Javal's Ophthalmometer and Atropine in determining Errors of Refraction, With an Incidental Notice of Eye-Strain and Graduated Tenotomies. A. E. DAVIS, A.M., M. D., BY Instructor in Diseases of the Eye, Post-Graduate Medical School; Assistant Surgeon to the Manhattan Eye and Ear Hospital: Attending Ophthalmic Surgeon to Bellevue Hospital, Out- door Department. ■Neto Xorfc fHeCical JJoumal. REPRINTED FROM THE Reprinted from the New York Medical Journal. JAVAL'S OPHTHALMOMETER AND ATROPINE IN DETERMINING ERRORS OE REFRACTION, WITH AN INCIDENTAL NOTICE OF EYE-STRAIN AND GRADUATED TENOTOMIES. By A. E. DAVIS, A. M., M. D., INSTRUCTOR IN DISEASES OF THE EYE, POST-GRADUATE MEDICAL SCHOOL ; ASSISTANT SURGEON TO THE MANHATTAN EYE AND EAR HOSPITAL ; ATTENDING OPHTHALMIC SURGEON TO BELLEVUE HOSPITAL, OUTDOOR DEPARTMENT. When we see a member of the profession charging the majority of us with gross ignorance, petty prejudice, big- otry, and with making many mistakes in diagnosis, and as being unfamiliar with and incapable of employing the latest methods of examination, and alsb with ignoring the dis- covery of a medical truth that is " fraught with incalculable good to humanity," we may suspect, at least, that those who make such charges against the medical profession and not the profession itself are the parties guilty of such ignorance and error. In this paper I propose to show that the author who in a recent number of this Journal has made such charges against the oculists of hospitals and dispensaries, is himself the one at fault in correctness of diagnosis and conclusions as to his cases. The truth of what I have just stated was never more plainly demonstrated than in two Copyright, 1892, by D. Appleton and Company. 2 ERRORS OF REFRACTION. articles upon Eye-strain, which have very recently appeared in the New York Medical Journal* Aside from an incidental notice of some of the extrava- gant statements made in those articles by the author, and em- phasized by quotations from the letters of his patients who gave him the credit of " doing wonders," " almost perform- ing miracles," and, in one case, " not of cure, but of resur- rection," etc., it is my purpose in this paper, by a report of over three hundred consecutive cases of refraction treated in the clinic of Professor Roosa, at the Manhattan Eye and Ear Hospital, from January 1, 1892, to July 1, 1892 (a period of six months), to emphasize the fact which Roosa, in a recent number of the Medical Record, has already brought prominently to the notice of the medical profes- sion-to wit, "that when Javal's ophthalmometer is used we can dispense with any mydriatic for the purpose of sus- pending the accommodation, except in very rare and en- tirely exceptional cases." It is my purpose also to demon- strate beyond cavil (and I think it quite possible) that he who uses atropine at this day to determine all cases of re- fraction, and thinks it " unscientific " to do otherwise, is not in advance of the times, as he seems to think, but, on the contrary, far in the rear. In the three hundred and eighteen cases here reported the examinations have not been made in a perfunctory way, " touched up with astringents, boric acid, etc., without any effort to determine the underlying cause." f The equipments for the examination of patients in this clinic are not sur- passed by those in private offices. Two ophthalmometers, perimeters, phorometers, optometers, and electric and gas lights in the refraction and operating rooms ; graduated rods in the refraction rooms, measuring the exact distance of the * N. Y. Med. Jour., March 26, June, 1892. f N. Y. Med. Jour., loc. cit., p. 649. ERRORS OF REFRACTION. 3 patient from the test-cards; test-cards of all descriptions, a number of trial cases and sets of prisms, color tests, etc.- in fact, everything that is required for a complete and thor- ough examination-is at hand and is used. When a patient comes in and some refractive error is suspected, he is not touched up with some astringent and told to come again, but is assigned to an assistant surgeon, who examines the patient thoroughly, and, after so doing, reports back to the surgeon. The routine practice in the refractive cases is, first, to examine the eyes with J aval's ophthalmometer ; second, test the eyes with the trial glasses; third, in the dark room examine the cornea and anterior portions of the eye by the oblique illumination; fourth, examine the fundus of the eyes with the ophthalmoscope, indirect and direct method. If any pathological changes are found, of course the field is taken, also color perception; but this would not then be a simple refraction case. This is the first test. If fhe patient is a simple presbyope and has no astigmatism, glasses are given at once; if not presbyopic, and especially if astigmatism is present, the patient is referred back to the same assistant surgeon for a second time, and sometimes even for a third examination. Now, there is nothing perfunctory or hasty about that examination. And as to the accurate fitting of frames to the face of each patient and centering the glass, the greatest care is exercised on this point, the optician to the hospital being one of the very best opticians in the city, who keeps a skilled clerk at the hospital who fills all orders -none being filled outside. There is no error or second- hand work, therefore, on the glasses. The history in full of each case is kept on record just as in private cases. The report in full of a few cases will attest this fact. Conse- quently the statistics of these cases are just as reliable as those collected from private practice, and I suspect the ex- amination has been even more thorough as a rule. So much 4 ERRORS OF REFRACTION. in defense of the statistics drawn from the three hundred and eighteen cases here reported, and in answer to the sweeping charges made against such institutions as ours. To come at once to the main point in this paper-" How often is it necessary to resort to atropine in the determina- tion of errors of refraction ? "-it is interesting to learn that in only five instances in the three hundred and eighteen cases was it necessary to use atropine to determine the error of refraction, or in one case in sixty-four I Is not this con- clusive proof of Roosa's recent statement, " that it is only in the very rare and entirely exceptional cases that any my- driatic is needed to suspend the accommodation " ? To me it is quite sufficient. It is to be remembered that these are not picked cases, but consecutive, as they have occurred in the clinic for six months. As mixed astigmatic cases are thought to be the most difficult to fit without the use of atropine, I shall report three or four such cases, in addition to a few others in de- tail, which I have fitted without the use of atropine, at the clinic,* from January to July, 1892. Case I.-Asthenopia, a Typical Case ; Relief from Correc- tion of Mixed, Astigmatism with the Rule in Both Eyes.-Mrs. Jane W., aged thirty-five. Mrs. W. can not read or sew for any length of time without getting severe pains in the eyes, which extend to the head. She is of a neurotic temperament and has three daughters of a like temperament, and all asthe- nopic from astigmatic eyes, the mother having mixed astig- matism with the rule in both eyes; the youngest daughter, aged twelve, having mixed astigmatism with the rule in the right eye, and simple hyperopic astigmatism in the left eye; the next daughter, aged fifteen, having simple hyperopic astig- matism with the rule in one eye, and simple hyperopic * I could, if necessary, report two cases of mixed astigmatism from office practice, but the cases in the clinic have been examined with the same care as those at the office. ERRORS OF REFRACTION. 5 astigmatism against the rule in the other eye; the oldest daughter, aged seventeen, having irregular astigmatism, with diffuse opacities of both corneae. This is an interesting group. All but the oldest daughter, with diffuse opacities of both cor- neas, w*ere fitted with glasses, without the use of atropine, by means of Javal's ophthalmometer and trial lenses. February 9, 1892.-Javal's ophthalmometer gives the mother astigmatism, with the rule, 3'50 D., ax. 90° + or 180° - , in both eyes. R. V. = ff : f| ? w. + 2 c. 90° 0-1'50 c., 180°. L. V. = || : f|; w. + 2 c. 90° O - 1'50 c., 180°. 11th.- R. V. = : f|; w.+ 1-25 c., 90° 0-1'50 c., 180°- L. V. = : ff; w.4- 1'25 c., 90° O - 1'50 c., 180°. Jaeger No. 1 = 7" to 18". Ordered a sphero-cylinder + 1'25 D. O- 2 75 c., 180°, over each eye. So far the glasses have given perfect satisfaction. Case II.-Asthenopia, Constant Headache, and Inability to read or write for any great Length of Time; Relief by Cor- rection of Astigmatism.-Wilhelmina W., aged twelve, youngest daughter of Case I. Her asthenopic symptoms were almost identical with those of her mother. Ophthalmometer gave her astigmatism with the rule 3 1). 90°+ or 180°- right eye; 1 D. 90° + or 180 °- left eye. R. V. = : f|; w. + 2 c. 90° Q - 1 c., 180°. L. V. = f |: f|; w. 4- 0'50 c., 90°. February 13th.-Test the same. A sphero-cylinder + 2 DQ-3 c., 180° right, and + 0 50 c., 90° left, ordered. Case HI. Asthenopia from a Low Degree of Astigmatism with the Rule at an Off Axis in One Eye and Astigmatism against the Rule in the Opposite Eye ; Relief from Correction. -Lettie W., aged fifteen, second daughter of Case I. Asthe- nopic symptoms similar to those of her mother and sister. Ophthalmometer gives her astigmatism with the rule, 0'50 D., 45°+ or 135° - right eye. Astigmatism against the rule 0'25 D., 180°+ or 90° - left eye. R. V. = f|: f| w. 0'25 c., 90°. L. V. = ||: f|; w. + 0'25 c., 180°. Jaeger No. 1 = 8" to 20". February 11th.-Vision f| in each eye with the same glasses ordered. 6 ERRORS OF REFRACTION. The oldest daughter in this family, with irregular astigma- tism and corneal opacities, had very poor vision and always will have. No attempt was made to fit her with glasses. Case IV. Asthenopia: Constant Pain in Eyes on using them ; Relief by Correction of Astigmatism.- Ella M., aged twenty-three. The only one in her family troubled with her eyes. Eyes and head ache after using the eyes for close work. Ophthalmometer shows her to have astigmatism with the rule. 3 D., 75°+ or 165°- right eye. 3 D., 105°+ or 15°-left eye. R. V. = ircro: ; w. + 1 c., 75° Q -• 1'25 c., 165°. L. V. = ott• i w- - 5 D. Q - 2'50 c., 15 . February 25th.-Ophthalmometer shows the same readings. R. V. = ; w. + 1-25 c., 75°O - 1 c. 165°. L. V.= jlo : Tint + ; W. - 4 D. Q - 2-25 c., 15°. Jaeger No. 1 = 6" to 12". Ordered sphere cylinder + 1'25 D. - 2 25 c., 165° right, and - ID. 2 - 2'25 c., 15° left. Here we have a mixed astigmatism in one eye and a com- pound myopic astigmatism in the other. She uses the eyes to- gether with perfect relief from all asthenopic symptoms at this writing. Case V. Blurring of Images when using Eyes for Near Work; Insufficiency of the Interni; Mixed Astigmatism in both Eyes with the Rule.-The family history of this young man is good and he himself in good health. His asthenopic symp- toms are marked. Ophthalmometer gives him astigmatism with the rule 3'50 D. in each eye; axis 105°+ or 15°- right, 75° + or 165°- left. R. V. = : f g; w. + 2 c., 105° Q - 1 c., 15°. L. V. = Ta/o ■ H i w- + 1'50 c., 75° Q - 1-50 c., 165°. Reads Jaeger No. 1, 5" to 12". February 25th.-Tests same. Ordered + 2D.Q - 3 c., 15° right; + P50 D. Q - 3 c., 165° left. At present writing patient is still wearing glasses and relieved of all asthenopic symptoms. Case VI. Periodic Convergent Squint, associated with Compound Hyperopic Astigmatism ; Eyes Straight with Glasses on.-Sam K., aged twelve. Has had a periodic squint of right eye for more than two years. lias worn simple spherical glasses 4- 4 D., but without effect. Ophthalmometer gives him ERRORS OF REFRACTION. 7 astigmatism with the rule 2 D. each, 90°+ or 180'- right; 120° + or 30°- left. R. V. = + ; w. + 4 I). Q + 2 c., 90°. L. V. = f$:|£4-; w. + 3*50 D. Q + 1-50 c., 120°. Reads Jaeger No. 1, 5" to 12". Two davs later, March 12th, Javal gave same readings. R. V. = +; w. + 4 D. Q + 1'75 c., 90°. L. V. = >§; w. + 3'50 D. Q + 1'50 c., 120°. Or- dered for constant wear. The ophthalmoscope was used in this case as in all the rest. This last case illustrates a set of cases-squint cases or cases with a tendency to squint, manifested by a periodical squint-where the hyperopia has to be fully corrected to obtain the best results. These are the cases in which sometimes the use of atropine is beneficial, though it was not used in this case. The desired effect, however, was obtained. His eye has never squinted since he had the glasses. There may be an objection raised to the report of the foregoing cases on the ground that not enough time has elapsed since the patients have been fitted with glasses to form a correct idea of their final benefit to the patient. The objection is a very reasonable one and quite just. This report of 318 cases from January 1, 1892, to July 1, 1892, has been chiefly to demonstrate the fact that atro- pine to suspend the accommodation in determining errors of refraction is but rarely called for (1 in 64 times), and, secondly, that the most difficult cases can be fitted without the use of atropine, as shown by the cases of mixed astigma- tism and compound hyperopic astigmatism at off axes re- ported here in detail. That the final result of these cases will be just as good or better than those fitted under atro- pine is evidenced by the fact that those cases, similar to these now reported, which were fitted two and three years ago at the clinic and in private practice without the use of any mydriatic, are still wearing their glasses and are per- 8 ERRORS OF REFRACTION. fectly comfortable. A case to the point-and, fortunately, for illustration, a mixed astigmatic one which has been fitted two years-came to the clinic very lately to have the frames of her glasses, which had broken, repaired. This young woman, Katie McG., aged twenty-nine, robust in health, a waitress, came to the clinic in July, 1890, complaining of severe headaches all the time, intensified by using the eyes for any near work. She was fitted by means of the ophthalmome- ter and trial lenses without the use of atropine and a mixed astigmatic glass prescribed: +1'50 D.Q3'75 c., 180° right; 4- 1'50 D. Q - 4 c., 180° left. These glasses gave immediate relief and have continued to do so. Since the glasses have been broken the headaches have returned, for which reason she came again to the hospital. The ophthalmometer gave astigmatism the same as two years previously-4'50 D., 90° 4- 180°- right; 4 75 D., 90° + 180°- left. The glasses could not be improved upon. It may be asked, How do we know when it is necessary to use atropine in a case ? That, again, is easy. When we get very little or no improvement in vision by the glasses indicated by the ophthalmometer, or when there is no astig- matism and the ophthalmoscope shows a high degree of hyperopia, then, and not until then, is it justifiable to use atropine. As an example I give one of the five cases in the three hundred and eighteen in which atropine was used. Case VJI. Asthenopia ; Vision not improved by the Glasses indicated by the Ophthalmometer ; Atropine used to suspend the Accommodation; the Axis and Amount of Astigmatism under A tropine corresponded to that indicated by the Ophthalmometer. -January 26, 1892, Ella M., aged sixteen. This patient suf- fered much from headaches and pains in her eyes, especially when she used her eyes for near work of any kind. Her general health is fairly good. The ophthalmometer gave her astig- matism, with the rule, 1 D. in each eye; 75° 4- 165°-, right; 90° + 180°-, left. R. V. = 5 L. V. = f-fa. No glass improved ERRORS OF REFRACTION. 9 the vision appreciably. Atropine ordered, a solution of four grains to the ounce, to be instilled three times a day for four days. January 30th.-R. V. = w. + 5 D. O + 0'75 c., 75°. L. V. = ; w. 4- 3-50 D. O + 0*75 c., 90°. February 6 th.-R. V. = ; w. + 2 D. O + 0 75 c., 75°. L. V. = ; w. + 1-50 D. O + 0'75 c., 90°. Ordered this last glass, which gave relief and comfort. It will be noticed at a glance in the cases-given in de- tail here that the axis of the astigmatism in each case, as indicated by the ophthalmometer, corresponds exactly to the axis of the glass accepted by the patient. And what is true of these few cases holds good in the main in the entire three hundred and eighteen cases, and should hold good in all cases properly examined with the ophthalmometer. In very few cases was there any difference in the axis in- dicated by the instrument and the axeis of the glass accepted by the patient, and when there was a difference it was not more than 5° ; possibly in one case out of a thou- sand, as much as 10°. As an indicator, then, of the axis of the astigmatism in any given case, we find that Javal's in- strument is a much safer guide than atropine, and this on the evidence of one who believes in the efficacy of atropine, Dr. George M. Gould,* of Philadelphia. Dr. Gould, in speaking of the change of axis of the glass when the patient came from under the influence of atropine, from what it was when the patient's accommodation was paralyzed, has this to say: " I have had several such cases, the patient, after the return of the accommodation, emphatically refus- ing the axis as clearly demanded under the mydriatic.' I wish to be put upon record as saying that " the oph- thalmometer is a surer means of obtaining the correct axis * The Statistics and Lessons of Fifteen Hundred Cases of Refrac- tion. Journal of the Amer. Med. Assoc., pp. 432-442. 10 ERRORS OF REFRACTION. of astigmatism and the axis of the glass that will be ac- cepted by the patient, than suspending the accommodation by the use of atropine, and obtaining the axis by that means." The ophthalmometer measures the eye when it is active and in its natural state, whereas the eye meas- ured when its accommodation is suspended is in an un- natural state. Now, as to the amount of astigmatism as indicated by the ophthalmometer and that accepted by the patient, we need never be in doubt as to the proper glass to prescribe if we will only follow what Java! has taught us, and what Roosa has reiterated in his writings, that in astigmatism " with the rule "-that is, the vertical axis of the cornea be- ing the more curved, let the astigmatism be hyperopic, my- opic, mixed, simple, or compound-we have only to subtract one half to three quarters of a dioptre from that indicated by the instrument to have the proper glass, and in astigmatism " against the rule," the horizontal meridian of the cornea being the more curved, let the astigmatism be hyperopic, myopic, mixed, simple, or compound, to give full correction we add half a dioptre to that indicated by the instrument. The exception to this rule is rare, the error of half a diopter too much with, and half a dioptre too little against the rule, being a constant one and one to be expected, makes the ophthalmometer not " almost indispensable to ophthalmologists," but absolutely indispensable to ophthal- mologists who wish to keep in the front ranks. And on these very points, the amount of astigmatism and the axis of the glass indicated, I am brought to a consideration of a re- cent article* upon the diagnosis of astigmatism by Javal's ophthalmometer. In the entire eighty-eight comparative tests the author wholly ignored the rule laid down by Javal to subtract half a dioptre when the astigmatism was with the *Y. Y. Med. Jour., July 16, 1892, pp. 66-70. ERRORS OF REFRACTION. 11 rule, or give full correction or add half a dioptre when the astigmatism was against the rule, lie seems to have expected more of the instrument than Javal ever alleged for it. In fact, he would have it perfect, and when he failed to obtain perfect results with it he is led to say : " For one reason or another, therefore, the ophthalmometric findings could not, without a knowledge of the variation incident to the instru- ment (Italics mine), be regarded as a safe guide to the diag- nosis of astigmatism." All I have to say is, he who is with- out that knowledge has himself to blame, for " the variation incident to the instrument " is a constant one and ought to be by this time a well-known one, considering the num- ber of times such fact has been in print. Again, in regard to the difference in the axis of the astigmatism indicated by the instrument and that found later under atropine in these eighty-eight comparative tests, I am led to believe, by one case (XIII), that the fault lay not in the instrument but in the observer. I may be wrong in my supposition, and trust that I may be corrected if I am. In Table A, Case XIII, page 69, of article referred to, the author makes the following reading : " R. ± 1, ax. 180°. L. ± 1, ax. 180°. First observation: R. E. ax. 165° or 75° ; the axis immediately changed to 180° or 90°." In a foot-note upon this case the author says : "Note in Case XIII the change in axis which occurred during the exami- nation." If the same thing happened with Dr. Woodward in the examination of this case as has happened with me many times, especially when I first began the use of the in- strument, the explanation of " the change in axis which oc- curred during the examination " is very easy. It was due simply to the patient having changed the level of her eyes by a slight rotation of her head. If we are not very care- ful to sight through the transverse slit in the disc just above the tube of the instrument to see that the patient's 12 ERRORS OF REFRACTION. eyes are exactly on the same horizontal plane-one just as high as the other-but place the patient before the instru- ment without this precaution, we are almost sure to make a mistake as to the correct axis. This point was thoroughly impressed upon my mind last winter by Javal himself in Paris. I mentioned the fact that the axis of the glass ac- cepted by the patient sometimes failed to correspond to that indicated by the instrument. He immediately had me place a patient before the instrument and make a measure- ment of her astigmatism. I did so, failing, however, to take the precaution to sight through the transverse slit above the tube to see that the patient's eyes were exactly level, found she had astigmatism and at an axis 5° from the vertical. Javal, without saying a word, sat down to the instrument, sighted through the transverse slit, leveled the patient's eyes correctly, then measured the astigmatism, giving the same amount as I had, but axis vertical. The trial lenses confirmed his reading. This was an object lesson for me. The least rotation of the head is enough to throw the axis off 5° or 10° from what it should be; hence the necessity of keeping the eyes not only steady, but in the same horizontal plane. The fact that the instrument does not always indicate the axes at right angles to each other is one of its points of merit and not demerit, for the axes of astigmatism of the cornea are not always at right angles, and when such is the case the instrument points it out clearly. For example, if the instrument says astigmatism with the rule, 90° or 165° - , if we find the individual hyperopic (+), prescribe a + glass, axis 90° ; and if we find him myopic ( -), give a - glass, axis 165°. After cataract extractions the ophthalmometer finds one of its most practical applications, for it is in these cases that we do not wish to worry the patient or irritate the eye. ERRORS OF REFRACTION. 13 By J aval's instrument we can find the amount and axis of the astigmatism in one minute's time, and test the eye in less than five. Time and again, by testing the axes shortly after cataract extractions, before we had the ophthalmome- ter, have I seen the eye irritated very much and sometimes iritis follow. The glasses prescribed by the readings from the instru- ment in these cases are more satisfactory than those pre- scribed without its use, and this because the astigmatism in these cases is usually of a high degree and at an off axis. By the instrument we find the amount and the exact axis. That we do not without its use is well illustrated by the experience of Dr. Baldwin, of Montgomery, Ala. ; for that matter, by the experience of all who have had many cata- ract cases; often, after an extraction with good result, no iritis in the course of healing and media clear at close of treatment, he had been unable to give a satisfactory glass, was conscious of the fact, but could do no better. He was pleased with the tests with the ophthalmometer of such cases at the Manhattan Eye and Ear Hospital, and bought one a year ago. We hope to have his testimony upon the instrument ere long. Our own experience with the ophthal- mometer in such cases has been the happiest. Before leaving this part of my paper, so firmly con- vinced am I that, where the merits of the ophthalmometer have not been duly appreciated, and that even in the hands of eminent men, in whom not the faintest lurking of a prejudice could be suspected, it has been due to the lack of observance of all the steps in the use of the instrument, I venture to give each step successively here of the technique of an examination. 1. Have a perfect light. The light from a large north window is best; two twenty-four candle-power electric lights next best. 14 ERRORS OF REFRACTION. 2. See that the telescope or tube of the instrument is correctly adjusted by sighting through it and bringing the cross-wires in good view. This is done by turning the ocular or eye-piece to the right when the observer is my- opic, and to the left when he is hyperopic. And the fur- ther to the left that the eye piece can be turned, yet the cross-wires be maintained in good view, the better; and for the same reason which we follow in prescribing glasses- the weaker the minus and the stronger the plus glass the better, because by this means no extra accommodation is called into play. 3. Place the patient at the instrument with his chin on the chin-rest and his forehead against the forehead-rest with his eyes wide open and upon a level. To know when the eyes are exactly horizontal, which is all-important, sight through the transverse slit in the disc just above the tube or telescope of the instrument. This point can not be insisted upon too much, for the least rotation of the head will throw the axis off 5° or 10° from what it really is, and then, when we come to the trial case and the axes do not correspond, we are prone to blame the instrument when we are our- selves at fault. 4. The eyes level, we are now ready to place the blind in front of one eye and focus the other. To focus the eye, sight along the upper side of the tube through the notch (something like a gun-sight) at the center of the cornea. Now sight through the tube, at the same time moving the instrument forward and backward on the planchet, and up and down by means of the screw, until the image of the disc, doubled by the prism in the telescope and reflected from the cornea inverted, comes into view. Pay no atten- tion to the two reflectors far out at the sides, but notice the two reflectors in the oval space made by the overlapping of the discs. ERRORS OF REFRACTION. 15 5. Obtain the " primary position." The " primary po- sition " is nothing more or less than that point at which the transverse lines, dividing the reflectors into halves, be- come opposite or coincident and form one continuous straight line, which is an indication simply (when there is any astigma- tism) that we have found one of the axes of the astigmatism. The other axis, in the great majority of cases, is 90° from this, therefore at right angles to it, and is the " secondary position." When there is no astigmatism the transverse lines are always opposite and coincident. When there is irregular astigmatism they are never coincident. To obtain the primary position, first turn the long indicator to 0°. If the transverse lines are coincident at this point, go no further; that is the primary position. If not coincident at the zero point, turn the tube from right to left-that is, the long indicator from 0° toward 135°. If the transverse lines do not become coincident before or when 135° is reached, go no further in that direction, but turn back to 0°, turning this time from left to right toward 45° ; the lineswill neces- sarily become coincident before 45° is reached. The pri- mary position is never further than 45° on either side of 0°. This I wish especially to emphasize, for if we turn further than the 135° mark on one side or the 45° mark on the other, we will make the instrument read astigmatism "with the rule " when it is really " against the rule," and vice versa. When the lines become coincident at 135° or 45°, the ex- treme limits, being just half way between 0° and 90° on either side, by preference take 135° as the primary posi- tion-this for the sake of nomenclature. We see, then, that the " primary position " may be at 0° or any point within 45° of that point, but never beyond. Having got the lines coincident, it is only necessary to approximate the reflectors to be ready for the next step. 6. That of obtaining the " second position." This is 16 ERRORS OF REFRACTION'. obtained by turning the long indicator 90° to the left from the primary position. If the reflectors overlap, there is astigmatism with the rule, and the number of steps of over- lapping is the amount of astigmatism. Say it overlaps two steps. It should be written thus : " Astigmatism with the rule, 2 I). 90°or 180°-." If the reflectors separate when the second position is reached, it indicates astigma- tism against the rule. Before moving the indicator from the second position, approximate the reflectors again, and then turn back to the primary position, when the plates will over- lap-say two steps. Written thus : " Astigmatism against the rule, 180° -{- or 90° -Nothing could be simpler than this, I am sure. Following the rules above, the long index always points the axis the plus glass will be worn, and the short index on the reflectors the axis the minus glass will be worn-in any case. It may be asked why I prefer to turn the cylinder from right to left. Simply that I may have the sliding index below, where I can get at it through the holes in the disc below. Of course the observer's eyes should be properly cor- rected if he has an error of refraction. Now, what does the instrument do ? It gives the amount of astigmatism and the axis. These points ascertained, the rest is easy. In order to get the best results with the instrument, it is not necessary to use atropine, as lately stated by a writer in the New York Medical Journal. That would be like trapping a bird, then shooting it. If you can catch the astigmatism " on the fly," so to speak, why subject your pa- tient to two weeks of unnecessary and uncalled-for delay in the great majority of cases ? Atropine has had its day of usefulness in ascertaining errors of refraction. The oph- thalmometer has replaced it in the offices of many oculists, and I predict, with others, that it will almost wholly take ERRORS OF REFRACTION. 17 the place of the old method of testing with atropine before a great while elapses. Dr. Roosa, who now prefers its use to atropine, was one of the first if not the very first writer to insist upon the use of atropine to determine astigmatism before the ophthalmometer had been made a practical in- strument.* He now uses the ophthalmometer because its employment is a great advance on the old method. The ophthalmometer is not always absolutely perfect in its measurements of the eye, and never will be for that mat- ter, or any other instrument, as long as the human eye re- mains a human eye and does not become a piece of ma- chinery. No cast-iron mechanical rules will ever apply to a living, acting tissue. Graduated Tenotomies.-Having shown by the fore- going cases that the determination of errors of refraction without the use of atropine is eminently scientific and not unscientific, as the author of the two articles upon eye- strain referred to in the beginning of this paper has assert- ed, it now remains to notice some of the extraordinary allegations in those articles. The statements in these articles upon eye-strain, now un- der consideration, would deserve to go by unnoticed did they nottend to lead the general practitioner astray; for to the serious-minded specialist they are rather a source of amuse- ment and surprise than of interest. The style of writing is characteristic. The author begins first by maligning his fellow-practitioners, especially those opposed to his views- to wit: " Most of the medical contributions that have latelv appeared as antagonistic to the view that ' eye-strain ' con- stitutes an important factor in the neuropathic tendency, and that functional nervous diseases can be relieved or modified by eye treatment, are based largely upon statistics * Transactions of the American Ophthalmological Society, Newport, 1878. 18 ERRORS OF REFRACTION. derived from the observations of those who are manifestly ignorant of the latter methods of examination, or who fail to employ them from bigotry and prejudice." (Italics mine.) Secondly, in referring to the cases sent to him he has this to say: " These patients took no drugs, they continued in their customary vocations, and they got well. All former experiments with drugs and doctors had failed to bring about a like result. (Italics mine.) To many of these patients the verbal or written opinion of prominent medical men had been given prior to my seeing them ' that organic dis- ease unquestionably existed, and that the eyes had nothing to do with the causation of the symptom,' and several had been pronounced by conscientious medical advisers as in- curable." * Thirdly, the adulations of patients are rather freely given, as: " Your patient is the wonder of this re- gion. She rivals the ' Jersey Lily ' in her feats of walking." Another from a mother : " This seems almost a miracle when one remembers how the boy suffered before coming to you." Worst and last from a friend, alluding to the cure of one of his patients as one " not of cure, but of resurrection." View our critical author again as a giver of medical ad- vice, first, to his benighted brother oculists, of whom he has formed a very bad opinion on account of some of their assertions that have come to " his own ears " through pa- tients, which are, in his own words, " indicative of inex- perience, bigotry, or prejudice." And, further : " In the light shed upon a field of scientific inquiry by such a set of remarkable cases [our author's cases], is it not a justifiable source of surprise that many oculists of prominence, in full possession of the facts, refuse to-day to follow implicit- ly, and others even to try, a method of treatment whose details have been quite fully described in medical litera ture ?" We never thought before that it was an attribute * Loc. cit. M. K Med. Jour., June, 1892, p. 649. ERRORS OF REFRACTION. 19 of great-mindedness, at least in this day and generation, to follow any one implicitly, especially on very doubtful ground. And when a method has been tried, as has been the case with graduated tenotomies, and found wanting nine hun- dred and ninety-nine times in a thousand, or rather a thou- sand times in a thousand cases, then it is time to give it up. Graduated tenotomies have been tried at the Manhattan Eye and Ear Hospital, but have long ago been abandoned by all the surgeons. Dr. Webster and Dr. Pomeroy some- times, very rarely, for a muscular insufficiency, do a tenoto- my, a complete tenotomy, but not a graduated or partial tenotomy. Dr. Pomeroy " cuts till he gets effect," each time doing a complete tenotomy, and, if he gets a tempo- rary over-effect, thinks it just as well or better than other- wise. Dr. Emerson, for a marked muscular insufficiency, also favors a complete tenotomy. Roosa's views upon this subject are well known. But to return to the author of Eye-strain. His advice to the general practitioner seems to be given in the in- terest of revenue only. Listen : "We are now prepared to pass to the consideration of some cases that I have selected from my case-books, in order to demonstrate, 'if possible, beyond cavil [among other laudable acts] that it is the duty of a physician to have the eyes of all patients afflicted with abnormal nervous disturbances examined early by some ocu- list who is familiar with and employs the latest methods.''' (Italics mine.) That would be a rich harvest for the latest- informed oculist, I must say. But how about Dr. Falloppius, who, only a few years since, insisted on cutting out the ovaries for " abnormal nervous disturbances," unsexed a great number of women, and in many instances did more harm than good ? Again, have not the aurist, the laryngologist, the genito-urinary surgeon, the rectal surgeon, and the die- tetic physician the same claim upon the physician in his 20 ERRORS OF REFRACTION. cases of abnormal nervous disturbances as the oculist ? I know of none among them, however, who has the courage to demonstrate beyond cavil that it is the general practi- tioner's duty to send all such cases to him. We have much to learn perhaps. It has been necessary to make the preceding remarks because the author of the brochure upon Eye-strain in- dulged in eight columns of explanations of his own good results and other people's bad results before reporting his cases. We pass now to a brief consideration of those cases, and we must say the reported results are wonderful. I reproduce, first, the table of cases as given by him, believing that is the best and quickest way to get at them, and to show that the criticisms are fair: It is manifest, at a glance at this table, that his whole report, from a scientific point of view, and especially in re- gard to muscular errors which he considers of so much im- portance, is rendered valueless from one important omission -that is, a statement of the conditions of the muscles at the close of treatment. If he had inserted a column in his table showing the condition of the muscles at the close of treatment as well as at the beginning, then we could have formed some idea of how much of the good effect was due to graduated tenotomies. How carefully he has avoided this ! But I do him an injustice. In one case, and in only one (II), did he give the condition of the muscles at the close of treatment (not in the table, but in detail in the body of the brochure) ; and, strange to say, the " esophoria " and " hypophoria " were exactly the same at the close of the treatment as at the beginning, as follows : " Eye defects.-On the 17th of November, 1888, patient showed normal vision in both eyes; adduction, 54° ; abduc- tion, 5° -; right sursumduction, 2° -; left sursumduction, ERRORS OF REFRACTION. 21 2°-; esophoria, 2° ; left (right is meant, as is shown by read- ing case in detail) hyperphoria, 1°. "Condition at Close of Treatment.-On December 26, 1889, the patient was again seen. lie had experienced no return of attacks, was in excellent health, and had taken no medicine for thirteen months. He still shows 1° of right hyperphoria ; esophoria of 2° ; adduction, 58° ; abduction, 7°-; right sursumduction, 4°; left sursumduction, 1° + . On April 2, 1892, this patient reported last at the office. He is still wearing 2° prism for the remaining esophoria.' Though we see that the esophoria and hypophoria remained exactly the same (four graduated tenotomies were done), nevertheless, the " almost miracle " of a cure brought about in this case was thought to be due chiefly to graduated tenotomies. In fact, as the case is reported, it shows that graduated tenotomies had no effect whatever, and the cure must have been produced by the wearing of prisms, as that was the other treatment. As the condition of the muscles at the close of treatment in the fourteen other cases, where graduated tenotomies were done, was not given, we, of course, do not know how much effect the operations had, but if they did as much good as in Case II, where he did give a final report of the muscles, then they had no effect, and the whole report falls to the ground. To judge all the cases by one seems unjust, but we do this from necessity, as in only one case did he give a full report, and we measure the others by that. We are now prepared to form a true idea of some of the wonderful cures brought about by graduated tenotomies, prisms, etc. Tn the table we turn first to- Case I. Of Complete Mental and Physical Collapse as- sociated with Compound Hyperopic Astigmatism and Hyper- phoria and Esophoria-where, by a complete correction of the error of refraction and two graduated tenotomies, a 22 ERRORS OF REFRACTION. " practical cure " was brought about. The case speaks for itself without comment further than it is my opinion that the glasses were the chief source of benefit. Case II has already been discussed, and the potency of graduated tenotomies as a remedial agency shown, in this case at least, to be nil. I am of the opinion that the same nil effect of graduated tenotomies would have been shown in the other cases had the final condition of the muscles been reported. Case III. Chronic Epilepsy (of Twenty-four Years' Standing).-Latent hyperopia of 2'50 D., and manifest " esophoria " 4°. By a full correction of the hyperopia and graduated tenotomies upon the interni, " an apparent cure " was effected. Here again we give the credit of cure to the glasses, and not to the tenotomies. The condition of the muscles at the close of treatment is not given; and, not only judging this case from the preceding (Case II), but from a case of epilepsy we have seen, where the attacks oc- curred twice daily, which were entirely relieved by glasses as long as they were worn, but returned on taking them off, we think the glasses could account for the benefit here derived. I choose again to call attention to some of the logic in- dulged in by the author in this case. " It may be well, however, for me to mention in this connection a few of the reasons why, in my judgment, the treatment of the eyes has totally failed, in the hands of some observers, to relieve or modify some nervous condi- tions that had withstood judicious medication for years; and why it is, subsequently, in more experienced hands (Ital- ics mine), treatment of the same patients directed to their eye-muscles has led not infrequently to the happiest results. " 1. I would call attention to the fact that preconceived notions about old methods must be abandoned without preju- dice, when a new method is to be tried. ERRORS OF REFRACTION. 23 "2. Each observer must of necessity make himself thor- oughly familiar with all the details of the method which he proposes to employ before he is competent to decide pro or con respecting its merits." If our author has made himself familiar with the use of Javal's ophthalmometer, the fact is nowhere manifested in the report of his cases. In not a single case (even the latest ones) is there an indication that the instrument has been used as an aid to ascertaining the condition of the cornea. It seems to have been ignored altogether. The use of the " phorometer " is loudly enough proclaimed, but the use of the " ophthalmometer," the most useful instrument in the practice of ophthalmology, unless it be the ophthalmoscope, is passed by lightly indeed. Case IV-chronic epilepsy-is a very similar case to the preceding one, the error of refraction being one of mixed astigmatism and a muscular error of " esophoria " of 4°; the " esophoria " was ignored, full correction was given, and the patient made a good recovery. Why were 4° of mani- fest esophoria left uncorrected in this case ? Case V. Chronic Epilepsy.-Simple hyperopic astig- matism in one eye and mixed astigmatism in the other, with 11° of esophoria. A full correction of errors of refraction was ordered, and graduated tenotomies on the interni were performed. A cure reported. Case VI. " Complete Nervous Prostration (of over Five Years'1 Duration), with Constant Pain in the Head ; Inability to use the Eyes, and to walk but a Few Steps." Eye Defects.-Patient had latent hyperphoria of l-25 D., and manifest esophoria of 2°. Treatment.-Static electricity, which helped the walking very little, but had no effect on the pain in her head. Spherical glasses and graduated tenotomies on the externi and left superior rectus. 24 ERRORS OF REFRACTION. Result.-" Wonder of this region " ; " engaged in teach- ing physical culture in a ladies' school." " The improve- ment gained by eye treatment has therefore been demon- strated to be not only permanent, but progressive." 1 wonder if the graduated tenotomies had as much effect upon the exophoria and hypophoria in this case as upon the esophoria and hypophoria in Case II ? Why is not the condition of the muscles after the operation given, so that the public can judge for itself how much effect the graduated tenotomies had ? Simply reporting the patient as cured is nil to the public as a proof that graduated tenotomies brought about the cure, or even greatly helped in it, as is proved by Case II, where graduated tenotomies were performed, the patient got well, yet the esophoria and hypophoria for which the partial tenotomies were per- formed, and which presumably were causing the trouble, remained exactly the same. 1 must confess that this is somewhat paradoxical to me, but to those who perform miracles it may be simple and plain enough. Case VII (" effect magical " ; a friend alluded to this case as one of "resurrection "). "Complete Nervous Pros- tration." " Eye Defects.-The patient was found to be emme- tropic (when under atropine). Esophoria (manifest) of 3° existed." From the symptoms narrated in this case-" im- pending suffocation," " spasm of the larynx," etc.-I should think it a clear case of hysteria, though the author thinks otherwise. And from the result obtained-" com- plete recovery of her health within two months "-I am still more inclined to my view, especially when we remem- ber that there was no error of refraction detected (under atropine, which, by the way, is not always positive); and that for the 3° of manifest esophoria and a " high degree " of latent esophoria, only two graduated tenotomies were ERRORS OF REFRACTION. 25 done. We have already seen how much good graduated tenotomies did. Practically, then, this patient had nothing done for her except suggestion. I have performed miracles of this kind myself. For instance, a patient was led into Manhattan Eye and Ear Hospital blind (?) by two attend- ants, and a single drop of a two-per-cent, solution of cocaine gave him sight ! Case VIII. " Nervous Prostration with Symptoms of Melancholia ; Confirmed Sleeplessness ; Confusion of Mind and Constant Headache.'" " Eye Defects.-Hyperopia, 0'75 D. under atropine. Eso- phoria, 3°, which under prisms came up to 7°. Adduction, 23°; abduction, 5°; right sursumduction, 1° -j- ; left sur- sumduction, 2° Treatment.-Full correction for distance, 2 D. for read- ing ; afterward increased to 2'50 D. " A graduated tenoto- my of the internus of both eyes was eventually performed in order to properly adjust the balance between the two eyes." (Italics mine.) Knowing the effect of graduated tenotomies, we can judge how much effect they had in " properly adjusting the balance between the two eyes." Giving them due credit in this case, I should say the glasses accomplished the good that was effected. All this talk about graduated tenoto- mies would seem to indicate that the error of refraction amounted to little indeed, but the error in adjustment of the muscles, indicated by " heterophoria," to a great deal. That " heterophoria " is of little importance is evidenced from the fact that it so often occurs. If not manifest, it is latent and can always, in any case, be induced by means of prisms. Any one who has practiced testing the eye muscles from day to day very well knows how they vary in strength -even within an hour's time the tests will be different. Hence the ignorance and stupidity displayed by those who 26 ERRORS OF REFRACTION. habitually endeavor " to properly adjust the balance be- tween the two eyes " by graduated tenotomies. They make latent esophoria and latent hypophoria to cover a multitude of sins. Whenever a case does not do as well as it should, they usually suspect a latent esophoria or hypophoria and usually find it. This patient No. 8, who was resurrected, had a relapse of her nervous symptoms and died. Case IX was one of melancholia with morbid impulses, and severe neuralgia of the bladder and prostate gland, which was completely cured by full correction of 2'50 D. of latent hyperopia and graduated tenotomies on the interni. " His prostatic neuralgia was of a severe and intractable type, and its cause could not be discovered; yet it disappeared at once after a free operation upon the interni." I suppose this means that the genito-urinary surgeons are to turn their patients over to the oculists when they can not discover the cause of their troubles. Not a bad thing for the ocu- lists. Case X. A case of " Nervous Prostration " completely cured by glasses and graduated tenotomies. Case XI. " Complete Nervous Prostration, with One Year of Confinement in Bed and Chronic Bladder Trouble." " Eye Defects.-Hyperopia, 1'75 D.; presbyopia, 4'50 D.; esophoria, 7°; adduction, 23°; abduction, 3° -]-. Later on she disclosed riyht hyperphoria, 3°." Treatment.-Prisms, hyperopic glasses, and graduated tenotomies. Result.-Bladder trouble relieved entirely. " The sec- ond day after the first graduated tenotomy she reported that she had walked a mile and a half." I should say that this was a wonderful result indeed, for this patient had been confined to her bed for a year, yet on the second day after a graduated tenotomy upon one of the eye muscles ERRORS OF REFRACTION. 27 she walks a mile and a half. Again, " five days after the first tenotomy a second one was performed upon the other internal rectus, prisms having been worn in the mean time. Two days following this operation the patient walked five miles, visited an art museum in the morning, and attended a theatre in the evening." It seems to me from such state- ments that, in a combat between prize-fighters, their trainers would be guilty of a great oversight in their training of them if they failed to have graduated tenotomies performed upon their eye muscles. It can be demonstrated within a week's time that both have some form of " heterophoria." In fact, an induced heterophoria by means of prisms can be found in any subject. There is always in every individual a latent heterophoria, and always will be as long as we are living beings and not machines or automatons. Case XII. " Facial Neuralgia so Severe as to prompt Suicide and Uncontrollable by Drugs." " Eye Defects.-llypermetropia (under atropine), -|- 2'00 s. Esophoria, 6°." I want to call attention especially to the way in which atropine was used in this case. " So intense was his agony that he declared something must be done at once, as he feared that he could not re- strain much longer his suicidal tendency. Atropine was dropped into his eyes at once to determine his hypermetro- pia. lie was told to protect his eyes from the light by a pair of dark glasses and return in two hours. He came in smiling at the appointed time, saying that his neuralgia had entirely disappeared. Two dioptres of hypermetropia was found, and a -f- TOO s. glass was given for constant wear. Later graduated tenotomies weie done upon both internal recti for the relief of the esophoria, and a stronger glass ( + 2-00 s.) was given for reading. Since then he has had no attack of neuralgia, and has been perfectly well for two 28 ERRORS OF REFRACTION. years. He occasionally, after severe eye work, has some slight symptoms of his old asthenopia." Here we find a patient with two dioptres of latent hy- peropia fitted with glasses in two hours' time after atropine had been dropped into the eye, and apparently from one in- stillation. Comment upon such practice is hardly needed. If this is a simple case of thoroughness of examination and a scientific use of atropine, then the times have changed, and patients' eye muscles with them. Atropine, when thor- oughly used, is unreliable as to the axis of the glass in cases of astigmatism, as not very long since pointed out by Dr. Gould, of Philadelphia ; and when used as in this case, is of no value scientifically or practically. It takes at least two or three days-not two hours-and sometimes much longer, to paralyze the accommodation with atropine ; this is a well established physiological fact. Cases XIII and XIV were cases of nervous prostration, one of which was cured by glasses and graduated tenoto- mies, and the other by glasses alone. Case XV. " Aggravated Type of Chorea, accompanied by Deformity, Headache, Asthenopia, and Inability to Work.'"1 There are two or three remarkable things in this case to me. First, " that no one who had seen her could make a diagnosis." A case of aggravated chronic chorea ought certainly to have enough symptoms present so that no in- telligent doctor could mistake the diagnosis. But perhaps the second remarkable thing in this case accounts for a lack of diagnosis by the doctors "who had seen the patient. "No inco-ordination existed." How any one could have aggra- vated chorea and not have inco ordination is a mystery to me. If inco-ordination does not exist when the patient can not make use of her limbs from spasmodic action of the muscles, then I fail to appreciate the meaning of the term inco-ordination. ERRORS OF REFRACTION. 29 " The region of the fourth button of her dress " also leaves us in doubt as to the position of the patient's chin when we do not know where the button was, high up or low down, front or back, for it may be in almost any of these places. Case XVI. Constant Headache associated with Nervous Prostration.-Treatment consisted simply in ordering the glasses for constant wear to correct her error of focus. " Rapid and complete cure." Case XVII. " Chronic Chorea, Loss of Power in Right Arm and both Legs."-Treatment consisted in " wearing of prisms for some time, then graduated tenotomies upon the interni. " Result.-Complete restoration of power to the limbs and disappearance of all choreic movements." The case speaks for itself and suggests a new treatment for paralyzed limbs. Case XVIII. Constant headache cured by wearing sphero-cylindric glasses and prisms. So much for the eighteen remarkable cases and the statements made in connection with them. If I have succeeded in the present paper by the report of the three hundred and eighteen cases of refraction in es- tablishing the fact that it is not necessary or scientific to use atropine to determine errors of refraction, and inci- dentally by the review of eighteen cases, in most of which graduated tenotomies were done, have shown the absurdity of such a procedure as performing graduated tenotomy, then the purpose of the paper has been accomplished. One last thought in closing. How fortunate for the dignity of the ophthalmologists of America that but an exceptional few of them obtain wonderful, miraculous, and resurrecting results, and that by graduated tenotomies ! A quotation from G. A. Berry, of Edinburgh, by St. John Roosa, in the Medical 30 ERRORS OF REFRACTION. Record, March 26, 1892, p. 338, illustrates this point: "For my part, I regard the practice, which, to judge from the lit- erature of the subject, is not uncommon in America, of fre- quently performing tenotomies, or so-called partial tenoto- mies, for lateral deviations as a disgrace to modern ophthal- mology. As to the frequent ordering of prisms for similar conditions, that is a practice which, while it displays the same ignorance, is open to less serious objections, inasmuch as it only affects the pockets of the patient and that to a less extent than operative interference." Again, when in Paris last winter I asked an ophthalmologist, who perhaps knows more about refraction than any other man now living, what he thought of the men who frequently practiced graduated tenotomies for muscular insufficiencies. He replied by say- ing, if I would excuse him for saying so, " they display great ignorance." 463 Fifth Avenue. 1 'dSBQ Sex. 0) tuc Symptoms. Duration. Former treatment, j Previous diagnoses. EYE TESTS. Eye treatment. Results. Refractive errors. Muscular errors. 1 Male. H Complete mental 1 year. Medicinal, Organic cere- o n J +0'50 8. v. u.-j +o-75 c., ax. SO" Left Spherical and A practical cure. Patient still . and physical collapse. massage, bral softening hyperphoria, cylindrical has some headache, but has water (by several „ c | +1 ■ 25 s. glasses. Grad- entirely regained his mind and Insomnia. 6 months. treatment, physicians). u- 8' I +0 50 c., ax. 90° Esophoria, uated tenoto- is able to resume control of Severe neuralgic 20 years. electricity, Hvpermetropia. 7°. my of left sup. his finances. The insomnia attacks. diet, etc. • Astigmatism. rectus. Grad- uated tenoto- and neuralgia have ceased. my of right internal rectus 2 Male. IS) Epilepsy. 5 years. Enormous Epileptic No defect in either eye, even when under full Esophoria Wearing of One attack during past two Epileptic mania. 2 years. doses of mania (papers (mostly prismatic years. Patient has taken no bromides, w'ere drawn effects of atropine. latent). glasses. Grad- drugs for nearly four years, with chloral, to commit the Right uated tenoto- and has entirelv regained his arsenic, and patient to an hvperphoria my of right mental and physical strength. other drugs, asylum as an (entirely sup. rectus. Both had been seriously af- without incurable). latent at Graduated fected bv the bromides in the any relief. first visit). tenotomy of each intern us. past. 3 Male. 43 Epilepsy. 24 years. Enormous Epilepsy Hypermetropia. Esophoria Full correc- An apparent cure. Patient doses of bro- (from early «;D;p2-50s. (mostly tion of the hy- taken no drugs and has had mides for masturbation latent). permetropia no seizures for nearly six many years and later (Entirely latent, and by spherical years. without bene- sexual therefore unsuspected glasses. Grad- fit, cerebral excesses). by the patient.) uated tenoto- galvanism, inies upon massage. both interni. An apparent cure. Patient has I Male. 35 Epilepsy Unknown. Unknown. Epilepsy. 0 TA J +1 '50 s. o. _2'75c.,ax. 180* Esophoria, Spherical 4°. and cylindrical glasses only. not had a fit since April, 1890. P q J + 1'50 s. 1 -2'75c., ax. 180" Hypermetropia. Astigmatism. Patient has not had a fit for Correction 5 Male. 26 Epilepsv. 6 years. Bromides in Epilepsy. O. D. + 0'50 c., ax. 90° Esophoria, An approach to mental imbecility Since very large This patient n q J + 4'00 c., ax. 180° | -1'03 c., ax. 90° 11". bv spherical eighteen months. Has taken bromides doses, causing had seen and cylindri- no drugs. Has regained his from bromides. were begun. serious men- many physi- Hypermetropia. cal glasses. intellect and gone into busi- tai sluggish- cians of emi- Astigmatism. Graduated ness pursuits. Travels with- ness and nence and tenotomies out an attendant and weighs apathy. none had dis- upon both eighteen pounds more than agreed on the interni. when eye treatment was be- diagnosis. gun. 6 Female. 21 Complete nervous 5 years. Electricity, Organic O. D. +125 s. Left Spherical Patient is now teaching gym- nastics in a ladies' school. prostration. massage, drugs or all spinal and O. S.+ 1-25 s. hyperphoria, 2". glasses. Grad- Constant pain 5 years. brain disease Hvpermetropia. uated tenoto- in head. kinds. (by several Exophoria, mies upon Inability to walk. 5 years. physicans). 2°. both externi and left supe- rior rectus. 7 Female. 42 Nervous 10 years. Electricity, Organic dis- Emmetropia. Esophoria, Graduated This patient had never suspect- prostration. massage, ease had been (No defect, even under 3°. tenotomies ed any eye trouble ; but made Trembling of 8 years. drugs of all strongly sus- atropine.) (A much upon both a perfect recovery within a face and limbs. kinds, pected. This higher degree interni. month after the last tenotomy Neuralgic attacks 16 years. uterine patient had of latent was performed. Five years of a violent form. treatment. employed physicians by the score and had received no benefits from drugs. esophoria disclosed itself later). have elapsed without a return of a single symptom. For over sixteen years she had been a hopeless invalid. This patient was enabled to re- 8 Female. 12 Great 1 year. Had consulted Organic Hypermetropia. Esophoria, Spherical despondency. an oculist who " found brain disease (). D.+0-75 s. Right glasses for sume her profession, and was Confusion of 1 year. had been O. S.+0-75 s. distance. restored to health without the mind and thought. nothing suspected. (Under atropine.) hyperphoria, Strong read- use of dregs until w'ithin a Loss of 1 year. wrong in the eyes. Had One physician Presbyopia. 2'. ing glasses. week of her death. The full emotional control. "feared the Spherical glasses Graduated history of this case is of spe- Confirmed 1 year. been under approach of (+2'50) tolerated well tenotomies cial interest. sleeplessness. care of a spe- melancholia." for reading, sewing, upon both Constant 1 year. cialist who Undoubted etc. interni and headache. prescribed symptoms of right superior drugs, elec- insanity had rectus tricity, and appeared at muscle. restricted diet, with only partial and temporary benefit. Had times. never used glasses, even for reading or sewing. Spherical Complete cure. The patient is ! Male. 23 Melancholia. 1 year. This patient Cerebral 1 Hypermetropia. Esophoria, Morbid impulses. 1 year. had been congestion. O. D.+2-50 s. 12°. | glasses for restored to mental and physi- Severe neuralgia 8 months. treated for Organic O. S.-12-50 s. ! constant cal health, and has resumed (of bladder and months by a brain disease (Entirely latent and un- wear. 1 his profession. All neuralgic prostate gland). specialist for had been suspected by patient.) Graduated attacks have ceased for past prostatic dis- suspected. tenotomies five years. ease. He had upon both also taken interni. drugs of all kinds for his mental condition. UQ c5 O Sex. J 4 Symptoms. Duration. Former treatment. Previous diagnoses. EYE TESTS. Eye treatment. Results. Refractive errors. Muscular errors. 10 Male. 16 Nervous 15 years. This patient Cerebral Hypermetropia. Esophoria, I Graduated Complete recovery. During the prostration. had been un- congestion. O. D. +1-00 8. 13°. tenotomies past two years this patient has Sleeplessness. 15 years. der constant Excessive o. s.+roos. upon both had no return of his former Pain in head. 15 years. medical care. business interni. symptoms. Drugs gave no benefits cares. or relief. This patient has been able to 11 Female. 15 Complete nervous 1 year. Patient had Some Hypermetropia. Right Spherical prostration. Chronic >een confined obscure form O. D. + 175. hyperphoria, glasses for walk for miles and to take full 5 years. in bed for of abdominal O. S.+1-75. 3°. distance, and charge of her house since the bladder trouble. about one disease had Presbyopia. Esophoria, 1 stronger ones tenotomies were performed Chronic 1 year. year from been sus- + 4'50 s. needed for 7* for reading (two years and a half ago). sleeplessness. nervous col- lapse. Drugs of all kinds pected by the many pby- reading or sewing. or sewing. Graduated She has taken no drugs, sleeps well, and is apparently sicians who tenotomies restored to perfect health. had been had seen her upon both administered in consulta- internal recti without per- tion. and the manent bene- right superior fit. Uterine rectus treatment had accomplished muscle. 12 Male. 23 Chronic 10 years. nothing. Drugs of all Some local Hypermetropia. Esophoria, Spherical Complete cure. (No neuralgia neuralgia. Asthenopia. 5 years. kinds' without beneficial disease was suspected as g-D-f+2 00 8. 6°. glasses for distance, and for past two years.) Headaches. 10 years. results. the exciting stronger ones Patient had cause of the for reading. contemplated suicide. neuralgic paroxysms. Graduated tenotomies upon both internal recti muscles. Complete cure for past six years. This patient can walk for miles, and her digestive functions are perfect. 13 Female. 40 Nervous prostration. Confirmed 6 years. Most of Uterine treatment for years. Drugs The uterine trouble was always sup- Hypermetropia. 3®; [+1-50 8. Esophoria. 4*. Spherical glasses for reading, digestive troubles. Inability to walk her life. 6 years. of all kinds. " Rest cure" posed to be the chief sewing, etc. Graduated or endure fatigue. (f or 3 consecu- cause of the tenotomy five months). physical upon the Electricity weakness. left internal for months. rectus 14 Female. 45 Nervous Several Massage. Had taken The diag- Hypermetropia. Apparent muscle. Spherical A very rapid recovery of strength, and a return of the pupils to equal size. Almost prostration. Abnormally large years. 12 years. drugs of all kinds. Had nosis in this case had Astigmatism. O. D. +1'50s.O orthophoria. and cylindrical "'T pupil in one eye. consulted a been very + 0'50 c., ax. 75° glasses for complete reiiei or me m- Confirmed 1 year. prominent obscure to O. S.+ 1'50 s. Q constant somma. sleeplessness. oculist with- all that had +0'50 c., ax. 105° wear were out benefit. been called alone The wife of a to examine prescribed. prominent medical lecturer and this patient IS Female Chronic chorea. Aggravated deformity of head and limbs. Headache. Asthenopia. 16 years. 4 years. 16 years. 16 years. practitioner. This patient had been seen by many phy- sicians. Drugs and electricity had accom- plished noth- Organic spinal disease had been suspected. Hypermetropia. O° I +0*75 8 O. S. | +U <oS- Esophoria, 20° (mostly latent). Left hyperphoria, 3°. Graduated tenotomies upon both interni and left superior rectus muscle. Relief of the deformity of the head and neck, and marked amelioration of the other symptoms. The patient was enabled to return to her for- mer position, and has since been self-supporting. 16 Female 3S Constant headache. Nervous prostration. 16 years. 5 months. ing. Has been under uterine treatment wi.hont relief Has taken Organic disease had been suspected. Hypermetropia. Astigmatism. n n f +1-00 8. -L'-) +0'75c.,ax.ll5° O. S. +1-50 8. Orthophoria. Spherical and cylindrical glasses to fully correct Rapid and complete cure. The patient walked four miles in less than a week. No return of headache for past two years. drugs, elec- all latent tricity, mas- sage, etc., errors of refraction. r Female If Chronic chorea. Loss of power in right arm and both legs. 8 months. 6 weeks. withoutben'fii Drugs of all kinds. Organic brain disease (by an eminent neurologist of New York) Hypermetropia. Esophoria, 8°. Graduated tenotomies upon both interni. Pris- matic glasses Complete restoration of power to the limbs, and disappear- ance of all choreic move- ments. for some months prior to tenotomies Immediate cessation of all head- ache, that has not since re- turned. This patient is now perfectly well. if Female 1( Constant headache (very severe). Steady decrease 14 months. 14 months. Drugs. Rest from school. Country air. Had been ex- One oculist told the par- ents that the "child proba Hypermetropia. Astigmatism. O. D.+0-75 s. O. S.+0-75 c., ax. 90° : Esophoria, 2°. Cylindrical and spherical glasses, com- bined with in weight. amined by twc bly had prisms for the noted oculists tubercular meningitis." esophoria. S& REASONS WHY Pliys*ci®sWi8nMK ' " F0R ~ The NewYork Medical Journal, Edited by FRANK P. FOSTER, M.D., Published by D. APPLETON & CO., 1, 3, & 5 Bond St 1. BECAUSE : It is the LEADING- JOURNAL of America, and contains more reading-matter than any other journal of its class, 2. BECAUSE : It is the exponent of the most advanced scientific medical thought. 3. BECAUSE : Its contributors are among the most learned medi- cal men of this country. 4. BECAUSE: Its "Original Articles" are the results of sci- entific observation and research, and are of infinite practical value to the general practitioner. 5. 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