The Errors of Refraction 
in a Series of Two Thousand Eyes, 
And Some of the Symptoms related thereto. 
BY 
F. W. MABLOW, M.D., M.B.C.S.E., 
SYRACUSE, N.Y., 
Professor of Ophthalmology in the Medical Department of 
Syracuse University ; Member of the American Ophthal- 
mological Society and of the Ophthalmological Society 
of the United Kingdom of Great Britain and Ireland ; 
Formerly Clinical Assistant at the Royal 
London Ophthalmic Hospital, Moorfields, etc. 
REPRINTED FROM THE 
Nelrs ¥orfc JIHetncal journal 
for July 13, 1895. Reprinted from the New York Medical Journal 
for July 13, 1895. 
THE ERRORS OF REFRACTION 
IN A SERIES OF TWO THOUSAND EYES, 
AND SOME OF THE SYMPTOMS RELATED THERETO.* 
By F. W. MARLOW, M. D., M. R. C.S.E., 
SYRACUSE, N. Y., 
PROFESSOR OF OPHTHALMOLOGY 
IN THE MEDICAL DEPARTMENT OF SYRACUSE UNIVERSITY ; 
MEMBER OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY AND OF 
THE OPHTHALMOLOGICAL SOCIETY OF 
THE UNITED KINGDOM OF GREAT BRITAIN AND IRELAND ; 
FORMERLY CLINICAL ASSISTANT AT 
THE ROYAL LONDON OPHTHALMIC HOSPITAL, MOORFIELDS, ETC. 
The cases upon which the following paper is based 
were seen in private practice between April 22, 1893, and 
January 22, 1895. No selection has been made, the cases 
being taken as they came, with the exception of those hav- 
ing corneal or lenticular opacity, or disease at the fundus 
sufficient to interfere with the proper estimation of the re- 
fraction. 
The examinations and records were made with a con- 
siderable degree of uniformity, both as regards practical 
methods and the working theories underlying them. When 
the cases were seen and recorded, there was no thought of 
tabulating them, and the records are consequently in some 
* Read, in part, before the Syracuse Academy of Medicine, May 7, 
1895. 
Copyright, 1895, by D. Appleton and Company. THE ERRORS OF REFRACTION 
2 
respects less complete than they otherwise would have 
been. 
With very few exceptions each case was examined 
twice. In the great majority of cases a mydriatic was used 
previous to the second examination, a complete paralysis of 
the accommodation being produced. 
Thus, hydrobromide of homatropine (in solution, gr. 
viii ad j) was used in 1,512 eyes or in 756 cases, sul- 
phate of atropine in 148 eyes or in 74 cases, and in 20 
cases the use of homatropine was followed by the pro- 
longed use of atropine, on account of persistent spasm of 
the accommodation. 
Beyond the very occasional occurrence of transient 
symptoms of atropine poisoning, nothing but the tempo- 
rary inconvenience of accommodative paralysis can be set 
down against the use of these drugs. 
The examinations were made with the ophthalmometer 
of Javal, followed by subjective tests with test types and 
lenses, with the ophthalmoscope, and in a certain number 
of cases the shadow test was used-the most accurate of all 
objective methods for the estimation of refractive errors. 
In the cases of a few young children the latter method had 
to be relied upon exclusively. 
The ophthalmometer was used in almost every case. In 
rare cases only did the corneal astigmatism prove to be the 
only astigmatism present, in the vast majority there being 
a difference between the findings of the instrument and the 
total astigmatism, a difference which in one case amounted 
to 3 D. 
The constancy with which a difference between the 
corneal and total astigmatism is found shows that some 
lenticular astigmatism is almost invariable, although usu- 
ally of low degree. 
I omitted to make any tabulation of the cases in this IN TWO THOUSAND EYES. 
3 
respect, but the impression gained from my total experi- 
ence with the ophthalmometer so far is that, while mod- 
erate and high degrees of astigmatism are mainly corneal, 
astigmatism of some degree (usually low) is present more 
frequently in the lens than in the cornea. In other words, 
the cases in which no corneal astigmatism exists are com- 
moner than those in which there is no difference between 
the corneal and the total astigmatism-no lenticular astig- 
matism. 
The principal meridians of the corneal astigmatism 
correspond usually with those of the total astigmatism in 
the higher degrees. In the lower degrees there may be, 
and commonly is, much difference. Indeed, in cases of cor- 
neal astigmatism of 0'25 D. or 0'5 D. with the rule, the 
principal meridians of the total are often placed near 45° 
and 135°, or even against the rule. 
On the whole the instrument probably saves no time. 
In a minority of cases it gives a very useful indication of 
the direction in which to begin work. But in the majority 
it affords no information beyond the fact that there is a 
certain small amount of corneal astigmatism, which is of 
interest, but, as it bears no constant relation to the total 
astigmatism, practically valueless. In children it is less 
useful than in adults, on account of the greater difficulty in 
obtaining the necessary steady fixation. 
Sex.-Three hundred and fifty-nine of the patients were 
males and six hundred and forty-one females, or thirty-six 
per cent, male and sixty-four per cent, female. 
Age.-Sixty of the patients were in the first decade of 
life, 212 in the second, 275 in the third, 201 in the fourth, 
138 in the fifth, 80 in the sixth, and 34 were above sixty 
years of age. 
About fifty per cent, then came under observation be- 
tween the ages of ten and thirty. Although this corre- 4 
TIIE ERRORS OF REFRACTION 
sponds with the observation of others, it is by no means a 
sure indication of the time of onset of the symptoms of 
eye-strain, for these have commonly existed for years be- 
fore the patient has come under observation. 
Statistics derived from hospital or dispensary reports 
bearing on the relative frequency of the different forms of 
refractive error are, I believe, extremely misleading, in the 
direction chiefly of making astigmatism much rarer, simple 
hypermetropia commoner, and simple myopia infinitely 
commoner than either really is. There seems reason, in- 
deed, to doubt the existence of a simple uncomplicated 
myopia-i. e., a myopia without astigmatism, anisome- 
tropia, or heterophoria. 
The differences between hospital and private statistics 
depend doubtless on the different degrees of intelligence in 
the two classes of patients, on the greater amount of time 
which is expended in private practice on these cases, and 
on the fact that in hospital practice they are often rele- 
gated to the less experienced members of the staff and to 
students. 
The following table presents a comparison between hos- 
pital and private statistics as to the grosser facts. The in- 
Mass. Char. Eye' 
and Ear Inf., 
1891 and 1893. 
N. Y. Ophthal. 
and Aural Inst., 
1890 and 1893. [ 
Newark Eye and 
Ear Inf., 1890, 
1891,and 1893. 
Brooklyn ditto. J 
This series 
Total num- 
ber of cases. 
jw 
o 
I-* ce 
o O 
Cases of 
astigmatism. 
co co 
Per cent, 
of total. 
ex 
o -r 
Simple hy- 
permetropia. 
-Y O 
co o 
Per cent, 
of total. 
1-• 
t-' 
Simple 
myopia. 
Per cent, 
of total. 
H-* 
i-* co 
Emmetropia. 
H-* bO 
Per cent, 
of total. IN TWO THOUSAND EYES. 
5 
stitutions named were selected for the reason that their 
reports were ready at hand. 
it has been assumed that the cases placed under the 
head of astigmatism included all varieties and degrees of 
astigmatism, that those under the heading of hypermetropia 
were cases of simple hypermetropia, and similarly with 
myopia. 
While cases of astigmatism are nearly three times as 
common in private practice as in hospital statistics, simple 
hypermetropia is more than six times and simple myopia 
one hundred and fifty times commoner in the latter than in 
the former. 
The following tables show the distribution of this series 
of two thousand eyes among the different forms of refrac- 
tion : 
Hypermetropia. 
Eyes. 
Per cent, 
of hyper- 
metropia. 
Per cent, 
of all. 
Simple hvpermetropia 
229 
16'0 
11-4 
Simple hypermetropic astigmatism 
308 
21-5 
15-0 
Compound hypermetropic astigmatism .. 
891 
62-5 
45-0 
Total hypermetropia 
1,428 
100-0 
71-4 
Myopia. 
Eyes. 
Per cent, 
of myopia. 
Per cent, 
of al]. 
Simple myopia 
19 
3-5 
1-9 
Simple myopic astigmatism 
156 
28-5 
7-8 
Compound myopic astigmatism 
252 
46'0 
12-6 
Mixed astigmatism 
122 
22-0 
6-1 
Total myopia 
549 
100-0 
27-4 
Emmetropia 
23 
1-2 6 
THE ERRORS OF REFRACTION 
By adding together the numbers of astigmatic eyes in 
the above tables we find that in 1,722 of the 1,977 hyper- 
metropic or myopic eyes there was astigmatism in addition 
to hypermetropia or myopia. Astigmatism, then, was pres- 
ent in eighty-six per cent, of the total number, and conse- 
quently is the commonest of all errors of refraction, hyper- 
metropia coming next with 71'4 per cent. 
If we reckon by patients instead of by eyes, we find 
that 919 out of the 1,000, or practically ninety-two per cent., 
had some astigmatism in one or both eyes ; about seventy- 
five per cent, were hypermetropic, twenty-five per cent, my- 
opic, and only one patient, or one tenth of one per cent, of the 
whole number, was free from refractive error in both eyes. 
Of 1,428 hypermetropic eyes, 229, or sixteen per cent., 
had no astigmatism (or less than 0'25 D.); whereas, of the 
549 myopic eyes, only 19, or 3'5 per cent., were free from 
astigmatism. That is to say, that among hypermetropic 
eyes simple hypermetropia is four and a half times com- 
moner than simple myopia among myopic eyes. 
If we reckon again by patients instead of by eyes, the 
contrast between the relative frequency of simple hyperme- 
tropia and simple myopia is still more striking. 
Thus, simple hypermetropia constitutes about nine per 
cent, of the farsighted, and simple myopia a little more 
than a third of one per cent, of the nearsighted; or simple 
hypermetropia is about twenty-five times as common among 
the farsighted as simple myopia among the nearsighted. 
While astigmatism is very frequently found in hyperme- 
tropes, its presence is all but invariable among myopes. 
Now, when it is taken into consideration that the eye 
is almost always hypermetropic at birth and for some time 
afterward, and that myopia is an acquired condition or 
pathological process, developing in a certain number of 
these originally hypermetropic eyes, the fact that those in- IN TWO THOUSAND EFES. 
7 
dividuals in whom one or both eyes are astigmatic are prac- 
tically exclusively selected has great significance. It be- 
comes evident that the subjects of simple hypermetropia 
have but little tendency to become myopic, and it seems 
highly probable that the presence of astigmatism is an im- 
portant factor in the causation of myopia. 
Glasses of different strength for the two eyes were re- 
quired in 716 cases, or in over seventy-one per cent., and 
if a difference in the position of the axis is taken into con- 
sideration, the percentage of asymmetry rises still higher, 
for, of 452 cases, there was an unsymmetrical relation of 
the axes in over sixty-six per cent. Among the hyperme- 
tropes there was unequal refraction in about seventy per 
cent, of the cases, whereas in myopes it was present in 
about seventy-four per cent. Individuals whose refraction 
is dissimilar in the two eyes are, then, presumably some- 
what more prone to become myopic. (In this paper a dif- 
ference in refraction amounting to 0'25 D. is taken into 
account. If the higher degrees of anisometropia alone 
were considered, a larger proportion still would probably 
be found among the myopes.) 
There is one other form of congenital anomaly which is 
found in a large number of cases of myopia-namely, a 
faulty condition of muscular equilibrium. Some form of 
heterophoria was present in 117 of the cases of myopia. 
An impression gained from the study of individual cases 
that these errors play an important part in producing myo- 
pia is scarcely borne out by the statistics as a whole, which 
give the percentage of heterophoria in myopes as somewhat 
less than that in the whole series. When, however, only 
those cases are taken into consideration in which the hetero- 
phoria has been thought worthy of correction, the situa- 
tion changes. Thus, a correction for latent deviation was 
prescribed in thirty per cent, of the cases of myopia, in nine- 8 
THE ERRORS OE REFRACTION 
teen per cent, of other forms of refraction, and in twenty- 
two per cent, of the whole number of cases. 
In other words, it was necessary to correct heterophoria 
in myopia in over fifty per cent, more cases than in other 
forms of refraction. 
To summarize briefly: 
In myopia we find astigmatism, anisometropia, and 
heterophoria more frequently than in other forms of ametro- 
pia ; and, since the myopia has developed in eyes originally 
hypermetropic, the myopic process has evidently selected 
those individuals in whom astigmatism, anisometropia, and 
heterophoria were present, and consequently we find in cases 
of myopia two groups of conditions : 
1. A congenital group, consisting of one or more of the 
three previously mentioned anomalies, and 
2. An acquired group-the pathological elongation of 
the eyeball characteristic of the myopic eye, and the changes 
secondary to it. 
I believe it is not far from the truth to say that the sec- 
ond group is the result of the first, plus, in some cases, cer- 
tain defective hygienic conditions. 
In the 245 cases of myopia occurring in this series 
there is no case in which one or more of these congenital 
defects is not present, and if these cases fairly typify the 
conditions found in myopia, and I believe they do, it means 
that ordinary nearsighted glasses-concave spherical lenses 
-of equal strength for the two eyes are practically never 
correct, and since this generalization has formed in my mind 
I have looked in vain for a case of simple uncomplicated 
myopia. The bearing of this upon practice is important, 
for experience is beginning to show that when these con- 
genital defects are corrected the myopia ceases to progress, 
and that when they are uncorrected, and concave spherical 
glasses simply prescribed, the myopia tends to be pro- IN TWO THOUSAND EYES. 
9 
gressive ; and there is little doubt that the careful correc- 
tion of these errors in children now just beginning will 
bear fruit in a great diminution in the percentage of the 
nearsighted in the next generation. 
Astigmatism.-No case of astigmatism is recorded in 
this paper of less degree than 0'25 D. Although it is 
probable that an error of 0T25 D. produces in some per- 
sons annoying symptoms, its importance is not yet gener- 
ally acknowledged, and consequently cases of this degree 
have been classed as simple hypermetropia or myopia. 
In the majority of cases the astigmatism did not exceed 
0'5 D.; in no case did it exceed 6 D. 
The following table shows the distribution of all the 
astigmatic eyes into four groups according to the degree of 
error: 
NUMBER OF EYES. 
Per cent, 
of all 
astigmatic 
eyes. 
Right 
Left. 
Total. 
Astigmatism = 0'25 D. to 0'5 D.... 
584 
558 
1,142 
66J 
0-75 D. to 1 D 
165 
152 
317 
18* 
1-25 D. to 2 D 
64 
81 
145 
8* 
2'25 D. and upward 
54 
64 
118 
7 ' 
- 
, 
- 
Total 
867 
855 
1,722 
100 
Eyes. 
Per cent, of 
astigmatic 
eyes. 
With rule 
1,196 
69'5 
Against rule 
464 
27'0 
Axis at 45° or 135° 
62 
3-5 
Axis oblique, i. e., at least 5° from vertical or 
horizontal 
1,329 
77-0 
Axis exactly vertical or horizontal 
393 
23-0 
The next table shows the direction of the axis: 
An analysis of the cases shows that the influence of the 
lower degrees of astigmatism in the production of astheno- 10 
THE ERRORS OF REFRACTION 
pia and allied symptoms is at least as great as (really some- 
what greater than) that of the higher degrees. 
The next table shows the relative frequency of some of 
the symptoms in the four groups of astigmatic cases: 
0-25 to 0-5 D... 
0-75 to 1 D 
1 • 25 to 2 D 
2'25 and upward 
Degbee of 
Astigmatism. 
- »-» ex 
oo o ot 
o to ex GO 
Number of 
cases. 
- 
CX O 1-' H-1 
to ex 
Headache. 
CX O ~- 
o o o ex 
Per cent. 
H-' 
-J 00 
Megrim. 
M H to K) 
-q- eo i-* i-* 
Per cent. 
1-* tO CO GO 
-<r oo 
Vertigo. 
r-* tO tO CO 
<TO H W 
Per cent. 
co oo 
o ex 
Photo- 
phobia. 
ex o o o 
Per cent. 
to 
o <r oo ex 
oo o >-* 
Defective 
vision. 
oo ex 
ex o o ex 
Per cent. 
It will be observed that as the percentage of defective 
vision rises that of headache and the other symptoms falls. 
External Ocular Muscles.-There was an apparently 
normal equilibrium in 453 cases. A latent deviation was 
demonstrated in 494. A manifest strabismus was present 
in 28, and in the remaining 25 cases no record was made. 
The following table shows the distribution of the va- 
rious forms of heterophoria in the different kinds of re- 
fraction : 
Total. 
In myopia 
and mixed 
astigma- 
tism. 
Per cent, 
in myopia, 
etc. 
In hyper- 
metropia 
(all 
forms). 
Per cent, in 
hyper- 
metropia. 
Esophoria 
193 
46 
17 
147 
20 
Exophoria 
169 
57 
21 
112 
15 
Hyperphoria 
207 
74 
27 
133 
18 
Owing to the fact that most of the cases of hyperphoria 
were complicated by the presence of a lateral deviating ten- 
dency, and consequently appear twice, the number of cases 
of heterophoria appears to be exaggerated in this table. 
Esophoria, then, appears to be a little, and only a little, 
commoner in hypermetropic than in myopic individuals. 
Probably in a number of these cases the relaxation of the IN TWO THOUSAND EYES. 
11 
accommodation following the correction of the refraction 
has been accompanied by a diminution in the degree of, or 
by a complete abolition of the esophoria, and even in some 
cases by the development or manifestation of an exophoria. 
It certainly is a common experience to find some time 
after the full correction of hypermetropia or hypermetropic 
astigmatism that a latent divergence exists, whereas at the 
primary examinations no such deviating tendency could be 
demonstrated, or even a low degree of esophoria was present. 
These statistics mainly are derived from the primary ex- 
aminations, as only a small percentage of the patients have 
come back for subsequent examination, and consequently 
represent a slightly too large percentage of esophoria in 
hypermetropia. 
Exophcria and hyperphoria are distinctly commoner in 
myopes than in hypermetropes. Not, however, I believe, 
because myopia has any influence in producing them, but 
rather because, as previously suggested, their presence con- 
stitutes a predisposition to the onset of the myopic process. 
In 219 cases, or in twenty-two per cent, of the whole 
number, a prismatic correction was prescribed. 
Tenotomies were performed in ten cases. 
Symptoms.-The commonest symptom, as might be ex- 
pected, was an inability to use the eyes for near work for 
an ordinary length of time-asthenopia. This occurred 
in 810 out of the 1,000 cases. 
The next symptom in order of frequency is headache, 
which was present in 755 cases, or in over seventy-five per 
cent. This occurs in every degree of intensity, from a 
slight dull aching or sense of pressure to the severest par- 
oxysmal pain, requiring the administration of a general an- 
aesthetic for its control. So far as intensity of pain is con- 
cerned, there is no degree which may not be the result of 
eye-strain. 12 
THE ERRORS OF REFRACTION 
Although in cases of headache from eye-strain the pres- 
ence of asthenopic symptoms is the rule, there are many 
exceptions. Thus, in 113 of the 755 cases of headache, or 
in about fifteen per cent., no symptoms of asthenopia were 
present. This fact is of interest in connection with the 
statements made and opinions expressed by some ophthal- 
mologists that eye-strain does not give rise to headache and 
the more unusual and remote functional disturbances with- 
out causing at the same time symptoms involving the eyes 
themselves-opinions certainly very widely at variance with 
the facts. So far from being the necessary accompaniment 
of headache, etc., the onset of local ocular symptoms often 
seems to be the occasion for the more remote symptoms to 
diminish or cease entirely. Every ophthalmologist must be 
familiar with cases in which the patient, the subject of 
headache or other functional neurosis, has experienced no 
difficulty in the prolonged use of the eyes until some 
definite period of life when asthenopic symptoms have de- 
veloped, and coincidently the headaches or other nervous 
symptoms have diminished or come to an end. 
The next table shows the relative frequency with which 
the different parts of the head are the subjects of pain. 
Here again the numbers in the table are somewhat too 
large, on account of some cases appearing under more than 
one heading: 
Location. 
Total 
number 
of cases. 
Limited 
to this 
region. 
Commencing 
in this region 
and extend- 
ing to other 
parts. 
Affecting 
this region 
seconda- 
rily. 
Frontal 
381 
208 
110 
63 
Temporal 
158 
58 
50 
50 
Occipital 
199 
50 
38 
111 
Orbital 
121 
43 
40 
38 
Cervical (" back of neck ").. 
79 
23 
6 
50 
Vertical 
98 
49 
49 
General 
17 
Unstated 
63 IN TWO THOUSAND EYES. 
13 
Time of Onset.-This was noted in 480 cases, and was 
as follows: In 216, on waking from sleep; in 29, soon 
after rising ; in 102, during the latter part of the day ; in 
80, after use of the eyes, and in 53, at any time. 
The statement has been made recently in more than 
one journal that the onset of headache on waking is char- 
acteristic of that due to iniranasal pressure, in contradis- 
tinction to that arising from eye-strain. It may be true 
that the headache of intranasal pressure tends to com- 
mence on waking. It is certainly not true that this tend- 
ency is of any value in distinguishing it from that due to 
eye-strain. 
It has been thought by some that the headache due to 
refractive error is more apt to be frontal, and that pro- 
duced by external muscular error occipital in location. 
It must be confessed that on account of the almost in- 
variable commingling of the two classes of errors their 
relative influence in this regard is very difficult to ascertain. 
There is no doubt, however, that astigmatism may be the 
cause of occipital or cervical headache, and that hetero- 
phoria may cause frontal headache. The impression gained 
from the study of these and other cases is that the location 
of the headache is determined by some individual and un- 
determinable peculiarity in the patient-by idiosyncrasy- 
and bears no definite relation to the kind of ocular error 
present. 
So far as it goes, however, the present series of cases 
shows evidence in favor of the idea that frontal headache 
is more associated with refractive error and occipital with 
external muscular error. 
There is a higher percentage of simple hypermetropia 
and astigmatism of all kinds in the cases of frontal head- 
ache than in the occipital cases, and a decidedly higher 
percentage of heterophoria (all forms) in occipital than in 14 
THE ERRORS OF REFRACTION 
frontal headache. To this general statement there is this 
exception, that esophoria is a trifle more frequent in the 
frontal than in the occipital cases. 
The following table gives the actual figures : 
SIMPLE 
HY. 
ASTIG- 
MATISM. 
HETERO- 
PHORIA. 
EXO- 
PHORIA. 
ESO- 
PHORIA. 
HYPER- 
PHORIA. 
OQ 
z 
aS 
o 
Per ct. 
QQ 
<D 
CC 
o8 
o 
Cases. 
fe 
Ph 
Cases. 
1 Per ct. 
| Cases. 
o 
Ph 
0Q 
<D 
OQ 
o3 
o 
Per ct. 
Frontal head- 
ache,;! 18 cases 
21 
6'5 
301 
94 
159 
50-0 
46 
15-0 
61 
19 
52 
16-0 
Occipital head- 
ache, 88 cases. 
3 
3'5 
80 
91 
62 
70-5 
22 
25-5 
16 
18 
24 
26-5 
Of the 755 cases the headache was accompanied by nau- 
sea or vomiting, and described as a " sick headache," in 187 
cases. 
The remaining symptoms which were taken into ac- 
count in the tabulation of the cases are stated below in the 
order of frequency : 
Intolerance of light in greater or less degree occurred in 
488 cases, or in about forty-nine per cent. 
Defective vision was complained of or admitted in 482 
cases, or in forty-eight per cent.; but in the majority of 
cases amounted to only occasional blurring. 
Vertigo, varying much in frequency and degree, was a 
symptom in 290 cases, or in twenty-nine per cent. 
Lacrymation occurred in 280 cases, or in twenty-eight 
per cent. 
Diplopia was complained of in 81 cases, or eight per cent. 
Mental symptoms, such as depression of spirits, confu- 
sion of thought, nervousness, irritability of temper, etc., 
occurred in 71 cases, or in seven per cent. 
Insomnia was present in 63 cases, or over six per cent. 
Nausea, independent of headache, occurred as a direct 
result of eye-strain in 20 cases, or in two per cent. IN TWO THOUSAND EYES. 
15 
Epilepsy, in 15 cases. 
Chorea, in 5 cases. 
Conjunctivitis and Meibomian tumors, in 51 cases. 
Blepharitis, in 18 cases. 
In conclusion, there are some symptoms the connection 
of which with eye-strain is not recognized until the correc- 
tion of the latter has relieved or modified them. Foremost 
among these is an interference with general nutrition. It is 
a common experience to see a marked gain in flesh, coupled 
with improvement in general health, follow the relief of 
any form of eye-strain. The symptoms of nervous dyspep- 
sia frequently disappear under similar conditions. The 
dependence of chronic dyspepsia, finally, upon eye-strain 
is, I believe, far more frequent than is commonly supposed. 
It is not contended, however, that there is any direct con- 
nection between eye-strain and any of the remote or general 
nervous symptoms previously detailed. These symptoms 
are in the majority of cases not the result of reflex action ; 
but it seems probable that the excessive expenditure of 
nervous energy to maintain clear and single vision, neces- 
sitated by the presence of refractive and muscular errors, 
results in a state of neurasthenia the symptoms of which 
vary with the idiosyncrasy, age, condition, mode of life, 
etc., of the patient. The refractive and muscular errors 
constitute a leak through which the reserve of nervous 
energy is lost. Without their correction the maintenance 
or recovery of good health is for many people impossible. 
As an example of the unusual symptoms which may result 
from neurasthenia thus induced, the following case is re- 
lated : 
In October, 1893, I examined the eyes of Mrs. L. I. F., who 
complained of nearsightedness, much headache, difficulty in 
seeing, even with her glasses, and a tendency to keep one eye 
closed. 16 
THE ERRORS OF REFRACTION. 
She was wearing concave spherical glasses, 9'5 D. for the 
right eye and 10 D. for the left, prescribed for her some years 
previously by a well-known New York homoeopathic oculist. 
Examination showed in the right eye a myopia of 15 D. 
and astigmatism of 2-25 D. ; in the left, myopia of 10 D. and 
astigmatism of 2-25 D.; a latent divergence of five or six de- 
grees, and hyperphoria of four degrees. Glasses correcting the 
whole of the astigmatism and myopia and the greater part of 
the heterophoria gave her, after a day or tw'O of discomfort, 
constant binocular single vision, which she had previously en- 
joyed only intermittently and imperfectly. 
She recently reported to me that she has been perfectly 
comfortable with the glasses ever since, her headaches and 
ocular symptoms having ceased, and made the following state- 
ment: That for the two years preceding the time of examina- 
tion she had been suffering from attacks of asthma of increasing 
frequency, finally occurring once in two weeks, and from a 
cough, which, intermittent at first, had become chronic for 
some months, and from loss of flesh. Since the change of glasses 
there has been no attack of asthma and the cough has com- 
pletely ceased; she has gained flesh, and is in the enjoyment 
of perfect health. She attributes the change in her condition 
solely to the relief of eye-strain. 
401 Montgomery Street. The New York Medical Journal. 
A WEEKLY REVIEW OF MEDICINE. 
EDITED BY 
FRANK P. FOSTER, M.D. 
THE PHYSICIAN who would keep abreast with the advances ink 
medical science must read a live weekly medical journal, in which 
scientific facts are presented in a clear manner; one for which the 
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accurate observers ; a journal that is stripped of every feature irrelevant 
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tiously edited ; one that bears upon every page the stamp of desire to 
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but, by means of its correct editing, instructs them in the very important 
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and correct manner. Too much stress can not be laid upon this feature, 
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for the city practitioner; it covers the entire range of medicine and 
surgery. A very important feature of the Journal is the number and 
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