fast or lead the unwholesome life of large cities, and alsofor the broad, flat German face, than it does for culture. My own community, which shows far-sight to be the sole factor in 84 per cent. and a factor in 90 per cent. of a thousand consecutive cases of ametropia, is especially well-equipped with high-graded public-schools, highschools and colleges. It must be the wise administration of these and the superior conditions for health generally that has so effectually kept down the development of myopia.

Seventy-seven per cent. of the one thousand patients had astigmatism in one or both eyes that required correction. Just another 77 per cent. took a lens in one eyethat differed in strength or axis from that of the other eye.

While 240 of the cases were forty-five years of age or over, only twenty-eight had uncomplicated presbyopia.

These last three statements show the utter stupidity and folly of allowing ignorant, rule-of-thumb refractionists, whether they be strolling spectacle venders, druggists or jewelers, to abuse the most delicate, complicated and important of all the special sense organs.

Here

Let us consider well the actual state of things. are one thousand consecutive cases that require the helpof lenses. Their average age is 33.10 years, an age when the accommodation has yet a range of six full diopters; 77 in every 100 have astigmatism that needs correction; 77 in every 100 must have a lens in the right eye that differs from the one in the left; all but 28 out of 240 presbyopes have their presbyopia complicated with some other error of refraction.

What chance has even a three-months graduate in refraction to do justice to such an array of complications? What equipment fits one for this work?

The task of refracting properly is so intimately and inseparably bound up with such a variety of medical and surgical problems that, as the days go by, I am more and more convinced that none but physicians should undertake this work, and the more physician a man is the better refractionist he will be.

How often it happens to the oculist to make the first diagnosis of Bright's disease, diabetes, syphilis, scleroses, brain-lesions, glaucoma, cataract, and numerous other local and general diseases.

Eye-strain itself, with its protean symptomatology, is just beginning to be properly studied and appreciated. Ranney, Gould and their followers may be extremists, but a powerfully active radicalism is needed to move a heavy, often stupid, conservatism toward the golden mean of truth.

There is a point in refraction that I feel sure has not received the attention that it merits. In connection with the treatment of astigmatism against the rule, I noticed it and practiced it for nearly ten years before I ever saw or heard of any reference to it by another, when I saw some discussion of it last year by Dr. Steele, of Chattanooga, in a local journal.

The point is that light, passing obliquely through a spherical lens, is acted upon as if a cylindrical lens of the same variety as the spherical had been added, with its axis parallel to the axis on which the spherical is tilted, the cylindrical effect, of course, varying in degree according to the strength of the spherical and the amount of tilting. The practical effect is, for instance, that a presbyope who has normal distant vision with S plus 1.00 D on C plus 1.00 D ax 180°, will, in the ordinary bifocal lens, reject part or all of this cylinder for near work, according to the strength and obliquity of the reading-lens. He will ac

cept all of the cylinder only when the axis of vision is perpendicular to the plane of the lens. As this is rarely the case in the ordinary bifocal glasses, it becomes a point of great practical importance.

Of course it makes no difference whether there is astigmatism against the rule or not. We must get the axis of vision perpendicular to the plane of the lens, in any case, or make allowance for the cylindrical effect of a tilted lens.

The deep periscopic lens is very nearly a solution of the mechanical difficulties of these cases. Unfortunately, however, as my optician informs me, the deep periscopic bifocal is practical only with the cemented segment, which, during the hot summers of this latitude, is very apt to cloud or scale off.

Another practical point that I have never seen mentioned in a text-book or journal is that a cylindrical lens, set in a test-frame, in front or behind a strong spherical, such as is used in aphakia, gives a result that is respectively too strong or too weak, when the identical cylindrical is ground in the same lens with the spherical.

In ordinary cases of aphakia, if the test is made with the cylinder in front of the spherical, the cylinder of the finished lens will be from 50 D to 1.00 D too strong.

In other words, when dealing with strong lenses, where a cylinder is combined with a sphere, the distance between the two lenses in the test-frame is not a negligible quantity.

I have thought to solve this difficulty by placing the sphere in the place where it is to be worn and then testing with the cylinders, first in front and then behind the sphere, finding the sum of the cylinders giving best vision in the two positions, dividing this by two and ordering the quotient as the approximately correct cylinder.

IS BILATERAL OPERATION FOR CATARACT EVER JUSTIFIABLE? AND IF NOT, HOW SOON AFTER THE OPERATION ON THE FIRST EYE IS IT SAFE TO EXTRACT THE SECOND CATARACT?

By A. W. CALHOUN, M.D., ATLANTA.

An exhaustive review of text-books, medical journals. special periodicals and pamphlets revealed a total lack of literature bearing on this subject, and a letter of inquiry, sent to forty-one competent and experienced oculists in different sections of the country showed the greatest diversity of opinion; about an equal number being on each side of the question.

This paper, therefore, is largely based on a personal and clinical experience of more than fifteen hundred cataract operations.

I can conceive of no circumstances that would justify me in making bilateral extraction of cataract. There are so many sources of infection and so many opportunities for it, that we can never be sure that an eye will not be infected during or after an operation, however careful we may have been in our work, or however perfect the patient's local, mental or physical condition may have been. The difficulty of cleansing the conjunctival sac is well-known. Indeed, the assertion has been made that the sac can not be made aseptic.

The intimate connection, through the lachrymal canal, between the nasal mucous membranes and the conjunc

tiva, renders the latter peculiarly susceptible to all the irritations and inflammations of the former, and every operator must recall to mind cases of infection traceable to this source. Regardless of the great advance made in the operation for cataract and its after-treatment, in spite of every precaution, suppuration occasionally occurs, and will continue to occur. A distinguished surgeon recently stated to me that he had seen suppuration occur thirty days after a seemingly successful extraction.

More frequently an iritis springs up, not necessarily fatal to the eye, but most distressing to the patient, and equally discouraging to the surgeon. Unexpectedly and without apparent cause, an anomaly in the healing process sometimes becomes a menace to the eye after extraction, adding another danger as to infection, and this would necessarily interfere with the normal process of healing in the fellow eye. I have had cases take not only days, but weeks, for the thorough healing of the corneal wound, there being all the while slight, gradually diminishing seeping of the aqueous through the wound. Some remote or hidden constitutional weakness was no doubt the cause of this. Such a case is a decided disturber of the surgeon's peace of mind, and would be suggestive of grave disaster in a case of double operation for cataract. Therefore the possibility of infection alone should cause the too enthusiastic surgeon to pause and seriously consider before proceeding to the bilateral extraction.

How absolutely helpless a patient must feel, with both eyes operated on at the same time; and if a severe form of iritis or other serious inflammation should set up in one or both eyes, there would certainly be great mental depression; and a cheerful and hopeful spirit is a mighty force in aiding recovery from any ailment.