prejudice the superstition of "the typical case." In the last analysis there is no "typical case," and no set of "rules" that will apply mechanically even to two cases; every day will bring a patient whose disease is so nearly unique that the solution of the riddle must be sought from new starting points and resolved by new methods.

Among many illustrative cases of these truths worthy of being chronicled the following one is noteworthy:

Several months ago a gentleman, aged 41, occupying an important position at the head of a great institution, came to me giving a sad life-long history of eyestrain, and whose eyes them

FIGURES I AND 2. DRAWING TABLES, SUBSTITUTES FOR SCHOOL

DESKS.

In

selves showed the patent demonstrations of present disease. the left eye the cornea was quite leucomatous and the iris was bound down to the capsule of the lens. In the right eye the cornea was also leucomatous, but part of the pupillary space was clear. Unfortunately the cloudy portion was the south-west, i. e., the lower and the outer two-thirds, the clear part being the north-east (upper and inner) third. The injury dated from infancy, since which time the man had been much afflicted with visual difficulties and resultant suffering. At the age of II glasses were ordered by a well-known oculist, and an iridectomy upon the left was performed. He had to leave school at 14. When about 16 years of age the internal and the external recti of the left eye were severed, for what purpose I could not learn

or understand. His spectacles were changed thereafter "from time to time." In 1906 he had a sudden and severe attack of "neurasthenia," and was in the hospital for several months. In January, 1907, two able general physicians, in consultation, found "periodical blood-crises" "agoraphobia," and the like, and concluded that the inciting cause was eye-strain. Glasses were got from the oculist which destroyed all definition of objects beyond a few feet, and his health began to improve. The prescription was:

During the last year the patient had suffered constantly from increasing pain in the eyes and head, and another oculist was consulted who at first ordered distance and near glasses. This order was:

The pain continuing as before, the left lenses were replaced by a "ground" or "steamed" lens designed to prevent vision, but the pain kept worsening.

After long and varied testing I secured 20 20+ vision with the right eye, but this degree of acuity was found by having the patient depress or tilt the head south-west by which maneuver the axis of macular vision could better pass through the clear space of the cornea. The final order was:

R. S. 0.25 + C. 1.25 ax. 70°

L. + S. 2. 00 + C. 4.00 ax. 105° Distance

R. S. 1. 25 & cyl,

L. Plano and Blinder} Near. Two separate pairs of spectacles

It is worthy of note that the symmetry of these astigmatic axes is a proof that the extreme amblyopia had not by any means been wholly caused by the leucoma. If he had always had a correct lens before this eye it would now have much better acuteness of vision. If the right eye was to be made useful for near vision, bifocals were out of the question because of the location of the bit of clear corneal space. The little vision possible to the left eye, even with its great increase by the high cylinder, was trebly necessary to keep the retina functional, to avoid dangers and accidents from the left side of the head and to preserve the possibility of some useful vision through operation in case of future loss of the right eye. It would have increased trouble to add sph.3.00 for near-work to this eye with its present accommodational paralysis, and the like, and a blinder

was therefore ordered to exclude the left eye from near vision, which greatly aided in lessening confusion and eyestrain.

I had now concluded that if the man's work in life, and even his life itself, were to be continued, he must be made to see, in reading and writing, through the transparent one-third of corneal space at the north-east side. With this conviction the difficult problem was now given. How to solve it was certainly another matter! My first thought was to use for the right eye, a high-power prism, the apex north-east, at such an axis as would insure macular transfixion of the cone of rays with the least possible tilt of the head south-west. But the relative location of the corneal clear-space, the shapes of the nose and the orbital border disallowed the plan. The distance-lenses needed no study as the usual "flat" lenses provided sufficient means in. walking and looking at distant objects. For reading and writing the right lens was ordered of large size and of toric shape, the optical center displaced north-east, and the whole fitted close under the orbital border and to the nasal bridge.

The patient had long been tormented by the appearance of great distortion of objects, but this at once disappeared upon getting the new spectacles.

It is evident that all this would not allow the patient to read and write as "needs must," in his case, if the book and writing paper should be held or placed, as with every one else, below a level of the eyes. The remaining problem was therefore to devise a method whereby the book and paper could be held above and to the left. I had for years been advising all patients to place their writing paper, books, etc., on a writing stand or leaf adjustable at any desired height and inclinable at an angle of about 35°. In this particular patient's case, it was only necessary to elevate the desk-leaf still higher, to the level of the eyes, and incline it at a still sharper angle. I show photographs of the device in use.

Soon after my patient got his adjustable stand, he made a discouraging and rather alarming report by long distance telephone. He recovered from his untoward symptoms in a few days, however, and went to work again. Soon there was a letter saying that he had been able to read an hour or two at a time, and had gone to the theater without ill effects.

Another letter followed two weeks later, from which I quote: "Had faith in you from the first, but during two weeks preceding present week have had serious doubts of my own ability to fulfill your expectations. With present week there has certainly been a remarkable change and I am sure the improvement is not imaginary. Am using eyes regularly a small portion of each day and with complete comfort. Chief difficulty continues to be the artificial light at night and "stiff" or "lame" eyes in the morning. In addition to the tilted drawing table, I have the

device reproduced in miniature for my desk. This second rack is at a fixed height above the desk and also at a fixed angle. With these two reading tables I find it very convenient to keep my work above my desk, with reference books and papers on the larger drawing table by my side."

The last report received was as follows:

In

"You told me that only Mrs. Eddy worked miracles. this I believe you were wrong for I think we are having a little

miracle of our own. My eyes have constantly improved and I am now using them from two to four and even five hours a day with the greatest comfort I have known for a long time. My chief trouble continues to be at night, although this too I believe to be growing less. I shall be glad to see you but cannot very well come to Ithaca unless you consider it necessary. I am still using the elevated desk with increasing satisfaction."

CAYUGA HEIGHTS.

Conference of Ophthalmologists with Organization Officials of Michigan on Family Physician Refracting

HE promotion of family physician refracting calls for the coöperation of all physicians. It is believed that if these understood its value, all would seek its possession. To promote this understanding, the Detroit Ophthalmological Club invited to its meeting of May, 1910, the leading officials of Michigan medical societies and educational institutions. The following guests were present, took part in the discussions and endorsed the resolutions adopted-namely: Dr. J. H. Carstens, President Michigan State Medical Society; Dr. Winfred Haughey, Secretary-Editor Michigan State Medical Society; Dr. Frank B. Tibbals, Chairman Medico-Legal Committee, Michigan State Medical Society; Dr. Charles T. McClintock, Member of Committee on Organization, Michigan State Medical Society; Dr. Guy L. Kiefer, Health Officer of Detroit; Dr. W. C. Martindale, Superintendent Detroit Public Schools; Dr. Gerald Edmonds, of Honor, Mich., and Dr. W. C. Garvin, of Millington, Mich., family doctors doing simple refracting. The chairman of the council of the Michigan State Medical Society, Dr. W. T. Dodge, sent a letter supporting the movement. Though unable to be present, like support was given by the following gentlemen— namely, Dr. Victor C. Vaughan, Dean of the Medical Departinent of Michigan University; Dr. H. O. Walker, Secretary of the Detroit Medical College: Dr. Arthur D. Helmes, President of the Wayne County (Detroit) Medical Society.

The chairman of the meeting, Dr. Leartus Connor, opened the discussion by a paper on "The Economic Value of Family Physician Refracting." He called attention to the fact that in the United States were about 180,000,000 human eyes; 135,000 doctors: 3,000 ophthalmologists. This averages 60,000 eyes for each ophthalmologist. As every eye over forty years needs refracting, most of them several times, and as very many eyes under forty need refracting, we have an explanation of the fact that the ophthalmologists never have been able to meet the refractive needs of all the people in the United States. Because the family physicians never have been trained to supply these needs, salesmen of spectacles entered the field, and gave such

1. NOTE BY THE EDITOR.-This report was sent to the JOURNAL by Dr. A. A. Hubbell of Buffalo, with the request that it be published in this Magazine. Dr. Hubbell adds a foot note to the report expressing the opinion that it should be indorsed by the regents of the University of the State of New York. He says also that he has advocated for many years the restoration of all forms of medica! practice, even the correction of errors of ocular refraction and motility, to the medical profession, where it belongs.