upon whom it has been, and will be used, with a view of determining the permanence or otherwise of its apparently good effects, and also of ascertaining whether or not there develop any untoward concomitant results. In the meantime, let us possess our souls in patience, holding a rein upon our naturally ardent expectations, and suspend our judgment until all the evidence shall be in. DR MISTAKES IN DIAGNOSIS. R. RICHARD C. CABOT, of Boston, is a man who is deservedly held in high repute by the entire medical profession throughout the country as an exceedingly able exponent of medical science and practice. He holds a chair of medicine in Harvard University; is the author of a standard text-book on physical diagnosis; enjoys a large and successful practice; is a man of exceptionally high personal character and integrity, and is, in addition, one of those really great personalities in medicine whose influence and work have extended beyond the confines of his own calling, and have told effectively in the direction of wise philanthropy and practical sociology. At the last convention of the American Medical Association, held in St. Louis. this gentleman, with a moral courage and intellectual honesty which marks him (if any further indication should be necessary) as a great man, presented a unique and thought-provoking paper, prepared out of his own personal experience, entitled “A Study of Mistaken Diagnosis," in which he analyzed the clinical history of one thousand cases, diagnosed by himself in the Massachusetts General Hospital, which afterward came to autopsy, comparing the showings of the post-mortem examination with the clinical findings. The paper has recently been published in the Journal of the American Medical Association, and makes exceedingly interesting and instructive reading. The analysis, as may be supposed, is a very comprehensive one, embracing almost every type of disease in various stages and manifestations, and represents a careful and systematic investigation of every case, both before and after death. Its net result shows that the diagnosis was correct in only about 50% of the entire aggregation of cases; in the other 50%, the post-mortem demonstrated that he was mistaken in his diagnosis, either by commission or omission, i. e., he had either diagnosed conditions which were not present, or had overlooked those that were there, and it must be borne in mind that in this 50% of correct diagnoses there were a large number of cases of diseases whose manifestations are so plain that the merest tyro in medicine would recognize them almost at a glance; such, for instance, as typhoid fever, diabetes, pneumonia, meningitis, valvular disease of the heart, and others which present a well-marked and easily recognized group of symptoms. It is therefore plain that, if all these simple cases had been eliminated, the proportion of mistakes would have been much greater; for, according to Dr. Cabot's statements, the percentage of correct diagnosis reached the low figures of 16% in acute nephritis, 20% in acute pericarditis, 22% in chronic myocarditis, 33% in bronchopneumonia, and so on. Now, if a man of Dr. Cabot's recognized supremacy in the field of diagnosis, with the courage and candor to face the real facts, confesses that he is only able to make a correct diagnosis in something like 50% of all the cases that he undertakes -and considerably less than that in those diseases which make anything like a tax upon expert skill-what is the irresistible conclusion concerning the thousands of practicing physicians whose skill in this direction is admittedly far below that of Dr. Cabot, who have not the facilities that lie at his command, and whose opportunities for verification or disproof are practically nil? Now, there is nothing in this state of things, in itself, at all derogatory to the intelligence and efficiency of the physician. No one who has the most elementary appreciation of the conditions and difficulties surrounding medical diagnosisranging all the way from individual idiosyncrasies to pathological variationswill for a moment misinterpret the showing made by the analysis. And that a man like Cabot should deliberately undertake and frankly publish such an analysis. displays a sincerity of mind, a love of truth and a devotion to science which can hardly be too highly commended. Such a spirit among its exponents will not weaken, but strengthen, public faith in medicine. Nevertheless, we can not evade the net significance of Dr. Cabot's frank analysis that the present status of medical diagnostics is represented by something less than a 50% standard of efficiency, or at least of accuracy. From which we may fitly deduce three lessons: First, the propriety of a modest and unpretentious bearing toward each other and the public. Second, the importance of verifying or correcting our clinical diagnoses, wherever possible, by an autopsy. Third, the value of a frank and honest discussion of our mistakes, which is doubtless of more real profit than the customary tiresome recital of our notable-and often accidental-successes. OR I wish to be surprised by disease or T "Eye Reflexes." BY WILLIAM H. PHILLIPS, M. D. Professor of Ophthalmology and Otology, Cleveland Homeopathic Medical College. HE influence of the eye reflexes in the causation of obscure and distressing neuroses is nowadays so well recognized that no exponent of the subject is any longer under the necessity of clearing the ground for its discussion. Dr. Phillips describes the typical grinding and sick headaches, following the excessive use of ametropic eyes, and argues the strong probability of an ocular etiology for the true "migraine" headaches, for which no sufficient somatic cause can be demonstrated. Temporary blindness, persistent headache following acute diseases, certain types of insomnia, and even epileptoid seizures, are attributed by the author to remote eye reflexes. The true condition can usually be demonstrated by instillation of atropin, which, however, must be done cautiously in middle-aged patients. Accurate fitting of proper lenses is the efficient means of relief in such cases. common reflexes, while epilepsy, chorea, spinal curvature, tic, and the more disastrous fundus changes in choroid and retina, are not rare. Headaches-Those most commonly noted are located in the brow, temples, or in the eyes themselves, of a dull, heavy, grinding character, occurring usually after use of the eyes at the near point, and relieved by rest or quiet. Occipital headaches, occurring often independently of use of the eyes for The great improvement in the quality of the refraction work done by the average oculist today over that done a few years ago, and the fact that this work has come to occupy a position of prime importance in every oculist's office, is undoubtedly due to the careful study of a somewhat voluminous literature upon "eye strain" which has lately appeared. Many reflexes, which a decade ago were attributed to almost everything under the sun, for which rectums were stretched and ovaries excised, and for reading, but following a visit to the which even now spinal cords are pounded and massaged, have had their origin traced to ocular disturbances by these writers. And, as time adds to the list of oculists who are aiming to do absolutely accurate refraction work, confirmation of the claims of these men are daily reported, so much so that few progressive men today attempt operative measures or even treatment of any kind in obscure nervous cases without demanding first a careful refraction of the eyes. Some Effects of Eye Strain. Headaches, gastric derangements, nervous prostration, insomnias, intestinal toxemias, styes, chalazia, blinking, are theater, attendance upon church service or any special use of the eyes at the distant point, are frequent. Sick headaches, occurring periodically and following upon some nervous strain or excitement as a card game, from riding in a car, from shopping, are very frequent. Headaches occurring at the menstrual period are occasionally ocular, the constant strain of the refractive error only needing the added enervating influence of the menstrual epoch to precipitate the explosion. Migraine. The ocular origin of "true migraine," so called, preceded by an aura, especially an ophthalmic one, is even now a mooted question. Among oculists who are doing exact refraction work migraine cases are frequently reported as cured; by others the attacks are still referred to gout, lithemia, heredity, or other vaporous conditions, lenses having no influence over the condition. The scintillating scotomas of migraine, characterized by areas of blindness surrounded or crossed by bright scintillating margins of light which many patients experience just preceding an attack of migraine, are probably due to exhaustion. or irritation of the nerve centers. Undoubtedly they do occur as the result of disturbances in the central nervous system or some general toxemia, but the general trend of opinion favors ocular exhaustion as the cause. Another peculiar affection experienced by some people is a recurring attack of temporary blindness very similar to the scotomas of migraine, usually affecting one eye only, and lasting but a few minutes, and not uncommonly associated with headache or other disturbances. Formerly attributed to gastric derangements of some sort, it is now considered almost exclusively an evidence of eye strain and due to vasomotor spasm or exhaustion somewhere along the visual receiving apparatus. Persistent headache following acute diseases, grip, typhoid, the exanthems, or other debilitating illness, and occurring in people who formerly were entirely. free from the same, are usually of ocular origin. Insomnia is often an evidence of ocular turgescence from abuse of the eyes or as the result of a refractive error. Nictitation, chronic marginal blepharitis, and recurring phlyctenular conjunctivitis, are all frequently associated with eye strain. Remote Reflexes. Among the more remote reflexes, epileptoid seizures and choreas are occasionally associated with muscular imbalances and astigmias, and the treat ment of no case is complete without a thorough examination of the eyes. More recently spinal curvature has been referred to certain oblique astigmias which cause head tilting and consequent faulty desk positions, and unbiased investigators seem to confirm the truth of this claim. Cases of breakdown during school life, and the nervous prostrations of later life are often but instances of a nervous system sapped of its strength or thrown into a of irritability by an asymetrical astigmia or an exophoria. Between the ages of forty and fifty, when the accommodative range has sunk so far that the near point has receded beyond the reading distance, eye reflexes are very common. Muscle imbalances appear from the disturbance of the relation between accommodation and convergence, and patients who previously carried a moderate astigmia, hypermetropia, or imbalance, with impunity, now manifest all the signs of eye strain. Long-continued neglect or abuse of the eyes produces certain fundus changes; low grades of retino-choroiditis, granular changes in the macular region with reduced acuity of vision, and later destruction of the choroid with resulting nutritive changes in the vitreous and lens. Many times eye strain as the factor in a given condition can be demonstrated by the use of a 5-grain solution of atropin in the eyes. In using this one must be careful, especially in middle life or later, to exclude glaucoma, as this disease produces many of the symptoms of eye strain. If relief is obtained very soon, one may be almost certain that a properly fitted lens will be the solution of the case. Failure to relieve, however, does not negative eye-reflex, as the strain from a muscle imbalance is not so nullified by atropin as that from accommodation, nor is the ocular turgescence in choroidal irritations relieved except by its long continuance. |