God and a black-beetle”’ style—are those who
not only do not know the cause of the functional dis-
eases they cannot cure, but who also scorn the new
views which might explain their causes.

6. The modern god of the neurologic and psychiatric
nescience is “degeneracy.” He is a poor graven
image at best, and of the barbaric type. His supposed
existence explains nothing, and moreover he really
does not exist. It would be sad indeed if Nordau
and Lombroso were even the “ most minor of minut-
est” prophets of evolution. The “stigmata of degen-
eration ” of some modern pseudoscience will long be
a mirth-provoking subject for those with a genuine
sense of humor. In the present instance, it seems that,
Nordau and Co. have forgotten some of the principal
evidences of “ degeneracy,” e. g., in the father—bald-
ness ; being a protestant clergyman; the possession of
some money coupled with personal preferences as to
charity; half-rates; nonpayment of debts. On the
part of the mother, loquacity ; defects of parents (diag-
nosed as such by the scorner). On the part of the
RECEPTION OF MEDICAL DISCOVERIES. 457

child, being the only one; unsymmetric “ astygma-
tism ;” scoliosis ; weak feet; fat. (The girl is 5 feet 5
inches high, and weighs 145 pounds.) On the part of
the world, degeneracy is due to being the children of
clergymen and of Jews.

7. The reenactment of the old historic worn-out
farce is exemplified admirably in this gentleman’s atti-
tude of settling the whole matter adversely, and with
scorn or with kind and supercilious silence, when any
new thought is suggested as to the origin and cure
of an admittedly inexplainable disease—and in a
special case in which there has been no cure, although
the parents seem to have done too much rather than
too little in their long and earnest attempts to cure
the child.

In a rough way, therefore, those opposed to new
medical truth may be divided into three classes: (1)
Those frankly and publicly opposed; (2) those who
cry “ exaggeration ”; (3) those who are silent. Those

;  w# Violently against are the crude, dogmatic minds, inca-
« pable by nature of seeing or doing much for the
progress of science or the good of their fellow men.
They have the single merit of a partial frankness, and
their bigotry in the long run helps the cause of truth
some in calling the attention of a certain class to their
extremism. The criers of exaggeration are more
harmful by their plan of damning with faint praise

and thus aiding the lazy to be more indifferent. The
458 BIOGRAPHIC CLINICS.

silent men are the worst enemies of progress. The
silent leader, whose silence is motived upon a cunning
selfishness, is the most guilty of all the murderers of
new truth. In every city there are several or many
“leading physicians” (general physicians and neu-
rologists) looked up to, and their advice followed by
their pupils, and by the rank and file of the profes-
sion. By their professorships, hospital and society
positions, text-books, etc., they have secured and ac-
cepted their oracular and judicial powers. They con
trol the minds of many others who are trying to secure
such a future standing for themselves as the master
now has. For twenty or thirty years these men have
had placed before them the abundant clinical evidences
and testimonies of reputable men, that eyestrain does
produce varied and profound systemic symptoms and
diseases. Not one of these authorities has done any
frank, judicial weighing of the matter; not one has
publicly stated his opinion. There is no evidence that
one of them has thought it worth while to test its
truth or falsity, or even to say that it should be tested.
If it is wholly false they should have said so; if it is
in part true, they should have said to their followers
and pupils just how far they were prepared to assent
and advise trial; if it is in part true, thousands of
patients have been condemned to nonrelief by the
silence. Not one has publicly stated that the cure
depends upon at least seventy-seven reasons, usually
RECEPTION OF MEDICAL DISCOVERIES. 459

neglected by most of the oculists of the world. The
opinions, concerning this subject of several of these
silent men, are known to me. I have their letters or
word-of-mouth consent to the essentials of the conten-
tion I and others have made. But I am not permitted
to name these men, nor to quote from their “ confiden-
tial” admissions. In fact, even under the condition
of “confidential communications,” they would, per-
haps, not consent to all that the eyestrain theorists have
advocated.

They affect to think that we have gone a hundred
times farther than we have really gone. Their mental
vision is fixed upon an abstract scientific fact, forgetting
that in medicine all is concrete and individual, and
that neglect of a possible method of cure shows indif-
ference to the sufferings of patients. One of the most
well known of American physicians verbally con-
fesses that the eyestrain advocates are “ essentially
right.” He admits many marvellous cures by glasses
of many and varied systemic conditions, but to say
that “ all and always such diseases are due to eyestrain,
etc, No!” “No one ever contended they were,”
brings only continued public silence. Another has for
a dozen or more years referred such cases, hundreds
of them, and still does so, to one oculist after another,
until the careful one is found who finally cures. He
admits again “essentially ” all that the most extreme
of oculists would ask for—but he admits it only priv-
460 BIOGRAPHIC CLINICS.

ately, when even the most modest public admission
would immediately bring the matter to the test in a
multitude of cases under the care of those who follow
his advice. They continue unrelieved while even he
admits that the trial of glasses would not do that
strange mysterious “harm,” so feared by many.
Drugs, rest-cures, trips abroad, and a hundred devices
of therapeutists of as many types—they do no “ harm,”
but trying a pair of glasses is somehow dangerous,
most dangerous, advice!

It is a strange condition of mind, one, however, not
inexplainable, one wholly unworthy of the positions
these men occupy. It is in truth the logical, though
callous, result of these positions—the effort to hold
them or to secure higher ones. Perhaps the condition
will pass away only with the better education of the
profession, which will make a far larger number of
men the equals of the “leaders”; then a justifiable indi-
vidualism of the many will do away with the absurd
dependence upon the authority which makes the public
clamor for “the best and most famous consultant
in ee
Let it also be recognized that in science, and espe-
cially in medical science, the self-assumed leaders who
oppose new truth are criminals. It is time that we
were frank and blunt about it. The illiterate may
ignore without blame. A few medical men, even the
mass, may also ignore, and deserve only a moderate
RECEPTION OF MEDICAL DISCOVERIES. 461

censure. None, absolutely none, may oppose and
denounce and vilify. Who does so of medical men
is culpable.

But when leaders and authorities do this it is plain
homicide, murder, at least in the second degree. For
the function of a leader is precisely to judge rightly
of just these things. For that he is looked up to and
his advice followed. This is the office he arrogates
to himself; it was not thrust upon him; he assumed it,
and the assumption was a guarantee, under penalty of
fitness, culture, learning, experience and just judg-
ment. He was under no obligation human or divine
to render adverse judgment and to persecute. Wher-
ever there is great power lodged in a man’s hands, its
bad use is or should be punished. We need a ma-
chinery to punish these false judges. Monuments
should be raised to commemorate their shame, their
vulgar egotism, and their professional crimes. It mat-
ters not to the patients dead of neglect and false judg-
ment, whether it was homicide or murder of any
degree, but to society and to the profession, it does
matter. Who killed the thousands of mothers who
needlessly died of puerperal fever, the millions who
died of smallpox, after Holmes and Semmelweiss and
Jesty and Jenner had demonstrated the truth? There
are to-day several millions of people as needlessly
suffering the agonies of migraine: who are respon-
sible? The names of a hundred learned editors, neu-
462 BIOGRAPHIC CLINICS,

d

rologists, oculists and “ leaders’ in medicine could be
given.

Although the scoffers and critics fill the public ear
with their clamor it is quite probable that at the present
time the believers in the eyestrain doctrine are more
numerous and certainly more discriminating and mod-
est, more truly conservative, in stating their belief
than the deniers. References to only a few of such
testimonies happening to be present are the follow-
ing:—Dr. Snell, of Sheffield, England, in a masterly
article in the Lancet,’ improved and enlarged and pub-
lished as a separate volume,.entitled ‘“ Eyestrain as a
Cause of Headache and Other Neuroses”’ ;? Pronger,
“Slight Errors of Refraction and Their Influence on
the Nervous System”; Browne and Stevenson,
“ Squint Occurring in Children” ;* Callan, *‘ Migraine
and Functional Headaches from Eyestrain” ;> Thomas,
‘Some Remote Effects of Eyestrain ” ;> Stephenson,
“Ocular Headaches ” ;7 Zimmermann, ‘“ Ocular Head-
ache and Other Ocular Reflexes ” ;* Harman, ‘“ Head-

*Lancet, April 30, 1904.

* Simpkin, Marshall, Hamilton Kent & Co., Ltd., London,
1904.

*R. Ackrill, Harrogate, 1904.

* Bailliére, Tindall & Cox, London, 1904.

*Journal American Medical Association, March 28, 1891.

° Northwestern Lancet, June, 1903.

" Medical Press and Circular, February 4, 1903.

* New York Medical Journal, November 21, 28, 1903.
RECEPTION OF MEDICAL DISCOVERIES. 463

aches” ;* Hinchelwood, “ Some Observations, etc.’’; ?
Toms, “ Eye-work in General Practice.”

A hundred other references might be cited if space
permitted. I adda few quotations from some recent
good journals and capable ophthalmologists and phy-
sicians: Dr. E. Jackson,* Dr. Robert E. Edes,* Dr. W.
F. Southard,* The Pacific Medical Journal, Dr. H. M.

1 The Medical Press, November 18, 1903.

2 Glasgow Medical Journal, January, 1904.

3 Medical News, November 3, 1900. Also another article
entitled “Ocular Reflex Neuroses” (abdominal types)—the
reference to the journal unfortunately lost. ~

4If the reader is familiar with what eyestrain can do, and
does do, in the way of curtailing usefulness and destroying the
pleasure of living, let him fairly ask whether many of these
symptoms may not have been due to eyestrain? Whether it
is not probable they were due to eyestrain. Whether, although
the eyestrain explanation has been offered by Dr. Gould, we
are not forced to admit that the only alternative to its accept-
ance is to relegate these cases to the mysteries of Providence,
or the unknown regions of neurology, and attempt no explana-
tion of them whatever?—Colorado Medicine, Dr. E. Jackson,
March, 1904.

5 The ciliary is the purest type of such a muscle and un-
doubtedly its overaction, and especially its action which accom-
plishes its object for a time and with much difficulty, is the
cause of more headaches than that of any other one.—Dr.
Robert T. Edes, British Medical and Surgical Journal, March
3, 1904.

6 There is no specialist who has kept an accurate record
of his cases for a series of years but will bear Dr. Gould out
in his conclusions.—Pacific Medical Journal, April, 1904.
464 BIOGRAPHIC CLINICS.

Hurd,* Dr. James W. Walker,? The Cleveland Medical
Journal,’ Dr. Frederick E. Cheney,* The St. Paul Med-
ical Journal,’ Dr. L. A. W. Alleman,® Dr. W. H. Car-

1You have already made a deep impression upon the pro-
fessional mind and I am sure you will reap an abundant reward
in the consciousness that from now on all physicians will rec-
ognize the truth of your contention—Dr. H. M. Hurd,
Baltimore.

2 As a general practitioner I can say that the judicious
employment of an expert refractionist will rob the practitioner
of many of his chronic cases, and in place of fees he will have
to be content with gratitude,—if the oculist does not get all of
that. Our duty, however, is none the less clear—Dr. James
W. Walker, Journal American Medicine, March 28, 1903.

3A distinct service to the profession at large—Cleveland
Medical Journal.

* As to sick-headaches I certainly expect to cure the greater
proportion of them.—Dr. Frederick E. Cheney, Boston, per-
sonal letter.

5 That headache, insomnia, night terrors, nervous dyspepsia,
sick-headache, migraine, and a host of other similar symptoms
result from eyestrain, and are relieved by proper glasses, every
physician and especially every oculist, is well aware—JSt. Paul
Medical Journal, March, 1904.

6 The lesson you are trying to teach the public is a much
needed one, and the discussion to which your work has given
rise has done more to enlighten the general public on the
danger of eyestrain, which is not necessarily evidenced by eye-
symptoms, than all the papers that have been written —Dr.
L. A. W. Alleman, Brooklyn.
RECEPTION OF MEDICAL DISCOVERIES. 465

malt," Dr. A. G. Bennett,” Dr. S. D. Risley;* Dr.
Talcott Williams,‘ Dr. N. Senn,® Dr. Solomon Solis
Cohen.®

? What ophthalmologist has not had the same or similar
experiences ?—Dr. W. H. Carmalt, New Haven.

? Heartily endorse your conclusions.—Dr. A. G. Bennett,
Buffalo.

5] can’t see how any experienced ophthalmologist can fail
to agree with Dr. Gould’s thesis——Dr. S. D. Risley.

*It is a mystery to me why doctors do not see what is so
plain—Dr. Talcott Williams.

5 Nothing has done more toward calling the attention of the
profession and the public to the baneful effects of eyestrain
than these two books . I have finished reading your won-
derful book; I was so fascinated with it that I could not stop
until I had read it from cover to cover. I have written and
sent to the editor of the Journal American Medical Associa-
tion a three-page review. [Not published.] I hope the book
will reach every doctor in the world—Dr. N. Senn, Chicago.

6 The dependence of migraine upon eyestrain as an exciting
cause in a large number of cases can no longer be denied by
the most doubting Thomas. .. Unquestionably it is a truth
of vast significance. Unquestionably physicians have not yet
fully realized that significance.

Dr. Gould’s great merit lies not so much in his individual
theory of the causation of migraine as in his directing strong!y
the attention of the medical profession, and it is to be hoped
of workers in literature and science who are not physicians,
to the necessity of the relief of eyestrain by suitable glasses,
with recorrection from time to time, as the refraction alters
and the reflex disturbances recur; the other, and in some
respects greater, being the importance of gathering all facts
concerning the ill health of any individual into a comprehen-
sive whole, rather than to consider detached fragments as
things utterly apart. As the writer has elsewhere expressed

31
466 BIOGRAPHIC CLINICS.

Quotations might be added from letters of the fol-
lowing physicians:—R. Matas, E. Souchon, W. S.
Halsted, J. S. Prout, H. O. Reik, C. E. Ehinger,
S. C. Ayres, Russell Murdoch, David Coggin, H. G.
Sherman, W. F. Southard, H. F. Hansell, John Van
Duyn, H. L. Swain, T. D. Crothers, T. H. Fenton, A.
B. Adams, Peter A. Callan, Wm. H. Welch, Lewis H.
Taylor, Mary E. Bates, A. A. Eshner, W. C. Hollo-
peter, Baker (of Cleveland), Geo. F. Libby, F. W.
Marlowe, Geo. F. Case, J. W. Putnam.

Reviews accepting the eyestrain theory and favoring

the same thought, “the spokes are many, but the hub is one.”
This method applies indirectly even to pathologic accidents
such as acute infections, but its direct bearing is of course
upon what may be termed the basic condition of health or
disorder.

Dr. Gould has shown that much, if not all, of the constant or
recurring distress of a number of the leading spirits of the
nineteenth century—distress otherwise mysterious and unac-
countable—was in all probability due to refractive defects
of the eyes and the consequent accommodational strain made
necessary during work. It might, therefore, have been re-
lieved in large part, if not entirely, by suitable glasses; and,
this is the great, but therefore simple, lesson for physician
and for patient. In emphasizing this lesson the author has
emphasized old and unappreciated truth; he has also added
to the sum of truth. It is a work well worth the doing; a
work certainly not inferior to the invention of a new stain-
ing fluid, the synthesis of a new hypnotic drug, or the descrip-
tion of a new symptom-complex; a work of which the true
value will become more apparent as the years increase—Dr
Solomon Solis-Cohen in Science, April 29, 1904.
“RECEPTION OF MEDICAL DISCOVERIES. 467

the general view have appeared in The Harvard Grad-
uates Magasine, Bulletin of the American Academy
of Medicine, Fort Wayne Medical Journal, Medical
Review of Reviews, Canadian Journal of Medicine and
Surgery, California Medical Journal, St. Paul Med-
ical Journal, Dublin Medical Journal, Medical Press
and Circular, The Lancet, Bulletin of the Chicago
Health Department, Medical Bulletin, The Practi-
tioner, The Nation, Cleveland Medical Journal, Quar-
terly Medical Journal, Wisconsin Medical Recorder,
California State Medical Journal, Medical Council,
Mind, The General Practitioner, Treatment, etc.
Especially would I call attention to the opinion of
one who has for about half a century been one of
America’s leading refractionists, an honored physician
of St. Louis, the dean, one might say, of the oculists
of our country, Dr. John Green (quoted on pages

55-58).
PROBLEMS OF PRESBYOPIA.
Bear
.

CHAPTER XIII.

SOME PROBLEMS OF PRESBYOPIA.

Wuen I began practice I did as I had been taught
regarding the correction of presbyopia. Text-books,
teachers and general custom agreed that presbyopia
began some time after forty, and that no mydriatic was
needed in such patients. There was a rough rule wan-
dering about that plus spherical lenses of one diopter
were needed in forty-five-year-old patients, twos at
fifty, threes at sixty. This was about the time of the
“Punch, Brother, Punch with care, a blue slip ticket
for a five-cent fare, etc.” Actual dealing with pres-
byopic patients soon brought me up sharp. Rules like
those of the street-car conductors would not work out
in the oculist’s office. If any rules at all were admis-
sible they had to be of a different kind from those of
the text-books; in some ways far more definite, in
others more indefinite. Some of these cautions I have
brought to clearness are as follows:

t. In oncoming and progressive presbyopia, cyclo-

*Read in the Section on Ophthalmology of the American
Medical Association, at the fifty-fifth annual session, June,
1904, and published in the Journal of the Association January
21, 1905.

471
472 BIOGRAPHIC CLINICS.

plegia is generally necessary to obtain the static refrac-
tion on which the presbyopic correction is based.

Precisely in eyes whose accommodation powers is
being narrowed and lessened is the mydriatic most
needed in order that eyestrain may not be increased by
the close limits in which function is being compressed.
When there is youth and a high range of accommo-
dation the refractive error may not produce the injury
taking place in the presbyopic. This is a truth so self-
evident that it is astonishing to find it utterly ignored
in Europe and too commonly ignored in our country.

The slightest misplacing of the axis of astigmatism,
the failure to get the accurate amount of the error of
refraction, the least imprecision in correcting the slight
anisometropia, insure more trouble in the presbyop-
ically lamed eyes than in others with plasticity and with
activity of neutralizing or compensating powers. If
there are symptoms of eyestrain, and especially if ac-
companied with any doubts in my mind as to accuracy,
I do not hesitate to use a mydriatic up to the ages of
fifty-five or sixty. I think almost all patients up to
fifty should have it. I mean homatropin and cocain
and instilled in the office.

Discrimination as to those with latent or manifest
glaucomic tendencies is, of course, demanded. The in-
dividual expertness of the oculist must also be consid-
ered. The art of refraction requires a skill, a judgment
and a delicacy of perception, as great and rare as in
SOME PROBLEMS OF PRESBYOPIA. 473

any other calling, greater, I believe, than in surgical or
inflammatory conditions. A highly exceptional mas-
tery of the art may succeed in estimating the error of
refraction without a mydriatic when others would fail.
None may safely lay claim to such ability. None, at
least, may safely trust himself in its habitual employ-
ment. Easy-going assumption of it is another phasing
of the characteristics which have duped us since prov-
erbs and folk-tales and the ophthalmometer were
invented.

2. The age at which presbyopic corrections should
first be given depends on the preexisting refractive
error.

The old rules as to forty-five, etc., are nonsense. If
the patient has two diopters of hyperopia, the pres-
byopic correction will be needed much earlier than if
he is emmetropic. If he has myopia, the necessity will
arise later, as is well understood. But astigmatism
creates a greater indefiniteness, and especially if it is
unequal or if unsymmetric. Anisometropia further
complicates all rules and makes them still more indefi-
nite. The onset of troublesome presbyopia also de-
pends on whether the ametropia has been corrected or
not for years previous.

3. The correction of the presbyopic error of one or
both eyes is often dependent on the existence in one
eye of amblyopia from disuse.

This exclusion of one eye from function always
474 BIOGRAPHIC CLINICS.

brings most difficult problems. If of high degree and
of long standing it may not be possible to get reac-
tion or to stimulate the lost power into function. As
a rule I believe in saving partially ruined eyes, and it
is possible to do so more often than has been supposed.
Such eyes exist far more frequently than text-books
and teachers tell us about. In some rare cases at the
presbyopic age the attempt to save the eye and bring
it into function is not only possible, but will produce
most decided rebellion on the part of eye and brain.
These “hurt eyes,” with stippled maculas which let
you stare at them, and which so plainly show neglect
and sin, both lay and medical, are daily visitors to the
oculist’s office and they make his hair gray sooner than
should be.

4. Less accommodation in one eye than in the other
may condition the amount of the presbyopic correction.

This inequality of function may be the result of anis-
ometropia, of right-eyedness or left-eyedness, of a pe-
culiarity of occupation, of monocular disease or injury,
of heterophoria, etc. It is of more frequency than is
suspected, and causes much ill-success in the correction
of presbyopia.

5. The onset of presbyopia demanding correction
may be delayed beyond the usual age by hypertrophied
accommodation.

This abnormalism of excessive accommodation is the
result of lack of presbyopic lenses, with the resultant
SOME PROBLEMS OF PRESBYOPIA. 475

over-function of the ciliary muscle and abnormally
retained elasticity of the lens. Excessive use of any
organ, or abnormally prolonged use, produces disease.
That of the accommodation in presbyopia causes eye-
strain and all of its reflexes. The eye itself or the
organs which bear the brunt of the derouted reflexes
must suffer. I have heard of one oculist who attempted
for many years to postpone presbyopia requiring cor-
rection into old age. That is a human vivisection
experiment that would be somewhat interesting to
science, but which I should be far from wishing to try
in my own case.. We see daily the injury and the suf-
fering it causes in old people who indulge in the
puerile vanity of ability to “read without glasses.”
The result is that they do not read much, their little
intellect goes to seed, and the little reading they do
produces disease.

6. The correction of presbyopia at an early or late
age and the high or low degree of the error depends
on the amount of near work demanded of the eyes.

In nonreading farmers, workmen, seamen, etc., the
correction is not required to be made at so early an
age, nor perhaps in so high a degree as in sewing-
women, literary people, engravers, etc. A hurried test
may also result in a too low correction, because the
accommodation by a moment’s intense effort may
prefer a lower lens than would be required in more
prolonged use of the eyes at near range.
476 BIOGRAPHIC CLINICS.

7. Presbyopes who deceive the oculist as to their
age may suffer if he has not been alert minded to
detect the error.

One must be on his guard in treating “ women of
doubtful age.”

8. The peculiarity of the habitual occupation may
necessitate a higher and earlier correction than is usual.

Embroidering, “sewing on black,’ engraving,
watch-making, measuring in sixty-fourths of an inch,
etc., are kinds of employment that make inordinate
demands on the accommodation.

9. The light, its quality, power, etc., must also be
inquired into.

If a patient works all day by artificial light, or by
poor daylight, in darkened rooms, if the angle at which
even a good light strikes the work is not right, eye-
strain is sure to result. If after a long day of strain,
under these hurtful conditions, reading, sewing, etc.,
are continued at home, and again, perhaps, with bad
lights, the results must be deplorable.

10. The position of the body and head in sewing,
reading or other near work may be harmful to the
eyes and the general health.

If the book, sewing material, writing, etc., is placed
in the lap, or in such a position that the head is bent
over, the spine curved, and the chest flattened, the in-
jury to the patient’s eyes is almost certain because
of nonillumination of the page, paper, etc., and also
SOME PROBLEMS OF PRESBYOPIA. 477

because of the improper position of the eyes and head.
The health generally must be harmed by the com-
pressed condition of the pelvic organs and the lungs,
poor respiration, etc.

Bookkeepers, etc., should stand at their work as
much as they.may, and chairs at desks should be low,
the desk high, the writing leaf inclined, the axis of
vision as nearly as may be perpendicular to the plane
of work and of the spectacle lenses. The single dis-
advantage of the bifocal lenses is that they compel the
axis of vision to be inclined downward. For this rea-
son they should be set high before the eyes, and the
habit advised of “ chin-up.” Book rests, book holders,
etc., should be encouraged. In my boyhood “ sewing-
birds’ screwed to tables were common. They were
most excellent devices.

11. The state of the general health, the preserved
vitality, the vigor of will and of body, will also con-
dition the early or high correction.

A flaccid muscular tone, anemia, denutrition, care
and worry, a melancholic or pessimistic disposition or
philosophy of life may not be entirely overlooked.
Patients so handicapped require a fuller or earlier
presbyopic correction than those who are more vig-
orous. Their innervational power is lessened and
sometimes nothing the oculist can do will enable them
to carry on severe near work when presbyopia doubles
their strain.
478 BIOGRAPHIC CLINICS.

12. Failure to cure the reflexes of eyestrain may be
due to the want of bifocals.

Two separate pairs of lenses can not correct eye-
strain as do the double lenses. With a distant pair
only there is an hour or more of strain every day in
eating meals. There is also forgetfulness to change
or indifference to the need of it, lenses are not repaired,
are misplaced, or lost, etc. The one disadvantage of
bifocal lenses is counterbalanced a hundred times by
the manifest benefits over the distant and near glasses
made separate.

13. Eyeglasses being more prone to maladjustment
than spectacles may be the cause of failure to bring
relief of the symptoms or sequels of presbyopic eye-
strain.

There are few noses capable of retaining bifocal
eye-glasses in a correct position. The more expert the
optician the more the attempt may be tried. This is
especially true if the patient can consult the fitter at
least once a month. Patients who by reason of living
at a distance can not do so should not be allowed
bifocal eye-glasses under any circumstances. To those
with high degrees of astigmatism they must also be
forbidden, except for one nose in ten thousand. Vanity
causes a deal of suffering both to patient and oculist.
It may prevent the patient wearing any glasses and
thus double the local and systemic reflexes. When,
as usual, vanity demands eye-glasses, and the result is
SOME PROBLEMS OF PRESBYOPIA. 479

certain to prove bad, my custom is to tell the patient
to consult another oculist. No greater ill fortune
could happen to your rival than to have the patient go
to him. And there is no better punishment for vanity
than eye-glasses, unless it be the rest cure.

14. Premature presbyopia, or paresis of the accom-
modation, may occur years before the usual age, and
explain failure to relieve symptoms when none of the
preceding causes will do so.

The patient may have contracted a chronic habit of
reading at too great a distance and the presbyopic
lenses ordered may force him to hold the page or sit at
writing at a shorter distance than is comfortable or
perhaps best.

This is especially true if there is exophoria or insuffi-
cient adduction power. If this is so, the adduction
should be increased until comfort is secured, habitual
reading or writing at, say, twenty inches may itself be
a source of eyestrain. :

16. The patient may have supernormal adduction
power and the presbyopic lenses ordered may force
him to read or write at too short a distance.

In this case, at least until the adduction lessens,. the
too weak lenses may cause discomfort.

17. The symptoms may not be due to presbyopia,
nor to any eyestrain, but to systemic disease.

Every oculist has had many patients whose symp-
toms had been treated by glasses alone, or whose
480 BIOGRAPHIC CLINICS.

ocular muscles had been “ clipped,” when all the time
there was concealed or unknown systemic disease, e. g.,
nephritis, diabetes, anemia, etc., or some morbid result
of bad dietetic or other habits, which were the only or
chief causes of trouble. This does not in the least
excuse those wonderful oculists who find that all eye-
strain symptoms and reflexes are due to systemic con-
ditions. That is a good way to please the referrer of
cases, and to conceal inaccurate refraction. But. it is
not the best way to practise ophthalmology.

The preceding rules are, in fact, non-rules; they are
in truth, cautions to have no rules in correcting pres-
byopia. Every case is exceptional and individual and
requires a freedom of the mind from bias or prejudice
of any kind. Precision in estimating the conditions,
infinite patience, delicacy and conscientiousness, in
hunting out the individual variation there before one,
and inexhaustible ingenuity in meeting all the varied
and varying phases and factors, are the prerequisites.

There is but one invariable rule: Have no rule.
Rules are the makeshifts of the lazy and unintelligent.
The cunning rely on them, forgetful that cunning is
really stupidity. Optical machines are often rules
made into iron rods, scales and wheels. They may be
of service if used not as dictators but as slight helpers,
in the hands of the intelligent and guiding machinist,
but they may serve as the excuse and ruin of those
SOME PROBLEMS OF PRESBYOPIA. 481

who rely on them to the exclusion of intelligence and
diagnostic skill.

Any number of cases could be epitomized, illus-
trating the foregoing suggestions. I shall content
myself with but few, because in every oculist’s memory
there doubtless arises plenty of examples.

Case 1.—A lawyer who carried on a tremendous amount of
eye work had an enormously high and complicated compound
hyperopic astigmatism. Despite a perfect correction of his
ametropia by capable and good oculists, and despite the best
treatment by general physicians, his dyspepsia persisted. In
obedience to his demand his oculists had allowed him to wear
bifocal eye-glasses. A difference of five degrees or ten degrees
in his astigmatic axes, inevitably caused by maladjusted eye-
glasses, rendered his ametropic correction worse than useless.
They failed to cure their patient because they did not demand
spectacles.

Case 2—A woman of 39 had sick-headache which reap-
peared every few weeks despite my best correction of her low
compound hyperopic astigmatism. I had three times gone
over my work and found no change in her glasses was to be
made. I feared I had what I had always been looking for—a
typical migraine which I could not cure with glasses. Inquiry
elicited the fact that the woman habitually did an enormous
amount of literary work. I ordered presbyopic correction and
bifocal spectacles to be worn constantly and the “migraine ”
has never shown a sign of itself since.

Case 3.—A healthy clear-headed intellectual man was given
two pairs of spectacles for his myopic astigmatism, a stronger
or higher correction for use at the theater, driving, etc., a
weaker correction for reading and daily or constant use. For
a year his wife and daughter observed, without telling him,
that whenever he wore the strong, or accommodation-exciting

32
482 BIOGRAPHIC CLINICS.

glasses he “caught cold” with coryza, hoarseness, etc., which
at once disappeared when the weaker lenses were used. He
used the stronger ones but few times a year. When certain
of the strange coincidences his wife told her husband. In the
past ten years the cold has been produced in this way a hun-
dred or more times. Now if his weaker glasses get “ crooked,”
or maladjusted, miscorrecting his axis of astigmatism by a few
degrees, his cold promptly appears, to vanish in an hour after
a visit to the optician.

Case 4—A gentleman of 50 years of age had consulted many
of the most famous oculists because of severe and frequently
recurring subconjunctival hemorrhages. Some of these had
refracted his eyes, some had not, but all had followed a not
uncommon custom of charging such symptoms to gout. None
had found any error of refraction, except, of course, a couple
of diopters of presbyopia. By the most competent authority
his eyes had been pronounced mathematically emmetropic and
perfect. None, of course, had used a cycloplegic. With par-
alyzed accommodation I found 0.25 D. of simple myopic astig-
matism axis 180 degrees in each eye. For several years he
has had no hemorrhages and by his glasses he has had also
such relief from other cerebral symptoms that he has had
heavy iron spectacles made for use in his bath, so that he may
not be without lenses for a minute.
SUGGESTIONS AS TO POSTMYD-
RIATIC REFRACTION TESTS.
APPENDIX A.

SUGGESTIONS AS TO POSTMYDRIATIC REFRAC-
TION TESTS,

THE reasons why “ glasses fail to give relief” are
many, and I have elsewhere formulated sixty-eight.
When my patients go to other oculists I am always
anxious to secure the records of work done and pre-
scriptions ordered by them, so that I may learn what
my mistakes have been, and thus be on my guard in
future cases. Nothing is so instructive to the physi-
cian and helpful to the patient as the willingness to
correct one’s own errors, “ relax one’s own accommo-
dation”’ and gain guidance and rules for future use.
In studying my own case records and those of patients
who have been treated by other oculists, I constantly
come upon the fact that we have in the past paid too
scant attention to the postmydriatic tests before pre-
scribing glasses. Many oculists indeed do not make
such tests but prescribe while the eyes are still under
the cycloplegic. One well-known oculist writes me
that he does not use a cycloplegic at all because he finds
such wide, frequent,and contradictory changes between
the results that he can do better without the cyclo-
plegic. This seems to me a profound error.

'From Annals of Ophthalmology, July, 1904.

485
486 BIOGRAPHIC CLINICS.

The differences between the refraction under cyclo-
plegia and that after the accommodation-paralysis has
passed off, are indeed marked, frequent and even con-
tradictory, and I estimate that these differences will be
found in from ten to twenty percent of cases. They
may possibly be due:

t. To the kind of cycloplegic used.

The stronger and more lasting ones, I judge, cause
the greatest differences. Homatropin and cocain
(combined) are the least liable to cause them.

2. To the method of instillation, purity of the
drug, etc.

Used in the office for one hour prior to the tests,
about every seven minutes, seems to me to give the
best results.

3. To the time at which the tests are made.

They should be made at the height of the physiologic
effect of the drug, not before or after.

4. To the hyperemia caused by the drug, the differ-
ences in physiologic conditions due to it, etc.

These may readily cause changes in corneal curves,
tensions in muscles, etc.

To these causes may be added the following:

5. To the inclination of the axes of vision when the
tests are made.

Most of our looking, and especially all straining
work, reading, writing, sewing, etc., is done with the
axes directed downward. Our tests in the oculists’
POSTMYDRIATIC TESTS. 487

offices, under cycloplegia, are usually made with the
twenty-foot cards on a level with the eyes. I have
seen oculists’ offices in which the cards were even con-
siderably higher, making the axes incline upward. It
seems evident that the muscular tensions in looking on
a level or downward may frequently be so different as
to change corneal curves, etc. When in conjunction
with the next cause, as practically this factor must be
taken, we have a possible source of changes of high
importance.

6. To the fact of whether the test is made at the
twenty-foot or the fourtecn-inch distance.

The muscular tensions are certainly different in the
two locations of the object fixed upon, and this, espe-
cially in cooperation with the preceding cause, may
result in marked changes of astigmatic axes or
amounts, etc.

7. To the fact per se of paralysis of the cihary
muscles and conversely of the full exercise of accom-
modation without cycloplegia.

A different result, sometimes existing, seems to be
ascribable to the direct influence of active or paralyzed
accommodation, the mechanism being difficult to
understand.

8. To the well-understood difference in refraction of
the central parts of the cornea and of those more per-

ipherally located.
488 BIOGRAPHIC CLINICS.

The test with the pin-hole disc brings this out in
cases of doubt.

9. To the influence of binocular fusion.

There is sometimes a change of the axes of astig-
matism when both eyes are in function from that made
with the monocular test.

10. Torticollis, or Tilted Head; a twisted and tilted
position of the head may be caused by a displacement
of the axis of astigmatism of the dominant eye.

I have discovered about thirty-five such cases among
my patients during the past four months,’ in many
of which there was secondary spinal curvature,
all demonstrably due to an axis of astigmatism in the
right eye from 10° to 20° out of symmetry. When
the head was kept perfectly erect the misplaced axis
was manifest. In the erect position the patient was
“unable to see” with the axis chosen when the head
was inclined to the former habitual position, and vice
versa.

The practical lesson I have drawn from these ten
considerations is that in cases of doubt or failure to
relieve eyestrain reflexes, and in all cases of unsym-
metric astigmatism, retests should be made, under cyclo-
plegia and with great care; but especially as regards
the postmydriatic tests with the accommodation
spurred to its utmost; with near-tests in the reading

*See Amedican Medicine, March 26, 1904.
POSTMYDRIATIC TESTS. 489

position ; in the cases of canted or twisted heads; and
with both eyes open at near and distance.

These ten reasons should have been added to the
sixty-eight already enumerated,’ making seventy-eight
in all, “ why glasses failed to give relief.”

1See American Medicine, July 4, 1903, and “ Biographic
Clinics,” Volume II.
A CASE OF “MATHEMATICALLY-
PERFECT EYES.”
APPENDIX B.

A CASE OF “MATHEMATICALLY-PERFECT
EYES,”

On October 12, 1897, I was consulted by a gentle-
man fifty years of age, whose chief complaint was of
subconjunctival hemorrhage, which had occurred on
an average every two weeks during the past year. I
found out that he had consulted a great many oculists
during this time, who had either given general treat-
ment for gout (of which there was some slight evi-
dence), or has sent him to the general practitioner,
or had only prescribed reading glasses, etc. The hem-
orrhages seemed to come on spontaneously and were
bothersome chiefly because they gave the man such a
frightful appearance and caused mental worry, rather
than any decided pain or trouble of vision. One eye
was generally affected at a time, and as the hemor-
rhage only stopped when the subconjunctival space
was thoroughly filled with blood, the appearance of
the eye and patient is easily imagined by any one. I
frankly asked the gentleman what he supposed I could
do for him, when the large number of the best men in
the city had failed. His own faith was plainly little,

1 Read before the Section of Ophthalmology, American Med-
ical Association, June, 1898.

493
494 BIOGRAPHIC CLINICS.

but I was compelled to try. General disease of any
pronounced type was excluded by thorough examina-
tion; the family history and personal history were
beyond reproach, and one of our most careful “ inter-
nists” had treated him on general principles for this
one ocular symptom without influencing it in the least.
The muscular coordinations of the eyes were as perfect
as they could be, and by all non-mydriatic tests both
eyes were absolutely emmetropic; the visual acuity
was 20/20-+. Indeed, the man had soon told me that
he was an optical curiosity, other oculists having mar-
veled at the emmetropism of his eyes, and one espe-
cially—a man of large practice and scientific ability—
had repeatedly said that his was the only pair of
“mathematically perfect eyes”? he had ever seen. It
was certainly a gloomy outlook for the man with a
fad—the “ oculist hobby-rider.”

Relying, however, upon the results of many expe-
riences I proceeded to work upon the basis of what
have become axioms to me, viz., No mydriasis, no
diagnosis of refraction, and all presbyopia is only rela-
tive. Under a mydriatic I found the visual acuity as
perfect as it had been without it. Then I comforted
myself with another maxim: Perfect visual acuity is
no proof of the nonexistence of an error of refraction,
and I was soon able to demonstrate an error as follows:

R.— Cyl. 0.25 D. ax. 90°
L.— Cyl. 0.25 D. ax. 180°
MATHEMATICALLY PERFECT EYES. 495

Now, I did not say to myself that this tiny error of
refraction was the cause of the conjunctival hemor-
rhage; I did not then dream that it was, and told the
patient that if any local cause for this existed I be-
lieved it was due to the failure to use presbyopic
glasses while eating meals, card-playing, etc. With
this end in view I ordered bifocal spectacles, for dis-
tance the cylinders as above, and for near a proper
spherical added. Then came downright rebellion;
the man was mad at the idea of wearing the “ hideous
things.” I said, then, that this was my prescription
and, unless followed, I stood discharged. He went
away savage and disgusted, but did order the bifocals,
wore them one day and, more wrathful than ever,
ordered the optician to turn them into two separate
pairs of eye-glasses. As I washed my hands of the
case, I allowed the optician to do as the man desired,
and not seeing him again I supposed he had left me
for another and less dogmatic adviser. I had quite
forgotten about the matter when, in two months, my
office boy brought up a bill my secretary had sent the
man, and a check to pay it, saying the gentleman had
asked to have the receipt signed, would not come up,
etc. Luckily, I remembered the name and returned
the receipt by my own hand, impelled by a certain
quizzical curiosity. He was evidently in a very dif-
ferent mood, said he did not want to trouble me, in-
tended writing, etc., but was glad now to tell me how
496 BIOGRAPHIC CLINICS.

happy he was with his eye-glasses. I have seen him
several times since, and to shorten an overlong story,
I will say that not only has there been no recurrence
of the hemorrhages, except one very small one, since
getting the glasses, but a previous discomfort uncom-
plained of, and hardly recognized, is completely re-
lieved, but returns at once if the low cylinders are not
worn; this discomfort is now so decided that he has
had made heavy steel spectacles to wear in his bath,
the sense of pressure and irritation being so great even
in a time so short as that. i

I shall not attempt to explain the modus operandi
of a low astigmatism producing so severe and un-
wonted a result as these hemorrhages. That it did
produce them I have not the shadow of a doubt, and
the method is perhaps readily enough divined by all
of you. There is only a single negative I wish to
emphasize, and this is the reason I have gone into the
rather gossipy details of this case: there is not the least
crevice where through may creep the suspicion of hyp-
notism or autosuggestion. The man was mad at me
and I was provoked at him; he refused to follow
orders; had no faith in the diagnosis or the doctor;
and as a cap to the climax I was utterly mistaken in
my diagnosis! It was not the need of bifocals, or of
presbyopic correction that was the true etiologic fac-
tor, but simply the low myopic reversed astigmatism.
The fact of this only came out through unfaith and
MATHEMATICALLY PERFECT EYES. 497

indirection, by wearing the forbidden eye-glasses.

This has led me to entitle this report a case, i. @.,
a disease of emmetropically perfect eyes, and so many
lessons are suggested by it, lessons which I myself
have long needed, and which, perhaps, one or two of
you may profit by, that I have been moved to report
the case chiefly for the fun of the haec fabula docets.
These shall be most briefly recapitulated.

1. The most important lesson that springs into view,
one which every day, and in every journal, and in
every other case report, should be printed in double
caps, is this: Although a patient has been examined by
one or more good oculists and glasses prescribed, or
reported as not needed, the fact has no significance
whatever. It does not prove that eyestrain does not”
exist, nor that it is not a source of any of the results
that eyestrain may produce. This seems extreme and
even revolutionistic, but it is literally true. In this
case the proof of the pudding is not in the eating.
There are a hundred qualifications needed to the bald
statement that “ glasses did not lessen the symptoms,”
or “the oculist reported the eye-examination was neg-
ative,” or ‘eyestrain was ruled out by careful tests,”
etc., etc. I don’t care a button for such an assertion;
it is simply meaningless unless very many other con-
siderations go with it. Do not for an instant think
I make an exception of myself, or wish to cast any slur
upon the work of others; that would be simply silly.

33

‘
498 BIOGRAPHIC CLINICS.

What I mean, of course, is that in these infinitely deli-
cate matters, in these calculations of infinitesimals,
slight differences, inobviable personal equations, etc.,
may indeed occur and be the reason of failure, but
beyond all this there are numberless questions, e. g.,
as to correctness of make and accuracy of adjustment
of the glasses; as to methods of wear or non-use; as
to habits and peculiarities of eye-work ; as to the length
of disease; as to suddenness of consequent refraction
changes; as to the frequent impossibility of curing a
result by curing its cause; as to complicating causes;
as to intercurrent general diseases, etc., etc. Not only
in the case reported, but in hundreds more I have
learned that my own errors, mistakes, and blunders,
as well as those of others, may show the fallacy of a
single judgment; a multitude of provisos must be ex-
cluded and the subsequent history closely scanned in
order to prove or to disprove the lumpish dictum
“glasses gave no relief.” Facts are stupid and useless
things without an intellect to discriminate, marshal
and use them. It takes more than a lot of rocks to
make a lock or a breakwater.

2. A very slight or uncorrected error of refraction
may be the cause of strange and serious reflexes and
results, and this is especially true if it be unsym-
metrical astigmatism, and still more surely if it is a
low degree myopic astigmatism, in which there is no
means of escape by blunting into amblyopia, or by
MATHEMATICALLY PERFECT EYES. 499

shunting into heterophoria, and no’ possibility of a
ciliary-muscle contraction overcoming the defect.

3. Low-grade myopic astigmatisms are hard to diag-
nose and are in practice too commonly overlooked and
neglected, although they must be as common rela-
tively as hyperopic varieties.

4. It is only by the mydriatic, combined with infinite
patience, delicacy, and skill that such astigmatisms are
correctly diagnosed. Perfect visual acuity is no dis-
proof of coexisting ametropia.

5. The mydriatic is more necessary in presbyopia
than previously. All the text-books and teachings are
wrong in this. Precisely when the compensatory
mechanism is being narrowed by presbyopia, ‘is there
the greatest need of accuracy in the correction of the
smallest degrees of anisometropia and astigmatism.
Then, also, the vital powers are failing and the cat-
aract-age is nearing, so that precision in refraction is
doubly and trebly imperative. Presbyopia is always
relative, never absolute, particularly if proper glasses
have not been worn during many previous years.
Without a mydriatic there is no adequate estimate of
errors of refraction, and between the ages of forty and
fifty-five the estimate should be painstaking to the
uttermost degree, especially if any suspicious reflexes
exist.

6. Absolute emmetropia, “a mathematically perfect
500 BIOGRAPHIC CLINICS.

pair of eyes,” does not, I believe, exist. A perfect leaf
has not been found, nor absolute symmetry in any
organic thing. The report of perfect emmetropia is
a confession of negligence and unskilfulness. I have
made such reports myself and can, therefore, speak
dogmatically. If such a diagnosis has been made
without a mydriatic the negligence deserves a much
harsher naming.

7. And even if there were such a mathematically
perfect pair of eyes, I can easily imagine circumstances
in which such eyes might be the cause of morbid
results. As orthophoria is always a disease, so emme-
tropia, in a seamstress or in almost any hard-pushed
eye-worker ; in a neurasthenic, in a heterophoric, or in
a presbyope, may functionally be a disease and require
correction by glasses. Emmetropia is nature’s unreal-
ized ideal for the animal, savage and primitive man.
A low degree simple myopia, alike in both eyes, is the
desideratum of the slave of civilization.

To focus this long-winded reading into a sentence
I should say that when a possible or suspicious ocular
reflex exists, painstaking mydriatic refraction and cor-
rection are necessary both in presbyopia and in “a
mathematically perfect pair of eyes.” And when this
has been admitted comes the rider that even after all
has been done it cannot, with utter certainty, be said
that the eyestrain was not, or is not, the ultimate
source of the morbid symptom.
INDEX.

Abdomen, diseases of and eyestrain............ ihn See wine 40
“Academy headache ...c00 00.0.0 cceee eee ees vuweuaveswes 151
Accommodation—paresis of and inhibition reflex......... 392
paresis Of we cvseaaex MEISE OES Ree Re ee Mevteddudeand dias 379
subnormal, and premature presbyopia.................. 377
Adjustability of desk seat....... ip RUS PEGE ae CARO P OWS S 307
Adjustment of the body and astigmatism................... 288
Advance hindered by “leaders”................. 16, 66, 68, 231
Air-passages, upper, inflammations of and eyestrain......... 40
Alcoholism and eyestrain.......... 00.000 ccc ee ese ee eens 194
Ambidexterity, nonexistence of.......... 0.00 c cece eens 353
Ametropia—and general body conditions................. « 3O
and imyOpla: of cieie melee veeda awha Ms REM ES 36
Anesthesias and migraine........... 00.0 c cece cece eens 237
Anomalies of refraction—and cataract...............0. 000s 36
and: COnJUNCEIVITIG’ ic asiaeins voua Gude dene 6 dee re Bae 35
AS) SIRNA 66 ced hae RES dda S ewe ewes bse 35
arid hétérophoria: 24s. wicsacced ga nada ties ano eieneea es 35
OH SiS awe de vbn'g bse teed a esas Ges oan 4- nas eeaRe Res 35
AO OVA ae lh Sa eae news) RRR ORES 35
Andi Strabismus: cca cccowamarctads camasadeda ta weeeaeues 35
Antisepsis and Semmelweiss............. 0.00: . ee eue cues 426
Appendicitis and eyestrain... ....... 0... eee e cece nee eee 40
Astigmatism—according to rule, axis in..............-0-- 145
and adjustment of the hodys«y«ss044 sexe os ecaw a owas 288
ainl, GVeEStYal .icc6 ss gaewe eee aes 4 EE Sa bh es so eRe 18
and héadachese -oc3 ada.ahatidiersn tae eihieh Gaon ob RELAS Echgoe 18
and: head-tilting® a<ccu.iasein Shans eode wean cece 42, 277
anid. Myopia .s2x0soscss uewe ees tak ad SOwesE eae eos eres 433
502 INDEX.

Astigmatism—and puberty .......... 0. cece erence cree 49

and slanted Writings wii swage wade degans He aaa eRe 299

asymmetric, and head-tilting..........-.. cee eee eee eee 371

asymmetry: of axeS IMs acca. casein ect e scene ena eee 146

effects. Of cdcaw iy s2avesexatembages sear ayo sats 130

importance of low degrees of........... 000s e cece eee 140

in, the. dOMINANt EYEs...c4.¢ cee wel ed ee ee ee eee ES 369
Axes, asymmetry of in astigmatism.................0 0005: 146
Amis im astigmatism. according to rule... ...0s06vuusercnsas 145
Bieyele and headache .. 244 ¢40ac4 pa uveweas ove erga es ween es 153
Biographic Clinics reviewed by Dr. John Green............. Ss
Biology in relation to the new ophthalmology.............. 4
Blind, supposedly so, found not to be.......-... cece eee nee 69
Brain-disease—and eyestrain ....... 0... cece eee eee eee 434

So-called, Ard EyeStMi..o.4..4ncKnne ia desea is enese sa 188
“ Brain-fag ” and eyestrain ....... 0c. cece eee eee e eee 109, 234
Bright’s disease and eyesifain.. ..0..sccessesannaceseueae 187
Caer, the, and The 296100. c400949 4 oy Hewat a eerenrenees 29
Cataract and refractive anomalies............-..222000008 36
Cephalalgia Spasmodiéa .....+4sc0eeeeduneay oeeusugeee sean 312
Chest-pain, and eyestrait.csciuec aces eideaaees dence was « 383
Children in New York Schools, eyestrain of............... I
Civilization—and eyestrain ........ 0.0 cee eee cece eee ee 47, 65

and increase of functional diseases.............. 000005 47

process of and dextrality. ..s.c4.c0cneeseetunesaes wan 346
Clinical proofs of the eyestrain theory..................0. 10
Colds—and influenzas, Symonds.......... 00.00: cece eee . 86

ori “MUS ISINE: ey enw pe P44 EES EG A eee BA Rw he eee 236
“Collective investigations ” of eyestrain................005 18
Complexity of the €y@sssccacisiwu sas ou tetas sare nea waa wees 59
Conditions, general, of the body and ametropia............. 39
Conjunctivitis and refractive anomalies................0005 35
Continent, the, of Europe, and eyestrain............. Oo, 17, 22%
Crime: and eyestrain’ «6 aaciiescess 6 dea aed mamarasew gn wanes 2, 45
Curvature of spine—and slanted writing................0.. 252

WG SYCCITAIN: 6.40455 We KG Awe HR EO ESK IO BES RERRAES 2, 41, 251
Cycling and headache........ 0.0.0... c ccc cc ececueueveees 153
Deafness and eyestrain..... 000.0000 ccc ccc cece cece ees 396
Depression and eyestrain.......... 0.0... c cece cceeeae 193, 240
Dermatitis and eyestrain........ 0.00.0 e eee cece eeeee 385
Desk—inclination of .........0 0... c cece ccc eee eee eas 308, 315
inclination of and eyestrain............. 0c. cseeeeeeue 307
Desks—inciination of and writing posture................. 272
atid Slantéd writing. sis ssa oe cman ueecce ie waeen obae 272
the, im Schools ..404.5 deans oh ba edited Goede dwnedarees 322
Desk-seat, adjustability of 2.0.0.0... 00.00 ccc cece eee eens 307
Deéxttal,. definition :0f o.c20 acuie. Sarsds omge ee eens down vacus 343
Dextrality—and civilization 1.0.0.0... 0000 ccc cee eee ee eee 346
and intellectual functions..............000..00ee eee ee 350
and) Sinisttality® i ds «acawaa stew buy aaa aig Swis eelgiy BA Be 341
definition of and of corresponding terms.............. 344
AN) MUSIC 4'snaon sham g watts dknea puchusdbivs eR Se ee Gruss odd 347
PEASONS LOD sige hd:i uepndaeed Racewe + Mademewn hee wee MERE 341
Dextrocularity—confirmation of the theory................ a9
pathologic results Of ©... .... 0c c cece cece neces 363
Difficulties of obtaining correct glasses.............000000 4
Discoveries, medical—motives for ignoring................ 430
TeceptiOn Of sass ercs4 wears tases SEER S Base oa Melody 415
Discovery of eyestrain... ...... 2.00. ccc cece 433
of subnormal accommodation in the young............. 408
Diseases—of abdomen and eyestrain................-.0085 40
of frontal sinus and eyestrain.................0 0.00 40
Dominant eye—and astigmatism...............0.0 cee eee 369
and. Slanted, wfiting'ssc06 sacedle pane omalayerd gue We sewne 301
1A. WITTE! as cudinc tse 4 Sotuned ates eee FOS OSs 5 OE gir
necessity for préS@rvind ii cscsesueeseceem erenee serous 867
Dysmenorrhea and eyestrait, , ..«ne ss coc oseen ee nauuaca aun 20
Dyspepsia. atid eyestraiiie cis sicss cies ascede re egaraes ges 48
Edes, R. T., on Eyestrain and its effects.............-2+4- 9
Ellis on eyestrain of Wagner........... 00 e eee eee eens x 38
Emmetropic eyes ...... 2 cece cer een ence en eeeenenee 15, 30, 496

Energy’ of SyM0fids. iio. i34.9 ates. hic0ees mega EYRE ORE . 89
504 INDEX,

English profession and eyestrain...........5 cece reer ees 10, 17
Enuresis wid €Vesivattivesve+coveesaat aves ee hoses us aeons 43
Epilepsy and eyestrain............. etree rT as, 6s, 76, 192
Haquilibritm a& visual n€GeSsity.. oo. ec sc wcawe se ee deed naan 88
Equipment of ophthalmic clinics inadequate................ 69
Errors, of refraction, slight, and morbid results.......... £5, 3%
Heile of eyestrain... co dase: 650504540 eese 42 EE ERE 49 eee 334
Evohitien and. He Gyl8.0 0500 cacaee recess ci eee awn nden Sy, 61
Exaggeration and eyestrain........ ee ee eee ee 443, 457
Exaggerations of the opposition to the eyestrain theory...... 22
Exercise, severe physical, and eyestrain (Taine)........... 103
EYVO—And: -CAMIET A. service sie: ays d-o.8 4 RGid- gi eud vanarandqeuanen cla) seeded Poarreiiese 29
ed hand, relation GE. cinuvs vs ke caead eo ade Saeed eon 366
Sid PCS! cece ch ee ye kes aa PRR ee ed oo 488d Os ee 62
and migraine ..... eeu s KR ea EY EAS 20, 46, 65, 67, 221, 244
MOWUIERAIY GE 2c5s6 cs Gedden a bepedens a pee ee os ead ee 59
dominant, and slanted writing............. 000 se eee eee 301
dominant: astigmatism: ithe. p.c acs sasiinnwnad eee a a Oe eye 369
eomninatity 1h WHILE: «you easaswevedene cus en aaa eeew oo 311
dominant, necessity for preserving...........-..00-00e 367
Eye-glasses vs. spectacles........ 20.2.0 2 cca cee ee eee eee enee 480
Eyes—and evolution ............. ie Beetitightetelad Mican poe 57, 61
CCUBCMONIE: oc a'eas eee geeueeN Ne ee oo ad ROKER EY 15, 30, 496
importance of inequality of............. 0c cee eee eee 145
mathematically perfect ......... 0.0 cece eee eee I5, 30, 496
Eyesight, defective, of New York school-children........... z
Eyestrain and alcoholism......... UAvPRRE ER VSS EAS REMOES 194
and. appendicitis: .5 204 2tsaase Genesee cade cea eanmnwes 40
atid) astigniatisM” sacs ccd ahalsainieee ead ke ot aimee 18
and brain-disease ........... CLAW De Oe RAE RS 434
and brain-disease so-called.......... 0.0. c cece eee 188
and: *brain-fag shwewecaa hs sedeweie hike Sieeeets 109, 234
and Bright’s disease .......... 0.00. cc cee ee c eee cee ees 187
and. Ghést-paiti: 22.020 4amssainen eset daniels eedoeuea 383
anid civilization: wisssuatdedgactnad avy cds kee sey 47, 65

and Continent of Europe
Eyestrain and crime ...... 0.0.00 c cece ccc cece ceceunvees 2, 45
and depression orca cess suc s ee adievawcieoues 193, 240
and dermatitis .............. BN ties apes bced tb ald ane ad 385
and desk, slope Of........... 0. ccc eee cceeccceceeues 307
and diseases of abdomen........... gules RAE Ra Ree ee 40
and disease of frontal sinus...... Peach dod) Aegan Bayete ane dob 40
and disorders of motility....... ena Mhw Geek ara» 238
and disorders of sensation................0ceceeceees 238
and disorders of stomach................. aediah iitiaseaia es 41
and dysmenorrhea. i253 casa ee secs maine casa ae whan es - 20
din ySPEPSia: io de Mica ath euleaien sveston sy cae eae bs 47
aid, QnUnesiS: caine es sinariaid coeinas aeeaRee D oeee5 SHOES se 33
and! epilepsy ‘se os ieetend 422546 ee eed owen 45, 65, 70, 172
and €XAGSETALON . 2s nuecieie ess bak wend Oa dae EMD SN ans 443, 457
and: forgetfulness: sae. piwiilay sds as Qeawee sana s IQI, 192
and functional diseases......... 0.00. cee cece neces 47, 65
ANG) BOUb a Han scans band bid celal Be arava o Mldmiaew akon wave Date 15, 188
and hearing ....... Rua ake e Sei eeGea EE ECRE SEREE ESA 396
and, hystetia iis av sca nqand 4d 4 MEER ER Sa KonetRS 173, 180
and inflammations of the upper air-passages........... 40
and injury to the head.......... spin ahidy esas be dose x atpenghuar oad 391
and: insanity” sos siete c's bree boas oe ae 45, 65; 70, 194, 241
and intemperance sass diate 8 ected sic aad 9.064 o araauene 194
and literary work........... Ad fis av ast cae Syn ce wae haan 241
and. smedical literature... c4.ce4 ses gnans Seda S aoe he ene 438
and medical periodicals... ...... 20... cece eee cee eee eee 442
Sd. MieMOTy, APSE OF. s.ceneyeennc se neew tre adaws 19I, 192
and menstrual disorders........... 0... eee e eee eee 20, 49
atid. WMeTAINE 4: 4eaanewaa es 20, 46, 65, 67, 221, 244, 377, 450
and miscellaneous disorders ............. II, 12, 13, 14, 40
mid. neurasthenla: «12. acweiseads eae views a 173, 180, 195, 198
and neurologists, the ........ Mav eeeh ee aaa nes ead ee 439
and nutritional disorders ....0c45.0s+eeane seas se eea nce 19
and PESSIMISM, nscue dead daw Rear ak awe POR new 72, 240
and profession in England...... Ep auth adanee aie ae 10, 37
and refraction, low errors Of............ cece eee eee 449
506 INDEX.

Eyestrain and rest-cure ........ 0.00.0 cece ee erence eeenes 44
and ‘school-lfe: 362 sameness oadliaclga da ne clene d 2 edea aia 69
and ‘ScoliOSIS> i522 yaa te soede eeeca Rete ee oes Bo Aly @Ety 397
BG SEG SiCHOSS os k54 cer dbeman me ce oo Rad BA RES ERE 181
and severe physical exercise (Taine)..........-..0.5- 103
Std Sinisiroeularnty os seue xed deeeeands oy dees eeweweed 401
and spitial curvatire....4-6.454054045 e0eeaEs 2. at 263; 377
MN SUITS weds Siow aed ermon sdhne eK 45, 65, 73, 93, 192
and text=books~ scmcdihnudiaa ama sate eed deh Rhe ak adn esol, 231
and ‘toothache — 22 e's es sy 20g 246 wwe dlie Sea alacd nie ei draaians 387
ANd tAIESIORTIOCES 44 ccd 5 ca dena kee dew PY oNe se RS Re eR 181
AIG! ELUATI CYS 2 a oresedichaiva ley Gs. save ted are eens arg Saha are ee OA Bp OF
and tuberculosis, Symonds........... 0.0 - cee eee eee 86
Ald WASOMOTO? Dishir Panes. cuca s deagew sn noes dau suwx BI
as a cause of headache and other neuroses............. 117
as viewed by Dr. John Green............. 202s eee 55
basic similarities in symptoms of sufferers............. 109
Bases, Snes analysis Ol os ou s4s5 eu eee eey ee eee ea dane 137
collective investigations Of... 0... 0. ccc cee eee eee eee 18
discovered by physicists........... LE Deed KERR LOR 5
MISCOVOTE OE ce tana eed eaedRe wakes Rms ewan Dede e Ana oe 433
Vis! OE. occa test a acdaadale eae eie e canea are Miao lee eiaetranacacs aie 334
functional LESuUlts: mnavine rene ox eae MAARAOR A OL eee We sishe 32
eupitic: GYNIDIONIS: Olesen. cove cesdas Bee wede eee naians 128
BIC AINESS: OF a etccsurnais, D8 Aka baven Qn praenndeae hen h iecaoe 127, 191
headache of, situation, characteristics, etc.............. 125
HIGH) anda sag ecadionnceeene esd see uaycuceeagn eee 118
how it produces its effects........... 00... ee eee eee ee 9
in psychologic development of the young.............. 10
Insomnia Of sissies daw bras oramaw sa aay eae 127, 164, 192
PIGEALGHe HOON waenided icy easton aw exes dees ss 54, 438, 462
Mobius” belief aS) tO. ia sgeedens ia scswamignedeine asad iit
of New York school-children........... 0... 0c eee eee I
of: “Daine? sh cosanee cae s tenet eee mma sa beau a es ae 99
of “Wasner, Dri EIS: Gtiie ys case ats sigmiies ce tees oo eS 18

preponderance of women with.................005 137, 233
INDEX. 507

   

Eyestrain, professional opinions upon ..................82, 231
scoliosis, and the orthopedist.............. 0.0.00 ce eee 453
theory and leaders of the profession................... 458
theory, clinical proofs of............0. 000 cece cece eee 10
theory, Dr. John Green upon............0 0. cece eee eee 467
theory opposers, exaggerations of.................0005 22
theory prejudiced by inaccurate work................. 52
theory, professional opinion of..............00ece eee 463
theory, reasons for rejection of............. 0 cee eee 50
unfortunate 4éhm. 4 4c6 aesees< ca aiasde sone dod guna ne Hoe 31
why sometimes not relieved by spectacles............. 448
writing a particular cause of........ 00.00. ee cee eee 337

Forgetfulness and eyestrain... .....c.c0 cc sneacenanncens IQl, 192

Functional—disease and civilization.....................- 47
disease and eyestrain... ......... cc cece eee re eee e es Avy 08
origin and results of eyestrain..............-. 00. .000- 32

Function—morbid, and pathology.................00 2.0008 o
OE medical Ieadetiss cea ccedee 4d Rae dee ne esa eeewrena eo 461

Functions, interdependence of............-.0 eee eee ee eens 38

Gastric—crisis of migraine........... cece cee ee eee ee 235
symptoms of eyestrain..... 00... e eee eee eee eee eee 128

General health and presbyopia........ 0... cece e eee eee eee 479

General Medicine in relation to the new ophthalmology...... 27

(Fiddiness Of CVeOSEVAIM «400909 Ghee es bee a CoRR EST Owe a we 127, Ig!

Glasses, correct, difficulties of obtaining................64. 4

Glaucoma and refractive anomalies............ 0000 eee eee a6

Gout—and, eyestrainic. c.6 cos cee ceed peace sansa ened. 15, 188
atid Migraine... .s5s sew ee deed Sse De eee ge Raed gene 236

Gravity and slanted writing............ 0.6 cece eee eee eee 298

Green, Dr. John—Upon Eyestrain and Biographic Clinics.... 55
upon the eyestrain theory.........-. ee eee eee eee eee 467

Hand and eye, relation Of........ 0... ce eee eee eee eens 366

Handwriting, slanted—and hygiene..........--..e eee eee 295
and visual function....... 0... cece eee eee teen eenee 295

Hare on nutritional disorders and eyestrain...............- 19

Headache—“ academy "0... eee cee ee teen eee ISI
508 INDEX.

 

Headache and astigmatism .......... 000 crete cnet eeeeee . 18
Oy bityele cicdeccs ds hoe ews Senta AG He OA eRe 153
and eyestrain ..... SauhAiDe! Ach Nad Hrtud Incysuageaaneceinees Inf, 125, Tor
ocular GTISI. Obes a dsccs boc ees hos RRM ree de ee R OST 23
of eyestrain, situation, characteristics, etc. ..........-- 125
Of EYGONES cnc cic ds cee ean Tas Soden EEE BRAGG HEE HORS 79
SPASMOGIC'chargnnsca-aeea ind Gena eel elaciaD abre ousted aetauemy 212
“SHHEALER ” ~ Luke hac asses ode Se eroairea mA ae eee ace ae e I5X

Head, injuries to and evestraitissi4ceunsea se eaue ese eeeeses 391

Heéad-tilting—and astigmatism .......0.c0.058855%5 AZ, 279, 372
anid. SCO]LOSISS succes card fo Bsa. Wye cach aanw olla an ond GCETE. aN iteteanitetaend 4o1
other organie sesults of... ..ccccsance cecnedes erenewes 283

Hearing and €yestrains :sascsea ng caeuas a's yaar es Vamaigen’s 396

Heredity and migraine........... ccc ece reece ec eetnnetenee 230

Heterophoria and refractive anomalies.............6..0005 35

Hotz; Dri -F: C., on refiactiOns ios seceaaaacien cadmas 8

House-organs and scientific advancement...............005 445

Hygiene and slanted writing... ........ 02.002 e cece eens 295

HyStéria and @yéstrailt on. eee e era es eke wa eee eean se 173, 180

Mumination of school-vrooms...civesece cence eens eenees nee 283

Inaccurate work and acceptance of eyestrain theory........ 52

Inclination of desk in writing..... Recetas sa enemies te 272, 308, 315

Indifference of profession to medical discoveries....... 5, 16, 23

Inequality Of Gyes, importance Of. 0... 6000 ce eecwawe sows 145

Insanity and eyestraim.. ci tecsuca ss euvadeies 45, 65, 70, 194, 241

Dasonmiig of eyestrattliscuces io cee cenes saeeean ees on 127, 164, 192

intellect aud ‘ViSiGH. «4 sa4ky eenesege eeeesass er hegeng ene 62

Intellectual functions and dextrality.................022 0005 350

Intemperance and eyestrain............. 0. eee cee eee eee 194

Interdependence of functions............ 0.00 0c eee eee eee 38

Introduction; ws cscusu a0 sheedew eee tee. sh aieraeenee dens eee I

Investigations “ collective” of eyestrain................4.4- 18

Ivitis and refractive anmomalies..... 4 004-cceceanvarvrsues 35

Keratitis and refractive anomalies......... Dp madomnin BG dee es 35

Leaders, medical—function of.........-.020ceeeeceeceeees 461

and eyestrain theory: «0040566. daee0s caeaiare se eeee ead 458
INDEX. 509

Leaders, medical—opposition of to advance....... 16, 66, 68, 231
Light for working, quality of and presbyopia............... 478
Literary work and eyestrain.............. 0.0 cee cece eevee 241
Literature, medical, and eyestrain.................. 54, 438, 462
Logomachy and psychiatry.......... 0000 ccc seen cee ee es 44
Malposture—and slanted writing.............00 cece eeeee 295
not the cause of myopia............. cee cece ee eee 329
‘writing, factors: Of soo. ni nen Pec wawe yan be s Hees 298
Medical—discoveries, motives for ignoring................. 430
discoveries, reception Of............0 0. cee ee eee anes 415
leaders, function Of. :c0.0c04 6000 es aad seed anderen ees 461
leaders and eyestrain theory.......... 0.20. cece eee eee 458
leaders, opposition of to advance............ 16, 66, 68, 231
HPSrative UWpGn GyeStfaltiie sce acieeeeciev sea veeeereneun 462
periodicals and: eyestrain ..6.casceeave ee ewe wees eens 442
Medicine, general, in relation to the new ophthalmology.... 27
Memory, lapse of, and eyestrain............ 0.000000) IQI, 192
Menopause—and migraine 2.4... i cc08 cases se pene ves ranean 233
and présbyopiad <i ricus saws weteckosoee ve eae ge weds 49, 233
Menstrual disorders and eyestrain...........0 0. eee eee aes 20, 49
Migraine—and eyestrain ............ 20, 46, 65, 67, 221, 244, 450
and Heredity vices emesiscaed peeing re CARA Gifgaeea ensue 230
And GCulat *Paralysi6.c.c oe ve5ce hese ooo Ree EROS RENTERS S 238
and ‘presbyOpia) snide we Qids canes RE Ged debe eee ae 235
And: puberty cacy qussiog roe agar at wee since Same eee 245
and scotoma scintillans.......... 0... cece eee eee eens 222
pnd The O¥eracer sess Qe ke Sees aa Bees 20, 46, 65, 67, 221, 244

and the menopause....... 0.0... 0. csc eee eee eens 233
CAUSE: OF ccna ease t Sede dE BEGAN DUREE Gas 201, 207, 244, 377
classification and etiology...........c cece cece cree eee 207

_ colds, rheumatism and gout.............. esse esse eee 236
defivation of tetims« cv cccscanns cece swan eae ee ame wes 201
gastric crisis Of... 0.0.0... eee eee eee cee eee ete 235
history and etiology Of........-. cece eee eee eee eee 201

in literature and history............. shapers Gio toudione 203

pareses, paralyses, and anesthesias.......--.--.+.+++4- 237
510 INDEX.

Migraine—pertodicity Of xvave8ee ct neesauys oa Sade ee ve wen 234
prodromal symptoms .......... cece eee cette eens 216
PSYCHIC “<GISOPAETS: Oli. icia sid dundue dad aera Phe sanac ores 239
relation to age, sex, and occupation................2605 232
SQ Quel Ss! OE! .syajpei sein 'y big eceasmae-a hs aremnerinia alah dale yeis Mae AiueNe RS 243
the typical attack: :<4.dacepewes adr syeseues snremedas 217
REALISTIC. OE «year og tnecdad enaigvectineed aner quero aut dee Saas SapoeRes 242

Mobis: and. eyestrain. «oi ac aay an nerewndead ate tad honed munnets III

Morbidity of slight errors of refraction................005 15

Motility, disorders of, and eyestrain..............0 00 eens 238

Motives for ignoring advance in medicine................. 430

Muscle-balance, faulty ....... 0... cece ee eee re eee eee ee ees 149

Music, tlesivaliy: dties..0.yavewae ees omnes haw enw aw ates 347

Mydriasis—in presbyOpid. couccsvcuyesueaceaneneneune sss us 474
suggestions as to refraction tests after................ 487

My driatic’ ESSEMtVAl,.focicais creed: 4 ncoy eidedvacw soavecdiigre: ed bie eed ad Gasanvaee 147

Myopia—and. ametropia. sa sa cncsescccinacawe es Pee baa eeae 36
Bird WSUSMALIGH noonats a4 eee esa age Ree sg eee aceue eae 433
and Slanted WritiO® ocicy yes es ddas Rage Pee ete een G44 BES 295
POSES OE ad Keune ss 0s (avewne he edeawecar se isna ed iaae 331
mot gaused. by malposturé, 1. ses iaeewsws rr eden ssa ses 329

Nearswork and presbyopia......sc00% 05 eccu sus deawne va eee azz

Neck-curves precede spinal curves.............0 0000s eeu 253

Nervous system and slight errors of refraction.......... 187; Tog

Neurasthenia and eyestrain..............0000- 173, 180, 195, 198

Neurologist’s, a, confession.............+.¢ Be scab) ale itt ac ee 23

Neurologists, the, and eyestrain, .4...0.¢s00804scees eda ewe 439

Night-terrors of John Addington Symonds................. 78

Nutrition, disorders of and eyestrain........... 00.0.0 ce eee 19

Occidental writing postures and scoliosis............... 280, 317

Ocular—origin of headache. .-...05 0.66 s8 abe e et eee ewe wee 23
paralysis and! migraine ...¢. 224.295 s0rgnrerrenescats nau 238

Ophthalmic clinics conducted by students................05 69

Ophthalmology—and prophylaxis ......... 0... cee ee eeuee ay
most difficult field of practice. ...cccccunicncnacase ewan I5

new and old, relations to each other. c...e. ec eusaances 34
INDEX. 511

Ophthalmology—* new ” definition of ............000000005 23
old and new, distinction between.............02 0.0005 27
“Sold,” definition Of: 64 ssw i isccw was ween pa enue ea wkebe de oF
reactionary Spirit itisc.vesdaseese sie ds oeeesx cannes 17
the new, in relation to General Medicine, Biology, and

Soctology” sxdgecuacid Gases Aateac cea ice ip ene He 27

Opposition of “leaders” to advance............. 16, 66, 68, 231

Opticians and rural patients............ 0.0.0. cee eee ene

Optics—pathologic 2... ... cece cee ee ee eee teen - 30
physiologic: 24 spas soda dkgue yaad reese mew hes eee eae 29, 30

Oriental writing postures and scoliosis...............05 289, 317

Origin of slanted writing............ ccc cece ee ee etnies 326

Orthopedist, the, and eyestrain and scoliosis............... 453

Paper—position of in writing and scoliosis.........:...... 285
position on desk in writing........... 0... 0c cee ee eee 304

Paralysis—and migraine 2044. .04c.ece2ssdaes ee eso ae dems 237
Ocular, and WiSraniGe<s bs vac anes 00049449 SESH ESL 6 Oe 238

Patesis atid -Mieralie wii shad cde one ee eee RE EES 237

Pathogenesis of tuberculosis, Symonds..............0-+0005 87

Pathologic—opties: <0 setae net ae sled oye an wade ee ORw se 30
results of dextrocularity and sinistrocularity........... 363

Pathology—and morbid function.......... 00... c seen eee eee 3
Bnd Vision vse areas te dow ewa aa ae AeA Ra 7
caused by abnormal physiology.............0 00sec eee 32

Pen, position of in writing...... 2.0... cece eens 308

Perfect, mathematically, eyes.....0c.0000+ AA hide od Be 15, 30, 496

Periodicity of migraine....... cc cece cee eects nee tetenenes 234

Pessimism and eyestrain... ......... 0c cece cece eee ete 72, 240

Physicists the discoverers of eyestrain..........e cee eens se

Physiolowie! CPt eS 4.sos.«: s.smng patinda’s Visors, adorns Bah ai alniieds 26, 30

Physiology, abnormal, the origin of pathology.............- 32

Position of pen in writing... ..... 6... cee cee eee eee 308

Posture—morbid, in writing.............eee ee ee 2, 252, 264, 272
sitting, and scoliosis............00ee essere eters cone 284
thé, Gn WHitlhS: gacsseces seeew oop ees Heuser Vee wes 264

Premature presbyopia and subnormal accommodation........ 377
512 INDEX.

Presbyopia—and general health..........---ee eee ee neers 479
and the menopause..........0 00 eee creer erences 49, 233
and migraine ..........- 2. eee eee eee teen eet eres 233
and mydriasis .......... 0 cece eee eee tet e teens 474
Aid NEAPWOTKE avicca sce eae d ee reece SoH eed s ER RE TES 477
and quality of working light........---... eee eee seers 478
begins: with life... .. cc cece eee ene eens 405
ONSERIOE scare iW aatatn asad RaWEN BAER ee wis ea A es 473
premature, and subnormal accommodation............-. 377
Symonds) sesernaia sad yc ers s comiene sees teneeeiucn PRS go
Problems of presbyopia..... 15... eee eee e erect ene enee 473
Professional—indifference .......... 0c cece eee eneeee 5, 46, 231
opinion of eyestrain theory...........++..++-+- G5, 2a, 409
Profession—English, attitude toward eyestrain........... 10, 17
leaders of, and eyestrain theory............-.e eee eeeee 458
Pronger, C. Ernest, “ Slight errors of refraction and their
influence on the nervous system”’....... 0.0.00 seen scenes 157
Proofs, clinical, of the eyestrain theory............-...... 10
Prophylaxis in ophthalmologys... ses .0e ene cu eveneweyeuns 37
Peyeniatry arid lopiimachy....4 0.400070 ¢s4a0a 5 eeee te eceas 44
Psychic disorders of migraine......... 0.0.00 cece cee ee eee 239
Psychology of development in youth and eyestrain.......... 10
Puberty—and astieinatisnt coas cy cede eres ee ges eee scenawve 49
Wit DOTA oe doe 5 RAO RBWER ES Raha s Oa se eed toe oke 233
Reactionary spirit in ophthalmology.................... wie ES
Reasons for dextrality......! It aad eka ea cas ota We Sov everest aay Wes Sate 341
Reception of Medical discoveries.............0000 ec eeeeee 415
Rejection of eyestrain theory, reasons for................. 50
Refractionist and the optician........... 2.00.0 cee cee eee 34
Refraction==Fy C: Hotz ons acovescasiowasaesaawaw eke wes 8
HOE FOr BOCUPR Give canseeda eye enw dcaemnee eens ied sas 474
should be accurately taught............. 00... eceeeeee 53
slight errors, and morbid results............. US, 3%, 187; 449
slight errors, influence on nervous system............. 157
-tests, post-mydriatic, suggestions as to................ 487

“work; inaccurate: os pais e ged ead saaiee shod sake es 378
INDEX. 513

Refractive—anomalies and heterophoria................-.- 35
anomalies and strabismus...................0ceceueue 35
EFPOTS: ANCTEASING sc.nsuyalsetas ooh do MMOS Gong wa suninde ee 194
Rest-cures iand. teyesttain. «24 496% o0n34 cand apaaan many ecad 44
Rheumatism and migraine.........0..0.0. 0.0.0 ccc ee eens 236
SCHOOIGESK: tHE: 5 4 cesta encase aud. ea snnss alan eee er arab avs 322
Schoolelife: and ieyesttaime. 4 wie aed Hapyeed dew + esuachicn pes 69
School-room, illumination of........... 00000. ccc e eevee 283
Scientific advancement and house-organs.................. 445
Scoliosis—age when first noticed........ 00.0.0. 0 ce eee eee 254
afid eyestrain, i .c.% taiee is ew Salonen piedebbagibg ta 2, 41, 251
and illumination of school-rooms..............0..0 005 283
and oriental and occidental writing postures........ 289, 317
Atid, SItTHNS-POStUTS: ose quae Ws dis ode elses Berd Gagadoneen weve 284
and, slanted writings 0cc.csms piensa ys ete x emne2§ 2 295

and position of writing paper.......... 0... cece eee eee 285
CALISES: Oil i4.> a hae coensaus: sosceurd ya Siarctudl- bod eases chad ah eae usec ae INS. ts 258
eyestrain, and the orthopedist.............. 0c ee eeeuee 453
frequéncy Of 2. 4neve.eesdeerayege ered a egy ebagac ed ws 255

IM PEIAION £0 SER ise.o. kas a-p duane d drerais a geaunt & JWeretee aepmcted S 255
Oonlar Tachets Gloss onss came od koe E ROH RL ORO EAR BRASS 251
statistics of the kind of curves............-0 0.0 eevee. 256
Scotoma scintillans and migraine............-.00e eee eee eae
Sea-sickness and eyestrain........... 020 e cece cee nee 181
Semmelweiss and antisepsiS.............6 2000. c ee eee eee 426
Sensation, disorders of, and eyestrain...........-.+--2505- 238
Sicksheadache: aiccaacesadaniite sreka hes win ase ee eS ELSE 212
Similarities in symptoms of eyestrain sufferers.............- 109
Sinistral, definition Of 2.5 0... nne0 62 e504 geaven se seorsa states 344
Sinistrality—and dextrality ....... 0.06.00 eee eee eee eee 341
definition of corresponding termsS...........+-0+-e sees 344
OTIGIN: OE vga scedend ace cap FE RAMS RAED oS oe aE ime te 355
Sinistrocularity—and eyestrain .....-.. 6. ee ee ee eee cee 401
pathologic results of... ..... 00.052 e eee ee tee eeeeee 363
Sinus, frontal, inflammation of and eyestrain.......-.-.+--. 40
Sitting-posture and scoliosis.....-..-. 60.000 e centre e ees 284

34
514 INDEX.

Slanted writing—and malposture in writing........-.....-- 252
and ‘Visual functiones.. sas geee aa se maernale ye ae tee Bees BS 295
Sleepiness: of Syovds 0.0 ccc cece seis sn on ea gSe eRe TE 79
Slight errors of refraction—and their influence on the nervous
evetem (C, Rernest Prongem) sc 4. ecvavecvacsascewee ns 157
MICE OL oc ooo kG eeu OY BENNER RE ws 15, 31 449
Slope of desk and eyestrain...........-.....5. 272, 307, 308, 315
Snell's analysis of eyestrain cases. si. caccckadraneyeewenent 137
Snell, Simeon, ‘‘ Eyestrain as a cause of headache and other
MEUTOSES”” na cede ho seSe dees SI WRERS PEDRO SS Cees 117
Sociology in relation to the new ophthalmology............ 27
Some problems of presbyopin... 5.144 case ccn eve cieiveawres 473
Seectacles— not OMMNPOTEHE 14 0e0cey cpa kow ie arwuue ia wanwes 24
WSs Gye=glasses gee iceeedhesass Hae Eee based ee soe ey 480
why they sometimes fail to relieve..............002005 448
Speech-center—location of 14444444 pe8cd4 peeve bus eewnwes 350
relation to intellectual functions..............0.0000 05 365
Spine, curvature of—atid eyestrain... .ccsccsccvaeecess 4, 41, 251
arid Slanted WHS... Goa daw e040 o Acedia od aabes de eiscis 252, 295
aid. waiting Posttrtee. ses ccessnaitee see e ens e404 Romer 289, 317
Stomach disorders and eyestrain..............00 cues ee eeee Al
Strabismus and refractive anomalies.............--.200005 35
Subnormal accommodation and premature presbyopia........ 397.
Suffering of Symonds, connection with writing............. 82
Suggestions as to post-mydriatic refraction tests............ 487
Suicide and eyestrain................0000005 48; 65, 73, 03, roa
Symonds, John Addington—colds and influenzas........... 86
CRIES Ooi Semcg ne eh Ses oeek eid ds wel dake Bas $h4 ed 89
life tragédy~ Of... ssc seeunaednuttsataraeamanat ns aauees 77
PHESHYOPIAl Gar cawanemcawiod PAE MeO aiGARaie’s wanes 90
tuberculosis of and eyestrain............ 0.0000. eves 86
walking for relief of symptoms....................005 84
writing and suffering connected............... 000.0005 82
Taine; bhedlth, Of acanaciea sate aee aoe addanccs tise gis wha a9
severe exercise and eyestrain..............0 000 cee aaee 103
Walking +5 ea. anaes stay Syawe sede we uw oa oo en 105
INDEX, 515

Teaching, accurate, necessary in refraction work........... 53
Testing, careful, essential.........0. 000.000. c cece ee eee 148
Text-books on eyestrain........ 0.0... cece eee eee eeeeeee 231
ETneater ”* HSACACHE: coz Geordie a not ~ w pan Queene OR aver eienaieiaann See I51
The history and etiology of migraine....................0. 20%
The life tragedy of John Addington Symonds............... a9
The new ophthalmology and its relation to general medicine,
biology, and sociology.......... 0... cece eee e eee eens 27
The optician and the refractionist....................0005 34
The optic and ocular factors in the etiology of the scoliosis
of ‘Schooleehildineny: 2 asic actucd pieced oh oboe ve gas Aga we Aer 251
Toothache and. -evyestrainades vaasaea wads eccaayy sea iotees 387
Train-sickness and eyestrain............. Per eaeen a Ia 181
Dravell Of Symonds x i.4 x cnc iGo er were bw eae aga 82
Drwarey and yestratits vcsada wen oe see 4 AOR eR ORS ROO a, 9
Truths, new, modes of killing........ 2.00. c cc eee cece eee 429
Tuberculosis of Symonds and eyestrain.................45. 86
Vasomotor disturbances and eyestrain.............-...0005 21
Visioni—and: Equilibria, coced. cece earcson peare eee ae eko es oa oe 288
She SWCD 4 scene cout dar eeene ee eer seeweedaenwaes g%, Gr
SIM TSE. Scand aeanes easy coeedteteaede eee as onws 62
OG ALN OWE y ak ac etek ake AREY Hoe SEARS 7
of the writing-field necessary........... 0.00. c eee eee 312
Viewal function—and slanted writing. ..00. 0.364 s0cesvcnewe 253
the vause af slated writit@....008 ciecuasaeensnverews 295
Wagner, Ellis on eyestrain Of... 10... cece cee eee 18
Wallkine—Symonds 44. sccscasesas saws reves ea enun re eeedas 84
VRE avekibe vas 4 Gee 28 404 RESET Dae ee Rees eee eaas 105
Walton, G. L., a neurologist, and his admissions............ 23
Women, preponderance of with eyestrain............... 137, 233
Writing—and suffering, Symonds, connection between....... 82
a particular cause of eyestrain... .. 66. eee ee eee 337
dominant eye inks = Sica cad sieatene lawn ge adentuupee ts 301, 311
-field, necessity of seeing.......... 5.0.0 cece eee teens 312
malpostire:, factors Of... s.ss;2eche sesesaageuieeyeouse 298

-position, leaning to the right.................000.005, 310
516 INDEX
Writing—position of pen .......... 0.0.0 e eee eee teaaa 308.
POSbures.y2.40 Geneente we VARine ene ata 264, 272, 298, 310
posture and school-desks........ 0.0.0 ccs e ee eees 272
POstUre, MOR fis 0. cig,cces2.) gulasadiarwdacdagnatne 3, 259, 264, 272
slanted, and astigmatism............ 0. ccc ceeeeeenceee 299
slamted, amd desks. ovccuxeceias ses casignnieeee ee oes 272, 295
slanted, and dominant €¥0..5244¢4s44e0¢e0x "se gee 301, 311
slanted). And: -SraVILY foils icc gee Fd lerlnavonds § S808 ene aes 298
Slantéd,. dnd, Wy Pienes wow aexcd ee sha aKA Ee DORA Sha SOR 295
slanted, and malposture o....5 665200 cs ceva eee ene a daa 295
slanted, and: MyOPlaueciwresyrcaseada peewee eaenaceaaa 295
Slanted. Ad Saouoees soa ec ok oe o ws A Pm EON COO RE HER 252
slanted, and spinal curvature.............. 0000000000. 295
slanted and the visual function.................... 253, 205
slanted, when, it ofigitiated ..u.56.0cces5 papain nae pase 326

Vertical ws, Slanted ss viseese dads bo i4 ee oss AER RES ESRD 296