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 With Emraetropia Possible in botli Eyes, Wliat 
 Porlion of the Ametropia Shall we Correct ? 
 
 
 Hv fASKV A. WOOD, t ,M.. \i,i,., c in. \<.<,, III.. 
 
 l't..t...M,r ,.1 ()|.lillialini.lni:y in ;li. I'.i^t (JnuliMlc! M.iIi.mI S.l„,n|, n,i,;ii;n; Ophllialniii.- 
 
 S.irucMi Ir. Cock Cniiiily Hospital, t„ i|„. Akxiaii Il..>|.ital aixl U, thr 
 
 KiiuTijriicv lliispit.il. Ihiraui). 
 
 
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 KKI'KIMKP I KiiM 
 
 IMK Rl I K \i I liiM'^ I 
 
 llo-TiiN, Mass. 
 
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 With Emmelropia Possible in botli Eyes, Wliat 
 Portion of tlie Ametropia Sliail we Correct ? 
 
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 It\ I ,\Si;V A. \V<)()I>, I M, Ml), I Mil M.d. Ii 1.. 
 
 Pr<>lrsMir ot (»|ilillialmiili>>;y in tlii I'i>sl (ira<lti;ili' Miiliial Srliiinl, l'liiiay:o; < >|iliili:i|inio 
 
 Siirjfi-nn to fdok foiinty llnspital, In tin- Ali xian Hospital anil to iIk 
 
 Knicrifi niv llo'.pilal, l'liirii;o. 
 
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 llii>tiiN, Ma---- 
 
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 wnii i:MMi:ru()iM.\ i-ossium; i\ isoimi dw:-^ 
 
 \vii.\r I'OKi'ioN oi- riii: .\Mi:ri<()i'i.\ 
 
 siiAi.i. w i: coKKiar- 
 
 \:\ i. \>\:\ A \\ (M iD ( \i \i |) ( 
 
 MM M.li ll I . 
 
 I'l..|. 
 
 ■■•' <>|ll)llulllin|(,yv III till |'.i>t (;,.l<l,i.ill- \ImIk-.iI S.lhHil, I hi, Mi;,., (l|,lil|,,,|,i,i, 
 >iir«.Miii H. luiils roui.ly llospii.il, ti. lilt Alixi.ii. Il(>>|>il:il ,iii<| i.. ili, 
 
 ■ •illll tlJIIIIV ll.lNjIM.il. t Illc.lHd. 
 
 FOK m.iiiN yrais p.ist tlir y:ri\iti'st diwiNitx i>t opinion has <,!). 
 taiiK'd as iii^Mids tlif amount ot tlu- H'traitivi- (.•rii.T to Ik- coi- 
 itHti'il in a u;ivi.ii case. Sonu' ocnlists oidt-r, in the lii^luT (k-yivfs of 
 aniftroiiia. a lull v.dm'i.-lion foi' nadin^' and a |)artial one for near 
 u<»ik, while some are for orderinL,' in e\er\ instaiKe a full correction 
 of the eiior in lioth eyes, while others ne\ei order more tlian the 
 nianiti'st amonnt. Sonu- nentrah/e one-halt o| the total mvopia. 
 Some have a sort of graduated scale with ii'li'Unce to hotli mvopia 
 and hyperopia. Some regard the correction of astigmatism as an 
 imceitaiii experiment, and still others tiill.iv\ rnles tor the correction 
 o| the \ iiioiis kinds I.I ametropia as com])licated and apparentiv as 
 dillicnlt of application as the s\stem of the '^amlilei who aspires «Mo 
 l)riak the hank" at Monte L'arlo. 
 
 1 am aiipiainted with some ophlhalmoliH^ist-, tor whosi' judgment 
 '4inerall\ 1 havi- the "greatest lespect, who set theniselvis to over- 
 come tin- patii'iit's hyperopia and h\|Kiopic astigmatism in nuich 
 the sami- wa\ that sie',4:e was foinieilv laid to a medii'val fortress. 
 .\ preliminary surve\ of the ontworks is made when the amonnt of 
 the mamtest erior is c.ilculated. I'his consumes a ^ooil deal of time 
 and p.itit lue and is not .dsva\s s.ilisfactoi v since ohservation parties 
 .ire not allowed to apjMoach verv close to the inner fortifications, 
 and are in the natnn- ot things lialde to he dcciived l>v a nmnlier of 
 
60 
 
 circ»iinMaiKi>. No\t .i .>>, Inplc^'ic is iim-»1 (wliuh. tn immv ..iit tin- 
 simile, nu'.uiH that pl.iiis of tlu- l..rtificati<mH aiv cuiminv;lv .)l)tainc«l) 
 an.l tlu« tiiu- stall- of things is iiuinaski-a. 'Plui\ llu- tiu-my is.liivin 
 within lus tirst liiu- of .U-fcncc by onlcrinn, just as s.h.m as tht- ef- 
 fects of tlu« cyvloph-^'ia havi- worn off, a«* lai^-i- a ju rcinta^,'i- of tlio 
 total hyiHM..pia as he will acopt. I'inally after the sii-^e has lasteil 
 two or three months an assanlt is matle hy land and sea ami v.niO- 
 times the works capitidate ; s,.n\etimes the patient's total error is 
 found to etpial liis manifest, otlen it lalN short of it. In any event 
 he is ordered onl\ what is manifest. 
 
 Sureh we ou-ht to he al le to accomplish the end in \iew hy a 
 methotries> complicated, less ixpeiisive an.l less uasteful ol time 
 than this. Personally. I have earnestly sought for snniv detinile 
 rules, t.umded upon well known laws of physioloj^ical optics, where- 
 by one could readily determine h..w much, if aiu . of the t..t.d ame- 
 tropia shoul.l be crre.ted in a -i\en casr. In cnnnon uith other 
 ophthalmolo^'ists I h.ne xNaited for satisfactory an-uers to certain 
 (juestions -.imrieswliicli every practical man is a-kinuhimsell to-day. 
 Whv do some myopes ^jratef id l> accept a full correction uhile 
 others having' the sa.ne kind a«i.l amonnt ol error, refuse to ssear the 
 prescribed ji'lasses.- Ibnx is it that c-rtain patients ob>tin.iteI\ re- 
 ject a full correction ..f their hyperopia- On the other han.l. u hy 
 do some bavin- appari. Illy the s.„ne retractive condition lindtiuir 
 tn.ubles promptly relie\e.l l-> tlu- s.,,ne prescription . - 
 
 What are we to du with pati.iits vxlw refuse all corrections and 
 why do thev act in this nnsfendy mannei : I lave we any means of 
 .lecidinj: beforehand ^^hether a patient will accept a full correctb.n 
 of his retractixe err<.r? If unco,nb..table at first, svill be eventually 
 ,d)lain relief? If s,,. bou lunu' u ill the st, u--;le ...ntinue .• 
 
 What amount .md kind of u..,k udl the ametropr be able t.. do .- 
 Shall be Kive up b .ok-keepini,' and t .ke to raisi.,- vegetables in .. 
 market «;«rden - Had the sclmlar brtter return to scbo-.l at .nee, 
 or should he wait until next term neM >ear? Will he be able to 
 enter colU-ue in the antuun. .^ Will be ever be able to do bou.^ ol 
 continued near work at ni^bt .^ I bes. a.e a feu ot the nun.e,o..s 
 and important .p.estions, tin an^vsers to uhicb. m ese.) ca^i . ue 
 shouhi be able after a lew rNamiuat.ous f. suppl\ u.lb . unsi.leiable 
 
 accuracv 
 
 The ke\ to these problems i. furnished, to my min.l. by the tol- 
 Inwin- proposition and bv u bat mav be ter.ned a corollarv to ,t : 
 
 4 
 
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 yi 
 
 1 
 
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 I 
 
 .1 '"//.////"// -./,/w,7/-/,//„ ,•„//:,./•/,•,/ <^i w<v///.v of ijhssrs /„fn „ 
 >/.>/,- nf .,hs„l„t,' ,-t„m,trn/^„, /.v ///,. must, fviiivr for all iiiufs „f 
 vyr unrl-, as A./m- „> , :■, ;•, /,./•//"// of f'/„ :■/.«//,// af^f^aratus as 
 
 A.lvo.Mf.s ,,t MMiu' p.irtiiiil.ir >N>Uin ..i .Iciliii^' with ivfiactivf 
 tMi-.iiv. in u 1.1.1, piifial c..nv.ti..iis play .m iin|...il,,i:l lulf, sprak ..l 
 "Mukiii- llu- p.itii-iit ccmtoifal.k-" as ii that ui-ic thi- chiit cikI <.I 
 flu-ir work. It si-i-iiis t.. im- tliat wc shunl,! aim rather t<. provi<li- 
 niir patifiils sv ith ulassis. if tht-v niv.l thnii at aP. that will «ivc most 
 ai.l iiui sati>tactiuii /// tliv /,.„:^ run, t-vui at tin- cxpcnsi- of a little 
 pivsfiit (listoiufcrl. 
 
 If this first piopu,itiuii lu' ailmilti.I. if natmaily follows that wluii 
 Ihf fiiiUorii-c-tioii of a refractive i-rror has Ihtm j^ixtn and the pa- 
 tient contimu-sio i omplaiii of asthenopia (.r retle\ s\ niploms of ocular 
 ori;,'iii, we n)a\ with almost aKsoliiti- eeitaintv, assunn' that tln' 
 tr.iihlf |il■^ ihii'll) oi entiiely without the (li<iplru s\stem. 
 
 H'.MiinL; tiiesi- two lluoiems in mind, let us consi.Ur si.nic- ot the 
 conditions present in pel sons whose anutiopii- ivrs (althoiij^h po- 
 tentially emnutii)|)ic ) lefnsr to accept a total oi ii ma\ he, i\rn a 
 paitial correction ot their eriors. 
 
 I'lif Ci>nJiti>ii >f th, riliarv ihiimI,. It is alletied w ith naich 
 plausil.ility and show of authoiltv. tiiat the ciliar\ nuiscli is almost 
 i'ntir>'ly respcnsiliK- \^^\ tiu- refusal of the e\es |o adapt themselves to 
 the new older ot thini^s luou'^ht aliout li\ the total correction of niv- 
 opia. hyperopia and asti;,Mi)atism. 
 
 riie classic pietnres of Iwaiioff ( llandlnich (U'r <^es. Anj^eidi. i 
 p. .'7 I ,t. M\/.) have lon^' heen the comfort and lefnj^'e of tliose wlu« 
 teach tlie partial correction do^ma. Thev . as e\ I'rvhmlv knows, 
 show, tijst ot all, tlie annular, radiatin;^ and nu'ridional lihres of the 
 ciliaiv nnisili', as si-en in the ennuetni|)ic e\e. 
 
 Sevondlv.ii h\ pi-rliophiiil wedi^e of ciicular lihres is jiictured, 
 said to Ii.' charactei istii- ,,\ hvpiiopia. The nniscle in nisopia is de- 
 picted a> iia\inL; its circuiai tihres altoi,'ether or almost entireh 
 wanting, while its meridional la\er is unusnalK well developed. 
 This argument troin the an.itomic.il standpoint would h^^ im.uiswer- 
 aliir it all casi-s oi will m.n ked h\ peropi.i oi m\ opi.i njectid a com- 
 |)lett' I oriection. i>ul the tact is that .i l.ut^e peicentam of patients 
 e\liil)itin.; tlu'se errors almost innnedi.tteh' accipt .i full coriectiou 
 o| them, .ire ^ratefid fot it .ind do not reipiire to return fot addition. il 
 e\.imii\ations ol their e\es and ch.m^es in their glasses. 
 
5A 
 
 .,tr..phu.Uct all llu- asMstancr lunU-.l I.. .a.i> on llu' wmk o| local 
 a.liust..u-iU un.Ur ll.c m-w o.iulit.ons until oti.n l1a.t^ ol flu- nu.^. I.- 
 ,„v propniv .Uvilopr.! tluon.^h rx.iv.sr. In ;n.s .vrnt 1 .nu h.n.iv 
 convimva tnun ohscivat.on i .m.I .•xpcricu .• u.th -.uh ...si>, 
 ,l,,t win!.- NVtMkn.- ol acoMun.o.lativf H»o,l i^ ..cc;.h;oually a mm- 
 .n,, l.,i. lolnlU .onvvlM.- .•.'.i.un utractiM- nior^. its inip-.ttan..- 
 h..- !.. n nnuh ovcv-r..t.a. Tlu' .ilia.) nn.sv U- nsnally a.lapts .Is.ll 
 vci> . M'lilv to .li>plaa-nu'nt.. l.oth o| thf accuMonu-.l nrar a.ul ta. 
 point.. piovi.UaoiluT part, .-t .lu' fvt- art- in tluir .,o,nul m....'. 
 
 I nul.lt. sp.-akin.4 ol ,lu- ivl.itivr .,M.plitu<U- ol .u voMun...iat.on a.ul 
 c.u.Pj.n.c ... a.mt,..pia. u .....,k^ thai i.. .nxop*^' "'' •'""•'"" "' ""• 
 , ,,,,„„.,|,„„.., ..H.a.... 1..A.. til.... Il.a' ot o.nxntin.cc. uh.K' l.>- 
 p.ropia .alls to, ,n ..v . .ns..u..u.. a.ul yi tlu-.v o,..m..x:.s m..1. a 
 l.„iU,.|. i., th. rcla.u.n IkIxnc... tlu- two lu,.vti..,.. that Lnuun... 
 vision .s u-ali/.lan.l .....int .i.u-.l u ith omuIoM. p.osulr.l alua.\> tl.at 
 in.uTvationan.l tin- nu.^. .ila. i-u., .... .u.nna!. 
 
 Il.tcropl, > ■ l',.is.spfl'..i'l.v tlu- ...-t con„H..n nl.sta.U- to 
 ,lu-s.,c ,lv UMl./atu.nol c..„.t..,t.a.lr r.n.nfirol'i^'' ^nui a Inll o..- 
 , . ', ,.' ,nv > .,M,l.ahU'ic»ractivc'c-noi>houl.li.fM. l.r altin.pti.l 
 whhoul UrM .^t.,.,at..,, .In- ..lativ.- stnni:.!. ot ih. .Nt.in^i. o^t>!a. 
 
 '"wiuu. .... .X ....plr, a patu-nt <1.ks not a.-..pt a ti.ll c....v.t.on .,1 
 
 hi. n.vonia or hyperopia, the fault ,. ...n.i. .uo.c l.k.lv to ,vs..U- ... 
 
 ,vc.,k .-''r'M .1 .Mln.u th... ... anv c.ul.tion ^^\v^^v^.^ ot 1... ..l.a.A 
 
 ,„„.,1, I, >o:..s t.. ..u- tUat ... .IcaUn- vxith tlu- r>c- n.us. U- svr ^^^■ 
 
 pn.n- t.. .vlv to, ,. ., ,„.o, ,n .t.o., re-aulin- tluir Inn.tu.ns n.o.r np-a 
 cuM.i.ical r.M.Us ..l.tai.u-.l !-> th. ns.ot pho.o.n.tt- ,. a.ul otlur n.sin.- 
 ,„,;.. .atlHT tha,. ..p •» ^..l-l't.-ns .K-.U.col ...... a .t.ulv ot p ,vs.- 
 
 ..l...Mcal opti.s. Suu-h i. .-> n.ou- .....s.a.to, v ...ul -no,. ~.u-..t.t.. o 
 
 hnv an .v.•,^ aa^ acpiuinta,,.. ui>h th. .vlat...... .,1 tlu ....... -a-.^U- 
 
 .,, N,.,l ,.,,h.- an. piun.l. ... .......iat,..,, tha.. t- l-ow^s ...a.,> 
 
 l-lu-,a.l that both convex a.ul c.....a^. ^L.-^-ncM •' .h.^.t..- 
 
 „,„.ce npon ...■.ve„e..cc-cflo. ts Inl No.t ..ui S:.v..,e ... I .v .l-.u.. 
 
 certain ,..K^... chuLk. ....- .U-alin^ with n tnu t.v. ., .o,. ,.. the- 
 
 L,..eohs«rvatu.:.^.....h,, M.hiec.. l-..i .... a S....K ... th. ..l...u.,.- 
 shil, iK-tSNcc-n c..nvc-.«encc a.ul a..;..n,.„...ia....... 
 
 \Vc-h..v.-.ntlu-..V,u!iesa., att.n.l.. to .xi-K-.n wl.N . :n .. la-U.' 
 
Sh 
 
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 lliimliii .: i-r-ul im.'h'ij)! I, llii' piuiliK limi 'it .ilisoliid »'imiii'tni. 
 
 ))l.l is ;(lilliil llil l>N II It, till t\l"« .Mill '^lati lulls li>ilM<l I'V dtlll'lh. 
 
 ••rill' iih.ns sti.im 11(11 ^•>.ii\ li'i tin i ;irii i tioii n| i |). lu^l). 
 liV|Hiiiu Iiiniiii is iiioif Uii.<tl\ l.nim l>\ llif iui\<'i;- »\-liiii in iii;iii\ 
 iMsi-s.it i\o,)htti i;i. III. Ill wmild III' till- |)>..iiil"p.(\«>pli(>iiii svlikli tlu'inr- 
 l\'Clin'4 li'iisis wniilil « n.jiiiiUi . Tliiis tluir i- .1 u.im.ii tni iiiiikmy 
 111! (.iim-v timis .11 .ill. "I milv a |);iili.il >iiiin.ii<,ii oi liyiKTimtni|.i;i, 
 
 III t«l t.lill iM)j)ln>| Iv 1 .IMS 
 
 ••WliM li.iN ii<ii ^tcii onr >-t III. IMS li\ |H'iniftii<jH> wi-atiii},' ciiuifor- 
 tiiMy conc.tvc lciis4-s wlm ^mild iii»t l«iai llu' u-i n| vinui'x Ii iisi > .' 
 Such cMsrs h.ivi- alw.ixs t>iTM »-\i>|)li..i ic. .\t liist pn.liaMy tn'iii 
 niif I" si-\fi,il IjuiMs .1 m\ilnaiu. in lis | 1 1 iiutKipii: t'M's, sviH in- 
 iMViisf the I -"j)|i.ii ia. w ill Ii ^st■ll .111 I \"plii'i i.i i>i miivi It it iiil" oitl.n- 
 plKiii.i 1.1 lA. 11 mt<i .111 is.ipli.iii.i. Allli-tslMi l.ilii.il l.iti ic plioiia 
 au- u hells iihuli.il'U- s\ ithiii ihr tii^l ti ss hniii s atu 1 ( si s liasi' liiii 
 hi'.unht iiiuK'i thf iiilhkiu. >.t .iius.in.il;^.-. ICsophmia dfpi luliii^ <.|\ 
 hspiMiiHliupi.i sulfls is sshiills iiliiSKl 1\ ailsaiHiiij^ uais, as \sill 
 as lis yl.issisth.it tulls »nriiit the local ciU'i. It is;*'" nliisul 
 al'tci the liist liss huiiis l.\ tlu iisi nl a ins >li i.itic, ami this nhi t H'li- 
 tiiuiv'^ sMlii till' r.iiiiiiiiUMl iisr tit' tlu- (iiU'4. 
 
 •'/>,,/.'/, //oil. . (iisi- .1 tnll luiuvih.ii u| hypi'imi'lK'pia ssluii as- 
 s.H i.ili-(l ssith I'Miphdiia. ( -• ) (ii\r u<> ccimticii m .>nls a paiti.il 
 cuiiictiiiii lit hsiKTiiH-tiiipi.i svlu'ii associatid ssith (.xuphniia. ( ,^ ) 
 (iivr .1 lull oru-ctiiiii .if myopia sslicii .iss.,ciati.l ssith c\oph..iia, and 
 svlicii flu'if is .iithophoii.i. (|) (lisconls .1 paiti.d coiivctioii ..i 
 i,,,n,- .It .ill .il iiisiijii.i. sslu'ii a-s,Hiati.l ss itii fs.iphoria. (;) A lull 
 c.im'cti'Mi ..t' hsp.iniitiMpi.i cun-s .1 psmdi .-I'^.iph.nia in i s.,pll..^lc 
 CJ^st•s. .iiid i rcilfs a psciido-fx.iphoiia in rxophoiic casfv. (i.) A 
 lull ...ticctioii ol myopi.i cuivs a psi'udo-c\.iplioria in c\. .phone 
 cscs .iiid cicatfs a psi'iulo-t-..ph.>ii.i in csuphoi ic I'sis. (7) Inhs- 
 jKTiii.lropi.iassoci.iti'd ssiih iiitri u.il stiahisinu-. lulls cmv tiU'j; K'Uscs 
 aidi-d I's Ills. hi.ttusrriiiosi'. ill psiu.lo-rM.ph.M ia .md thus 111. .kr it pos- 
 sil.K' t.H the mii.linu' -rus.itiou to csiiuic cnti ol ol llu' cons .Tum-^ 
 .i-iileis III s,Kh a svav as to irstiain the tnu- cs..p!.oi i.i, .iiid thus cmv 
 llic stiahisiniis. (.S) In msopia associated ssith e\otroi)ia. tiilly 
 coirectiuu lenses svith my-.tics, ssiU remove pscudo-cxophoi i.i an.l 
 thus lu.ilxe it p.issihle h.r the mii.liiH^' sensation to resti.iin the tnu 
 cxoph.uia .lud theivhv cmv an external s.|niiit. (o) .\ns test |..i 
 l.itei.il he;ei..p!i..ti.i ssithmthe tiisl less hoiiis .ittef heuimun- a 
 ms.hi.itic is ssholls miieliahle. eseu ssith leusi's .m." 
 
5* 
 
 i 
 
 111 .inuthtT pl.ici- tiu' s.iiiii' .intlioi attempts ti. Im in.il.iu' .1 \siiikiii<^ 
 lull' tor tlu ciin(.-».iii)n nt kI'Ihiiio asti<;iuati-in. I i'avo littU' (.xptii- 
 c'lu'i' <>t its onv-iatiuns, Imt 1 can casilv ln-lii'Vi' tli.it in tlu' total i.(ii- 
 rcL'tion lit thi- t"nn i>t iTint, tlu ciuulitii'ii ot tli'.' Ml.ii(|iu' inii'^v.-Ios is 
 an iinp'iitaiit taitui. 
 
 **SlCL'lv.-'s rule l<if p!.Kiii'4 tlu' a\ts ut eoi ii'ttiiiL; c\ limlcrs in dh- 
 li'MK' a-ti'^nia'.i^m wuiilil In pei li-ctidh itsi'li it tlu- ul'licjiK' nniscli-s 
 \\ I'll' alwavs harnionions. 
 
 •• r.iis nil'.' i'-. in ib.isi- ».-ast s in whioli tlu' aMs t>\ tlu' piupt-r ri>>/~ 
 .'■('V c\linik'is t,>r the tw.i i'Ms iliMTLTf, place the cylinileis at those 
 points whieh will j^ive the a\is thr '^-leatest iliM'i 'j;enee ]H'rni'.tli'(l l>y 
 till' tests; and in thosi ea^i'- in \shivh tlu- axes eonveim', plaee tluni 
 at the f>oints whieh w'll 'j,\\v tlieni tlu' «^reatist eon\ i r._;inee pei- 
 Uiitte'l h\ the te^t^. I>\ Mihstitut';n>4 i'iii>t for j^i,til,>t and ; /<»■ 
 viir-,!, tlu' same iiiK' a|)j"ilu'- to 1 uitcivf *.\lindeis. 
 
 ••'Theie IS no rule Ailhout ex.iptious,' applies to th.e Stiele iiile, 
 hut till' exeeptions m thi- iiisianee -honld have onl;, a tempoiaiv ap- 
 ajiplieation. That the leason loi tlu--e exeejition- ma\ he eleail\ 
 imderstooil. it mas h.' stated tlial in any toini ot nneoi lectiil ohliipu- 
 asriiiiiiitism ( livp.-i nu'tiopie, m\<ipie or mixed ) i! the meridian^ of 
 "■reate^t enisatme di\er^e a!'"\f tiiere is eonscjuiiit ^tiain on the su- 
 p.-rior ohliuae iiias.l.-s; it thesj niridians eonvei^e ahoxi- there is 
 then, n.c z^- iril\ , strain on the inliioi ohliipie mn-i U -. It in any 
 <jt' t'aese cases the strain i'- on t'le supiiior olilii|iu- niusele- i meridi- 
 ans ot -greatest eurvatnie <li\erL;m'^ ahovr) and thesr nuiseles aie in- 
 sutilcient (o\clop!ioria superior) Steele"- rule holds .j;ood. luii it m 
 tills coMilition the mteiior oi.|ii|nes shoul.l he in-ulliciem (cyclophoiia 
 iivterior) the rule should he rev.-rsfd t 'mpoiarilx. .\'.;am when the 
 meridiatis of greatest e\n\a!me Coin eri4e ahow and tluie is eyelo- 
 pho'.ia superior, Steele'- nile loi pla* iu'^ the axe>. iil the eyhmieis 
 must he revi;rscil for tile tMiie, -.s a.-iea- it there is iveK-phoiia ni- 
 ferior tlu- rule shoiiM lie Ifdknved. ' 
 
 In a'l the ahove cases, where i\ patli.d eornetion i^ advised, that 
 c<jurse »>f action i- com\--illed iii \ieu ot tin- insnthcii ney ot crtain 
 miiscK"-. hut as Sa\ i-j;i i)o-nt- out. l/i, f^ff^rr thii:i: t,' •/<• u >/,/, > 
 the eircttmstit'. . /!' rii t r. li,, //, trr.'/'/i,->ii -:.///.// ///,/;■ 
 itsrlf ' f' (/i, il>t/ii Hopf'.l I .///./ ///(// -,■ •. il J liH i "f- 
 
 rrriin,, ■! !'.■■ • , i ' > fi-f rrr.>r . l"i:iin|j that, we sha!! .<i leaM 
 have a rea- n tor d viatin;^ jroiii the hettei piaetiei . 
 
 .•U'( . A M-!\ sli-^l.t aci(uaintaiue witli tlu \soik o| the ophihal- 
 
 \ 
 
ss 
 
 1 
 
 I 
 
 T 
 
 9 
 
 molo^jist is siinicii'Mt to ti'.K'li ii^ tliat it is somftinu's (liOiciilt to pcr- 
 suatlf tlu' nrnldii' a^fd liyptTopo c.r myi.j'f to accept a total cor- 
 ivclion ot his rrtractivi' crn.r, a ditliciilty not t'ri'ciiuMUly <.Micoiint(.'r(.'(i 
 in (k-alin;^ witli voiiiij^ci patifiits. /'//c //(//'// nf ycurs is not to lie 
 ovcicomr in a dav. wlutluT one deals with the ciliary nniscle or 
 with other ot„'ans. Douhtless, also, the new and unaccnstonii'd in- 
 nervation-inipid^fs reiiuired to regulate the chan;^'e(l relations between 
 acconnnodation and conver};ence ^rowui'4 out ot a full correction, 
 are ^'enerated with ahont as much cerebral eftort as are nwxlillcations 
 in ttu' contour of the lens controlled liy those undeveloped ciliar\ 
 tilires, whose contraction \\i' niav su])p< >e to lie necessary tor (.'Ifi'Ct- 
 ive \ision. In praclice. howevi'r. the e\is and the nervous sy>tein, 
 other circumstances bein;4 ta\iprabU\ siiortly adapt theniseKes to the 
 iniproved stati' ot thin';,'s ii\ the i^rcal majority ot ca^es. 
 
 .\ii:M<iiutr,>pia, liven wherv with j^lasses visinn i-> normal in 
 I'i'her i\e. tile patient ma\ not obtain binocidar vision tor near or 
 distant \s(irU, becan-e he has acipiirc-d thi' lial>it of usiu'^ one eye to 
 the e\clusic.ii of the otlu'i, and ma\ promptly refu-e a lull or in- 
 deed anv correction that makes more disjinct the du!lcd imaL,^' ot 
 the second eve. Tiiere are n(. i>voblems in .ipi,thalmolo,uy that re- 
 (juires more patience, mme experience, and better judgment tor 
 theii successtul s.dntion than those presinted i>\ tlie refractive anom- 
 alies of anis(.melr..pes and far too little is siid al out them in uoiks 
 ..n refraction. I'lii-. is not the place to di-cuvs an\ of them except 
 to s.i\ th.it, rr/i-n'^ p^trii'/is. as .^niod rcMdi- .\w obtainable by tuUy 
 coiiectin- the erior in both ese-, as bv .my otiier sin..,dc method ot 
 procedure. Where relief isn..t ob^.ine.l bs this method ,.r u here 
 ,nmo\in^ svmptonis aie engendered b\ it u e uuist not hastilv iumi> 
 I,, the conclusion that the rttraciion of oneexe onl\ should receive 
 oi ih.it a p.iitial correction should be L;i\ en on one or on 
 e.isilv iiappen that the troul'l-' i- traceable to 
 ,,:ntsol thi\isual apparatus not concerned in dluvt vision. Ihi- 
 .•,onM be remedied, il posslbU'. so that both i\es max rc/.-ethe 
 benefits that acciue to the eu'iiiettopic state. 
 
 />/>c,/vc,s <-/'///.• fmnins. I'lu' question in leiraclion s,,metime- is 
 //,7 uh.it percent. i-eot the tot.d erioi wesh.dl n<-uli ali/e but u het her 
 uesh.dlordet .ms ul.|ss>-s ,u ,dl. I'he.e are c.ses in u hich the cn- 
 
 ,1,1, t tneco.nsol the exes is sncl, -ex en xx here the p.Uient l.,is cen- 
 
 ,,,,llx .1 luli acuilx of xision in both exes -that one cumot cons.i. 
 i.iitx to anv consider.d.le use of tiiem bx onleiin- 
 
 V 
 
 attt-ntion. 
 botii sides. 
 
 ■nliotislx 
 
 •' I 
 
 
5k 
 
 I 
 
 lO 
 
 .mv suit of glass. 'IMk- pirsiMicc ot choroiditis, a bi-fiinninj; optic 
 iKTvc atrophv, a liypt'tacinia of the chscs, a liistoty of <j;hmc<iiiiatoiis 
 attacks, ami a do/fii other circumstaiicfs iiulicatis the lucd ot rest 
 Irmu work coiuhim-d with other trcattiient, after or (iiiriny which. 
 the refractive error inav I'e corr^Hted when it is urgently calKd tor. 
 in such cases the oidlist will, as a iiile. pr<>li;il>lv tind it wise to 
 correct nnlv tlie in.inife><t irror. 
 
 Or r ft /> J //<>>/. Wiiile it is statiii}^ a very eleinentaiy law in Oph- 
 thalmol. iijv. to sav that the kind and amount of woik shunld in- 
 lUience the selection nf the kuse- t<> he worn hy the patient, it is al- 
 so true th.it otlier factors .ire of paramount importance, and should 
 not he lost sijrht of. 
 
 W'h.it difference does it ni.ike t<> :i myopic fn<4raver <'t 5 I), 
 whether he is ordered .1 full coirection. a half collection ui no cor- 
 rection a' all it he wisjies to do his wmk .it. s;i\ . j<i 011., and 
 camiot comm.iiul tiierewitii the lucissaiy mimher ol inetei angles o| 
 conver<;ence ? ( )r if he has. ..r can e.isily inchice a choroiilal con- 
 <i,'estion or snifivs fn-m acute d\ -j>'psia : What alont the t\pi'- 
 writei \\ ho lioes lui W'Pik with a poor illumination or who is so 
 anemic th.it she cannot walk up a tli-^ht ..t stalls without h;.vii!;,' an 
 alt.ick ot tempoi.irv heart f.iiluie; 
 
 /•'/til/ />/' /'/fKU/a'iir fi\tif/<>>f. ICviu when theie .ire, as there 
 should alwayo. he. normal amplitude ol accommodation aixl a -ut- 
 llcienc\ tif conver^jeiKc tor ohjects held in trout of the eye. s,,iik 
 liart-'f the field of hinoculai 1i\ation ma\ he cmtiacted, and this con- 
 traction -hould intlmnce the pn-ti ihmji "-f '^'lasse- in patients hke 
 compositoiv. l.ook-keepeis. car-checkers and otluis who recpiiie to 
 usr their muscles m various ,piarters of 'die lield. and .it widelv \aiy- 
 iim dist.inces fi.»m the e\e. Ot c«»urse the condition and r.lative 
 streu'^'th of all the extrinsic muscles should he examined ih.it weak 
 points ma\ he guarded. The ohlique mu-(?l. s in sUv li c.ists ale 
 often.it fault and would h< wisi- to lo||o\v S.i\ .i;_;e"s iiiK- loi col • 
 rectin.: relia..ti\ tiioi- when c\clopliori.i is present. 
 
 /iV//rv OiiiLir Svniptf'tiiy. Most ohservers, svhatever theii \ lew s 
 rej^ardiu',' the correction ot ielracti\e anomalies when the tiouhles 
 oomplainetl of are purely oi)tic d (h!mrin'„' of jiriiit. tempoiaiv dis- 
 appear.mce of words, etc.) seem iiu lined to favor a tull correction o| 
 the error (u-tiall\ asti-matism and lis iniopi.t ) in the headaJu-s. i\i- 
 p.iin- and n(Urah_'i.i that lesult tioui ihein. In the s.mie w.iv chronu 
 hh-phar:iis, voniuncti\ itis an. I oih. 1 lellex loe.il and ueiu-ral .Iiscm-.s 
 
 " 
 
 ^* 
 
 ^iff 
 
 VM 
 
S' 
 
 1 
 
 1 1 
 
 due to t-'vc- >,traii', (iem;in<l not only tnlly coni-ctn\<,' k'lisi-s hut also 
 the- rc-moval of any olistack- tliat rcMulcrs enunctropia ditricult. 
 
 Dvfcctivc hiHfrva/iiii of the eye iiiiisclis. '/'raiisitorv am/ 
 .*>iirt/a/ parcscs. Cuiiciuil diseases. Tlu'sc canst-s of nm.-cular 
 asthcin)pia aix- sonictinii-s mistaken for Kww lictiTophoria, and arc, in 
 my expcricnc, mort' ccnnnon tlian is i^cncrally supposed. After 
 doses of certain drni,'s. during convalescence from acute diseases, 
 durin<,' attacks of indi^'estion and in affections that lower the muscular 
 tone f^enerally, there may l)e a tran-ient insuihciency of tlie ex- 
 trinsic ocular muscles as well as a decrease in the ciliary power. 
 Transitory pareses following' diphtheria, syphillis, excess of venery, 
 etc., are often to he met with. Here the (juestion is not one of 
 j^Iasses of any stren«,'th, hut ratlier a l>uildin<,' up of the system and 
 treatment of the disease that originally hrouiiht on the muscular 
 trouhle. Apart from tliese considerations one finds an "irntahle" 
 condition of other parts of the ocular apparatus dependant upon a 
 state of ill health not easy to deline .>r to account for. !"or example, 
 tile ophthalmoloj,Msl has no more emharassin^,' symptom to deal 
 with, whatever its ori'^in, than insonmia. I'alHuts suffering,' from 
 sleeplessness are not -,Mateful for j;lasses prescrihed in accordance 
 with anyhody's rules, and one must approach such cases cautiously, 
 and not promise too mucli, even when the refractive error is of hi<,di 
 (lej^ree or the asthenoi)ic -ymptoms well marked. 
 
 ■DiMiKiiutaio e nun luiire 
 A-i'ftliue f i\oii vfiiirc 
 .S7<;(, /// litio f HO'I (tcnnir, 
 Solid tic ii)Nf da moiiio" 
 
 runs the Italian jinj,'le, and the physician who sees many such cases 
 will prohahlv re-echo the sentiment. 
 
 One should not he le<l into prescrihinj,' s'^'^^^"'^ f'"' '"i'^'"' '-''''■"'■^ "^ 
 ,efracti..t> or into treating sli^dit deunees of luterophoria in the pres- 
 ence of anv of the ahove mentioned diseases, or othei well lecog- 
 ni/ed s-.urces of ocular irritation such as, for example, hypertrophic 
 riuuitis, neurasthenia, dental .lisease, true neural-ia -.f tlie face and 
 head, disease of the lids, sclera or lachrymal apparatus. If glasses 
 .uust'he prescribed it is perhaps better to -ive a manifest correction 
 .,1 the hyperopia, and a partial correctUm of myopia, pointin- out 
 ,o the patient that treatment of the accom]>anvinu' .lisease is impera- 
 tive befori' proper glasses can be prescribed. 
 
 'IMu- oculist who intelli-enlly orders a full correction in cases proper 
 
 lor It, requires in the very n.ilure of tlnn-s to make himself ac- 
 
 ■-«- 
 
6S 
 
 iiuainteil, not only with the coiuiitioii and functions of tlu" parts con- 
 cerni'il in the visual act, hut also nf all portions of tin- or}»anism. In 
 so far as ho docs this Ik- distinsjnislu-s himself from the optician or 
 jeweler "who also sells <^lasses." ICven his method of examination 
 (y//('(j'</ the state of the refraction) must he more precise and more 
 carefully applied than when he decides to order a partial correction 
 of the error. In this j>ar(icular, it seems to me, he sho\dd always 
 examine everv patient with the oblique illumination and, throu<;h the 
 dilated pupil, with the ophthalmo'>ci>pe ; he should always use a 
 cyclopie<i;ic -.ntficiently .stronj^ to ilevelop the total ametropia (homa- 
 tropine and cocaine discs are effective in the ^reat majority of cases 
 where atropine is not especially indicated or cannot be employed ). 
 he shcndd make himself perfect in the exercise of souie objective 
 methotl, skiascopy for example, of determining the amount of the 
 refractive error and. last of all, he should eniploy every device pos- 
 sible to i-licit reliabli' information from the patient during; the sub- 
 jective examination. 
 
 And when the prescription for the glasses is haiuled over there 
 should be a distinct »mderstandin<^ between patient and prcscriber as 
 to the conditions under which tlu\ are to lie wori\. temporarily, for 
 near uork. for u-«e on tlu street, whenever it may be. Siich an 
 understandinjj, arrived at in the maimer imlicateil. will assist in re- 
 movinj; the imi)ns>ion. not aifojiether continetl to the laity, that 
 tjlas>es for a dcdiar an.! A (piarter are about as ^ootl as those obtained 
 on an oculist'- pre>cri|)tion. 
 
 I < 1 ^ I , \ >. I A 1 1 \ M ^ S 1 K I I 1 
 
c