time you do not, as many have thought, endanger the good eye with sympathetic ophthalmia. I have never made Mules' operation, since it did not appeal to me. I had rather have a stump made from the natural vitreous humor than one made by the introduction of a glass or silver ball, since these balls often come out, and also since we have cases on record where sympathetic ophthalmia has been caused by this (Mules') operation.

H

SOME POINTS OUT OF MY OWN EXPERIENCE IN REFRACTION AND THE FITTING OF

GLASSES.

BY ROSS P. COX, M.D., ROME.

The important role that glasses play in the care of eye troubles is illustrated by the fact that sixty to eighty per cent. of all eye patients require the fitting of proper lenses.

When we recall that the wearing of glasses is an incident certain to befall every individual that lives beyond middle life, their timely and proper adjustment becomes a subject of special interest and importance.

It is my faith that no case should receive any glass at all unless the need is sufficient to warrant the best lens, fitted in the best possible manner.

I think the loose and hasty prescribing of "restingglasses," "strengthening-glasses," and the like, on vague and insufficient grounds, is unscientific.

The vast output of bad refraction is harmful, not only by entailing bootless expense, but also, in addition to direct injury it may do, it is apt to block the way to good work and relief.

I believe that inexact refraction is much commoner in Europe than in our own country.

Prof. Fuchs, of Vienna, once stated to me that, in his opinion, the benefit of fine refracting, so much practiced in America, was due chiefly to suggestion. My under

standing was that he considered most lenses of less than three-quarters of a diopter a refinement of doubtful utility.

Certain it is that much of the refraction of continental Europe done often upon children, without the aid of any cycloplegic, would be considered crude and imperfect by many American refractionists, and particularly so by the Philadelphia school, which, I think, preeminently cultivates a nice precision in these matters.

The pith of the matter, it seems, is a fine discrimination as to the kind of work an eye must do. Imperfections that are negligible in an ox-cart wheel would mean swift destruction, if allowed in the wheel of an express engine.

The last thousand consecutive cases for whom I have prescribed glasses form the basis of this paper. The ages. of these patients range from four to ninety years. The average age is 33.1 years.

Forty-four per cent. of these cases were refracted under atropine, homatropine was used for 15 per cent., and no cycloplegic was used for the remaining 41 per cent.

As to the use of cycloplegics, it has been my rule, practically without exceptions, to refuse to give glasses to children under fifteen years of age, unless I was first allowed to place the eyes under the full effect of atropine. From the ages of fifteen to forty I still prefer atropine in all difficult or complicated cases, but am content with homatropine in the great majority of cases. Within this last limit, especially if the patient is above thirty-five years of age and there are no evident complications, after using all available helps, and often, after tests repeated on different days, I sometimes consent to dispense with a cycloplegic, but usually under protest and after disclaiming all responsibility for results.

From the age of forty to fifty I still urge the use of homatropine in selected cases, and the results have been

so satisfactory that I am strongly encouraged to extend the use of homatropine at this rather advanced age. I follow those who conclude these cases with a weak solution of eserine. Occasionally I have to resort to atropine after having failed with homatropine, but never in persons over forty years of age.

By far the most frequent error, slightly exceeding 53 per cent. of all the cases, was compound hypermetropic astigmatism. One fourth of these had astigmatism in one eye only.

Next, in point of frequency, came simple hypermetropia, with 21 per cent.

Included with these is the, to me, astonishingly small number of cases of uncomplicated presbyopia. These amounted to about one-quarter of one per cent., being only 28 in the 1,000.

Next came simple far-sighted astigmatism, with 9 4-10 per cent. This makes 84 per cent. in which the sole error was some kind of hypermetropia.

Five per cent. had mixed astigmatism. One and seventenths per cent. were far-sighted in one eye and nearsighted in the other.

Thus we find that hypermetropia was a factor in over nine hundred of the cases.

Simple myopia was the error in only 1 per cent., compound myopic astigmatism in 6.15 per cent., and simple myopic astigmatism in just 2 per cent. of the cases.

There were more than nine times as many far-sighted as there were near-sighted cases.

This is a much smaller proportion of myopia than I have ever seen in any table of comparison. In many parts of Europe, as, for instance, at Copenhagen, 8 per cent. or more of the entire population are near-sighted. (Noyes.)

In Germany forty to sixty per cent. of the pupils in many of the upper grades are myopic.

Randall gives a table of 72,565 ametropes, of which 50 per cent. are hypermetropic and 44 per cent. myopic. In contrast to his 44 to 50, my results show 51⁄2 to 50. The myopia cases, however, obey the usual age rule.

Taking the age periods of eight years and under, from eight to twelve years, from twelve to sixteen years, and from sixteen to twenty years, the number of myopes were respectively 2, 6, 9 and 25.

The number of pupils with myopia in the nine grades of the Rome public schools is below 15 per cent., and I believe considerably below it.

Now we know that wild and domestic animals, savages, half-civilized people and babies are far-sighted, while highly-civilized communities are supposed to yield a high per cent. of myopia.

A professor in Vienna who had three diopters of nearsight assured me that he considered this a great advantage. He could work indefinitely without strain to his accommodation, got finer images and was freed from the necessity of presbyopic glasses.

On the other hand, he must use lenses all his life to secure any of the manifold practical advantages of farsight, not to mention the enchantment that distance lends to the view.

Moreover, Donders, who ought to know, says that the myopic eye is a sick eye, nor must we lose sight of that tendency it has to get progressively sicker.

However advantageous it may be in some communities to limit the view to the end of one's nose, the conditions. are quite different in homes that nestle among the foothills of the Blue Ridge, on the banks of the "beautiful winding Etowah."

There is also a growing impression that near-sight stands more for children that go to school without break