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liarity of this defect lies in the fact that it is susceptible of recognition and correction only by one who has made the eye a special study. A person who is nearsighted may select a glass from an optician's stock, adapted to his degree of myopia; and even the hypermetrope, if his case be uncomplicated with ciliary spasm, may not err in his selection to any serious extent. Not so is it with one who is astigmatic. Each case must be worked out by itself and be corrected accordingly.
Among the masses, there is undoubtedly a strong prejudice against the early use of spectacles, or eye-glasses; but, as the subject becomes more fully understood, this prejudice will melt away. You would think a surgeon sadly remiss in his duties who attempted to treat a fractured limb without a splint, or a diseased hip without extension, and yet you see cases in your daily practice that stand in urgent need of the relief and benefit that a proper glass alone can afford. One may observe on the streets to-day ten children wearing glasses where only one was noticeable a few years since; but where one is seen to-day ten more ought to be seen, for it is safe to say that, if suitable glasses were prescribed before the age of twelve years, the number of persons affected with refractive errors would soon begin to decrease, and the amount of inconvenience and discomfort, and even of actual suffering, would rapidly be diminished. The practical conclusion, then, is; let the eyes of the young be examined, and, if found defective, provided with suitable glasses so soon as their possessors are old enough to wear them with safety, and until then do not allow excessive reading or study.
The question now presents itself, How shall the general practitioner, who has paid no special attention to ophthalmology, recognize these defects? In reply I suggest, Provide yourselves, first, with an ordinary set of test-types and lines, and second, with an optometer. With the use of the former, doubtless, you are all more or less familiar. Regarding the latter, however, much less is generally known; yet I have found it of so much assistance, not only in verifying a diagnosis but in saving time by at least approximating to the required lens, that, with your permission, I shall exhibit one and explain its uses.
So far as I know, this form of instrument is not mentioned in any work on ophthalmology; neither do I find it advertised or shown in the catalogue of any instrumentmaker. I do not even know to whom the credit of its discovery belongs. The one before you was modeled after one obtained, more than a dozen years ago, from the Royal Ophthalmic Hospital in London, and it is the simplest and most serviceable form of the instrument that I am familiar with. It consists, as you see, of a straight rod, two feet long by three quarters of an inch wide and one quarter of an inch thick, graduated in inches and in fractions of an inch. At one end is firmly attached a semicircular metallic frame in which an ordinary ten-inch double-convex lens is placed. A small clamp, so arranged as to slide back and forth upon the stick, contains a card printed in No. 1, or brilliant type. Closing one eye and placing the ten-inch lens before the other, a young normal eye should read the print with ease as it is moved along from the three to the ten-inch point. If one can not read out as far as the ten point, but can read nearer than the three point, myopia is indicated; if not as far as the ten point and not as near as the three point, astigmatism is probable; if beyond the ten point, hyperopia certainly exists; and if to the ten point but not nearer than the five point, presbyopia may be assumed. In cases of children we can, of course, eliminate this last defect. When more than one refractive error is present, we can not recognize the defect so easily or estimate it so closely; but even then, by careful observation, the exceptions become nearly as instructive as the rules. Suppose that a patient reads easily from the three to the fifteen point. To find the glass which he would require to correct his hypermetropia, we multiply the standard point ten, at which he ought to read, by fifteen, the point to which he actually does read, and divide the product by the difference between the two points; e. g., 10 x 15 150 ÷ 5 = 30. A plus glass will therefore correct the hypermetropia. Again, if he read nearer than the three point and less than the ten point, say from two to six, we probably have myopia to deal with, and we make our calculation as follows: multiply his
punctum remotum, which is six, by the standard point, ten, and again divide by the difference; e. g., 6 × 10 = 60 ÷ 4 = 15. A minus lens will practically correct his nearsightedness. In astigmatism, this instrument is of no service further than that it enables us to arrive at a diagnosis by exclusion. In this defect, we depend principally upon our ophthalmoscope and the test-lines. In presbyopia, we may take the point five as a standard for the near point and calculate as before. If a person can not read nearer than the eight point, then 5 X 8=40 ÷ 3 = 13. A plus will therefore be suitable for his reading-glass.
I do not intend to convey the idea, by what I have just said, that any one having a set of test-types and an optometer would be justified in assuming that he is duly equipped and qualified to prescribe glasses for his patients. Those of us who have devoted special study to this branch know that it oftentimes requires all of the many means at our disposal to arrive at a correct solution of the difficulty; but I do think that, by a little attention to and practice with these two inexpensive and easily understood appliances, any physician may satisfy himself whether or not his patient be in need of an examination at the hands of an oculist, and will have it in his power to contribute largely to the solution of this difficult problem presented to us:
What shall we do to lessen the rapidly increasing number of defective eyes among children?
THE DIETETIC TREATMENT OF DYSPEPSIA.
By AUSTIN FLINT, M. D., of New York County.
THE term dyspepsia is often used in a sense nearly or quite synonymous with the term indigestion. These two terms are defined in Dunglison's dictionary as equivalent. The French dictionary by Littré and Robin and the recent "Dictionnaire usuel" give to each term a distinct definition. In the "Real Encyclopädie," begun in 1880 and completed in 1883, indigestion is not treated of as distinct from dyspepsia, the former being considered as embraced in the latter.
The name dyspepsia, from its derivation, denotes an affection not necessarily involving indigestion. The name signifies difficulty of digestion. Now, digestion may be difficult and attended with more or less suffering and disturbance of the nervous system, the digestive function, nevertheless, being duly and completely performed. Clinical observation shows that dyspepsia, in this sense of the term, occurs without indigestion, the latter term embracing the various forms of disordered digestion. Cases are of frequent occurrence in which symptoms. arising from difficult, or, as we may say, labored digestion, are unattended by symptoms that denote any perversion or incompleteness of the digestive function. It may be said, and justly, that dyspepsia is often associated with indigestion, and that the latter can hardly exist without the former; but the point which I wish to make at the outset of this paper is, that the term dyspepsia denotes an affection distinct from, and irrespective of, indigestion, the latter term being considered as denoting an af
fection characterized by such symptoms as nausea, vomiting, flatulence, acidity, and diarrhoea, which show the digestive function to be either perverted or incomplete. By late German writers, the affection which it suffices to call dyspepsia is designated as nervous or neurasthenic dyspepsia.1
In this brief paper, I must be content with an enumeration of some of the symptoms which belong to the clinical history of dyspepsia. The local symptom referable to the stomach is a sense of weight or of oppression in this region after the ingestion of food. The abnormal sensations are sometimes of an indefinite but distressing character. There may or may not be tenderness on pressure over the stomach. Absolute pain is sometimes felt. These local symptoms are much diminished, and they may disappear when the stomach is free from ingesta. The appetite may be more or less impaired, but it is often not diminished, and not unfrequently it is increased. Patients complain in some cases of what is vulgarly known as a sensation of "goneness."
The symptoms, aside from those which are local, as regards the stomach, relate specially to the nervous system. Patients are depressed, irritable, and hypochondriacal. There is lack of buoyancy, energy, and of both physical and intellectual endurance. Vertigo is a not infrequent symptom. Neuralgic pains in the head and elsewhere are common. Sleep is disturbed or there is insomnia. Disordered action of the heart is of frequent occurrence. Constipation is the rule. There is undue susceptibility to cold. All these symptoms may be measurably explained, in many instances, by co-existing anæmia. The dyspepsia leads to impoverishment of the blood, often because alimentation is reduced below the needs of nutrition, and this condition tends in no small degree to increase the dyspepsia
1 Vide articles by Leube and Ewart in "Verhandlungen des Congresses für innere Medicin," Dritter Congress, Wiesbaden, 1884, together with a discussion by several members of the Congress. Leube has demonstrated the existence of nervous dyspepsia, without any disturbance of gastric digestion, by withdrawing the contents of the stomach at different stages of the process of digestion, and ascertaining, by the use of the stomach-tube, the duration of this process in the stomach of patients suffering with dyspepsia.