of seeing near objects clearly is lost. Dr. Oliver Wendell Holmes has spoken of this period as the "trombone period," when the book is pushed back and forth to find the most comfortable reading point. When the near point of clear vision has passed beyond the usual distance for work we have the condition to which Donder's has given the name presbyopia. If clear vision is obtained, it is with great effort, and the near focal point moves constantly further and further away, and the task becomes more and more impossible, when at last all elasticity has been lost, the ciliary muscle rests from its labors, and the headaches cease. Old age in the past was therefore the goal to which those who suffered from recurrent headaches looked for relief of pain.14 Theoretically, the visual axes of the eye should be parallel, when a distant object is observed, and the external ocular muscles should be in a state of physiological equilibrium (orthophoria). Frequently there is not a perfect muscle balance, and the visual axes of the eyes may tend to diverge from parallelism. If they did diverge we should have a condition of double vision, but so strong is the desire for binocular vision, that by continued muscular effort, the defect of muscle balance is overcome. I have briefly enumerated the ocular abnormalities which may be the cause of headaches, and it will be noted that they all demand unusual muscular effort for their correction. There is another cause of ocular headache to which I have alludednamely, abnormal use of the eye. In nature, the eyes were not intended for constant near use, and with poor illumination and long hours of steady work it is only natural that the eyes should rebel. Ocular headaches may begin when the eyes are first used for prolonged near work, and Standish says that nearly all frequently recurring headaches in school children are due to eye-strain. The period of puberty, a time when the body is in a state of nervous strain, is often a factor in developing those forms of ametropia which had better remained latent. The amount of error is often of slight importance, as in one person a small error might cause great disturbance, while in another it would give rise to no inconvenience. Likewise the disturbance in vision is of little significance, as the myope with greatly diminished vision may never complain of headache, while the hypermetrope with a vision of 20-15 may complain bitterly of his headache or migraine. Frequently this latter class of cases is dismissed by the family physician with the statement that his eyes cannot be the cause of his suffering because of their exceptional acuity of vision. Ocular headaches are described as throbbing, thumping or boring. Frequently there is a sensation of weight, fullness or deep seated pain in the eye balls. Any part of the head may ache, but the pains are usually referred to the forehead or back of the neck at the base of the skull. During the attack there is usually intolerance of light and sound. Gastric disturbances such as anorexia, nausea and vomiting are common symptoms17 and are frequently considered as due to gastric disease.12 There is often a nervous irritability, and lack of power to concentrate the attention and for days the patient may feel unable to follow his usual vocation as Gould has shown in his Biographic Clinics.18 Insomnia and general failure of strength may be present.13 Ocular headaches usually follow long and close use of the eyes as in reading, book-keeping or needlework, or they may occur where no excessive amount of near eye work can be shown.17 During vacations and rest from near work they are usually absent.18 An ocular headache may last for only a few hours, and may pass off after an hour's sleep, or, in the more severe cases, the victim may be confined to his room and bed for several days with a "sick headache." Consider the effect of such suffering on one who depends for his daily bread upon the use of his eyes, and in his willingness to seek relief in any form, you have, I doubt not, the cause of many a case of drughabit. As Oscar Wilkinson says, in his article on the “Ocular Treatment of Headaches and Migraine." "Clerks, book-keepers, seamstresses, tailors, students, teachers, writers and professional men by thousands and tens of thousands did their work with "bursting heads" and "maddened brains" before the physiologist taught us how they might be relieved." "The proof of the pudding is in the eating," and the diagnosis of the ocular origin of headaches can only be considered conclusive when any existing error has been corrected and the disturbances of which it has been the cause have ceased.17 Atropine or other mydriatic, by its paralyzing action on the ciliary muscle, will frequently relieve a headache due to eye-strain, and in this respect is of diagnostic importance.15 With the treatment of the attack I shall not detain you, as it requires only rest, quiet, a saline cathartic, and some form of anodyne. As a rule, a careful examination of the eyes should be made, and in the young, errors of refraction should always be made after the use of a mydriatic to guard against the spasm of accommodation so frequently found in these cases.5 According to Goux16, a transient mydriatic usually gives satisfactory results, but some cases only reveal their full error after atropia has been used. Dixon, (Latent Hypermetropia, etc.) argues that even under full mydriasis the ciliary muscle may not completely relax the spasm formed in correcting a latent hypermetropia. Full correction of an error of refraction may not give complete satisfaction, if the general health is impaired, or the eyes improperly used. Tonic measures and attention to the hygiene of the eyes are of the utmost importance. Glasses for the relief of headache are for constant use as the cause is always present. Clear vision with the proper correction may not be obtained for several days, or until the ciliary muscle has relaxed. The examination made by jewelers and opticians who allow the patient to select his own glass, and seek always for clearest vision, are, as a rule, absolutely unreliable. 1. Burnham, G. H., The Canadian Practitioner and Review, August, '05. 2. Standish, Boston Med. & Surg. J., '92. 3. Standish, Norris & Oliver, Syst. Dis. of the Eye. II. 12. Wilkinson, Ann. of Ophth, April, '06. 13. Bishop, Ophthalmic Record, Mch., '06. 15. Wood & Fitz, Practice of Medicine. 16. Goux, Phys. & Surg., Detriot & Ann Arbor, Apr., '04. 17. De Schweinitz & Randall, An American Text-Book of Diseases of the Eye. 18. Gould, Biographic Clinics, Ear, Nose and Throat. CANCRUM ORIS, WITH REPORT OF A CASE. BY ZACHARIAH B. CHAMBLEE, M. D., North Birmingham. Member of the Medical Association of the State of Alabama. Cancrum Oris, gangrenous-stomatitis or noma, as it is sometimes called, is an affection characterized by a rapidly progressive gangrene, starting on the gums or cheeks and destroying the tissues very rapidly. This awful disease is, fortunately, a very rare one, and occurs only in children, and under very bad hygienic and sanitary conditions. Children between the ages of two and five years are most usually affected. This disease is said to be a secondary disease, always following some acute disease and never occurring primarily. In more than fifty per cent. of the cases it is secondary to measles. It also follows scarlet fever, and next in frequency typhoid, although it may follow any of the acute diseases. It begins as an ulcer on the buccal mucous membrane, on the gums, or roof of the mouth. It is very insidious in its onset and an ulcer of considerable size may be found before any attention is directed to the child's mouth. In most of the cases the ulcer begins on the left side of the mouth, and soon a brownish, swollen induration extends around to all adjacent parts. This sloughing ulcer soon destroys the gums and perforates the cheeks and a portion of the tongue; and, if the child lives many days, may involve the nose, eyes and ears and in fact other parts of the body. Clinically, a more pathetic scene can hardly be met with than that of a child dying with its tongue protruding, swollen, and sloughing off, and emitting a horrible odor; and the worst of it is nothing that mortal man can do will alleviate the little one's suffering; the child dying in a week or at most, ten days. In mild cases, when the gangrene is not so destructive as to cause death, the child will be left with a perforated or very much deformed check, the bones being often partially destroyed, and sometimes having a stiffening or ankylosed jaw. Naturally, in so severe a local disease as this, the constitutional symptoms would be grave; usually the gastro-intestinal symptoms are early and severe, due partly to the irritating sloughs being swallowed directly into the alimentary canal. There is usually also a severe diarrhoea and a high temperature, ranging from 103 to 105 F. The child is very restless and may have chills during the course of the disease, due to septic poison. The child is very often bathed in profuse sweat; sometimes due to the difficulty in breathing, also to disturbed circulation. The pulse is very rapid and the prostration is extreme. Lingard has described a thread-like bacillus which he finds constantly in cases of noma; but just what relation this bacillus plays in the causation of this disease is doubtful. The TREATMENT. treatment is very unsatisfactory. The disease is often far advanced when the case falls into our hands, usually a large sloughing sore is already present. Antiseptics are to be employed freely and of these a solution of copper sulphate applied freely over all of the involved parts is one of the best. Formaline, iron, glycerine, iodine, chlorate potash, nitrate of silver, either stick or in solution, carbolic acid, the I'aquelin cautery and fuming nitric acid are probably the most effectual, and should be applied early if much good is hoped to be accomplished. The child's constitutional condition is to be looked after with the greatest care, for to support the patient and render his resistant power as great as possible is the only hope in any treatment. Strychnia, brandy, beef juice, iron and concentrated nourishment are recommended. Nutritive enemata, such as are recommended for stricture of the oesophagus, should also be tried, when the condition of the throat interferes to any extent with deglutition. Fruit juices, such as lemons, oranges, limes, etc., have been recommended by some with the idea of the disease bearing some relation to scurvy, but this I think is of very little importance. A few remarks on the following case will illustrate how quickly a case may prove fatal and how hopeless we are in the face of so dreaded a disease. I was called, in October last, to see the three year old child of Mr. and Mrs. H. J. White, who for the past six or eight months had lived out in a grove on a hill side in a tent, with the best hygienic surroundings possible everything thoroughly sanitary and in good condition. The mother was healthy, and had three other healthy children, all robust and fat; the child had never had any sickness previous |