If a convex lens does injure. the vision, the eye is probably normal and needs only rest and hygienic treatment. But no eye should be dismissed without other tests being made. If at a distance of six meters he cannot read type No. 6, but can read, say No. 4, his vision is expressed by the fraction 4/6, and he is either myopic or astigmatic-perhaps both. Wheel Test. Now instruct the patient to look at the fan-wheel which is at the top of the type card, and ask him if all of the spokes of the wheel look equally black to him. If they do, but he is still unable to read No. 6 type at six meters, his error is simply myopia, and may be measured and corrected as described in a previous chapter. If the spokes of the wheel appear unequally black to him-one intensely black and another quite faint-he has an astigmatism, and must be dealt with as laid down elsewhere. Convex Lens for Relaxation, If for any reason neither atropin nor any other drugs are available, a very satisfactory relaxation of accommodation can be obtained by mounting a convex lens before the eye. Usually a 1.50 D. or 2.00 D. is about right, but the necessary strength varies with the patient. A sufficiently strong diopter should be used completely to paralyze accommodation. When this method is used, the dioptrism of the lens used must of course be added or subtracted from the result of the test, the same as in the case of atropin. From an optical standpoint the most important things to be observed are: 1. That the size of the lens is sufficient to cover the eye. Optician's prescription blanks usually designate this by a graded scale of sizes, represented by 0, 00, 000, etc. 2. That the center of the lens coincides exactly with the visual axis of the eye. This is insured by a proper measurement of the width between the two pupil centers. For distance vision the lenses should then be made to stand perpendicularly; for near vision they should converge in accordance with the visual axes. 3. In myopia and astigmatism the lens should not be further than 13 mm. from the eye. Hypermetropes, and especially presbyopes, may generally suit their own comfort and convenience in this respect. 4. In astigmatism it is of course essential that the lenses always maintain the angle at which they are prescribed. To insure this, it is always advisable that astigmatic patients wear bow-spectacles. However, there are now in the market very improved makes of eyeglasses that provide for this necessity, and these may be worn in selected cases. Care must be taken that they do not become bent and out of shape, for this spoils the tilt of the cylinder axis and defeats the purpose of the lens. Latent Hyperopia. It has already been seen that hypermetropes are obliged to use some of their accommodation for long distance vision. Hence there is always a certain amount of undetected hyperopia, called latent hypermetropia, which is made. manifest only under atropin, when the ciliary muscle is completely relaxed, so that the results under atropin will be found to be about 1 D. more than without it. It is advisable to provide for about one-half of this latent hypermetropia in prescribing the glass. Hence if the tests have been made under atropin, about 0.50 should be deducted from the result in prescribing, and if made without atropin 0.50 should be added, in prescribing the glasses. In hypermetropes, so long as No. 6 type can be read at six meters, the glasses need only be worn when near work is being done. If, however, even distant vision is defective, they should wear glasses to correct this. When hypermetropia is accompanied by strabismus (squint) full correction (latent and manifest) should be worn constantly. Myopes whose myopia is of low degree may be given eye-glasses for use in distant vision, and be allowed to read and write without any glasses. In myopia of medium degree they should wear their full correction constantly. To this general rule there are two exceptions: A. Where the myopia is of high degree the concave glasses diminish the size of the retinal image so much that the patient brings the object close to his eye to make the image larger. In this case the purpose of the glasses defeats itself, and it is wiser to gradually accustom the patient to his correction until his acuteness of vision is sufficiently improved to stand full correction. B. In cases of high myopia where the patient has got into the habit of converging in excess of his accommodation, full correction, while giving excellent distant vision, may cause him much pain when used for reading, and in this event he must be given full correction for distance and weaker glasses for reading, gradually increasing the strength of the latter until he can bear his full correction for both purposes. In these cases we subtract from the full correction the lens whose focal length is the same as the distance at which he desires to read. Thus, suppose his full correction is 9 D., and he wishes reading glasses for a distance of 33 cm. A 3 D. lens has a focal length of 33 cm. (the focal lengths of the lenses are marked upon the trial cases) and we therefore subtract 3 D. from -9 D. and give him reading glasses of -6 D. Hygienic Treatment. Myopes should be carefully instructed in hygienic measures, even after correction. They should avoid long or strenuous convergence, and frequently rest the eye by looking into the distance. They should read and write in bold letters, with the paper at 33 cm. at least from the eye, and sedulously avoid the stooping posture when reading or writing, which induces congestion of the eye-ball and aggravates the myopia. Malignant Progressive Myopia. It should not be forgotten that myopia may be, and frequently is, a progressive and malignant condition, and upon signs of such progression or malignancy a competent oculist should be consulted without delay. Astigmatic patients should wear their glasses constantly. If the astigmatism is associated with high degrees of hypermetropia or myopia, necessitating separate glasses for near and distant use, the full correction of the astigmatism should be put into both pairs of glasses. The astigmatism is due, as already seen, to the irregular shape of the cornea, hence it does not change with accommodation or under any other conditions. Diminishing Effect of Concave Lenses. It should not be forgotten that convex glasses, by bringing forward the nodal point, enlarge the visual angle and so increase the size of the image, and concave glasses, by carrying back the nodal point, decrease the visual angle and so diminish the size of the image. This should be explained to patients, especially those wearing concave glasses, who are apt to complain that they do not see clearly with them, whereas the truth is they do not see as largely with them. Never be satisfied with one kind of test. Confirm it with other methods. Always relax the eye, if possible, in a patient under 30. Astigmatism in a young patient cannot be properly estimated without relaxation. Look out for ciliary spasm. When the patient begins to get erratic in his replies-seeing first one thing and then another-stop testing and insist upon rest or use a convex lens. Have a system and follow it out. Nothing weakens a patient's confidence. and confuses the refractionist like aimless pottering. Having carefully attended to the correction of the refraction, pay equally careful attention to the mechanical features of the glasses. They are of great importance, and often make just the difference between success and failure. OH, DOCTOR, DOCTOR, DOCTOR. Nobody loves a doctor, Nobody cares for him, We hate his pills and curse his bills And fear his aspect grim. But when we're ill, in language shrill Please come right over quick! Nobody loves a doctor, He cures less than he kills, For one he saves, a thousand graves With poison'd stiffs he fills. He is a hardened sinner, A liar, knave and cheat, Some day he'll die and then he'll fry, But meanwhile, we repeat: "Oh, doctor, doctor, doctor! Pray hark to my distress, My baby's crying and maybe dying, So please don't stop to dressOh, doctor, doctor doctor! I've had an awful fright, The world would better be An addle-pated drone, Please, doctor, I need you, -GLENN ROBERT GUERNSEY. CENTIGRADE AND FAHRENHEIT. A correspondent of The Lancet offers the following new alternative method of converting degrees Centigrade into degrees Fahrenheit, which may be found easier to perform mentally as the figures can be more easily retained in the memory-viz., multiply by 2, deduct onetenth of the product, and add 32. Example (a), 30° C. 86° F. Method: 30X2-60. 60-6-54. 54x32-86. Example (b), 37° C.-98.6° F. Method: 37X2-74. 74-7.4-66.6. 66.632-98.6. Example (c), 40° C. 104° F. Method: 40X2-80. 80-8-72. 72+32=104. THE SICK ROOM. AFTER-CARE OF LAPAROTOMY PATIENTS. ALPH WALDO, in the Internation al Journal of Surgery, points out that the use of saline by the rectum immediately following laparotomy prevents in a large measure the thirst that the patient is apt to suffer for the next twenty-four hours of convalescence. Anything that you can do to establish reaction as soon as possible will lessen the liability to postoperative pneumonia. These patients are not allowed to suffer too much pain, and a rational amount of morphin, hypodermically, is given. Usually the first hypodermic and morphin is not always necessary is of a grain. After that, if the drug is indicated, it is seldom necessary to administer more than 1-6 grain at a time. These patients are allowed to drink freely of water, given in small amounts. The nurse is told to give the patient all the water she wants with a teaspoon. For the first twenty-four hours they receive nothing by the stomach but water. After that broth or strained soups are administered, at first in small quantities, and later, as toleration is established, in larger amounts at longer intervals. Usually at the end of the second day a cathartic is given, rather mild in character, so that the patient's bowels are moved by the third day. After this, if there are no digestive disturbances, or more strictly speaking, no vomiting, these patients are placed on a fairly generous diet of semisolids; and if there is no temperature at the end of the fifth day, the diet is made quite liberal. It is a mistake to put into the alimentary canal a lot of food that is going to decompose and cause gas, which is usually the rule within the first twenty-four hours after a laparotomy. On the other hand, these patients should be given as much food as they can assimilate. It is an equally great mistake to starve them when they are hungry and able to take food. THE BLANKET SPLINT. F. X. Koltes describes this improved appliance in the U. S. Naval Medical Bulletin: Depending on their thickness, two or three blankets are folded in such a way as to form a strip, the width of which corresponds to the length of the intended splint (if for fractured leg, the distance from 4 inches below the heel to 6 inches above the knee). The strip is rolled from both ends about pieces of broom handle which serve to give rigidity, the rolls meeting in the center and being of equal diameter. The apparatus is turned over, the rolls separated a little, allowing the intervening portion to sag, thus forming a kind of hammock. The splint is applied as follows: An assistant raises the limb (a leg in this case) to a considerable angle, while under it are laid transversely pieces of wide muslin bandage about four feet long. The splint is then placed on the strips, the injured member is laid on the hammock, and, depending on the diameter of the limb at the point of apposition, the rolls are separated or folded in as necessary, so that they may be everywhere firmly applied to the sides, and that the leg may everywhere rest on the hammock. While the surgeon holds the limb securely within the splint, the assistant brings the muslin strips around and ties them firmly in front, one below the heel, one below the knee, one above the ankle, and one above the knee, some cotton being inserted underneath for padding if necessary. The strip below the heel serves to keep the foot at proper flexion and it may be supplemented by a piece of cardboard. In cases in which the blankets are likely to become soiled with discharges, a piece of rubber sheeting may be employed. WHEN SALINE INFUSIONS ARE DANGEROUS. Bertelsman relates that Konig has twice seen death hastened by large intravenous infusions of saline solutions. He had previously strongly recommended them, and the present paper was written chiefly to meet the objections of Heineke and others to them. Heineke says that they are strongly contraindicated in peritonitis cases in which occur disturbances of circulation from paralysis of the vasomotor centres. In these cases the heart is deprived of blood because the greater part of the latter is retained in the relaxed abdominal vessels. Bertelsman believes that by filling up the whole system of bloodvessels a quantity can be introduced which will compensate for the relaxation of the abdominal vessels. The heart will thus be filled and after some time the circulation will return approximately to the normal. In this way favorable operative conditions will be produced. That this hope is justified he has proved many times. It has been shown that in peritonitis we do not have to deal with the bacterial contents of the blood, since surgical peritonitis, as a rule, is not a general infection. It is well known that saline solution impairs the bacterial properties of the blood, and that therefore it should not be employed in general infections. When there already exists weakness of the heart, one should proceed with more care. In severe pneumonias, since the bacteria are circulating in the blood, the disturbances of the circulation can best be combated by small quantities of saline solution with adrenalin added. "GREEN DAYS" FOR THE DIABETIC. Foster, in the American Journal of the Medical Sciences, advocates a "green" or vegetable day for diabetic patients, the object of which is to decrease the food ingest, chiefly the protein factor. This is demanded in some cases because the ability to utilize carbohydrate is so slight that not even that resulting from the breaking down of the protein molecule. is not burned. A "vegetable" day is then an attempt to put completely at rest a certain function, and in making up the dietary for such a routine the less protein entering into the food the better; of course, all carbohydrates are excluded. The bulk of food taken, therefore, is fat, and as this is of necessity small, a vegetable day amounts to the starvation days advised by Naunyn, with a thin disguise. The vegetables that may be used in this diet are any of the green variety that contain little or no carbohydrate other than cellulose (Table B); of these spinach, celery, cabbage, beet-tops, and the salads serve best. These may be varied to suit the taste of the patient. The vegetable day might be ordered as follows: Breakfast: A cup of coffee, a teaspoonful of cream, 3 egg yolks, served as omelet, with tomatoes and parsley. Luncheon: 1 cup of bouillon; asparagus with egg sauce. 4 P. M.: A cup of coffee or a glass of wine with 1 casoid biscuit. Dinner: A cup of bouillon; 1 box of sardines; spinach (boiled); 1 glass of wine or whisky. Vegetable days are prone to increase markedly the formation of ketone bodies, and on this account, if the patient's urine shows the ferric chloride reaction before the diet is commenced, alkalies should be given during the vegetable day; 25 grams of a mixture of equal parts of sodium bicarbonate and citrate is usually sufficient. Vegetable days have their function in diminishing the sugar excretion, and in order completely to free the urine from sugar several vegetable days may. be necessary. When this is the case, however, a most careful urine analysis is necessary daily to determine the degree of acidosis. When severe grades of ketonuria are caused by these "green days" it is best to follow them with one day of oatmeal. The number of days of each variety of |