{"1": {"fulltext": "", "height": "3810", "width": "2377", "jp2-path": "diseasesofeye00nett_0_0001.jp2"}, "2": {"fulltext": "Glass _\\nBook-\\nCOPYRIGHT DEPOSIT", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0002.jp2"}, "3": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0003.jp2"}, "4": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0004.jp2"}, "5": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0005.jp2"}, "6": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0006.jp2"}, "7": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0007.jp2"}, "8": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0008.jp2"}, "9": {"fulltext": "BY\\nEDWARD NETTLESHIP, F.R.C.S.,\\nOPHTHALMIC SURGEON AT ST. THOMAS\u00e2\u0080\u0099 HOSPITAL, LONDON SURGEON TO THE\\nROYAL LONDON (MOORFIELDS) OPHTHALMIC HOSPITAL.\\nREVISED AND EDITED BY\\nWM. CAMPBELL POSEY, A. B., M. D.,\\nOPHTHALMIC SURGEON TO THE HOWARD AND EPILEPTIC HOSPITALS, PHILA\u00c2\u00ac\\nDELPHIA; ASSISTANT-SURGEON, WILLS\u00e2\u0080\u0099 EYE HOSPITAL; FELLOW OF THE\\nCOLLEGE OF PHYSICIANS OF PHILADELPHIA; ASSOCIATE MEMBER\\nOF THE AMERICAN OPHTHALMOLOGICAL SOCIETY, ETC.\\nSIXTH AMERICAN FROM THE SIXTH ENGLISH EDITION.\\nWITH A SUPPLEMENT ON EXAMINATIONS FOR\\nCOLOR-BLINDNESS AND ACUITY OF\\nVISION AND HEARING BY\\nWILLIAM THOMSON, M. D.,\\ni\\nEMERITUS PROFESSOR OF OPHTHALMOLOGY IN THE JEFFERSON MEDICAL\\nCOLLEGE OF PHILADELPHIA.\\nWITH 5 COLORED PLATES AND 192 ENGRAVINGS.\\nLEA BROTHELS CO.,\\nPHILADELPHIA AND NEW YORK.\\n1900\\nV,\\nI\\n9 I", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0009.jp2"}, "10": {"fulltext": "11372\\n64897\\nLibrary of CoiMr-s S\\nTwo Cortes Rcccnco\\nJUN 27 1900\\nC\u00c2\u00bbpyrig*t m ity\\n9muu L7 y /pot)\\nQ+\\nStCOMO COPY.\\n0 vf\\n0 K0\u00c2\u00a3K DIVISION,\\nJUL 7 1900\\ndl I Y\\nw\\nEntered according to the Act of Congress in the year 1900, by\\nLEA BROTHERS CO.,\\nIn the Office of the Librarian of Congress All rights reserved.\\nJ\\\\ S", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0010.jp2"}, "11": {"fulltext": "TO\\nJONATHAN HUTCHINSON, F.R.S.,\\ni\\nCONSULTING SURGEON TO THE MOORFIELDS OPHTHALMIC\\nI\\nHOSPITAL AND TO THE LONDON HOSPITAL, ETC..\\nV\\nTHIS\\nBOOK IS DEDICATED\\nIN GRATEFUL ADMIRATION OF HIS EMINENT QUALITIES AS A\\nCLINICAL TEACHER AND INVESTIGATOR.\\n(iii", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0011.jp2"}, "12": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0012.jp2"}, "13": {"fulltext": "PREFACE TO THE SIXTH EDITION.\\nA work which has passed through the press six times\\nin England and six in America has proved its usefulness.\\nIn certain points the views and practice of American oph\u00c2\u00ac\\nthalmologists differ from those prevailing in Great Britain,\\nhence the publishers have taken the opportunity presented\\nby the exhaustion of another edition to have it revised and\\nadapted even more completely to the needs of American\\nstudents and practitioners of this branch. They accord\u00c2\u00ac\\ningly desired the present Editor to undertake this task,\\nand to add whatever was necessary to make it a thoroughly\\nup-to-date American text-book.\\nThe book has been completely revised, therefore, partic\u00c2\u00ac\\nular attention being given to the methods of examination\\nusually followed in this country, and a number of thera\u00c2\u00ac\\npeutic measures have been added which have recently been\\nlargely employed by American ophthalmologists. While\\nthe text bearing upon the different diseases of the eye has\\nbeen altered as little as possible, as it has been this feature\\nof the book particularly which has led to its world-wide\\npopularity, the Editor has introduced into the section on\\ndiseases of the conjunctiva the latest views regarding the\\nbacteriological origin of several varieties of conjunctivitis,\\nand has given descriptions of several new forms of ocular\\ndiseases.\\nv", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0013.jp2"}, "14": {"fulltext": "VI\\nPREFACE.\\nA large number of illustrations have been inserted to\\nelucidate the text and to explain the new apparatus which\\nhas been described, and the section on the visual tests for\\nrailway employes has been thoroughly revised by Dr.\\nThomson.\\nIn the Appendix will be found the laws governing the\\nvisual tests for admission into the public services of the\\nUnited States. These have been obtained from the author\u00c2\u00ac\\nities at Washington, and are presented for the first time in\\na collected form, in the hope that they may prove useful\\nto those who conduct the examinations of candidates for\\nthe Army, Navy, and Merchant Marine. The methods\\nemployed in examining the eyes of school children in\\ncertain American cities have also been added.\\nIn conclusion, the Editor desires to express his apprecia\u00c2\u00ac\\ntion and thanks to Mr. Nettleship and to Mr. W. T.\\nHolmes Spicer, the reviser of several English editions of\\nthe book, for their courtesy and kindness in granting their\\nconsent to this American edition.\\nW. C. P.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0014.jp2"}, "15": {"fulltext": "CONTENTS.\\nPART I.\u00e2\u0080\u0094MEANS OF DIAGNOSIS.\\nPAGE\\nList of Abbreviations .17\\nCHAPTER I.\\nOPTICAL OUTLINES.\\nLenses and prisms; Refraction of the eye, and conditions of\\nclear vision; Numeration of spectacle lenses; Table show\u00c2\u00ac\\ning the equivalent numbers of lenses made by the inch\\nscale and metrical scale respectively 17\u00e2\u0080\u009430\\nCHAPTER II.\\nEXTERNAL EXAMINATION OF THE EYE.\\nExamination of: 1. The lids; 2. The conjunctival cul-de-sac;\\n3. The eyeball; 4. Information derived from the blood\u00c2\u00ac\\nvessels visible on the surface of the eyeball; 5. The cor\u00c2\u00ac\\nnea; 6. The iris; 7. The pupils; 8. The lens; 9. The\\nmobility of the eyeball; 10. To estimate the tension of\\nthe eyeball; 11. Testing the acuteness of sight; 12. Ac\u00c2\u00ac\\ncommodation; 13. Balance of external eye-muscles; 14.\\nThe ophthalmometer 15. The field of vision 16. Color\\nperception.37\u00e2\u0080\u009457\\nCHAPTER III.\\nEXAMINATION OF THE EYE BY ARTIFICIAL LIGHT.\\n1. Focal or oblique\u00e2\u0080\u009d illumination.\\n2. Ophthalmoscopic examination Use of the ophthalmoscope.\\nvii)", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0015.jp2"}, "16": {"fulltext": "CONTENTS.\\nviii\\nPAGE\\nIndirect method Appearance of optic disk scleral ring, phy\u00c2\u00ac\\nsiological pit, lamina cribrosa; of choroid; of retina;\\nvessels, yellow spot, fovea centralis.\\nDirect method: Examination of vitreous; Determination of\\nrefraction Table of relation between refraction and length\\nof eye Examination of fine details by direct method.\\nRetinoscopy.. 58\u00e2\u0080\u009483\\nPART II.\u00e2\u0080\u0094CLINICAL DIVISION.\\nCHAPTER IV.\\nDISEASES OF THE EYELIDS.\\nBlepharitis; Stye; Meibomian cyst; Horns and warty forma\u00c2\u00ac\\ntions Molluscum contagiosum Xanthelasma Pediculus\\npubis. Ulcers: Rodent cancer; Tertiary syphilis; Tuber\u00c2\u00ac\\ncle of conjunctiva; Lupus; Chancre. Congenital ptosis\\nEpicantlius; Congenital trichiasis 85\u00e2\u0080\u009493\\nCHAPTER V.\\nDISEASES OF THE LACHRYMAL APPARATUS\\nEpiphora, stillicidium lachrymarum, and lachrymation.\\nEpiphora from alterations of punctual and canaliculus; Dacry-\\nolitlis.\\nDiseases of lachrymal sac and nasal duct: Mucocele and lachry\u00c2\u00ac\\nmal abscess; Stricture of nasal duct; Lachrymal abscess\\nin newborn infants 94\u00e2\u0080\u0094101\\nCHAPTER VI.\\nDISEASES OF THE CONJUNCTIVA.\\nPurulent and gonorrhoeal ophthalmia; Muco-purulent oph\u00c2\u00ac\\nthalmia; Catarrhal and other forms of muco-purulent\\nophthalmia; Follicular conjunctivitis; Membranous and\\ndiphtheritic ophthalmia; Granular ophthalmia; Results\\nof granular ophthalmia; Pannus, distichiasis and trichia-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0016.jp2"}, "17": {"fulltext": "I\\nCONTENTS.\\nsis Organic entropion Chronic conjunctivitis; Amyloid\\ndisease; Spring catarrh Conjunctivitis from drugs; Oph\u00c2\u00ac\\nthalmia nodosa; Primary shrinking of conjunctiva;\\nSnow-blindness.101\u00e2\u0080\u0094124\\nCHAPTER VII.\\nDISEASES OF THE CORNEA.\\nA. Ulcers and non-specific inflammation.\\nAppearances of the cornea in disease: \u00e2\u0080\u009cSteamy\u00e2\u0080\u009d and\\n\u00e2\u0080\u009cground-glass\u00e2\u0080\u009d cornea; Infiltration; Swelling; Ulcera\u00c2\u00ac\\ntion Nebula and leucoma.\\nSymptoms in ulceration; Photophobia Congestion\\nPain.\\nClinical types of ulcer: Simple ulcer; Facetting ulcer;\\nPhlyctenular affections; Phlyctenular, or recurrent vas\u00c2\u00ac\\ncular ulcer; Marginal conjunctivitis. (Spring catarrh);\\nCrescentic ulcer of old age; Infective ulcers; Abscess and\\nsuppurating ulcer; Hypopyon; Onyx; Keratomalacia;\\nHerpes; Superficial punctate keratitis.\\nTreatment of ulcers of cornea.\\nB. Diffuse keratitis.\\nSyphilitic keratitis. Other affections of the cornea:\\nKeratitis punctata; Corneal changes in glaucoma; Conical\\ncornea; Buphtlialmos (Hydrophthalmos); Calcareous\\nfilm; Arcus senilis; Inflammatory arcus; Opacity from\\nuse of lead lotion; Staining of conjunctiva or cornea\\nfrom use of nitrate of silver 125\u00e2\u0080\u0094152\\nCHAPTER VIII.\\nDISEASES OF THE IRIS.\\nIritis, symptoms: Muddiness and discoloration of iris; Syn-\\nechiae; Corneal haze; Ciliary congestion; Pain; Lymph\\nnodules; Hypopyon.\\nResults of iritis.\\nCauses: Syphilis; Rheumatism; Gout; Sympathetic\\ndisease; Injuries and local causes; Chronic iritis.\\nTreatment of iritis.\\nCongenital irideremia; Coloboma; Persistent pupillary mem\u00c2\u00ac\\nbrane. 153\u00e2\u0080\u0094165", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0017.jp2"}, "18": {"fulltext": "X\\nCONTENTS.\\nCHAPTER IX.\\nDISEASES OF THE CILIARY REGION.\\nPAGE\\nEpiscleritis (or scleritis), sclero-keratitis and allied diseases:\\nCyclitis (iridochoroiditis, \u00e2\u0080\u009cserous iritis\u00e2\u0080\u009d); Traumatic\\ncyclitis (or panophthalmitis).\\nSympathetic affections; Sympathetic irritation; Sympathetic\\ninflammation; Treatment 166\u00e2\u0080\u0094179\\nCHAPTER X.\\nINJURIES OF THE EYEBALL.\\nContusion and concussion injuries: Rupture of eyeball; Intra\u00c2\u00ac\\nocular hemorrhage; Detachment of iris; Dislocation of\\nlens; Detachment of retina; Rupture of choroid; Paral\u00c2\u00ac\\nysis of iris and ciliary muscle; Iritis; Commotio retinae;\\nTraumatic myopia. Treatment of blows on eye; Dislo\u00c2\u00ac\\ncation of lens.\\nSurface wounds of eyeball: Abrasion and foreign body on\\ncornea; Foreign body on conjunctiva.\\nBurns and scalds; Prognosis uncertain for some days: Lime-\\nburn Serious results of severe burns.\\nPenetrating wounds of eyeball; Slight cases; Severe cases;\\nTraumatic cataract; Cyclitis; Foreign body in eye. Treat\u00c2\u00ac\\nment. Rules as to the excision of wounded eyes. Electro\u00c2\u00ac\\nmagnet for removing bits of iron.180\u00e2\u0080\u0094190\\nCHAPTER XI.\\nCATARACT.\\nSenile changes in lens.\\nDefinition of cataract: General cataract: Nuclear and\\ncortical, each may be hard (senile) or soft (juvenile);\\nCongenital. Partial cataract; Lamellar; Pyramidal;\\nAnterior and posterior polar. Cataract following wound\\nor concussion of eyeball.\\nPrimary and secondary cataract.\\nSymptoms and diagnosis of cataract. Prognosis before and\\nafter operation.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0018.jp2"}, "19": {"fulltext": "CONTENTS.\\nxi\\nPAGE\\nTreatment: Palliative; Atropine. Radical; Extraction; Dis\u00c2\u00ac\\ncission or solution; Suction.\\nRules as to operating for cataract; Artificial ripening\\nof cataract; Causes of failure after extraction Hemor\u00c2\u00ac\\nrhage; Suppuration of globe; Iritis; Prolapse of Iris;\\nInfluence of lachrymal disease.\\nSight after removal of cataract.\\nTreatment of lamellar cataract.\\nCataract following injury; Dislocation of lens 191\u00e2\u0080\u0094212\\nCHAPTER XII.\\nDISEASES OF THE CHOROID.\\nParticipation by the retina and the vitreous.\\nAppearance in health Appearance in disease: Atrophy, pig\u00c2\u00ac\\nment in choroid and retina Exudations, syphilitic, tuber\u00c2\u00ac\\ncular; Rupture; Colloid change Hemorrhages.\\nClinical forms of disease: Syphilitic choroiditis disseminata;\\nMyopic changes; Central senile choroiditis; Pseudo\u00c2\u00ac\\nglioma Other forms.\\nColoboma; Albinism.213\u00e2\u0080\u0094228\\nCHAPTER XIII.\\nDISEASES OF THE RETINA.\\nAppearances in health Bloodvessels, yellow spot, and \u00e2\u0080\u009chalo\u00e2\u0080\u009d\\naround it; Opaque nerve-fibres.\u00e2\u0080\u009d\\nAppearances in disease: Congestion Retinitis, diffuse,\\nlocalized, with white spots and hemorrhages, solitary patch.\\nHemorrhage; Pigmentation Atrophy; Disk in atrophy of\\nretina; Detachment.\\nClinical forms of disease: Syphilitic retinitis; Albuminuric;\\nHemorrhagic; Retinitis apoplectica and large single\\nhemorrhages; Embolism and thrombosis; Retinitis pig\u00c2\u00ac\\nmentosa Retinitis from intense light 229\u00e2\u0080\u0094253\\nCHAPTER XIV.\\nDISEASES OF THE OPTIC NERVE.\\nRelation between changes at the disk, disease of the optic\\nnerve, and affection of sight.\\nPathological changes in optic nerve.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0019.jp2"}, "20": {"fulltext": "CONTENTS.\\nXll\\nPAGE\\nAppearances of optic disk in disease: Inflammation, optic\\nneuritis, papillitis, or choked disk; Atrophy after papil\u00c2\u00ac\\nlitis; Papillo-retinitis.\\nEtiology of papillitis. Retro-ocular neuritis; Syphilis\\ncausing papillitis.\\nAtrophy of disk: Appearances and causes; Clinical\\naspects; State of sight, field of vision, and color per\u00c2\u00ac\\nception A. Double atrophy; B. Single atrophy 254\u00e2\u0080\u0094268\\nCHAPTER XY.\\nAMBLYOPIA AND FUNCTIONAL DISORDERS OF SIGHT.\\n\u00e2\u0080\u009cAmblyopia\u00e2\u0080\u009d and \u00e2\u0080\u009camaurosis:\u00e2\u0080\u009d Single amblyopia: From\\nsuppression or congenital defect; From defective images\\nFrom retro-ocular neuritis. Double amblyopia: Central\\namblyopia (tobacco amblyopia).\\nHemianopia; Hysterical amblyopia and hypercesthesia oculi;\\nAsthenopia\\nFunctional disorders of vision; Endemic nyctalopia; Heme\u00c2\u00ac\\nralopia; Colored vision; Micropsia; Muscse volitantes;\\nDiplopia; Malingering; Color-blindness 269\u00e2\u0080\u0094285\\nCHAPTER XVI.\\nDISEASES OF THE VITREOUS HUMOR.\\nUsually secondary to other disease of eye.\\nExamination for opacities: Cholesterine; Blood Blood\u00c2\u00ac\\nvessels in vitreous; Cysticercus.\\nConditions causing disease of vitreous: Myopia; Blows and\\nwounds; Spontaneous hemorrhoge; Cvclitis, choroiditis,\\nretinitis; Sympathetic disease 286\u00e2\u0080\u0094290\\nCHAPTER XVII.\\nGLAUCOMA.\\nPrimary and secondary.\\nPrimary glaucoma: Premonitory stage Chronic or Simple\\nSubacute; Acute Absolute.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0020.jp2"}, "21": {"fulltext": "CONTENTS.\\nx 111\\nPAGE.\\nOphthalmoscopic changes Clipping of disk.\\nSymptoms explained; Mechanism.\\nGeneral and diathetic causes; Treatment; Prognosis\\nSecondary glaucoma; Conditions causing it 291\u00e2\u0080\u0094310\\nCHAPTER XVIII.\\nTUMORS AND NEW-GROWTHS.\\nA. Of the conjunctiva and front of the eyeball. Cauliflower\\nwart; Lupus; Syphilitictarsitis; Pinguecula; Pterygium;\\nLymphatic cysts; Dermoid tumor Episcleritis simulat\u00c2\u00ac\\ning tumor; Fibro fatty growth; Cystic tumors; Fibrous\\nand Bony tumors Epithelioma; Sarcoma.\\nB. Intraocular tumors. Glioma of retina; Sarcoma of\\nchoroid Tubercular tumor of choroid. Tumors of iris\\nSarcoma; Sebaceous tumor; Cysts; Granuloma 311\u00e2\u0080\u0094320\\nCHAPTER XIX.\\nINJURIES, DISEASES, AND TUMORS OF THE ORBIT.\\nContusion and concussion injuries. Emphysema of orbit;\\nTraumatic ptosis.\\nAbscess and cellulitis of orbit; Inflammation and abscess of\\nlachrymal gland.\\nWounds: Of eyelids; of orbit; Large foreign bodies in orbit.\\nTumors of orbit. General symptoms: Distention of frontal\\nsinus; Ivory exostosis; Tumors growing from parts around\\nthe orbit; Pulsating exophthalmos; Cystic tumors; Solid\\nintraorbital tumors. Naevus. Dermoid tumor in eye\u00c2\u00ac\\nbrow 321\u00e2\u0080\u0094328\\nCHAPTER XX.\\nERRORS OF REFRACTION AND ACCOMMODATION.\\nEmmetropia Ametropia.\\nMyopia. Symptoms: Insufficiency of internal recti. Poste\u00c2\u00ac\\nrior staphyloma and crescent; Other complications; Tests\\nfor causes; Measurement of degree; Treatment; Spec\u00c2\u00ac\\ntacles Tenotomy.\\nHypermetropia. Symptoms: Accommodative asthenopia;\\nTests for hypermetropia; Treatment; Spectacles.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0021.jp2"}, "22": {"fulltext": "XIV\\nCONTENTS\\nPAGE.\\nAstigmatism. Regular and irregular; Seat; Focal interval;\\nCylindrical lenses Forms of regular astigmatism Detec\u00c2\u00ac\\ntion and measurement; Spectacles.\\nUnequal refraction in the two eyes (anisometropia).\\nPresbyopia: Rate of progress Treatment: Range and region\\nof accommodation in E., M., and H 329\u00e2\u0080\u0094364\\nCHAPTER XXI.\\nSTRABISMUS AND PARALYSIS.\\nDefinition of strabismus; Diplopia True and false image\\nHomonymous and crossed diplopia Suppression of false\\nimage.\\nCauses: Strabismus from over-action from weakness; from\\ndisuse; from weakness following tenotomy; from paral\u00c2\u00ac\\nysis.\\nParalysis of sixth nerve (external rectus); of fourth nerve\\n(superior oblique); of third nerve; Ophthalmoplegia\\nexterna; Primary and secondary strabismus; Giddiness\\nin paralytic strabismus.\\nAffections of internal muscle of eye: Physiology and action\\nof drugs on the internal muscles; Affections of pupil\\nalone; of accommodation alone of pupil and accommo\u00c2\u00ac\\ndation Ophthalmoplegia interna.\\nCauses of external ocular paralyses: Syphilitic\\ngrowths; Meningitis Tumors Rheumatism Causes of\\ninternal ocular paralyses; Treatment.\\nNystagmus. 365\u00e2\u0080\u0094392\\nCHAPTER XXII.\\nOPERATIONS.\\nA. On the eyelids.\\nEpilation Eversion of lid Meibomian cyst; Inspection\\nof cornea; Spasmodic entropion; Organic entropion and\\ntrichiasis Ectropion Blepliaroplasty Ptosis; Cantho-\\nplasty Peritomy Symblepharon.\\nB. On the lachrymal apparatus.\\nLachrymal abscess; Slitting canaliculus; Stricture of\\nnasal duct, (1) probing, ^2) incising, 3) syringing.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0022.jp2"}, "23": {"fulltext": "CONTENTS.\\nxv\\nPACE.\\nC For strabismus.\\nTenotomy: Graefe\u00e2\u0080\u0099s; Critchett\u00e2\u0080\u0099s; Liebreich\u00e2\u0080\u0099s; Readjust\u00c2\u00ac\\nment and advancement.\\nD. Excision of the eye and alternative operations: Abscission,\\noptico-ciliary neurotomy, evisceration.\\nE. On the cornea.\\nForeign body Paracentesis Corneal section for ulcer\\nConical cornea.\\nF. On the iris.\\nIridectomy For artificial pupil for glaucoma. Irido-\\ndesis; Iridotomy (iritomy).\\nSclerotomy.\\nG. For cataract.\\nExtraction: Linear Graefe\u00e2\u0080\u0099s \u00e2\u0080\u009cmodified linear Short\\nflap Corneal section; Old flap; Complication during\\nextraction Treatment after extraction Secondary opera\u00c2\u00ac\\ntions Discission or solution Suction; Treatment after\\nsolution and suction.\\nAnaesthesia in ophthalmic surgery 393\u00e2\u0080\u0094445\\nPART III.\u00e2\u0080\u0094DISEASES OF THE EYE IN RELA\u00c2\u00ac\\nTION TO GENERAL DISEASES.\\nCHAPTER XXIII.\\nA. GENERAL DISEASES.\\nEye diseases caused by: Syphilis, acquired and inherited, dis\u00c2\u00ac\\neases of optic nerve and oculomotor nerves in relation to\\nsyphilis; Smallpox, scarlet fever, typhus, etc.; diphtheria;\\nMeasles Mumps Chicken-pox and whooping-cough\\nMalarial fevers Relapsing fever; Epidemic cerebro\u00c2\u00ac\\nspinal meningitis; Purpura and scurvy; Pyaemia and\\nSepticaemia Lead-poisoning Alcohol; Tobacco Bisul\u00c2\u00ac\\nphide of carbon Quinine Kidney disease Diabetes;\\nLeucocythaemia; Pernicious anaemia; Heart disease\\nTuberculosis Rheumatism and gonorrhoeal rheumatism;\\nGout, personal and inherited Struma; Entozoa.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0023.jp2"}, "24": {"fulltext": "XVI\\nCONTENTS.\\nB. LOCAL DISEASE AT A DISTANCE FROM THE EYE.\\nPAGE\\nEye symptoms caused by: Megrim Neuralgia and sympathetic\\ndisease; Diseases of brain; Cerebral tumor; Syphilitic\\ndisease; Meningitis; Cerebritis; Hydrocephalus; Diseases\\nof spinal cord; Myelitis; Locomotor ataxy; General par\u00c2\u00ac\\nalysis of insane; Lateral and insular sclerosis; Motor\\ndisorders of eyes and affections of the pupils in cerebral\\nand spinal disease.\\nC. THE EYE SHARING IN A LOCAL DISEASE OF THE\\nNEIGHBORING PARTS.\\nEye symptoms caused by: Herpes zoster of fifth nerve; Para\u00c2\u00ac\\nlysis of fifth, of facial, and of cervical sympathetic nerves;\\nExophthalmic goitre; erysipelas and orbital cellulitis.\\nThe teeth in inherited syphilis 447-478\\n[SUPPLEMENT.\\nInstructions for examination of railway employes as to vision,\\ncolor-blindness, and hearing; Acuteness of vision; Range\\nof vision Field of vision Color-sense Hearing Ex\u00c2\u00ac\\nplanations 479-511]\\nAPPENDIX.\\nFormulae.513\\nBandages. Shades. Protective glass.526\\nTest types, etc..529\\nOphthalmoscopes.530\\nPerimeters. 533\\nRequirements of candidates for public services 536\\nMethod of examining the eyes of scholars in the public schools 539\\nIndex\\n541", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0024.jp2"}, "25": {"fulltext": "PART I.\\nMEANS OF DIAGNOSIS.\\nThe following abbreviations will be used in this work:\\nAcc.\\nAccommodation.\\nP-\\nPunctum proximum,\\nAs.\\nAstigmatism.\\nor near point.\\nAx.\\nAxis of cylindrical\\nPr.\\nPresbyopia.\\nlenses.\\nr.\\nPunctum remotissi-\\nB.\\nBase of prism.\\nsum,or far point.\\nC. or Cv\\nmi\\nCylindrical lens.\\nS. or\\nSph.\\nSpherical lenses.\\nD.\\nDioptre.\\nT.\\nTension; Tn, normal\\nE.\\nEmmetropia.\\ntension; T,\\nIT.\\nHypermetropia.\\nincreased, and\\nm.\\nMetre; cm. centime-\\nT, dimin-\\ntre; mm. milli-\\nislied tension.\\nmetre.\\nY.\\nVisual acuity.\\nM.\\nMyopia.\\ny. s.\\nYellow spot of the\\n0. D.\\nOptic disc.\\nretina.\\nCHAPTER\\nI.\\nOPTICAL OUTLINES.\\n1. Kays of light are deviated or refracted when they\\npass from one transparent medium, e. g., air, into another\\nof different density, e. g. y water or glass.\\n2. If the time occupied by light in passing through a given\\ndistance in air be taken as the time occupied in passing the\\n2 (17)", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0025.jp2"}, "26": {"fulltext": "18\\nMEANS OF DIAGNOSIS.\\nsame distance in crown glass of which ordinary lenses are\\nmade is 1.5, and for rock crystal, pebble\u00e2\u0080\u009d of opticians,\\n1.66, such a number is the \u00e2\u0080\u009crefractive index\u00e2\u0080\u009d of the\\nsubstance. Every ray is refracted except the one which\\nfalls perpendicularly to the surface, Fig. 1, a.\\n3. In passing from a less into a more refractive medium\\nthe deviation is always toward the perpendicular to the\\nrefracting surface; in passing from a more into a less\\nrefracting medium it is always, and to the same extent,\\naway from the perpendicular, Fig. 1, b i. e., the angle x\\nin the figure the angle y.\\nFig. 1.\\nRefraction by a medium with parallel sides.\\n4. Hence, if the sides of the medium, Fig. 1, m, be par\u00c2\u00ac\\nallel, the rays on emerging are restored to their original\\ndirection (6), and, if the medium be thin, very nearly to\\ntheir original path.\\n5. But if, as in a prism, the sides of m form an angle,\\nFig. 2, a, the angles of incidence and emergence, x and y,\\nstill being equal, b must also form an angle with b. The\\nangle a is the refracting angle\u00e2\u0080\u009d or edge of the prism;\\nthe opposite side is the base.\u00e2\u0080\u009d The figure shows that\\nlight is always deviated toward the base. The deviation,\\nshown by the angle d, is equal to about half the refracting\\nangle a if the prism be of crown glass. The relative direc-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0026.jp2"}, "27": {"fulltext": "OPTICAL OUTLINES.\\n19\\ntion of the rays is not changed by a prism; if parallel or\\ndivergent before incidence, they are parallel or similarly\\ndivergent after emergence, Fig. 3.\\nFig. 2.\\nRefraction by a prism.\\n6. An object seems to lie, or is projected,\u00e2\u0080\u009d in the direc\u00c2\u00ac\\ntion which the rays have as they enter the eye; oh Fig.\\n3, seen by an eye at a or b seems to be at o b, where it\\nwould be if the rays a b had undergone no deviation.\\nFig. 3.\\nApparent displacement of object by a prism.\\n7. For very thin prisms the deviation a and Fig. 4,\\nremains the same for varying angles of incidence. For\\nthin lenses this is expressed by saying that the angle d, Fig.\\n5, is the same for the rays at a a b b\\\\ and c c incident at\\ndifferent angles, but at the same distance from the axis.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0027.jp2"}, "28": {"fulltext": "20\\nMEANS OF DIAGNOSIS.\\n8. An ordinary lens is a segment of a sphere, plano\u00c2\u00ac\\nconvex or plano-concave, or of two spheres whose centres\\nare joined by the axis of the lens (biconvex or biconcave).\\nFig. 4.\\nRefraction the same for different angles of incidence.\\n9. A lens is regarded as formed of an infinite number of\\nminute prisms, each with a different refracting angle. Fig.\\n6 shows two such elements of a convex lens, the angle (a)\\nof the prism at the edge of the lens being larger, and,\\nFig.5.\\nRefraction by a thin lens the same for all rays incident at the same\\ndistance from the axis.\\ntherefore, in accordance with 5, refracting more than y5,\\nthe angle of the prism near the axis. If two parallel rays,\\na and b, traverse this system a will be more refracted than\\nb, and the rays will meet at/. Fig. 7 shows the correspond-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0028.jp2"}, "29": {"fulltext": "OPTICAL OUTLINES.\\n21\\nmg facts for a concave lens by which parallel rays are\\nmade divergent.\\n10. The only ray not refracted by a lens is the one pass\u00c2\u00ac\\ning through the centre of each surface, compare 2, which\\nFig. G.\\nPrismatic elements of a convex lens.\\nis the principal axis, ax Fig. 8. Secondary axes are rays\\n(such as s. ax) entering and emerging at points on the lens\\nparallel to each other, and hence, see 4, not altered in\\ndirection all rays which pass through the central point of\\nthe lens are secondary axes, except the principal axis.\\nFig. 7. Fig. 8.\\nPrismatic elements of a concave lens. Axes of a lens.\\n11. The principal focus, Fig. 10, of a lens is the point\\nwhere the rays, a a that were parallel before they trav\u00c2\u00ac\\nersed the lens meet, after they have passed through it; the\\ndeviation of each ray varying directly with its distance from\\nthe principal axis, Fig. 6.\\nBut this is only approximately true. In an ordinary lens\\nthe rays, a, Fig. 9, which traverse the margin are reflected", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0029.jp2"}, "30": {"fulltext": "22\\nME A NS OF DIAGNOSIS.\\nmore, and meet sooner, than the rays b which lie nearer the\\naxis; and the result is, not one focus, but a number of foci.\\n\u00e2\u0080\u009cSpherical aberration increases with the size of the lens.\\nIn the eye it is, to a great extent, prevented by the iris, which\\ncuts off the light from the margin of the crystalline lens.\\nFig. 9.\\nSpherical aberration.\\nIf parallel rays are incident from the side toward/, Fig.\\n10, they will be focussed at at the same distance from\\nthe lens as/; hence every lens has two principal foci\u00e2\u0080\u0094\\nanterior and posterior.\\nFig. 10.\\nFoci of a convex lens.\\n12. Tli epatli of a ray passing from one point to another\\nis the same, whatever its direction; the path of the ray b b\\nFig. 10, is the same, whether it passes from c or in the\\ncontrary direction.\\n13. From 7 it follows that in Fig. 10 the angles a and", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0030.jp2"}, "31": {"fulltext": "OPTICAL OUTLINES.\\n23\\na are equal, and hence the ray b, diverging from cf, will\\nnot meet the axis at/, but at c cf and cf f are conju\u00c2\u00ac\\ngate points and each is the conjugate focus of the other.\\nThe angle a or a remaining the same, then if cf be further\\nfrom the lens c will approach it. A ray (c) directed\\ntoward the axis will be focussed at c because the angle\\na a; no real conjugate to c f exists; but if the ray\\nstart fron c f it will, on taking the direction c appear\\nto have come from vf which consequently is the virtual\\nfocus of c f see 6.\\n14. All the foci of concave lenses are virtual. In Fig.\\n11, a, parallel to the axis, is made divergent (see Fig. 7),\\nits virtual focus being at/; similarly cf is the virtual con\u00c2\u00ac\\njugate focus of the point emitting the ray b.\\nFig. 11\\nFoci of a concave lens.\\n15. In equally biconvex or biconcave lenses of crown\\nglass the principal focus f is at the centre of curvature of\\neither surface of the lens\u00e2\u0080\u0094 i. e., f =r, the radius in plano\u00c2\u00ac\\nconvex, or concave, lenses/\u00e2\u0080\u0094 2r.\\n10. Images. The image formed by a lens consists of foci,\\neach of which corresponds to a point on the object. Given\\nthe foci of the boundary points of an object, we have the\\nposition and size of its image.\\nIn Fig. 12 the object a b lies beyond the focus/. From\\nthe terminal point a take two rays, a and d the former a\\nsecondary axis, and therefore unrefracted, the latter par-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0031.jp2"}, "32": {"fulltext": "24\\nMEANS OF DIAGNOSIS.\\nallel to the principal axis, and therefore passing after\\nrefraction through the principal focus These two rays\\n(and all others which pass through the lens from the point\\na) will meet at A, the conjugate focus of a. Similarly the\\nfocus of the point b is found, and the real inverted conju\u00c2\u00ac\\ngate image of a b is formed at A b. The relative sizes of\\na b and A b vary as their distances from the lens.\\nFig. 12.\\nReal inverted image formed by a convex lens.\\nIf a b be so far off that its rays are virtually parallel on\\nreaching the lens, its image A b will be at and very\\nsmall. If a b be at its rays will become parallel after\\nrefraction, \u00c2\u00a7\u00c2\u00a711 and 12, and form no image. If a b lies\\nbetween/ or/ and the lens, the rays will diverge after\\nrefraction, and again will not form an image, see Fig. 10,\\nc T-\\nBut in the last two cases a virtual image is seen by an\\neye so placed as to receive the rays. In Fig. 13 two rays\\nfrom a take after refraction the course shown by a and a\\nvirtually meeting at A, see Fig. 10, vf and an observer\\nat x will see at A b a virtual, magnified erect image of a b.\\nThe enlargement in Fig. 13 is greater the nearer a b is\\nto/ and greatest when it is at/ But as a b has no real\\nexistence, its apparent size varies with the known, or esti\u00c2\u00ac\\nmated, distance of the surface against which it is projected.\\nA uniform distance of projection of about 12 (30 cm.) is", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0032.jp2"}, "33": {"fulltext": "OPTICAL OUTLINES.\\n25\\ntaken in comparing the magnifying power of different\\nlenses.\\nWhen a b is at Fig. 13, we shall find on trial that the\\nimage A b can be seen well only by bringing the eye close\\nup to the lens at a greater distance only part of the image\\nFig. 13.\\nVirtual erect image formed by a convex lens.\\nwill be seen, and this part will be less brightly lighted.\\nThis is important in direct ophthalmoscopic examination.\\nThus in Fig. 14 an observer placed anywhere between\\nthe lens and x, receiving rays from every part of a b, will\\nsee the whole image. But if he withdraw to y, his eye\\nFig. 14.\\nVirtual image result of observer varying distance of his eye from the lens.\\nwill receive rays only from the central part of a b, and\\nwill therefore not see the ends of the object.\\nIt is easily shown by similar constructions that the images\\nformed by concave lenses are always virtual, erect, and dim in-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0033.jp2"}, "34": {"fulltext": "2 6\\nMEANS OF DIAGNOSIS.\\nishecl, whatever the distance of the object, Fig 15. Com\u00c2\u00ac\\npare Fig. 11.\\n17. The size of the image (whether real or virtual) varies\\nwith (1) the focal length of the lens, and (2) the distance\\nof the object from the principal focus.\\nFig. 15.\\nImage formed by a concave lens.\\n(1) The shorter the focus of the lens, the greater is its\\neffect or the stronger it is the refractive power of a lens\\nvaries inversely as its focal length.\\n(2) For a convex lens, the image, whether real or vir\u00c2\u00ac\\ntual, is larger\u00e2\u0080\u0094 i. e., the effect greater\u00e2\u0080\u0094the nearer the\\nobject is to the principal focus, whether within or beyond ii.\\nFor a concave lens, the image is smaller\u00e2\u0080\u0094 i. e., the effect\\ngreater\u00e2\u0080\u0094the further the object is from the lens, whether\\nwithin or beyond the focus.\\n18. Prisms. Any object viewed through a prism seems\\ndisplaced toward the edge of the prism, and the amount of\\nthe displacement varies directly as the size of the refract\u00c2\u00ac\\ning angle, 5 and 6. The eye is directed toward the\\nposition which the object now seems to take, and this effect\\nmay be variously utilized: 1. To lessen the convergence of\\nthe visual lines without removing the object further from\\nthe eyes. In Fig. 16 the eyes, r and l, are looking at the\\nobject, oh, with a convergence of the visual lines repre\u00c2\u00ac\\nsented by the angle a. If prisms be now added with their\\nedges toward the temples they deflect the light, so that it\\nenters the eyes under the smaller angle ft, as if it had come", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0034.jp2"}, "35": {"fulltext": "OPTICAL OUTLINES.\\n27\\nfrom ob and toward this point the eyes will be directed,\\nthough the object still remains at ob. The same effect is\\ngiven by a single prism of twice the strength before one\\nFig. 16.\\nEffect of prisms in lessening convergence.\\neye, though the actual movement is then limited to the eye\\nin question. If spectacle lenses be placed so that the visual\\nlines do not pass through their centres they act as prisms,\\nthough the strength of the prismatic action varies with the\\npower of the lens and the amount of this decentration.\u00e2\u0080\u0099\\nTable Showing the Prismatic Effect of Decentring\\nLenses (Maddox).\\nAmount of Deeentration in Millimetres.\\nLens.\\n1 D\\n5 mm.\\n17\\n10 mm.\\n35\\n15 mm.\\n52\\n2 D\\n35\\n1\u00c2\u00b0\\n9\\n1\u00c2\u00b0 43\\n3 D\\n52\\n1\\n43\\n2\\n34\\n4 D\\n1\u00c2\u00b0 10\\n2 18\\n3\\n26\\n6 D\\n1 43\\n6\\n2G\\n5\\n9\\n8 D\\n2 18\\n4\\n35\\n6\\n50", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0035.jp2"}, "36": {"fulltext": "28\\nMEANS OF DIAGNOSIS.\\nIn Fig. 17 the visual lines pass outside the centres of the\\nconvex lenses, a and inside those of the concave lenses, b.\\nEach pair therefore acts as a prism with its edge outward.\\n2. To remove double vision caused by slight degrees of stra\u00c2\u00ac\\nbismus. The prism so alters the direction of the rays as to\\ncompensate for the abnormal direction of the visual line.\\nFig. 17. Fig. 18.\\nLenses acting as prisms.\\nDiplopia removed by prism.\\nIn Fig. 18 r is directed toward x instead of toward ob, and\\ntwo images of ob are seen, see Chapter XXI. The prism,\\np, deflects the rays to y, the yellow spot, and single binocu\u00c2\u00ac\\nlar vision is the result. 3. To test the strength of the ocular\\nmuscles. In Fig. 19 the prism at first causes diplopia by\\ndisplacing the rays from the yellow spot, y y of the eye, R,\\nsee Chapter XXI. By a compensating rotation of the eye\\n(cornea outward), shown in the figure by the change of\\nthe transverse axis from 1 to 2 y is brought inward to the\\nsituation of im, the images are fused and single vision re\u00c2\u00ac\\nstored the effect of the prism is overcome by the action", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0036.jp2"}, "37": {"fulltext": "OPTICAL OUTLINES.\\n29\\nof the external rectus. This fusion power\u00e2\u0080\u009d of the sev\u00c2\u00ac\\neral pairs of muscles may be expressed by the strongest\\nprism that each pair can overcome. The fusion power of\\nthe two external recti is represented by a prism of about\\n8\u00c2\u00b0; that of the two internals by 25\u00c2\u00b0 to 50\u00c2\u00b0 or more; that of\\nthe superior and inferior recti, acting against each other,\\nby only about 3\u00c2\u00b0. 4. Feigned blindness of one eye may\\noften be exposed by means of the diplopia, unexpected by\\nFig. 19.\\nPrism used for testing strength of muscle.\\nthe patient, produced by a prism. The prism should be\\nstronger than can be overcome by any effort\u00e2\u0080\u0094 e. g., 8\u00c2\u00b0 or\\n10\u00c2\u00b0, base upward or downward. The patient is best thrown\\noff his guard if the prism be held before the sound eye. If\\nhe now exclaims that he sees double, he must of course be\\nseeing with both eyes.\\n19. Refraction of the eye. The eye presents three refract\u00c2\u00ac\\ning surfaces\u00e2\u0080\u0094the front of the cornea, 1 the front of the lens,\\n1 The posterior surface of the cornea being parallel with the anterior\\ncauses no deviation, and the aqueous has the same refractive power as the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0037.jp2"}, "38": {"fulltext": "30\\nMEANS OF DIAGNOSIS.\\nand the front of the vitreous; and in the normally formed\\nor emmetropic eye (E.), with the accommodation relaxed,\\nthe principal focus, 11, of these combined dioptric media\\nfalls exactly upon the layer of rods and cones of the retina\\ni. e., the eye in a state of accommodative rest is adapted\\nfor parallel rays. The point at which the secondary axial\\nrays, see 10, Fig. 8, cross, the posterior nodal point\u00e2\u0080\u009d\\nn, Fig. 20, lies, in the normally formed eye, at 15 mm. in\\nfront of the yellow spot of the retina, and very nearly coin\u00c2\u00ac\\ncides with the posterior pole of the crystalline lens. The\\nFig. 20.\\nVisual angle and retinal image. Ob, object; v, visual angle n, nodal point\\nwhere the axial rays cross d, distance from n to the retina. The position of\\nthe retina in different states of refraction is shown by the three curved lines\\nto the right, H. being represented by the line nearest to, and N. by the one\\nfurthest from, n, while the middle thin line shows the retina in E.\\nangle included between the lines joining n with the ex\u00c2\u00ac\\ntremities of the object, ob, is the visual angle v. If the\\ndistance, d from n to the retina remain the same, the size\\nof any image, Im, on the retina will depend on the size of\\nthe angle, v, and this again on the size and distance of ob.\\nBut if the distance, d, alters, the size of the image, Im, is\\naltered without any change in v. Now the length of d\\nvaries with the length of the posterior segment of the eye;\\nit is greater in myopia (M.) and less in hypermetropia (H.),\\nand hence the retinal image of an object at a given dis-\\ncornea. Hence the refractive effect of the cornea and aqueous together is\\nthe same as if the corneal tissue extended from the front of the cornea to the\\nfront of the lens.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0038.jp2"}, "39": {"fulltext": "OPTICAL OUTLINES.\\n31\\ntance is, as the figure shows, larger in myopia and smaller\\nin hypermetropia than in the normally formed eye. The\\nlength of d also varies with the position of n, and this is\\ninfluenced by the positions and curvatures of the several\\nrefractive surfaces, n is slightly advanced by the increased\\nconvexity of the lens during accommodation, and much\\nmore so if the same change of refraction be induced by a\\nconvex lens held in front of the cornea: hence convex\\nlenses, by lengthening d, enlarge the retinal image. Con\u00c2\u00ac\\ncave lenses put n further back, and, by thus shortening d,\\nlessen the image. If the lens which corrects any optical\\nerror of the eye be placed at the anterior focus\u00e2\u0080\u009d of the\\neye, 1 13 mm., or half an inch, in front of the cornea, n\\nmoves to its normal distance (15 mm.) from the retina,\\nwhatever the length of the eye, and the images are there\u00c2\u00ac\\nfore reduced or enlarged to the same size as in the emme\u00c2\u00ac\\ntropic eye. For definition of astigmatism see Chapter XX.\\nThe length of the visual axis, a line drawn from the yellow\\nspot to the cornea in the direction of the object looked at,\\nis about 23 mm. The centre of rotation of the eye is rather\\nbehind the centre of this axis, and G mm. behind the back\\nof the lens. The focal length of the cornea is 31 mm., and\\nthat of the crystalline lens varies from 43 mm. with accom\u00c2\u00ac\\nmodation relaxed, to 33 mm. during strong accommodation.\\n20. The apparent size of an object depends, in the first\\nplace, on the size of its retinal image and this, as already\\nshown, 19, p. 30, depends upon (a) the size of the visual\\nangle, and (6) the distance of the retina from the nodal\\npoint. It is clear that in Fig. 20 a smaller object placed\\nnearer to the eye or a larger one placed further off might\\nsubtend the same angle as Ob, and therefore have a retinal\\nimage of the same size. There are, however, other factors\\ncontributing to our estimate of the size of objects, espe-\\ni The anterior focus is the point where rays, which were parallel in the\\nvitreous, are focussed in front of the cornea.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0039.jp2"}, "40": {"fulltext": "32\\nMEANS OF DIAGNOSIS.\\ncially contrast of light and shade, estimation of distance,\\nand effort of accommodation.\\nA white object on a black ground looks larger than a\\nblack object of the same size on a white ground. The\\nfurther off an object is judged to be, the larger does it\\nlook. 1 The greater the accommodative effort used, what\u00c2\u00ac\\never may be the distance of the object, the smaller does\\nit appear; thus patients whose eyes are partly under\\nthe influence of atropine, and presbyopic persons whose\\nglasses are too weak, complain that near objects, if looked\\nat intently for a short time, become much smaller; while\\nwhen one eye is under the action of eserine, causing spasm\\nof the accommodation, objects appear larger than if held\\nat the same distance from the other eye. Prisms with their\\nbases toward the temples seem to diminish objects seen\\nthrough them by necessitating excessive convergence of\\nthe eyes, the converse of Fig. 16.\\nThe optical conditions of clear sight are as follows:\\n(1) The image must be clearly focussed on the retina\u00e2\u0080\u0094\\ni. e., the retina must lie exactly at the focus of the rays\\nwhich proceed from the object looked at; (2) it must be\\nformed at the centre of the yellow spot, Chapter II., 11\\n(3) it must have a certain size, and this is expressed by the\\nsize of the corresponding visual angle, v, Fig. 20; with\\ngood indoor light v must be equal to at least five minutes\\n(y^th of a degree) in order that the form of the image may\\nbe perceived an object subtending any smaller angle, down\\nto about one minute, is still visible, though only as a point\\nof light 2 (4) the cornea, lens, and vitreous must be clear;\\n(5) the illumination must be sufficient. Influence of the\\npupil: Other things being equal, the larger the pupil the\\n1 In bright light, as in the open air, the mininmm visual angle is consid\u00c2\u00ac\\nerably less than 5 minutes.\\n2 Apparent distance is also influenced by the color of the object. The\\nchromatic aberration of the eye is said to afford the explanation; rays of dif\u00c2\u00ac\\nferent refrangibilities being focussed on slightly different parts of the retina.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0040.jp2"}, "41": {"fulltext": "OPTICAL OUTLINES.\\n33\\nworse is the sight, definition being lessened by the spherical\\naberration caused by the marginal part of the lens, Fig. 9.\\nSee \u00e2\u0080\u009cArtificial Pupil.\u00e2\u0080\u009d\\nThe smaller the pupil, the less is the spherical aberration\\n(p. 30), and ccet. par., the better the V. Also the smaller the\\npupil the less is the accommodation needed for near vision.\\nIf the pupil be so small as to subtend an angle, angle of\\ndivergence,\u00e2\u0080\u009d of not more than five minutes with any point on\\nthe object, the object will be clearly seen without accommoda\u00c2\u00ac\\ntion. By calculation it appears that if the pupil had a diame\u00c2\u00ac\\nter 0.66 mm. it would subtend an angle of divergence of five\\nminutes at about 0.5 m. (18 i. e., with a pupil of 0.66 mm.\\nprint should, in good light, be clearly seen at 18 without any\\naccommodation. That this is true may be proved by looking\\nat fine print through a hole of the above size in a thin card\\nheld as close as possible to the eye.\\nNumeration of spectacle lenses. Some system of num\u00c2\u00ac\\nbering is required which shall indicate the refractive power\\nof the lenses used for spectacles. Two systems are current.\\nIn the first system, which was till lately universal, the unit\\nof strength is a strong lens of 1 focal length. As all the\\nlenses used are weaker than this, their relative strengths\\ncan be expressed only by using fractions. Thus, a lens of\\n2\u00e2\u0080\u009d focus, being half as strong as the unit, 17, 1, is ex\u00c2\u00ac\\npressed as 1; a lens of 10\u00e2\u0080\u009d focus is y 1 of 20\u00e2\u0080\u009d focus\\nand so on. The objections are, that fractions are inconve\u00c2\u00ac\\nnient in practice that the intervals between the successive\\nnumbers are very unequal; and that the length of the inch\\nis not the same in all countries, so that a glass of the same\\nnumber has not quite the same focal length when made by\\nthe Paris, English, and German inches respectively. 1 In\\nthe second system, which has almost displaced the old one,\\nthe metrical scale is used, the unit is a weak lens of 1 metre\\ni 1 English 25.3 mm., 1 French 27 mm., 1 Austrian 26.3 mm.,\\n1 Prussian 26.1 mm.\\n3", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0041.jp2"}, "42": {"fulltext": "34\\nMEANS OF DIAGNOSIS.\\n(100 cm.) focal length, known as a dioptre (D.), and the\\nlenses differ by equal refractive intervals. A lens twice\\nas strong as the unit, with a focal length of half a metre\\n(50 cm.), is 2 dioptres (2 D.), a lens of ten times the\\nstrength, or one-tenth of a metre focus (10 cm.), is 10 D.,\\nand so on. The weakest lenses are 0.25, 0.5, and 0.75 D.,\\nand numbers differing by 0.5 or 0.25 D. are also introduced\\nbetween the whole numbers. A slight inconvenience of\\nthe metrical dioptric system is that the number of the lens\\ndoes not express its focal length. This, however, is obtained\\nby dividing 100 by the number of the lens in D.; thus the\\nfocal length of 4 D. 25 cm. If it be desired to\\nconvert one system into the other, this can be done, pro\u00c2\u00ac\\nvided that we know what inch was used in making the lens\\nwhose equivalent is required in D. The metre is equal to\\nabout 37 French and 39 English or German a lens of\\n36 French, No. 36 or old scale, or of 40 English or\\nGerman, No. 40 or -fo, is very nearly the equivalent of\\nID. A lens of 6 French (i 6 g) will therefore be equal\\nto 6 D.; a lens of 18 French (\u00e2\u0096\u00a0Jg- 2 D., etc.; a\\nlens of 4D. i\u00e2\u0080\u0094 i. e., a lens of 9 French, etc.\\nThe following lenses are used for spectacles, and are,\\ntherefore, necessary in a complete set of trial glasses. The\\nfirst column gives the number in D., the second the focal\\nlength in centimetres, the third the approximate numbers\\non the French inch scale, the denominator of each frac\u00c2\u00ac\\ntion showing the focal length in French inches. It will be\\nseen that some metrical lenses have no exact equivalents on\\nthe inch system. In the following table, and throughout\\nthe book, convex lenses are indicated, according to custom,\\nby the sign; concave lenses, by the sign.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0042.jp2"}, "43": {"fulltext": "OPTICAL OUTLINES.\\n35\\n1.\\nD.\\n(Dioptres.)\\n2.\\nFocal\\nLength in\\ncm.\\n3.\\nNo. and\\nFocal Length\\nin Paris\\ninches.\\n1.\\nD.\\n(Dioptres.)\\n2.\\nFocal\\nLength in\\ncm.\\n3.\\nNo. and\\nFocal Length\\nin Paris\\ninches.\\n0.25\\n400\\n5\\n20\\n1\\nT\\n0.5\\n200\\n1\\n7 2\\n5.5\\n18\\n0.75\\n133\\n1\\nTT1T\\n6\\n16\\nl\\n6\\n1\\n100\\n3T\\n7\\n14\\n1.25\\n80\\nA\\n8\\n12.5\\ni\\n4\\n1.5\\n66\\n1\\n2 4\\n9\\n11\\n1\\n4\\n1.75\\n57\\n_1_\\n2 2\\n10\\n10\\ni A\\n2\\n50\\n1\\nTF\\n11\\n9\\n2.25\\n44\\n1\\nT6\\n12\\n8.3\\n1\\nT\\n2.5\\n40\\n1\\n1 4\\n13\\n7.7\\n2.75\\n36\\n1\\n1 3\\n14\\n7\\n1\\n2^\\n3\\n33\\n1\\n1 2\\n15\\n6.7\\n1\\n2A\\n3.5\\n28\\n1\\nTO\\n16\\n6.2\\n1\\n2A\\n4\\n25\\n1\\n9\\n18\\n5.5\\n1\\n2\\n4.5\\n22\\n1\\n8\\n20\\n5\\nFig. 21.\\nTrial-frame.\\nTo ascertain the refraction, the lenses are placed before\\nthe eye under examination in a trial-frame, Fig. 21. This", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0043.jp2"}, "44": {"fulltext": "36\\nMEANS 01 DIAGNOSIS.\\napparatus is constructed of metal, and is so arranged that\\nthe lenses are fitted into a series of grooves in a half-circle\\nbefore the eye. For convenience in ascertaining the axis\\nof the astigmatism the degrees are marked on a dial on\\nthe outer aspect of the half-circle containing the lenses.\\nPrisms are numbered by their angle of refraction, which\\nis (p. 22) about double the angle of deviation another\\nmethod is to name the prism by the number of degrees of\\ndeviation which it produces; to indicate that degrees of\\ndeviation are meant the letter d should be used; thus\\nprism 2\u00c2\u00b0 d indicates that the prism produces a deviation\\nof 2\u00c2\u00b0 (Maddox). Prisms cannot be used as spectacles of\\na greater strength than about 4\u00c2\u00b0 d in each eye on account\\nof the dispersion of light which they produce.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0044.jp2"}, "45": {"fulltext": "CHAPTER II.\\nEXTERNAL EXAMINATION OF THE EYE.\\nIt is very important that a systematic observation of all\\nparts of the eye and its adnexa should be made in every\\ncase; and that nothing should escape his attention, the\\nstudent is advised to accustom himself to observe some such\\nplan of examination as the following:\\n1. The Lids. \u00e2\u0080\u0094The appearance of the skin, the width of\\nthe palpebral fissure, and the condition of the edges of the\\nlids and of the cilia should be carefully noted. The puncta\\nshould be examined; and if obstruction in the lachrymal\\npassages be suspected, gentle pressure should be made over\\nthe sac with the finger, with a view to expressing any re\u00c2\u00ac\\ntained contents.\\n2. The Conjunctival Cul-de-sac. \u00e2\u0080\u0094The degree of vascu\u00c2\u00ac\\nlarity of the tarsal as well as of the bulbar mucous mem\u00c2\u00ac\\nbrane should be ascertained, and the presence of granula\u00c2\u00ac\\ntions or abnormal secretion. The upper lid should be\\neverted by the surgeon grasping the ciliary border with the\\nthumb and index-finger of his left hand, while he depresses\\nthe upper edge of the tarsus with a probe or the forefinger\\nof his right hand, the patient being requested to look fix\u00c2\u00ac\\nedly downward.\\n3. The Eyeball. \u00e2\u0080\u0094The position of the globe in the orbit,\\nand its size and relationship to the fellow eye, should be\\ncarefully noted.\\nExophthalmos proptosis) or protrusion of the eyeball:\\nenlargement of the eyeball. Unequal prominence of the\\ntwo eyes is best ascertained by seating the patient in a\\n(37)", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0045.jp2"}, "46": {"fulltext": "38\\nMEANS OF DIAGNOSIS.\\nchair, standing behind him, and comparing the summits\\nof the two cornea with each other, and with the bridge of\\nthe nose, or the line of the e) r ebrows. It can also be\\nascertained by placing the straight edge of a card from the\\nFig. 22.\\nMethod of holding the upper eyelid. (Wells.)\\neyebrow to the prominence of the cheek below the eye, and\\nmeasuring the distance of the cornea from the card on the\\ntwo sides. The appearance of prominence or recession, as\\nseen from the front, depends very much on the quantity\\nof sclerotic exposed; thus, slight ptosis gives a sunken\\nappearance to the eyes, and in slight cases of Graves\u00e2\u0080\u0099 dis\u00c2\u00ac\\nease the proptosis seems to increase when the upper lids are\\nspasmodically raised. It is to be remembered that real\\nprominence of the eye may depend on enlargement of the\\neyeball\u00e2\u0080\u0094myopia, staphyloma, intraocular tumor\u00e2\u0080\u0094as well\\nas on its protrusion, and that if only one eye be myopic\\nthe appearance will be unsymmetrical. Decided proptosis\\nmay follow tenotomy or paralysis of one or more ocular\\nmuscles.\\nEnophthalmos, or retraction of the eyeball sometimes\\nfollows wasting of the adipose tissue of the orbit, conse-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0046.jp2"}, "47": {"fulltext": "Vessels of the front of the eyeball, c.m. Ciliary muscle. Ch. Choroid.\\nSet. Sclerotic. V.V. Vena vorticosa, l. Marginal loop-plexus of cornea.\\nAnt. and Post. Conj. Anterior and posterior conjunctival vessels. Ant. Cil.\\nA. and V. Anterior ciliary arteries and veins. (Simplified and altered from\\nLeber.)\\n4. Information derived from the bloodvesssls visible on\\nthe surface of the eyeball. Three systems of vessels have\\nEXTERNAL EXAMINATION OF THE EYE. 39\\nquent upon se\\\\eie blows with much extravasation of\\nblood (see p. 32). In hypermetropia, in which the eye\u00c2\u00ac\\nball is too short, and in the cases of paralysis of the cer\u00c2\u00ac\\nvical sympathetic, the eye often looks sunken.\\nFig. 23.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0047.jp2"}, "48": {"fulltext": "40\\nMEANS OF DIAGNOSIS.\\nto be considered in disease; but most of them are too small\\nto be easily seen in health. 1. The vessels proper to the\\nconjunctiva, posterior conjunctival vessels in which it is not\\nFig. 24.\\nConjunctival congestion (engorgement of the posterior conjunctival arteries\\nand veins. (After Guthrie.)\\nimportant to distinguish between arteries and veins, Fig.\\n23, Post. Conj., and Fig. 24. 2. The anterior ciliary vessels,\\nlying in the subconjunctival tissue; their perforating arte-\\nFig. 25.\\nCongestion of the perforating branches of the anterior ciliary arteries.\\n(Dalrymple.) The dusky spots at the seats of perforation are often seen in\\ndark-complexioned persons.\\nrial branches supply the sclerotic, iris, and ciliary body*\\ntheir veins receive blood from Schlemm\u00e2\u0080\u0099s canal and the\\nciliary body. The perforating branches of the arteries", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0048.jp2"}, "49": {"fulltext": "EXTERNAL EXAMINATION OF THE EYE. 41\\nFig. 23, A, are seen in health as several comparatively\\nlarge tortuous vessels which stop short about T y or\\nfrom the corneal margin, Fig. 25; their very numerous,\\nsmall, non-perforating (episcleral) branches are invisible\\nin health, but form, when distended, a pink zone of fine,\\nnearly straight, very closely-set vessels round the cornea,\\nFig. 23, a, and Fig. 26, ciliary congestion,\u00e2\u0080\u009d circum-\\ncorneal zone,\u00e2\u0080\u009d see Iritis and Diseases of Cornea; the per\u00c2\u00ac\\nforating veins are very small, but more numerous than the\\nperforating arteries, Fig. 23, v, and their episcleral twigs\\nform a closely-meshed network, Fig. 27. 3. The vessels\\nproper to the margin of the cornea and immediately adja\u00c2\u00ac\\ncent zone of conjunctiva, anterior conjunctival vessels, and\\ntheir loop-plexus on the corneal border, Fig. 23, l, and Fig.\\n59; by these numerous minute branches, which are off\u00c2\u00ac\\nshoots of the anterior ciliary vessels, Systems 1 and 2 anas\u00c2\u00ac\\ntomose.\\nFig. 26. Fig. 27.\\nCiliary congestion, engorgement Congestion of anterior ciliary\\nof episcleral twigs of anterior ciliary veins, episcleral venous plexus,\\narteries. (After Dalrymple.) (After Dalrymple.)\\nSpeaking generally, congestion composed of (1) tortuous,\\nbright brick-red vessels moving with the conjunctiva when\\nit is slid over the globe, and least intense just around the\\ncornea, Fig. 24, indicates a pure conjunctivitis, and is usu\u00c2\u00ac\\nally accompanied by muco-purulent or purulent discharge.\\n(2) A zone of pink congestion surrounding the cornea, and", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0049.jp2"}, "50": {"fulltext": "42\\nMEANS OF DIAGNOSIS.\\nformed by small, straight, closely set, parallel vessels, radi\u00c2\u00ac\\nating from the cornea, and not moving with the conjunc\u00c2\u00ac\\ntiva, anterior ciliary arterial twigs, Fig. 26, points to irri\u00c2\u00ac\\ntation or inflammation of the cornea or iris. A more scanty\\nzone of dark or dusky color, Fig. 27, which, when severe,\\nis finely reticulated, episcleral venus plexus, often points to\\nglaucoma, but may accompany other diseases, especially in\\nold people. Congestion in the same region, more deeply\\nseated, and of a peculiar lilac tint, especially if unequal in\\ndifferent parts of the zone, shows cyclitis or deep scleritis.\\n(3) Congestion in the same zone also composed of small,\\nsuperficially placed, bright red vessels, often encroaching\\na little on the cornea, anterior conjunctival vessels and loop\\nplexus of cornea, Fig. 59, shows a tendency to irritable cor\u00c2\u00ac\\nneal inflammation, which is often superficial. Localized\\nor fasciculated congestion generally points to phlyctenular\\ndisease, Figs. 51 and 52. Although in the severe forms\\nof all acute diseases of the front of the eye these types of\\ncongestion are usually mixed and but imperfectly distin\u00c2\u00ac\\nguishable, much information may often be derived from\\nattention to the leading forms described.\\n5. The Cornea.\u00e2\u0080\u0094It must be ascertained whether this mem\u00c2\u00ac\\nbrane be transparent or clouded, and whether its curvature\\nis regular. To detect irregularity of the corneal surface,\\nthe patient faces the window and follows with his eyes an\\nobject\u00e2\u0080\u0094 e. y., the uplifted finger\u00e2\u0080\u0094held about 18 from him\\nand moved slowly in different directions. The image of\\nthe window reflected from the cornea will become distorted\\nor broken as it passes over any irregularity, such as an\\nabrasion or ulcer. Loss of surface of the corneal epithe\u00c2\u00ac\\nlium may be easily demonstrated by placing a drop of a\\nsolution of fluorescin into the eye; this stains the surface\\nfrom which the epithelium is removed, but leaves the rest\\nof the cornea clear. Finer changes in the cornea are best\\nstudied by oblique illumination or by a lens of high mag-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0050.jp2"}, "51": {"fulltext": "EXTERNAL EXAMINATION OF THE EYE. 43\\nnifying power, such as a Hartnack, or through the binocu\u00c2\u00ac\\nlar magnifying lens of Jackson.\\nThe anterior chamber should be studied especially re\u00c2\u00ac\\ngarding its depth and the presence of any exudate in it.\\n6. The Iris.\u00e2\u0080\u0094The color of the iris should be compared\\nwith that of the fellow eye. Occasionally the two irides,\\nalthough healthy, differ in color, one being blue or gray,\\nthe other brown or greenish more frequently a large sec\u00c2\u00ac\\ntor-shaped patch of dark color occupies part of the iris\\nof one eye. Small pigmented spots are often seen on the\\niris. If the iris of an inflamed eye looks greenish, that of\\nits fellow being blue, we should suspect iritis; and if the\\niris of a defective eye be different from its fellow, some\\nmorbid change should be suspected. Chapter VIII.\\n7. The pupils are to be examined as to their equality, size\\nin ordinary light, mobility, and form. The pupils are often\\nlarge and inactive, and sometimes oval, in amaurotic\\npatients, in glaucoma, and in paralysis of the circular\\nfibres of the iris, supplied by the third nerve. They may\\nbe too large, though active, in myopia and in conditions of\\ndefective nerve-tone. Wide, recent dilatation of one pupil\\nor both, with dimness of sight but without ophthalmoscopic\\nsigns of disease, is usually traceable to atropine or bella\u00c2\u00ac\\ndonna, used by accident or design. When very small the\\npupil is seldom quite round.\\nThe size of the pupil is best obtained by the pupillome-\\nter devised by Hirschberg. This consists of a glass slide,\\nwhich is graduated in millimetres, and has marked upon it\\nin addition a series of circles ranging from 1 to 10 mm. in\\ndiameter. The instrument is held close to the eye under\\nexamination, and the circle readily found which corresponds\\nto the diameter of the pupil.\\n8. The Lens.\u00e2\u0080\u0094Opacities in the lens are often visible to\\nthe naked eye, but they are best studied by oblique illumi\u00c2\u00ac\\nnation or by the ophthalmoscope. The observer should", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0051.jp2"}, "52": {"fulltext": "44\\nMEANS OF DIAGNOSIS.\\nnot be misled and suspect the presence of cataract by the\\ngray reflex which is frequently emitted from senile lenses.\\nThe centre of the pupil usually lies a little to the nasal\\nside of the corneal centre. 1 The pupils should be round,\\nand, when equally lighted, equal in size. When one eye\\nis shaded its pupil should dilate considerably, and on ex\u00c2\u00ac\\nposure contract quickly to its former size, direct reflex action\\nduring this trial the other pupil will act, but to a much less\\nextent, indirect reflex action. The pupils contract when the\\ngaze is directed to a near object (say 6 distant), i. e during\\naccommodation and convergence, and dilate in looking\\nat a distant object; but the range of this associated action\\nis much less than that of the reflex action. The pupil\\ndilates when painful impressions are made on the sensory\\nnerves of the skin, e. g., by the faradic brush or by prick\u00c2\u00ac\\ning with a pin. The pupils may be motionless to light and\\nshade from iritic adhesions (Chapter VIII.) or from atrophy\\nof the iris in glaucoma or other local disease; such condi\u00c2\u00ac\\ntions should be carefully noted or excluded. Reflex action\\nis lost when the eyes are blind from disease of the optic\\nnerves or retin se if only one eye be blind, the direct action\\nof the pupil is lost in that eye, but (unless there be disease\\nof the third nerve) its indirect action is much increased.\\nWhen one eye is blind the pupil is often rather larger\\nthan that of the other. Reflex action may also be lost\\nwithout any affection of sight, and without loss of associated\\naction. Chapters XXI. and XXIII.\\nPermanent inequality of the pupils without disease, either\\nof eyes or of nervous system, is rare, but temporary dilata\u00c2\u00ac\\ntion of one pupil is not uncommon. When very active\\npupils are suddenly exposed after being shaded they often\\noscillate for a few seconds before settling, and finally re-\\n1 This eccentricity varies in degree and exact position in different persons.\\nCompare Irregular Astigmatism.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0052.jp2"}, "53": {"fulltext": "EXTERNAL EXAMINATION OF THE EYE. 45\\nmain a little larger than at the first moment of exposure.\\nConsiderable differences in the action of the pupils, both in\\nrange and rapidity are compatible with health in general,\\nhowever, the pupils become smaller, and lose both in range\\nand rapidity of action with advancing years atropine also\\noften causes only partial dilatation in old people. Marked\\ninactivity, with small size, should excite suspicion of spinal\\nor cerebral disease (Chapter XXIII.). The pupils are\\nsmaller whenever the iris is congested, whether this be a\\nmerely local condition, e. g., in abrasion of cornea, or form\\npart of a more general congestion, as in typhus fever 1 and\\nin plethoric states, or be caused by venous obstruction, as\\nin mitral regurgitation and bronchitis. They are large in\\nansemia, in conditions, such as aortic insufficiency, where\\nthe systemic arteries are badly filled, and during rigors;\\nirritation of the sympathetic nerve in the neck is an occa\u00c2\u00ac\\nsional cause of mydriasis. Chapter XXI.\\n9. The mobility of the eyeball may be impaired in any\\nor every direction, and in any degree. Commonly only\\none eye is affected. First, to test the lateral and vertical\\nmovements, direct the patient with both eyes open to look\\nsuccessively toward, or follow a pencil or finger moved in,\\neach of the four directions, up, down, right, and left; next,\\nto test the power of convergence, he looks at the object held\\nvertically in the middle line, rather below the horizontal,\\nand gradually approached from 2 to about 6 In each\\nposition we must notice both eyes; thus, when the patient\\nlooks to his right we have to note the outward movement\\nof his right and the inward movement of his left. The\\nfixed marks for the inward and outward movements are\\nthe inner and outer canthi, and as the apparent range of\\nmovement judged in this way varies a little in different\\n1 The small pupil of typhus and the frequently large pupil of typhoid are\\nascribed by Murchison to the differences in the vascularity of the iris in\\nthese diseases. Continued Fevers, p. 541.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0053.jp2"}, "54": {"fulltext": "46\\nMEANS OF DIAGNOSES.\\npeople, the corresponding movements of the two eyes\\nshould always be compared. In looking strongly outward\\nthe corneal margin does not in all persons quite reach the\\nouter canthus, but it should always reach the inner can thus\\nduring inward rotation. In children and stupid people the\\nmovements are often defective from inattention. In very\\nmyopic eyes the movements are somewhat defective in all\\ndirections. The vertical movements are best shown by\\nnoting the position of the cornea in relation to the border\\nof the lower lid; the border of the upper lid is less trust\u00c2\u00ac\\nworthy, since there may be some ptosis or other cause of\\ninequality between the two sides.\\nThe range of movement of the eye, \u00e2\u0080\u009cfield of fixation or\\n\u00e2\u0080\u009cfield of direct vision/\u00e2\u0080\u0099 can be measured on the perimeter in\\nthe same way as the ordinary field of indirect vision.\u00e2\u0080\u009d The\\ntest-object, e. g., a word of small print, moved along the vari\u00c2\u00ac\\nous meridians from the centre toward the periphery, is fol\u00c2\u00ac\\nlowed by the eye under examination until it can no longer be\\nread\u00e2\u0080\u0094 i. e., until the visual axis can no longer be directed to it.\\nA coarse test-object would be recognized by parts of the retina\\naway from the yellow spot, and must, therefore, not be used.\\nIn this way it is found that the normal range of movement of\\nthe eye extends through about 45\u00c2\u00b0 in each direction from the\\ncentre. The state of mobility of the eye, and the progress, in\\ncases of ocular paralysis, may be accurately recorded in this\\nway. 1\\n10. To estimate the tension of the eyeball (T.), the patient\\nlooks steadily down, and gently closes the eyelids; the ob\u00c2\u00ac\\nserver then makes light pressure on the globe through the\\nupper lid, alternately with a finger of each hand as in try\u00c2\u00ac\\ning for fluctuation, but much more delicately. The finger\u00c2\u00ac\\ntips are placed very near together, and as far back over\\nthe sclerotic as possible, not over the cornea; The pressure\\n1 For further details consult a paper by Landolt in Trans. Internat. Med.\\nCongress, London, 1881, vol. iii. p. 25.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0054.jp2"}, "55": {"fulltext": "EXTERNAL EXAMINATION OF THE EYE. 47\\nmust be gentle, and be directed vertically downward not\\nbackward. It is best for each observer to keep to one pair\\nof fingers, not to use the index at one time and the middle\\nfinger at another. Patient and observer should always be\\nin the same relative position, and it is best for both to\\nstand and face one another. Always compare the tension\\nof the two eyes. Be sure that the eye does not roll upward\\nduring examination, for if this occur a wrong estimate of\\nthe tension may be formed. Some test both eyes at once\\nwith two fingers of each hand. Normal tension is expressed\\nby T. n. Recognizable increase and decrease are indicated\\nby the -(-or sign, followed by the figure 1, 2, or 3. Thus\\nT. -f- 1 means decided increase; T. 2, greater increase,\\nbut the eye can still be indented; T. -4- 3, eye very hard,\\ncannot be indented by moderate pressure T.\u00e2\u0080\u0094 1 2 3\\nindicate successive degrees of lowered tension. A note of\\ninterrogation (T. -f- or for doubtful cases, and T. n.\\nfor the normal, give nine degrees which may be usefully\\ndistinguished. Even good observers sometimes differ as\\nto the minor changes of tension. Apart from variations\\nin delicacy of touch it is to be remembered that eyes deeply\\nset in the orbits are more difficult to test, and that T. in a\\nfew cases really does change at short intervals\u00e2\u0080\u0094 e. g., within\\nhalf an hour. Increase in the rigidity of the sclerotic,\\nwhich often occurs in old age; or in its thickness, as the\\nresult of disease, may increase the apparent tension, though\\nthe internal pressure may be normal or even too low.\\nWhen an eye contains bone it feels like wood covered\\nwith wash-leather. 1\\nThe student has proceeded thus far without the aid of\\ninstruments other than a convex spherical lens. To com\u00c2\u00ac\\nplete the functional examination of the eye it is necessary\\ni 4\\ni Plates of bone, sometimes joined so as to form a cup, are not uncommonly\\nfound on the inner (retinal) surface of the choroid in eyes which have been\\nlong blind from iridochoroiditis.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0055.jp2"}, "56": {"fulltext": "48\\nMEANS OF DIAGNOSIS.\\nto have recourse to more or less complicated apparatus. It\\nhas become the custom in America, at this stage of the ex\u00c2\u00ac\\namination, to seat the patient in front of a phorometer, Fig.\\n28. This is an instrument especially constructed to measure\\nthe relative strength of the ocular muscles. In addition to\\na Maddox rod (see page 51) and rotary prisms which are\\nplaced before each eye for this purpose, the instrument is\\nprovided with cells to carry test-lenses, so that the refrac\u00c2\u00ac\\ntion of the eye may be determined without the employment\\nFig. 28.\\nof the old-fashioned trial-frame. The first step in the ex\u00c2\u00ac\\namination is the determination of the acuteness of vision.\\n11. Testing the acuteness of sight. By acuteness of sight\\n(Y.) is meant the power of distinguishing/orm, and, as com\u00c2\u00ac\\nmonly used, the term refers only to the centre of the visual\\nfield, the peripheral part of the retina having a very im\u00c2\u00ac\\nperfect power of distinguishing form and size. Y. varies\\nconsiderably in different persons whose eyes are normal. It\\nis said to diminish somewhat in old age, without disease\\nof the eyes (Donders). The standard taken as normal is\\nthe power of distinguishing square letters that subtend a\\nvisual angle of five minutes, Fig. 20 and p. 31, the limbs\\nof which are of uniform thickness, each limb subtending\\nan angle of one minute (Snellen\u00e2\u0080\u0099s Test Types). The types", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0056.jp2"}, "57": {"fulltext": "EXTERNAL EXAMINATION OF THE EYE. 49\\nare made of various sizes, each being numbered according\\nto the distance, in feet or metres, at which it subtends a\\nvisual angle of five minutes. Thus, No. 6 subtends this angle\\nat 6 in., No. 3 at 3 m., No. 1 at 1 m., etc. Numerically,\\nacuteness of vision is expressed by a fraction, of which the\\ndenominator is the number of the type D, and the numer\u00c2\u00ac\\nator the greatest distance (d) at which it can be read,\\nY if No. 6 is read at 6 m. or 1\u00e2\u0080\u0094 i. e., Y is nor\u00c2\u00ac\\nmal if only No. 18 can be read at 6 m. T 6 g if only\\n60, then d Any distance greater than about 3 m.\\nmay be selected for this test\u00e2\u0080\u0094 i. e., No. 3 read at 3 m., or\\nNo. 5 at 5 m., generally shows the same acuteness as No.\\n6 read at 6 m. But at distances less than 3 m. the accom\u00c2\u00ac\\nmodation comes into play, and the illumination is often\\nbrighter; hence No. 1 at 1 m. (1) does not necessarily show\\nthe same state of sight as No. 6 at 6 m. It is there\u00c2\u00ac\\nfore best, by recording the fractions unreduced, to indicate\\nthe distance at which the test was used. For testing near\\nvision, Snellen\u00e2\u0080\u0099s types are thought by some to be practi\u00c2\u00ac\\ncally inferior to those of Jaeger and others, in which the\\nletters have the form and proportions found in ordinary\\ntype. See Appendix. If V. be very bad (less than g 6 Q or\\nJq), it may be expressed accurately enough by noting the\\ndistance at which the outspread fingers can be counted\\nwhen exposed to a good light and against a dark back\u00c2\u00ac\\nground. Below this point we can still distinguish good\\nfrom bad, or uncertain, perception of light and shade (p.\\n1 by alternately exposing and shading the eye with the\\nhand, without touching the face.\\nIn using the test types it is necessary to insure that the\\nillumination shall not fall below a certain level; it has\\nbeen found by Snellen that if it be reduced below 20 metre\\ncandles 1 the acuteness of vision rapidly declines. Each\\neye should be tested separately.\\ni Strictly from a point about in front of the cornea, since the glass\\ncannot be placed upon the eyeball.\\n4", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0057.jp2"}, "58": {"fulltext": "50\\nMEANS OF DIAGNOSIS.\\n12. Accommodation (Acc.) is tested clinically by meas\u00c2\u00ac\\nuring the nearest point (pundum proximum p at which\\nthe smallest readable type (Snellen\u00e2\u0080\u0099s 0.5 or Jaeger\u00e2\u0080\u0099s 1) can\\nbe clearly seen. This type being carried in a bracket\\non an arm of the phorometer, which is graded in centi\u00c2\u00ac\\nmetres. The region of accommodation is the space in\\nwhich it is available, see Presbyopia. The amplitude\\npower, or range of Acc. is expressed in terms of the convex\\nFig. 29.\\nAccommodation represented by a convex lens.\\nlens, whose focal length the distance from the cornea 1 to\\np., this being the lens which adapts V. in an eye without\\nAcc. from the farthest point of distinct vision punctum\\nremotissimum, r.) to p. Thus in Fig. 29 let p. be at 10\\ncm. if Acc. be then relaxed, i. e., the eye be adapted\\nfor parallel rays, the rays from p. will be focussed at\\nC. F., behind the retina; but V. will again be clear at\\n10 cm. if a lens, l, of 10 cm. focus 10 D., see p. 42)\\nbe held close to the cornea; because the rays from p will\\nbe made parallel by l before entering the eye (Chapter\\nI., 11 and 12), and will therefore be focussed on the\\nretina.\\nConvergence of the visual axes upon a point at any\\ngiven distance is usually associated with accommodation\\nfor the same distance. The two functions can, however,\\n1 A metre candle (m.c.) is the light given by a standard candle at one metre\\ndistance (Snellen: Bowman Lecture, 1896).", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0058.jp2"}, "59": {"fulltext": "EXTERNAL EXAMINATION OF TIIE EYE. 51\\nbe somewhat dissociated to an extent that varies with age\\nand in different persons; i. e., Ace. can be either relaxed\\na little or increased a little, without changing any given\\ndegree of convergence; this independent portion is known\\nas the relative accommodation.\\n13. Balance of External Eye Muscles.\u00e2\u0080\u0094The purpose of\\nthe various tests for the determination of ocular muscle\\nbalance is to destroy the desire to fuse the retinal images\\nin both eyes by changing the image of one eye. This is\\nbest accomplished by means of the Maddox rod, Fig.\\n30, which consists of a series of rods of glass conveniently\\nFig. 30.\\nadjusted in a metallic disc, and so adjusted in the phorom-\\neter employed by the Editor that it may be rotated into\\nthe vertical and horizontal positions with great accuracy.\\nThe patient is seated before the phorometer, and is told\\nto regard a small point of light or a candle-flame 5 m.\\nawav. The rod is then swung into a vertical position\\nbefore the eye with best vision and if the horizontal streak\\nof light which is projected upon the retina by means of\\nthe cylindrical action of the rod passes through the unal\u00c2\u00ac\\ntered flame seen by the other eye, there is said to be ver\u00c2\u00ac\\ntical muscle balance, or orthophoria; if, on the other hand,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0059.jp2"}, "60": {"fulltext": "52\\nMEANS OF DIAGNOSIS.\\nthe streak deviates higher or lower than the light, the con\u00c2\u00ac\\ndition is designated as hyperphoria or the tendency of one\\nvisual axis to turn above the other. The rod is now turned\\ninto the horizontal axis, and a vertical streak obtained.\\nShould this pass through the flame, lateral orthophoria is\\nsaid to exist. Should, however, the streak be displaced\\ntoward the same side as that before which the rod is held,\\nconvergence of the visual axes, or esophoria, is said to be\\npresent; exophoria, or divergence of the visual axis, when\\nthe streak is on the opposite side.\\nThe degree of the heterophoria, the term used to express\\nany latent ocular deviation, is measured by the prism\\nrequired to bring the images into the normal relations of\\northophoria. 1\\nThe Maddox test for the reading distance consists in\\nplacing a prism of 8\u00c2\u00b0 base up or down before one eye,\\nwhile the gaze is directed at an arrow, printed on a card\\nwhich is adjusted on the arm of the phorometer at 40\\ncm. from the eyes, the degree of the deviation produced by\\nthe prism being readily ascertained by rotary prisms before\\nthe eyes.\\nHaving ascertained the latent deviations, it now becomes\\nnecessary to measure the strength of the eye muscles in rotat\u00c2\u00ac\\ning the eyes. For this purpose the eyes are directed toward\\nthe flame, which is still held at their level, 5 m. distant,\\nand the rotary prisms swung into position before the eyes,\\nwith their bases in. They are then slowly rotated until the\\npatient sees two flames, when the reading of the prism is\\nnoted and the power of the rectus extend\u00e2\u0080\u0094 i. e., the abduct\u00c2\u00ac\\ning power\u00e2\u0080\u0094elicited. The prisms are then rotated so that\\ntheir bases are out, and the reading of the prisms noted\\nwhen double vision is once more obtained, eliciting the\\n1 Esotropia and exotropia are names which have been introduced by\\nStevens to designate actual deviations of the eyes, and to replace the older\\nterms of convergent and divergent strabismus respectively.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0060.jp2"}, "61": {"fulltext": "EXTERNAL EXAMINATION OF THE EYE. 53\\nadducting power, or that of the rectus interni. To ascer\u00c2\u00ac\\ntain the strength of the vertical muscles, supra and infra\\nduction, the prisms are rotated into vertical positions.\\nIt has been found after many observations that normally\\nabduction ranges from 6\u00c2\u00b0 to 8\u00c2\u00b0, adduction from 16\u00c2\u00b0 to\\n30\u00c2\u00b0, and supra and infra duction from 2\u00c2\u00b0 to 3\u00c2\u00b0. If these\\nratios do not obtain in any given case, lieterophoria un\u00c2\u00ac\\ndoubtedly exists.\\n14. The Ophthalmometer.\u00e2\u0080\u0094This instrument has been\\nFig. 31.\\ndevised to obtain the measurements of the radius of curva\u00c2\u00ac\\nture of the cornea, and consists of a telescope mounted", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0061.jp2"}, "62": {"fulltext": "54\\nMEANS OF DIAGNOSIS.\\nupon a tripod, which can be moved laterally, higher or\\nlower or backward or forward, to obtain the proper focus\\nof the observed eye. The cornea is viewed through a\\ndouble refracting prism contained in the telescope, which\\nproduces a double image, and the measure of the displace-\\nment which occurs after the strength of the prism has been\\naltered sufficiently to bring the images into contact, and\\ncorrespondingly to the size of the corneal image, represents\\nthe amount of the astigmatism. The amount and axis of\\nthe corneal astigmatism may be usually accurately obtained\\nby means of this instrument, but glasses should never be\\nprescribed from it to the exclusion of the final test\u00e2\u0080\u0094 i. e.,\\nthe trial-lenses.\\n15. The field of vision (F) (properly, of indirect vision\\nis the entire surface from which, at a given distance, light\\nreaches the percipient part of the retina, the eye being\\nstationary, Fig. 32. If each part of the field be equidis\u00c2\u00ac\\ntant from the part of the retina to which it corresponds,\\nthe field will be hemispherical, with its inner or concave\\nsurface toward the eye; it may, however, be projected on\\nto a flat surface, and for many clinical purposes this is suffi\u00c2\u00ac\\ncient. For roughly testing the field\u00e2\u0080\u0094 e. g., in a case of\\nchronic glaucoma, or of atrophy of optic nerve, or of hemi\u00c2\u00ac\\nanopsia\u00e2\u0080\u0094the following is generally enough. Place the\\npatient with his back to the window; let him cover one\\neye, and look steadily at your eye or nose, as a centre,\\nfrom a distance of 18 or 2 Then hold up your hands with\\nthe fingers spread out in a plane with your face, and ascer\u00c2\u00ac\\ntain the greatest distance from the central point at which\\nthey remain visible when moved in various directions\u00e2\u0080\u0094up,\\ndown, in, out, and diagonally. The patient must look\\nsteadily at the face, and not allow his eye to wander after\\nthe moving fingers.\\nA more exact method is to make the patient gaze, with\\none eye covered, at a white mark (the fixation spot\u00e2\u0080\u009d)", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0062.jp2"}, "63": {"fulltext": "EXTERNAL EXAMINATION OF THE EYE. 55\\non a large blackboard at a distance of 12 or 18 and to\\nmove a piece of white chalk set in a long black handle,\\nfrom various parts of the periphery toward the fixation\\nspot, until the patient exclaims that he sees something\\nwhite. If a mark be made on the board at about eight\\nsuch peripheral points, a line joining them will give, with\\nfair accuracy, the boundary of the visual field if this be\\nnot larger than 45\u00c2\u00b0 in any direction but beyond that\\nangle the object, if on a flat surface, will be much too far\\nFig. 32.\\nField of vision with radius of 12 projected up to 45\u00c2\u00b0 on to a flat\\nsurface two feet square. F, fixation spot.\\nfrom the eye to make the test accurate, see Fig. 32. A\\ntrue map, unless the field be much contracted, can be\\nmade only by means of an instrument, the perimeter, see\\nappendix for description of, which consists essentially of\\nan arc marked in degrees, and movable around a central\\npivot on which the patient fixes his gaze. Thus meas\u00c2\u00ac\\nured the field covers a somewhat oval portion of the\\nhemisphere, the smaller end being upward and inward,\\nFig. 33. From the fixation point it extends 90\u00c2\u00b0 or more\\nin the outward direction, but only about 65\u00c2\u00b0 or rather less", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0063.jp2"}, "64": {"fulltext": "56\\nMEANS OF DIAGNOSIS.\\nFig. 33.\\nField of vision of right eye as projected by the patient on the inner surface\\nof a hemisphere, the pole of which forms the object of regard (half-diagram\u00c2\u00ac\\nmatic). T, temporal; N, nasal side, w, boundary for white; b, for blue;\\nr, for red g. for green. (Landolt.)\\nFig. 34.\\nBinocular field of vision. The white part is the portion common to the two\\neyes\u00e2\u0080\u0094 i. e., possessing binocular vision the shaded (temporal) part shows the\\nportion in which binocular vision is wanting. F. Fixation point. The two\\nblind spots are marked by round spots. (Simplified, after Forster.)", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0064.jp2"}, "65": {"fulltext": "EXTERNAL EXAMINATION OF THE EYE. 57\\ninward, upward, and downward. The visual fields of the\\ntwo eyes overlap only at their inner and central parts, so\\nthat binocular vision is impossible in the outer part of the\\nfield, Fig. 34.\\n16. Color perception is best expressed by the power of dis\u00c2\u00ac\\ncriminating between various colors without naming them.\\nThe best test-objects are a series of skeins of colored wool,\\nor, for pocket use, smaller strips of colored paper, or col\u00c2\u00ac\\nored stuffs. A color-blind person will expose his defect by\\nplacing together, or confusing as similar, certain colors,\\nusually mixed tints, which to the normal eye appear quite\\ndifferent. The set of wools now in common use was intro\u00c2\u00ac\\nduced by Prof. Holmgren, of Upsala. See Appendix. Ac\u00c2\u00ac\\nquired color-blindness, from atrophy of the optic nerves,\\nmay often be detected quite well by asking the names, if\\nthe patient has been well trained in colors. But for the\\ncongenitally color-blind the confusion test,\u00e2\u0080\u009d without\\nnames, is far better; first, because such persons can often\\ndistinguish ordinary colored objects from one another by\\ndifferences of shade i. e., by differences in the quantity\\nof white light which they reflect, and hence they escape de\u00c2\u00ac\\ntection unless tested with a large series of different colors\\nin many shades, some of which shades, containing equal\\nquantities of white, will look, to them, exactly alike; and,\\nsecondly, though such persons often use the names for colors\\nfreely, the words do not convey the same meaning to them\\nas to those with normal color sense, and hopeless confusion\\nresults from an examination so made. For details, see\\nChapter XV. and Appendix.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0065.jp2"}, "66": {"fulltext": "CHAPTER III.\\nEXAMINATION OF THE EYE BY ARTIFICIAL LIGHT.\\nThis includes (1) examination by focal or oblique light;\\n(2) examination by the ophthalmoscope.\\n1. Examination by Focal or Oblique Light.\\nIn using focal, oblique, or lateral illumination the anterior\\nparts of the eye are examined with the light of a lamp\\nconcentrated by a convex lens. The method is used to\\ndetect or examine opacities of the cornea, changes in the\\nappearance of the iris, alterations in the outline and area\\nof the pupil from iritis, and opacities of the lens. Such\\nan examination is to be made by routine in every case\\nbefore using the ophthalmoscope. We require a somewhat\\ndarkened room, a convex lens of two or three inches focal\\nlength, one of the large ophthalmoscopic lenses, and a\\nbright, naked lamp-flame.\\nThe patient is seated with his face toward the light,\\nwhich is at about 2 distance. The lens, held between the\\nfinger and thumb, is used like a burning-glass, being placed\\nat about its own focal length from the patient\u00e2\u0080\u0099s cornea, and\\nin the line of the light, so as to throw a bright pencil of\\nlight on the front of the eye at an angle with the obser\u00c2\u00ac\\nver\u00e2\u0080\u0099s line of sight. Thus all the superficial media and struc\u00c2\u00ac\\ntures of the eye can be successively examined under strong\\nillumination, the distance of the lens being varied a little,\\naccording as its focus is required to fall on the cornea, the\\niris, or the anterior or posterior surface of the crystalline\\n(58)", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0066.jp2"}, "67": {"fulltext": "EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 59\\nlens, Fig. 35. By varying the position of the light and of\\nthe patient\u00e2\u0080\u0099s eye, making him look up, down, and to each\\nside, we can examine all parts of the corneal surface, of\\nthe iris, of the pupillary area\u00e2\u0080\u0094 i. e., the anterior capsule of\\nthe lens, and of the lens substance. If the light be thrown\\nat a very acute angle on the cornea or lens, opacities are\\nFig. 35.\\nFocal illumination.\\nmuch more visible than if it fall almost perpendicularly.\\nBy habitually magnifying the illuminated parts by a second\\nlens held in the other hand, much additional information\\ncan be gained.\\nFor complete exploration of all parts of the crystalline\\nlens the pupil must be dilated with atropine, but careful", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0067.jp2"}, "68": {"fulltext": "GO\\nMEANS OF DIAGNOSIS.\\nexamination without atropine will generally enable us to\\ndetect opacities lying in or near the axis of the lens even\\nif deeply seated. In examining the posterior pole of the\\nlens the light must be thrown almost perpendicularly into\\nthe pupil, and the observer must place his eye as nearly in\\nthe same direction as is possible without intercepting the\\nincident light. Opacities of the cornea and anterior layers\\nof the lens appear whitish, deep opacities in the lens, espe\u00c2\u00ac\\ncially in old people, look yellowish, by focal light. Tumors,\\nlarge opacities in the vitreous, and retinal detachments\\nmay be seen by this method if they lie close behind the\\nlens. Minute foreign bodies in the cornea will often be\\nseen by focal light when invisible, because covered by hazy\\nepithelium, in daylight.\\n2. Ophthalmoscopic Examination.\\nThe ophthalmoscope enables us to see the parts of the\\neye behind the crystalline lens, by making the observer\u00e2\u0080\u0099s\\neye virtually the source of illumination for the observed\\neye. Rays of light entering the pupil in a given direction\\nare partly reflected back by the choroid and retina, and on\\nemerging from the pupil take the same or very nearly the\\nsame course that they had on entering 12, p. 22). Hence\\nthe eye of the observer, if so placed as to receive these\\nreturning rays, must also be so placed as to cut off the\\nentering rays; as, therefore, no light can enter in the\\nnecessary direction, none can return to the observer\u00e2\u0080\u0099s eye.\\nThis is why the pupil is usually black. Although with a\\nlarge pupil, especially in a hypermetropic or myopic eye,\\nthe observer receives some of the returning rays, because\\nhe does not intercept all the entering light, and in this way\\nsees the pupil of a fiery red instead of black, still for any\\nuseful examination the observer\u00e2\u0080\u0099s eye must, as already\\nstated, be in the central path of the entering and emerg-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0068.jp2"}, "69": {"fulltext": "EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 01\\no is gained by looking through a small\\nhole in a mirror, by which light is reflected into the\\npatient\u00e2\u0080\u0099s pupil, and this perforated mirror is the ophthal\u00c2\u00ac\\nmoscope. There are two ways of seeing the deep parts of\\nthe eyeball by this means.\\n1. The indirect method of examination, by which a clear,\\nreal, inverted image of the fundus, somewhat magnified,\\nis formed in the air between the patient and the observer.\\nThe fundus of the eye seen on this principle is magnified\\nabout five diameters, if the eye be normal. The image is\\nlarger in h and smaller in m. Notice that if the obser\u00c2\u00ac\\nver\u00e2\u0080\u0099s head be moved slightly from side to side, the image\\nwill appear to move in the opposite direction.\\n2. The direct method of examination, by which, except\\nwhen the eye is myopic, a virtual erect image is seen, more\\nmagnified than in the former method and situated behind\\nthe patient\u00e2\u0080\u0099s eye.\\nThe emmetropic eye, with the accommodation fully re\u00c2\u00ac\\nlaxed, is adjusted for distant objects i. e., parallel rays, and\\nreceives a clear image of such objects on the layer of rods\\nand cones of the retina (p. 30). A clear image of the\\nfundus of the eye\u00e2\u0080\u0094i. e., the retina, optic disk, and choroid,\\ncan be obtained in such an eye on condition that the eyes,\\nboth of patient and observer, be adjusted for infinite dis\u00c2\u00ac\\ntance\u00e2\u0080\u0094 i. e., for parallel rays; in other words, that the\\naccommodation of both be relaxed. The fundus so seen\\nis magnified about 20 diameters.\\nIn order to use the ophthalmoscope 1 it is first necessary\\nto learn to manage the mirror and light. 1. Seat the\\npatient in a darkened room and place a lamp with a large,\\nsteady, naked flame on a level with his eyes, a few inches\\nfrom his head, and about in a line with his ear. The lamp\\nmay be on either side, but is usually placed on his left, and\\n1 For choice of instruments see Appendix.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0069.jp2"}, "70": {"fulltext": "G2\\nMEANS OF DIAGNOSIS.\\nit is better to keep to the same side until practice has given\\nsteadiness to the various combined movements which are\\nnecessary. 2. Sit down in front of the patient with his\\nface fronting your own, feature to feature. It is most con\u00c2\u00ac\\nvenient for the observer\u00e2\u0080\u0099s face to be a little higher than\\nthat of the patient. 3. Take the mirror of the ophthal\u00c2\u00ac\\nmoscope, without any lens behind, and without the large\\nlens, in your left hand for examining the patient\u00e2\u0080\u0099s left eye,\\nand vice versa for his right eye, hold it, mirror toward the\\npatient, close to your own eye, and with the sight-hole\\nplaced so that with your other eye closed you see the\\npatient through it. Now rotate the mirror slightly toward\\nthe lamp until the light reflected from the flame is thrown\\ninto the patient\u00e2\u0080\u0099s pupil, and open your other eye. 4. You\\nwill so far have seen nothing except the front of the\\npatient\u00e2\u0080\u0099s eye, unless atropine have been used, for he will\\nhave looked at the centre of the mirror, and his pupil,\\nstrongly contracted, will look either black or very dull\\nred. 5. Now tell him to look steadily a little to one side,\\ninto vacancy, or at an object on the other side of the room.\\nThe pupil will now become red\u00e2\u0080\u0094bright fiery red if it be\\nrather large; a duller red if it be small or the patient\u00e2\u0080\u0099s\\ncomplexion be dark. In one position, when the eye under\\nexamination looks a little inward, the red will change to a\\nyellowish or whitish color, and this indicates the position\\nof the optic disk. 6. Learn to keep the light steadily on\\nthe pupil, during slow movements backward and forward\\nand from side to side, taking care that the patient keeps\\nhis eye all the time in the same position, and does not\\nfollow the movements of the mirror; the test of steadiness\\nwill be that the pupil remains of a good red color in all\\npositions. Up to this point the examination may be made\\nwithout atropine; and so far only a uniform red glare will\\nhave been seen, no details of the fundus being visible, unless\\nthe patient be either myopic or considerably hypermetropic.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0070.jp2"}, "71": {"fulltext": "EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 03\\nOphthalmoscopic examination by the indirect method.\u00e2\u0080\u009d The thick lines r r rays from the lamp, are reflected from\\nthe mirror to, in the directions r r traverse the lens l and are focussed in front of the retina ob, on which they therefore\\nthrow a diffused light. From the fundus thus lighted, pencils of rays, shown by thin lines, are given off, which emerge\\nfrom the eye parallel and form a clear inverted image, im, at the focus of the lens l this image is viewed through the\\nsight-hole by the observer obs. The distance between obs and im is about 10 and from im to a about 5", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0071.jp2"}, "72": {"fulltext": "64\\nMEANS OF DIAGNOSIS.\\nIn order to see the details of the fundus it is best to\\nbegin by learning the indirect method,\u00e2\u0080\u009d Fig. 36, for,\\nthough rather less easy, it is more generally useful than\\nthe direct.\\nTake the mirror without any lens behind it in one hand, 1\\nand one of the large convex \u00e2\u0080\u009cobjective\u00e2\u0080\u009d lenses corre\u00c2\u00ac\\nsponding to l in the other. Always, if possible, have the\\npupil dilated with atropine, for by this means you learn to\\nsee the fundus much more quickly and easily. In exam\u00c2\u00ac\\nining the patient\u00e2\u0080\u0099s right eye, apply the mirror with your\\nright hand to your right eye, holding the lens in your left\\nhand; it is best to reverse everything for his left eye, but\\nthe position of the light need not be changed. The hand\\nwhich carries the lens should be steadied by resting the\\nlittle or ring-finger against the patient\u00e2\u0080\u0099s brow or temple.\\nWe usually begin by looking for the optic disk, which\\nis one of the most important and easily seen parts. As\\nthe disk lies to the nasal side of the posterior pole of the\\neye, the cornea must be rotated a little inward\u00e2\u0080\u0094 i. e., the\\nback of the eye outward, in order to bring the disk oppo\u00c2\u00ac\\nsite the pupil, when the observer is immediately in front;\\nthe right eye, e. g., must be directed to the observer\u00e2\u0080\u0099s right\\near, or to the uplifted little finger of his mirror hand. The\\npatient must turn his eye, not his head, in the required\\ndirection. The lens should be held about 2 -3 and the\\nobserver\u00e2\u0080\u0099s eye be about 15\u00e2\u0080\u009d, from the patient\u00e2\u0080\u0099s eye; the\\nimage of the fundus being formed in the air 2\u00e2\u0080\u009d or 3 in\\nfront of the lens will thus be situated about 10 from the\\nobserver.\\nThe bright red glare, from the choroid will be obvious\\nenough; but most beginners find some difficulty in avoid-\\n1 But many learn to see the image more quickly and easily by placing a\\nconvex lens of 4 D. behind the mirror. If the observer wears glasses for\\nreading he should wear them, or put a lens of the same strength behind the\\nmirror, for the indirect examination.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0072.jp2"}, "73": {"fulltext": "EX AMIN A TION OF EYE BY ARTIFICIAL LIGHT. 65\\ning the reflection of the light from the patient\u00e2\u0080\u0099s cornea,\\nand in adjusting the accommodation and the distance of\\nthe head, so as to see the image clearly. The head must\\nbe slowly moved a little further from or nearer to the\\npatient, and at the same time an attempt made to adjust\\nthe eyes, both being kept open, for a point between the\\nobserver and the lens. As a rule, the disk and retinal\\nvessels are seen clearly at the first sitting.\\nThe optic disk \u00e2\u0080\u0094ending of the optic nerve in the eye\\nabove the lamina cribrosa, optic papilla, Figs. 37 and 39\u00e2\u0080\u0094\\nis round, well defined, much lighter in color than the fiery\\nred of the surrounding fundus, and numerous bloodvessels\\nare seen to radiate from its centre, chiefly upward and\\ndownward. As soon as the disk can be easily seen the\\nstudent must pass on to the study of the most important\\ndetails of this part itself, and of the other parts of the\\nfundus. Some of these will be described here and others\\nin the chapters on Diseases of the Choroid and Retina, and\\non the Errors of Refraction.\\nThe disk, as a whole, is grayish-pink in color with an\\nadmixture of yellow. It is nearly circular, but seldom per\u00c2\u00ac\\nfectly so, being often apparently oval or slightly irregular.\\nTwo differently colored parts are noticeable\u00e2\u0080\u0094a central\\npatch, whiter than the rest, into which most of the blood\u00c2\u00ac\\nvessels dip; and a surrounding part of pink or grayish-\\npink. In many eyes, especially in old persons, we distin\u00c2\u00ac\\nguish a third part, a narrow boundary line of lighter color,\\nwhich represents the border of the sclerotic, sceleral ring\\nFig. 37. The bloodvessels consist of several large trunks\\nand a varying number of small twigs; the large trunks\\nemerge from the central white part of the disk, and often\\nbifurcate once or twice on its area; the small twigs may\\nemerge separately from various parts of the disk, or form\\nbranches of the large trunks.\\nVariations. The color of the disk appears paler or\\n5", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0073.jp2"}, "74": {"fulltext": "66\\nMEANS OF DIAGNOSIS.\\ndarker according to the color of the surrounding choroid,\\nthe brightness of the light used, and the patient\u00e2\u0080\u0099s age and\\nstate of health. A curved line of dark pigment often\\nbounds a part of the circumference of the disk, Fig. 39,\\nand has no pathological meaning. The central white patch\\nvaries greatly in size, position, and distinctness; it may be\\nso small as hardly to be perceptible, or very large; may\\nshade off gradually or be abruptly defined may be central\\nor eccentric; when large it generally shows a grayish stip\u00c2\u00ac\\npling or mottling, Fig. 39. This central white patch repre\u00c2\u00ac\\nsents a hollow, the physiological cup or pit, compare Figs.\\n39 and 40, left by the nerve-fibres as they radiate out from\\nFig. 37.\\nOphthalmoscopic appearances of healthy fundus in a person of very fair\\ncomplexion. Scleral ring well marked. Left eye, inverted image. (Wecker\\nand Jaeger.)\\nthe centres of the disk toward the retina, like the tentacles\\nof an open sea-anemone; and through it the chief blood\u00c2\u00ac\\nvessels pass on their way between the nerve and the retina.\\nThis depression is generally shaped like a funnel or a dimple,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0074.jp2"}, "75": {"fulltext": "EXAMINATION OF EYE BY ARTIFICIAL LIGHT. G7\\nwith gradually sloping sides, Fig. 40; but sometimes the\\nsides are steep, or even overhanging; in other eyes it is\\nwide, shallowed and enlarged toward the outer side of the\\ndisks. The physiological pit is whiter than the rest of the\\ndisk, because the grayish-pink nerve-fibres are absent at\\nthis part, and we can therefore see down to the opaque,\\nwhite, fibrous tissue which, under the name of lamina cri-\\nbrosa forms the floor of the whole disk, Fig. 39. The\\nstippled appearance often noticed in the pit is caused by the\\nholes in this lamina, through which the bundles of nerve-\\nfibres pass on their way to the retina; the holes appear\\ndarker because filled by non-medullated nerve-fibres, which\\nreflect but little light.\\nThe other parts of the fundus. The groundwork is of a\\nbright fiery red\u00e2\u0080\u0094the choroid, not the retina; in many eyes\\nthis color is nearly uniform, but in persons of very light\\nor very dark complexion we see a pattern of closely set,\\ntortuous, red bands (vessels of the choroid), separated by\\nspaces either darker or of lighter color, Fig. 37. For\\ndetails see Chapter XII.\\nUpon this red ground the vessels of the retina divide\\nand subdivide dichotomously. It will be noticed that the\\nchief trunks pass almost vertically upward and downward,\\nand that no large branches go to the part apparently inward\\nfrom the disk\u00e2\u0080\u0094-to the left in the figure; that the visible\\nretinal vessels are comparatively few and are widely spread\\nthat they become progressively smaller as they recede from\\nthe optic disk; and that they never anastomose with each\\nother. Special attention must be given to the part, appar\u00c2\u00ac\\nently to the inner, nasal, side of the optic disk, really to\\nits outer, temporal side\u00e2\u0080\u0094which is the region of most accu\u00c2\u00ac\\nrate vision, the yellow spot, y. s., macula lutea, or shortly,\\nmacula.\u00e2\u0080\u009d In this region, which comes into view when the\\npatient looks straight at the ophthalmoscope, the choroidal\\nred is duller and darker than elsewhere. It is skirted by", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0075.jp2"}, "76": {"fulltext": "68\\nMEANS OF DIAGNOSIS.\\nlarge retinal vessels which give off numerous twigs toward\\nits centre, though none of them can be seen quite to reach\\nthat point; compare Fig. 88, Chapter XIII. In many\\neyes nothing but these indefinite characters mark the\\ny. s.; but in some, especially in dark eyes and young\\npatients, a minute bright dot occupies its centre, and is\\nencircled by an ill-bounded dark area, around which again\\na peculiar, shifting, white halo is seen. The minute dot is\\nthe fovea centralis the thinnest part of the retina. The\\nneighborhood of the disk and y. s. forms the central region\\nof the fundus. The peripheral parts are explored by tell\u00c2\u00ac\\ning the patient to look successively up, down, and to each\\nside, without moving his head. To see the extreme periph\u00c2\u00ac\\nery the observer must move his head as well as the patient\\nhis eye. Toward the periphery the choroidal trunk-vessels\\nare often plainly visible even when none are distinguishable\\nat the more central parts.\\nThe vessels of the retina are easily distinguished from\\nthose of the choroid by their course and mode of branch\u00c2\u00ac\\ning; by the small size of all except the main trunks; by\\ntheir sharper outline and clearer tint; but especially by\\nthe presence of a light streak along the centre of each,\\nFig. 37, which gives them an appearance of roundness,\\nvery different from the flat, band-like look of the cho\u00c2\u00ac\\nroidal vessels. They are divisible into two sets a darker,\\nlarger, somewhat tortuous set\u00e2\u0080\u0094the veins; and a lighter,\\nbrighter red, smaller, and usually straighter set\u00e2\u0080\u0094the arte\u00c2\u00ac\\nries the diameter of corresponding branches being about\\nas 3 to 2. The arteries and veins run pretty accurately\\nin pairs. Pressure on the eyeball, through the upper lids,\\ncauses visible pulsation of the arteries on the disk.\\nThe indirect method of examination is most generally\\nuseful, because it gives a large field of view under a low\\nmagnifying power, about five diameters, and thus allows\\nus to appreciate the general character and distribution of", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0076.jp2"}, "77": {"fulltext": "EXAMINATION OF EYE BY ARTIFICIAL LIGHT. G9\\nany morbid changes better than if we begin with the direct\\nmethod, in which the field of view is smaller and the maor-\\nnifying power much greater. It has also the great advan\u00c2\u00ac\\ntage of being equally applicable in all states of refraction,\\nwhereas if the patient be myopic his fundus cannot be\\nexamined by the direct method without the aid of a suit\u00c2\u00ac\\nable concave lens, found experimentally, placed behind the\\nmirror (p. 72). The inversion of the image seen by the\\nindirect method is such that what appears to be upper is\\nlower, and what appears to be R. is L.\\nIn the \u00e2\u0080\u009cdirect method\u00e2\u0080\u009d the examination is made by\\nthe mirror alone, or with a lens behind it, but without the\\nintervention of the objective lens.\\nBy this method the parts, unless the eye be myopic, are\\nseen in their true position, Fig. 38, the upper part of the\\nimage corresponding to the upper part of the fundus, the\\nright to the right, etc.: it is, therefore, often called the\\nmethod of the erect\u00e2\u0080\u009d or upright\u00e2\u0080\u009d image; though, as\\nwill be seen below, these terms are not strictly convertible\\nwith \u00e2\u0080\u009cdirect examination.\u00e2\u0080\u009d It is used: (1) To test the\\naction of the pupils in direct fixation (2) to detect opaci\u00c2\u00ac\\nties in the media, or detachment of the retina (3) to deter\u00c2\u00ac\\nmine the fixation power by observing the corneal reflex;\\n(4) to ascertain the condition of the patient\u00e2\u0080\u0099s refraction\u00e2\u0080\u0094\\ni. e.y the relation of his retina to the focus of his lens-\\nsystem (5) for the minute examination of the fundus by\\nthe highly magnified, virtual, erect image (Fig. 39).\\n1. The patient should be directed to look at the sight-hole\\nof the mirror, and the light should be turned alternately\\non and off the eye; the change in shape and size of the\\npupil will then be seen as the light falls on the yellow spot.\\n2. To examine the media, the patient should move his eyes\\nfreely in different directions while the light is thrown into\\nthe pupil from a distance of about twelve inches. Detach\u00c2\u00ac\\nments of the retina may be seen, as well as opacities in the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0077.jp2"}, "78": {"fulltext": "Fig. 38.\\n70\\nMEANS OF DIAGNOSIS.\\neye divergent would be focussed behind the retina as at/, and hence illuminate the fundus diffusely. The returning\\npencils (thin lines) are parallel or divergent, according as the eye is E. or EL, on leaving the eye, and appear to pro\u00c2\u00ac\\nceed from a highly magnified erect image im\\\\ behind the eye. It is seen that only those lamp-rays which strike close\\nto the sight-hole are available if the hole be too large no rays will enter the pupil, and the fundus will not be illumi\u00c2\u00ac\\nnated.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0078.jp2"}, "79": {"fulltext": "EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 71\\ncornea, lens, and vitreous. These latter will appear black\\nagainst the red background of the eye. For more careful\\nexamination of fine opacities, a strong convex lens is placed\\nbehind the mirror, and the observer draws nearer to the\\npatient.\\n3. This method, attention to which was called by\\nPriestley Smith, is practised in the following way: The\\npatient is told to look at the mirror; the observer turns\\nthe light on one of the patient\u00e2\u0080\u0099s eyes, and notices the\\nexact position of the light reflex from the surface of the\\ncornea; he then quickly turns the light to the other eye,\\nand compares the position of the corneal light reflex in\\nthe two eyes. The corneal reflex generally stands a little\\nnearer the inner than the outer edge of the pupil, as the\\nvisual axis usually lies to the inner side of the axis of the\\ncornea; if both eyes be properly directed, the position of\\nthe corneal reflex will be symmetrical in the two eyes. I 11\\nthis way imperfect fixation or strabismus will be readily\\ndetected.\\n4. To ascertain the refraction If, when using the mirror\\nalone at a distance of 12 -18 or more, from the patient\u00e2\u0080\u0099s\\neye, we see some of the retinal vessels clearly and easily,\\nthe eye is either myopic or hypermetropic. If, when the\\nobserver\u00e2\u0080\u0099s head is moved slightly from side to side, the\\nvessels seem to move in the same direction, the image seen\\nis a virtual one and the eye hypermetropic. The eye is\\nmyopic if the vessels seem to move in the contrary direc\u00c2\u00ac\\ntion the image in M. is, indeed, formed and seen in the\\nsame way as the inverted image seen by the \u00e2\u0080\u009cindirect\u00e2\u0080\u009d\\nmethod of examination (compare Figs. 36 and 117), but\\nexcept in the highest degrees of M. it is too large and too\\nfar from the patient to be useful for detailed examination.\\nIn low degrees of M. this image is formed so far in front\\nof the patient\u00e2\u0080\u0099s eye as to be visible only when the observer\\nis distant perhaps 3 r or 4 while in E. and in the lower", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0079.jp2"}, "80": {"fulltext": "72\\nMEANS OF DIAGNOSIS.\\ndegrees of H. the (erect) image will not be easily seen at\\na greater distance than 12 or 18 (Fig. 14). If, there\u00c2\u00ac\\nfore, in order to get a clear image by the direct method,\\nthe observer has to go either very near to, or a long way\\nfrom, the patient, no great error of refraction can be\\npresent.\\nThe above tests only reveal qualitatively the presence of\\neither M. or H., but by a modification of the method the\\nquantity of any error of refraction\u00e2\u0080\u0094 e. g., H., can be de\u00c2\u00ac\\ntermined with great accuracy. Determination of the refrac\u00c2\u00ac\\ntion by the ophthalmoscope. In E. the erect image can be\\nseen only if the observer be near to the patient, and also\\ncompletely relax his accommodation; for when the ob\u00c2\u00ac\\nserver\u00e2\u0080\u0099s head is withdrawn from the patient\u00e2\u0080\u0099s eye the field\\nof view of illumination rapidly diminish, hence in E. no\\nuseful view can be gained by the direct method without\\ngoing very near to the eye.\\nIn H., where the retina is within the focus of the lens-\\nsystem, the erect image is seen when close to the patient\u00e2\u0080\u0099s\\neye only by an effort of accommodation in the observer,\\nbut it can also be seen at a distance as well as close to the\\npatient.\\nIf now the observer, instead of increasing the convexity\\nof his crystalline, place a convex lens of equivalent power\\nbehind his ophthalmoscope mirror, this lens will be a\\nmeasure of the patient\u00e2\u0080\u0099s H.\u00e2\u0080\u0094 i. e., it will be the lens\\nwhich, when the patient\u00e2\u0080\u0099s accommodation is in abeyance,\\nwill be needed to bring parallel rays to a focus on his\\nretina. If a higher lens be used, the fundus will be more\\nor less blurred.\\nHence to measure H.: (1) Acc. both in patient and\\nobserver must be fully relaxed, usually by atropine in the\\npatient and by voluntary effort in the observer; (2) the\\nobserver must go as close as possible to the patient; (3) he\\nmust then place convex lenses behind his mirror, begin-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0080.jp2"}, "81": {"fulltext": "EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 73\\nning at the weakest and increasing the strength, till the\\nhighest is reached which still permits the details of the\\no. d., or, better, of the y. s., to be seen with perfect clear\u00c2\u00ac\\nness. By practice the distance between the cornete of\\npatient and observer may be reduced to about 1 The\\nlight must be on the same side as the eye under examina\u00c2\u00ac\\ntion. The right eye must examine the right, and vice versa.\\nIn the same way, though with less accuracy in the high\\ndegrees, M. can be measured by means of concave lenses;\\nthe lowest lens with which a clear, erect image is obtained\\nbeing slightly more than the measure of the M.\\nIt is sometimes useful to know how much lengthening or\\nshortening of the eye corresponds to a given neutralizing lens.\\nThe following numbers, slightly altered from Knapp, are suffi\u00c2\u00ac\\nciently near the truth. The distance between the eye of the\\nobserver and that of the patient is supposed to he not more\\nthan 1 inch.\\nH.\\nof 1\\nD. represents shortening\\nof 0.3\\nmm\\nu\\n2\\na\\nfi\\n0.5\\nu\\n\u00c2\u00abc\\n3\\ncc\\n1.0\\nu\\n5\\nIt\\ncc\\n1.5\\nu\\n6\\na\\ncc\\n2.0\\ncc\\na\\n9\\ntc\\nic\\n3.0\\na\\ncc\\n12\\ncc\\nil\\n4.0\\n11\\nit\\n18\\nIt\\ncc\\nG.O\\ncc\\nM.\\nof 1\\nD. represents leng\\nthening of 0.3\\nmm,\\n(i\\n2\\nic\\ncc\\n0.5\\ncc\\n3\\nll\\ncc\\n0.9\\ncc\\nti\\n5\\ncc\\n1.3\\ncc\\n(i\\n6\\na\\ncc\\n1.75\\nu\\n9\\ncc\\nll\\n2.6\\ncc\\nt\\n12\\nti\\ntl\\n3.5\\nu\\n18\\nll\\ncc\\n5.0\\ncc\\nAstigmatism (As.) may also be measured by this method,\\nthe refraction being estimated successively in the two chief\\nmeridians by means of appropriate retinal vessels. See", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0081.jp2"}, "82": {"fulltext": "74\\nMEANS OF DIAGNOSIS.\\nAstigmatism. Any line\u00e2\u0080\u0094 e. g., a horizontally running\\nvessel\u00e2\u0080\u0094is seen by means of rays which pass through the\\nmeridian of the cornea at a right angle to its course;\\nhence if a vertical vessel be clearly seen through a -f 2D.\\nlens there is H. 2 D. in the horizontal meridian, etc.\\nThis application of the direct method needs much prac\u00c2\u00ac\\ntice. The lenses, of which there are twenty or more, are\\nso placed that they can be revolved behind the mirror\\nand brought in succession opposite the sight-hole. There\\nare many forms of these \u00e2\u0080\u009crefraction ophthalmoscopes,\u00e2\u0080\u009d\\nvarying in the details of their construction. See Appendix.\\nFig. 39.\\nOphthalmoscopic appearance of healthy disk, as seen in the erect image.\\nDark vessels, veins. Physiological pit stippled. X 15 diameters. (After\\nJaeger.)\\n5. The erect image is very valuable, on account of the\\nhigh magnifying power, about 20 diameters in the E. eye,\\nfor the examination of the finer details of the fundus. The\\ndisk looks less sharply defined, because more magnified,\\nthan when seen by the indirect method both the disk and\\nthe retina often show a faint radiating striation, the nerve-\\nfibres; the lamina eribrosa is often more brilliantly white;\\nand the pigment epithelium of the choroid can be recog\u00c2\u00ac\\nnized as a fine, uniform dark stippling.\\nIf the refraction be E. or H. no lens is needed behind", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0082.jp2"}, "83": {"fulltext": "EXAMINATION OF EYE BY ARTIFICIAL LIGHT.\\nthe mirror; if M., a concave lens must be placed behind\\nthe mirror, of sufficient strength to give a good, clear,\\nerect image. The observer must come as near as possible\\nto the patient.\\nBy reference to Fig. 38 it will be seen that only those\\nrays are useful which strike near the centre of the mirror,\\nnone others entering the patient\u00e2\u0080\u0099s pupil; hence, if the\\naperture in the mirror be too large the fundus will not\\nbe well lighted. It should not be larger than 3 mm. nor\\nsmaller than 2 mm.\\nThe Shadow Test (Retinoscopy, Skiascopy).\\nBy this method the refraction is determined by noticing\\nthe direction of movement of the light thrown on to the\\nFig. 40.\\nVertical section of healthy optic disk, etc. X about 15. R. Retina, outer\\nlayers shaded vertically, nerve-fibre layer shaded longitudinally. Ch. Cho\u00c2\u00ac\\nroid. Scl. Sclerotic. L. Cr. Lamina cribrosa. S. V. Subvaginal space be\u00c2\u00ac\\ntween outer and inner sheath of optic nerve. The central vein and one of\\nthe divisions of the central artery are seen in the nerve and disk.\\nretina by the mirror, when the latter is rotated. The\\ndegree of error of refraction is measured by the lens,\\nwhich, placed close to the patient\u00e2\u0080\u0099s eye in a case of", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0083.jp2"}, "84": {"fulltext": "76\\nMEANS OF DIAGNOSIS.\\nametropia, renders the movement and other characters\\nof the illumination the same as in emmetropia.\\nThe test is most accurate when used at a great distance\\nfrom the patient; in practice a distance of about 1 m.\\n(100-120 cm., or 3 -4 is chosen. The observer, seated\\nin front of his patient, throws the light from an ophthal\u00c2\u00ac\\nmoscope mirror into the patient\u00e2\u0080\u0099s pupil. He will then\\nsee the area of the pupil illuminated, and on slightly\\nrotating the mirror will notice a movement in this lighted\\narea, which movement will have a direction either the\\nsame as, or opposite to, that in which the mirror is turned,\\n\u00e2\u0080\u009cwith\u00e2\u0080\u009d or \u00e2\u0080\u009cagainst\u00e2\u0080\u009d the mirror. The lighted area is\\nbordered by a dark shadow, and it is to the edge of this\\nshadow that attention must be directed. This edge is par\u00c2\u00ac\\nallel to the axis on which the mirror is turned, but moves\\nin, and shows the refraction of, the meridian at right angles\\nto it\u00e2\u0080\u0094 e. g., the shadow whose edge passes vertically across\\nthe pupil moves across the horizontal meridian, the refrac\u00c2\u00ac\\ntion of which it indicates, and vice versa. Itetinoscopy may\\nbe practised with a concave or a plane mirror. With the\\nformer the shadow moves against the mirror in E., H.,\\nand low M., and with the mirror in M. of more than 1 D.\\nWith the latter these movements are exactly reversed.\\nThe light should be thrown as nearly as possible in the\\ndirection of the visual axis, and the lamp be placed imme\u00c2\u00ac\\ndiately over the patient\u00e2\u0080\u0099s head rather than to one side.\\n1. With a concave mirror, of about 22 cm. focus, Fig.\\n41. In Fig. 41, 1, the mirror, m, forms an inverted image,\\ni, of the light, l, at its principal focus, and i becomes the\\nsource of light for the eye, e. A second image of i, again\\ninverted, is formed at T on the retina of e. If the far\\npoint of e be at i this retinal image, T, will be clear and\\ndistinct, but in every other case it will be more or less\\nout of focus and indistinct. On rotating m to m i\\nwill move to r and i to i and these movements (of i", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0084.jp2"}, "85": {"fulltext": "EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 77\\nFig. 41.\\nRetinoscopy (with concave mirror).", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0085.jp2"}, "86": {"fulltext": "78\\nMEANS OF DIAGNOSIS.\\nand i will occur, no matter what the refraction of e\\nmay be.\\nThe observer placed behind m sees an image of i formed\\nin the same way as the image of the fundus seen by the\\ndirect method, and therefore either inverted and real, or\\nerect and virtual, according as the refraction of the eye\\nis M. or H. (p. 72). If the observer\u00e2\u0080\u0099s eye be accurately\\nadapted for this image of T, he will indeed see not only\\nthe light and shadow, but the retinal vessels; he neglects\\nthese, however, in attending to the movements of the\\nshadow.\\nIn the following description, l, t, and i 2 are disregarded.\\nT or i 2 being considered as the source of light.\\nIf e be myopic Fig. 41, 2, the image of T is real and\\ninverted and formed at i the far point of e (compare\\nFig. 117). On rotating the mirror, as in Fig. 41, 1, 7\\nwill move to T 2 and i will move to r /2 i. e., the image\\nseen by the observer moves in the same direction as (o)\\nwith the mirror.\\nIf e be hypermetropic Fig. 41, 3, or emmetropic, ray#\\nreflected from its retina leave the eye divergent or par\u00c2\u00ac\\nallel, and are not brought to a focus after emerging; the\\nobserver therefore sees a virtual image erect at i the vir\u00c2\u00ac\\ntual focus of i compare Fig. 13, and sees its movements\\nactually as they occur- -i. e., in the same direction as the\\nmovements of the real image T or i 2 and therefore\\n\u00e2\u0080\u009cagainst\u00e2\u0080\u009d the movements of the mirror. Hence in H.\\nand Em. the shadow moves against the mirror.\\nThe above statement for myopia is true only if the\\nobserver be beyond the far point of the observed eye.\\nSee Myopia. In M. of 1 D. the rays returning from the\\npatient\u00e2\u0080\u0099s eye are focussed at a distance of 1 m., and if the\\nobserver intercept these rays before they meet (Fig. 41, 4)\\nhe will refer them toward i and i 2 and obtain an erect,\\nvirtual but unfocussed image of i the movements of which", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0086.jp2"}, "87": {"fulltext": "EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 79\\nwill be the same as those in H. or E., Fig. 41, 3\u00e2\u0080\u0094 i. e.,\\nagainst the mirror. Hence, at a distance of about 1 m.,\\nmovement against the mirror may indicate M. of about\\n1 D., or E. or H. The lowest M. which can give the char\u00c2\u00ac\\nacteristic movement at this distance is slightly more than\\n1 D., say 1.25 D.\\n2. With a plane mirror, Fig. 42. Here the source of\\nlight for the observed eye is an erect and virtual image of\\nthe flame formed at the same distance behind the mirror\\nas the lamp is in front of it. In Fig. 42, 1, this image is\\nat l, the virtual focus of l. A second and inverted image\\nof l is formed on the retina of e at 1 The movements of\\nthese images, on rotation of the mirror, are the reverse of\\nthose of the image 1 (and its retinal image 1 Fig. 41, 1,\\nobtained when the concave mirror is used. When the\\nmirror m is rotated to m l will move in the opposite\\ndirection to l but its retinal image 1 will move to T\u00e2\u0080\u0094 i. e\\nin the same direction as, or with the mirror. These move\u00c2\u00ac\\nments of l and 1 occur in every eye, whatever its refrac\u00c2\u00ac\\ntion. In E. and H., however, the movement of the retinal\\nimaore is seen as it occurs, and therefore with the mirror;\\nbut in M., Fig. 42, 2, the observer sees an inverted image of\\n1 formed at the far point of e, and its movements are exactly\\nthe reverse of those of the retinal image. Therefore, when\\non rotating m to m i moves to i 2 the image T seen by the\\nobserver moves to i 2 i. e., against the mirror. If the plane\\nmirror be used at a distance of rather more than 1 m. (3 -4\\nfrom the patient, a movement of the shadow with the\\nmirror will occur in M. of 1 D. or less, for the reasons given\\npreviously, Fig. 41, 4; but if the observer be about 2 m.\\n(say 7 away the characteristic movement against the mir\u00c2\u00ac\\nror will be obtained unless the M. be less than 0.5 D.;\\nsince the far point of an eye with M. 0.5 D., and there\u00c2\u00ac\\nfore the image seen, is at 2 m. As a plane mirror gives\\nat a long distance a better illumination than a concave one,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0087.jp2"}, "88": {"fulltext": "Fig. 42.\\n80\\nMEANS OF DIAGNOSIS\\nRetinoscopy (with plane mirror", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0088.jp2"}, "89": {"fulltext": "EX A MIN A TION OF EYE BY ARTIFICIAL LIGHT, gj\\nit can, if necessary, be used at a greater distance from the\\npatient, and by this means low degrees of ametropia be very\\naccurately measured. Generally, however, the distance\\ngiven (3 -4 will be found most convenient.\\nIn employing retinoscopy the patient is armed with a\\ntrial frame into which lenses are successively put until\\none is reached which just reverses the movement of the\\nshadow. This lens indicates nearly, but not quite, the\\nrefraction of the eye under observation. In H. we must\\nsubtract (about) 1 D. from the lowest -f- lens which re\u00c2\u00ac\\nverses the shadow, because we know that this movement\\nwould not occur till a myopia of at least 1 D. had been\\nproduced. In M., for the same reason, 1 D. must be added\\nto the lowest lens which reverses the shadow.\\nAstigmatism is easily detected, and Its amount measured\\nby observing, on rotating the mirror, first from side to side,\\nthen from above downward, whether the shadow has the\\nsame movement and characters in each direction; or by\\nnoting that when the shadow in one meridian is \u00e2\u0080\u009ccorrected\\nby a lens, the meridian at right angles to it still shows de\u00c2\u00ac\\ncided ametropia. The lens is then found which corrects\\nthe latter meridian, and the As. equals the difference\\nbetween the two lenses.\\nApart from the direction in which the image (and shadow)\\nmoves, something maybe learned from variations in (1) its\\nbrightness (2) its rate of movement; (3) the form, straight\\nor crescentic, of its border. The image is brightest, its\\nmovement quickest and most extensive, in very low M.\\nand in Em. The higher the ametropia, whether M. or\\nH., the duller is the illumination, the slower and less\\nextensive its movement, and the more crescentic and ill-\\ndefined its shadow border. The brightness of the image\\ndepends on how clearly i, Fig. 41, 1, is focussed on the\\nretina the more accurately T is an image of i, the brighter\\nand larger will i Fig. 41, 2 or 3, be; and as the flame is\\n6", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0089.jp2"}, "90": {"fulltext": "82\\nMEANS OF 1)1 A GNOSIS.\\nrectangular, the borders of the image will be nearly straight.\\nThese conditions occur when the eye is exactly adapted\\nfor the distance of i\u00e2\u0080\u0094 l. e., in M. of 1 D. or less. If the\\nM. be higher than 1 D.,i will be out of focus, and there\u00c2\u00ac\\nfore be spread over a larger retinal area, and being formed\\nby the same number of rays as before, it will be less bright.\\nThe image i Fig. 41, 2, will be correspondingly diffused\\nand dull, and being formed nearer to the patient\u00e2\u0080\u0099s eye, as\\nfor example at x, it will move only from x to x in the\\nsame time as i takes in moving to i 2 and hence its move\u00c2\u00ac\\nment is slower and less extensive. The same is true in H.,\\nFig, 41, 3, because the higher the H., the more diffused is\\ni and the nearer is i to the patient\u00e2\u0080\u0099s eye. In both cases,\\nhigh M. and high H., the border of the shadow is cres\u00c2\u00ac\\ncentic because the diffused image forms a nearly round\\narea on the retina.\\nSome American retinoscopists are accustomed to perform\\nthe shadow test with the light close to the eye of the ex\u00c2\u00ac\\naminer, while the patient is seated precisely 1 m. distant.\\nA small plane mirror is employed, and the light is obtained\\nthrough an aperture in a cover chimney, which should not\\nbe more than 1 cm. in diameter. It is claimed for this\\nmethod that a much more brilliant and smaller reflection\\nis obtained than when the light is placed behind the patient,\\nand that more accurate results are rendered possible.\\nRetinoscopy is a valuable means of objectively determin\u00c2\u00ac\\ning the quantity of any error of refraction, and as it is\\nmore easily learned, and on the whole more accurate in its\\nresults, than estimation by the direct method, it has, in the\\nhands of many, almost displaced the latter method during\\nthe last four or five years as a preliminary to testing the\\npatient with trial lenses. For the quick discovery of very\\nslight astigmatism, and of the direction of the chief meri\u00c2\u00ac\\ndians in astigmatism of all degrees, retinoscopy probably\\nexcels all other methods.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0090.jp2"}, "91": {"fulltext": "EXAMINATION OF EYE BY ARTIFICIAL LIGHT. 83\\nRetinoscopy, however, carries with it none of the col\u00c2\u00ac\\nlateral advantages afforded by a thorough training in the\\nmore difficult \u00e2\u0080\u009cdirect method for in retinoscopy we see\\nnothing and think nothing of the condition of the fundus\\nof the eye. Accurate retinoscopy is not quicker than\\nmeasurement by this direct method; indeed, with a good\\ninstrument the latter method certainly has the advantage\\nin rapidity.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0091.jp2"}, "92": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0092.jp2"}, "93": {"fulltext": "PART II.\\nCLINICAL DIVISION.\\nCHAPTER IV.\\nDISEASES OF THE EYELIDS.\\nThe border of the lid, which contains the Meibomian\\nglands, the follicles of the eyelashes, and certain modified\\nsweat-glands and sebaceous glands, is often the seat of\\ntroublesome disease. Being half skin and half mucous\\nmembrane, it is moist and more susceptible than the skin\\nitself to irritation by external causes; being a free border,\\nits circulation is terminal, and therefore especially liable\\nto stagnation. Its numerous and deeply-reaching glandu\u00c2\u00ac\\nlar structures, therefore, furnish an apt seat for chronic\\ninflammatory changes.\\nBlepharitis (ophthalmia tarsi, tinea tarsi, sycosis tarsi)\\nincludes all cases in which the border of the eyelid is the\\nseat of subacute or chronic inflammation. There are sev\u00c2\u00ac\\neral types. The skin is not much altered, but chronic thick\u00c2\u00ac\\nening of the conjunctiva near the border of the lid is gen\u00c2\u00ac\\nerally observed. The disease may affect both lids or only\\none, and the whole length or only a part.\\nIn the commonest and worst form the glands and eye\u00c2\u00ac\\nlash-follicles are the principal seats of the disease. The\\nsymptoms are, firm thickening and dusky congestion of\\nthe border region, with exudation of sticky secretion from\\n(85)", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0093.jp2"}, "94": {"fulltext": "86\\nCLINICAL DIVISION.\\nits edge, gluing the lashes together into little pencils. Very\\nmild cases present merely overgrowth of lashes and excess\\nof Meibomian secretion. But generally the disease pro\u00c2\u00ac\\ngresses little excoriations, and ulcers covered by scab,\\nform along the free border, and often minute pustules\\nappear; the thickening and vascularity increase; the\\nlashes are loosened, and free bleeding occurs if they are\\npulled out. After months or years of varying activity\\nsome or all of the hair-follicles become altered in size and\\ndirection, or quite obliterated, and the lashes stunted, mis\u00c2\u00ac\\nplaced, or entirely lost. As the thickening gradually dis\u00c2\u00ac\\nappears, little lines, or thin seams, of scar form just within\\nthe edge of the lid, and often cause slight eversion. The\\nresulting exposure of the marginal conjunctiva, added to\\nthe scantiness of the cilia, causes the disagreeably raw and\\nbald appearance termed lippitudo; and epiphora, from\\neversion, tumefaction, or narrowing of the puncta, often\\nresults. Often, however, the disease leads to nothing\\nworse than the permanent loss of a certain number of the\\nlashes.\\nIn another type the changes are quite superficial\u00e2\u0080\u0094mar\u00c2\u00ac\\nginal eczema the patient is liable, perhaps through life, to\\nsoreness and redness of the borders of the lids, and little\\ncrusts, scales, or pustules form at the roots of the lashes,\\nthe growth of the lashes not being much interfered with.\\nIn such people the eyes look weak or tender; the condi\u00c2\u00ac\\ntion is made worse by exposure to heat, dust, and wind,\\nand by long spells of work. See Chronic Lacrhymal Con\u00c2\u00ac\\njunctivitis, p. 121.\\nOphthalmia tarsi generally begins in childhood, and an\\nattack of measles is a common exciting cause. It seldom\\nbecomes severe or persistent except from neglect of clean\u00c2\u00ac\\nliness in a child with sluggish circulation the patients are\\ngenerally anaemic, often scrofulous, and the condition is\\nthen often the result of a previous more acute ophthalmia.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0094.jp2"}, "95": {"fulltext": "DISEASES OF TIIE EYELIDS.\\n87\\nIn adults severe sycosis of the eyelids may accompany\\nsycosis of the beard, but, as a rule, no tendency to such\\ndisease of the skin is observed.\\nTreatment.\u00e2\u0080\u0094 When the inflammatory symptoms are\\nsevere nothing has such a marked effect as pulling out all\\nthe lashes. Cases of a few weeks\u00e2\u0080\u0099 standing may be cured\\nand recurrences in older cases very much relieved by one or\\ntwo such epilations, together with local remedies. Local\\napplications are always needed (1) for the removal of the\\nscabs (2) to subdue the inflammatory symptoms. A warm\\nalkaline and tar lotion, with which the lids are to be care\u00c2\u00ac\\nfully soaked for a quarter of an hour night and morning,\\nfollowed by a weak mercurial ointment applied along the\\nedges of the lids after each bathing, is an efficient plan if\\nthe mother will take pains. In bad cases painting, or pen\u00c2\u00ac\\ncilling, the border of the lid with nitrate of silver, either in\\nstrong solution, or the diluted stick, or the use of weak\\ncopper drops, is very useful in addition to the ointment.\\nIn old cases with much epiphora the canaliculus is to be\\nslit up. The patients generally need a long course of iron.\\n(F. 1, 2, 3, 6, 18, 19, 20, 28, 29.)\\nA stye is the result of suppurative inflammation of the\\nconnective tissue, or of one of the glands, in the margin\\nof the lid. Owing to the close texture of the tarsus and\\nthe vascularity of the parts, the pain and swelling are\\noften severe, and even alarming to the patient. The\\nmatter generally points around an eyelash but if seated\\nin a Meibomian gland, it may point either to the border\\nof the lid or to the conjunctiva, rarely to the skin.\\nStyes almost always show some derangement of health,\\nespecially of the stomach or reproductive organs. Over\u00c2\u00ac\\nuse of the eyes, especially if ametropic, is the exciting\\ncause in some cases; exposure to cold wind in others.\\nStyes are very apt to recur, singly or in crops, for several\\nweeks or months.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0095.jp2"}, "96": {"fulltext": "88\\nCLINICAL DIVISION.\\nTreatment. \u00e2\u0080\u0094A stye may sometimes be cut short, if\\nseen quite early, by the vigorous use of an antiphlogistic\\nlotion; but an incision followed by hot fomentations or\\na poultice is usually more efficacious; the puncture must\\nbe made parallel to the free border, and extend rather\\ndeeply; a Beer\u00e2\u0080\u0099s knife or broad needle, Figs. 176 and\\n161, may be used. The health always needs attending\\nto, and a purgative iron mixture often suits better than\\nanything else.\\nSome persons are subject to very small pustules or styes,\\nmuch more superficial than the above, and less closely\\nassociated with derangement of health.\\nA Meibomian gland is often the scene of chronic over\u00c2\u00ac\\ngrowth, a little tumor in the substance of the lid being the\\nFig. 43.\\nChalazion. (Dalrymple.)\\nresult\u00e2\u0080\u0094Meibomian cyst, chalazion. In a few weeks or\\nmonths the growth becomes as large as a pea, forming a\\nfirm, hemispherical, painless swelling, over which the\\nskin is freely movable. A dusky spot where the tarsal\\ntissues are thinned marks the conjunctival aspect, and\\nwhen spontaneous rupture has occurred, a flattened mass", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0096.jp2"}, "97": {"fulltext": "DISEASES OE THE EYELIDS.\\n89\\nof granulation is found there. The deeper part of the\\ngland is the common seat of disease; if, as sometimes\\nhappens, the part near the edge of the lid is affected, the\\ntumor usually remains very small. Occasionally the\\ngrowth pushes forward, and adhesion to the skin occurs;\\neven then it is easily distinguished from a sebaceous cyst\\nby the firmness of its deep attachment. During its course\\nthe cyst may inflame and even suppurate, and in the latter\\ncase it forms one variety of stye.\u00e2\u0080\u009d The same tumor may\\ninflame several times, and finally suppurate and shrink.\\nLike styes, these tumors are apt to continue forming one\\nafter another. They are much commoner in young adults\\nthan earlier or later in life, but they are now and then seen\\nin infants. Patients as often apply for the disfigurement\\nas for any discomfort which these little growths occasion.\\nTreatment.\u00e2\u0080\u0094 The cyst is to be removed from the inner\\nsurface of the lid but if it points forward, the incision\\nmay be in the skin. The tumor generally consists of a\\nsoft, pinkish, gelatinous mass, or of a gruelly or puriform\\nfluid, without a cyst wall. Sometimes the contents are\\nvery firm and adherent. See Operations.\\nSmall yellow dots are sometimes seen on the inner sur\u00c2\u00ac\\nface of the lids, due to little cheesy collections in the Meibo\u00c2\u00ac\\nmian glands, and causing irritation by their hardness.\\nThey should be picked out with the point of a knife.\\nWarty formations are not very common on the border\\nof the lid, and are of little consequence except in elderly\\npeople, in whom they should be looked upon with suspi\u00c2\u00ac\\ncion as possible starting-points of rodent cancer. A small,\\nfleshy, yellowish-red, flattened growth is sometimes met\\nwith just upon the tarsal border, and apparently seated at\\nthe mouth of a Meibomian gland. It causes some irrita\u00c2\u00ac\\ntion, and should be pared off. Small pellucid cysts are also\\nnot uncommon on the lid border. Cutaneous horns are\\noccasionally seen on the skin of the eyelids.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0097.jp2"}, "98": {"fulltext": "90\\nCL I SIC A L DIVISION.\\nMolluscum contagiosum is partly an ophthalmic disease,\\nbecause so often seated upon the eyelids. One or more\\nlittle rounded prominences, showing a small dimpled ori\u00c2\u00ac\\nfice at the top, plugged by dry, sebaceous matter, are seen\\nin the skin, varying from the size of a mustard-seed to a\\ncherry, but usually not larger than a sweat-pea; at first\\nthey are hemispherical, but afterward become constricted\\nat the base. The skin is tightly stretched, thinned, and\\nadherent. The larger specimens sometimes inflame, and\\ntheir true nature may then, without due care, be mis\u00c2\u00ac\\ntaken. Each molluscum must be removed, the white,\\nlobulated, gland-like mass which forms the growth being\\nsqueezed out through the incision made by a knife or scis\u00c2\u00ac\\nsors.\\nXanthelasma palpebrarum appears as one or more yellow\\npatches like pieces of wash-leather in the skin, varying\\nfrom mere dots to the size of a kidney bean, quite soft in\\ntexture, and very little raised. The disease is commonest\\nnear the inner canthus, and unless symmetrical is usually\\non the left side. It occurs chiefly in elderly persons who\\nhave previously been subject to become very dark around\\nthe eyes when out of health. The patches are due to in\u00c2\u00ac\\nfiltration of the deeper parts of the skin by groups of cells\\nloaded with yellow fat. The frequency of xanthelasma in\\nthe eyelids is, perhaps, related to the normal presence of\\ncertain peculiar granular cells, some of which contain pig\u00c2\u00ac\\nment, in the skin of these parts.\\nThe pediculus pubis (crab-louse) in very rare cases will\\nreach the eyelashes and flourish there. The lice cling close\\nto the border of the lid, and look like dirty scabs; the eggs\\nare darker, and may also be mistaken for bits of dirt. The\\nabsence of inflammation and the rather peculiar appear\u00c2\u00ac\\nances will lead, in doubtful cases, to the use of a magnify\u00c2\u00ac\\ning glass, by which the question will be at once settled.\\nUlcers on the eyelids may be malignant, tubercular,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0098.jp2"}, "99": {"fulltext": "DISEASES OF TIIE EYELIDS.\\n91\\nlupous, or syphilitic; and in the last case the sore may\\nbe either a chancre or a tertiary nicer.\\nj\\nRodent cancer (rodent ulcer, flat epithelial cancer) is by\\nfar the commonest form of carcinoma affecting the eye\u00c2\u00ac\\nlids cases of eyelid cancer occasionally present both the\\nclinical and pathological characters of ordinary epithe\u00c2\u00ac\\nlioma. The peculiarities of rodent cancer are that it is\\nof very slow growth, that ulceration almost keeps pace\\nwith the new growth, and that it does not cause infection\\nof lymphatics. It seldom begins before, generally not\\nuntil considerably after, middle life, and its course often\\nextends over many years. Beginning as a \u00e2\u0080\u009cpimple\u00e2\u0080\u009d or\\nwart,\u00e2\u0080\u009d it slowly spreads, but years may pass before the\\nulcer is as large as a sixpence. When first seen we gener\u00c2\u00ac\\nally find a shallow ulcer, covered by a thin scab, most\\noften involving the skin at the inner end of the lower lid.\\nits edge is raised, sinuous, nodular, and very hard, but\\nneither inflamed nor tender. Slowly extending both in\\narea and depth, it attacks all tissues alike, finally destroy\u00c2\u00ac\\ning the eyeball and opening into the nose. In a very few\\nchronic cases the disease remains quite superficial, and\\ncicatrization may occur at some parts of the ulcerated\\nsurface. Now and then a considerable nodule of growth\\nforms in the skin before ulceration begins.\\nThe diagnosis is generally easy. A long-standing ulcer\\nof the eyelids in an adult is nearly certain to be rodent\\ncancer. Tertiary syphilitic ulcers are much less chronic,\\nmore inflamed and punched out, and devoid of the very\\npeculiar, hard edge of rodent ulcer; moreover they are\\nvery rare. Lupus seldom occurs so late in life as rodent\\ncancer, presents more inflammation and much less hard\u00c2\u00ac\\nness, and is often accompanied by lupus elsewhere on the\\ncutaneous or mucous surfaces. Lupus is seldom difficult\\nto distinguish on the eyelids from tertiary syphilis, the\\nlatter being more acute, more dusky, and showing more", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0099.jp2"}, "100": {"fulltext": "92\\nCLINICAL DIVISION.\\nloss of substance, with none of the little, ill-defined, soft\\ntubercles seen in lupus.\\nWhen a chancre occurs on the eyelid 1 the induration and\\nswelling are usually very marked, the surface abraded and\\nmoist, but not much ulcerated; the glands in front of the\\near and behind the jaw become much enlarged.\\nSeveral cases are on record in which a hard chancre\\nformed on the palpebral conjunctiva, so far from the\\nborder of the lid as to be quite concealed. In such cases\\nthe swelling bears considerable resemblance to a large\\nMeibomian cyst; there are enlarged glands and well-\\nmarked constitutional symptoms.\\nTreatment of Rodent Cancer. Early removal is\\nof great importance, and probably the more so in pro\u00c2\u00ac\\nportion to the youth of the patient. Chloride of zinc\\npaste or the actual cautery is necessary in addition to\\nthe knife in bad cases; scraping may also be employed.\\nThe disease is very apt to return locally. Even in very\\nadvanced cases, where complete removal is impossible,\\nthe patient may be made much more comfortable, and\\nlife probably prolonged, by vigorous and repeated treat\u00c2\u00ac\\nment.\\nTubercle of the Conjunctiva is generally primary; it\\nbegins in the upper lid in the tarsal conjunctiva, or in the\\nretrotarsal fold; as a rule, the upper lid is swollen, and\\nwhen everted presents either a punched-out ulcer with a\\ngray base, or a mass of small gray miliary tubercles. The\\npre-auricular gland is very frequently enlarged, and may\\nsuppurate. If left alone the disease may spread to the\\neyeball, or invade the substance of the lid, and may lead\\nto secondary infection of other parts of the body. The\\ndiseased parts should be excised, or thoroughly scraped\\nand cauterized, and the operation should be repeated as\\nlong as any trace of the disease remains.\\nn j\\n1 An interesting monograph on this subject was read by Dr. De Beck at the\\nAmerican Ophth. Soc., July, 1SS6.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0100.jp2"}, "101": {"fulltext": "DISEASES OF THE EYELIDS.\\n93\\nCongenital ptosis is a not very rare affection. It may be\\ndouble or unilateral, is present from birth, and its causation\\nis unknown. I believe it is never complete. It sometimes\\nseems to diminish in the first few years of life, but probably\\nnever disappears. Although the lid droops, the skin is often\\nscanty, the lid being tight and deficient in the natural\\nfolds. Operations have been devised for producing deep\\ncicatricial bands, by means of subcutaneous sutures passed\\nfrom the brow to the tarsus (Bowman, Pagenstecher,\\nWecker). Panas has devised a new operation more re\u00c2\u00ac\\ncently. These rather tedious procedures avoid the risk of\\nfurther shortening of the lid which attends the simpler\\noperation of removing an elliptical fold of skin. I have\\nobtained considerable improvement from Pagenstecher\u00e2\u0080\u0099s\\noperation.\\nEpicanthus is a rare condition, in which a fold of skin\\nstretches across from the inner end of the brow to the side\\nof the nose, hiding the inner canthus. If it does not dis\u00c2\u00ac\\nappear as the child\u00e2\u0080\u0099s nose develops, an operation\u00e2\u0080\u0094removal\\nof a piece of skin from the bridge of the nose, sometimes\\ncombined Avith canthoplasty\u00e2\u0080\u0094is indicated.\\nCongenital trichiasis. This condition is not very uncom\u00c2\u00ac\\nmon in children; the lashes of the lower lid, instead of\\nhaving their normal direction, are turned upward and\\nbackward, and come into contact Avith the globe, giving\\nrise to irritation of the conjunctiva and cornea. To restore\\nthe lashes to their proper direction, an elliptical piece of\\nskin should be removed from the loAver lid.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0101.jp2"}, "102": {"fulltext": "CHAPTER V.\\nDISEASES OF THE LACHRYMAL APPARATUS 1\\nThese may be divided into the affections of the secreting\\nparts\u00e2\u0080\u0094the lachrymal gland and its ducts; and those of the\\ndrainage apparatus\u00e2\u0080\u0094the puncta, canaliculi, lachrymal sac,\\nand nasal duct. In the great majority of cases the fault\\nlies entirely in the drainage system.\\nThe flow of tears over the edge of the lid, watery eye,\u00e2\u0080\u009d\\nis called epiphora or stillicidium lacrymarum. No useful\\npurpose is served by keeping the two names, and only the\\nformer will be here used. Lachrymation indicates the in\u00c2\u00ac\\ncreased flow which often accompanies inflammation of the\\neyeball.\\nDiseases of the Secretory Apparatus.\\nDacryoadenitis.\u00e2\u0080\u0094 Inflammation of the lachrymal gland\\nis of rare occurrence, either in the acute or chronic form.\\nIt is indicated by swelling and oedema of the upper lid,\\nand pain and tenderness on pressure of the gland and the\\nadjacent supraorbital margin. The disease may assume a\\npurulent form, when an abscess may open either upon the\\nconjunctiva or through the skin.\\nRheumatism, cold, syphilis, septicaemia, and mumps have\\nall been ascribed as the cause in various cases, while the\\nspread of inflammation from the conjunctiva and cornea\\nhas been noted in a number of instances.\\nTreatment. \u00e2\u0080\u0094Hot applications and poultices in the\\nearly stages, followed by free incision under the supra\u00c2\u00ac\\norbital region as soon as pus has formed. In the chronic\\n94", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0102.jp2"}, "103": {"fulltext": "DISEASES OF TIIE LACHRYMAL APPARATUS. 95\\nvariety the local application of absorptive ointments, such\\nas the mercurial and compound iodine, should be employed,\\nwhile potassium iodide, mercury, and the salicylates should\\nbe administered internally. In acute cases an active calo\u00c2\u00ac\\nmel purge should be prescribed, followed by large doses\\nof quinine.\\nNeoplasms, such as sarcoma and adenoma, and hyper\u00c2\u00ac\\ntrophy of the gland, are of rare occurrence. The latter\\nis at times of congenital origin, but is usually an affection\\nof later years. The gland may attain a large size, and\\ncause serious damage to the eyeball by compression.\\nDiseases of the Excretory Apparatus.\\nThe drainage system may be at fault in any part from\\nthe puncta to the lower end of the nasal duct.\\nThe slightest change in the position of the lower punc-\\ntum causes epiphora. In health the punctum is directed\\nbackward against the eye; if it look upward or forward\\nthe tears do not all reach it, and some will then flow over\\nthe lid. Thus in paralysis of the facial nerve the patient\\nsometimes comes to us for epiphora before he notices the\\nother symptoms; the watering is caused partly by loss of\\nthe compressing and sucking action of the punctum that is\\neffected in winking, by those fibres of the orbicularis which\\nlie in relation with the lachrymal sac, partly by a slight\\nfalling of the lid away from the eye and a consequent dis\u00c2\u00ac\\nplacement of the punctum. The various chronic diseases\\nof the border of the lids (ophthalmia tarsi), and also gran\u00c2\u00ac\\nular disease of the conjunctiva (granular lids), are common\\nsources of (1) tumefaction, with narrowing, of the puncta\\nand canaliculi; (2) cicatricial stricture of the same parts;\\nin both cases the puncta are displaced as well as con\u00c2\u00ac\\nstricted. Narrowing even to complete obliteration of the\\npuncta is sometimes seen as the result of former inflam\u00c2\u00ac\\nmation, of which all traces have long since passed away.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0103.jp2"}, "104": {"fulltext": "96\\nCLISICA L DIVISION.\\nWounds bv which the canaliculi are cut across cause their\\nm\\nobliteration, and epiphora is the result.\\nIn all the above cases the epiphora is accompanied by a\\nvisible change in the size or position of the punetum, none\\nof the signs of inflammation in the lachrymal sac or stric\u00c2\u00ac\\nture in the nasal duct being present; and simple division\\nof the canaliculus will cure, or much relieve, the watering.\\nSee Operations. This is, however, seldom necessary in the\\nepiphora of facial paralysis.\\nThe canaliculus is occasionally plugged by the growth\\nin it of a mycelial fungus, which, mingled with pus-cells\\nand mucus, forms a yellowish or greenish, putty-like con\u00c2\u00ac\\ncretion. These masess sometimes calcifv, and are then\\ncalled daeryoliths. 1 2\\nEpiphora not explained by the above causes is usually\\ndue to obstruction in the nasal duct, and is accompanied\\nbv distention and disease of the laehrvmal sac from the\\nsame cause. Primary disease of the lachrymal sac is rare.\\nObstruction of the nasal duct is usually caused by chronic\\nthickening of the mucous and submucous tissues lining the\\ncanal. Dense, hard thickening causes a stricture, often\\nvery tight and unyielding; but obstruction is often present\\nthough the canal be of full size or perhaps even dilated,*\\nexcess of mucus being apparently the chief cause. Disease\\nof the duct occurs at all ages, and is more common in\\nfemales than males. 3 In some cases the change evidentlv\\nforms a part of a chronic disease of the naso-pharyngeal\\nmucous membrane, but in many no cause can be assigned.\\nSometimes stricture is the result of periostitis or of necrosis,\\nand of these conditions syphilis, either acquired or inher-\\n1 The same term is applied to concretions, stUl more rare, in the ducts of\\nthe lachrymal gland.\\n2 There can be little doubt that the healthy nasal duct varies much in size\\nin different persons (Xoyes).\\ns In a group of 113 consecutive cases I find S9 females and 24 males.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0104.jp2"}, "105": {"fulltext": "DISEASES OF THE LACHRYMAL APPARATUS. 97\\nited, scarlet fever, and smallpox are the more common\\ncauses. Injuries to, and growths in, the nose, or invading\\nit, account for a few cases.\\nA stricture may be seated at any part of the duct; but\\nthe upper end, where there is often a natural narrowing, is\\nthe commonest spot.\\nObstruction of the nasal duct, by preventing the escape\\nof tears, leads to distention of the lachrymal sac, to chronic\\nthickening of its lining membrane, and increased secretion\\nof mucus. The mucus may be clear or turbid. At length\\na point is reached at which the distention can be seen as a\\nlittle swelling under the skin at the inner canthus, mucocele\\nor chronic dacryocystitis. This swelling can generally be\\ndispersed by pressure with the finger, the mucus and tears\\neither regurgitating through the canaliculi or being forced\\nthrough the duct into the nose. In cases of old standing\\nthe sac is often much thickened, and may contain polypi,\\nand the swelling cannot then be entirely dispersed by pres\u00c2\u00ac\\nsure.\\nA mucocele is always very apt to inflame and suppurate,\\nthe result being a lachrymal abscess. Most cases of lachry\u00c2\u00ac\\nmal abscess, indeed, have been preceded by mucocele. Its\\nformation gives rise to great pain, and to tense, brawny,\\ndusky swelling, which, extending for a considerable dis\u00c2\u00ac\\ntance around the sac, is sometimes mistaken for erysipelas.\\nThe matter always points a little below the tendo palpebra\u00c2\u00ac\\nrum the pus often burrows in front of the sac, forming\\nlittle pouches in the cellular tissue, and if allowed to open\\nspontaneously, a fistula, very troublesome to cure, is likely\\nto follow. If seen early, before there is decided pointing,\\nit is best to open the abscess by slitting the lower canal\u00c2\u00ac\\niculus freely into the sac, and passing a knife down the\\nnasal duct; anaesthesia is usually necessary. If interfer\u00c2\u00ac\\nence be delayed, the skin over the sac soon becomes thinned,\\nand the abscess is then best opened through the skin by\\n7", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0105.jp2"}, "106": {"fulltext": "98\\nCLINICAL DIVISION.\\na free puncture inclined downward and a little outward;\\nno anaesthetic is necessary, and the resulting scar is insig\u00c2\u00ac\\nnificant. When the thickening has subsided, under the\\nuse of warm lead lotion dressing, the stricture of the duct\\nis to be treated; but the mucocele will form again, and\\nanother abscess may occur at any time unless a free pass\u00c2\u00ac\\nage can be restored down the nasal duct.\\nObstinate chronic conjunctivitis is often set up by unre\u00c2\u00ac\\nlieved lachrymal obstruction (p. 121). It has long been\\nknown that severe suppurative inflammation is very likely\\nto occur after any operation performed on the cornea when\\nthere is pus in the lachrymal sac. See Cataract. These\\nevidences of local irritation and infection are now known\\nto depend upon septic organisms, which, owing to the\\nobstruction, collect in the lachrymal sac.\\nTreatment of Mucocele and Lachrymal Stric\u00c2\u00ac\\nture. The object aimed at is the permanent dilatation\\nof the stricture; but, whether this can be gained or not,\\na free opening from the canaliculus into the sac should be\\nmaintained, so that the secretions may be often and easily\\nsqueezed out.\\nThis may be either palliative or curative. The former\\nconsists in repeatedly pressing the contents of the lachry\u00c2\u00ac\\nmal sac into the nose by the finger, and by the employ\u00c2\u00ac\\nment of antiseptic and astringent eye washes, or by throw\u00c2\u00ac\\ning a stream of boric acid solution into the sac by means\\nof an Anel syringe. Attention must be directed toward\\nthe nasal mucous membrane, and any local irritation exist\u00c2\u00ac\\ning about the nasal opening of the duct must be controlled\\nwith local applications.\\nThe curative plan of treatment resolves itself into some\\nform of surgical procedure. These measures have been\\nconveniently classed by Theobald under four heads: 1.\\nThose which aim to restore the natural passages. 2. Those\\nwhich have for their object the formation of a new passage", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0106.jp2"}, "107": {"fulltext": "DISEASES OF THE LACHRYMAL APPARATUS. 99\\ninto the nose for the tears. 3. Those which aim at the\\nobliteration of the natural passages\u00e2\u0080\u0094the lachrymal sac and\\nduct. 4. The removal of the lachrymal gland for the pur\u00c2\u00ac\\npose of arresting the secretion of tears.\\nDilatation by probing, Chapter XXII., is the ordinary\\nand best treatment for all strictures, whether there be\\nmucocele or not, the rule being to use the largest probe\\nthat will pass readily. The probing is repeated every few\\ndays or less often, according to the duration of its effect,\\nand often needs to be continued for weeks or months. The\\npatient may sometimes learn to use the probe himself.\\nWhen the stricture is tough and tight, it is best at once\\nto divide it by thrusting a strong-backed, narrow knife\\ndown the duct, and afterward to use probes. In cases\\nwhere the stricture is quite soft, and the obstruction due\\nrather to general thickening of the mucous membrane and\\nover-secretion of mucus, than to dense fibrous thickening,\\nfrequent washing out of the duct with water, or weak\\nastringents, by means of a lachrymal syringe, is quite as\\nbeneficial as, and less painful than, probing. The diligent\\nuse of astringent lotions to the conjunctiva is also useful,\\nparticularly in soft strictures, some of the lotion reaching\\nthe sac and duct. In cases of long standing, where other\\ntreatment has failed and the sac is much thickened, or\\nwhen it is necessary to perform an operation like extrac\u00c2\u00ac\\ntion of cataract, excision of the lachrymal sac, or its com\u00c2\u00ac\\nplete obliteration by the actual cautery, should be resorted\\nto; extirpation of the lachrymal gland is also occasionally\\npractised. For refractory children, and for patients who\\ncannot be seen often, a style of silver or lead, passed in\\nexactly the same way as a probe, but worn constantly for\\nmany weeks, is very useful; but it may slip into the sac\\nout of reach unless furnished with a bend or head so large\\nas to be somewhat unsightly. As a rule, probing should\\nnot be begun until the inflammatory thickening and ten-\\nUcfC/", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0107.jp2"}, "108": {"fulltext": "100\\nCLINICAL DIVISION.\\nderness following a lachrymal abscess have subsided. If\\nthe probe be used too often, or with much violence, or if\\nfalse passages be made, the case may easily be made worse\\ninstead of better. It must be confessed, indeed, that in\\nmany lachrymal cases, whether the stricture be soft or\\nfirm, treatment, however skilful, gives only partial relief\\nto the epiphora.\\nSuppuration of the lachrymal sac, on one or both sides,\\nsometimes takes place in newborn infants without apparent\\ncause; if there be much redness, the abscess should be\\nopened, but the suppuration is sometimes chronic, and\\nwill cease under the use of astringent lotions. The cases\\nof epiphora with contracted punctum, which are sometimes\\nmet with in older children, may perhaps be the conse\u00c2\u00ac\\nquences of this infantile suppuration.\\nCases in which the sac or duct is obliterated by injury\\ncan seldom be relieved.\\ni\\ni\\nt.\\nc", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0108.jp2"}, "109": {"fulltext": "CHAPTER VI.\\nDISEASES OF TIIE CONJUNCTIVA.\\nThe conjunctiva, like the urethra, is subject to purulent\\ninflammation, and, like the respiratory mucous membrane,\\nis liable to the muco-purulent and to the membranous or\\ndiphtheritic forms of disease. All cases in which there is\\nyellow discharge are in greater or less degree contagious.\\nThe congestion, which forms a part of conjunctivitis, is\\nmuch influenced by age; the younger the patient the less\\nis the congestion in proportion to the discharge\u00e2\u0080\u0094a fact to\\nbe borne in mind in examining patients at both ends of\\nthe scale.\\nPurulent ophthalmia (0. neonatorum, Gonorrhoeal O.,\\nBlennorrhoea of the conjunctiva) is generally due to con\u00c2\u00ac\\ntagion from the same disease, or from an acute or chronic\\ndischarge from the urethra or vagina, which may or may\\nnot be gonorrhoeal. It is commonest in newborn infants\\nwhose eyes have been inoculated from the mother during\\nbirth next in adults with gonorrhoea; it is also seen some\u00c2\u00ac\\ntimes in young girls who have non-venereal discharge from\\nthe genitals.\\nThe active cause of this form of conjunctivitis is a micro\u00c2\u00ac\\norganism, the gonococcus, first discovered by ISTeisser in\\n1879. These are found in the pus-cells of the conjunctival\\ndischarge, and also in the superficial cells of the conjunc\u00c2\u00ac\\ntiva itself they are arranged in pairs, which are generally\\naggregated together. The gonococcus is said (1) to be\\nabsent in some of the milder forms of infantile ophthalmia;\\n(2) when cultivated to be capable of producing purulent\\n101", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0109.jp2"}, "110": {"fulltext": "102\\nCLINICAL DIVISION.\\nophthalmia by inoculation (3) to be usually present in the\\nvaginal discharge of women whose babies have purulent\\nophthalmia. Gonorrhoea was experimentally produced by\\ninoculation with pus from purulent ophthalmia long before\\nthe days of bacterial pathology. Like gonorrhoea, puru\u00c2\u00ac\\nlent ophthalmia may occur more than once. It varies\\ngreatly in severity, but is, on the whole, much worse in\\nadults than in infants, perhaps because there is much more\\nadenoid tissue in the conjunctiva of adults than of babies\\n(Widmark).\\nFrom an examination of the records of 158 cases of puru\u00c2\u00ac\\nlent ophthalmia in adults occurring in the wards at Moor-\\nfields 1 the disease is found to be more common in males than\\nin females in the proportion of 126 to 32, and the right eye is\\nmore frequently attacked than the left. The influence of\\nage on the prospect of recovery is very great; early adult\\nlife is the time when the resistance is greatest; practically\\nevery eye that was attacked when the patient was over\\nforty was lost. The other modifying causes are the dura\u00c2\u00ac\\ntion of the urethral discharge at the time of the inocula\u00c2\u00ac\\ntion and the time of beginning treatment; inoculation\\nduring the later stages of the gonorrhoea led to milder\\nattacks in the eye, and the earlier the patient came under\\ntreatment the better the result. In many of the cases\\nthere was a history of \u00e2\u0080\u009cweak eyes\u00e2\u0080\u009d before the attack;\\nthis may have been due to a congestion of the anterior\\npart of the eye from the circulation of the gonorrhoeal\\npoison in the blood, or to a previous condition of the eye\u00c2\u00ac\\nlids produced by blepharitis or granular disease.\\nThe disease sets in from twelve to about forty-eight hours\\nafter inoculation; in infants the third day after birth is\\nalmost invariably given as the date when discharge was\\nfirst noticed. Itchiness and slight redness of conjunctiva\\n1 Holmes Spicer: Ophthalmic Hospital Reports, vol. xiii. p. 211.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0110.jp2"}, "111": {"fulltext": "DISEASES OF THE CONJUNCTIVA.\\n103\\nsoon pass on to intense congestion of conjunctiva, with\\nchemosis, tense inflammatory swelling of the lids, great\\npain and discharge. The discharge at first is serous, or\\nlike turbid whey, but soon becomes more profuse, creamy\\n(purulent), and yellow, or even slightly greenish. Dark,\\nabrupt ecchymoses are often present. The lids, always\\nswollen, hot, and red, in bad cases become very tense and\\ndusky. The upper lid hangs down over the lower, and is\\noften so stiff that it cannot be completely everted. The\\nconjunctiva is succulent and easily bleeds.\\nThe disease if untreated declines spontaneously, and the\\ndischarge almost ceases in about six weeks, the palbebral\\nconjunctiva being left thick, relaxed, and more or less\\ngranular. Cicatricial changes, identical with, but less\\nsevere than, those resulting from chronic granular lids,\\nand analogous to those which occur in stricture of the\\nurethra, sometimes follow; considerable permanent thick\u00c2\u00ac\\nening of the ocular conjunctiva may also occur.\\nThere is a great risk to the cornea in this disease, partly\\nfrom strangulation of the vessels, partly from the local in\u00c2\u00ac\\nfluence of the discharge. If within the first two or three\\ndays the cornea becomes hazy and dull, like that of a dead\\nfish, there is great risk that total or extensive sloughing\\nwill occur. In many of the milder cases ulcers form a\\nlittle below the centre, and rapidly cause perforation. In\\nother cases clear, deep ulcers form close to the edge of the\\ncornea. There is less risk of ulceration of the cornea in\\nthe purulent ophthalmia of infants than in that of adults.\\nEither one or both eyes may be attacked in adults one\\neye often escapes; in infants, where the inoculation occurs\\nduring birth, both eyes almost always suffer.\\nTreatment. If only one eye be affected, and the\\npatient be old enough to obey orders, the sound eye must\\nbe covered with the shield introduced by Dr. Buller; take\\ntwo pieces of India-rubber plaster, one 4the other 4", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0111.jp2"}, "112": {"fulltext": "104\\nCLINICAL DIVISION.\\nsquare, cut a round window in the middle of each, and\\nstick them together, with a small watch-glass inserted into\\nFig. 44.\\nBuller\u00e2\u0080\u0099s shield.\\nthe window. The plaster is fixed by its free border, and\\nby other strips, to the nose, forehead, and cheek, and the\\npatient looks through the glass; the lower outer angle is\\nleft open for ventilation; particular attention is to be paid\\nto the fastening on the nose. All concerned are to be\\nwarned as to the risk of contagion and the means of con\u00c2\u00ac\\nveying it. The essential curative measures are: 1. Fre\u00c2\u00ac\\nquent removal of the discharge by the free use of weak\\nantiseptic or astringent lotions (F. 3, 12, 13, 16, 17, 22).\\nEvery hour, day and night, the lids are gently opened\\nand the discharge removed with soft bits of moistened rag", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0112.jp2"}, "113": {"fulltext": "DISEASES OF THE CONJUNCTIVA.\\n105\\nor cotton wool. In adults, where the swelling is often ex\u00c2\u00ac\\ntreme and very brawny, the cleansing must be done very\\ngently, lest the congestion and irritability be increased.\\n2. Iodoform, at first extensively tried, has, I believe, not\\ngiven satisfaction in this disease. Many surgeons greatly\\nprefer weak nitrate of silver (F. 3) to all other remedies.\\n3. Strong solutions of nitrate of silver, or the mitigated\\nsolid nitrate (F. 1 and 2), are of great service in shortening\\nthe attack and lessening the risks, and, whatever other\\ntreatment be adopted, they should be used in all severe\\ncases unless specially contraindicated. The above-men\u00c2\u00ac\\ntioned analysis showed the very great superiority of\\nstrong nitrate of silver (grs. x or xx to 5 j) over all\\nother kinds of treatment. A ten- or twenty-grain solu\u00c2\u00ac\\ntion is brushed freely over the conjunctiva of the lids,\\neverted as well as possible, and freed from discharge. If\\nthe mitigated stick is used, more care is needed; and to\\nprevent too great an effect it is to be washed off with\\nwater, after waiting about fifteen seconds. These strong\\napplications must be made by the surgeon. The pain\\ncaused by them is lessened, and the benefit increased, by\\nfree bathing with cold or iced water afterward. The\\napplication is not to be repeated until the discharge,\\nwhich will be markedly lessened for some hours, has\\nbegun to increase again; once a day is enough in many\\ncases. 4. Between the cleansings either warm or cold\\napplications; warmth is often preferred by the patient.\\n5. In the early stage, in adults, several leeches to the\\ntemple will give relief, or, if the swelling be very tense,\\nwe may divide the outer canthus with scissors or knife,\\nand thus both bleed and relax the parts at the same time.\\nRemoval of the ring of conjunctiva which overlaps the\\ncornea is valuable when the chemosis is severe. 6. The\\nlids should be often anointed with a simple ointment.\\nProtargol has lately been substituted for silver in the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0113.jp2"}, "114": {"fulltext": "106\\nCLINICAL DIVISION\\ntreatment of purulent conjunctivitis, with excellent results.\\nThe drug possesses all of the bactericidal properties of the\\nsilver without causing so much pain. It should be used in\\nthe strength of from 1 to 5 per cent.\\nThe following additional precautions are important:\\nStrong nitrate of silver applications are unsafe in the\\nearliest stage, before free discharge has set in, and also\\nin cases where, even later in the disease, there is much\\nhard, brawny swelling of the ocular conjunctiva and com\u00c2\u00ac\\nparatively little discharge; cases, in fact, approaching the\\ncondition known as diphtheritic ophthalmia. In these,\\neither very cold or very hot applications, leeches, cleanli\u00c2\u00ac\\nness, and weak lotions should be chiefly relied upon. Ice\\nand leeches are seldom advisable for infants. It is of ex\u00c2\u00ac\\ntreme importance to begin treatment very early, for the\\ncornea is often irreparably damaged within two or three\\ndays. The patients, if adults, are often in feeble health,\\nand need supporting treatment. Ulceration of the cornea\\ndoes not contraindicate the use of strong nitrate of silver\\nif the discharge is abundant. Treatment must be con\u00c2\u00ac\\ntinued so long as there is any discharge, for a relapse of\\npurulent discharge often takes place if remedies are dis\u00c2\u00ac\\ncontinued too soon. I once saw hemorrhage continuing\\nfor some time, without apparent cause, from the conjunc\u00c2\u00ac\\ntiva of the lid, in a child recovering from purulent ophthal\u00c2\u00ac\\nmia. Serious conjunctival hemorrhage has been noted by\\nPomeroy and Schmidt-Rimpler.\\nThe systematic prevention of ophthalmia neonatorum by\\nthe cleansing and disinfection of the eyes of every infant\\nimmediately after birth, sometimes preceded by disinfec\u00c2\u00ac\\ntion of the maternal passages, has been introduced by\\nCrede and largely carried out in many lying-in hospitals,\\nespecially on the Continent. Crede applies a few drops of\\na 2 per cent, solution of nitrate of silver (about 8 grs. to\\n3 j) to the conjunctival sac once. Various other agents or", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0114.jp2"}, "115": {"fulltext": "DISEASES OF THE CONJUNCTIVA.\\n107\\nweaker solutions of silver have been used. The general\\nresult of such measures has been to reduce the number\\nof cases in an astonishing degree; and as it is calculated\\nthat about a third of all the blind in Europe have become\\nso by the ravages of this disease, considerable importance\\nis to be attached to the general adoption of Crede\u00e2\u0080\u0099s prin\u00c2\u00ac\\nciple by medical men and mid wives. 1\\nCatarrhal Conjunctivitis. Simple Acute Conjunctivitis.\\n\u00e2\u0080\u0094This is the most common and best characterized of the\\nacute ophthalmias. The disease attains its height very\\nquickly, almost always attacks both eyes, and recovery is\\nspontaneous in about a fortnight. All stages of life are\\nliable, but childhood and early adolescence are especially\\nprone to it. The lids are somewhat swollen and red, but\\nnever tense. Often the conjunctive of the lids is alone\\ninfected, but in the severer cases the bulbar conjunctiva is\\naffected as well. The secretion is usually mucoid in char\u00c2\u00ac\\nacter, and causes the eyelids to \u00e2\u0080\u009cstick\u00e2\u0080\u009d on awakening in\\nthe morning; but in other cases it becomes mucopurulent\\nand is very abundant. There are often ecchymotic patches\\nin the conjunctiva. The cornea seldom suffers.\\nThe symptoms are often most annoying, preventing\\nsleep, those afflicted with it complaining of a sensation of\\nsand in the eye, of heaviness of the eyelids, and of the\\nsecretions excoriating the lids and the surrounding skin.\\nThe causes are mechanical irritation, from either the\\npresence of a foreign body or exposure to wind, dust, or\\nsmoke. The disease may also accompany the exanthemata,\\nor may be found in association with constitutional disorders,\\nlike typhoid fever, or with disease of some of the surround\u00c2\u00ac\\ning structures, such as eczema of the lids and nasal\\ncatarrh.\\nAcute Catarrhal Conjunctivitis .\u00e2\u0080\u0094This is also known as\\n1 Particulars and statistics may be found in Edinburgh Medical Journal,\\nApril, 1883 (Or. A. R. Simpson), and in more recent papers.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0115.jp2"}, "116": {"fulltext": "108\\nCLINICAL DIVISION.\\nacute contagious conjunctivitis epidemic conjunctivitis, and\\npink eye. This variety is a special form of conjunctivitis,\\nand is due to a specific bacillus. Koch isolated this bacil\u00c2\u00ac\\nlus when studying the acute conjunctivitis of Egypt.\\nWeeks discovered it independently in New York, and\\nMorax has studied its development in Paris. The pneu\u00c2\u00ac\\nmococcus of Frankel, which is held by Gifford to be a fre\u00c2\u00ac\\nquent cause of acute conjunctivitis, according to Parinaud\\nand Morax is found but rarely in this disease.\\nThis form of conjunctivitis is most common in warm\\nweather, or perhaps at the change from cold to warm. All\\nages are liable, and both eyes are usually affected.\\nIn this variety acute symptoms are preceded by a short\\nand mild period of incubation. At the end of thirty-six\\nhours the entire conjunctiva becomes swollen and injected,\\nand minute hemorrhagic areas appear scattered over the\\nmembrane. The swelling of the conjunctiva is most\\nmarked in the retrotarsal folds, bulbar chemosis being rare.\\nThe lids, as a rule, are greatly swollen and glued together\\nby the thick, ropy secretion. The eyes feel hot and burn,\\nand the sensation of their containing sand is complained\\nof. The disease attains its height in three days, and the\\nacute symptoms subside in about ten days but three weeks\\nor more elapse before the conjunctiva regains its normal\\nappearance. The prognosis is good, as the cornea is but\\nrarely implicated.\\nThe disease is very contagious, and if care be not taken\\nto isolate these already affected the other members of the\\nfamily usually suffer.\\nAlthough the history of its epidemic character will sug\u00c2\u00ac\\ngest the diagnosis in many cases, recourse must be had to\\nthe microscope to determine its precise nature.\\nTreatment. \u00e2\u0080\u0094In ordinary simple conjunctivitis the re\u00c2\u00ac\\nmoval of the cause, stopping the use of the eyes, protecting\\nthem from light and dust by dark glasses, and the employ-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0116.jp2"}, "117": {"fulltext": "DISEASES OF TIIE CONJUNCT! VA.\\n109\\nmerit of a mild antiseptic wash will be sufficient to attain\\na cure. Ice compresses applied for fifteen minutes, every\\ntwo or three hours, will afford considerable relief to the\\nsubjective sensations. Careful attention to the health is\\nnecessary. The patient should not be confined to the\\nhouse, but with a large shade over both eyes should take\\nplenty of exercise in fine weather. The eyes should not be\\nbandaged in any form of conjunctivitis, and poultices should\\nnever be employed. If there be not too much irritation\\nand swelling of the conjunctiva, and if the secretion be at\\nall marked, a weak solution of silver nitrate (gr. ij-v to\\nf oj) should be brought in contact with the inflamed con\u00c2\u00ac\\njunctiva by means of a swab, the effect of this drug being\\nimmediately neutralized by salt water. The edges of the\\nlids should be kept moist with vaseline, and after the acute\\nstage has passed zinc sulphate and alum (gr. j to f 3 j) should\\nbe employed.\\nIn acute contagious conjunctivitis isolation should be in\u00c2\u00ac\\nsisted upon and cold compresses maintained constantly\\nnight and day. The eyes should be flushed repeatedly and\\nfreed from all discharge with boracic acid solution, and\\nsilver nitrate applied as in simple conjunctivitis. Gifford\\nstrongly recommends the employment of zinc chloride (gr.\\nj to f 5 j) as a collyrium, claiming for this astringent almost\\nspecific properties in this affection. Lead acetate (gr. j to\\nf 5j), hydrogen peroxide, and formalin (Schering\u00e2\u0080\u0099s solution,\\n1 500 to 1 200) have also been employed.\\nParinaud has described a rare form of conjunctivitis due\\nto infection of animal origin, probably corresponding to\\nthe lymphoma of the conjunctiva of Goldzieher. In addi\u00c2\u00ac\\ntion to swelling of the lids and mucopurulent discharge,\\nlarge polypoid granulations appear upon the conjunctiva,\\nespecially in the retrotarsal folds. Usually but one eye is\\naffected, and the lymphatic glands of the same side may\\nsuppurate. No microorganism has been isolated. The", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0117.jp2"}, "118": {"fulltext": "110\\nCLINICAL DIVLSION.\\ndisease usually lasts several months, but complete recovery\\nis attained. In a case of this nature occurring in a patient\\nwith Malta fever, the Editor caused the disappearance of\\nthe granulations by the prolonged use of alum and silver\\nnitrate. Surgical removal of the polypoid masses is not\\nadvised.\\nFollicular conjunctivitis. This occurs generally in chil\u00c2\u00ac\\ndren or young adults, and is characterized by the forma\u00c2\u00ac\\ntion of small, clear elevations, consisting of adenoid tissue,\\nin the conjunctiva of the lower lid; in some cases they\\nare present also in the retrotarsal fold of the upper lid.\\nThese granulations often give rise to no symptoms, and are\\nonly part of a general tendency to adenoid enlargement.\\nThey occur mainly as the result of overcrowding, living in\\nunventilated rooms, or are due to the overuse of atropine.\\nThis condition may have no significance, but it undoubtedly\\npredisposes the patient to acute attacks of conjunctivitis of\\nvarious kinds, either of the muco-purulent or granular\\nvarieties.\\nSome forms of acute conjunctivitis, with little or no dis\u00c2\u00ac\\ncharge, are seen both in children and adults, which do\\nnot conform to the above types, and are of comparatively\\nslight importance. Many such appear to depend on changes\\nof weather or exposure to cold, and are complicated with\\nphlyctenula. A few are distinctly rheumatic. The con\u00c2\u00ac\\njunctiva is involved more or less in herpes zoster of the\\nophthalmic division of the fifth nerve, in erysipelas of the\\nface, in the early stage of measles, and slightly in eczema\\nof the face. Slight degrees of chronic conjunctivitis are\\nset up by various local irritants, dust, smoke, cold wind,\\netc., and by the strain attending the use of the eyes with\u00c2\u00ac\\nout glasses in cases of hypermetropia. Mention must be\\nmade of the cases sometimes seen in children, where an\\nophthalmia appears to form part of an impetiginous or\\nherpetic eruption on the face, with which it is simulta-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0118.jp2"}, "119": {"fulltext": "DISEASES OF THE CONJUNCTIVA.\\nIll\\nneons. These again differ from the more common cases, in\\nwhich the lids, cheek, and lining membrane of the nose\\nare irritated into an eruption by tears and discharge from\\na pre-existing conjunctivitis.\\nMuco-purulent ophthalmia of any kind becomes a very\\nimportant affair if it breaks out in schools or armies, etc.,\\nwhere granular disease of the eyelids is prevalent (p. 113).\\nMembranous and diphtheritic ophthalmia. In a few\\ncases of ophthalmia, either purulent or muco-purulent,\\nthe discharge adheres to the conjunctiva in the form of\\na membrane, membranous or croupous ophthalmia. Still\\nmore rarely, in addition to membrane on the surface, the\\nwhole depth of the conjunctiva is stiffened by solid exuda\u00c2\u00ac\\ntion, which much impairs the mobility both of the lids and\\neyeballs, and, by compressing the vessels, prevents the form\u00c2\u00ac\\nation of free discharge, and places the nutrition of the\\ncornea in great peril. It is to the latter cases that the\\nterm diphtheritic has been limited by most authors; but\\nwe find many connecting links between the two types, and\\nbetween each of them and the ordinary purulent and\\nmuco-purulent cases.\\nIt is of much consequence in practice, both for prognosis\\nand treatment, to recognize the presence of membranous\\ndischarge and of solid infiltration in any case of ophthal\u00c2\u00ac\\nmia for the liability to severe corneal damage is much\\nincreased by either of these conditions, especially by the\\nlatter. The membrane may cover the whole inside of the\\nlids, or it may occur in separate, or in confluent patches;\\nit often begins at the border of the lid, and is seldom found\\non the ocular conjunctiva. It can be peeled off, the con\u00c2\u00ac\\njunctiva beneath bleeding freely unless infiltrated and solid\\nin the latter case the membrane is more adherent, the con\u00c2\u00ac\\njunctiva is of a palish color, and scarcely bleeds when ex\u00c2\u00ac\\nposed, and there is little or no purulent discharge. In most\\ncases the solid products, whether membrane or deep infil-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0119.jp2"}, "120": {"fulltext": "112\\nCLINICAL DIVISION.\\ntration, pass after some days into a stage of liquefaction,\\nwith free purulent secretion. In rare cases the membrane\\nforms and reforms for months. As regards cause 1. Very\\nrarely the process creeps up to the conjunctiva from the\\nnose in cases of primary diphtheria, or is caused by inocu\u00c2\u00ac\\nlation of the conjunctiva with membrane; while in a few\\nthe ophthalmia forms the first symptom of general diph\u00c2\u00ac\\ntheria, or of masked or anomalous scarlet fever. 2. More\\ncommonly it is part of a diphtheritic type of inflammation\\nfollowing some acute illness. 3. It may be caused by the\\noveruse of caustics in ordinary purulent ophthalmia. 4. It\\nmay be due to contagion, either from a similar case or from\\na purulent ophthalmia, or a gonorrhoea, the diphtheritic\\ntype depending on some peculiarity in the health or tissues\\nof the recipient. Membranous and diphtheritic ophthalmia\\nare seen most often in children from two to eight years old,\\nless commonly in adults and infants. It is more common in\\nNorth Germany than in other parts of Europe, but severe\\nand even fatal cases are well known in our own country.\\nIn two cases I have seen the same condition attack the\\nskin of the eyelids and cause sloughing patches.\\nThe Klebs-Loffler bacillus is present in the secretion as\\nwell as other microorganisms, such as staphylococci, strep\u00c2\u00ac\\ntococci, and non-virulent Xerosis bacilli.\\nTreatment. In treatment the cardinal point is not to\\nuse nitrate of silver in any form when there is scanty dis\u00c2\u00ac\\ncharge and much solid infiltration of the conjunctiva.\\nThe agents to be relied upon are (1) either ice or hot\\nfomentations\u00e2\u0080\u0094ice, if it can be used continuously and well;\\nfomentations, to encourage liquid exudation and determi\u00c2\u00ac\\nnation to the skin if the cold treatment cannot be carried\\nout, or fails to make any impression on the case (2) leeches,\\nif the patient\u00e2\u0080\u0099s state will bear them; (3) great cleanliness.\\nThe presence of membrane is no bar to the use of caustics,\\nprovided that the conjunctiva is succulent, red, and bleeds", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0120.jp2"}, "121": {"fulltext": "DISEASES OF THE CONJUNCTIVA.\\n113\\neasily. Mr. Tweedy strongly advises quinine lotion used\\nvery frequently (F. 21). The constitutional treatment\\nwith antitoxin has yielded distinctly favorable results.\\nStandish found that the injections should be repeated as\\noften as every sixteen hours.\\nGranular ophthalmia (trachoma) is a very important\\nmalady, characterized by slowly progressive changes in\\nthe conjunctiva of the eyelids, in consequence of which\\nthis membrane becomes thickened, vascular, and rough\u00c2\u00ac\\nened by firm hemispherical elevations, instead of being\\npale, thin, and smooth. The change usually begins in the\\nconjunctiva of the lower lid, extending to the submucous\\ntissue of both lids at a later period, and giving rise to the\\ngrowth of much organized new tissue in the deep parts of\\nthe conjunctiva. This tissue is afterward partly absorbed\\nand partly converted iuto dense, tendinous scar, which by\\nvery close shrinking often gives rise to much trouble. It\\nis stated by Reid and others that trachoma follicles come\\nto the surface, open, discharge their contents, and leave\\nminute ulcers but it cannot be said clinically that trachoma\\nis an ulcerative disease, and the prominences are not gran\u00c2\u00ac\\nulations in the pathological sense. 1 There have been, and\\nstill are, extraordinary differences of opinion as to the\\norigin and nature of the \u00e2\u0080\u009cgranulations\u00e2\u0080\u009d or \u00e2\u0080\u009ctrachoma\\nbodies in this disease. The latest researches favor the\\nview that they are derived from natural lymphatic fol\u00c2\u00ac\\nlicles. Fig. 45 shows a section through some recent\\ntrachoma bodies.\\nThe disease shows itself in two forms:\\n(a) The papillae undergo considerable enlargement with\u00c2\u00ac\\nout the appearance of granulations on the surface; the\\nconjunctiva covering the tarsus of the upper lid is most\\naffected, and appears red and velvety. This is known as\\nthe papillary form.\\n1 I am aware that Raehlmami makes a contrary statement.\\n8", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0121.jp2"}, "122": {"fulltext": "114\\nCLINICAL DIVISION.\\n(6) The other variety shows itself by the presence on\\nboth lids of a number of rounded, pale, semi-transparent\\nbodies like little grains of boiled sago; the so-called\\nFig. 45.\\nMicroscopical section through four recent trachoma bodies, sago-grain\\ngranulation,\u00e2\u0080\u009d from the lower lid of a young Irish soldier whose eyes became\\naffected in the Egyptian campaigns. The epithelial cells become almost\\nindistinguishable from those of the growth where they cover the largest\\nnodule. No reticulum can be made out between the cells of which the\\ngrowths are composed. X 14.\\n\u00e2\u0080\u009cvesicular,\u00e2\u0080\u009d or sago-grain,\u00e2\u0080\u009d or \u00e2\u0080\u009cfollicular\u00e2\u0080\u009d granula\u00c2\u00ac\\ntions (Fig. 46).\\nFig. 46.\\nConjunctiva of upper lid in chronic granular conjunctivitis. (Ault.)\\nThe two forms of conjunctival affection may occur sepa\u00c2\u00ac\\nrately, but are usually combined.\\nIn the earlier stages there may be congestion of the con\u00c2\u00ac\\njunctiva with a good deal of discharge; after a time the\\ndischarge lessens, but the granulations remain; in some\\ncases the amount of congestion and discharge is never\\ngreat, and there is little to call attention to the eyes.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0122.jp2"}, "123": {"fulltext": "DISEASES OF THE CONJUNCTIVA.\\n115\\nGranular disease is very important because it greatly\\nincreases the susceptibility of the conjunctiva to take on\\nacute inflammation and to produce contagious discharge;\\nmakes it less amenable to treatment, and very liable to\\nrelapses of ophthalmia for many years; and often gives\\nrise to deformities of the lid and to serious damage of the\\ncornea. In crowded poor-law schools we see many cases\\nof granular lids in which there is no history of an acute\\nattack having ever occurred, but in ordinary practice it is\\nrare to see such.\\nChronic granular disease is the result (1) of prolonged\\novercrowding, or rather of long residence in badly ven\u00c2\u00ac\\ntilated and damp rooms; it used to be very abundant in\\nthe army and navy, and is still seen in great perfection in\\nworkhouse schools; (2) a generally low state of health, no\\ndoubt, increases the susceptibility to it; (3) it is, cceteris\\nparibus more common and most quickly produced in chil\u00c2\u00ac\\ndren (4) certain races are peculiarly liable to suffer\u00e2\u0080\u0094\\ne. g., the Irish, the Jews and some other Eastern races,\\nand some of the German and French races. The Irish\\nand Jews carry it with them all over the world, and trans\u00c2\u00ac\\nmit the liability to their descendants wherever they live.\\nNegroes in America are said by Bennett to be immune to\\ntrachoma, but his observations have been confined to the\\nSouthern States; (5) damp and low-lying climates are\\nmore productive of it than others; thus it is rare in Switz\u00c2\u00ac\\nerland. Possibly what are now race tendencies may be the\\nexpression of climatic conditions acting on the same race\\nthrough many generations. It is difficult clinically to\\ndecide whether the trachoma growths, apart from the dis\u00c2\u00ac\\ncharge, are caused by contagion or by the influence of noil-\\nvital causes, such as damp and impure air. They are\\nprobably due to an increase of normally existing adenoid\\ntissue, which acts as a filtering agent to prevent the entrance\\nof deleterious matters into the blood. When accompanied", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0123.jp2"}, "124": {"fulltext": "116\\nCLINICAL DIVISION.\\nby discharge the disease is contagious and it is generally\\nheld that the discharge from a case of trachoma is specific\\ni. e., that it will give rise by contagion not only to muco\u00c2\u00ac\\npurulent or purulent ophthalmia, but also to the true gran\u00c2\u00ac\\nular disease.\\nSattler, in 1881-82, believed that he had discovered a\\nspecific microbe for trachoma; his results have been sub\u00c2\u00ac\\nstantially confirmed by Michel and others, but proof is still\\nwanting that the diplococcus of Sattler is the cause of\\ntrachoma. Most of the micro-organisms hitherto described\\nhave been found by Ridley in the normal conjunctiva.\\nThose who practise in the army, or who have charge of\\nsuch institutions as pauper schools, will find that in prac\u00c2\u00ac\\ntice the causes of the chronic granular condition are inex\u00c2\u00ac\\ntricably mixed up with all kinds of facilities for contagion,\\nand that it will be necessary to fight against two enemies\\n\u00e2\u0080\u0094the causes predisposing to chronic granular disease, and\\nthe sources of contagious discharge. The former is to be\\ncombated by improved hygienic conditions, especially by\\nfree ventilation, dry air, abundant open-air exercise, and\\nimprovement of the general vigor. The sources of con\u00c2\u00ac\\ntagion are endless, especially since, as has been stated,\\ngranular patients are liable to relapses of muco-purulent\\ndischarge from almost any slight irritation. Frequent\\ninspection of all the eyes, rigid separation of all who show\\nany discharge or are known as especially subject to re\u00c2\u00ac\\nlapses, arrangements for washing such as will prevent the\\nuse of towels and water in common, extreme care against\\nthe introduction of contagious cases from without\u00e2\u0080\u0094such are\\nthe chief preventive measures. Extra j^recautions will be\\nneeded in time of war or famine, or when measles or scar\u00c2\u00ac\\nlet fever are prevalent, or during marches through hot,\\nsandy, or windy districts.\\nTreatment. The curative treatment, when discharge\\nis present, does not differ from that of the acute ophthal-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0124.jp2"}, "125": {"fulltext": "DISEASES OF THE CONJUNCTIVA,\\n117\\nmise already given. The use of strong astringents, solid\\nsulphate of copper, or caustics, nitrate of silver in strong\\nsolution, or in the mitigated solid pencil, or perchloride of\\nmercury (F. 11), however, is generally needed in order to\\nmake much impression on the granular state of the lids.\\nThe lids being thoroughly everted, are touched all over\\nwith one or other application, and this is repeated daily,\\nor less often some experience being required before we\\ncan decide how often to touch the eyelids in each case.\\nBy careful treatment on this principle most patients may\\nbe kept comfortably free from active symptoms, many\\nrelapses may be prevented, the duration of the disease\\nshortened, and the risks of secondary damage to the\\ncornea much lessened. Do what we will, however, gran\u00c2\u00ac\\nular disease, when well established, is most tedious, and\\nfastens many risks and disabilities on its subjects for years\\nto come.\\nFor routine treatment on a large scale nothing is so\\neffectual as nitrate of silver, either a ten- or twenty-grain\\nsolution or the mitigated solid point (F. 1 and 2). But\\nsilver has the disadvantage of sometimes permanently\\nstaining the conjunctiva after long use, and in very\\nchronic cases I think either sulphate of copper or the\\nlapis divinus (F. 5) is to be preferred, especially as the\\npatient may sometimes be taught to evert his own lids\\nand use it himself. The solid mitigated nitrate of silver\\nneeds washing off with water at first, but in old cases it is\\noften better not to do so.\\nVarious operative measures have been recommended for\\nshortening the duration of the disease; among these are\\nthe burning of the individual granulations with the gal-\\nvano-cautery, and expression or scarification of the granu\u00c2\u00ac\\nlations.\\nThe method of expression is carried out by everting the\\nlid, grasping it between roller forceps, and squeezing out", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0125.jp2"}, "126": {"fulltext": "118\\nCLINICAL DIVISION.\\nthe contents of the granulations; it is often combined with\\nthe application of strong perchloride of mercury to the lid.\\nThese methods undoubtedly lead to a considerable im\u00c2\u00ac\\nprovement in the condition of the lids, which is sometimes\\npermanent; but with the adoption of very severe methods\\nthere is always a risk of increasing the contraction of the\\nconjunctiva.\\nResults of Granular Disease. Friction by the\\ngranulations of the upper lid, Fig. 47, a, especially in\\nFig. 47. 6\\nGranular upper lid. a. Granulations, b. Line of scar in typical position,\\nparallel with border of lid.\\ncases of long standing where some scarring is present\\noften causes cloudiness of the cornea, partly from ulcera\u00c2\u00ac\\ntion, but mainly from the growth of a layer of new and\\nvery vascular tissue in the superficial layers of the cornea\u00e2\u0080\u0094\\npannus, 1 Fig. 48. In later periods the conjunctiva and\\ndeeper tissues are shortened and puckered by the scar\\nfollowing absorption of the granulations,\u00e2\u0080\u009d Fig. 47, b.\\nThese changes, when severe, often lead to inversion of the\\nborder of the lid, entropion; when slighter, some or all of\\nthe lashes may be distorted so as to rub against the cornea,\\n1 It is doubtful how far the development of pannus is due to friction, or to\\nextension of the trachoma over the sclerotic to the cornea. Trachoma bodies\\nmay certainly be sometimes seen on the ocular conjunctiva. Raehlmann\\nstates that the first sign of pannus consists in a collection of lymph-cells in\\nthe cornea beneath Bowman\u00e2\u0080\u0099s membrane; subsequently a layer resembling\\nadenoid tissue is found there containing blood and lymphatic vessels. That\\nfriction may alter the epithelium is proved by certain cases in which the\\nupper half of the cornea loses its polish during a temporary papillary rough\u00c2\u00ac\\nening of the upper lid.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0126.jp2"}, "127": {"fulltext": "DISEASES OF THE CONJUNCTIVA.\\n119\\nwithout actually turning inward, distichiasis, trichiasis; and\\nthese conditions are often combined with pannus. Pannus\\nFig. 48.\\nSection showing layer of new and vascular tissues (pannus) between cpithe\u00c2\u00ab\\nlium (Ept.) and cornea (C.). Scl. Sclerotic. C. M. Ciliary muscle. Sch. C.\\nScnlemm\u00e2\u0080\u0099s canal. I. Iris. X about 10 diameters.\\nbegins beneath the upper lid; its vessels are superficial\\nand continuous with those of the conjunctiva, and are dis\u00c2\u00ac\\ntributed in relation to the parts covered by the lid, not in\\nreference to the structure of the cornea, Fig. 49. The\\nproper corneal tissue suffers but little except where ulcers\\noccur; but when the vascularity is extreme it may soften\\nand bulge, even without ulcerating.\\nPannus disappears when the granular lid or the dis-\\nFlG. 49.\\nPannus affecting upper half of cornea.\\nplacement of lashes is cured. Very severe and universal\\npannus is sometimes best treated by the induction of acute", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0127.jp2"}, "128": {"fulltext": "120\\nCLINICAL DIVISION.\\nconjunctivitis, the inflammation being followed by oblit\u00c2\u00ac\\neration of vessels and clearing of the cornea; this treat\u00c2\u00ac\\nment needs judgment and caution. An infusion of the\\nseeds known in commerce as jequirity\u00e2\u0080\u009d (F. 44), intro\u00c2\u00ac\\nduced into Europe by de Wecker, is used for the pur\u00c2\u00ac\\npose it probably depends for its action upon a non\u00c2\u00ac\\norgan ized ferment such as is found in some other seeds.\\nA very acute attack of diphtheritic or purulent ophthal\u00c2\u00ac\\nmia with much swelling comes on a few hours after the\\ninfusion has been used, lasts a few days, and is followed\\nby a more or less shrinking of the trachoma bodies and of\\nthe vessels. It occasionally causes glandular swellings in\\nthe neck and considerable general disturbance. Repeated\\nattacks may be induced with safety at intervals of a few\\nweeks. Much difference of opinion exists as to the clinical\\nvalue of jequirity, owing to its having been often employed\\ntoo strong and in unsuitable cases; it is not safe unless\\nthere are vessels on the cornea, and, safety apart, it is\\nof little or no use if the conjunctiva be succulent and\\nproducing pus. It should be reserved for old, dry, gran\u00c2\u00ac\\nular lids with more or less pannus, and in such I have\\nrepeatedly had excellent results from it. Removal of a\\nzone of conjunctiva and subconjunctival tissue, syndectomy\\nperitomy from around the cornea is free from risk and some\u00c2\u00ac\\ntimes very beneficial in old cases, which, though severe,\\nare not bad enough for inoculation. In old cases of gran\u00c2\u00ac\\nular disease, even where no complications have arisen, the\\nupper lids often droop from relaxation of the loose con\u00c2\u00ac\\njunctiva above the tarsal cartilage, and the patient acquires\\na sleepy look.\\nFor the cure of the displaced lashes and incurved eye\u00c2\u00ac\\nlids we may (1) repeatedly pull out the lashes with for\u00c2\u00ac\\nceps (2) extirpate all the lashes by cutting out a narrow\\nstrip of the marginal tissues of the lid; (3) attempt by\\noperation to restore the lashes to their proper direction,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0128.jp2"}, "129": {"fulltext": "DISEASES OF THE CONJUNCTIVA.\\n121\\nChapter XXII.; (4) employ electrolysis; for a few lashes\\nI now use sewing needles, inserting several at a time into\\nthe hair follicles and passing the current through all at\\nonce, by means of a broad eyelid forceps. Such opera\u00c2\u00ac\\ntions well selected and carefully performed give very good\\nresults; but as the inner surface of the lid continues to\\nshorten, and this shortening tends to reproduce the orig\u00c2\u00ac\\ninal state of things, some of these procedures give only\\ntemporary relief.\\nChronic conjunctivitis, chiefly of the lower lid, is a com\u00c2\u00ac\\nmon disease, especially in elderly people. There is more\\nor less soreness and smarting, redness and papillary rough\u00c2\u00ac\\nness of the inner surface of the lid or of both lids, but\\nvery little discharge and no trachoma granulations. The\\ncaruncle is red and fleshy, as it is in all forms of palpebral\\nconjunctivitis, and there is often soreness of the lids at the\\ncanthi. Lapis divinus is one of the best applications, and\\nyellow ointment is sometimes useful (F. 5 and 25).\\nLachrymal conjunctivitis. Troublesome chronic conjunc\u00c2\u00ac\\ntivitis, often complicated by small pustules at the roots of\\nthe lashes, or by chronic blepharitis, is a common result of\\nlachrymal obstruction. Micro-organisms of several kinds\\nassociated with pus-formation have been found in these\\nlittle abscesses, as well as in pus from the lachrymal sac.\\nPalpebral conjunctivitis of long standing, with watering,\\ngummy discharge, and more or less blepharitis, should,\\nespecially if confined to one eye, always lead to the sus\u00c2\u00ac\\npicion of mucocele or chronic lachrymal abscess.\\nThe rare disease described as amyloid of the conjunc\u00c2\u00ac\\ntiva seems scarcely to have been noticed in this country.\\nDetailed accounts of its clinical and pathological characters\\nmay be found in Knapp\u00e2\u0080\u0099s Archives of Ophthalmology vols.\\nx. and xi., and an excellent abstract of one of these papers\\nappeared in the Ophthalmic Review for August, 1882.\\nSpring catarrh. A peculiar and apparently specific", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0129.jp2"}, "130": {"fulltext": "122\\nCLINICAL DIVISION.\\nchronic disease, affecting the conjunctiva of the globe and\\nupper lid. In the former situation it takes the form of\\nconfluent, broad patches of fleshy-looking thickening, of a\\nlight-brown, pink color, slightly overlapping the edge of\\nthe cornea for a considerable part of its circumference.\\nIn the latter situation it occurs as large, pale, flat-topped\\ngranulations, which are sometimes made to assume poly\u00c2\u00ac\\ngonal outlines by their pressure upon one another. They\\nbegin, like trachoma, at the inner and outer end of the\\nlid; either variety may occur separately. The disease is\\nworse in the warm part of the year, but it lasts in some\\ncases many years, and gives but little trouble the growths\\non the upper lid do not produce pannus. The thickening\\nis said to consist chiefly of epithelium, and not to affect\\nthe deep tissues.\\nUnlike trachoma, it occurs commonly in all classes of\\nsociety, and is probably not contagious: hence its differ\u00c2\u00ac\\nential diagnosis in children at school is very important.\\nHitherto it has not been much noticed in America, but\\nprobably it is not so rare as has been thought.\\nTreatment can be only palliative, for the disease does\\nnot yield readily to therapeutic measures. Non-irritating\\nremedies should be applied, as caustics and the stronger\\nastringents increase the inflammation. The Editor has\\nhad excellent results follow frequent cleansing of the con\u00c2\u00ac\\njunctival cul-de-sacs with a solution of acetic acid (gr. ij\u00e2\u0080\u0094\\nviij to the ounce). Operative measures are contraindicated.\\nConjunctivitis from drugs. The local use of atropine\\nsometimes gives rise to a peculiar inflammation of the\\nconjunctiva and skin of the lid atropine irritation. The\\nconjunctiva of the lids becomes vascular, thickened, and\\neven granular, and usually the skin is reddened, slightly\\nexcoriated, and somewhat shining. This effect of atro\u00c2\u00ac\\npine is common in old people. Some persons are very\\nsusceptible, and cannot bear even a drop or two with-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0130.jp2"}, "131": {"fulltext": "DISEASES OF THE CONJUNCTIVA.\\n123\\nout suffering in some degree. Scopoline, daturine, and\\nduboisine cause less irritation, and may be used instead;\\nbut it is better, if possible, not to use mydriatics at all\\nfor a few days. An ointment containing lead and zinc\\nshould be applied to the lids, and zinc or silver lotion to\\nthe conjunctiva; sometimes glycerine suits better than\\nointment. In susceptible persons I have not found this\\npeculiar inflammation prevented, either by the use of\\nsolutions made with antiseptics or of solutions quite\\nfreshly made. Eserine sometimes causes identical symp\u00c2\u00ac\\ntoms. Congestion of the conjunctiva has been seen among\\nthose employed in aniline dye works; conjunctivitis was\\nseen by Trousseau in 4 to 5 per cent, of patients treated\\nfor psoriasis by chrysophanic acid. If continued long\\nenough arsenic will in some persons produce redness and\\ncongestion of the conjunctiva. The action of jequirity is\\ndescribed on page 120.\\nOphthalmia nodosa (Saemisch). This singular affection\\nis brought about by the irritation of the caterpillar hairs\\nintroduced into the conjunctival sac. The hairs set up a\\nnodular inflammation of the conjunctiva which may ex\u00c2\u00ac\\ntend to the iris and deeper parts of the eye. The hairs\\nshould be removed from the conjunctiva, and the inflam\u00c2\u00ac\\nmatory symptoms treated as they arise. 1\\nPrimary shrinking of the conjunctiva (Pemphigus of the\\nConjunctiva). A very peculiar and rather rare disease, in\\nwhich, with the phenomena of chronic inflammation, the\\nwhole conjunctiva slowly atrophies and contracts, owing\\nto the formation in it of cicatricial tissue. During the\\nearlier stages the thickening of the tarsus and the con\u00c2\u00ac\\ngestion, with scarring of the palpebral conjunctiva, have\\nsometimes led to the disease being mistaken for trachoma;\\nthe two maladies are, however, quite distinct. Finally the\\nwhole conjunctival sac disappears, and the free borders of\\ni See paper by Lawford Ophthalmic Transactions, vol. xiv. 210.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0131.jp2"}, "132": {"fulltext": "124\\nCLINICAL DIVISION.\\nthe lids, fixed closely to the globe, are directly continuous\\nwith the cornea, which, irritated and dried by exposure\\nand want of secretion, becomes opaque and covered by\\ncrusts\u00e2\u0080\u0094\u00e2\u0080\u009cxerosis.\u00e2\u0080\u009d No treatment seems of any use.\\nIn some of the cases there has been a history of general\\npemphigus, and reason to believe that the disease of the\\nconjunctiva resulted from a modified form of pemphigus\\neruption.\\nBlindness from Exposure to Intense Light. Snow-blind\u00c2\u00ac\\nness. \u00e2\u0080\u0094Chorio-retinitis localized in the macular region has\\nbeen seen at times in individuals who had observed eclipses\\nwithout proper protecting glasses. The inflammation orig\u00c2\u00ac\\ninated by this cause is usually quite active and central\\nvision is always affected. Long exposure of the eyes to\\nthe glare from snow gives rise to an acute conjunctivitis\\nattended with intense pain, photophobia, and occasionally\\nconjunctival hemorrhages. Similar attacks result from\\ntemporary or even momentary exposure to the intense light\\nof the electric arc; this is likely to occur in the operation\\nof electric welding, when the thickness of the arc is very\\ngreat.\\nThe effect on the eye seems to be of the same nature as\\nthe scorching: or blistering of the skin which is sometimes\\nproduced under the same circumstances. According to\\nSnell, 1 spectacles made up of six layers of glass, alter\u00c2\u00ac\\nnately red and blue, are worn as a protection to the eyes\\nby the workmen engaged in this occupation.\\n1 British Medical Association, Bristol, 1894.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0132.jp2"}, "133": {"fulltext": "CHAPTER VII.\\nDISEASES OF THE CORNEA.\\nA. Ulcers and Non-specific Inflammatory Diseases.\\nInflammation of the cornea may be circumscribed or\\ndiffuse, and, though usually affecting the proper corneal\\ntissue, may be limited to the epithelium or either of its\\nsurfaces. It may be a local process leading to formation\\nof pus or to ulceration; or the expression of a constitu\u00c2\u00ac\\ntional disease, such as inherited syphilis; or it may form\\npart, and perhaps only a minor part, of disease involving\\nalso the deeper part of the eyeball\u00e2\u0080\u0094the iris (kerato-iritis),\\nor sclerotic (sclero-keratitis), for example.\\nThe different varieties of corneal ulceration and sup\u00c2\u00ac\\npurative inflammation form a very large and important\\ncontingent of ophthalmic cases. The cornea, although a\\nfibrous structure, is further removed from the bloodvessels\\nthan almost any other tissue, and its delicate surface is\\nmuch exposed it is, therefore, extremely susceptible both\\nto external irritants and to disturbances of nutrition from\\ndefective supply, or bad quality, of blood; ulceration of\\nthe cornea always means deficient vitality. Lastly, its\\nsurface is so delicate, and its perfect transparency and\\nregularity so important, that slight injuries and irritations\\nare of more moment here than in any other part of the\\nbody.\\nWhen inflamed the cornea always loses its transparency.\\nIf only the anterior epithelium be involved, the surface\\nloses its polish, and looks like clear glass which has been\\nbreathed upon\u00e2\u0080\u0094\u00e2\u0080\u0098 steamy/ or finely pitted\u00e2\u0080\u0094a condition\\n125", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0133.jp2"}, "134": {"fulltext": "126\\nCLINICAL DIVISION.\\noccurring in many states of disease. Thickening of the\\nepithelium, and, still more, exudation into the corneal tis\u00c2\u00ac\\nsue, are shown by a white, grayish, or yellowish tint. If\\nthe corneal tissue be opalescent, while .the surface is at the\\nsame time \u00e2\u0080\u009csteamy, the term \u00e2\u0080\u009cground-glass gives a good\\nidea of the appearance, though to make the simile correct\\nthe glass ought to be milky throughout, as well as ground\\non the surface. Rapid suppurative inflammation is pre\u00c2\u00ac\\nceded by a stage of diffused opalescence hence rapid opal\u00c2\u00ac\\nescence is a sign of imminent danger in such diseases as\\npurulent ophthalmia, severe burns, or paralysis of the fifth\\nnerve. Fluorescence of the cornea has been seen as the\\nresult of the use of quinine lotions to the eye, and appears\\nto be due to the deposit of crystals of quinine in the cornea.\\nBefore describing the most important types of corneal\\nulcer, it is convenient to mention the principal changes\\nattendant on ulceration of the cornea in general. An ulcer\\nof the cornea is preceded by a stage of infiltration, and\\nthe inflamed spot is generally a little raised. After the\\ncentre of the spot has broken down into an ulcer, the\\nextent, density, and color of the infiltration at its base\\nand edges are important guides to its future course. The\\nulcer, when healed, leaves a hazy or opaque spot, leucoma\\nif dense, nebula if faint, which is slight and may disappear\\nentirely if superficial, but will in part be permanent if the\\nulcer have been deep. These opacities are likely to clear,\\ncceteris paribus, in proportion to the youth of the patient;\\ntime, also, is a very important element, nebulae often con\u00c2\u00ac\\ntinuing to clear slowly for years; local stimulation aids in\\nthe removal of the opacities, one of the best applications\\nbeing the ointment of yellow oxide of mercury (F. 25, 26).\\nOther modes of local stimulation have been recommended,\\nsuch as tattooing, massage, electrolysis, and the use of various\\npowders, especially insufflations of calomel. If this drug be\\ndusted into the eye, however, the internal administration of", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0134.jp2"}, "135": {"fulltext": "DISEASES OF THE CORNEA.\\n127\\nany of the iodine salts should be discontinued, on account\\nof the formation of iodide of mercury, which is extremely\\nirritating to the eye. Several successful attempts have been\\nmade to transplant circular portions of the clear cornea,\\nremoved from the rabbit by a trephine, to replace portions\\nof the human cornea rendered opaque by disease. To do\\nthis successfully it is necessary to leave behind Descemet\u00e2\u0080\u0099s\\nmembrane in the diseased cornea (v. Hippie). Ulcers\\nwhich have little or no infiltration often heal slowly, but\\nleave a permanent facet or flattening; such facets destroy\\nthe regular curvature of the cornea, and thus often cause\\nmore damage to vision than a considerable degree of mere\\nclouding. During repair bloodvessels often form and pass\\nfrom the nearest part of the corneal edge to the ulcer, to\\ndisappear when healing is complete; phlyctenular ulcers,\\nhowever, are vascular from the beginning. Corneal im\u00c2\u00ac\\nperfections are, of course, most damaging to vision when\\nplaced over the pupil.\\nThe chief symptoms of corneal ulceration are (1) photo\u00c2\u00ac\\nphobia with its consequence, spasm of the orbicularis,\\nblepharospasm; (2) congestion; (3 pain. All three symp\u00c2\u00ac\\ntoms vary extremely in degree in different cases. As a\\nbroad rule, with many exceptions, we may say that intol\u00c2\u00ac\\nerance of light is worse in children than in adults, worse\\nwith superficial than with deep ulcers, and worse in per\u00c2\u00ac\\nsons who are strumous and irritable than in those with\\nhealthy tissues and good tone. Photophobia should always\\nlead to a. careful inspection of the cornea, and we shall\\nthen sometimes be surprised to fiud how slight a change\\ngives rise to this symptom in its severest form. The de\u00c2\u00ac\\ngree of congestion varies with the seat and cause of the\\nulcer, and with the patient\u00e2\u0080\u0099s age, being usually greatest in\\nadults. The visible congestion is, as in iritis, due especi\u00c2\u00ac\\nally to distention of the subconjunctival twigs of the ciliary\\nzone, Fig. 23, Ant. Oil., and Fig. 2G; but there is often", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0135.jp2"}, "136": {"fulltext": "128\\nCLINICAL DIVISION.\\ncongestion of the conjunctival vessels as well. In some\\nforms of marginal ulcer only those vessels which feed the\\ndiseased part are congested. Great pain in and around\\nthe eye often attends the earlier stages of corneal abscess,\\nand is common in many acute ulcers; as a symptom, it, of\\ncourse, always needs careful attention it is generally re\u00c2\u00ac\\nlieved by those local measures which are best for the dis\u00c2\u00ac\\nease itself.\\nTypes of Corneal Ulceration.\\n1. The simple ulcer begins as a little grayish-white spot,\\nat first elevated and bluntly conical, afterward showing a\\nminute, shallow crater; the congestion and photophobia\\nvary, but are often slight. The ulcer is usually single,\\nbut it is apt to recur in the same, or the other eye. The\\ninfiltration often extends into the corneal tissue, and the\\nresidual opacity remains for a long time, if not perma\u00c2\u00ac\\nnently. The patients are always badly nourished. In\\nmost cases the ulcer quickly heals, but now and then the\\ninfiltration passes into an abscess or a spreading, suppu\u00c2\u00ac\\nrating ulcer.\\nLess commonly we meet with a central ulcer, or a suc\u00c2\u00ac\\ncession of ulcers, of a much more chronic character, and\\nattended with little or no infiltration. After lasting for\\nmonths the loss of tissue is only partly repaired, and a\\nshallow depresssion or a flat facet is left, with but little\\nloss of transparency. Some of the best examples are seen\\nin anaemic or strumous patients with granular lids of long\\nstanding.\\n2. Phlyctenular conjunctivitis (phlyctenular keratitis, pus\u00c2\u00ac\\ntular ophthalmia, marginal keratitis, strumous ophthalmia,\\nlymphatic conjunctivitis). The formation of little pap\u00c2\u00ac\\nules, or pustules, on or near the corneal margin is exceed\u00c2\u00ac\\ningly common, either independently, or as a complication\\nof some existing ophthalmia. Although there are many", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0136.jp2"}, "137": {"fulltext": "DISEASES OF THE CORNEA.\\n129\\nvarieties and degrees of phlyctenular inflammation in re\u00c2\u00ac\\nspect to the seat, extent, and course of the disease, the fol\u00c2\u00ac\\nlowing features are common to all. They show a strong\\ntendency to recur during several years; they are seldom\\nFig. 50.\\nPhlyctenular conjunctivitis in a scrofulous subject. (Dalrymple.)\\nseen in very young children, and comparatively seldom\\nafter middle life; they occur often in children who have\\na tendency to enlargement of their lymphatic glands;\\nblepharitis is often seen in the same patients; the first\\nattack often follows closely after an acute exanthem, and\\nespecially after measles; the cases are much influenced\\no", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0137.jp2"}, "138": {"fulltext": "130\\nCLINICAL DIVISION.\\nby climate and weather, and their condition often varies\\nextremely from day to day without making either progress\\nor regress.\\nAn elevated spot, like a papule, commonly about the\\nsize of a small mustard-seed, is seen either on the white\\nof the eye near the cornea, or upon, or just within, the\\nFig. 51.\\nPhlyctenular ophthalmia, conjunctival form. (Dalrymple.)\\ncorneal border. It is preceded and accompanied by local\u00c2\u00ac\\nized congestion. Its top sometimes becomes as yellow as\\nthat of an acne pustule, but more often when seen it has\\nbecome abraded, and aphthous-looking. Pustules at a\\nlittle distance from the cornea, Fig, 51, although gener\u00c2\u00ac\\nally larger than those seated on the corneal border, occa\u00c2\u00ac\\nsion less photophobia, and are more easily cured. Pustules\\nat the corneal border, though often very small, cause trou\u00c2\u00ac\\nblesome and even very severe photophobia; they are\\ntroublesome in proportion rather to their number than\\ntheir size, and if so numerous as to form a ring around\\nthe cornea their cure is often very tedious.\\nA pustule is always liable, even when it has begun on\\nthe conjunctiva, to advance as a superficial ulcer on to the\\ncornea, though it never extends in the opposite direction\\nover the sclerotic. Such a phlyctenular ulcer if it do not\\nstop near the corneal border, will make, in an almost radial\\ndirection, for the centre, carrying with it a leash of vessels", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0138.jp2"}, "139": {"fulltext": "DISEASES OF THE CORNEA.\\n131\\nwhich lie upon the track of opacity left in the wake of the\\nulcer, Fig. 52. Finally, the ulceration stops, the vessels\\ndwindle and disappear, but the path of opacity seldom\\nclears up entirely. The term recurrent vascular ulcer is\\nused when such ulcers are solitary; but they are often\\nFig. 52.\\nPhlyctenular ulcer. (Travers.)\\nmultiple as well as recurrent, and then, in the end, we find\\nthe cornea covered by a thin, irregular network of super\u00c2\u00ac\\nficial vessels on a patchy, uneven, hazy surface, the so-called\\n\u00e2\u0080\u0098\u00e2\u0080\u0098phlyctenular pannus.\\nA common variety of phlyctenular inflammation, aptly\\ncalled marginal conjunctivitis, perhaps allied to the spring\\ncatarrh of Continental authors, occurs in the form of a\\nslight, granular-looking, often vascular swelling, beginning\\nas a crescent above or below, but often extending all round\\nthe edge of the cornea. If the process continue the cornea\\nis invaded by a densely vascular, superficially ulcerated,\\nand yet thickened zone. It is to be distinguished from a\\ndeeper variety of marginal keratitis alluded to at p. 141.\\nIn another variety a single pustule just within the border\\nof the cornea ulcerates deeply, becomes surrounded by\\nswollen, softened, suppurating tissue, and may perforate;\\nsuch cases are seen in weaklv women and strumous children.\\nIn very rare cases, what appears to be an ordinary conjunc\u00c2\u00ac\\ntival pustule persists, grows deeply, and may even perforate", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0139.jp2"}, "140": {"fulltext": "132\\nCLINICAL DIVISION.\\nthe sclerotic in the form of an ulcer or it may infiltrate the\\nsclerotic and the ciliary body beneath, forming a soft, seini-\\nsuppnrating tumor, whence the inflammation is likely to\\nspread to the vitreous and destroy the eye. Stopping short\\nof these extreme results, such a .case forms one type of\\nepiscleritis. Chapter IX.\\nOccasionally a large, sometimes solitary blister forms\\nunder the anterior corneal epithelium; it rises quickly,\\nis attended by severe neuralgic pains, which is often re\u00c2\u00ac\\nlieved when the vesicle bursts, about a day after the onset.\\nThe condition is liable to relapse in the same cornea, and\\nseems often, though not always, to have its origin in a\\nsuperficial injury. It is sometimes called relapsing bul\u00c2\u00ac\\nlous keratitis.\\nThe corneal changes produced by the friction of granu\u00c2\u00ac\\nlar lids have been considered under that subject. The\\npannus of granular lids usually differs from the \u00e2\u0080\u009cphlyc\u00c2\u00ac\\ntenular pannus just mentioned in being denser and more\\nuniform beneath the upper lid, Fig. 49; any doubt is dis\u00c2\u00ac\\npelled by everting the lid. But it must be borne in mind\\nthat ulceration of the cornea often occurs as a complica\u00c2\u00ac\\ntion of trachomatous pannus.\\n3. In old persons a crescentic ulcer sometimes forms in\\nthe situation of, or actually upon, an arcus senilis. Though\\nthese cases generally do well, they should be watched, for\\nat first they may be indistinguishable from more serious\\nforms about to be described.\\nIn rare cases, the ulcer instead of healing shows a ten\u00c2\u00ac\\ndency to spread, and gradually to invade the whole cornea,\\nthe characteristic feature being the undermining of the\\nadjacent healthy cornea by the advancing edge of the\\nulcer. Perforation never takes place, but with occasional\\nperiods of quiescence the whole surface of the cornea is\\ninvaded, and rendered permanently opaque. This form of\\nchronic serpiginous ulcer is more common in tropical coun-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0140.jp2"}, "141": {"fulltext": "DISEASES OF THE CORNEA.\\n133\\ntries than in England, and seems to yield to no treatment\\nshort of the actual cautery. It is sometimes known as\\nrodent ulcer of the cornea.\\n4. Acute infective corneal ulcers. Several varieties of dan\u00c2\u00ac\\ngerous corneal ulcer may be grouped together as probably\\ndepending upon local infection, and there seems to be no\\nFig. 53.\\nAcute serpiginous ulcer of cornea, with crescentic border of infiltration.\\n(From a sketch by Dr. Herbert Habershon.)\\ndoubt that destructive inflammation of the cornea may\\noccur in utero. Differing widely in rapidity and depth,\\nthey argee in being often the result of slight injuries by\\nchips of metal, beards of corn, etc., in tending to spread\\nat one border while healing at another, in the absence of\\n\u00e2\u0080\u009cvessels of repair,\u00e2\u0080\u009d such as are usually formed during the\\nhealing of other ulcers, and in being often complicated\\nwith hypopyon. Fig. 54.\\nThe most important variety is the acute serpiginous ulcer,\\nwhich begins as a gray spot showing slight ulceration, and\\nhaving a sharply cut border, one part of which is more\\ndensely opaque than the rest Fig. 53; this infiltrated, ad\u00c2\u00ac\\nvancing edge is the distinguishing mark of the ulcer. If\\nthe ulcer have lasted some little time, a portion of its edge,\\nusually that nearest the corneal border, will be more or\\nless filled up in such a state the most conspicuous part of\\nthe ulcer is crescentic. Fig. 53. Unless quickly checked\\nthe process often spreads widely, eats deeply, becomes com-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0141.jp2"}, "142": {"fulltext": "134\\nCLINICAL DIVISION.\\nplicated with iritis and hypopyon, and leads to perforation\\nof the cornea.\\nProbably many cases of corneal abscess and acute sup\u00c2\u00ac\\npurating ulcer of less distinct type than the above are,\\nlike it, due to infection.\\nAbscess may occur at any age, but, like serpiginous\\nulcer, is more common in those who are old, underfed, or\\ndamaged by drink; the simple ulcer of children, however,\\nmay go on to abscess. Abscess usually forms at the centre\\nof the corneal area as a small round raised spot, with great\\npain and congestion; rapidly enlarging, it usually bursts\\nforward, leaving a round ulcer covered with lymphy pus,\\nbut it may perforate the hinder surface of the cornea;\\nhypopyon often occurs. The purulent infiltration may\\nspread rapidly and destroy almost the whole cornea.\\nHypopyon signifies a collection of pus or puro-lymph at\\nthe lowest part of the anterior chamber; its upper boun\u00c2\u00ac\\ndary is usually, but not always level. Fig. 54. It may\\noccur with any ulcer, whether deep or not, which is accom\u00c2\u00ac\\npanied by purulent infiltration of the surrounding cornea;\\nor with corneal abscess. The pus may be derived either\\nfrom an abscess breaking through the posterior surface of\\nthe cornea, or from suppuration of the epithelium covering\\nDescemet\u00e2\u0080\u0099s membrane, or from the surface of the iris.\\nSimple iritis now and then gives rise to hypopyon. The\\ndiameter of the anterior chamber being rather greater\\nthan the apparent diameter of the clear cornea, a very\\nsmall hypopyon may be hidden behind the overlapping\\nedge of the sclerotic. In some cases of severe corneal\\nsuppuration, Fig. 55, a, the pus sinks down between the\\nlamellae of the cornea, b. To this condition the term onyx\\nis applied, and should be limited, though it is sometimes\\nused in other senses. The term, however, may very well\\nbe discarded. Onyx and hypopyon often co-exist, and\\nthen the distinction between them can hardly be made", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0142.jp2"}, "143": {"fulltext": "DISEASES OE THE CORNEA\\n135\\nwithout tapping the anterior chamber. Hypopyon, if\\nliquid, will, but onyx will not, change its position if the\\npatient lies down; as, however, the pus of hypopyon is\\noften gelatinous or fibrinous, this test loses much of its\\nvalue. The distinction can sometimes be made by means\\nof oblique illumination, if the cornea in front of an hypo\u00c2\u00ac\\npyon remain clear.\\nFig. 54.\\nHypopyon, seen from the\\nfront, and in section, to show\\nthat the pus is behind the\\ncornea.\\nFig. 55.\\n5. Keratomalacia or primary sloughing of the cornea,\\noccurs in young children who are the subjects of grave\\ndisturbances of nutrition. The first manifestation of the\\naffection is a dryness of the conjunctiva, which is no\\nlonger moistened by the tears; small, triangular patches\\nof roughened epithelium, covered with foam, similar to\\nthose which appear in adults with night-blindness, so\\ncalled xerotic patches, are found on each side of the cor\u00c2\u00ac\\nnea. The dryness spreads to the cornea, which soon be\u00c2\u00ac\\ncomes dull; this is followed by infiltration and rapid\\ndestruction of the whole or part of the cornea. In the\\ntypical cases there is little intolerance of light and no dis\u00c2\u00ac\\ncharge. Keratomalacia appears in England mostly in", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0143.jp2"}, "144": {"fulltext": "136\\nCLINICAL DIVISION.\\nhand-reared infants who are insufficiently nourished in\\nconsequence of unsuitable food or of prolonged diarrhoea;\\nit may occur after severe attacks of measles, scarlet fever,\\netc., and frequently comes on during the late stages of not\\nvery severe ophthalmia neonatorum in children who are the\\nsubjects of congenital syphilis. It also occurs in breast-fed\\ninfants in countries where long religious fasts are practised.\\nThe children are extremely ill, and very frequently die.\\n6. Febrile herpes of the cornea appear as small vesicles\\nwhich rupture and leave shallow, punched-out ulcers.\\nThese sometimes spread generally over the surface, having\\na defined gray, infiltrated edge, but occasionally the ulcera\u00c2\u00ac\\ntion takes the form of a stem with irregular, broad buds or\\nbranches, not unlike a liverwort, the disease being super\u00c2\u00ac\\nficial from beginning to end and showing no tendency to the\\nformation of pus, but spoiling the surface of the cornea\u00e2\u0080\u0094\\ndendritic creeping ulcer.\\nIn rare cases of keratitis beginning as vesicles, small\\nfilaments are seen adhering to the surface of the cornea;\\nthese filaments are seen under the microscope to consist of\\na twisted strand made up of epithelial cells and mucus.\\nThis affection has been called filamentary keratitis (Leber,\\nNuel, Hess).\\nSuperficial punctate keratitis (Fuchs) probably also be\u00c2\u00ac\\nlongs to this group. It begins with the symptoms of an\\nacute catarrh of the eyes and nose. The corneal changes\\nconsist of minute gray opacities with a slightly raised sur\u00c2\u00ac\\nface the symptoms of irritation soon disappear, but the\\nopacities persist for a longer period. They do not ulcer\u00c2\u00ac\\nate, and as a rule the vision is unimpaired.\\n7. For Herpes Zoster and Neuro-paralytic Keratitis, see\\nChapter XXIII.\\n8. Ulceration of the cornea from exposure occurs in par\u00c2\u00ac\\nalysis of the orbicularis, in some cases of cicatricial con\u00c2\u00ac\\ntraction of the lid, in severe cases of exophthalmic goitre,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0144.jp2"}, "145": {"fulltext": "DISEASES OF THE CORNEA.\\n137\\nand in persons who are comatose for any length of time.\\nIt is often possible to avoid this by closing the lids with\\na strip of adhesive plaster, but it may be necessary to pare\\nthe edges of the lid and stitch them partly together.\\n9. A form of keratitis has been observed in those en\u00c2\u00ac\\ngaged in shucking oysters, to which the name of oyster-\\nshuckers keratitis has been given. Randolph, of Baltimore,\\nshowed that this was not a purely infectious disease, but\\nthat it was due to mechanical irritation of the cornea by\\nthe fine particles of lime of the oyster-shell.\\nTreatment of Ulcers of the Cornea. The prin\u00c2\u00ac\\nciples of local treatment for the various types of corneal\\nulceration .are 1. To favor healing by keeping the surface\\nat rest. 2. To relieve pain, photophobia, and severe con\u00c2\u00ac\\ngestion. 3. To promote absorption of pus, whether in\\nthe corneal layers or in the anterior chamber. 4. To\\ncheck the spread of local infection by scraping, actual\\ncautery, and antiseptics. 5. By incision to evacuate pus\\nbetween the corneal layers (abscess), or in the anterior\\nchamber (hypopyon), when abundant or increasing. 6.\\nTo stimulate the surface of ulcers which have begun to\\nheal, or of indolent ones which are stationary. 7. Counter\u00c2\u00ac\\nirritation by a seton in certain chronic cases. 8. When\\nthe corneal ulceration is caused by granular lids, or asso\u00c2\u00ac\\nciated with any form of acute ophthalmia, the treatment\\nof the conjunctiva is usually more important than that\\nof the cornea. 9. Where nutrition is defective, as in\\nkeratomalacia, it is highly necessary to inquire into and\\nremedy any defect in feeding; cod-liver oil is generally of\\ngreat value in such cases.\\nOften we have no difficulty in deciding upon the treat\u00c2\u00ac\\nment. But in some cases, especially the severer ones,\\nmuch judgment is needed and it is sometimes impossible\\nto predict with certainty what measures will be best.\\nUlcers of the cornea are so often a sign of bad health", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0145.jp2"}, "146": {"fulltext": "138\\nCLINICAL DIVISION.\\nthat every care should be bestowed upon the patient\u00e2\u0080\u0099s gen\u00c2\u00ac\\neral state.\\nTreating the matter clinically, we shall find that local\\nstimulation is best for a large number of the cases, as they\\nfirst come under notice, including phlyctenular cases,\\nchronic superficial ulcers of various kinds, and even many\\nrecent ulcers if not threatening to suppurate. As a gen\u00c2\u00ac\\neral rule, this plan alone is not suitable when there is much\\nphotophobia, but exceptions occur, especially in old-standing\\ncases. The most convenient remedy is the ointment of\\namorphous yellow oxide of mercury (F. 12 and 13), of\\nwhich a piece about as large as a hemp-seed is to be put\\ninside the eyelids once or twice a day. If smarting con\u00c2\u00ac\\ntinue for more than half an hour the ointment should be\\nwashed out with warm water; and if the irritability in\u00c2\u00ac\\ncrease after a few days\u00e2\u0080\u0099 use of the ointment, the prepara\u00c2\u00ac\\ntion must be weakened or discontinued. The same oint\u00c2\u00ac\\nment, combined with atropine, gives excellent results in\\ncases of superficial ulcer with much photophobia (F. 14).\\nCalomel flicked into the eye daily or less often is also an\\nadmirable remedy. Nitrate of silver in the form of solid\\nmitigated stick (F. 1) is useful if carefully applied to large\\nconjunctival pustules, and occasionally to indolent corneal\\nulcers; its use, however, needs some skill, and is seldom\\nreally necessary\u00e2\u0080\u0094solutions of from 5 to 10 grains to the\\nounce may be cautiously used by the surgeon instead of\\nthe yellow ointment, and are particularly valuable in old\\nvascular ulcers and in ulcers with conjunctivitis. When\\nin doubt it is best to depend for a few days on atropine\\nalone, used once or twice a day.\\nIn all cases of corneal disease attended with intolerance\\nof light the patient is to wear a large shade over both eyes,\\nor, better, a pair of \u00e2\u0080\u009cgoggles;\u00e2\u0080\u009d a little patch over one\\neye does not relieve photophobia. If the intolerance of\\nlight be excessive, it is sometimes useful to douche the face", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0146.jp2"}, "147": {"fulltext": "DISEASES OF THE CORNEA.\\n139\\nand eyes with a stream of cold water. The patients should\\nbe allowed to go out; many a child is kept within doors,\\nto the injury of its health, who, with suitable protection,\\ncan go out daily without the least detriment to its eyes.\\nIn chronic and relapsing cases, with photophobia and\\nirritability, where all other methods have had a good trial,\\na seton gives the best results, whether the eye be much\\ncongested or not. The silk must be very thick, the punc\u00c2\u00ac\\ntures should be at least an inch apart, and be so placed\\nthat the scars may be hidden by the hair on the temple\\nor behind the ear. The seton is to be moved daily, and if\\nacting badly may be dressed with savin ointment; it should\\nbe worn at least six weeks. Severe inflammation, and even\\nabscess, sometimes sets in a few days after the insertion of\\nthe thread, and in very rare cases secondary bleeding has\\noccurred from a branch of the temporal artery. To avoid\\nwounding this artery the skin is to be held well away from\\nthe head.\\nVery severe, recent phlyctenular cases are occasionally\\ndifficult to influence, and remain practically blind with\\nspasm of the lids for weeks. There is seldom any risk,\\nprovided that the cornea be examined at intervals of a\\nfew days, and in the end such cases do well. Calomel\\ndusted on the cornea sometimes helps more than any other\\nlocal measure, and change of air, especially to the seaside,\\nfrequently effects a more rapid cure than any local treat\u00c2\u00ac\\nment.\\nCases for which the stimulating treatment is suitable\\nseldom need the eye to be bandaged, though, as men\u00c2\u00ac\\ntioned, they often need a shade or goggles.\\nThe remaining methods are applicable to the severer\\nforms of ulceration\u00e2\u0080\u0094the serpiginous ulcer, deep suppu\u00c2\u00ac\\nrating ulcers, abscess, and generally all ulcers with hypo\u00c2\u00ac\\npyon, and all acute ulcers in elderly persons. In many\\ncases of severe type, at an early stage, the pain may be", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0147.jp2"}, "148": {"fulltext": "140\\nCLINICAL DIVISION.\\nrelieved and the ulceration stopped by very hot fomenta\u00c2\u00ac\\ntions (of water, poppyhead, or belladonna) to the eyelids\\nfor twenty minutes every two hours, the eye being tied up\\nin the internals with a large pad of cotton-wool and ban\u00c2\u00ac\\ndage, and atropine used two or three times a day; the\\npatient must rest, have good food, often with alcohol, and\\ntake quinine, or bark and ammonia. If, nevertheless, the\\nulceration spread, or a hypopyon form or increase, incision\\nof the cornea and the use of topical remedies are called\\nfor. Of such remedies the best seem to be the actual\\ncautery, preceded by scraping with a sharp spoon, and\\nfollowed by iodoform or boric acid. The actual cautery\\nmay be either the fine galvano-cautery, or a very small\\nPaquelin the edge of the ulcer is to be well burnt before\\nthe heat is applied to the floor, and I like to burn a little\\nbeyond the opaque edge. Instead of the cautery, pure\\ncarbolic acid or strong solutions of nitrate of silver,\\napplied directly to the ulcer, often succeed in checking\\nits course.\\nIodoform, which is probably the most useful corneal\\nantiseptic, may be used in powder or strong ointment (20\\nor 30 gr. to 5 j; F. 30) freely three times a day or more;\\nit gives no pain. Boric acid may be used in the same\\nway. For dendritic ulcers, absolute alcohol rubbed thor\u00c2\u00ac\\noughly into the ulcerated surface, or pure carbolic acid or\\nperchloride of mercury of 2 or 4 per cent, strength applied\\nwith a camel-hair brush, are generally successful.\\nHypopyon, if large, Fig. 54, or increasing, must be let\\nout, and on the whole, for most cases, Saemisch\u00e2\u0080\u0099s plan of\\ncutting through the cornea quite across the ulcer is the\\nbest for this purpose, because if there be pent-up pus in\\nthe cornea this section will allow its removal at the same\\ntime; the section should be made with a Graefe\u00e2\u0080\u0099s cataract\\nknife, Fig. 170, entered with its back toward the lens at\\none border of the ulcer, carried across the anterior cham-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0148.jp2"}, "149": {"fulltext": "DISEASES OE THE CORNEA.\\n141\\nber, and brought out at the other side of the ulcer. It is\\nsometimes an advantage to keep up leakage by reopening\\nthe wound with a probe for a few days. Corneal section\\nalso often instantly relieves the severe pain of these cases;\\nthe section may sometimes be made with equally good\\neffect in the lower part of the cornea away from the ulcer.\\nIf the ulcer have already perforated and the eye be worth\\nsaving, iridectomy should be done, either by drawing the\\nprolapsed iris freely through the perforation and cutting\\nit off, or by making an incision in a sound part of the\\ncornea. I believe that careful scraping and burning will\\ndo much to reduce the severity of infective corneal ulcers.\\nSome of these ulcers are accompanied by a good deal of\\nmuco-purulent conjunctivitis, for which a ten-grain solu\u00c2\u00ac\\ntion of nitrate of silver, painted inside the lower lid with\\na brush about once a day, may generally be used its effect\\nmust be watched, and its employment discontinued if it\\nincreases irritability.\\nUse of atropine and eserine in severe ulcers of the cornea.\\nFormerly either atropine, or belladonna lotion, was used\\nfor nearly every case of severe corneal ulcer. Atropine\\noften relieves pain, prevents or lessens iritis, and probably\\nlessens engorgement of the vessels of the iris and ciliary\\nregion it may generally be used, sparingly, as an auxil\u00c2\u00ac\\niary in suppurating and serpiginous cases, but it tends to\\nincrease any existing conjunctival inflammation. During\\nthe last few years eserine has come into use for certain\\ncases which would formerly have been treated chiefly by\\natropine. The deep, funnel-shaped, suppurating ulcer\\nwhich sometimes develops from a marginal pustule is the\\nmost suitable for treatment by eserine, whether compli\u00c2\u00ac\\ncated with hypopyon or not. Although in a bad case of\\nthis sort, hot fomentations and the compress are necessary,\\nI have seen a certain number of less severe ones recover\\nunder eserine alone, used about six times a day (F. 39).", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0149.jp2"}, "150": {"fulltext": "142\\nCLINICAL LI VISION.\\nEserine probably acts partly by enlarging the surface of\\nthe iris and dilating the ciliary arteries, thus favoring ab\u00c2\u00ac\\nsorption and increasing the nutrition of the cornea. For\\nthis reason in keratomalacia, where the cornea suffers from\\ninsufficient nourishment, it should be used without delay.\\nThe opacity sometimes clears up in a remarkable way\\nunder its use; possibly, also, it acts locally on the ulcer\u00c2\u00ac\\nated surface. There is no clinical proof that eserine lowers\\ntension unless the tension has been previously increased, as\\nit seldom is in corneal ulcers. Eserine causes congestion\\nof the deep vessels of the ciliary region, and after a time\\nincreases the photophobia and irritability of the eye these\\nsymptoms usually coincide with disappearance of the cor\u00c2\u00ac\\nneal infiltration and the commencement of vascularization\\nof the ulcer, and when this stage is reached the eserine\\nshould be discontinued.\\nThe alteruate use of heat and cold for short periods is\\nrecommended in some obstinate cases of corneal ulceration,\\nthe object being to improve nutrition by causing frequent\\nchanges in the quantity and rate of the blood-supply.\\nB. Diffuse Keratitis.\\nSyphilitic, interstitial or parenchymatous keratitis.\\nIn this disease the cornea in its whole thickness under\u00c2\u00ac\\ngoes a chronic inflammation, which shows no tendency\\neither to the formation of pus or to ulceration. After\\nseveral months the inflammatory products are either\\nwholly or in great part absorbed, and the transparency\\nof the cornea restored in proportion.\\nThe changes in the cornea are usually preceded for a\\nfew days by some ciliary congestiou and watering. Then\\na faint cloudiness is seen in one or more large patches, and\\nthe surface, if carefully looked at, is found to be steamy.\u00e2\u0080\u009d\\nThese nebulous areas may lie in any part of the cornea. In", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0150.jp2"}, "151": {"fulltext": "DISEASES OF THE CORNEA.\\n143\\nfrom two to about four weeks the whole cornea has usually\\npassed into a condition of white haziness, with steamy sur\u00c2\u00ac\\nface, of which the term ground-glass gives the best idea.\\nEven now, however, careful inspection, especially by focal\\nFig. 56.\\nInterstitial keratitis.\\nlight, will show that the opacity is by no means uniform,\\nthat it shows many whiter spots, or large, denser clouds,\\nscattered about in the general mist; in very severe cases\\nthe whole cornea is quite opaque and the iris hidden but\\nFig. 57.\\nThickening of cornea and formation of vessels in its layers in syphilitic\\nkeratitis. Subconjunctival tissue thickened. X about 10 diameters. Com\u00c2\u00ac\\npare with Fig. 48.\\nas a rule the iris and pupil can be seen, though very imper\u00c2\u00ac\\nfectly. Fig. 56. In many cases iritis occurs and posterior\\nsynechise are formed; cyclitis, with deposit in the back of\\nthe cornea, is a very frequent accompaniment of the cor\u00c2\u00ac\\nneal affection; in a large proportion of cases of interstitial", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0151.jp2"}, "152": {"fulltext": "144\\nCLINIC A L I) I VISION.\\nkeratitis there is evidence of early participation of the\\nuveal layer in the inflammatory process. Bloodvessels\\nderived from branches of the ciliary vessels, Fig. 23, are\\noften formed in the layers of the cornea, Fig. 57; they\\nare small but set thickly, and in patches; as they are\\ncovered by a certain thickness of hazy cornea, their\\nbright scarlet is toned down to a dull reddish-pink color\\n\u00e2\u0080\u0094\u00e2\u0080\u009csalmon patch of Hutchinson. The separate vessels\\nare visible only if magnified (p. 71), when we see that the\\ntrunks, passing in from the border, divide at acute angles\\ninto very numerous twigs, lying close to each other, and\\nFig. 58.\\nVessels in interstitial keratitis. Marginal vascular keratitis.\\ntaking a nearly straight course toward the centre, Fig. 58.\\nThese salmon patches, when small, are often crescentic,\\nbut if large tend to assume a sector-shape. In another\\ntype the vascularity begins as a narrow fringe of looped\\nvessels which are continuous with the loop plexus of the\\ncorneal margin, Fig. 59, compare Fig. 23, l, and gradually\\nextend from above and below toward the centre. The vessels\\nin these cases are somewhat more superficial, and the cor\u00c2\u00ac\\nneal tissue in which they lie is always swollen by infiltra\u00c2\u00ac\\ntion. This type, which forms a variety of marginal kera\u00c2\u00ac\\ntitis, compare p. 131, usually occurs in syphilitic subjects,\\nFig. 59.\\n1", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0152.jp2"}, "153": {"fulltext": "DISEASES OF THE CORNEA.\\n145\\nbut I believe that some of the patients are at the same\\ntime strumous. A similar condition, sometimes leading to\\nsecondary glaucoma, occurs now and then in elderly people.\\nIn extreme cases of either type of vascular keratitis the\\nvessels cover the whole cornea, except a small central\\nisland.\\nThe degree of congestion and the subjective symptoms\\nin syphilitic keratitis vary very much; as a general rule\\nthere is but moderate photophobia and pain, but when the\\nciliary congestion is great these symptoms are sometimes\\nvery severe and protracted.\\nThe attack can be shortened and its severity lessened by\\ntreatment; but the disease is always slow, and from six to\\ntwelve months may be taken as a fair average for its dura\u00c2\u00ac\\ntion from beginning to end. Very bad cases with exces\u00c2\u00ac\\nsively dense opacity sometimes continue to improve for\\nseveral years, and may recover an unexpected degree of\\nsight. Perfect recovery of transparency is less common,\\neven in moderate cases, than is sometimes supposed, but\\nthe slight degree of haziness which so often remains does\\nnot much affect the sight. The epithelium usually becomes\\nsmooth before the cornea becomes transparent, but in severe\\ncases irregularities of surface may remain and render the\\ndiagnosis difficult. Very minute vessels, as in Fig. 58, seen\\nby direct ophthalmoscopic examination with a high -f- lens\\n(p. 71), nearly straight, and branching at acute angles with\\nshort, abrupt rectangular bends here and there, are often\\nleft, and when found are good evidence of previous inter\u00c2\u00ac\\nstitial keratitis.\\nSyphilitic keratitis is almost always symmetrical, though\\nan interval of a few weeks commonly separates its onset in\\nthe two eyes; rarely the interval is several months, a year,\\nor even more. It generally occurs between about the ages\\nof six and fifteen sometimes as early as two and a half\\nor three years; in rare instances it may set in after forty\\n10", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0153.jp2"}, "154": {"fulltext": "146\\nCLINICAL DIVISION.\\nmany of the very late cases are severe and complicated. If\\nit occur very early, the attack is generally mild. Relapses\\nof greater or less severity are common. Not only does iritis\\noccur with tolerable frequency, but we occasionally meet\\nwith deep-seated inflammation in the ciliary region, giving\\nrise either to secondary glaucoma, or to stretching and\\nelongation of the globe in the ciliary zone, or to soften\u00c2\u00ac\\ning and shrinking of the eyeball. 1 Dots of opacity may\\nsometimes be seen on the back of the cornea at its lower\\npart, before the cornea itself is much altered (p. 148); some\u00c2\u00ac\\ntimes, too, the interstitial exudation is much more dense at\\nthe lower part of the cornea than elsewhere. Syphilitic\\nkeratitis in strumous children often shows more irri\u00c2\u00ac\\ntability, photophobia, and conjunctival congestion than\\nin others; but it is very seldom that ulceration occurs,\\nand although in the worst cases the cornea becomes soft\u00c2\u00ac\\nened and yellowish, and for a time seems likely to give\\nway, actual perforation is one of the rarest events.\\nPannus from granular disease may coexist with syphilitic\\nkeratitis.\\nTreatment. A long but mild course of mercury is cer\u00c2\u00ac\\ntainly of use. It is customary to give iodide of potassium\\nalso, and it probably has some influence. If the patients\\nbe very anaemic, and they often are so, iron, or the syrup\\nof its iodide, is more advisable than iodide of potassium\\nas an adjunct to the mercury. Locally it is well to use\\natropine by routine until the disease has reached its height,\\non the ground that iritis may be present. Setons, in my\\nexperience, are seldom of use; but in cases attended by\\nsevere and prolonged photophobia and ciliary congestion\\n1 When the cornea has cleared, ophthalmoscopic signs of past choroiditis,\\nChapter XII., are often found at the fundus. The choroiditis often dates\\nmuch further back than the keratitis, but there is little doubt that it may\\nrelapse, or occur as an accompaniment of the corneal disease. Chapter\\nXXIII.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0154.jp2"}, "155": {"fulltext": "DISEASES OF THE CORFEA.\\n147\\niridectomy is occasionally followed by rapid improvement;\\nthis operation, however, is seldom needed or justifiable\\nunless there be decided glaucomatous symptoms. When\\nall inflammatory symptoms have subsided, the local use of\\nyellow ointment or calomel (F. 24 and 25) appears to aid\\nthe absorption of the residual opacity.\\nThe form of keratitis above described is caused by in\u00c2\u00ac\\nherited syphilis. In rare cases it has been seen as the\\nresult of secondary acquired syphilis. Other cases of dif\u00c2\u00ac\\nfuse keratitis occur in which syphilis has no share but they\\nare seldom symmetrical, nor do they occur early in life.\\nThat diffuse chronic keratitis, affecting both eyes of chil\u00c2\u00ac\\ndren and adolescents, is, when well characterized, almost\\ninvariably the result of hereditary syphilis, is proved by\\nabundant evidence. A large proportion of its subjects\\nshow some of the other signs of hereditary syphilis in\\nthe teeth, skin, ears (deafness), physiognomy, mouth, or\\nbones. When the patients themselves show no such signs,\\na history of infantile syphilis in the patient or in some\\nbrothers and sisters, or of acquired syphilis in one or\\nother parent, may often be obtained. 1 That this keratitis\\nstands in no causal relation to struma is clear, because the\\nordinary signs of struma are not found oftener in its vic\u00c2\u00ac\\ntims than in other children, because persons who are de\u00c2\u00ac\\ncidedly strumous do not suffer from this keratitis more\\noften than others, and because the forms of eye disease\\nwhich are universally recognized as strumous\u00e2\u0080\u009d (ophthal\u00c2\u00ac\\nmia tarsi, phlyctenular disease, and relapsing ulcers of\\ncornea) very seldom accompany this diffuse keratitis. Illus\u00c2\u00ac\\ntrations of the teeth in inherited syphilis are given in Fig.\\n181, Chapter XXIII.\\n1 I have found other personal evidence of inherited syphilis in 54 per cent,\\nof my cases of interstitial keratitis, and evidence from the family history in\\n14 per cent, more\u00e2\u0080\u0094total 68 per cent.; and in most of the remaining 32 per\\ncent, there have been strong reasons to suspect it.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0155.jp2"}, "156": {"fulltext": "148\\nCLINICAL DIVISION\\nOther Affections of the Cornea.\\nThe cornea is more or less involved in several diseases in\\nwhich the primary, or the principal, seat of mischief lies\\nin another part of the eye. It is important for purposes\\nof diagnosis to compare these secondary or complicating\\naffections with the primary diseases of the cornea already\\ndescribed.\\nIn iritis the lower half of the cornea often becomes\\nsteamy, and more or less hazy. In some cases a number\\nof small, separate, opaque dots are seen on the posterior\\nelastic lamina (Descemet\u00e2\u0080\u0099s membrane), often so minute\\nas to need magnifying (p. 71). These dots are sharply\\nFig. 60.\\nKeratitis punctata. (From a sketch by Dr. Herringham.)\\ndefined, the large ones looking very like minute drops of\\ncold gravy-fat, the smallest like grains of gray sand in cases\\nof long standing they may be either very white or highly\\npigmented. They are generally arranged in a triangle,\\nwith its apex toward the centre and its base at the lower\\nmargin of the cornea, the smallest dots being near the\\ncentre, Fig. 60; but in some cases, sympathetic ophthal\u00c2\u00ac\\nmitis especially, the dots are scattered over the whole\\ncornea. They are of course difficult to detect in propor\u00c2\u00ac\\ntion as the corneal tissue itself is hazy.\\nThe term keratitis punctata is used to express this accu\u00c2\u00ac\\nmulation of dots on the back of the cornea; and by some\\nauthors is allowed to include also allied cases in which\\nsmall spots with hazy outlines are seen in the cornea", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0156.jp2"}, "157": {"fulltext": "DISEASES OF THE CORNEA.\\n149\\nproper. Keratitis punctata is, almost without exception,\\nsecondary to some demonstrable disease of the cornea, iris,\\nor choroid and vitreous. But a few cases are seen, chiefly\\nin young adults, where the corneal dots form the principal,\\nif not the sole, visible change; the number of such cases\\ndiminishes, however, in proportion to the care with which\\nother lesions are sought (p. 68). Snellen has found micro\u00c2\u00ac\\nscopically that these dots on Descemet\u00e2\u0080\u0099s membrane consist\\nof colonies of bacteria. 1\\nIt is now and then difficult to say, in a mixed case,\\nwhether the iritis or keratitis have been the initial change\\nbut when this doubt arises the cornea has generally been\\nthe starting-point; and with care we are seldom at a loss\\nto decide whether the case be one of syphilitic keratitis\\nwith iritis, of sclerotitis with corneal mischief and iritis,\\nor of primary iritis with secondary haze of the cornea.\\nSee Chapters VIII. and IX.\\nSlight loss of transparency of the cornea occurs in most\\ncases of glaucoma. The earliest change is a fine, uniform\\nsteaminess of the epithelium. In very severe, acute cases\\nthe cornea becomes hazy throughout, though not in a high\\ndegree. The same haze occurs in chronic cases of long\\nstanding with great increase of tension, but the epithelial\\n\u00e2\u0080\u009csteaminess\u00e2\u0080\u009d often then gives place to a coarser \u00e2\u0080\u009cpit\u00c2\u00ac\\nting,\u00e2\u0080\u009d with little depressions and elevations (vesicles), espe\u00c2\u00ac\\ncially on the part which is uncovered by the lids.\\nConical cornea. In this condition the central part of the\\ncornea very slowly bulges forward, forming a bluntly con\u00c2\u00ac\\nical curve. The focal length of the affected part of the\\ncornea is thereby shortened, and the eye becomes myopic.\\nThe curvature, however, is not uniform, and hence irregular\\nastigmatism complicates the myopia. Chapter XX.\\nThe disease, which is rare, occurs chiefly in young adults,\\n2 Ophtli. Revue, 1894, p. 259.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0157.jp2"}, "158": {"fulltext": "150\\nCLINICAL DIVISION.\\nespecially women, and is often associated with chronic dys\u00c2\u00ac\\npepsia its onset is sometimes dated from a severe, exhaust\u00c2\u00ac\\ning illness; it appears to be due to defective nutrition of\\nthat part of the cornea which is furthest from the blood\u00c2\u00ac\\nvessels. In advanced cases the protrusion of the cornea\\nis very evident, whether viewed from the front or from the\\nside, but slight degrees are less easily distinguished from\\nordinary myopic astigmatism. In high degrees the apex\\nof the cone, which is situated rather below the centre of\\nthe cornea, often becomes nebulous. The disease may pro\u00c2\u00ac\\ngress to a high degree, or stop before great damage has\\nbeen done. Concave glasses alone are of little use; but\\nthey are sometimes useful in combination with a screen\\nperforated by a narrow slit or small, central hole, which\\nallows the light to pass only through the centre, or through\\nsome one meridian, of the cornea. In advanced cases an\\noperation must be performed, which, by substituting a con\u00c2\u00ac\\ntracting cicatrix for the corneal tissue at or near the apex\\nof the cone, shall lead to a diminution of the curvature.\\nChapter XXII.\\nIn buphthalmos (hydrophthalmos) the corneal changes\\nare often very conspicuous, although not essential. In this\\nrare and very peculiar malady there is a general and\\nslowly progressive enlargement of cornea, anterior part\\nof sclerotic, and iris, together with extreme deepening of\\nthe anterior chamber and slight increase of tension. The\\ncornea often becomes hazy or semi-opaque. The disease,\\nwhich may perhaps be looked upon as a congenital or in\u00c2\u00ac\\nfantile form of glaucoma, is either present at birth or comes\\non in early infancy, and usually causes blindness. Opera\u00c2\u00ac\\ntive treatment generally fails, but eserine is said to be use\u00c2\u00ac\\nful. See Glaucoma.\\nA rare but peculiar form of corneal disease, generally\\nseen in elderly persons, is the transverse calcareous film\\nforming an oval patch of light-gray opacity, which runs", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0158.jp2"}, "159": {"fulltext": "DISEASES OF THE CORNEA.\\n151\\nalmost horizontally across the cornea. It lies beneath the\\nepithelium, and consists of minute crystalline granules,\\nchiefly calcareous.\\nArcus senilis is caused by fatty degeneration of the cor\u00c2\u00ac\\nneal tissue just within its margin. Fig. 61. It first appears\\nbeneath the upper lid, next beneath the lower, thus forming\\ntwo narrow white or yellowish crescents, the horns of which\\nfinally meet at the sides of the cornea; it always begins,\\nand remains most intense, on a line slightly within the\\nsclero-corneal junction, and the degeneration is most marked\\nin the superficial layers of the cornea, beneath the anterior\\nelastic lamina; in other words, the change is greatest at\\nFig. 61.\\nArcus senilis. (From a sketch by Dr. Herringham.)\\nthe part most influenced by the marginal bloodvessels.\\nArcus, though seldom seen except in senile persons, is not\\nfound to interfere with the union of a wound carried\\nthrough it, though the tissue of the arcus is often very\\ntough and hard.\\nLess regular forms of arcus are seen as the result of\\nprolonged or relapsing inflammations near the corneal\\nborder, whether ulcerative or not. It is generally easy to\\ndistinguish such an arcus, because the opacity is denser\\nand more patchy, and its outlines less regular than in the\\nprimary form; when arcus is seen unusually early in life\\nit is generally of this inflammatory kind, for simple arcus\\nis rare below forty.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0159.jp2"}, "160": {"fulltext": "152\\nCLINICAL I)I VISION.\\nCongenital opacity of the cornea sometimes occurs in\\nmore than one generation or in more than one member of\\na family; one form of congenital opacity closely resem\u00c2\u00ac\\nbles the arcus senilis in form and situation.\\nOpacity of a very characteristic kind is likely to follow\\nthe use of a lotion containing lead when the surface of the\\ncornea is abraded. An insoluble, densely opaque, very\\nwhite film of lead salts is precipitated on, and adheres\\nvery firmly to, the ulcerated surface; the spot is sharply\\ndefined, and looks like white paint. If precipitated on a\\ndeep and much inflamed ulcer, the layer of tissue to which\\nthe film adheres is often thrown off, but when there is only\\na superficial abrasion or ulcer, the lead adheres very firmly,\\nand can only be scraped off imperfectly. But even in the\\nlatter cases the film is probably after a time thrown off or\\nworn off, if we may judge by the fact that nearly all the\\nlead opacities which come under notice are comparatively\\nnew. The practical lesson is never to use a lead lotion for\\nthe eye when there is any suspicion that the corneal sur\u00c2\u00ac\\nface is broken.\\nThe prolonged use of nitrate of silver whether in a weak\\nor strong form, is sometimes followed by a dull, brownish-\\ngreen, permanent discoloration of the conjunctiva, and even\\nthe cornea may become slightly stained.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0160.jp2"}, "161": {"fulltext": "CHAPTER VIII.\\nDISEASES OF THE IRIS.\\nIritis.\\nInflammation of the iris may be caused by certain\\nspecific blood diseases, especially syphilis; or may be the\\nexjwession of a tendency to relapses of inflammation in\\ncertain tissues under the influence largely of climate and\\nweather; it often occurs in the course of ulcers and of\\nwounds and other injuries of the cornea; also with diffuse\\nkeratitis and sclerotitis. Iritis also forms a very impor\u00c2\u00ac\\ntant part of the remarkable and serious disease known as\\nsympathetic ophthalmitis.\\nAcute iritis, whatever its cause, is shown by a change\\nin the color of the iris, indistinctness or muddiness\u00e2\u0080\u009d of\\nits texture, diminution of its mobility, and the formation\\nof adhesions j posterior synechias between its posterior\\n(uveal) surface and the capsule of the lens; there is, be\u00c2\u00ac\\nsides, in most cases, a dulness of the whole iris and pupil,\\ncaused by muddiness of the aqueous humor, and partly\\nalso by slight corneal changes (p. 148). The eyeball is\\ncongested and the sight usually dimmed. There may or\\nmay not be pain, photophobia, and lachrymation.\\nThe congestion is often almost confined to a zone, about\\none-twelfth or one-eighth of an inch wide, which surrounds\\nthe cornea, its color pink (not raw-red), the vessels small,\\nradiating, nearly straight, and lying beneath the conjunc\u00c2\u00ac\\ntiva, ciliary or circumcorneal congestion Fig. 26. These\\nare the episcleral branches of the anterior ciliary arteries.\\nFig. 23. Quite the same congestion is seen in many other\\n153", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0161.jp2"}, "162": {"fulltext": "154\\nCLINICAL DIVISION.\\nconditions, e. g., corneal ulceration (p. 127); while on the\\nother hand, in some cases of iritis, the superficial (conjunc\u00c2\u00ac\\ntival) vessels are engorged also, especially in their anterior\\ndivisions, which are chiefly offshoots of the ciliary system.\\nWe, therefore, never diagnose iritis from the character of\\nthe congestion alone but the disease being proved by the\\nother symptoms, the kind and degree of congestion help\\nus to judge of its severity.\\nThe altered color of the iris is due to its congestion\\nand the effusion of lymph and serum into its substance;\\na blue or gray iris becomes greenish, a brown one is but\\nlittle changed. The inflammatory swelling of the iris\\nalso accounts both for the blurring (muddiness) of its\\nbeautifully reticulated structure, and for the sluggishness\\nof movement noticed in the early period. Lymph is soon\\nthrown out at one or more spots on its posterior surface,\\nand still further hampers its movements by adhering to\\nthe lens-capsule; and most cases do not come under notice\\ntill such synechiae have formed. The quantity of solid\\nexudation, Avhether on the hinder surface or into the\\nstructure of the iris, varies much; it is usually greatest\\nin syphilitic iritis, when distinct nodules of pink or yel\u00c2\u00ac\\nlowish color are sometimes seen projecting from the front\\nsurface, generally close to the pupil. In rare cases pus\\nthrown off by the iris into the aqueous subsides and forms\\nhypopyon; a corresponding deposit of blood constitutes\\nhyphsema. Firm adhesions to the lens-capsule may be\\npresent without much evidence of exudation into the\\nstructure of the iris. Exudative changes are usually\\nmost abundant at the inner ring of the iris, where its\\ncapillary vessels are far the most numerous. Fig. 62.\\nApparent discoloration of the iris is, however, often due\\nentirely to suspension of blood corpuscles, or inflammatory\\nproducts, in the aqueous humor; sometimes this altered\\nfluid coagulates into a slightly turbid, gelatinous mass,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0162.jp2"}, "163": {"fulltext": "DISEASES OF THE IRIS\\n155\\nwhich almost fills the chamber\u00e2\u0080\u0094\u00e2\u0080\u009c spongy exudation.\u00e2\u0080\u009d\\nThe aqueous sometimes becomes yellow without losing\\ntransparency.\\nThe tension of the eyeball, usually unaltered in acute\\niritis, may be a little increased; rarely it is considerably\\ndiminished, and in such cases there are generally other\\npeculiarities.\\nFig. 62.\\nVessels of human iris artificially injected capillaries most numerous at\\npapillary border, and next at ciliary border.\\nThe condition of the pupil alone is diagnostic in all\\nexcept very mild or incipient cases of iritis. It is sluggisli\\nor motionless, and not quite round it is also rather smaller\\nthan its fellow, supposing the iritis to be one-sided, because\\nthe surface of the iris is increased (and the pupil, there\u00c2\u00ac\\nfore, encroached on) whenever its vessels are distended (p.\\n43). Atropine causes it to dilate between the synechia);\\nthe synechise, being fixed, appear as angular projections\\nwhen the iris on each side of them has retracted. If there\\nbe only one adhesion, it will merely notch the pupil at one\\nspot; if the adhesions be numerous, the pupil will be cre-\\nnated oy irregular. Fig. 63. If the whole pupillary ring,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0163.jp2"}, "164": {"fulltext": "156\\nCLINICAL DIVISION.\\nor still more, if the entire posterior surface of the iris\\nbe adherent, scarcely any dilatation will be effected; the\\nformer condition is called annular or circular synechia,\\nand its result is exclusion of the pupil; the latter is known\\nas total posterior synechia. If the synechise be new and\\nthe lymph soft, the rejfeated use of atropine will break\\nthem down, and the pupil will become round; but even\\nthen some of the uveal pigment, which is easily separable\\nfrom the posterior surface of the iris, often remains behind,\\nFig. 63. Fig. 64.\\nIritic adhesions (posterior synechise) causing irreg- Spots of pigment and\\nularity of pupil. (Wecker and Jaeger.) lymph at seat of former\\niritic adhesions.\\nglued to the lens-capsule by a little lymph. Fig. 64. The\\npresence of one or more such spots of brown pigment on\\nthe capsule is always conclusive proof of present or of past\\niritis. The pupillary area itself in severe iritis is often filled\\nby grayish or yellowish lymph, which spreads over it from\\nthe iris; if such exudation becomes organized, a dense\\nwhite membrane or a delicate film, often, however, pre\u00c2\u00ac\\nsenting one or more little clear holes, is formed over the\\npupil \u00e2\u0080\u0094occlusion of the pupil. The iris may be inflamed\\nwithout any lymph being effused from its hinder surface,\\nand then the pupil, though sluggish, acting imperfectly to\\natropine, and never dilating widely, will present no poste\u00c2\u00ac\\nrior synechise nor any adhesion of pigment spots to the\\nlens, but it will always be discolored (serous iritis); iritis\\nof this kind often occurs with ulceration of the cornea,\\nand as a complication of deeper inflammations (p. 170).", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0164.jp2"}, "165": {"fulltext": "DISEASES OE THE IBIS.\\n157\\nPain referred to the eyeball and to the parts supplied by\\nthe first, and sometimes by the second division of the fifth\\nnerve, is common with iritis, especially in the early period.\\nIt is, however, a very variable symptom, and gives no clue\\nto the amount of structural change, being sometimes quite\\ninsignificant when much lymph is thrown out. The pain\\nis seldom constant, but comes on at intervals, is often worse\\nat night, and is described as shooting, throbbing, or aching.\\nIt is commonly referred to the temple or forehead, as well\\nas to the eyeball; sometimes also to the side of the nose\\nand to the upper teeth. Photophobia and watering are\\ngenerally proportionate to the pain.\\nThe duration of acute iritis varies from a few days, when\\nmild, to many weeks when severe. The defect of sight is\\nproportionate to the haziness of the cornea, aqueous, and\\npupillary space, but in some cases is increased by changes\\nin the vitreous. Iritis sometimes sets in very gradually,\\ncausing no marked congestion or pain, but slowly giving\\nrise to the formation of tough adhesions, and often to the\\ngrowth of a thin membrane over the pupillary area; in\\nsome of these cases the iris becomes thickened and tough,\\nand its large vessels undergo much dilatation, while in others\\nkeratitis punctata occurs. See Cyclitis, p. 170; Diseases\\nof Cornea, p. 148; and Sympathetic Ophthalmitis, p. 173.\\nPermanent results of iritis. Reference has been made\\nto the adhesions, which are often permanent, and to the\\nspots of uveal pigment on the lens-capsule, which are\\nalways so; either condition tells a tale of past iritis, and\\nis thus a valuable aid to diagnosis. A blue iris which\\nhas undergone severe inflammation may remain greenish.\\nPatches of atrophy may follow severe plastic exudations\\ninto the iris, and are recognized by their whitish color and\\nthinness. Large patches of new pigment occasionally form,\\nextending from the pupillary border on to the anterior sur\u00c2\u00ac\\nface.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0165.jp2"}, "166": {"fulltext": "15S\\nCLINICAL DIVISION.\\nWhen the pupil is excluded\u00e2\u0080\u009d or occluded,\u00e2\u0080\u009d the re\u00c2\u00ac\\nmainder of the iris being free, fluid collects in the poste\u00c2\u00ac\\nrior aqueous chamber, and by bulging the iris forward, and\\ndiminishing the depth of the anterior chamber, except at\\nits centre, gives the pupil a funnel-like appearance; if the\\nbulging be partial, or be divided by bands of tough mem\u00c2\u00ac\\nbrane, the iris looks cystic. Secondary glaucoma is likely\\nto follow, and the tension of the globe should, therefore, be\\nFig. 65.\\nDiagram to show the result upon the iris of exclusion of pupil (p. 156).\\n(From a specimen.)\\ncarefully noted whenever bulging is present; in not a few\\nof these cases, however, we find the eye soft and beginning\\nto shrink, the sequel, perhaps, of a glaucomatous state.\\nTotal posterior synechia\u00e2\u0080\u009d always shows a severe, though\\noften a chronic, iritis; it is often accompanied by deep-\\nseated disease, and followed by opacity of the lens, secon\u00c2\u00ac\\ndary cataract, and in some cases ultimately the lens becomes\\nabsorbed. Relapses of iritis are believed to be induced by\\nthe presence of synechise, even when there is no protrusion\\nof the iris by fluid; but their influence in this direction\\nhas, I believe, been much overrated.\\nIt must, however, be observed that there is still much differ\u00c2\u00ac\\nence of opinion on the point last referred to. The iritis of", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0166.jp2"}, "167": {"fulltext": "DISEASES OF THE IRIS.\\n150\\nsyphilis is held by some to be liable to recur, and to be by no\\nmeans limited to the secondary stage; and we still often hear\\nit stated that iritic adhesions, by preventing free movement of\\nthe iris, operate as sources of irritation, and thus predispose to\\nrelapse. I have seldom succeeded in getting a history of recent\\nsyphilis in cases of recurring iritis, while in a number of cases\\nof old iritis, with the history that the attack occurred during\\nsecondary syphilis years before, I have scarcely found one with\\nwell-marked history of relapses. On the other hand, I have\\nseveral times seen severe relapses in rheumatic cases after iri\u00c2\u00ac\\ndectomy had been performed as a preventive. All the evidence\\nseems to me to favor the view that recurrences of iritis depend,\\nas a rule, upon the constitutional cause of the disease.\\nThe following are the most important points as to the\\ncauses of iritis and the chief clinical differences between\\nthe several forms.\\nConstitutional Causes. Syphilis. The iritis is acute\\nit shows a great tendency to effusion of lymph and forma-\\nFig. 60.\\nNodules occurring in the secondary stage of syphilis, situated at the pupillary\\nborder of the iris (from a drawing by Mr. W. G. Laws).\\ntion of vascular nodules (plastic iritis), most commonly\\nsituated at the pupillary border of the iris (see Fig. 66)\\nand the nodules, when very large, may even suppurate\u00e2\u0080\u0094\\nit is symmetrical in a large proportion, probably at least\\ntwo-thirds, of the cases. But asymmetry and absence of\\nlymph-nodules are common. It occurs almost entirely in", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0167.jp2"}, "168": {"fulltext": "160\\nCLINICAL DIVISION.\\nsecondary syphilis, either acquired or inherited, and seldom\\nrelapses. Cases of iritis, associated generally with cyclitis\\nand dots on the back of the cornea, also occasionally appear\\nmany years after syphilitic infection. Its significance is\\nthus entirely different from that of the iritis which often\\ncomplicates syphilitic keratitis (p. 142).\\nRheumatism is the cause of most cases of relapsing un-\\nsvmmetrical iritis. The most common forms of rlieuma-\\n%j\\ntism which are followed by iritis are the chronic muscular\\nand tendinous, and the gonorrhoeal varieties: iritis does\\nnot occur as a sequel of acute rheumatic fever. See Chap\u00c2\u00ac\\nter XXIII. There is but little tendency to effusion of\\nFig. 67.\\nPlastic iritis with nodules in the angle of the anterior chamber, not syphilitic.\\nCompare with Fig. 66 (from an original drawing by Holmes Spicer).\\nlymph, and nodules are never formed, but there is occasion\u00c2\u00ac\\nally fluid hypopyon (pp. 134 and 154) the congestion and\\npain are often more severe than in syphilitic iritis. An\\nattack is usually unsymmetrical, though both eyes com\u00c2\u00ac\\nmonly suffer by turns. It relapses at intervals of months\\nor years. Even repeated attacks sometimes result in but\\nlittle damage to sight.\\nGout is apparently a cause in some cases of both acute\\nand insidious chronic iritis. It is perhaps doubtful whether\\nthe gout or the chronic rheumatism from which the same\\npatients sometimes suffer is the cause of the iritis. In its", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0168.jp2"}, "169": {"fulltext": "DISEASES OF THE IRIS.\\n161\\ntendency to relapse, and to affect only one eye at a time,\\ngouty resembles rheumatic iritis. The children of gouty\\nparents are occasionally liable to a very insidious and de\u00c2\u00ac\\nstructive form of chronic iritis, with disease of the vitreous,\\nkeratitis punctata, and glaucoma. Chapter XXIII.\\nChronic iritis (plastic iridochoroiditis In a few cases\\nsymmetrical iritis, of a chronic, progressive, and destructive\\ncharacter, is complicated with choroiditis, disease of vitre\u00c2\u00ac\\nous, and secondary cataract. These cases, for which it is\\nat present impossible to assign any cause, either general or\\nlocal, are chiefly seen in adults below middle life.\\nTuberculosis of the iris occurs in the young either in the\\nform of miliary deposits or as a single nodular growth;\\nowing to the deep position of the iris, such deposits are\\nsecondary to tuberculosis in some other part of the body.\\nSympathetic iritis. See Sympathetic Ophthalmitis.\\nLocal Causes. Injuries. Perforating wounds of the\\neyeball, particularly if irregular, contused, and compli\u00c2\u00ac\\ncated with wound of the lens, are often followed by iritis,\\nand more often if the patient be old than young. If the\\ncorneal wound suppurate, or become much infiltrated, the\\niritis is likely to be suppurative, and the inflammation to\\nspread to the ciliary processes and cause destructive pan\u00c2\u00ac\\nophthalmitis. Iritis may follow a wound of the lens-capsule\\nwithout wound of the iris, and with only a mere puncture\\nof the cornea. Examples of traumatic iritis from these\\nseveral causes are seen after the various operations for cat\u00c2\u00ac\\naract. The iritis following extraction of senile cataract is\\noften prolonged, attended by chemosis, much congestion,\\nand the formation of tough membrane behind the iris. See\\nCataract. Iritis may also follow superficial wounds and\\nabrasions of the cornea, or direct blows on the eye but it\\nis of great importance, whenever the question of injury\\ncomes in, to ascertain whether or not there has been a per\u00c2\u00ac\\nforating wound. Iritis often accompanies ulcers and other\\nn", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0169.jp2"}, "170": {"fulltext": "162\\nCLINICAL DIVISION.\\ninflammations of the cornea, especially when deep or com\u00c2\u00ac\\nplicated with hypopyon, or occurring in elderly persons.\\nIritis may accompany deep-seated disease of the eye.\\nTreatment. 1. In every case where iritis is present\\natropine is to be used often and continuously, in order to\\nbreak down adhesions already formed, and to allow any\\nlymph subsequently effused to be deposited outside the\\nordinary area of the pupil. A strong solution (four grains\\nof sulphate of atropine to one ounce of distilled water) or\\nan ointment (see Appendix) is to be placed in the conjunc\u00c2\u00ac\\ntival sac every hour in the early period. Even if the syn-\\nechise are, when first seen, already so tough that the atropine\\nhas no effect on them, it may prevent the formation of new\\nones on the same circle. Atropine also greatly relieves pain\\nin iritis, and lessens the congestion, and through these\\nmeans it no doubt helps materially to arrest exudation.\\nMild acute iritis may sometimes be cured by atropine alone.\\n2. If there be severe pain with much congestion, three or\\nfour leeches should be applied to the temple, to the malar\\neminence, or to the side of the nose. They may be repeated\\ndaily, in the same or smaller numbers, with advantage for\\nseveral days, if necessary; or after one leeching, repeated\\nblistering may be substituted. Some surgeons use opiates\\ninstead of, or in addition to, leeches. Leeches occasionally\\nincrease the pain. Severe pain in iritis can nearly always\\nbe quickly relieved by artificial heat, either fomentations or\\ndry heat, as hot as can be borne, to the eyelids. To apply\\ndry heat, take a piece of cotton-wool the size of two fists,\\nhold it to the fire, or against a tin-pot full of boiling water,\\ntill quite hot, and apply it to the lids; have another piece\\nready, and change as soon as the first gets cool; continue\\nthis for twenty minutes or more, and repeat it several times\\na day. 1 Paracentesis of the anterior chamber should be\\nI owe my knowledge of the value of dry heat to Mr. Liebreich.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0170.jp2"}, "171": {"fulltext": "DISEASES OF THE IRIS.\\n163\\nresorted to in severe iritis if the aqueous humor remain\\nvery turbid after a few days of other treatment; it may\\nbe repeated every day or two unless there is marked im\u00c2\u00ac\\nprovement.\\n3. Rest of the eyes is very important. Many an attack\\nis lengthened out, and many a relapse after partial cure is\\nbrought on, by the patient continuing at, or returning too\\nsoon to, work. It is not in most cases necessary to remain\\nin a perfectly dark room to wear a shade in the room with\\nthe blinds down is generally enough, provided that no\\nattempt be made to use the eyes. Work should not be\\nresumed till at least a week after all congestion has gone off.\\n4. Cold draughts of air on the eye and all causes of\\ncatching cold are to be very carefully avoided by keep\u00c2\u00ac\\ning the eye warmly tied up with a large pad of cotton-wool.\\n5. The cause of the disease is to be treated, and into this\\ncareful inquiry should always be made. If the iritis be\\nsyphilitic, treatment for secondary syphilis is proper, mer\u00c2\u00ac\\ncury being given just short of salivation for several months,\\neven though all the active eye symptoms quickly pass off.\\nThe rheumatic and gouty varieties are less definitely under\\nthe influence of internal remedies; iodide of potassium,\\nalkalies, colchicum, salicylate of soda, and turpentine, each\\nhave their advocates; when the pain is severe tincture of\\naconite is sometimes markedly useful; mercury is seldom\\nneeded, but in protracted and severe cases it may be given\\nwith advantage. It is sometimes advisable to combine\\nquinine or iron with the mercury in syphilis, or to give\\nthem in addition to other remedies in rheumatic cases.\\n6. As a rule, no stimulants are to be allowed, and the\\nbowels should be kept well open.\\n7. Iridectomy is needed for cases of severe iritis, even\\nwhen there is no increase of tension, if judicious local and\\ninternal treatment have been carefully tried for some weeks\\nwithout marked relief to the symptoms. It is chiefly in", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0171.jp2"}, "172": {"fulltext": "164\\nCLINICAL DIVISION.\\ncases of constitutional origin, either syphilitic or rheumatic,\\nand in the iritis accompanying ulcers of the cornea, that\\niridectomy is useful; it is not admissible in sympathetic\\niritis, nor in iritis after cataract extraction. Iridectomy\\nhas been largely employed to prevent relapses of iritis, but\\nthe operation has much less effect in this way than has often\\nbeen supposed it should not, therefore, be employed until\\nthe other means of cure have been fairly tried. It must\\nbe borne in mind that unless iridectomy is necessary, it is\\ninjurious, by producing an enlarged and irregular pupil\\nthrough which, for optical reasons (p. 22), the patient will\\noften not see so well as through the natural pupil, even\\nthough this be partially obstructed. In regard to all\\nmethods of local treatment we must bear in mind that\\nacute iritis occurs in all degrees of severity, and that the\\nmildest cases often need only atropine and rest.\\nTraumatic iritis, in the earliest stage, is best combated\\nby atropine, continuous cold obtained by laying upon the\\nclosed eyelids pieces of lint dipped in iced water and\\nchanged every few minutes, and by leeches. Cold is not\\nto be used in any other form of iritis and is useless even for\\ntraumatic cases after the first day or so; later, warmth is\\nmore appropriate.\\nCongenital irideremia (absence of iris) is occasionally\\nseen, and is often associated with other defects of the eye,\\nespecially opacities in the lens.\\nPupillary and capsulo-pupillary membranes. In early\\nfoetal life the capsule of the lens is vascular, supplied with\\nblood by the hyaloid artery; when the iris grows in from\\nthe anterior part of the choroid, and comes in contact with\\nthe capsule, its vessels anastomose with those of the capsule,\\nand the membrane so formed fills the pupil. Normally\\nthis membrane disappears entirely with the vessels of the\\nlens-capsule; sometimes the part attached to the capsule\\nonly disappears, leaving behind the anterior part of the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0172.jp2"}, "173": {"fulltext": "DISEASES OF THE IRIS.\\n165\\nstructure, which is known as the pupillary membrane. In\\nthis, bands of tissue, resembling that of the iris, run from\\none part of the anterior surface of the iris to another,\\nspringing from near the pupillary edge. Sometimes the\\nwhole thickness of the membrane remains, in which case\\nbands of tissue pass from the anterior surface of the iris to\\nthe capsule; this forms the capsulo-pupillary membrane.\\nSome of the latter cases have probably been described as\\nthe remains of intra-uterine iritis.\\nFir,. 68.\\nColoboma of iris. (Sichel.)\\nColoboma of the iris (congenital developmental cleft in\\nthe iris) gives the effect of a very regularly made iridec\u00c2\u00ac\\ntomy. It is always downward or slightly down-in, and is\\noften, but not always, symmetrical. It occurs in different\\ndegrees, and sometimes a mere line or seam in the iris indi\u00c2\u00ac\\ncates the slightest form of the defect. It often occurs with\u00c2\u00ac\\nout coloboma of the choroid.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0173.jp2"}, "174": {"fulltext": "CHAPTER IX.\\nDISEASES OF THE CILIARY REGION.\\nThis chapter is intended to include cases in which the\\nciliary body itself, or the corresponding part of the scle\u00c2\u00ac\\nrotic, or the episcleral tissue, is the sole seat, or at least the\\nheadquarters, of disease. From the abundance of vessels\\nand nerves in the ciliary body, and the importance of its\\nnutritive relations to the surrounding parts we find that\\nmany of the morbid processes of the ciliary region show a\\nstrong tendency to spread, according to their precise posi\u00c2\u00ac\\ntion and depth, to the cornea, iris, or vitreous, and by influ\u00c2\u00ac\\nencing the nutrition of the lens to cause secondary cataract.\\nAlthough alike on pathological and clinical grounds it is\\nnecessary to subdivide the class into groups, we may observe\\nthat the various diseases of this part show a general agree\u00c2\u00ac\\nment in some of their more important characters thus all\\nof them are protracted aud liable to relapse, and in all\\nthere is a marked tendency to patchiness, the morbid pro\u00c2\u00ac\\ncess being most intense in certain spots of the ciliary zone,\\nor even occurring in quite discrete areas. It is convenient\\nto make three principal clinical groups, the differences\\nbetween which are accounted for to a great extent by the\\ndepth of the tissue chiefly implicated. The most superficial\\nmay be taken first.\\n1. Episcleritis, more correctly scleritis, is the name given\\nto one or more large patches of congestion in the ciliary\\nregion, with some elevation of the conjunctiva from thick\u00c2\u00ac\\nening of the subjacent tissues. The congestion generally\\naffects the conjunctival as well as the deeper vessels, and\\n166", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0174.jp2"}, "175": {"fulltext": "DISEASES OF THE CILIARY REGION. 167\\nthe yellowish color of the exudation tones the bright blood-\\nred down to a more or less rusty tinge, which is especially\\nstriking at the central, thickest part of the patch. The\\nthickening seldom causes more than a low, widely spread\\nmound of swelling.\\nEpiscleritis is a rather rare disease. It occurs chiefly on\\nthe exposed parts of the ciliary region, and especially near\\nthe outer canthus; but the patches may occur at any part\\nof the circle, and exceptionally the inflammation is diffused\\nover a much wider area than the ciliary zone, extending far\\nback out of view. The iris is often a little discolored and\\nthe pupil sluggish, but actual iritis is the exception. There\\nis often much aching pain. The disease is subacute, reach\u00c2\u00ac\\ning its acme in not less than two or three weeks, and requir\u00c2\u00ac\\ning a much longer time before absorption is complete.\\nFresh patches are apt to spring up while old ones are de\u00c2\u00ac\\nclining, and so the disease may last for months; indeed,\\nrelapses at intervals, and in fresh spots, are the rule. It\\nusually affects only one eye at a time, but both often suffer\\nsooner or later. After the active changes have disappeared,\\na patch of the underlying sclerotic, of rather smaller size,\\nis generally seen to be dusky as if stained; it is doubtful\\nwhether such patches represent thinning of the sclerotic\\nfrom atrophy, or only staining; it is but seldom that they\\nshow any tendency to bulge as if thinned. In rare cases\\nthe exudation is much more abundant, and a large swelling\\nis formed, which may even contain pus; such cases pass by\\ngradations into conjunctival phylctenulse, and are generally\\nseen in children.\\nEpiscleritis is seldom seen except in adults, and is more\\ncommon in men than women. Inquiry often shows that the\\nsufferer is, either from occupation or temperament, particu\u00c2\u00ac\\nlarly liable to be affected by exposure to cold or by changes\\nof temperature. Some of the patients are rheumatic, some\\ngouty. Similar patches, but of a brownish, rather translu-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0175.jp2"}, "176": {"fulltext": "168\\nCLINICAL DIVISION.\\ncent appearance, are occasionally caused by tertiary syph\u00c2\u00ac\\nilis, acquired or inherited \u00e2\u0080\u0094gummatous scleritis.\\nIn the treatment, protection by a warm bandage, rest,\\nthe yellow ointment (F. 25), the use of repeated blisters,\\nand local stimulation of the swelling are generally the most\\nefficacious. Atropine is very useful in allaying pain. In\u00c2\u00ac\\nternal remedies seldom seem to exert much influence except\\nin syphilitic cases. Salicylate of soda has been highly\\nspoken of by some. Systematic kneading of the eye\\nthrough the closed lids massage and scraping away\\nthe exudation with a sharp spoon, after turning back the\\nconjunctiva, have also been recommended, and are worth\\ntrial.\\n2. Sclero-keratitis and sclero-iritis scrofulous sclero\u00c2\u00ac\\ntitis,\u00e2\u0080\u009d \u00e2\u0080\u009canterior choroiditis\u00e2\u0080\u009d). A more deeply-seated,\\nvery persistent or relapsing, subacute inflammation, char\u00c2\u00ac\\nacterized by congestion, of a violet tint, deep scleral con\u00c2\u00ac\\ngestion, p. 42, abruptly limited to the ciliary zone, and\\naffecting some parts of the zone more than others\u00e2\u0080\u0094ten\u00c2\u00ac\\ndency to patchiness. Early in the case there is a slight\\ndegree of bulging of the affected part, due partly to thick\u00c2\u00ac\\nening while patches of cloudy opacity, which may or may\\nnot ulcerate, appear in the cornea close to, and often con\u00c2\u00ac\\ntinuous with, its margin iritis generally occurs later; pain\\nand photophobia are often severe. After a varying interval,\\nalways weeks, more often months, the symptoms recede at\\nthe focus of greatest congestion, or it may be around the\\nentire zone, the sclerotic is left of a dusky color, sometimes\\ninterspersed with little yellowish patches, and permanent\\nhaziness of the most affected parts of the cornea remains.\\nThe disease is almost certain to relapse sooner or later; or\\na succession of fresh inflammatory foci follow each other\\nwithout any intervals of real recovery, the whole process\\nextending over months or years. After each attack more\\nhaze of cornea and fresh iritic adhesions are left. The", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0176.jp2"}, "177": {"fulltext": "DISEASES OF THE CILIARY REGION. 169\\nf-\\nsclerotic, in bad cases of some years\u00e2\u0080\u0099 standing, is much\\nstained, and may become bulged (ciliary or anterior staphy\u00c2\u00ac\\nloma), and the cornea becomes more opaque and altered in\\ncurve; the eye is then useless, though but seldom liable to\\nfurther active symptoms.\\nThe characteristic appearance of an eye which has been\\nmoderately affected, is the dusky color of the sclerotic,\\nand the irregular, patchy opacities in the cornea, Fig. 69,\\nwhich are often continuous with the sclerotic. The disease\\ndoes not occur in children, nor does it begin late in life;\\nmost of the patients are young or middle-aged adults, and\\nunlike the former variety, most are women. It is not asso-\\nFig. 69.\\nRelapsing sclero-keratitis. (From nature.)\\nciated with any special diathesis or dyscrasia, but generally\\ngoes along with a feeble circulation and liability to catch\\ncoldin some cases there is a definite family history of\\nscrofula or of phthisis. Predisposed persons are more likely\\nto suffer in cold weather, or after change to a colder or\\ndamper climate, or after any cause of exhaustion, such as\\nsuckling.\\nTreatment is at best but palliative. Local stimulation\\nby yellow ointment or calomel is very useful in some cases,\\nparticularly in those which verge toward the jdilyctenular\\ntype. In the early stages, especially when the congestion\\nis very violent and altogether subconjunctival, atropine", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0177.jp2"}, "178": {"fulltext": "170\\nCLINICAL DIVISION.\\noften gives relief, and it is, of course, useful for the iritis.\\nRepeated blistering is also to be tried, though not all cases\\nare benefited by it. I have not seen much benefit from\\nsetons. Warm, dry applications to the lids are, as a rule,\\nbetter than cold. Mercury, in small and long-continued\\ndoses, is certainly valuable when the patient is not anaemic\\nand feeble, but it is to be combined with cod-liver oil and\\niron. Protection from cold and bright light by goggles\\nis a very important measure, both during the attacks and\\nin the intervals between them. There is no rule as to sym\u00c2\u00ac\\nmetry; both eyes often suffer sooner or later, but some\u00c2\u00ac\\ntimes one escapes while the other is attacked repeatedly.\\nTransition forms occur between this disease and episcleritis.\\n3. Cyclitis with disease of vitreous and keratitis punctata\\nserous cyclitis,\u00e2\u0080\u009d chronic serous iridochoroiditis, serous\\niritis A small but important series of cases, in which\\nthere is congestion, as in mild iritis, and dulness of sight,\\nbut usually no pain or photophobia. It has been found by\\nTreacher Collins that the ciliary body in addition to its\\nother functions performs the part of a secreting gland con\u00c2\u00ac\\ncerned in the nutrition of the vitreous body and in the\\nelaboration of the aqueous fluid. When this gland is dis\u00c2\u00ac\\neased it gives rise to exudation into the vitreous, and to a\\nturbidity of the aqueous from which are deposited the dots\\non the cornea which are commonly known as keratitis punc\u00c2\u00ac\\ntata. Flocculi are found in the anterior part of the vitre\u00c2\u00ac\\nous, or numerous small dots of deposit are seen on the\\nposterior surface of the cornea, keratitis punctata, Fig.\\n60; the anterior chamber is often too deep, and insidious\\niritis often follows. Patches of recent choroiditis, Chapter\\nXII., are sometimes to be seen at the fundus. In bad cases\\nbuff-colored masses of deposit form in the lower part of the\\nangle between iris and cornea; or distinct nodules may be\\npresent on the iris near its periphery, but not, as in syph\u00c2\u00ac\\nilitic iritis, at the pupillary border, Fig. 61. Persistence,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0178.jp2"}, "179": {"fulltext": "DISEASES OE THE CILIARY REGION.\\n171\\nvariability, and liability to relapse are almost as marked\\nhere as in other members of the cyclitic group. The ten\u00c2\u00ac\\nsion is often slightly augmented at the beginning, but\\nusually becomes normal again. Sometimes, however, the\\neye passes into a permanent state of chronic glaucoma,\\nprobably from blocking of the ligamentum pectinatum\\nwith cells (see Glaucoma); but usually the final condition\\nin bad cases depends on the extent of the iritic adhesions,\\nfor when the synecliise are numerous and tough, and the\\niris is much altered in structure, or the pupil blocked by\\nexudation, secondary glaucoma is likely to arise from im\u00c2\u00ac\\nprisonment of fluid behind the iris, Fig. 65. When seen\\nquite early the diagnosis will probably be serous iritis,\u00e2\u0080\u009d\\nor ciliary congestion,\u00e2\u0080\u009d unless the eye be carefully exam\u00c2\u00ac\\nined for the pupil is generally free in all parts, or shows,\\nat most, one or two adhesions after atropine has been used.\\nIn a few cases the punctate deposits on the back of the\\ncornea constitute almost the only objective change, but\\nthese are rare. The refraction sometimes beomes tempo\u00c2\u00ac\\nrarily myopic in serous cyclitis.\\nThe cases occur in adolescents or young adults, and the\\ndisease is often sooner or later symmetrical. Many mild\\ncases recover perfectly, and in most others the final result\\nis satisfactory. In respect to cause, there is strong reason\\nto believe that many of these cases are the result of gout in\\na previous generation, the patient himself never having\\nhad the disease (Hutchinson.) The disease seems often to\\nbe excited in predisposed persons by prolonged overwork\\nor anxiety, combined with underfeeding or defective assim\u00c2\u00ac\\nilation the patients often describe themselves as delicate;\\nsome are phthisical. On the other hand, in some of the\\nworst cases, leading to secondary cataract, and ultimately\\nto shrinking of the eyes (p. 161), the patient appears to be\\nfrom first to last, in good health, and free from any ascer\u00c2\u00ac\\ntainable morbid diathesis.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0179.jp2"}, "180": {"fulltext": "172\\nCLINICAL DIVISION.\\nTreatment. In the treatment prolonged rest of the\\neyes is important. Atropine is usually necessary, but if\\nthere be increase of tension its effect must be carefully\\nwatched, and in cases where there are no iritic adhesions,\\neserine may have to be substituted. If the increase of\\ntension keeps up, and seems to be damaging the sight,\\niridectomy is necessary. Small doses of iodide of potas\u00c2\u00ac\\nsium and mercury appear to be useful in the earlier stages,\\ngiven with proper precautions, and accompanied by iron\\nand cod-liver oil. Change of climate would probably often\\nby very beneficial. In the worst cases, where the changes\\nare like those resulting from sympathetic ophthalmitis, no\\ntreatment seems to have any effect.\\nCases of acute inflammation are occasionally seen in\\nwhich most of the symptoms resemble those of acute iritis,\\nbut with the iris so little affected that it is evidently not\\nthe headquarters of the morbid action. The tension may\\nbe much reduced, while repeated and rapid variations,\\nboth in sight and objective symptoms, occur. Again, some\\ncases of syphilitic inflammation, which are classed as syph\u00c2\u00ac\\nilitic iritis,\u00e2\u0080\u009d might be more correctly called cyclitis.\u00e2\u0080\u009d\\nIn some cases of heredito-syphilitic keratitis there is much\\ncyclitic complication (p. 145), and this is always difficult\\nto treat.\\nPlastic inflammation of the ciliary body, following injury,\\ntraumatic iritis or iridocyclitis, is the usual starting-point of\\nthe changes which set up sympathetic inflammation of the\\nfellow-eye the tension is often lowered, and the symptoms\\nare subacute. The onset of purulent traumatic cyclitis pan\u00c2\u00ac\\nophthalmitis is signalized by congestion, pain, chemosis and\\nswelling of lids, and the appearance of opacity at the\\nwound. The inflammation quickly spreads to the iris,\\nciliary body, and vitreous; and then to the capsule of\\nTenon and the muscles, so that the eye becomes glued to\\nthe surrounding parts and fixed. If the lens be trans-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0180.jp2"}, "181": {"fulltext": "DISEASES OF THE CILIARY REGION. 173\\nparent a yellow or greenish reflection is, after a few days,\\nsometimes seen behind it, indicating the presence of pus\\nin the vitreous humor; but usually the cornea and aqueous\\nare too turbid, even should the lens be clear, to allow deep\\ninspection. Suppurative panophthalmitis occasionally sets\\nin acutely and without apparent cause in eyes which have\\nlong been blind from corneal disease or from glaucoma. It\\nmay also occur in pysemia, Chapter XXIII. See also\\nPseudo-glioma.\\nSympathetic Irritation and Sympathetic\\nOphthalmitis.\\nCertain morbid changes in one eye may set up either\\nfunctional disturbance or destructive inflammation in its\\nfellow. The term sympathetic irritation is given to the\\nformer, and sympathetic ophthalmitis, or ophthalmia, to the\\nlatter. Though these conditions may be combined, they\\nmore often occur separately, and it is very important to\\ndistinguish between them.\\nAlthough at present the exact nature of the changes\\nwhich precede sympathetic inflammation is unknown,\\nand their path has not been fully traced out, we are\\nsure (1) that the changes start from the region most\\nrichly supplied with vessels and nerves, viz., the ciliary\\nbody and iris (2) that the first changes recognized by the\\nsurgeon in the sympathizing eye are generally in the same\\nstructures (3) that the exciting eye has nearly always been\\nwounded, and in its anterior part, and that plastic inflam\u00c2\u00ac\\nmation of its uveal tract is always present; (4) that inflam\u00c2\u00ac\\nmatory changes have in some cases been found in the ciliary\\nnerves, and in the coverings of the optic nerve, of the\\nexciting eye.\\nWithin the last few years the hypothesis of transmission\\nalong the ciliary nerves, which had many adherents, has", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0181.jp2"}, "182": {"fulltext": "174\\nCLINICAL DIVISION.\\nbeen almost given up in favor of the theory of infection.\\nDeutschmann has shown (1882-84) that the introduction\\nof certain septic organisms into the interior of the eyeball,\\nin rabbits, is followed by acute inflammatory changes in the\\nother eye; and Gifford (1886), and others more recently,\\nhave obtained results which tend to confirm the infection\\ntheory. Most of Deutschmann\u00e2\u0080\u0099s subjects died in a few\\ndays, and though in many of them the ocular changes were\\nthose of inflammation traceable along the optic nerve-\\nsheaths of the \u00e2\u0080\u009cexciting\u00e2\u0080\u009d eye, by way of the chiasma,\\nand down the optic nerve to the optic disk of the sym\u00c2\u00ac\\npathizer,\u00e2\u0080\u009d still in one or two the morbid process had spread\\nto the vitreous and uveal coat. Berlin 1 had previously sug\u00c2\u00ac\\ngested that the second eye was infected by a special organ\u00c2\u00ac\\nism which could flourish only in the eye-tissues, and which\\nwas carried by the blood from the first eye; and Hutchin\u00c2\u00ac\\nson 2 afterward independently propounded a nearly identical\\nview. Though there are difficulties to be explained and\\ngaps to be filled in our knowledge before the infection\\ntheory in any form can be accepted, yet at the present time\\nit claims more and stronger adherents than any other; and\\nthe difficulties are perhaps not greater than for any other\\ntheory.\\nIn almost every case sympathetic inflammation is set up\\nby a perforating wound, either accidental or operative, in\\nthe ciliary region of the other eye\u00e2\u0080\u0094 i. e., within a zone,\\nnearly a quarter of an inch wide, surrounding the cornea.\\nThe risk attending a wound in this dangerous zone\u00e2\u0080\u009d is\\nincreased if it be lacerated, or heal slowly, or if the iris or\\nciliary body be engaged between the lips of the sclerotic,\\nor if the eye contain a foreign body; under all conditions,\\nindeed, which make the occurrence of plastic or purulent\\niridocyclitis probable. Sympathetic inflammation may also\\n1 Berlin, 1880.\\n2 Hutchinson, 1885.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0182.jp2"}, "183": {"fulltext": "DISEASES OF THE CILIARY REGION.\\n175\\nbe set up by a foreign body lodged in the eye, whether the\\nwound be in the ciliary region or not; by an eye contain\u00c2\u00ac\\ning a tumor, perhaps even if the eye has not been perfor\u00c2\u00ac\\nated by operation or ulceration by a purely corneal wound,\\nor a perforating ulcer, if complicated by adhesion of the\\niris, with dragging on the ciliary body.\\nSymptoms in the exciting eye. The exciting eye, when\\nit is causing sympathetic irritation generally shows ciliary\\ncongestion and photophobia, and often suffers neuralgic\\npain. In an eye which is causing sympathetic inflamma\u00c2\u00ac\\ntion, obvious iritis, often w r ith lowered tension, is usually\\npresent; but the iritis is often painless and without notice\u00c2\u00ac\\nable congestion, and thus may easily be overlooked; it is\\nespecially important to remember that the exciting eye,\\nthough its sight is always damaged, need not be blind, and\\nthat under certain circumstances it may in the end be the\\nbetter eye of the two.\\nSymptoms in the sympathizing eye. a. Sympathetic irri\u00c2\u00ac\\ntation. The eye is, in common speech, weak\u00e2\u0080\u009d or irri\u00c2\u00ac\\ntable.\u00e2\u0080\u009d It is intolerant of light, and easily flushes and waters\\nif exposed to bright light, or if much used; the accommo\u00c2\u00ac\\ndation is weakened or irritable, so that continued vision for\\nnear objects is painful, or even impossible; and the ciliary\\nmuscle seems liable to give way for a short time, the patient\\ncomplaining that near objects now and then suddenly be\u00c2\u00ac\\ncome misty for a while. Neuralgic pains, referred to the\\neye and side of the head, are also common. Temporary\\ndarkening of sight, indicating suspension of retinal func\u00c2\u00ac\\ntion, and subjective sensations of colored spots, clouds, etc.,\\noccur in certain cases. Such attacks may occur again and\\nagain in varying severity, lasting for days or weeks, and\\nfinally ceasing without ever passing on to structural change.\\nSympathetic irritation is always, and, as a rule, promptly,\\ncured by removal of the exciting eye; but occasionally\\nthe symptoms persist for some time afterward. A condition", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0183.jp2"}, "184": {"fulltext": "176\\nCLINICAL DIVISION.\\nwhich cannot be distinguished from hysterical blindness is\\nsometimes seen in the sympathizing\u00e2\u0080\u009d eye, but the term\\nsympathetic irritation does not then seem suitable. 1\\nb. Sympathetic inflammation ophthalmitis The disease\\nmay arise out of an attack of irritation,\u00e2\u0080\u009d but more com\u00c2\u00ac\\nmonly it sets in without any such warning. It may be\\nacute and severe, or so insidious as to escape the notice of\\nthe patient until well advanced. It is in nearly all cases\\na prolonged and a recurring disease; when once started it\\nis self-maintaining, and its course usually extends over\\nmany months, or even a year or two. In mild cases a good\\nrecovery eventually takes place, but in a large majority the\\neye becomes blind. The disease usually takes the form of\\na plastic iridocyclitis or iridochoroiditis with exudation\\nfrom the entire posterior surface of the iris, leading to total\\nposterior synechia. Its chief early peculiarities are a great\\nliability to dotted deposits on the back of the cornea, cloud\u00c2\u00ac\\ning of the vitreous by floating opacities, and often neuro\u00c2\u00ac\\nretinitis there is a dusky ciliary congestion with marked\\nengorgement of the large vessels which perforate the scle\u00c2\u00ac\\nrotic in the ciliary region. In acute and severe cases the\\ncongestion is intense, there is severe pain, photophobia, and\\ntenderness on pressure, and the iris, besides being thick, is\\nchanged in color to a peculiar buff or yellowish-brown, and\\nshows numerous enlarged bloodvessels. Attacks of intense\\nneuralgia of the fifth nerve characterize some cases. In\\ncases of all degrees the tension is often increased, the eye\\nbecoming decidedly glaucomatous for a longer or shorter\\ntime. Many dotted opacities appear in the lens, which\\nafterward becomes completely cataractous, and in some\\ncases is finally quite absorbed. In the worst cases the\\neye finally shrinks, but in many it remains glaucomatous\\n1 Mr. Gunn tells me that he has noticed that marked oscillation of the iris\\noften occurs when sympathetic irritation is about to give place to inflammation.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0184.jp2"}, "185": {"fulltext": "DISEASES OF THE CILIARY REGION. 177\\nwith total posterior synechia, corneal haze, and more or less\\nciliary staphyloma. In the mildest cases (the so-called\\n\u00e2\u0080\u009cserous\u00e2\u0080\u009d form) the disease never goes beyond a chronic\\niritis with punctate keratitis and disease of the vitreous,\\nwith which neuro-retinitis often, perhaps always, co-exists.\\nSympathetic ophthalmitis generally begins between six\\nweeks and about three months after the injury to the excit\u00c2\u00ac\\ning eye; very seldom sooner than three weeks\u00e2\u0080\u0094 i. e., not\\nuntil time has elapsed for well-marked inflammatory\\nchanges to occur at the seat of injury. On the other hand,\\nthe disease may set in at any length of time, even many\\nyears, after the lesion of the exciting eye. It occurs at all\\nages. Distinct inflammatory changes are probably always\\npresent in the exciting eye; but, as already stated, these\\nmay be very slight and difficult of detection. When care\u00c2\u00ac\\nfully observed, these changes are found to precede by some\\ndays, if not longer, the onset of structural disease in the\\nsympathizing eye, the morbid process apparently taking\\nsome time to travel from one eye to the other.\\nTreatment. By far the most important measure refers\\nto prevention. When once sympathetic inflammation has\\nbegun we can do little to modify its course. The clear\\nrecognition of this fact leads us to advise the excision 1 of\\nevery eye which is at the same time useless and liable to\\ncause sympathetic mischief\u00e2\u0080\u0094 i. e., of all eyes which are\\nblind from injury or destructive corneal disease; and to\\ngive this advice most urgently when the blind eye is already\\ntender or irritable, or is liable to become so, when it has\\nbeen lost by wound, and when it is probable that it may\\ncontain a foreign body. Any lost eye in which there are\\n1 Feeling doubtful whether either abscission or optico-ciliary neurotomy\\nconfers as great safety from sympathetic disease as does excision, I have not\\nperformed those operations. The more newly revived evisceration has not\\nyet been performed often enough for trustworthy conclusions to be drawn on\\nthis point.\\n12", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0185.jp2"}, "186": {"fulltext": "178\\nCLINICAL DIVISION.\\nsigns of past iritis, even if there be no history of injury,\\nis best removed, especially if shrunken. But much judg\u00c2\u00ac\\nment is needed if the damaged eye, though irritable and\\nlikely to cause mischief, still retains more or less sight.\\nEvery attention must then be paid to the exact position of\\nthe wound, the evidence as to its depth, the evidence of\\nhemorrhage, and especially to the condition of the lens,\\nand to the presence of the yellowish haziness behind the\\nlens which indicates lymph or pus in the vitreous. The\\ndate of the injury and the condition of the wound, whether\\nhealed by immediate union, or with scarring, puckering,\\nor flattening, are very important points. Irritation of the\\nfellow-eye may set in a few days after the injury; but since\\ninflammation very seldom begins sooner than two or three\\nweeks, we may, if we see the case early, watch it for a little\\ntime. Complete and prolonged rest in a darkened room is\\na very important element in the prevention of sympathetic\\nirritation and inflammation, and should always be insisted\\non when we are trying to save an injured eye. In rare\\ncases sympathetic inflammation sets in after the removal of\\nthe exciting eye, even after an interval of several weeks\u00e2\u0080\u0094\\na contingency which emphasizes the importance of excising\\nevery condemned eye at the earliest possible moment.\\nWhen sympathetic ophthalmitis has set in we can do com\u00c2\u00ac\\nparatively little.\\nA. The exciting eye if quite blind or so seriously dam\u00c2\u00ac\\naged as to be for practical purposes certainly useless, is to\\nbe excised at once, though the evidence of benefit from\\nthis course is slender. But it is not to be removed if there\\nis reason to hope for restoration of useful sight in it; if\\nthere is simply a moderate degree of subacute iritis, with\\nor without traumatic cataract, and with sight proportionate\\nto the state of the lens, the eye is to be carefully treated,\\nsince it may very probably in the end be the better of the\\ntwo (p. 175).", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0186.jp2"}, "187": {"fulltext": "DISEASES OF THE CILIARY REGION.\\n179\\nb. The sympathizing eye. The important measures are (1)\\natropine, used very often, as for acute iritis; (2) absolute\\nrest and exclusion of light by residence in a dark room\\nand with a black bandage over both eyes; (3) repeated\\nleeching if the symptoms are severe, or counter-irritation\\nby blisters or by a seton in chronic cases. (4) Mercury is\\nbelieved by some to be beueficial. Quinine is sometimes\\ngiveu. (5) As a rule, no operation is permissible while the\\ndisease is still active, since iridectomy, performed while\\nthere are active symptoms, is followed by closure of the\\ngap with fresh lymph. Operations in severe cases which\\nhave become quiet are seldom of use, the eye being gener\u00c2\u00ac\\nally then past recovery.\\nPrognosis. The prognosis is, as will be gathered very\\ngrave; even in the mildest cases, when seen quite early, we\\nmust be very cautious, for the disease often slowly progresses\\nfor many months.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0187.jp2"}, "188": {"fulltext": "CHAPTER X.\\nINJURIES OF THE EYEBALL.\\nA clear distinction is to be made between contusion\\nand concussion injuries, and wounds of the eyeball.\\n1. Contusion and concussion injuries. Rupture of the\\neyeball is commonly the result of severe direct blows. The\\nrent is nearly always in the sclerotic, either a little behind\\nor close to the corneal margin, with which it is concentric;\\nthe cornea itself is but seldom rent by a blow. The rup\u00c2\u00ac\\nture is usually large, involves all the tunics, and is followed\\nby immediate hemorrhage between the retina and choroid,\\nand into the vitreous and anterior chambers; the lens and\\nsome of the vitreous often escape; sight is usually reduced\\nto perception of light or of large objects. The conjunctiva,\\nhowever, often escapes untorn, and in such a case if the\\nlens pass through the rent in the sclerotic, it will be held\\ndown by the conjunctiva, and form a prominent, rounded,\\ntranslucent swelling over the rupture. The diagnosis of\\nrupture is generally easy, even if the rent be more or less\\nconcealed. The eyeball often shrinks; but occasionally it\\nrecovers with useful vision. Immediate excision is gener\u00c2\u00ac\\nally best when the wound is compound but if the con\u00c2\u00ac\\njunctiva be not torn, aud ocasionally even when it is, we\\nshould wait a few days until the disappearance of the blood\\nfrom the anterior chamber allows the deeper parts to be\\nseen. The treatment is the same as for wounds of the eye.\\nWhen the lens is lying beneath the conjunctiva it should\\n180\\nt", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0188.jp2"}, "189": {"fulltext": "INJURIES OF THE EYEBALL. 181\\nbe removed when the sclenil wound has healed, if we de\u00c2\u00ac\\ncide to save the eye.\\nIt may here be mentioned that copious hemorrhage,\\naccompanied by severe pain, sometimes occurs between the\\nchoroid and sclerotic as the result of sudden diminution of\\ntension, either by an operation, such as extraction of cata\u00c2\u00ac\\nract or iridectomy, or by a glancing wound of the cornea.\\nEyes in which this occurs are for the most part already\\nunsound and often glaucomatous.\\nBlows often cause internal damage without rupture of the\\nhard coats of the eye. The iris may be torn from its ciliary\\nattachment coredialysis so that two pupils are formed,\\nFig. 70, or the lens may be loosened or displaced by partial\\nrupture of its suspensory ligament, so that the iris, having\\nlost its support, will shake about with every movement\\nFig. 70.\\nSeparation of iris following a blow.\\n(tremulous iris Such lesions are likely to be obscured for\\na time by bleeding into the anterior chamber and into the\\nvitreous. The lens often becomes opaque afterward. De\u00c2\u00ac\\ntachment of the retina is often found after severe blows,\\nwhich have caused hemorrhage into the vitreous. Blows\\non the front of the eye may cause rupture of the choroid\\nor hemorrhage from choroidal or retinal vessels. These\\nchanges are found at the central part of the fundus, and if\\nthe yellow spot is involved visual acuteness is much dam\u00c2\u00ac\\naged. The rents in the choroid appear after the blood has", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0189.jp2"}, "190": {"fulltext": "182\\nCLINICAL DIVISION\\ncleared up as lines or narrow bands of atrophy bordered\\nby pigment, and often slightly curved toward the disk, Fig.\\n84. Hemorrhages from the choroidal vessels without rup\u00c2\u00ac\\nture of the choroid, usually leave some residual pigment\\nafter absorption. In an eye predisposed to detachment of\\nretina, a blow will sometimes determine its occurrence.\\nParalysis of the iris and ciliary muscle, with partial, some\u00c2\u00ac\\ntimes irregular dilatation of the pupil, are often the sole\\nresults of a blow on the eye; the defect of sight can be\\nremedied by a convex lens. Complete recovery is moder\u00c2\u00ac\\nately common, the ciliary muscle recovering before the iris.\\nPartial dilatation or imperfection of the pupil after a blow\\nis sometimes dependent on rupture of the sphincter, one or\\nmore notches in the pupillary border of the iris indicating\\nthe seat of the lesion or lesions. For Traumatic Iritis, see\\np. 161.\\nGreat defect of sight following a blow, neither remedied\\nby glasses nor accounted for by blood in the anterior cham\u00c2\u00ac\\nber, will generally mean copious hemorrhage into the vitre\u00c2\u00ac\\nous, with one or another of the changes just mentioned in\\nthe retina and choroid. The red blood may sometimes be\\nseen by focal light, but often its presence can only be\\ninferred from the opaque state of the vitreous. Probably\\nin most of these cases the blood comes from the large veins\\nof the ciliary body, but sometimes from the vessels of the\\nchoroid or retina. There may be no external ecchymosis.\\nThe tension of the globe is to be noted; it is not often\\nincreased unless inflammation has set in, or the eye has\\nbeen previously glaucomatous, and in some cases it is below\\nnormal. The prognosis should be very guarded whenever\\nthere is reason to think, from the opaque state of the parts\\nbehind the lens, that much bleeding has taken place, or\\nthat the retina is detached, or when the iris is tremulous or\\npartly detached, or if any rupture of the choroid can be\\nmade out. Blood in the anterior chamber is often com-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0190.jp2"}, "191": {"fulltext": "INJURIES OF THE EYEBALL.\\n183\\npletely absorbed in a day or two, or even sometimes in a\\nfew hours; but in the vitreous humor absorption, though\\nrapid, is less complete, and permanent opacities are often\\nieft. The use of atropine, the frequent application, during\\nthe first twenty-four hours, of iced water, or of an evap\u00c2\u00ac\\norating lotion to the lids, and occasional leeching if there\\nbe inflammatory symptoms, will do all that is possible for\\nthe first week or two after a severe blow with internal hem\u00c2\u00ac\\norrhage. If the lens be loosened, it may at any time act\\nas an irritating foreign body, or set up a glaucomatous\\ninflammation (Dislocation of Lens, p. 210). Now and then\\noptic neuritis occurs in the injured eye as the immediate\\neffect of the blow. Hemorrhage behind the choroid is\\nbelieved by some to account for certain well-known cases\\nin which, after a blow, there is defect of sight without\\nvisible change, or with localized temporary haze of retina\\n(commotio retinae). Temporary myopia or astigmatism\\nmay also follow a blow on the eye they depend on altered\\ncurvature of the lens, and are sometimes entirely removed\\nby paralyzing the ciliary muscle with atropine (see also\\nHysterical Amblyopia).\\n2. Wounds, a. Superficial abrasions of the cornea cause\\nmuch pain, with watering, photophobia, and ciliary con\u00c2\u00ac\\ngestion. They are frequently due to a scratch by a finger\u00c2\u00ac\\nnail of a baby at the breast. The abraded surface is often\\nvery small, and shows no opacity; it is detected by watch\u00c2\u00ac\\ning the reflection of a window from the cornea, while the\\npatient slowly moves the eye. Now and then the symp\u00c2\u00ac\\ntoms return after a long interval of cure. Many, if not\\nall, of the cases of relapsing bullae of the cornea seem to\\nhave originated in a slight superficial injury.\\nMinute fragments of metal or stone flying from tools,\\netc., often partly embed themselves in the cornea, foreign\\nbody on the cornea and give rise to varying degrees of\\nirritability and pain. The fragment soon becomes sur-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0191.jp2"}, "192": {"fulltext": "184\\nCLINICAL DIVISION.\\nrounded by a hazy zone of infiltration, but it remains\\neasily visible unless it be very small or covered by mucus\\nor epithelium. When in doubt always examine the cornea\\nby focal light with magnifying power.\\nThe pupil is often smaller than its fellow, and the\\ncolor of the iris altered, in cases of superficial injury\\nto the cornea, indicating congestion of the iris. Actual\\niritis sometimes occurs, but not unless the corneal wound\\ninflame.\\nTreatment. After surface injuries a drop of castor\\noil may be applied, and the eye kept closed for the day\\nwith a pad of wadding and a bandage. Atropine is re\u00c2\u00ac\\nquired if there be much irritation or threatened iritis. If\\nhypopyon appear the case becomes one of hypopyon ulcer.\\nFor removal of foreign bodies see Operations.\\nForeign bodies often adhere to the inner surface of the\\nupper lid; whenever a patient states that he has some\u00c2\u00ac\\nthing in his eye and nothing can be found on the cornea,\\nthe upper lid must be everted and examined.\\nLarge bodies sometimes pass far back into the upper or\\nlower conjunctival sulcus, and lie hidden for weeks or\\nmonths, causing only local inflammation and some thick\u00c2\u00ac\\nening of the conjunctiva. Search must be made, if needful,\\nwith a small scoop or probe whenever the suspicion arises.\\nSee Orbit.\\nb. Burns, scalds, and injuries by caustics, etc. The con\u00c2\u00ac\\njunctiva and cornea are often damaged by splashes of mol\u00c2\u00ac\\nten lead, or by strong alkalies or acids, of which lime, either\\nquick or freshly slaked, is the more common. The eyeball is\\nnot often scalded, the lids closing quickly enough to prevent\\nthe entrance of steam or hot water. As the full effect in\\nsuch cases is not apparent for some days, a cautious opinion\\nshould be given in the early stages.\\nThe effects of such accidents are manifested by (1)\\ninflammation of the cornea passing into suppurative kera-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0192.jp2"}, "193": {"fulltext": "INJURIES OF THE EYEBALL.\\n185\\ntitis with hypopyon, in bad cases; (2) scarring and short\u00c2\u00ac\\nening of the conjunctiva, and in bad cases adhesion of its\\npalpebral and ocular surfaces\u00e2\u0080\u0094 symblepharon.\\nThe most superficial burns whiten and dry the surface,\\nand in a few hours the epithelium is shed. This is shown\\non the cornea by a sharply outlined, slightly depressed area.\\nThe surface is clear if the damage be quite superficial and\\nrecent, but more or less opalescent, or even yellowish, if the\\ncase be a few days old, and the burn be deep enough to\\nhave caused destruction or inflammation of the true corneal\\ntissue. When there is much opacity it does not completely\\nclear, and considerable flattening of the cornea and neigh-\\nFig. 71.\\nBurns of conjunctiva. (White-Cooper.)\\nboring sclerotic often occurs at the seat of deep and exten\u00c2\u00ac\\nsive burns. The conjunctival whitening is followed by\\nmere desquamation and vascular reaction, or by ulceration\\nand scarring, according to the depth of the damage.\\nTreatment. In recent cases, seen before reaction has\\nbegun, a drop of castor oil once or twice a day, a few\\nleeches to the temple, and the use of a cold evaporating\\nlotion, or of iced water, will sometimes prevent inflamma\u00c2\u00ac\\ntion. If seen immediately after the accident, the conjunc-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0193.jp2"}, "194": {"fulltext": "186\\nCLINICAL DIVISION.\\ntival sac is to be carefully searched for fragments, or washed\\nwith very weak acid or alkaline solution if a liquid caustic\\nof the opposite character have done the damage. If inflam\u00c2\u00ac\\nmatory reaction be already present, treatment by compress,\\nhot fomentations, and the other means recommended for\\nsuppurating ulcers (p. 141), is most suitable. There is often\\nmuch pain and chemosis. See Operation for Symblepharon.\\nc. Penetrating wounds and gunshot injuries. When a\\npatient says that his eye is wounded, the first step is to\\nexamine the seat, extent, and character of the wound, ascer\u00c2\u00ac\\ntain the interval since the injury, and test the sight of the\\neye; the next to make out all we can about the wounding\\nbody, and especially whether any fragment has been left\\nwithin the eyeball.\\nVery large foreign bodies, such as pieces of glass, some\u00c2\u00ac\\ntimes lie for a long time in the eye without causing much\\ntrouble, the large wound having given exit to the contents\\nof the globe, and been followed by rapid shrinking without\\ninflammation.\\nTreatment. Penetrating wounds are least serious when\\nthey implicate the cornea alone, or the sclerotic behind the\\nciliary region\u00e2\u0080\u0094 i. e., one-fourth inch or more behind the\\ncornea. Penetrating wounds of the cornea without injury to\\nthe iris or lens, and without any prolapse of iris, are rare;\\nthey generally do very well, and if the case be not seen until\\none or two days after the injury, the wound will often have\\nhealed firmly enough to retain the aqueous, and it may be\\ndifficult to decide whether the whole thickness of the cornea\\nhave been penetrated or not. Wounds of the sclerotic seldom\\nunite without the interposition of a layer of lymph; when\\nseen early they should, if gaping, clean, and uncomplicated\\nby evidence of internal injury, be treated by the insertion\\nof fine sutures, which should be passed only through the\\nconjunctiva, followed by the use of ice.\\nBut penetrating wounds are usually very serious to the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0194.jp2"}, "195": {"fulltext": "INJURIES OF TIIE EYEBALL.\\n187\\ninjured eye; the iris is frequently lacerated and included\\nin the track of the wound; the lens is punctured, and\\nbecomes swollen and opaque from absorption of the aque\u00c2\u00ac\\nous humor (traumatic cataract it is liable in its swollen\\nstate to press on the ciliary processes, and cause grave\\nsymptoms extensive bleeding perhaps takes place into the\\nvitreous; within the first few days purulent inflammation\\nmay destroy the eye. The fellow-eye is, of course, often\\nin danger of sympathetic inflammation. Every case has,\\ntherefore, to be judged from two points of view, the damage\\nto the injured eye, and the risk to the sound one; and the\\nquestion whether to sacrifice or attempt to save the former,\\nis sometimes very difficult to decide.\\nI. In the two following cases the eye should be sacrificed\\nat once: 1. If the wound, lying wholly or partly in the\\ndangerous region,\u00e2\u0080\u009d be so large and so complicated with\\ninjury to deeper parts that no hope of useful sight remains.\\n2. If, even though the wound be small, it lie in the danger\u00c2\u00ac\\nous region, and have already set up severe iritis (pp. 161\\nand 172).\\nII. There is a large class of cases in which it is certain,\\nor very probable, that the eye contains a foreign body,\\nalthough the injury is not of itself fatal to sight, and has\\nnot as yet led to inflammation, or to shrinking, of the\\neye.\\nThe first question, then, is whether the foreign body can\\nbe seen; the second, whether or not it is steel or iron, and\\ntherefore possibly removable by a magnet. A foreign body,\\nif lying on or embedded in the iris, the lens being intact,\\nshould be removed, usually with the portion of iris to which\\nit is attached if loose in the anterior chamber its removal\\nmay be difficult. If it can be seen embedded in the lens\\nand the condition of the eye be otherwise favorable, a scoop\\nextraction may be done in the hope of removing the frag\u00c2\u00ac\\nment with the lens; or the lens may be allowed, or by a", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0195.jp2"}, "196": {"fulltext": "188\\nCLINICAL DIVISION.\\nneedle operation induced, to undergo partial absorption and\\nshrinking, so as to enclose the foreign body more firmly,\\nand, when subsequently extracted, bring it away. If we\\nare certain that the foreign body has passed into the vitre\u00c2\u00ac\\nous, whether through the lens or not, and whether by gun\u00c2\u00ac\\nshot or not, we can seldom save the eye. The foreign body\\ncan in such a case seldom be seen, but a track of opacity\\nthrough the lens, with blood in the vitreous, or even the\\nlatter alone, with conclusive history that the wound was\\nmade by a fragment or a shot, and not by an instrument\\nor large body, will generally decide us in favor of excision.\\nThese rules need some modification when the foreign body\\nis of iron or steel, since it is possible in certain cases, by\\nmeans of a strong electro-magnet, to remove such frag\u00c2\u00ac\\nments, even when lying in the vitreous. This may be done\\neither through the wound of entrance, more or less enlarged,\\nor through a fresh wound made where the body is seen, or\\nbelieved to lie. Many forms of magnet have been employed,\\nthe most successful in their application usually being those\\nin which a probe-ended instrument, powerfully magnetized\\nby being attached to the core of an electro-magnetic coil, is\\nintroduced into the eye in search of the body. Haab has\\nlately introduced large and very powerful electro-magnets\\ninto ophthalmic surgery; but, while very efficacious, they\\nare not often available except in a large hospital service.\\nThough a number of eyes have now been saved with useful\\nsight by means of the magnet, it must be remembered that the\\nextraction of the foreign body does not ensure the safety\\nof the eye that the eye may inflame or shrink, and remain\\nas potent a source of sympathetic disease as before, espe\u00c2\u00ac\\ncially so if iritis or threatened panophthalmitis were present\\nat the time of operation. 1 Foreign bodies occasionally\\n1 Mr. Snell, of Sheffield, who has probably had a larger experience of this\\nmethod than any one else, has published (June, 1883) an excellent mono\u00c2\u00ac\\ngraph, in which all the cases hitherto recorded are given, in addition to his\\nown. Hirschberg\u00e2\u0080\u0099s monograph on the subject (1885) brings the subject up to\\nlater date.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0196.jp2"}, "197": {"fulltext": "INJURIES OF THE EYEBALL.\\n189\\nbecome embedded at the fundus, beyond the dangerous\\nregion, and cause no further trouble. In gunshot cases the\\nshot often passes out through a counter-opening, and re\u00c2\u00ac\\nmains without doing harm to the orbit, though the eye is\\ndestroyed. Occasionally the choroid and retina are dam\u00c2\u00ac\\naged by hemorrhage caused by a shot or bullet traversing\\nthe orbit close to, but without demonstrable lesion of, the\\nsclerotic.\\nSince the introduction of the Rontgem rays into surgery\\nthe treatment of eyes containing metallic foreign bodies\\nhas been revolutionized, as it is now quite feasible by\\nmeans of a series of skiagrams to locate accurately the\\nposition of the bodies. This being accomplished, its removal\\nis comparatively simple.\\nIII. There remain cases of less severe character, in which\\nthere is no foreign body in the eye: (1) the wound is in\\nthe dangerous region and complicated with traumatic cata\u00c2\u00ac\\nract; (2) in the dangerous region without traumatic cata\u00c2\u00ac\\nract; (3) the injury is entirely corneal, and therefore not\\nin the dangerous zone, but the lens and iris are wounded;\\n(4) there is wound of cornea and iris only, the lens escap\u00c2\u00ac\\ning. In group (2) there will often be much difficulty in\\ndeciding what to do, it being presumed that the wounded\\neye shows no iritis or other signs of severe inflammation;\\nsome of the most difficult cases are those of wounds by sharp\\ninstruments close to the corneal border, with considerable\\nadhesion of the iris, or in which there is evidence that the\\ntrack lies between the lens and the ciliary processes, the\\nlens not being wounded, and useful sight remaining. If\\nthe patient be seen within two or three weeks of the injury,\\nand the sound eye show no irritation, we may safely watch\\nthe case for a few days. If decided sympathetic irritation\\nbe present, and do not yield after a few days\u00e2\u0080\u0099 treatment,\\nexcision is advisable, even though the lens of the wounded\\neye be uninjured. In regard to group (1), excision is, with-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0197.jp2"}, "198": {"fulltext": "190\\nCLINICAL DIVISION.\\nout doubt, the safest course in all cases, whether or not the\\neye be causing sympathetic symptoms or be itself especially\\nirritable; for there is little prospect of regaining useful\\nvision in an eye with a ciliary wound and traumatic cata\u00c2\u00ac\\nract. In group (3) excision is necessary if the wound be\\nvery large or irregular, and in some cases with small wound\\nbut persistent symptoms. In group (4) removal of the eye\\nis very seldom justifiable, unless the iris having healed\\ninto the wound chronic inflammatory changes are present,\\nor severe iritis and threatened panophthalmitis come on.\\nThe patient in all open cases must be warned, and must be\\nseen every few days for many weeks.\\nWhen sympathetic ophthalmitis has set in before the\\npatient asks advice, the rule as to the excision of the ex\u00c2\u00ac\\nciting eye is different.\\nThe treatment of wounded eyes which are not excised is\\nthe same as for traumatic iritis and cataract, viz., atropine,\\nrest, and local depletion. If seen before inflammation\\n(iritis) has begun, ice is to be used. If the iris have pro\u00c2\u00ac\\nlapsed into the wound the protrusion should be drawn\\nfurther out and a large piece of iris cut off, so that the\\nends when replaced by the curette may retract and remain\\nquite free from the wound (see Iridectomy); this may be\\ndone as much as a week after the injury. Even when seen\\nwithin an hour or two of the wound, the prolapse can\\nseldom, in my experience, be either returned by manipula\u00c2\u00ac\\ntion or made to retract by eserine or atropine.\\nIt is sometimes important to determine whether an excised\\neye contain a foreign body. If nothing can be found in\\nthe blood or lymph, etc., by feeling with a probe, it is best\\nto crush the soft parts, little by little, between finger and\\nthumb, when the smallest particle will be felt. If a shot\\nhave entered and left the eye, the counter-opening may, if\\nrecent, be found from the inside, although no irregularity\\nbe noticeable outside the eyeball.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0198.jp2"}, "199": {"fulltext": "CHAPTER XI.\\nCATARACT.\\nCataract means opacity of the crystalline lens, and is\\ndue to changes in the structure and composition of the\\nlens-fibres. The capsule is often thickened, but otherwise\\nnot much altered. The changes seldom occur throughout\\nthe whole lens at once, but begin first in a certain region\u00e2\u0080\u0094\\ne. g the centre nucleus or the superficial layers (cortex),\\nwhile in some forms of partial cataract the change never\\nspreads beyond the part first affected.\\nSenile changes in the lens. With advancing age the lens,\\nwhich is from birth firmest at the centre, becomes harder,\\nand acquires a very decided yellow color; its refractive\\npower usually decreases, its surface reflects more light, and\\nits substance becomes somewhat fluorescent. The result of\\nall these changes is, that at an advanced age the lens is\\nmore easily visible than in early life, the pupil becoming\\ngrayish instead of being quite black. This grayness of the\\npupil may easily be mistaken for cataract, but ophthalmo\u00c2\u00ac\\nscopic examination shows that the lens is transparent, the\\nfundus being seen without any appreciable haze. It has\\nhitherto been supposed that the lens became smaller in old\\nage, but the researches of Priestley Smith have lately shown\\nthat the lens continues to increase in all dimensions so long\\nas it remains transparent. As a rule, however, cataractous\\nlenses are undersized.\\nThe Etiology of Cataract. \u00e2\u0080\u0094In addition to the influence\\nexerted by age in the production of cataract, there are\\nother causes which occasionally act as factors. Thus,\\n191", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0199.jp2"}, "200": {"fulltext": "192\\nCLINICAL DIVISION.\\ndiabetes mellitus is responsible for about 1 per cent, of\\ncases, this variety being bilateral and developing rapidly.\\nRachitis, nephritis, and some affections of the skin are\\ncredited with the production of the condition. Certain\\ndrugs, such as ergot and naphthalin, when introduced into\\nthe system are eminently causal in character. Heredity\\nexerts a decided influence, and certain occupations, espe\u00c2\u00ac\\ncially glassblowing, favor its production.\\nLocal conditions within the eye not infrequently give rise\\nto opacity of the crystalline lens, and the frequeut conges\u00c2\u00ac\\ntion of the choroid which has been noted in senile cata\u00c2\u00ac\\nracts has occasioned the opinion that cataract may be due\\nto pathological changes in the choroid and ciliary bodies;\\nothers believe that cataracts develop as the result of errors\\nof refraction, and seek to prevent further development of\\nthe opacity by careful and repeated correction of all forms\\nof ametropia by glasses.\\nThe consistence of a cataract depends chiefly on the\\npatient\u00e2\u0080\u0099s age. The wide physical differences between cata\u00c2\u00ac\\nracts depend less on variations in the cause, position, or\\ncharacter of the opacity than on the degree of natural\\nhardness which is proper to the lens at the time when the\\nopacity sets in. Below about thirty-five all cataracts are\\nsoft.\u00e2\u0080\u009d\\nForms of General Cataract.\\n1. Nuclear cataract. The opacity begins in, and remains\\nmore dense at, the nucleus of the lens, thinning off gradu\u00c2\u00ac\\nally in all directions toward the cortex (Fig. 74); the\\nnucleus is not really opaque, but densely hazy. As the\\npatients are generally old, nuclear cataract is usually senile\\nand hard, and also often amber-colored or light brownish,\\nlike pea-soup fog.\\n2. Cortical cataract. The change begins in the super-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0200.jp2"}, "201": {"fulltext": "CATARACT.\\n193\\nficial parts, and generally takes the form of sharply defined\\nlines or streaks, or triangular patches, which point toward\\nthe axis of the lens, and whose shape is dependent on the\\narrangement of the lens-fibres. Fig. 75. They usually\\nbegin at the edge equator of the lens where they are hid\u00c2\u00ac\\nden by the iris, but when large enough they encroach on\\nthe pupil as whitish streaks or triangular patches. They\\naffect both the anterior and posterior layers of the lens,\\nand the intervening parts may be quite clear. Sooner or\\nlater the nucleus also becomes hazy (mixed cataract), and\\nthe whole lens eventually gets opaque.\\nSome cases of the large class known as \u00e2\u0080\u009csenile\u00e2\u0080\u009d or\\nhard cataract are nuclear from beginning to end \u00e2\u0080\u0094L e. y\\nformed by gradual extension of diffused opacity from the\\ncentre to the surface; more commonly they are of the\\nmixed variety.\\nA few cataracts beginning at the nucleus, and many\\nbeginning at the cortex, are not senile in the sense of\\naccompanying old age, and are, therefore, not hard. Some\\nsuch are caused by diabetes, but in many it is impossible\\nto say w 7 hy the lens should have become diseased. 1 Mey-\\nhofer (1886), observing that opacities in the lens are dispro\u00c2\u00ac\\nportionately common in glassblowers, suggests that radiant\\nheat may act as a direct cause of cataract. Many of them\\nare known as soft cataracts when complete. They gen\u00c2\u00ac\\nerally form quickly, in a few months. A few are congen\u00c2\u00ac\\nital. Whether nuclear or cortical, they are whiter and\\nmore uniform-looking than the slower cataracts of old age,\\nand the cortex often has a sheen, like satin or mother-of-\\npearl, or looks flaky like spermaceti.\\nIn some cortical cataracts we find only a great number\\n1 Lowered blood-supply from atheroma of the carotid has lately been sug\u00c2\u00ac\\ngested as a cause in some cases (Michel). Cataract does not seem to be often\\nrelated to renal disease; but when renal albuminuria is present in a case of\\ncataract, the prognosis for operation is decidedly less favorable than usual.\\n13", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0201.jp2"}, "202": {"fulltext": "194\\nCLINICAL DIVISION\\nof very small dots or short streaks\u00e2\u0080\u0094dotted cortical cata\u00c2\u00ac\\nract this form is generally stationary 7 or nearly so for\\nyears. Occasionally a single large, wedge-shaped opacity\\nwill form at some part of the cortex, and remain stationary\\nand solitary for many years. Sometimes in suspected cata\u00c2\u00ac\\nract, though no opaque striae are visible by focal illum\u00c2\u00ac\\nination, one or more dark streaks, \u00e2\u0080\u009cstriae of refraction\u00e2\u0080\u009d\\n(Bowman), are seen with the mirror, altering as its incli\u00c2\u00ac\\nnation is varied, and having much the same optical effect\\nas cracks in glass; these flaws should always be looked\\non as the beginning of cataract.\\nPartial Cataract.\\nThree forms need special notice.\\n1. Lamellar (zonular) cataract is a peculiar and well-\\nmarked form in which the superficial laminse and the\\nnucleus of the lens are clear, a layer or shell of opacity\\nbeing present between them. Fig. 77. Examination shows\\na degenerated layer between the nucleus and cortex; in\\nall the cases the nucleus has been been found degenerated.\\nIt is probable that the opacity is present at birth; it cer\u00c2\u00ac\\ntainly never forms late in life. The association of lamellar\\ncataracts with rickets, and with a marked deformity of the\\npermanent teeth, consisting of an abruptly limited defi\u00c2\u00ac\\nciency of the enamel on the part furthest from the gums,\\nis a very common one. The teeth affected are the first\\nmolars, canines, and incisors of the permanent set; the\\ndental changes are quite different from those which are\\npathognomonic of inherited syphilis. The great majority\\nof the subjects of lamellar cataract give a history of infan\u00c2\u00ac\\ntile convulsions. The cataract is probably due to some\\ntemporary interference with the nutrition of the lens in\\nintra-uterine life, during the deposition of the affected\\nlayers. Mr. Hutchinson has collected many facts in favor", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0202.jp2"}, "203": {"fulltext": "CA TAR ACT.\\n195\\nof the belief that the dental defect is due to stomatitis\\ninterfering with the calcification of the enamel before the\\neruption of the teeth, and that mercury is the cause of the\\nstomatitis. On this hypothesis the coincidence of the dental\\ndefect and of the cataract is due to mercury having been\\ngiven for the convulsions from which these children suffer.\\nIt is reasonable to suppose, however, that the defect of the\\ncrystalline lens and of the enamel, both of them epiblastic\\nstructures, may be caused by some common influence. The\\nsize of the opaque lamella or shell, and therefore its depth\\nfrom the surface of the lens, are subject to much variation,\\nand it may be much smaller than is shown in the figure.\\nThe opacity is often stationary for years, perhaps for life,\\nbut cases are sometimes met with in which we cannot doubt,\\nfrom the history, that the opacity has, without extending\\nperceptibly, become more dense; instances of lamellar\\nopacity spreading to the whole lens are, however, appar\u00c2\u00ac\\nently very rare.\\n2. Pyramidal cataract. A small, sharply-defined spot\\nof chalky-white opacity is present in the middle of the\\npupil, at the anterior pole of the lens, looking as if it lay\\nupon the capsule. When viewed sideways it seems to be\\nsuperficially embedded in the lens, and also sometimes\\nFig. 72.\\n0\\nPyramidal cataract seen from the front and in section.\\nstands forward as a little nipple or pyramid, Fig. 72. It\\nconsists of the degenerated products of a localized inflam\u00c2\u00ac\\nmation just beneath the lens-capsule, with the addition of\\norganized lymph derived from the iris and deposited on\\nthe front of the capsule, the capsule itself being puck-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0203.jp2"}, "204": {"fulltext": "196\\nCLINICAL DIVISION.\\nered and folded, Fig. 73. It is a stationary form,\\nscarcely ever becoming general.\\nPyramidal cataract is the re\u00c2\u00ac\\nsult of central perforating ulcer\u00c2\u00ac\\nation of the cornea in early life,\\nand of this ophthalmia neon\u00c2\u00ac\\natorum is nearly always the\\ncause it is, therefore, often asso\u00c2\u00ac\\nciated with corneal nebula. The\\ncontact between the exposed part\\nof the lens-capsule and the in\u00c2\u00ac\\nflamed cornea,which occurs when\\nthe aqueous has escaped through\\nthe hole in the ulcer, appears to\\nset up the localized subscapular\\ninflammation. Iritis in very\\nearly life may also cause similar\\nopacities at the points of adhe\u00c2\u00ac\\nsion between the iris and lens.\\nThe term anterior polar cata\u00c2\u00ac\\nract is applied both to the form\\njust described and to certain rare\\ncases in which general cataract\\nbegins at this part of the lens.\\n3. Cataract, which afterward becomes general, may\\nbegin as a thin layer at the middle of the hinder surface\\nof the lens\u00e2\u0080\u0094 posterior polar cataract. Fig. 76. There are\\nmany varieties, but in general the pole itself shows the\\nmost change, the opacity radiating outward from it in more\\nor less regular spokes. The color appears grayish, yellow\u00c2\u00ac\\nish, or even brown, because seen through the whole thick\u00c2\u00ac\\nness of the lens. Sometimes the opacity is due to formations\\nadherent to the back of the capsule\u00e2\u0080\u0094 i. e., in front of the\\nvitreous; but this can seldom be proved during life. Cata\u00c2\u00ac\\nract beginning at the posterior pole is often a sign of dis-\\nFig. 73.\\nMagnified section of an anterior\\npolar cataract of eleven years\u00e2\u0080\u0099 for\u00c2\u00ac\\nmation. A complete layer of hy\u00c2\u00ac\\naline capsule lined by cells is\\nshown behind the opacity, and a\\nhyaline layer in front of it. (After\\nTreacher Collins.)", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0204.jp2"}, "205": {"fulltext": "CATARACT.\\n197\\nease of the vitreous depending on choroidal mischief; it is\\ncommon in the later stages of retinitis pigmentosa and\\nsevere choroiditis, and in high degrees of myopia with dis\u00c2\u00ac\\nease of the vitreous. The prognosis, therefore, should\\nalways, be guarded in a case of cataract where the prin\u00c2\u00ac\\ncipal part of the opacity is in this position.\\nWhen a cataract forms without known connection with\\nother disease of the eye, it is said to be primary. The term\\ncomplicate cataract is used when it is the consequence of\\nsome local disease, such as severe iridocyclitis, glaucoma,\\ndetachment of the retina, or the growth of a tumor in the\\neye. Primary cataract is symmetrical in most cases, but\\nan interval, which may extend over several years, usually\\nseparates its onset in the two eyes. Complicate cataract,\\nof course, may or may not be symmetrical. Secondary\\ncataract is a term used to designate the remnant of lens\\nand capsular matter which often follows the removal of a\\nprimary cataract.\\nDiagnosis of Cataract. The subjective symptoms of\\ncataract depend solely on the obstruction and distortion of\\nthe entering light by the opacities. Objectively, cataract\\nis shown in advanced cases by the white or gray condition\\nof the pupil at the plane of the iris; in earlier stages by\\nwhitish opacity in the lens when examined by focal light\\n(p. 58), and by corresponding dark portions, lines, spots,\\nor patches in the red pupil when examined by the oph\u00c2\u00ac\\nthalmoscope mirror.\\nBoth subjective and objective symptoms differ with the\\nposition and quantity of the opacity. When the whole\\nlens is opaque the pupil is uniformly whitish the opacity\\nlies almost on a level with the iris, no space intervening,\\nand consequently, on examining by focal light we find that\\nthe iris casts no shadow on the opacity the brightest light\\nfrom the mirror will not penetrate the lens in quantity\\nenough to illuminate the choroid, and hence no red reflex", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0205.jp2"}, "206": {"fulltext": "198\\nCLINICAL DLVISION.\\nwill be obtained. Such a cataract is said to be mature or\\nripe,\u00e2\u0080\u009d and the affected eye will be in ordinary terms\\nblind.\u00e2\u0080\u009d If both cataracts be equally advanced, the\\npatient will be unable to see any objects; but he will dis\u00c2\u00ac\\ntinguish quite easily between light and shade when the eye\\nis alternately covered and uncovered in ordinary daylight,\\ngood perception of light, p. 1 and will tell correctly the\\nposition of a candle flame\u00e2\u0080\u0094good projection. The pupils\\nshould be active to light and not dilated, the tension\\nnormal.\\nIn a case of incipient cataract the patient complains of\\ngradual failure of sight, and we find the acuteness of\\nvision impaired, probably more in one eye than in the\\nother, and more for distant than for near objects. In the\\nearliest stages of senile cataract some degree of myopia\\nmay be developed (Chapter XX.), or, owing to irregular\\nrefraction by the lens, the patient may see with each eye\\ntwo or more images of any object close together \u00e2\u0080\u0094polyopia\\nuniocular is. If he can still read moderate type, the glasses\\nappropriate for his age and refraction, though giving some\\nhelp, do not remove the defect. If, as is usual, he be pres\u00c2\u00ac\\nbyopic, he will be likely to choose over-strong spectacles,\\nand to place objects too close to his eyes, so as to obtain\\nlarger retinal images, and thus compensate for want of\\nclearness. In nuclear cataract, as the axial rays of light\\nare most obstructed, sight is often better when the pupil is\\nrather large, and such patients tell us that they see better\\nin a dull light, or with the back to the window, or when\\nshading the eyes with the hand. In the cortical and more\\ndiffused forms this symptom is less marked.\\nOn examining by focal light, the pupil having been\\ndilated, an immature nuclear cataract appears as a yellow\u00c2\u00ac\\nish, rather deeply-seated haze, upon which a shadow is cast\\nby the iris on the side from which the light comes.\\nFig. 74, 3. On now using the mirror this same opacity", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0206.jp2"}, "207": {"fulltext": "CATARACT.\\n199\\nappears as a dull blur in the area of the red pupil, darkest\\nat the centre, and gradually thinning off on all sides, so\\nthat, at the margin of the pupil, the full red choroidal\\nFig. 74.\\n1 2 3\\nNuclear cataract. 1. Section of lens opacity densest at centre. 2. Opacity\\nas seen by transmitted light (ophthalmoscope mirror) with dilated pupil.\\n3. Opacity as seen by reflected light (focal illumination). The pupil is sup\u00c2\u00ac\\nposed to be dilated by atropine.\\nreflex may still be present; the details of the fundus, if\\nstill visible, are obscured by the hazy lens, the haze being\\nthickest when we look through the centre of the pupil.\\nFig. 74, 2. If the opacity be dense and large, a faint dull\\nredness will be visible, and that only at the border of the\\npupil.\\nCortical opacities, if small and confined to the equator\\n(or edge) of the lens, do not interfere with sight; they are\\neasily detected with a dilated pupil by throwing light very\\nobliquely behind the iris. When large and encroaching\\non the pupil they are visible in ordinary daylight. They\\noccur in the form of dots, streaks, or wedges; seen by focal\\nFig. 75.\\nCortical cataract. References as in preceding figure.\\nlight they are whitish or grayish, and more or less sharply\\ndefined according as they are in the anterior or posterior\\nlayers. Fig. 75, 3. With the mirror they appear black\\nor grayish, and of rather smaller size, Fig. 75, 2; and if", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0207.jp2"}, "208": {"fulltext": "200\\nCLINICAL DIVISION.\\nthe intervening substance be clear, the details of the fundus\\ncan be seen sharply between the bars of opacity. Some\\nforms of cataract begin with innumerable minute dots in\\nthe cortical layer.\\nPosterior polar opacities are seldom visible without care\u00c2\u00ac\\nful focal illumination, when we find a patchy or stellate\\nfigure very deeply seated in the axis of the lens, Fig. 76, 3\\n0\\nif large it looks concave like the bottom of a shallow cup.\\nWith the mirror it is seen as a dark star, Fig. 76, 2, or\\nnetwork, or irregular patch, but smaller than when seen\\nby focal light.\\nThe diagnosis of lamellar cataract is easy if its nature\\nbe understood, but by beginners it is often diagnosed as\\nnuclear.\u00e2\u0080\u009d The patients are generally children or young\\nadults; they complain of \u00e2\u0080\u009cnear sight\u00e2\u0080\u009d rather than of\\ncataract;\u00e2\u0080\u009d for the opacity is not usually very dense, and\\nwhether the refraction of their eyes be really myopic or\\nnot, they, like other cataractous patients, compensate for\\ndull retinal images by holding the object nearer, and so\\nincreasing the size of the images. The acuteness of vision\\nis always defective, and cannot be fully remedied by any\\nglasses. They often see rather better when the pupils are\\ndilated, either by shading the eyes or by means of atropine\\nin the latter case convex glasses 4 or -f 4.5 D.) are\\nnecessary for reading. The pupil presents a deeply-seated,\\nslight grayness, Fig. 77, 4, and when dilated with atropine\\nthe outline of the shell of opacity is exposed within it.\\nThis opacity is sharply defined, circular and whitish by\\nPosterior polar cataract. References as before.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0208.jp2"}, "209": {"fulltext": "CATARACT.\\n201\\nfocal light, interspersed in many cases with white specks,\\nwhich at its equator appear as little projections, Fig. 77, 3.\\nBy focal illumination we easily make out that the opacity\\nconsists of two distinct layers, that there is a layer of clear\\nlens-substance, cortex, in front of the anterior layer, and\\nthat the margin, equator, of the lens is clear. By the\\nmirror the opacity appears as a disk of nearly uniform\\ngrayish or dark color, sometimes with projections, or\\ndarker dots, and surrounded by a zone of bright-red\\nreflection from the fundus corresponding to the clear mar-\\nFig. 77.\\n12 3\\nLamellar cataract. 1, 2, 3, as before. 4 shows slight grayness of the undilated\\npupil owing to the layers of opacity being deeply seated.\\ngin of the lens. Fig. 77, 2. The opacity often appears\\nrather denser at its boundary, a sort of ring being formed\\nthere; and in some cases quite large spicules or patches\\nproject from the part. Not only does the size of the opaque\\nlamella, and, therefore, its depth from the surface of the\\nlens, differ greatly in different cases, but its thickness or\\ndegree of opacity varies also. The disease is nearly always\\nsymmetrical in the two eyes. Occasionally there are two\\nshells of opacity, one within the other, separated by a cer\u00c2\u00ac\\ntain amount of clear lens-substance.\\nThe lens may be cataractous at birth \u00e2\u0080\u0094congenital cata\u00c2\u00ac\\nract. This form, of which there are several varieties, is", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0209.jp2"}, "210": {"fulltext": "202\\nCLINICAL DIVISION.\\nnearly always symmetrical, and generally involves the\\nwhole lens. Often the development of the eyeball is de\u00c2\u00ac\\nfective, and though there are no synechise, the iris may act\\nbadly to atropine. Cases are seen from time to time in\\nwhich juvenile or perhaps congenital cataract appears in\\nmany members of a family, even in several generations.\\nPrognosis of Cataract, a. Course. Although opaci\u00c2\u00ac\\nties in the lens never clear up, 1 they advance with very\\nvarying rapidity in different cases. As a rough rule, the\\nprogress of a general cataract is rapid in proportion to the\\nyouth of the patient. Cataracts in old people commonly\\ntake from one to three years in reaching maturity\u00e2\u0080\u0094some\u00c2\u00ac\\ntimes much longer; there are cases of nuclear senile cata\u00c2\u00ac\\nract where the opacity never spreads to the cortex, and\\nthe cataract never becomes complete,\u00e2\u0080\u009d though it may\\nbecome dry and \u00e2\u0080\u009cripe\u00e2\u0080\u009d for operation. If the lens be\\nallowed to remain very long after it is opaque, further\\ndegenerative changes generally occur; it may become\\nharder and smaller, calcareous and fatty granules being\\nformed in it; or the cortex may liquefy while the nucleus\\nremains hard (Morgagnian cataract A congenital cataract\\nmay undergo absorption and shrink to a thin, firm, mem\u00c2\u00ac\\nbranous disk. Soft cataract in young adults, from what\u00c2\u00ac\\never cause, is generally complete in a few months.\\nb. Sight. The prognosis after operation is good when\\nthere is no other disease of the eye, and when the patient\\n(although advanced in years) is in fair general health. It\\nis not so good in diabetes, nor when the patient is in\\nobviously bad health, the eyes being then less tolerant of\\noperation. In the lamellar and other congenital varieties\\nit must be guarded, for the eyes are often defective in other\\nrespects, and sometimes very intolerant of operation; the\\nintellect, too, is sometimes defective, rendering the patient\\n1 Except sometimes in diabetes. Chapter XXIII.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0210.jp2"}, "211": {"fulltext": "CATARACT.\\n203\\nless able to make proper use of his eyes. In traumatic\\ncataract, of course, everything depends on the details of\\nthe injury, but, as a rule, the younger the patient the better\\nthe prospect of a quiet and uncomplicated absorption of\\nthe lens.\\nIn every case of immature cataract, the vitreous and\\nfundus should be carefully examined by the ophthalmo\u00c2\u00ac\\nscope, and the refraction ascertained. The presence of\\nhigh myopia is unfavorable, and the same is true of opaci\u00c2\u00ac\\nties in the vitreous, indicating, as they usually do, that it\\nis fluid. Any disease of the choroid or retina will, of\\ncourse, be prejudicial in proportion to its position and ex\u00c2\u00ac\\ntent. In every case before deciding to operate, the state\\nof the conjunctiva and lachrymal passages, the tension of\\nthe eye, and the size and mobility of the pupils to light,\\nare to be carefully noted.\\nTreatment. In the early stages of senile and nuclear\\ncataract, sight is improved by keeping the pupil moderately\\ndilated with a weak mydriatic solution, one-eighth of a\\ngrain of atropine to the ounce, used about three times a\\nweek. Dark glasses, by allowing some dilatation of the\\npupil, also assist. Stenopaic glasses are sometimes useful.\\nWith these exceptions, nothing except operative treatment\\nis of any use. The management of lamellar cataract\\nrequires separate description.\\nOperations for the removal of cataract are of three kinds\\n1. Extraction of the lens entire through a large wound in the\\ncornea, or at the sclero-corneal junction, the lens-capsule\\nremaining behind. By a few operators the lens is removed\\nentire in its capsule. 2. For soft cataracts, gradual absorp\u00c2\u00ac\\ntion, by the agency of the aqueous humor admitted through\\nneedle punctures in the capsule, just as after accidental\\ntraumatic cataract, needle operations, solution, discission.\\nThe operation needs repetition two or three times, at inter\u00c2\u00ac\\nvals of a few T weeks, and the whole process therefore occupies", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0211.jp2"}, "212": {"fulltext": "204\\nCLINICAL DIVISION.\\nthree or four months. 3. For soft cataracts, removal by\\ncurette or suction syringe, introduced into the anterior cham\u00c2\u00ac\\nber through a small wound near the margin of the cornea,\\nthe whole lens having been freely broken up by a discission\\noperation a few days previously. Chapter XXII. The\\nuse of the suction syringe is attended by risk of irido\u00c2\u00ac\\ncyclitis evacuation of the swollen lens along the groove\\nof a curette just passed into the wound is much safer, and\\nis almost equally effectual. The great advantage of this\\nmethod over that of gradual absorption is the saving of\\ntime, almost the whole lens being removed at one sitting.\\nExtraction is necessary for cataracts after about the age\\nof forty. The lens from this age onward is so firm that its\\nabsorption after discission occupies a much longer time\\nthan in childhood and youth; moreover, as already stated,\\nthe swelling of the lens after wound of the capsule is less\\neasily borne as age advances, and hence solution operations\\nbecome not only slower but attended by more danger.\\nIndeed, though suction and solution operations are appli\u00c2\u00ac\\ncable up to about the age of thirty-five, extraction is often\\npractised in preference at a much earlier age.\\nIf one eye present a complete cataract while the sight of\\nthe other is perfect, or at least serviceable, removal of the\\ncataract will confer little immediate benefit on the patient.\\nIndeed, if one eye be still fairly good, the patient will often\\nbe dissatisfied by finding his operated eye less useful than\\nhe expected, perhaps even not so useful as the other. In\\nsenile cataract, therefore, it is usually best not to operate\\nso long as the lens of the other eye remains nearly clear;\\nbut as soon as it becomes sufficiently affected to interfere\\nseriously with vision, extraction of the cataract from the\\nfirst eye is advisable, provided that the patient has a fair\\nprospect of life. The cataract in the first eye may be over\u00c2\u00ac\\nripe and less favorable for operation if it be left until the\\nsecond eye is quite ready. The removal of a single cata-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0212.jp2"}, "213": {"fulltext": "CATARACT.\\n205\\nract in young persons is often expedient on account of\\nappearance. In all cases of single cataract it must be\\nexplained that after the operation the two eyes will not\\nwork together on account of the extreme difference of\\nrefraction. See Anisometropia.\\nEven when both cataracts are mature at the same time,\\nit is safer to remove only one at once, because the after-\\ntreatment is more easily carried out upon one eye than\\nboth, and because after the double operation any untoward\\nresult in one eye adds to the difficulty of managing its\\nfellow; while a bad result after single extraction enables\\nus to take especial precautions, or to modify the operation\\nfor the second eye. Even if the patient be so old or feeble\\nthat the second eye may never come to operation, we shall\\nconsult his interests better by endeavoring to give him one\\ngood eye than by risking a bad result in attempting to\\nrestore both at the same time.\\nCataract occurring after the age of forty can seldom be\\nsafely extracted until it is complete or ripe.\u00e2\u0080\u009d The trans\u00c2\u00ac\\nparent portions of an immature cataract cannot be com\u00c2\u00ac\\npletely removed, partly because they are sticky, partly\\nbecause they cannot be seen; and, remaining behind in\\nthe eye, they act as irritants, and often set up iritis.\\nIncomplete juvenile cataract\u00e2\u0080\u0094 e.g., lamellar cataract, may\\nbe safely ripened by tearing the capsule with a needle (see\\nDiscission and Suction); but hard cataract cannot be so\\ntreated because the lens is too hard to absorb the aqueous\\nwell, and the senile eye is intolerant of injury to the lens.\\nSeveral years ago Professor Forster, of Breslau, proposed a\\nplan for hastening the completion of very slow senile cataracts\\nimmediately after the iridectomy he bruises the lens by rubbing\\nthe cornea firmly over the pupil with a cataract spoon or other\\nsmooth instrument; the capsule is not ruptured, but the lens-\\nfibres are broken up or so changed that they often become\\nopaque a few weeks or months after. Others adopt the safer", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0213.jp2"}, "214": {"fulltext": "206\\nCLINICAL DIVISION.\\nplan of bruising the lens directly by means of a small bulbous\\nspatula passed through the corneal wound. These methods\\nare very uncertain, sometimes having no effect, but the latter\\nmodification may be employed without risk in suitable cases.\\nThe principal causes of failure after extraction of cataract\\nare:\\n1. Hemorrhage between the choroid and sclerotic coming\\non, usually with severe pain, immediately after the opera\u00c2\u00ac\\ntion. The blood fills the eyeball, and often oozes from the\\nwound and soaks through the bandage.\\n2. Suppuration, beginning in the corneal wound, spread\u00c2\u00ac\\ning to the iris and vitreous, and in many to the entire cor\u00c2\u00ac\\nnea, and ending in total loss of the eye. It occasionally\\ntakes a less rapid course, and stops short of a fatal result.\\nThe alarm is given in from twelve hours to about three\\ndays after operation by the occurrence of pain, inflamma\u00c2\u00ac\\ntory oedema of the lids, particularly the free border of the\\nupper lid, and the appearance of some muco-purulent dis\u00c2\u00ac\\ncharge. On raising the lid the eye is found to be greatly con\u00c2\u00ac\\ngested, its conjunctiva cedematous, the edges of the wound\\nyellowish, and the cornea steamy and hazy. In very rapid\\ncases the pupil, especially near to the wound, will already\\nbe occupied by lymph. Suppuration is probably always\\ncaused by infection, though the source of the mischief of\\ncourse, often remains hidden. Chronic dacryocystitis is a\\nvery dangerous concomitant of cataract operations, the pus\\nescaping through the puncta and infecting the wound.\\nSuppuration is more probable if the wound lie in clear\\ncorneal tissue than if it be partly scleral, and if the patient\\nbe in bad or feeble health.\\nThe use of hot fomentations for an hour three or four\\ntimes a day, leeches if there be much pain, and internally\\na purge, followed by quinine and ammonia, and wine or\\nbrandy if the patient be feeble, should be at once resorted to.\\nAs to other measures opinions differ. From what I have", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0214.jp2"}, "215": {"fulltext": "CATARACT.\\n207\\nseen of my own cases and those of others, I am, at present,\\ninclined to agree with Horner and those who direct most\\nattention to the vigorous antiseptic treatment of the wound\\nitself; I have found that the actual (galvano-) cautery ap\u00c2\u00ac\\nplied deeply along the whole length of the wound, or wash\u00c2\u00ac\\ning out the wound, and the anterior chamber if necessary,\\nwith freshly prepared chlorine water, are more successful\\nthan any other measures they should be assisted, however,\\nby hot fomentations and the use of iodoform or of weak\\nlotions of chloride of zinc or bichloride of mercury, and by\\nleaving the eye open. 1 But only in the cases of moderate\\nrapidity and intensity can we hope, even partly, to arrest\\nthe disease, for the great majority of these cases go on to\\nsuppurative panophthalmitis, or to severe plastic irido\u00c2\u00ac\\ncyclitis with opacity of cornea and shrinking of the eyeball.\\n3. Iritis may set in between about the fourth and tenth\\ndays. Here also pain, oedema of the eyelids, and chemosis\\nare the earliest symptoms. There is lachrymation, but no\\nmuco-purulent discharge, and the cornea and wound usu\u00c2\u00ac\\nally remain clear. The iris is discolored (unless it happen\\nto be naturally greenish-brown), and the pupil dilates badly\\nwith atropine. Whenever, in a case presenting such symp\u00c2\u00ac\\ntoms, a good examination is rendered difficult on account\\nof the photophobia, iritis should be suspected. If the early\\nsymptoms are severe, a few leeches to the temple are very\\nuseful. Atropine and warmth are the best local measures.\\nIf atropine irritate, scopoline, daturine, or duboisine should\\nbe tried (F. 34, 36, 37).\\nThis inflammation is plastic, ending in the formation of\\nmore or less dense membrane in the pupil. Such mem\u00c2\u00ac\\nbrane, by contracitng and drawing the iris with it toward\\nthe operation scar, often displaces the pupil. Fig. 158\\nshows this in an extreme degree. The membrane is formed\\ni Mr. C. T. Collins, the house-surgeon at Moorflelds, suggested to me the\\nlast-named measure.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0215.jp2"}, "216": {"fulltext": "208\\nCLINICAL DIVISION.\\npartly by exudation from the iris and ciliary processes,\\niritis, cyclitis, partly by the lens-capsule and its proliferated\\nendothelial cells, capsulitis. Mixed forms of chronic kera\u00c2\u00ac\\ntitis and iritis sometimes occur, the corneal haze spreading\\nfrom the wound in the form of long lines or stripes. Iritis\\nof obstinately plastic type is liable to occur after extraction\\nof cataract in diabetes.\\n4. The iris may beocome incarcerated in or prolapse\\nthrough the wound at the operation, or a few days after\u00c2\u00ac\\nward by the reopening of a weakly united wound. When\\niridectomy has been done the prolapse appears as a little\\ndark bulging at one or both ends of the wound, and often\\ncauses prolonged irritability without actual iritis. The best\\ntreatment is to draw the protruding part further out, and\\nto cut it off as freely as possible, as in accidental wounds.\\nThe occurrence of prolapse is a reason for keeping the eye\\ntied up longer. The capsule also may be incarcerated in\\nor adherent to the wound after extraction, suction, or\\ncurette (simple linear) extraction. After-operations are\\nneeded if the pupil be much obstructed by capsular opaci\u00c2\u00ac\\nties or by the results of iritis; but nothing should be done\\nuntil active symptoms have subsided and the eye been\\nquiet for some weeks.\\nSight after the removal of cataract. In accounting for\\nthe state of the sight we have to remember that the acute\u00c2\u00ac\\nness of sight naturally decreases in old age; that slight\\niritis, producing a little filmy opacity in the pupil, is com\u00c2\u00ac\\nmon after extraction and that some eyes, with good sight,\\nremain irritable for long after the operation, and therefore\\ncannot be much used. Thus, putting aside the graver\\ncomplications, we find that, even of the eyes which do best,\\nonly a moderate proportion reach normal acuteness of\\nvision. Cases are considered good when the patient can\\nwith his glasses read anything between Nos. 1 and 14 Jaeger\\nand r 6 g- Snellen but a much less satisfactory result than", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0216.jp2"}, "217": {"fulltext": "CATARACT.\\n209\\nthis is very useful. About 5 per cent, of the eyes operated\\nupon are lost from various causes. The eye is rendered\\nextremely hypermetropic by removal of the lens, and fre\u00c2\u00ac\\nquently there is a good deal of astigmatism due to flatten\u00c2\u00ac\\ning of that meridian of the cornea which is at a right angle\\nwith the operation wound. Strong convex glasses are neces\u00c2\u00ac\\nsary for clear vision; these should seldom be allowed until\\nthree months after the operation, and at first they should\\nnot be continuously worn. Two pairs are needed: one\\nmakes the eye emmetropic, and gives clear distant vision\\nor 11 F the other (about -f-15 D.) is for reading,\\nsewing, etc., at about 10 (25 cm.) as during strong accom\u00c2\u00ac\\nmodation. When there is astigmatism it should usually be\\ncorrected. As all accommodation is lost, the patient has\\nno range of distinct vision.\\nLamellar cataract. If the patient can see enough to get\\non fairly well at school, or in his occupation, it may be best\\nnot to operate; but when, as is the rule, the opacity is\\ndense enough to interfere seriously with his prospects,\\nsomething must be done. The choice lies between artifi\u00c2\u00ac\\ncial pupil when the clear margin is wide and quite free\\nfrom spicules, and solution or extraction when it is narrow,\\nor when large spicules of opacity project into it from the\\nopaque lamella. Fig. 77. My own experience is decidedly\\nin favor of removing the lens in the majority of cases. A\\nvery good rule is to operate on only one eye at a time, thus\\nallowing the choice of a different operation on its fellow.\\nWhen a cataractous eye is absolutely blind some more\\ndeeply-seated disease must be present, and no operation\\nshould be undertaken; and when projection and p. 1. are\\nbad great caution is needed.\\nCataract following injury. Severe blows on the eye may\\nbe followed by opacity of the lens, the capsule and often\\nthe suspensory ligament being no doubt torn in some part\u00e2\u0080\u0094\\nconcussion cataract. Lawford has shown that rupture of the\\n14", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0217.jp2"}, "218": {"fulltext": "210\\nCLINICAL DIVISION.\\nposterior capsule may occur from a blow, while the anterior\\ncapsule remains intact (Ophth. Rev., vi. 281). Such a cata\u00c2\u00ac\\nract may remain incomplete and stationary for an indefi\u00c2\u00ac\\nnite period, but often it becomes complete. Traumatic\\ncataract proper is the result of wound of the lens-capsule;\\nthe aqueous passing through the aperture is imbibed by the\\nlens-fibres, which swell up, become opaque, and finally dis\u00c2\u00ac\\nintegrate and are absorbed. The opacity begins within a\\nfew hours of the wound it progresses quickly in proportion\\nas the wound is large and the patient young but both the\\nsymptoms and consequences are often more severe in old\\npersons. A free wound of the capsule, followed by rapid\\nswelling of the whole lens, may give rise, especially after\\nmiddle life, to severe glaucomatous symptoms and iritis.\\nIn from three to six months a wounded lens will generally\\nbe absorbed, and nothing but some chalky-looking detritus\\nremain in connection with the capsule. A very fine punc\u00c2\u00ac\\nture of the lens is occasionally followed by nothing more\\nthan a small patch or narrow track of opacity, or by very\\nslowly advancing general haze. Occasionally partial opaci\u00c2\u00ac\\nties of the lens caused by injury clear up entirely. The\\nobjects of treatment are to prevent iritis by atropine, and by\\nleeching if there be pain; it is usually safest to leave the\\nwounded lens to become absorbed, but we must be prepared\\nto extract it by linear operation or suction at any time\\nshould glaucoma, iritis, or severe irritation arise. A con\u00c2\u00ac\\ncussion cataract, however, is seldom completely absorbed;\\nthe lens shrinks, and may then become loosened and fall\\neither into the vitreous or aqueous chamber. I believe,\\ntherefore, that it is usually best to remove by operation a\\ncataract following a blow. It will often be observed in\\nboth these forms of cataract that the opacity appears at\\nthe posterior surface of the lens quite early, whether the\\nwound have penetrated deeply or not.\\nDislocation of the lens in its capsule is usually caused", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0218.jp2"}, "219": {"fulltext": "CATARACT.\\n211\\nby a blow on the eye, but may be spontaneous; it is, as a\\nrule, only partial. The iris is often tremulous where its\\nsupport is lost, and bulged forward at some other part\\nwhere the lens rests against it; by focal light, or by the\\nophthalmoscope, the free edge of the lens can be seen as a\\ncurved line passing across the pupil, more easily if the\\npupil be dilated. More rarely the dislocation is complete,\\neither into the vitreous or into the anterior chamber. A\\nfull-sized lens dislocated into the anterior chamber causes\\nacute glaucoma. Glaucoma, acute or chronic, may also\\nFig. 78.\\nDislocation of lens. (Jaeger.)\\nfollow at any time after a dislocation, either partial or\\ncomplete, into the vitreous. Dislocated lenses often be\u00c2\u00ac\\ncome opaque and shrunken, and then either remain loose\\nor become adherent, and in either event are likely, sooner\\nor later, to set up irritation and pain. Such a lens may\\nsometimes be made to pass at will through the pupil by\\naltering the position of the head. The edge of a trans\u00c2\u00ac\\nparent lens in the vitreous appears, by the mirror, as a\\ndark line; when in the anterior chamber it appears as a\\nbright line, by focal illumination. If the lens be dislocated\\ninto the anterior chamber it is necessary to extract it; a", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0219.jp2"}, "220": {"fulltext": "212\\nCLINICAL DIVISION.\\nmyotic should first be used to prevent backward displace\u00c2\u00ac\\nment of the lens into the vitreous. If the lens be floating\\nfreely in the vitreous it is impossible to remove it; if it be\\nonly partially dislocated it may be removed by the hook\\nor spoon. Congenital dislocation, ectopia lentis, is due to\\ndefective development of the suspensory ligament; it is\\noften accompanied by other defects of development, such\\nas coloboma.\\nFor dislocation of lens beneath conjunctiva in rupture\\nof the eye, see p. 180.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0220.jp2"}, "221": {"fulltext": "CHAPTER XII.\\nDISEASES OF THE CHOROID.\\nThe choroid is, next to the ciliary processes, the most\\nvascular part of the eyeball, and from it the outer layers\\nof the retina certainly, and the vitreous humor probably,\\nare mainly nourished. Inflammatory and degenerative\\nchanges often occur, some of them entirely local, as in\\nmyopia; others symptomatic or constitutional or of gener\u00c2\u00ac\\nalized disease, such as syphilis and tuberculosis. Choro\u00c2\u00ac\\niditis, unlike inflammations of its continuations, the ciliary\\nbody and iris, is seldom shown by external congestion or\\nsevere pain; and as none of its symptoms are characteris\u00c2\u00ac\\ntic, the diagnosis rests chiefly on ophthalmoscopic evidence.\\nBlemishes or scars, permanent and easily seen, nearly\\nalways follow disease of the choroid, and such spots and\\npatches are often as useful for diagnosis as cicatrices on\\nthe skin, and deserve as careful study. The retina lying\\nover an inflamed choroid often takes on active changes, or\\nbecomes atrophied afterward; but in other cases, marked\\nby equally severe changes, the retina is uninjured. Indeed,\\nthere is sometimes difficulty in deciding which of these two\\nstructures was first affected, especially as changes in the\\npigment epithelium, which is really part of the retina, are\\nas often the result of deep-seated retinitis, or retinal hem\u00c2\u00ac\\norrhage, as of superficial choroiditis. Patches of accumu\u00c2\u00ac\\nlated pigment, though usually indicating spots of former\\nchoroiditis, are sometimes the result of bleeding, either\\nfrom retinal or choroidal vessels, and their correct inter\u00c2\u00ac\\npretation may therefore be difficult.\\n213", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0221.jp2"}, "222": {"fulltext": "CLINICAL DIVISION.\\n214\\nAppearances in health. The choroid is composed chiefly\\nof bloodvessels and of cells containing dark-brown pigment.\\nThe quantity of pigment varies in different eyes, and to some\\ndegree in different parts of the same eye; it is scanty in\\nearly childhood, and in persons of fair complexion; more\\nabundant in persons with dark or red hair, brown irides,\\nor freckled skin more plentiful in the region of the yellow\\nspot than elsewhere. In old age the pigment epithelium\\nbecomes paler. When examining the choroid we need to\\nthink of four parts: (1) the retinal pigmented epithelium,\\nwhich is for ophthalmoscopic purposes choroidal, seen in\\nthe erect image as a fine dark stippling; (2) the capillary\\nlayer, chorio-capillaris, just beneath the epithelium, form\u00c2\u00ac\\ning a very close meshwork, the separate vessels of which\\nare not visible in life; (3) the larger bloodvessels, often\\neasily visible; (4) the pigmented connective-tissue cells of\\nthe choroid proper, which lie between the larger vessels.\\nIn the majority of eyes these four structures are so toned\\nas to give a nearly uniform, full red color by the ophthal\u00c2\u00ac\\nmoscope, blood-color predominating. In very dark races\\nthe pigment is so excessive that the fundus has an uniform\\nslaty color. In very fair persons, and young children, the\\ndeep pigment (4) is so scanty that the large vessels are sepa\u00c2\u00ac\\nrated by spaces of lighter color than themselves. Fig. 37.\\nIn dark persons these same spaces are of a deeper hue than\\nthe vessels, the latter appearing like light streams separated\\nby dark islands. See upper part of Fig. 88. Near to the\\ndisk and y. s. the vessels are extremely abundant and very\\ntortuous, the interspaces being small and irregular; but\\ntoward and in front of the equator the veins take a nearly\\nstraight course, converging toward the vence vorticosce, and\\nthe islands are larger and elongated. The veins are much\\nmore numerous and larger than the arteries, Fig. 80, but\\nwo cannot often distinguish between them in life. The\\nvessels of the choroid, unlike those of the retina, present no", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0222.jp2"}, "223": {"fulltext": "DISEASES OF THE CHOROID.\\n215\\nlight streak along the centre. The pigment epithelium\\nand the capillary layer tone down the above contrasts, and\\nso in old age, when the epithelial pigment is bleached, or\\nif the capillary layer be atrophied after superficial choroid\u00c2\u00ac\\nitis, Fig. 81, a and b, the above distinctions become very\\nmarked.\\nA vertical section of naturally injected human choroid\\nis shown in Fig. 79 the uppermost dark line (1) is the\\npigment epithelium; next are seen the capillary vessels\\n(2) cut across; then the more deeply-seated large vessels\\n(3) and the deep layer of stellate pigment-cells of the\\nchoroid proper (4). Fig. 80 is from an artificially injected\\nhuman choroid seen from the inner surface. The shaded\\nFig. 79.\\nHuman choroid, vertical section. Naturally injected. X 20.\\nportion is intended to represent the general effect produced\\nby all the vessels and the pigment epithelium. The lowest\\npart shows the large vessels with their elongated interspaces,\\nas may be seen in a case where the pigment epithelium and\\nchorio-capillaris are atrophied, Fig. 81, b; in a dark eye\\nthe interspaces in Fig. 80 would be darker than the vessels.\\nThe middle part shows the capillaries without the pigment\\nepithelium. Both figures are magnified about four times as\\nmuch as the image in the indirect ophthalmoscopic exam\u00c2\u00ac\\nination.\\nOphthalmoscopic Signs of Disease of the Choroid.\\nThe changes usually met with are indicative of atrophy.\\nThis may be partial or complete; primary, or following\\ninflammation or hemorrhage; in circumscribed spots and\\npatches, or in large and less abruptly bounded areas.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0223.jp2"}, "224": {"fulltext": "216\\nCLINICAL DIVISION.\\nSecondary changes are often present in the correspond\u00c2\u00ac\\ning parts of the retina. The chief signs of atrophy of the\\nchoroid are: (1) the substitution of a paler color, varying\\nFig. so.\\nVessels of human choroid artificially injected. Arteries cross-shaded.\\nCapillaries too dark and rather too small. The uppermost shaded part is\\nmeant to represent the effect of the pigment epithelium. X 20.\\nfrom pale red to yellowish-white, for the full red of health,\\nthe subjacent white sclerotic being more or less visible\\nwhere the atrophic changes have occurred; (2) black pig-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0224.jp2"}, "225": {"fulltext": "DISEASES OF THE CHOROID.\\n217\\nment in spots, patches, or rings, and in varying quantity,\\nupon or around the pale patches. These pigmentations\\nresult, first, from disturbance and heaping together of the\\nnormal pigment; second, from increase in its quantity;\\nthird, from blood-coloring matter left after extravasations.\\nPatches of primary atrophy\u00e2\u0080\u0094 e.cj., in myopia\u00e2\u0080\u0094are never\\nmuch pigmented unless bleeding has taken place. The\\namount of pigmentation in atrophy following choroiditis is\\nclosely related to that of the healthy choroid\u00e2\u0080\u0094 i. e., to the\\ncomplexion of the person.\\nFig. 81\\nAtrophy after syphilitic choroiditis, showing various degrees of wasting\\n(Hutchinson), a. Atrophy of pigment epithelium, b. Atrophy of epithe\u00c2\u00ac\\nlium and chorio-capillaris; the large vessels exposed, c. Spots of complete\\natrophy, many with pigment accumulation.\\nPigment at the fundus may lie in the retina as well as\\nin or on the choroid, and this is true whatever may have\\nbeen its origin, for in choroiditis with secondary retinitis\\nthe choroidal pigment often passes forward into the retina.\\nWhen a spot of pigment is distinctly seen to cover a reti\u00c2\u00ac\\nnal vessel that spot must be not only in, but very near", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0225.jp2"}, "226": {"fulltext": "218\\nCLINICAL DIVISION.\\nthe anterior (inner) surface of, the retina; and when the\\npigment has a linear, mossy or lace-like pattern, Fig. 91,\\nit is always in the retina; these are the only conclusive\\ntests of its position.\\nIt is important, and usually easy, to distinguish between\\npartial and complete atrophy of the choroid. In super\u00c2\u00ac\\nficial atrophy affecting the pigment epithelium and capil\u00c2\u00ac\\nlary layer, the large vessels are peculiarly distinct. Fig.\\n81, a and h. Such capillary or epithelial choriditis\\noften covers a large surface, the boundaries of which are\\nsometimes well-defined, sinuous and map-like, but are as\\noften ill-marked in the latter case we must carefully com\u00c2\u00ac\\npare different parts of the fundus, and also make allowance\\nfor the patient\u00e2\u0080\u0099s age and complexion. Complete atrophy\\nis shown by the presence of patches of white or yellowish-\\nwhite color of all possible variations in size, with sharply-\\ncut, circular or undulating borders, and with or without\\npigment accumulations. Fig. 81, c. The retinal vessels\\npass unobscurbed over patches of atrophied choroid, prov\u00c2\u00ac\\ning that the appearance is caused by some change deeper\\nthan the surface of the retina.\\nIf the patient comes with recent choroiditis we also often\\nsee patches of palish color, but they are less sharply\\nbounded, and frequently of a grayer or whiter (less yellow)\\ncolor than patches of atrophy moreover the edge of such\\na patch is softened, the texture of the choroid being dimly\\nvisible there, because only partly veiled by exudation. If\\nthe overlying retina be unaffected its vessels are clearly\\nseen over the diseased part, but if the retina itself is hazy\\nor opaque the exact seat of the exudation often cannot be\\nat once decided; and this difficulty is often increased by\\nthe hazy state of the vitreous.\\nSyphilitic choroiditis begins in, and is often confined to,\\nthe inner (capillary) layer of the choroid, Fig. 82, and\\nhence it often affects the retina. In miliary tuberculosis", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0226.jp2"}, "227": {"fulltext": "DISEASES OF THE CHOROID.\\n219\\nof the choroid the overlying retina is clear, and the growth\\nis, for the most part, deeply seated. Fig. 83. After very\\nsevere choroiditis, or extensive hemorrhage, absorption is\\noften incomplete; we find then, in addition to atrophy,\\ngray or white patches, or lines, which, in pattern and\\nFig. 82.\\nMinute exudations into inner layer of choroid in syphilitic choroiditis.\\nPigment epithelium adherent over the exudations, but elsewhere has been\\nwashed off. Ch. Choroid. Scl. Sclerotic. X 20.\\nappearance, remind us of keloid scars in the skin, or of\\npatches and lines of old thickening on serous membranes.\\nVery characteristic changes are seen after rupture of the\\nchoroid from sudden stretching caused by blows on the front\\nof the eye. These ruptures, always situated in the central\\nregion, occur in the form of long tapering lines of atrophy,\\nusually curved toward the disk, and sometimes branched,\\nFig. 83.\\nSection of miliary tubercle. Inner layers of choroid comparatively unaf\u00c2\u00ac\\nfected. The lighter shading, surrounding an artery in the deepest part of the\\ntubercle, represents the oldest part, which is caseating an artery is seen cut\\nacross in this part of the tubercle. X 20.\\nFig. 84; their borders are often pigmented. If seen soon\\nafter the blow, the rent is more or less hidden by blood,\\nand the retina over it is hazy.\\nThe pathological condition known as colloid disease\u00e2\u0080\u009d\\nof the choroid consists in the growth of very small hyaline", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0227.jp2"}, "228": {"fulltext": "220\\nCLINICAL DIVISION.\\nnodules, soft at first, afterward becoming hard like glass,\\nfrom the thin lamina elastica which lies between the pig\u00c2\u00ac\\nment epithelium and chorio-capillaris. It is common in\\nFig. 84.\\nRupture of choroid. (Wecker)\\neyes excised for old inflammatory mischief, and in partial\\natrophy after choroiditis. Fig. 85. But little is known\\nof its ophthalmoscopic equivalent, or its clinical characters.\\nFig. 85.\\nPartial atrophy after syphilitic choroiditis. Minute growths from inner sur\u00c2\u00ac\\nface of choroid, showing how they disturb the outer layers of the retina.\\nX 60.\\nProbably it may result from various forms of choroiditis,\\nand may also be a natural senile change.\\nHemorrhage from the choroidal vessels is not so often", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0228.jp2"}, "229": {"fulltext": "DISEASES OF THE CHOROID.\\n221\\nrecognized as from those of the retina, but may be seen\\nsometimes, especially in old people and in highly myopic\\neyes. The patches are more rounded than retinal hemor\u00c2\u00ac\\nrhages, and we can sometimes recognize the striation of the\\noverlying retina. Occasionally they are of immense size.\\nPatches of atrophy may follow.\\nClinical Forms of Choroidal Disease.\\n1. Numerous discrete patches of choroidal atrophy (some\u00c2\u00ac\\ntimes complete, as if a round bit had been punched out, in\\nothers incomplete, though equally round and well defined)\\nare scattered in different parts of the fundus, but are most\\nabundant toward the periphery; or, if scanty, are found\\nonly in the latter situation. They are more or less pig\u00c2\u00ac\\nmented, unless the patient\u00e2\u0080\u0099s complexion is extremely fair.\\nFig. 81, c.\\n2. The disease has the same distribution, but the patches\\nare confluent; or large areas of incomplete atrophy, pass\u00c2\u00ac\\ning by not very well-defined boundaries into the healthy\\nchoroid around, are interspersed with a certain number of\\nseparate patches; or without separate patches there may\\nbe a widely spread superficial atrophy with pigmentation.\\nFig. 81, a and b.\\nThese two types of choroiditis disseminata run into one\\nanother, different names being used by authors to indicate\\ntopographical varieties. Generally both eyes are affected,\\nthough unequally but in some cases one eye escapes. The\\nretina and disk often show signs of past or present inflam\u00c2\u00ac\\nmation.\\nSyphilis is by far the most frequent cause of symmetrical\\ndisseminated choroiditis. The choroiditis begins from one\\nto three years after the primary disease, whether this be\\nacquired or inherited occasionally at a later period.\\nThe discrete variety, Fig. 81, c, where the patches, though", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0229.jp2"}, "230": {"fulltext": "222\\nCLINICAL DIVISION.\\nusually involving the whole thickness of the choroid, are\\nnot connected by areas of superficial change, is the least\\nserious form, unless the patches are very abundant. A\\nmoderate number of such patches, confined to the periphery,\\ncause no appreciable damage to sight. The more super\u00c2\u00ac\\nficial and widely-spread varieties, in which the retina and\\ndisk are inflamed from the first, are far more serious. The\\ncapillary layer of the choroid seldom again becomes healthy,\\nand with its atrophy, even if the deeper vessels be not much\\nchanged, the retina suffers, passing into slowly progressing\\natrophy. The retina often becomes pigmented, Fig. 91, its\\nbloodvessels extremely narrowed, bordered by white lines\\nor sheathed in pigment, and the disk passes into a peculiar\\nhazy-yellowish atrophy, \u00e2\u0080\u009cwaxy disk\u00e2\u0080\u009d (Hutchinson); cho-\\nroiditic atrophy\u00e2\u0080\u009d (Gowers). The appearances may closely\\nimitate those in true retinitis pigmentosa, and the patient,\\nas in that disease, often suffers from marked night-blind\u00c2\u00ac\\nness. Such patients continue to get slowly worse for many\\nyears, and may become nearly blind.\\nSyphilitic choroiditis generally gives rise, at an early\\ndate, to opacities in the vitreous; these either form large,\\neasily seen, slowly floating, ill-defined clouds, or are so\\nminute and numerous as to cause a diffuse and somewhat\\ndense haziness, dust-like opacities,\u00e2\u0080\u009d (Forster). Chapter\\nXVI. Some of the larger ones may be permanent. In the\\nadvanced stages, as in true retinitis pigmentosa, posterior\\npolar cataract is sometimes developed.\\nThere are no constant differences between choroiditis in\\nacquired and in inherited syphilis; in many cases it would\\nbe impossible to guess, from the ophthalmoscopic changes,\\nwith which form of the disease we had to do. But there\\nis, on the whole, a greater tendency toward pigmentation in\\nthe choroiditis of hereditary than in that of acquired syph\u00c2\u00ac\\nilis, and this applies both to the choroidal patches and to\\nthe subsequent retinal pigmentation.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0230.jp2"}, "231": {"fulltext": "DISEASES OF THE CHOROID.\\n900\\n/jZi*\\nIn the treatment of syphilitic choroiditis we rely almost\\nentirely on the constitutional remedies for syphilis\u00e2\u0080\u0094mer\u00c2\u00ac\\ncury and iodide of potassium. In cases which are treated\\nearly, sight is much benefited, and the visible exudations\\nquickly melt away under mercury but I believe that even\\nin these complete restitution seldom takes place, the nutri\u00c2\u00ac\\ntion and arrangement of the pigment epithelium and bacil\u00c2\u00ac\\nlary layer of the retina being quickly and permanently\\ndamaged by exudations into or upon the chorio-capillaris,\\nas in Fig. 82. In the latter periods, when the choroid is\\nthinned by atrophy, or its inner surface roughened by little\\noutgrowths, Fig. 83, or when adhesions and cicatricial con\u00c2\u00ac\\ntractions have occurred between it and the retina, nothing\\ncan be done. A long mercurial course should, however,\\nalways be tried if the sight be still failing, even if the\\nchanges all look old; for in some cases, even of very long\\nstanding, fresh failure takes place from time to time, and\\nmercury has a very marked influence. In acute cases rest\\nof the eyes in a darkened room, and the employment of\\nthe artificial leech or of dry cupping at intervals of a few\\ndays, for some weeks, are useful. But it is often difficult\\nto ensure such functional rest, for the patients seldom have\\npain or other discomfort.\\nDisseminated choroiditis sometimes occurs without ascer\u00c2\u00ac\\ntainable evidence of syphilis, chiefly about the age of\\npuberty. Such cases often differ in some of their ophthal\u00c2\u00ac\\nmoscopic details from ordinary syphilitic cases, especially\\nin the immunity of the retina and disk and also in the\\nabsence of tendency to recur. It is but seldom that any\\ndefinite cause, such as exposure to bright light, can be\\nplausibly assigned.\\nIn choroiditis from any cause iritis may occur.\\n3. The choroidal disease is limited to the central region.\\nThere are many varieties of such localized change.\\nIn myopia the elongation which occurs at the posterior", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0231.jp2"}, "232": {"fulltext": "224\\nCLINICAL DIVISION\\npole of the eye very often causes atrophy of the choroidal\\ncontiguous to the disk, and usually only on the side next\\nthe yellow spot (see Myopia). The term posterior staphy\u00c2\u00ac\\nloma is applied to this form of disease when the eye is\\nmyopic, because the atrophy is a sign of posterior bulging\\nof the sclerotic. The term sclerotico-choroiditis posterior is\\noften used, though we but seldom see evidence of exudative\\nchanges or hemorrhagic effusions at the fundus in myopia.\\nA similar crescent, but seldom of great width, is very com\u00c2\u00ac\\nmonly seen bounding the lower margin of the disk in astig\u00c2\u00ac\\nmatic eyes; its widest part nearly always corresponds with\\nthe direction of the meridian of greatest curvature of the\\ncornea. Chapter XX. A narrow and less conspicuous\\ncrescent or zone of atrophy around the disk is seen in some\\nother states, notably in old persons, and in glaucoma. Sepa\u00c2\u00ac\\nrate round patches of complete atrophy, punched-out\\npatches,\u00e2\u0080\u009d at the central region may occur in myopia with\\nthe above-mentioned staphyloma, and must not then be\\nascribed to syphilitic choroiditis; in other cases of myopia\\nill-defined partial atrophy is seen about the y. s., sometimes\\nwith spilts or lines running horizontally toward the disk.\\nCentral senile choroiditis. Several varieties of disease\\nconfined to the region of the y. s. and disks are seen, and\\nchiefly in old persons. One of these, known as central senile\\nareolar choroiditis, is characterized by a white patch, often\\nvery large, occupying the whole central region of the fun\u00c2\u00ac\\ndus the particularly striking and rather rare form shown\\nin Fig. 86 may be a late stage of the former. In others a\\nlarger but less defined area is affected; some of these ap\u00c2\u00ac\\npearances undoubtedly result from large choroidal or reti\u00c2\u00ac\\nnal extravasation. In these areated forms the large deep\\nvessels are often much narrowed, or even converted into\\nwhite lines devoid of blood-color, by thickening of their\\ncoats. In another form, Fig. 87, the central region is occu\u00c2\u00ac\\npied by a number of small white or yellowish-white dots,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0232.jp2"}, "233": {"fulltext": "DISEASES OF THE CHOROID. 225\\nsometimes visible only in the erect image. This condition\\nis very peculiar, and appears to be almost stationary; the\\nFig. 86.\\nCentral choroiditis. (Wecker and Jaeger.)\\nFig. 87.\\nCentral guttate senile choroiditis.\\n15", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0233.jp2"}, "234": {"fulltext": "226\\nCLINICAL DIVISION.\\ndisks are sometimes decidedly pale; when very abundant\\nthe spots coalesce, and some pigmentation is found. The\\npathological anatomy and general relations of this disease\\nare incompletely known, but the white dots are probably\\ndue to a hyaline degeneration of the pigment epithelium\\nof the retina; it was first described by Hutchinson and\\nTay, and is tolerably common. It is symmetrical, and the\\nchanges may sometimes be mistaken for a slight albuminuric\\nretinitis. No treatment seems to have any influence. Every\\ncase of immature cataract should, when possible, be exam\u00c2\u00ac\\nined for central choroidal changes.\\n4. Suppurative choroiditis and iridochoroiditis. In this\\naffection an exudation into the vitreous is produced, which\\nappears as a yellow mass in the fundus of the eye. The\\ninflammation spreads to the ciliary body and iris, and the\\nwhole globe becomes congested; panophthalmitis may set\\nin, or the eye may undergo softening and shrink. This is\\ndue to (1) infection by pyogenic organisms from penetrating\\nwounds or perforating ulcers (2) infection from within by\\nseptic embolism as in pyaemia (metastatic choroiditis), or\\nby extension of inflammation from behind as in thrombosis\\nof the orbital veins, and in meningitis. The latter occurs\\nmostly in children, and is sometimes known as pseudo-glioma\\nfrom its resemblance to glioma of the retina. In these\\ncases iritic adhesions are usually present, T. is the eye\\nsomewhat shrunken, the anterior chamber deep at its\\nperiphery, while absent or shallow at the centre. There is\\noften the history of some illness with a definite inflamma\u00c2\u00ac\\ntion of the eye before the change is noticed in the pupil.\\nThe differential diagnosis from glioma is occasionally very\\ndifficult, and in case of doubt it is better to excise the eye\\n(see Glioma, Chapter XVIII.)\\n5. Anomalous forms of choroidal disease. Single large\\npatches of atrophy, with pigmentation, not located in any\\nparticular part, are occasionally met with. Probably some", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0234.jp2"}, "235": {"fulltext": "DISEASES OF THE CHOROID.\\n227\\nof these have followed the absorption of tubercular growths\\niu the choroid, while others are the result of large sponta\u00c2\u00ac\\nneous hemorrhages. A blow by a blunt object on the scle\u00c2\u00ac\\nrotic causing local bleeding, or inflammation and subse\u00c2\u00ac\\nquent atrophy, may account for such a patch at the\\nanterior part of the fundus. Single large patches of exu\u00c2\u00ac\\ndation are also met with, and are perhaps tubercular.\\nChoroidal disease in disseminated patches seems some\u00c2\u00ac\\ntimes to depend upon numerous scattered hemorrhages into\\nthe choroid, which may occur at different dates, and may\\nlead to patches of partial atrophy with pigmentation. The\\nlocal cause of such hemorrhages is obscure; the disease\\nmay occur in one eye or both, and in young adults of either\\nsex. It may perhaps be called hemorrhagic choroiditis\\n(compare Chapter XVI.) Although the changes produced\\nare very gross, some of these patients regain almost perfect\\nsight\u00e2\u0080\u0094a fact perhaps pointing to the deep layers of the\\nchoroid as the seat of disease. It is possible that over-use\\nof the eyes, or exposure to great heat or glare, sometimes\\ncauses choroiditis.\\nSingle spots of choroidal atrophy, especially toward the\\nperiphery, should, no less than abundant changes, always\\nexcite grave suspicion of former syphilis, and often furnish\\nvaluable corroborative evidence of that disease. The periph\u00c2\u00ac\\nery cannot be fully examined unless the pupil be widely\\ndilated. A few small, scattered spots of black pigment on\\nthe choroid, or in the retina, without evidence of atrophy\\nof the choroid, often indicate former hemorrhages. Such\\nspots are seen after recovery from albuminuric retinitis\\nwith hemorrhages, after blows on the eye, and sometimes\\nwithout any relevant history.\\nCongestion of the choroid is not commonly recognizable\\nby the ophthalmoscope. That active congestion does occur\\nis certain, and it would seem that myopic eyes are espe\u00c2\u00ac\\ncially liable to it, particularly when over-used or exposed", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0235.jp2"}, "236": {"fulltext": "228\\nCLINICAL DIVISION.\\nto bright light and great heat. Serious hemorrhage may\\nundoubtedly be excited under such circumstances. In con\u00c2\u00ac\\nditions of extreme anaemia the whole choroid becomes\\nunmistakably pale.\\nColoboma of the choroid, congenital deficiency of the\\nlower part, is shown ophthalmoscopically by a large sur\u00c2\u00ac\\nface of exposed sclerotic, often embracing the disk, which\\nis then much altered in form, and may be hardly recog\u00c2\u00ac\\nnizable, and extending downward to the periphery, where\\nit often narrows to a mere line or chink. The surface of\\nthe sclerotic, as judged by the course of the retinal vessels,\\nis often very irregular, from bulging of its floor backward.\\nThe coloboma is occasionally limited to the part around\\nthe nerve, or may form a separate patch. Coloboma of\\nthe choroid is often seen without coloboma of the iris, and\\nwhen both exist a bridge of choroidal tissue generally sepa\u00c2\u00ac\\nrates them in the region of the ciliary body. Cases of\\nso-called coloboma of the choroid at the yellow spot are\\nprobably examples of severe foetal or infantile inflamma\u00c2\u00ac\\ntion of that part.\\nAlbinism is accompanied by congenital absence of pig\u00c2\u00ac\\nment in the cells of the epithelium and stroma of the whole\\nuveal tract, choroid, ciliary processes, and iris. The pupil\\nlooks pink, because the fundus is lighted, to a great extent,\\nindirectly through the sclerotic. Sight is always defective,\\nand the eyes photophobic and usually oscillating. Many\\nalmost albinotic children become moderately pigmented as\\nthey grow up.\\ni", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0236.jp2"}, "237": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0237.jp2"}, "238": {"fulltext": "PLATE I.\\nFig. 1.\u00e2\u0080\u0094Normal Eye-ground (average tint).\\nFig. 2.\u00e2\u0080\u0094 Normal Eye-ground (brunette).", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0238.jp2"}, "239": {"fulltext": "CHAPTER XIJT.\\nDISEASES OF THE RETINA.\\nOf the many morbid changes to which the retina is sub\u00c2\u00ac\\nject, some begin and end in this membrane, such as albu\u00c2\u00ac\\nminuric retinitis and many forms of retinal hemorrhage;\\nin others the retina takes part in changes which begin in\\nthe optic nerve (neuro-retinitis), or in the choroid (choroido-\\nretinitis); very serious lesions also occur from embolism or\\nthrombosis of the central retinal vessels. The retina may\\nbe separated detached from the choroid by serous fluid\\nor blood. The retina may also be the seat of malignant\\ngrowth (glioma), and probably of tubercular inflammation.\\nIn health the human retina is so nearly transparent as\\nto be almost invisible by the ophthalmoscope during life,\\nor to the naked eye if examined immediately after excision.\\nWe see the retinal bloodvessels, but the retina itself, as a\\nrule, we do not see. The main bloodvessels are derived\\nfrom the arteria and vena centralis which enter the outer\\nside of the optic nerve, about 6 mm. behind the eye; the\\nveins and arteries are generally in pairs, the veins not being\\nmore numerous than the arteries; all pass from or to the\\noptic disk. Fig. 37. At the disk anastomoses, chiefly\\ncapillary, are formed between the vessels of the retina and\\nthose of the choroid and sclerotic. As no other anasto\u00c2\u00ac\\nmoses are formed by the vessels of the retina, the retinal\\ncirculation beyond the disk is terminal; and, further, as\\nthe vessels branch dichotomously, and the branches anas\u00c2\u00ac\\ntomose only by means of their capillaries, the circulation\\nof each considerable branch is terminal also. The capil\u00c2\u00ac\\nlaries, which are not visible by the ophthalmoscope, are\\n229", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0239.jp2"}, "240": {"fulltext": "230\\nCLINICAL DIVISION.\\nnarrower than those of the choroid, and their meshes be\u00c2\u00ac\\ncome much wider toward the anterior and less important\\nparts of the retina.\\nAt the y. s., Fig. 88, the only part used for accurate sight,\\nthe capillaries are very abundant, compare Fig. 79; but at the\\nvery centre of this region, fovea centralis where all the layers\\nexcept the cones and outer granules are excessively thin, there\\nare no vessels, the capillaries forming fine, close loops just\\naround it. The nerve-fibres in this part of the retina are finer\\nthan in other parts; they seem also to be much more abun\u00c2\u00ac\\ndant, for Bunge has found that in a case of central scotoma,\\nwhere only a very small part of the F. was lost, quite a\\nlarge tract of fibres (f of the whole) was atrophied in the\\noptic nerve. The fovea centralis corresponds to an area at the\\ncentre of F., measuring only 1|\u00c2\u00b0 in diameter; the part recog\u00c2\u00ac\\nnized as the macula lutea has an area, on the F., of about 7\u00c2\u00b0\\n(Bunge).\\nFig. 88.\\nV A V A V\\nBloodvessels of human retina at the yellow spot (artificial injection). The\\ncentral gap corresponds to the fovea centralis, a. Arteries, y. Veins.\\nN. Nasal side (toward disk). T. Temporal side. The meshes are many times\\nwider at the periphery of the retina.\\nIn children, especially those of dark complexion, a pecu\u00c2\u00ac\\nliar white, shifting reflection, or shimmer, is often seen at\\nthe y. s. region, and along the course of the principal ves\u00c2\u00ac\\nsels. It changes with every movement of the mirror, and\\nreminds one of the shifting reflection from \u00e2\u0080\u009cwatered\u00e2\u0080\u009d\\nand shot\u00e2\u0080\u009d silk. Around the y. s. it tabes the form of a", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0240.jp2"}, "241": {"fulltext": "DISEASES OF THE RETINA.\\n231\\nring or zone, and is known as the halo round the macula.\u00e2\u0080\u009d\\nWhen the choroid is highly pigmented, even if this shifting\\nreflection be absent, the retina is visible as a faint haze over\\nthe choroid like the bloom on a plum. Under the high\\nmagnifying power of the erect image the nerve-fibre layer is\\noften visible near the disk as a faintly-marked radiating\\nstriation. The sheaths of the large central vessels at their\\nemergence from the physiological pit show many variations\\nin thickness and opacity.\\nIn rare cases the medullary sheath of the optic nerve-\\nfibres, which should cease at the lamina cribrosa, is con\u00c2\u00ac\\ntinued through the disk into the retina, and causes the\\nophthalmoscopic appearance known as opaque nerve-\\nfibres.\u00e2\u0080\u009d This congenital peculiarity may affect the nerve-\\nfibres of the whole circumference of the disk, or only a\\npatch or tuft of the fibres; it may only just overlap the\\nedge of the disk, or may extend far into the retina; and\\nislands of similar opacity are sometimes seen in the retina\\nquite separated from the disk. It is to be particularly\\nnoted that the central part, physiological pit, of the disk is\\nnot affected, because it contains no nerve-fibres. The\\naffected patch is pure white, and quite opaque; its margin\\nthins out gradually, and is striated in fine lines, which\\nradiate from the disk like carded cotton-wool; the retinal\\nvessels may be buried in the opacity, or run unobscured on\\nits surface, and are of normal size. The deep layers of the\\naffected parts of the retina being obscurbed by the opacity,\\nan enlargement of the normal blind spot\u00e2\u0080\u009d is the result.\\nOne eye, or both, may be affected. There is seldom any\\ndifficulty in distinguishing this condition from opacity due\\nto neuro-retinitis.\\nOphthalmoscopic Signs of Retinal Disease.\\nCongestion. No amount of capillary congestion, whether\\npassive or active, alters the appearance of the retina; and", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0241.jp2"}, "242": {"fulltext": "232\\nCLINICAL DIVISION.\\nas to the large vessels, it is better to speak of the arteries\\nas unusually large or tortuous, or of the veins as turgid or\\ntortuous, than to use the general term congestion. Capil\u00c2\u00ac\\nlary congestion of the optic disk may undoubtedly be recog\u00c2\u00ac\\nnized but even here caution is needed, and much allowance\\nmust be made for differences of contrast depending on vari\u00c2\u00ac\\nations in the tint of the choroid, for the patient\u00e2\u0080\u0099s health\\nand age, and for the brightness of the light used, or, what\\nis the same thing, for the size of the pupil. Caution is also\\nneeded against drawing hasty inferences from the slight\\nhaziness of the outline of the disk, which may often be seen\\nin cases of hypermetropia, and which is certainly not always\\nmorbid.\\nThe ouly ophthalmoscopic proof of true retinitis is loss\\nof transparency of the retina, and two chief types are soon\\nrecognized according as the opacity is diffused, or consists\\nchiefly of abrupt spots and patches. Hemorrhages are\\npresent in many cases of retinitis but they may also occur\\nwithout either inflammation or oedema. The state of the\\ndisk varies much, but it seldom escapes entirely in a case\\nof extensive or prolonged retinitis. In a large majority of\\ncases of recent retinitis the visible changes are limited to\\nthe central region, where the retina is thickest and most\\nvascular.\\n1. The lessened transparency which accompanies diffuse\\nretinitis simply dulls the red choroidal reflex, and the term\\n\u00e2\u0080\u009csmoky\u00e2\u0080\u0099 is fairly descriptive of it. The same effect is\\ngiven by slight haziness of any of the anterior media, but\\na mistake is excusable only when there is diffused mistiness\\nof the vitreous from opacities which are too small to be\\neasily distinguished (Chapter XVI.), and the difficulty is\\nthen increased because this very condition of the vitreous\\noften co-exists with retinitis. A comparison of the erect\\nand inverted images is often useful; for if the diffused haze\\nnoticed by indirect examination be caused by retinitis, the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0242.jp2"}, "243": {"fulltext": "DISEASES OF THE RETINA.\\n233\\ndirect examination will often resolve what seemed an uni\u00c2\u00ac\\nform haze into a well-marked spotting or streaking. When\\nthe change is pronounced enough to cause a decidedly white\\nhaze of the retina there is no longer any doubt. The retinal\\narteries and veins are sometimes enlarged and tortuous in\\nretinitis, and in severe cases they are generally obscured in\\nsome part of their course. These forms of uniformly dif\u00c2\u00ac\\nfused retinitis are usually caused either by syphilis, embol\u00c2\u00ac\\nism, or thrombosis.\\nFig. 89.\\nAlbuminuric retinitis. (Liebkeich.)\\n2. Near the y. s. a number of small, intensely white,\\nrounded spots are seen, Fig. 89, either quite discrete or\\npartly confluent. When very abundant and confluent", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0243.jp2"}, "244": {"fulltext": "234\\nCLINICAL DIVISION.\\npartly confluent. When very abundant and confluent\\nthey form large, abruptly outlined patches, with irregular\\nborders, some parts of these patches being striated, others\\nstippled.\\n3. A number of separate patches are scattered about the\\ncentral region, but without special reference to the y. s.\\nThey are of irregular shape, white or pale buff, and some\u00c2\u00ac\\ntimes striated, Fig. 90; they are easily distinguished from\\npatches of choroidal atrophy by their color, the compara\u00c2\u00ac\\ntive softness of their outlines, and the absence of pigmen\u00c2\u00ac\\ntation.\\nIn types 2 and 3 some hemorrhages are usually present;\\nthe retina generally may be clear, but more often there is\\ndiffused haze and evidence of swelling. The hemorrhages\\nmay be so numerous and large as to form the chief feature,\\nand then the retinal veins will be very tortuous and dilated.\\nFig. 90.\\nRecent severe retinitis in renal disease. (Gowers.)\\nForms 2 and 3, which nearly always affect both eyes, are\\ngenerally associated with renal disease, but in rare cases", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0244.jp2"}, "245": {"fulltext": "DISEASES OF TIIE RETINA.\\n235\\nsimilar changes are caused by cerebral disease and other\\nconditions.\\n4. Rarely a single large patch or area of white opacity\\nis seen with softened, ill-defined edges, any retinal vessels\\nthat may cross it being obscured. Such a patch of retinitis\\nis usually caused either by subjacent choroiditis or by local\\nphlebitis or thrombosis.\\nHemorrhage into (or beneath) the retina is known by its\\ncolor, which is darker than that of an ordinary choroid,\\nbut redder and lighter than that of a very dark choroid.\\nBlood may be effused into any of the retinal layers, and\\nthe shape of the blood patches is mainly determined by\\ntheir position. When effused into the nerve-fibre layer,\\nor confined by the sheath of a large vessel, the extravasa\u00c2\u00ac\\ntion takes a linear or streaked form and structure, follow\u00c2\u00ac\\ning the direction of the nerve-fibres; extravasations in the\\ndeeper layers are rounded. Very large hemorrhages, many\\ntimes as large as the disk, sometimes occur near the yellow\\nspot, and probably all the layers then become infiltrated,\\nwhile sometimes the blood ruptures the anterior limiting\\nmembrane of the retina and passes into the vitreous.\\nRetinal hemorrhages may be large or small, single or\\nmultiple; limited to the central region or scattered in\\nall parts; linear, streaky or flame-shaped, punctate or\\nblotchy; they may lie alongside large vessels, or have no\\napparent relation to them. The hemorrhage may, as\\nalready mentioned, be the primary change, or may only\\nform part of a retinitis or papillo-retinitis. A hemor\u00c2\u00ac\\nrhage which is mottled, and of dark, dull color, is gener\u00c2\u00ac\\nally old. The rate of absorption varies very much;\\nhemorrhage after a blow is very quickly absorbed, while\\neffusions caused by the rupture of diseased vessels in old\\npeople, or accompanying retinitis from constitutional\\ncauses, often last for months, and leave permanent traces.\\nPigmentation of the retina has been referred to in con-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0245.jp2"}, "246": {"fulltext": "236\\nCLINICAL DIVISION.\\nnection with choroiditis. Whenever pigment in the fundus\\nforms long, sharply-defined lines, or is arranged in a mossy,\\nlace-like or reticulated pattern, we may safely infer that it\\nis situated in the retina, and generally that it lies along the\\nsheaths of the retinal vessels. Compare Fig. 91 with Fig.\\n78. Pigment in or on the choroid never takes such a pat\u00c2\u00ac\\ntern, being usually in blotches or rings. The two types,\\nhowever, are often mingled in cases of choroiditis with\\nsecondary affection of the retina; indeed, whenever we\\ndecide that the retina is pigmented, the choroid must be\\ncarefully examined for evidences of former choroiditis.\\nFig. 91.\\nStudy of pigment in the retina in a specimen of secondary retinitis\\npigmentosa, seen from the inner (vitreous) surface.\\nSpots of pigment may be left after the absorption of retinal\\nhemorrhages. Such spots can generally be distinguished\\nfrom those following choroiditis by their more uniform ap\u00c2\u00ac\\npearance and by the absence of signs of choroidal atrophy.\\nAtrophy of the retina, of which pigmentation of the\\nretina, when present, is always a sign, has for its most\\nconstant indication a marked shrinking of the retinal\\nbloodvessels, with thickening of their coats. When the\\natrophy follows a retinitis or choroido-retinitis (retinitis\\npigmentosa, syphilitic choroido-retinitis, etc.), all the layers\\nare involved, and the outer layers, those nearest the cho\u00c2\u00ac\\nroid, earlier than the inner; but when it is secondary\\nto disease of the optic nerve, optic neuritis, progressive\\natrophy, and glaucoma, only the layers of nerve-fibres and\\nganglion-cells are atrophied, the outer layers being found\\nperfect even after many years. A retina atrophied after", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0246.jp2"}, "247": {"fulltext": "DISEASES OF THE RETINA.\\n237\\nretinitis often does not regain perfect transparency, and if\\nthere have been choroiditis the retina remains especially\\nhazy in the parts where this has been most severe.\\nThe disk after severe retinitis or choroido-retinitis always\\npasses into atrophy, often of peculiar appearance, being\\npale, hazy, homogeneous-looking, and with a yellowish or\\nbrownish tint.\\nDetachment (separation) of the retina. As there is no\\ncontinuity of structure between the choroid and retina,\\nthe two may be easily separated by effusion of blood or\\nserous fluid, the result either of injury or disease, by morbid\\ngrowths, and by the traction of fibrous cords in the vit\u00c2\u00ac\\nreous. Such fibrous bands and strings develop in the\\nvitreous in some cases of iridocyclitis, and perhaps in\\nmyopic eyes without signs of inflammation. Occasionally\\nrents may be seen in the separated retina. It has been\\nsuggested that such rents occurring while the retina was\\nstill in situ might initiate the detachment by allowing the\\nintrusion of vitreous between the retina and choroid; and\\nFig. 92.\\nSection of eye with partial detachment of retina.\\nthis explanation may possibly hold good in very myopic\\neyes. The retina is separated at the expense of the vit\u00c2\u00ac\\nreous, which is proportionately absorbed, but always remains\\nattached at the disk and ora serrata, unless as the result of\\nwound or great violence. The depth, area, and situation\\nof the detachment are subject to much variety. Fig. 92\\nshows a diagrammatic section of an eye in which the lower", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0247.jp2"}, "248": {"fulltext": "238\\nCLINICAL DIVISION.\\npart of the retiua is separated. The pigment epithelium\\nalways remains on the choroid.\\nThe separated portion is usually far within the focal\\nlength of the eye; its erect image is, therefore, very easily\\nvisible by the direct method, when it appears as a gray or\\nwhitish reflection in some part of the field, the remainder\\nbeing of the natural red color; the detached part is gray\\nFig. 93.\\nDetachment of retina.\\nor whitish, because the retina has become opaque. With\\ncare we can accurately focus the surface of the gray reflec\u00c2\u00ac\\ntion, observe that it is folded, and see one or more retinal\\nvessels meandering upon it in a tortuous course; they ap\u00c2\u00ac\\npear small and of dark color, and have lost their central\\nlight streak. If the separation be deep, the outline of its\\nmore promiuent folds, Fig. 93, can be seen standing out\\nsharply against the red background, and in some cases the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0248.jp2"}, "249": {"fulltext": "DISEASES OF THE RETINA.\\n239\\nfolds flap about when the eye is quickly moved. In ex\u00c2\u00ac\\ntreme cases we can see the detached part by focal light.\\nWhen the detachment is recent, especially if shallow, the\\nchoroidal red is still seen through it; the diagnosis then\\nrests on the observation of whether the vessels in any part\\nare darker, smaller, and more tortuous than elsewhere, and\\nupon ophthalmoscopic estimation of the refraction of the\\nretinal vessels at different parts of the fundus, for the de\u00c2\u00ac\\ntached part will be much more hypermetropic than tire\\nrest. In very high myopia a shallow detachment may\\nstill lie behind the principal focus, and therefore not\\nyield an erect image without a suitable concave lens; in\\nsuch a case, and in others where minute rucks or folds of\\ndetachment are present, examination by the direct method\\nleads to a right diagnosis; as the image of the detached\\nportion is not in focus at the same moment as its surround\u00c2\u00ac\\ning parts, parallactic movement} is obtained, and the vessels\\nare tortuous. Deep and extensive detachment is often\\nassociated with opacities in the vitreous or lens, or with\\niritic adhesions; and any of these conditions interfere with\\nthe conclusive application of the above tests. In some\\ncases of detachment large patches and streaks of choroidal\\ndisease are to be found. The treatment of detachment of\\nthe retina is very unsatisfactory, improvement if obtained\\nbeing seldom permanent, even when treatment is under\u00c2\u00ac\\ntaken soon after the detachment has occurred. Puncture\\nof the sclerotic over the detachment is occasionally fol\u00c2\u00ac\\nlowed by marked improvement, and the result is said to\\nbe better if the sclerotic be laid bare by dissecting up the\\nconjunctiva before the puncture, and if the puncture be\\nrather broad, about 2 to 4 mm.; the subretinal fluid rap\u00c2\u00ac\\nidly drains away. The conjunctival wound should be\\n1 On closing one eye and viewing two objects, one beyond the other, but\\nin the same line, one object seems to move over the other when the head is\\nmoved from side to side.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0249.jp2"}, "250": {"fulltext": "240\\nCLINICAL DIVISION.\\nsutured. Profuse sweating and salivation, induced by\\npilocarpine (F. 41), have been recommended in recent\\ncases. Mere rest in bed for some days in a subdued light,\\nwith the eyes tied up, is often followed for a time by decided\\nimprovement of sight. The best results seem to have been\\nobtained by this means, combined with scleral puncture,\\nin recent cases.\\nClinical Forms of Retinal Disease.\\nThe symptoms of retinal disease relate only to the failure\\nof sight which they cause, and this may be either general,\\nor confined to a part of the field, according to the nature\\nof the case. Neither photophobia nor pain occurs in\\nuncomplicated retinitis.\\nSyphilitic retinitis is generally associated with, and sec\u00c2\u00ac\\nondary to, choroiditis, but the retinitis may be primary.\\nThe vitreous in this disease, as in syphilitic choroiditis, is\\noften hazy, and the opacities are sometimes seated deeply,\\njust in front of the retina. The changes are those of dif\u00c2\u00ac\\nfuse retinitis, with slight \u00e2\u0080\u009csmoky\u00e2\u0080\u009d haze, often confined\\nto the region of the yellow spot or disk; but in bad cases\\nthe haze passes into a whiter mistiness, and extends over a\\nmuch larger region; sometimes long, branching streaks\\nor bands of dense opacity are met with, and hemorrhages\\nmay occur. The disk is always hazy, and at first too red,\\nwhile the retinal vessels, both arteries and veins, are some\u00c2\u00ac\\nwhat turgid and tortuous; rarely the disk becomes opaque\\nand swollen. At a late period, in unfavorable cases, the\\nvessels shrink slowly, almost to threads, the retina often\\nbecomes pigmented at the periphery, and the pigmented\\nepithelium disappears,\\nSyphilitic retinitis is one of the secondary symptoms,\\nseldom setting in earlier than six or later than eighteen\\nmonths after the primary disease. It occurs in congenital\\nas well as acquired syphilis. It generally attacks both", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0250.jp2"}, "251": {"fulltext": "DISEASES OF THE RETINA.\\n241\\neyes, though often with an interval. Its onset is often\\nrapid, as judged by its chief symptom, failure of sight,\\nand it may be stated that, as a rule, the degree of ambly\u00c2\u00ac\\nopia is much higher than would be expected from the\\nophthalmoscopic changes. Night-blindness is often a pro\u00c2\u00ac\\nnounced symptom. Its course is chronic, seldom lasting\\nless than several months, and it shows a remarkable ten\u00c2\u00ac\\ndency, for many months, to repeated and rapid exacerba\u00c2\u00ac\\ntions after temporary recoveries, but with a tendency to\\nget worse rather than permanently better. Among the\\nearly symptoms are often a flickering\u00e2\u0080\u009d and micropsia;\\nthese, with the history of variations lasting for a few days\\nand of marked night-blindness, often lead to a correct sur\u00c2\u00ac\\nmise before ophthalmoscopic examination. There is, how\u00c2\u00ac\\never, nothing pathognomonic in any of the symptoms. An\\nannular defect in the visual field ring scotoma\u00e2\u0080\u009d) may\\noften be found if sought; in the late stages the field is\\ncontracted.\\nMercury produces most marked benefit, and when used\\nearly it permanently cures a large proportion of the cases;\\nbut in a number of cases, perhaps in those where there is\\nmost choroiditis, the disease goes slowly from bad to worse\\nfor several years, in spite of very prolonged mercurial\\ntreatment. Of the efficacy of prolonged disuse of the\\neyes, and of local counter-irritation or depletion, strongly\\nrecommended by many authors, I have had but little\\nexperience.\\nAlbuminuric retinitis (papillo-retinitis). The changes\\nare strongly marked, and so characteristic that it is pos\u00c2\u00ac\\nsible, in most cases, to say from an ophthalmoscopic exami\u00c2\u00ac\\nnation alone that the patient is suffering from kidney dis\u00c2\u00ac\\nease. In the sclerosis of the arteries which accompanies\\nchronic renal disease the retinal arteries frequently have\\nan unusually bright and sharp central light streak, and\\nare of a lighter color than normal; they have much the\\n16", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0251.jp2"}, "252": {"fulltext": "242\\nCLINICAL DIVISION.\\nFame appearance as would be presented by a piece of bright\\ncopper wire (Gunn). Where these arteries cross the veins\\nthe blood-current in the latter is interrupted.\\nThe earliest change, the stage of oedema and exudation,\\nis a general haze of grayish tint in the central region of\\nthe retina, mostly with some hemorrhages and soft-edged\\nwhitish patches, and with or without haze and swelling of\\nthe disk. In this stage the sight is often unimpaired, so\\nthe cases are seldom seen by ophthalmic surgeons till a few\\nweeks later, when the translucent, probably albuminous\\nexudations in the swollen retina have passed into a state\\nof fatty or fibrinous degeneration, a change which affects\\nboth the nerve-fibres and connective tissue.\\nIn the second stage we find a number of pure white dots,\\nspots, or patches in the hazy region, and especially grouped\\naround the yellow spot. Their peculiarity is their sharp\\ndefinition and pure, opaque white color; indeed, when\\nsmall and round they are almost glistening. When not\\nvery numerous they are generally confined to the yel\u00c2\u00ac\\nlow-spot region, from which they show a tendency to\\nradiate in lines; when very small and scanty they may\\nbe overlooked unless we examine the erect image; but\\nfrequently large patches are formed by the confluence of\\nsmall spots, and the borders of these patches are striated,\\ncrenated, or spotted. At this stage the soft-edged patches,\\nFig. 90, have often to a great extent disappeared, or be\u00c2\u00ac\\ncome merged into more general opacity of the retina; the\\ndisk is hazy and somewhat swollen, especially just at its\\nmargin, and the retina, as judged by the undulations of\\nits vessels and confirmed by post-mortem examination, is\\nmuch thickened. Hemorrhages are generally still present,\\nand occasionally they constitute the most marked feature;\\nthey are usually striated. Sometimes an artery is seen\\nsheathed by a dense white coating. 1 In another group\\n1 Illustrations of this are given in Gowers\u00e2\u0080\u0099 Medical Ophthalmoscopy, pi.\\nxii. fig. 1, and in Transactions of Ophthalmic Society, vol. ii. pi. ii.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0252.jp2"}, "253": {"fulltext": "DISEASES OF THE RETINA.\\n243\\npapillitis is the most marked change, though some bright\\nwhite retinal spots are always to be found by careful\\nexamination.\\nThe usual tendency is toward subsidence of the oedema\\nand absorption of the fatty deposits and extravasations,\\ngenerally with improvement of sight\u00e2\u0080\u0094the third stage, or\\nstage of absorption and atrophy.\\nIn the course of several months the white spots diminish\\nin size and number, until only a few very small ones are\\nleft near the yellow spot, with perhaps some residual haze:\\nthe blood-patches are slowly absorbed, often leaving small,\\nround pigment spots, and the retinal arteries may be\\nshrunken. In cases of only moderate severity almost\\nperfect sight is restored. But when the optic disk suffers\\nseverely (severe papillitis), or if the retinal disease be ex\u00c2\u00ac\\ncessive, and attended by great oedema, sight either im\u00c2\u00ac\\nproves very little, or, as the disk passes into atrophy and\\nthe retinal vessels contract, it may sink to almost total\\nblindness. Such a condition may be mistaken for atrophy\\nafter cerebral neuritis; but the presence of a few minute\\nbright dots or of some superficial disturbance of the cho\u00c2\u00ac\\nroid at the yellow spot, or of some scattered pigment spots\\nleft by extiavasations, will generally lead to a correct in\u00c2\u00ac\\nference. In the cases attended by the greatest swelling\\nand opacity of retina and disk, death often occurs before\\nretrogressive changes have taken place. In extreme\\ncases the retina may become deeply detached from the\\nchoroid.\\nAlbuminuric retinitis is almost invariably symmetrical,\\nbut seldom quite equal in degree or result in the two eyes.\\nThe kidney disease in the malady under consideration is\\nnearly always chronic. The retinitis may occur in any\\nchronic nephritis and in the albuminuria of pregnancy.\\nWhatever be the form of the kidney disease, the retinitis\\nusually occurs with other symptoms of active kidney mis-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0253.jp2"}, "254": {"fulltext": "244\\nCLINICAL DIVISION.\\nchief, such as headache, vomiting, loss of appetite, and\\noften anasarca; but occasionally the retinitis is the first\\nrecognizable sign. The quantity of albumin varies very\\nmuch. In the absence of anasarca the symptoms are often\\nput down to \u00e2\u0080\u009cbiliousness,\u00e2\u0080\u009d and as in such cases the failure\\nof sight is the most troublesome symptom, the ophthalmo\u00c2\u00ac\\nscope often leads to the correct diagnosis. A second attack\\nof retinitis sometimes occurs in connection with a relapse of\\nrenal symptoms. Many of the best marked cases of albu\u00c2\u00ac\\nminuric retinitis occur in the albuminuria of pregnancy,\\nand the prognosis for sight is good in many of these if the\\nsymptoms come on sufficiently late in the pregnancy to\\npermit of the cause being removed by the induction of\\nartificial labor; but some of them, probably cases of old\\nkidney disease, do very badly, and pass into atrophy of\\nthe nerves.\\nThough the diagnosis of renal disease, based on the\\npresence of the symmetrical retinal changes above de\u00c2\u00ac\\nscribed, will usually be verified by the physician, we do\\nunquestionably now and then meet with cases of similar\\nretinitis in which no kidney disease can be clinically\\nproved. Trousseau describes several cases of this sort in\\nwhich albumin appeared later. 1 Such cases need further\\nattention. The cases of cerebral neuro-retinitis mentioned\\nat p. 260, and rare cases of retinitis, exactly like renal\\nretinitis but confined to one eye, have also to be allowed\\nfor. Retinal changes more or less like those above de\u00c2\u00ac\\nscribed are also found in other chronic general diseases\u00e2\u0080\u0094\\ne. g., diabetes, pernicious anaemia, and leucocythaemia.\\nChapter XXIII.\\nThe term retinitis haemorrhagica has been given to cases\\ncharacterized by very numerous linear or flame-shaped\\nretinal hemorrhages, chiefly of small size, all over the\\n1 Bull, de l\u00e2\u0080\u0099Hopital des Quinze-vingts, iv. 4,173.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0254.jp2"}, "255": {"fulltext": "DISEASES OF THE RETINA.\\n245\\nfundus, or limited to the area of one vein, generally with\\nextreme venous engorgement and retinal oedema, but in\\nsome cases without these features. It usually occurs in\\nonly one eye at a time, and comes on rapidly. The patients\\nare often gouty or the subjects of disease of cardiac valves,\\nor of the arterial system. Thrombosis of the trunk of the\\nvena centralis retince is probably the determining cause of\\nFig. 94.\\nHemorrhagic retinitis. (Jaeger.)\\nthe condition 1 when there is much venous distention and\\nretinal oedema; multiple disease of minute retinal vessels\\nwhen these symptoms are absent. Retinitis hsemorrhagica,\\nof whichever type, is not common.\\nOther cases are seen where extravasations, varying much\\nin size, number, and shape, are scattered in different parts\\nof the fundus of one or both eyes. Some of them are prob-\\n1 Hutchinson, Michel: Graefe\u00e2\u0080\u0099s Arch. f. Ophth., xxiv. 2.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0255.jp2"}, "256": {"fulltext": "246\\nCLINIC A L DI VISION\\nably allied to the above, but often the nature of the case\\nis obscure, or the hemorrhages are related to senile degen\u00c2\u00ac\\neration of vessels. Such cases have been called retinitis\\napoplectica.\\nLastly, in an important group, a single very large ex\u00c2\u00ac\\ntravasation occurs on the surface of the retina beneath the\\ninternal limiting membrane from rupture of a large retinal\\nvessel, probably a vein\u00e2\u0080\u0094 sub hyaloid hemorrhage. The hem\u00c2\u00ac\\norrhage is generally in the yellow-spot region in process of\\nabsorption it becomes mottled, the densest parts remaining\\nlongest, and, if seen in that condition for the first time, the\\ncase may be taken for one of multiple hemorrhages. These\\nlarge extravasations cause great defect of sight, which comes\\non in an hour or two, but not with absolute suddenness.\\nAbsorption, in the several groups of cases just mentioned,\\nis very slow.\\nHemorrhages may occur from blows on the eye. They\\nare usually small and quickly absorbed, differing in the\\nlatter respect very much from the cases before described.\\nLeukaemic retinitis is characterized by retinal hemor\u00c2\u00ac\\nrhages or by extravasations of white blood-corpuscles into\\nthe retina the veins are enlarged, flattened, and tortuous\\nthe color of the choroid is often pale yellow. Retinal\\nhemorrhages and optic neuritis also occur in progressive\\npernicious anaemia.\\nDiabetic retinitis. See Chapter XXIII.\\nEmbolism of the central artery of the retina, or of one\\nor more of its main divisions, gives rise to a characteristic\\nretinitis, the cause of which can in most cases be recog\u00c2\u00ac\\nnized at once if it be recent; while in old cases the\\nappearances, taken with the history, lead to a right diag\u00c2\u00ac\\nnosis. Thrombosis of the artery causes similar changes.\\nThe leading symptom of embolism is the occurrence of\\nan instantaneous defect of sight, which is found on trial to\\nbe limited to one eye; sometimes the feeling is as if one", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0256.jp2"}, "257": {"fulltext": "DISEASES OF TIIE RETINA.\\n247\\neye had suddeuly become \u00e2\u0080\u009cshut,\u00e2\u0080\u009d the blindness being as\\nsudden as that from quickly closing the lids; but whether\\nthe defect amounts to absolute blindness or not depends on\\nthe position and size of the plug. Many of the patients\\nhave evidence of cardiac disease. Chorea has been present\\nin a few. In any case, owing to the temporary establish\u00c2\u00ac\\nment of collateral circulation by the capillary anastomoses\\nat the disk, the patient sometimes notices an improvement\\nof sight a few hours after the occurrence. This improve\u00c2\u00ac\\nment, however, is but slight, the collateral channels being\\nquite insufficient to meet the demand; nor is it often per\u00c2\u00ac\\nmanent, because the retina suffers very quickly from the\\nalmost complete stasis, oedema, and inflammation rapidly\\nsetting in and leading to permanent damage.\\nIf the case be seen within a few days of the occurrence,\\nthe red reflex of the choroid around the yellow spot and\\ndisk is quite obscured, or partially dulled, by a diffused\\nand uniform white mist. The* opacity is greatest just\\naround the centre of the yellow spot, where the retina is\\nvery vascular, Fig. 88, and where its cellular elements,\\nganglion and granule layers, are more abundant than\\nelsewhere; but at the very centre of the white mist a\\nsmall, round, red spot is generally seen, so well defined\\nthat it may be mistaken for a hemorrhage; it represents\\nthe fovea centralis, where the retina is so thin that the cho\u00c2\u00ac\\nroid continues to shine through it when the surrounding\\nparts are opaque it is spoken of by authors as the cherry-\\nred spot at the macula lutea.\u00e2\u0080\u009d This appearance is very\\nseldom seen except after sudden arrest of arterial blood-\\nsupply, by embolism or thrombosis of the arteria centralis,\\nand perhaps by hemorrhage into the optic nerve compres\u00c2\u00ac\\ning the vessels; and of these causes embolism appears to\\nbe the most common. The haze surrounds and generally\\naffects, the disk also, which soon becomes very pale. The\\nsmall veins in the yellow-spot region often stand out with", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0257.jp2"}, "258": {"fulltext": "248\\nCLINICAL DIVISION.\\ngreat distinctness, being enlarged by stasis, and conspicuous\\nfrom contrast with the white retina. Small hemorrhages\\nare often present. The larger retinal vessels, \u00e2\u0080\u009cboth arteries\\nand veins, are more or less diminished at and near the\\ndisk, the arteries in the most typical cases being reduced\\nto mere threads; both arteries and veins are, however,\\nsometimes observed to increase in size as they recede from\\nthe disk. The arteries, however, are not always extremely\\nshrunken in cases of retinal embolism, the variations de\u00c2\u00ac\\npending upon the position and size of the plug\u00e2\u0080\u0094 i. e., upon\\nwhether the occlusion is complete or not. The sudden and\\ncomplete failure of supply to a single branch of a retinal\\nartery is sometimes followed by its emptying and shrinking\\nto a white cord almost immediately. In other cases the\\nbranch may for a time be little if at all altered in size;\\nand yet its blood column may be quite stagnant, as is\\nproved by the impossibility of producing pulsation in it\\nby the firmest pressure on the globe, while the other\\nbranches respond perfectly to this test. Sometimes this\\npressure-test, which showed blockage of some or all\\nbranches shortly after the onset, again produces pulsa\u00c2\u00ac\\ntion a few days later without visible evidence of collateral\\ncirculation, thus proving the re-establishment of the main\\nchannel.\\nIn from one to about four weeks the cloudiness clears\\noff, and the disk passes into moderately white atrophy;\\nthe arteries, or some of them, according to the position\\nof the plugging, are either reduced to bloodless white\\nlines, or simply narrowed.\\nSight is almost always lost, or only perception of large\\nobjects retained, whatever be the final state of the blood\u00c2\u00ac\\nvessels. In the rare cases, where an embolus passes beyond\\nthe disk, and is arrested in the branch at some distance\\nfrom it, the changes are confined to the corresponding\\nsector of the retina, and a limited defect of the field is the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0258.jp2"}, "259": {"fulltext": "DISEASES OF THE RETINA.\\n249\\nonly permanent result. It is scarcely necessary to say\\nthat no treatment can be of any use in cases of lasting\\nocclusion of the retinal arteries. It will be obvious, too,\\nthat these lesions will be limited to one eye, though a\\nsimilar accident is occasionally seen afterward in the\\nother.\\nIn a few cases sudden, simultaneous blindness of both\\neyes has occurred with extremely diminished retinal arte\u00c2\u00ac\\nries, ischcemia retince, and iridectomy has been followed\\nby return of sight, lower tension causing re-establishment\\nof circulation. See also Quinine-blindness.\\nRetinitis pigmentosa is a very slowly progressive sym\u00c2\u00ac\\nmetrical disease, leading to atrophy of the retina, with\\nFig. 95.\\nExtreme concentric contraction of field of vision (R.) in a case of advanced\\nretinitis pigmentosa. The central dot shows the fixation point. The black\\nshows the part lost.\\ncollection of black pigment in its layers and around its\\nbloodvessels, and secondary atrophy of the disk. The\\nearliest symptom is inability to see well at night, or by\\nartificial light\u00e2\u0080\u0094night-blindness. Concentric contraction of\\nthe visual field soon occurs. Fig. 95. These defects may\\nreach a high degree, while central vision remains excel\u00c2\u00ac\\nlent in bright daylight. The symptoms are noticed at an\\nearlier stage by patients in whom the choroid is dark, and\\nabsorbs much light.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0259.jp2"}, "260": {"fulltext": "250\\nCLINICAL DIVISION.\\nOphthalmoscopic examination, where these symptoms\\nhave been present for some years, shows: (1) at the\\nequator or periphery a greater or less quantity of pig\u00c2\u00ac\\nment, arranged in a reticulated or linear manner, Fig.\\nFig. 96.\\nTypical pigmentary degeneration of the retina. (Jaeger.)\\n91, often with some small, separate dots; (2) in advanced\\ncases, evidence of removal of the pigment epithelium, but\\nno patches of choroidal atrophy (3) the pigment arranged\\nin a belt, which is generally uniform, the pattern being", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0260.jp2"}, "261": {"fulltext": "DISEASES OF THE RETINA.\\n251\\nmost crowded at the centre, and thinning out toward the\\nborders of the belt; (4) that the changes are always sym\u00c2\u00ac\\nmetrical, and the symmetry very precise. These appear\u00c2\u00ac\\nances are quite characteristic of true retinitis pigmentosa.\\nIn addition, we find (5) diminution in size of the retinal\\nbloodvessels, the arteries in advanced cases being mere\\nthreads; (6) a peculiar hazy, yellowish, waxy\u00e2\u0080\u009d pallor of\\nthe optic disk; (7) sometimes the pigmented parts of the\\nretina are quite hazy; (8) posterior polar cataract and dis\u00c2\u00ac\\nease of the vitreous are often present in the later stages.\\nThe latter changes (5 to 8), however, are found in many\\ncases of late retinitis consecutive to choroiditis, and are\\nnot peculiar to the present malady.\\nThe disease begins in childhood or adolescence, progresses\\nslowly but surely, and, as a rule, ends in blindness some\\ntime after middle life. A few cases of apparently recent\\norigin are seen in quite aged persons, and a few are con\u00c2\u00ac\\nsidered to be truly congenital. The quantity of pigment\\nvisible by the ophthalmoscope varies much in cases of\\napparently equal duration, and is not in direct relation\\nto the defect of sight; cases even occur, which certainly\\nbelong to the same category, in which no pigment is visible\\nduring life, the retina being merely hazy, though micro\u00c2\u00ac\\nscopical examination reveals abundance of minutely divided\\npigment (Poncet). The pathogenesis of the disease is not\\nfinally settled; it is at present doubtful whether there is\\nfrom the first a slow sclerosis of the connective-tissue\\nelements of the retina, with passage inward of pigment\\nfrom the pigment epithelium, or whether the disease be\u00c2\u00ac\\ngins in the superficial layer of the choroid and the pig\u00c2\u00ac\\nment epithelium. Its cause is obscure. It is undoubtedly\\nstrongly heritable, and many high authorities believe that\\nit is really produced by consanguinity of marriage, either\\nbetween the parents or near ancestors of the affected per\u00c2\u00ac\\nsons. Some of its subjects are of full mental and bodily", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0261.jp2"}, "262": {"fulltext": "252\\nCLINICAL DIVISION.\\nvigor; but many are badly grown, suffer from progressive\\ndeafness, and are defective in intellect. Although want\\nof education, as a consequence of defective sight and hear\u00c2\u00ac\\ning, may sometimes account for this result, we cannot thus\\nexplain the various defects and diseases of the nervous\\nsystem which are not infrequently noticed in kinsmen of\\nthe patients. That the subjects of this disease should be\\ndiscouraged from marrying is sufficiently evident. In a\\nfew cases galvanism has been followed by improvement\\nboth of vision and visual 1 field, but no other treatment\\nhas any influence. Complications such as cataract and\\nmyopia are not uncommon, and must be treated on gene\u00c2\u00ac\\nral principles.\\nIt is sometimes very difficult to distinguish widely dif\u00c2\u00ac\\nfused and superficial choroiditis, with pigmentation of\\nretina and atrophy of the disk, from true retinitis pig\u00c2\u00ac\\nmentosa. The question will generally relate to cause, as\\nbetween retinitis pigmentosa and choroido-retinitis from\\nsyphilis.\\nRetinal disease from intense light. A number of cases\\nhave now been observed in which blindness of a small\\narea at the centre of the field has been caused by staring\\nat the sun, usually during an eclipse. Corresponding to\\nthis functional defect, ophthalmoscopic evidences of cho\u00c2\u00ac\\nroiditis or choroido-retinitis have been found at the yellow\\nspot. The defect often lasts for months, if not perma\u00c2\u00ac\\nnently. 2\\nWhite connective-tissue strands are sometimes found\\nin the retina either as the result of hemorrhages or as a\\nprimary inflammatory process; bloodvessels of new forma\u00c2\u00ac\\ntion are frequently seen, and from them repeated hemor\u00c2\u00ac\\nrhages occur into the retina or vitreous (retinitis proliferans).\\n1 Gunn Ophthalmic Hospital Reports, x. 161, and others.\\n2 For accounts of cases and experiments on this affection, see London\\nMedical Record, October, 1883; also Ophthalmic Review, April and May.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0262.jp2"}, "263": {"fulltext": "DISEASES OF TIIE BE TIN A.\\n253\\nRetinitis circinata (Fuchs) occurs chiefly in old people,\\nand consists in a gray degeneration of the retina at the\\nyellow spot, surrounded by a brilliant white deposit of\\nsmall dots which become confluent into large areas sur\u00c2\u00ac\\nrounding the central gray degeneration. The exact nature\\nof this affection is unknown.\\n1 For accounts of cases and experiments on this affection, see London Medi\u00c2\u00ac\\ncal Record, October, 1883; also Ophthalmic Review, April and May.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0263.jp2"}, "264": {"fulltext": "CHAPTER XIV.\\nDISEASES OF THE OPTIC NERVE.\\nThe optic nerve is often diseased in its whole length, or\\nin some parts of its course, either within the skull, in the\\norbit, or at its ocular end.\\nThe effect of disease of the optic nerve in producing (1)\\nophthalmoscopic changes in its visible portion, the optic\\ndisk, or papilla optica and (2) defect of sight, varies greatly\\naccording to the seat, nature, and duration of the disease.\\nThe appearance of the disk may be entirely altered by\\noedema and inflammation, without the nerve-fibres losing\\ntheir conductivity, and, therefore, without loss or even de\u00c2\u00ac\\nfect of sight; on the other hand, inflammatory or atrophic\\nchanges, causing destruction of the nerve-fibres, may arise\\nin the nerve at a distance from the eye, and, while pro\u00c2\u00ac\\nducing great defect of sight, cause little or no immediate\\nchange at the disk. Although we are here concerned chiefly\\nwith the ophthalmoscopic and visual sides of the question, a\\nfew words are needed as to the morbid changes in the nerve.\\nThe pathological changes to which the optic nerve is\\nliable include those which affect other nerve-tissues. In\u00c2\u00ac\\nflammation (optic neuritis, papillitis varying in seat, cause,\\nand rapidity, and resulting in recovery or atrophy, may\\noriginate in the nerve itself, may pass down it from the\\n\u00e2\u0080\u0098brain (descending neuritis), or may extend into it from\\nparts around atrophy may occur from pressure by tumors,\\nor distention of neighboring cavities\u00e2\u0080\u0094 e. g., the third ven\u00c2\u00ac\\ntricle\u00e2\u0080\u0094or from laceration of the nerve or its central vessels\\nin the orbit, or damage from fracture of the optical canal;\\nand the optic nerve is very subject to primary atrophy.\\n254", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0264.jp2"}, "265": {"fulltext": "PLATE II.\\nFig. 1\\nFig. 2.\u00e2\u0080\u0094Ophthalmoscopic Appearances in Regressive Neuritis.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0265.jp2"}, "266": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0266.jp2"}, "267": {"fulltext": "DISEASES OF THE OPTIC NERVE.\\n255\\nLastly, the optic nerve.being surrounded by a lymphatic\\nspace, \u00e2\u0080\u009csubvaginal space,\u00e2\u0080\u009d which is continuous through\\nthe optic foramen with the meningeal spaces in the skull,\\nand is bounded by a tough, fibrous outer sheath,\u00e2\u0080\u009d is\\nliable to be affected by morbid processes going on in that\\nspace. This subvaginal or inter-sheath space, bounded\\nexternally by the outer sheath of the optic nerve, is lined\\ninternally by the inner sheath which is closely adherent to\\nthe nerve itself. Fig. 40. The relationship between optic\\nneuritis and cerebral disease is still imperfectly understood.\\nWidely differing kinds of intracranial disease, such as\\ntumor or meningitis, produce an increase of fluid in the\\ncavities of the brain. The increased pressure within the\\nskull so produced leads to a distention of the subvaginal\\nspace of the optic nerve; this is frequently found post\\nmortem.\\nBy many it is held that this alone is a sufficient cause of\\nthe optic neuritis, either by compressing the retinal veins\\nand producing choked disk\u00e2\u0080\u009d (v. Graefe), or by setting\\nup irritation in the nerve (Leber). The fact that optic\\nneuritis very generally subsides after trephining the skull\\n(Victor Horsley), even when the tumor is not removed,\\ngives strong support to this pressure theory.\\nOn the other hand, it has been proved microscopically\\nby many observers that the inflammation is not confined\\nto the head of the nerve, but extends backward along its\\ntrunk to the substance of the brain, and is continuous with\\nthe inflammatory focus in the brain; this occurs not only\\nin meningitis, but in remotely situated tumors, which are\\nalways surrounded by an area of hyperaemia. According\\nto this view the inflammatory appearances in the head of\\nthe optic nerve are due to a descending neuritis}\\n1 Gowers: Medical Ophthalmoscopy, Trans. Internat. Medical Congress,\\n1881; papers by S. Mackenzie, Brailey, Edmunds and Lawford, and Taylor,\\nTrans. Oph. Soc.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0267.jp2"}, "268": {"fulltext": "256\\nCLINICAL DIVISION.\\nAs already stated in previous chapters, inflammation may\\nextend into the disk from the retina or choroid near to it,\\nand may occur in consequence of the sudden arrest of the\\nblood-current caused by embolism and thrombosis of the\\ncentral retinal vessels in their course through the nerve.\\nThe ophthalmoscopic signs of papillitis are caused by\\nvarying degrees of oedema, congestion, and inflammation\\nof the disk. It is no longer useful to maintain the old\\nophthalmoscopic distinction between swollen disk,\u00e2\u0080\u009d or\\nchoked disk,\u00e2\u0080\u009d and optic neuritis.\u00e2\u0080\u009d The latter term\\nwas formerly reserved for cases showing little oedema but\\nmuch opacity, changes which were supposed especially to\\nindicate inflammation passing down the nerve from the\\nbrain; but if oedema and venous engorgement predom\u00c2\u00ac\\ninated, choked disk,\u00e2\u0080\u009d the changes were attributed to\\ncompression of the optic nerve by fluid in its sheath-space,\\nor with less reason to pressure on the ophthalmic vein at\\nthe cavernous sinus. The changes are often mixed, or vary\\nat different stages of the same case. The terms neuritis\\nand \u00e2\u0080\u009cpapillitis\u00e2\u0080\u009d will be here used to the exclusion of\\nchoked disk.\u00e2\u0080\u009d\\nThe most important early changes in optic papillitis are\\nblurring of the border of the disk by a grayish opalescent\\nhaze, distention of the large retinal veins, and swelling of\\nthe disk above the surrounding retina. Swelling is shown\\nby the abrupt bending of the vessels, with deepening of\\ntheir color and loss of the light streak\u00e2\u0080\u0094they are, in fact,\\nseen foreshortened also by noticing that slight lateral\\nmovements of the observer\u00e2\u0080\u0099s head, or lens, cause an appar\u00c2\u00ac\\nent movement of the vessels over the choroid behind,\\nbecause the two objects are on different levels parallactic\\ntest,\u00e2\u0080\u009d p. 239). The patient may die, or the disease may,\\nafter a longer or shorter time, recede at this stage. But\\nfurther changes generally occur, the haziness becomes a\\ndecided opacity, which more or less obscures the central", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0268.jp2"}, "269": {"fulltext": "DISEASES OF THE OPTIC NER VE.\\n257\\nvessels, and covers and extends beyond the border of the\\npapilla, Fig. 97, so that the disk appears enlarged; its\\ncolor becomes a mixture of yellow and pink with gray or\\nwhite, and it looks striated or fibrous, appearances due to\\na white opacity of the nerve-fibres mingled with numerous\\nsmall bloodvessels and hemorrhages. The veins become\\nlarger and more tortuous, or even kinked or knuckled; the\\narteries are either normal or somewhat contracted; there\\nFig. 97.\\nOphthalmoscopic appearance of severe recent papillitis. Several elongated\\npatches of blood near border of disk. Compare with Fig. 98. (After Hugh-\\nlings Jackson.)\\nmay be blood-patches. The swelling of the disk may be\\nvery great, and is appreciated either by the above-men\u00c2\u00ac\\ntioned foreshortening of the vessels, by the parallactic test,\\nor by ophthalmoscopic measurement.\\nSuch changes may disappear, leaving scarcely a trace;\\nor a certain degree of atrophic paleness of the disk, with\\nsome narrowing of the retinal vessels and thickening of\\ntheir sheaths, or other slight changes, may remain. But\\n17", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0269.jp2"}, "270": {"fulltext": "258\\nCLINICAL DIVISION\\nin many cases the disk gradually, in the course of weeks\\nor months, passes into a state of post-papillitic or con-\\nFig. 98.\\nSection of the swollen disk in papillitis, showing that the swelling is limited\\nto the layer of nerve-fibres (longitudinal shading); other retinal layers not\\naltered in thickness. (Compare with Fig. 40). X about 15.\\nFig. 99.\\nAtrophy of the disk after papillitis. Upper and lower margins still hazy;\\nveins still tortuous; arteries nearly normal; disturbance of choroidal pig\u00c2\u00ac\\nment at inner and outer border. Sight in this case remained fairly good.\\nThe disk is not represented white enough.\\nsecufive atrophy the opacity first becomes whiter and\\nsmoother looking woolly disk\u00e2\u0080\u0099\u00e2\u0080\u009d); then it slowly clears\\noff, generally first at the side next the yellow spot, and the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0270.jp2"}, "271": {"fulltext": "DISEASES OF THE OPTIC NERVE.\\n259\\nretinal vessels simultaneously shrink to a smaller size,\\nthough they often remain tortuous for a long time. Fig.\\n99. As the mist lifts, the sharp edge, and finally the\\nwhole surface of the disk, now of a staring white color,\\nagain come into view. A slight haziness often remains,\\nand the boundary of the disk is often notched and irreg\u00c2\u00ac\\nular but upon these signs too much reliance must not be\\nplaced.\\nSight is seldom much affected 1 until marked papillitis\\nhas existed some little time. If the morbid process quickly\\ncease, often no failure occurs; or the sight may fail, may\\neven sink almost to blindness for a short time, and recov\u00c2\u00ac\\nery may take place, if the changes cease before compression\\nof the nerve-fibres have given rise to atrophy. Early blind\u00c2\u00ac\\nness in double papillitis may be due to pressure on the\\nchiasma or tracts rather than to the changes we see in the\\neyes. Gradual failure late in the case, when retrogressive\\nchanges are already visible at the disk, is a bad sign. The\\nsight seldom changes, either for better or for Avorse, after\\nthe signs of acth r e papillitis have quite passed off; and\\nthough the relations between sight and final ophthalmo\u00c2\u00ac\\nscopic appearances vary, it is usually true (1) that great\\nshrinking of the central retinal vessels indicates a high\\ngrade of atrophy and great defect of sight, and is generally\\naccompanied by extreme pallor, with some residual hazi\u00c2\u00ac\\nness of the disk\u00e2\u0080\u0094advanced post-papillitic atrophy (2) that\\nconsiderable pallor and other slight changes, such as white\\nlines bounding the vessels, or streaks caused by increase of\\nthe connective tissue of the disk, are compatible with fairly\\ngood sight if the central vessels are not much shrunken.\\nAdvanced atrophy, undoubtedly folloAving papillitis, does\\ni Dr. Hughlings Jackson was the first to notice and insist upon the fre\u00c2\u00ac\\nquency of papillitis without failure of sight. The discovery Avas of immense\\nvalue, for double papillitis, without other changes in the eye, is one of the\\nmost important objective signs wo possess of the existence of tumor, or\\ninflammation, within the skull.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0271.jp2"}, "272": {"fulltext": "260\\nCLINICAL DIVISION.\\nnot, however, always show signs of the past violent inflam\u00c2\u00ac\\nmation the appearances may, indeed, be indistinguishable\\nfrom those caused by primary atrophy.\\nPapillitis is double in the great majority of cases. If\\nsingle, it generally indicates disease in the orbit. It is true\\nthat single papillitis, from intracranial disease, is occasion\u00c2\u00ac\\nally met with and that in many double cases inequalities\\nare often seen between the two eyes, as to time of onset,\\ndegree, and final result.\\nThe changes are not always limited strictly to the disk\\nand its border, pure papillitis, for in some cases a wide zone\\nof surrounding retina is hazy and swollen, exhibiting hemor\u00c2\u00ac\\nrhages and Avhite plaques, or lustrous white dots\u00e2\u0080\u0094 papillo\u00c2\u00ac\\nretinitis. It is not always easy to say, in such a case,\\nwhether the changes are due to renal disease, with great\\nswelling of the disk, or to some intracranial malady. In\\nrenal cases there is albuminuria, the kidney is in an ad\u00c2\u00ac\\nvanced stage of disease, 1 and the patients are seldom young\\nin the cases of neuro-retinitis most closely resembling renal\\ncases, but caused by cerebral disease, there is no albumin,\\nand the white deposits are seldom arranged quite as in\\nrenal retinitis, while the papillitis is greater than is usual\\nin renal cases.\\nEtiology (compare Chapter XXIII.). Papillitis occurs\\nchiefly in cases of irritative intracranial disease, viz., in\\nmeningitis, both acute and chronic, and in intracranial new-\\ngrowths of all kinds, whether inflammatory, syphilitic gum-\\nniata, tubercular, or neoplastic. It is very rare in cases\\nwhere there is neither inflammation nor tissue growth, as\\nin cerebral hemorrhage and intracranial aneurism. Fur\u00c2\u00ac\\nther, it must be stated that no constant relationship has\\nbeeu proved between papillitis and the seat, extent, or\\nduration of the intracranial disease. Papillitis has occa-\\n1 Gowers, p. 187.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0272.jp2"}, "273": {"fulltext": "DISEASES OF THE OPTIC NERVE.\\n261\\nsionally been found without coarse disease, but with widely\\ndiffused minute changes, in the brain. Thus the occurrence\\nof papillitis, although pointing very strongly to organic\\ndisease within the skull, and especially to intracranial\\ntumor, is not of itself either a localizing or a differenti\u00c2\u00ac\\nating symptom. Inflammation about the sphenoidal fis\u00c2\u00ac\\nsure, and tumors, nodes, and inflammations in the orbit,\\nare occasional causes of papillitis, which is then usually\\none-sided, and often accompanied by extreme oedema and\\nvenous distention in some of these there is protrusion of\\nthe eye with affection of other orbital nerves, and the exact\\nseat and nature of the disease may be obscure. Optic neu\u00c2\u00ac\\nritis from intracranial disease seldom recurs after subsi\u00c2\u00ac\\ndence. 1\\nOther occasional causes of double papillitis, with or with\u00c2\u00ac\\nout retinitis, are lead-poisoning, the various exanthemata,\\nincluding recent syphilis, sudden suppression of menses,\\nsimple chronic anaemia, rapid copious loss of blood, espe\u00c2\u00ac\\ncially from the stomach, and, perhaps, exposure to cold.\\nIn a few cases well-marked double papillitis occurs without\\nother symptoms, and without assignable cause.\\nCertain cases of failure of sight, usually single, with\\nslight neuritic changes at the disk, followed by recovery or\\nby atrophy, must be referred to a local, primary optic neu\u00c2\u00ac\\nritis some distance behind the eye, retro-ocular or retro-bulbar\\nneuritis. The changes are, clinically, very different from\\nthose above described.\\nSyphilitic disease within the skull is a common cause of\\npapillitis, but the eye changes alone furnish no clue to the\\ncause, nor to its mode of action, which may be (1) by\\ngiving rise to intracranial gumma, not in connection with\\nthe optic nerves, but acting as any other tumor acts (see\\nabove); (2) by direct implication of the chiasma or optic\\n1 A well-marked case has been recorded by Dr. James Anderson in the\\nOphthalmic Review for May, 1886.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0273.jp2"}, "274": {"fulltext": "2G2\\nCLINICAL DIVISION.\\ntracts in gummatous inflammation (3) in rare cases neuri\u00c2\u00ac\\ntis, ending in atrophy and blindness, occurs in secondary\\nsyphilis, with head symptoms pointing to meningitis;\\n(4) there are few cases of double papillitis in late secondary\\nsyphilis without either head symptoms or signs of ocular\\ndisease other than in the disks; these may properly be\\ncalled syphilitic optic neuritis.\u00e2\u0080\u009d\\nAtrophy of the Optic Disk.\\nBy this is meant atrophy of the nerve-fibres of the disk\\nand of the capillary vessels which feed it. The disk is too\\nwhite milk-white, bluish, grayish, or yellowish, in different\\ncases. Its color may be quite uniform, or some one part\\nmay be whiter than another; the stippling of the lamina\\nFig. 100.\\nFig. 101.\\nSimple atrophy of disk. Stip\u00c2\u00ac\\npling of lamina cribrosa exposed.\\n(Wecker.)\\nAtrophy of disk from spinal dis\u00c2\u00ac\\nease. Lamina cribrosa concealed.\\nVessels normal. (Wecker.)\\ncribrosa maybe more visible thgja in health, or on the other\\nhand, entirely absent, as if covered or filled up by white\\npaint. Figs. 100 and 101. The central retinal vessels\\nmay be shrunken or of full size, and their course natural\\nor too tortuous; both these points bear upon the diagnosis\\nof cause and the prognosis. The choroidal boundary may\\nbe too sharply defined, or, as in Fig. 99, too hazy; it may\\nbe even and circular, or irregular and notched. The scle-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0274.jp2"}, "275": {"fulltext": "DISEASES OF THE OPTIC NERVE.\\n263\\nrotic ring is often seen with unnatural clearness, exposed\\nby wasting of the overlying nerve-fibres. Mere pallor of\\nthe disk, such as we see in extreme general anaemia, must\\nnot be mistaken for atrophy; the change is then one of\\ncolor only, without unnatural distinctness, loss of trans\u00c2\u00ac\\nparency, or disturbance of outline.\\nVarieties. 1. The nerve-fibres undergo atrophy dur\u00c2\u00ac\\ning the absorption and shrinking of the new connective\\ntissue formed in severe neuritis (post-papillitic atrophy, p.\\n258 embolism, p. 246).\\n2. When the disk participates secondarily in inflamma\u00c2\u00ac\\ntion of the retina or choroid it also participates in the suc\u00c2\u00ac\\nceeding atrophy.\\n3. Atrophy of any part of the optic nerve or chiasma\\nfrom pressure\u00e2\u0080\u0094as by a tumor or by distention of the third\\nventricle in hydrocephalus\u00e2\u0080\u0094from injury, or local inflam\u00c2\u00ac\\nmation, leads to secondary atrophy, which sooner or later\\nreaches the disk. Such cases often show the conditions of\\npure atrophy, without adventitious ^opacity or disturbance\\nof outline, and often without change in the retinal vessels.\\nThey are not very common.\\n4. The optic nerves are liable to chronic sclerotic changes,\\nwith thickening of the connective-tissue framework and\\natrophy of the nerrve-fibres, without the occurrence of papil\u00c2\u00ac\\nlitis, The change in these cases appears often to begin at\\nthe disk, but the exact order of events in this large and\\nimportant group is not fully known. Groups 3 and 4 fur\u00c2\u00ac\\nnish the cases which are known clinically as primary\u00e2\u0080\u009d\\nor 1 progressive atrophy of the optic disk.\\nClinical aspects of atrophy of the disks. As in optic\\nneuritis, so in atrophy and pallor of the disk, there is no\\ninvariable relation between the apj^earance (especially the\\ncolor) of the disk and the patient\u00e2\u0080\u0099s sight. A considerable\\ndegree of pallor, which it may be impossible to distinguish\\nfrom true atrophy, is sometimes seen with excellent central", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0275.jp2"}, "276": {"fulltext": "264\\nCLINICAL DIVISION.\\nvision, though usually accompanied by some defect of the\\nvisual field. Again, the disks often look alike, although\\nthe sight is much better in one eye than the other.\\nL. Fig. 102. R.\\nIrregular contraction of fields of vision in a case of progressive atrophy of\\noptic nerves. The loss is symmetrical, but more advanced In the L., where\\nit has extended over the fixation point; in the R. it has just reached the fixa\u00c2\u00ac\\ntion point at one place. The black represents the parts lost.\\nPatients with atrophy of the disk come to us because they\\ncannot see well, or are quite blind. There are usually no\\nFig. 103.\\nIrregular contraction with central loss of L. visual field from progressive\\natrophy of optic nerve in locomotor ataxy. The black represents the blind\\nparts the shading shows partial loss of vision.\\nother local symptoms except such as may be furnished by\\nthe pupils. In post-papillitic atrophy the pupils are gen\u00c2\u00ac\\nerally too large and sluggish or motionless to light; in", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0276.jp2"}, "277": {"fulltext": "DISEASES OF THE OPTIC NERVE.\\n265\\nmost cases of primary progressive atrophy in the early\\nstages they are of ordinary size or smaller than usual, and\\nact very imperfectly. Chapter XXIII. When only one\\neye is alfected, the other being quite healthy, the pupil of\\nthe amaurotic eye has no direct action to light and is often\\na little larger than its fellow.\\nThe visual field in cases of atrophy is generally con\u00c2\u00ac\\ntracted, or shows irregular invasions or sector-like defects.\\nFigs. 102 and 103. Color-blindness is a marked symptom in\\nnearly all cases, but is not always proportionate to the loss\\nof visual acuteness, being in some much greater and in\\nothers much less than the state of central vision would lead\\nus to suspect. Green is the color lost first in nearly all\\ncases, and red next.\\nA. Cases in which both disks are atrophied may be con\u00c2\u00ac\\nveniently classified as follows in regard to diagnosis and\\nprognosis.\\n1. If the changes point decidedly to recently past papil\u00c2\u00ac\\nlitis, there is some prospect of improvement; but, on the\\nother hand, sight may for a time get worse. The case\\nmust of course be investigated most carefully as to the\\ncause of the neuritis. If sight have been stationary for\\nsome months, further change is unlikely.\\n2. If the retinal arteries are much shrunken, whether\\nneuritis has occurred or not, the prognosis is bad.\\nIf we cannot decide after careful examination whether\\npapillitis has been present or not, inquiry should be made\\nas to former symptoms of intracranial disease; since con\u00c2\u00ac\\nsecutive atrophy cannot always be distinguished from\\nprimary. But in a large number of those cases which\\npresent no ophthalmoscopic evidences of previous papillitis\\nthe history will be quite negative as to cerebral symptoms;\\nand these will, for the most part, fall into the two follow\u00c2\u00ac\\ning groups:\\n3. There are symptoms of chronic disease of the spinal", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0277.jp2"}, "278": {"fulltext": "26G\\nCLINICAL DIVISION.\\ncord, usually of locomotor ataxy; or much more rarely\\nsymptoms of general paralysis of the insane.\\n4. No cause can he assigned for the atrophy these cases\\nare less common than has been supposed.\\nThe sclerosis leading to atrophy of the disks in locomotor\\nataxy (3) usually comes on early in that disease, often be\u00c2\u00ac\\nfore well-marked spinal symptoms have appeared. The\\noptic atrophy always becomes symmetrical, though it gen\u00c2\u00ac\\nerally begins some months sooner in one eye than in the\\nother; it always progresses, though sometimes not for\\nyears, to complete, or all but complete, blindness. The\\ndisks are usually characterized by an uniformly opaque,\\ngray-white color, the lamina cribrosa being often concealed,\\nalthough neither the central vessels nor the disk margins\\nare obscured in the least. Fig. 101. The central vessels\\nare often not materially lessened in size, even when the\\npatient is quite blind.\\nCases of progressive atrophy are seen which resemble\\nthe above, but where no signs of spinal cord disease are\\npresent, even though the patient has been long blind (4).\\nIt is known that in some of these patients ataxic symptoms\\ncome on sooner or later, and it is highly probable that,\\ncould the cases be followed up for a sufficient number\\nof years, this termination would be found to be common j 1\\nindeed, pre-ataxic optic atrophy is now a recognized method\\nof onset of the disease. Undoubtedly in some cases the\\noptic nerve atrophy is not followed by locomotor ataxy,\\nbut some of the other signs of tabes dorsalis may be present,\\nas the Argyll-Robertson pupil or the loss of knee-jerk.\\nWe should probably be justified in grouping such cases\\n1 I have found decided spinal symptoms in 58 of a series of 76 consecutive\\ncases of progressive atrophy, and of the remaining 18, several showed one or\\nmore symptoms which were probably of spinal origin. Peltesohn finds about\\n40 per cent, of all cases of non-neuritic progressive optic atrophy in Hirsch-\\nberg\u00e2\u0080\u0099s clinic to be associated with spinal or cerebro-spinal disease. Knapp\u00e2\u0080\u0099s\\nArch., xvi. 142.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0278.jp2"}, "279": {"fulltext": "DISEASES OF THE OPTIC NERVE.\\n267\\nunder the heading of arrested tabes. Cases of Classes 3\\nand 4 are far more common in men than women. In a few\\nthe atrophy is caused by a tumor compressing the chiasma\\nwithout setting up papillitis.\\nIn making the prognosis of cases of progressive, uncom\u00c2\u00ac\\nplicated amblyopia or amaurosis, with more or less atrophy\\nof disks, special attention is to be paid to whether the\\nfailure was synchronous or not, and whether it is now\\nequal in the two eyes. The state of the field of vision in\\ncases seen early is also of much importance; peripheral\\ncontraction, as distinguished from central defect, is a bad\\nsign, for progressive atrophy seldom begins with defect in\\nthe centre of the field. In cases of gradual, uncompli\u00c2\u00ac\\ncated failure of sight, where the symptoms have from the\\nbeginning been equally symmetrical, the atrophic changes\\nare usually but slight in comparison with the defect of\\nsight.\\nB. Single amaurosis with atrophy of the disk in a majority\\nof cases indicates former embolism of the central artery,\\nsome local affection of the trunk of the optic nerve, \u00e2\u0080\u009cretro-\\nocular neuritis,\u00e2\u0080\u009d or pressure on the nerve by tumor just in\\nfront of the chiasma. But here it must be remembered\\nthat in cases of progressive atrophy, accompanying or pre\u00c2\u00ac\\nceding spinal disease, a very long interval occasionally\\nseparates the onset of the disease in the two eyes, 1 and we\\nmay see the first eye before the commencement of the dis\u00c2\u00ac\\nease in the second.\\nBlindness of one eye following immediately after a fall\\nor blow on the head indicates damage to the nerve from\\nfracture of the optic canal, or hemorrhage into the nerve-\\nsheath. If the nerve is torn across, visible atrophy of the\\ndisk sets in in a few weeks. The blow has generally been\\non the front of the head and on the same side as the\\n1 This interval may be three or four years, and an interval of from one to\\ntwo years is not very rare.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0279.jp2"}, "280": {"fulltext": "268\\nCLINICAL DIVISION.\\naffected eye. A similar condition follows wound or rup\u00c2\u00ac\\nture of the nerve in the orbit, by a thrust, stab, or gun\u00c2\u00ac\\nshot injury. Laceration of the central retinal vessels\\nalone, behind the point at which they enter the nerve,\\nis said to cause appearances like those due to embolism\\nand thrombosis. In cases of injury to the optic nerve\\nimprovement is rare.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0280.jp2"}, "281": {"fulltext": "CHAPTER XV.\\nAMBLYOPIA AND FUNCTIONAL DISORDERS OF SIGHT.\\nThe term amblyopia means dulness of sight, but its use\\nis generally restricted to cases of defective acuteness of\\nsight, short of blindness, in which there is little or no\\nophthalmoscopic change. Amaurosis indicates a more\\nadvanced affection\u00e2\u0080\u0094complete blindness without visible\\nchanges. These terms, then, refer to the patient\u00e2\u0080\u0099s symp\u00c2\u00ac\\ntoms, while papillitis and atrophy imply changes seen by\\nthe observer. Amblyopia may depend upon disease in the\\nretina in any part of the optic nerve or tract, or in the\\noptic centres; and it may be temporary or permanent.\\nIt is always most important to distinguish single from\\nsymmetrical cases.\\nTwo common and important forms of unsymmetrical\\namblyopia may be considered first.\\n1. Amblyopia from suppression of image (congenital am\u00c2\u00ac\\nblyopia). It is well known that many children with con\u00c2\u00ac\\nvergent squint see badly with the squinting eye; that this\\ndefect varies in degree, and may be so great that fingers\\ncan hardly be counted; that, at any rate in the higher\\ngrades, the defect is chiefly or only present in that part\\nof the visual field which is common to both eyes, Fig. 34,\\nand is irremediable; while in the lower degrees the defect\\nmay be more or less removed by separate practice of the\\ndefective eye. 1 It has been assumed by one school that\\nthis amblyopia is due to a congenital defect, presumably\\nof the visual centre, which determines the incidence of the\\n1 Of such improvement I have myself had very little experience.\\n269", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0281.jp2"}, "282": {"fulltext": "270\\nCLINICAL DIVISION.\\nsquint, just as defect due to an ulcer of the cornea may\\ndo. Another view supposes that the child, born with two\\ngood eyes, but being obliged to squint, owing to hyperme-\\ntropia, learns to suppress the consciousness of the image in\\nthe squinting eye in order to avoid the inconvenience of\\ndouble vision, and that this habit, if begun very early in\\nlife, causes permanent amblyopia of the eye, due to a de\u00c2\u00ac\\nfective development of the perceptive faculty in the corre\u00c2\u00ac\\nsponding centre. For the former view it is urged that no\\none has ever watched the onset of this amblyopia, since it\\nis always present at the youngest age when tests can be\\napplied; that we meet with cases of unexplained defect of\\none eye without squint; and that this supposed power of\\nsuppression cannot be learnt in later life, as is shown by\\nthe permanence of diplopia in all cases of paralytic squint\\nacquired after childhood. In favor of the suppression\\ntheory we may argue that while such defect might be\\nacquired early, it could not be expected to come on late,\\nafter the visual centre in question had been educated\\nprecisely as want of training of the ocular muscles in\\nearly infancy, from defective sight due to disease, leads\\nto incurable nystagmus (Chapter XXI.) much more fre\u00c2\u00ac\\nquently than do similar defects of sight acquired after the\\nmuscles have been got into harmonious use; that in many\\nof the cases of defect without squint a history of previous\\nsquint can be obtained and that if the defect were con\u00c2\u00ac\\ngenital it would involve the whole field equally, not only\\nthat part which is common to the two eyes. In alternating\\nconcomitant squint, whether convergent or divergent, there\\nis no diplopia, although the vision of each eye is as a rule\\nequally good the patient has the power of instantaneously\\nsuppressing the consciousness of the image in whichever\\nhappens to be the squinting eye\u00e2\u0080\u0094a fact in favor, so far\\n1 I believe that the spontaneous disappearance of hypermetropic squint,\\nwhich is not uncommon, has received too little attention.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0282.jp2"}, "283": {"fulltext": "AMBLYOPIA.\\n271\\nas it goes, of the suppression theory. On the other hand,\\nit is true that in cases of anisometropia great variations\\nare encountered in the degree of perfection to which the\\nmore ametropic eye can be raised by glasses\u00e2\u0080\u0094a fact per\u00c2\u00ac\\nhaps in favor of the congenital amblyopia theory.\\n2. Amblyopia from defective retinal images. In cases of\\nhigh hypermetropia or astigmatism, when clear images have\\nnever been formed, the correction of the optical defect by\\nglasses at the earliest practicable age often fails, at any\\nrate for a time, to give full acuteness of sight. Want of\\neducation in the appreciation of clear images is probably\\nthe chief cause, though defective development of the retina\\nmay also come into play. We may explain in the same\\nway the common cases in which, with anisometropia (Chap\u00c2\u00ac\\nter XX.), the sight of the more ametropic eye, even when\\ncorrected by the proper glasses, remains defective, although\\nno squint has ever existed; and in some degree also the\\ndefect often observed after perfectly successful operations\\nfor cataract in children. Amblyopia of this kind when\\ndiscovered late in life is seldom altered by correcting the\\noptical error, but in children the sight often improves\\nwhen suitable glasses are constantly worn.\\nGreat defect of one eye from the causes just mentioned,\\nor gradual painless failure from disease, often exists un\u00c2\u00ac\\nknown for years, until accidentally discovered by closing\\nthe sound eye or by trying the sight of each eye separately\\ne. g., in an examination for the army or other public\\nservice. The patient in such cases is naturally concerned\\nat what he thinks is a recent defect, but caution is needed\\nin accepting his view, unless he has previously been in the\\nhabit of sighting objects with the eye in question, as in\\nrifle-shooting. But sudden failure of one eye is, as a rule,\\ndated correctly.\\nIn cases of amblyopia not belonging to the above cate\u00c2\u00ac\\ngories, a definite date of onset will generally be given.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0283.jp2"}, "284": {"fulltext": "272\\nCLINICAL DIVISION.\\nTwo principal divisions may be formed, according as the\\namblyopia affects one eye or both.\\n3. Cases of recent failure of one eye with little or no\\nophthalmoscopic change occur rather rarely, and gener\u00c2\u00ac\\nally in young adults; the onset is often rapid, with neu\u00c2\u00ac\\nralgic pain, sometimes very severe, in the same side of the\\nhead. There may be pain in moving the eye, or tender\u00c2\u00ac\\nness when it is pressed back into the orbit. The degree of\\namblyopia varies much, but is often especially marked at\\nthe centre of the field. The disk of the affected eye is\\nsometimes hazy and congested. The attack is often attri\u00c2\u00ac\\nbuted to exposure to cold. Most of the cases recover under\\nthe use of blisters and iodide of potassium, but in a certain\\nnumber the defect is permanent, and the disk becomes\\natrophied. Such cases are most probably caused by a\\nretro-ocular neuritis, often slight and transient, and the\\ncases are perhaps analogous to peripheral paralysis of the\\nfacial nerve.\\n4. Much more common is a progressive and equal failure\\nin both eyes, often amounting in a few weeks or months to\\ngreat defect (14 or 20 Jaeger, or V. from to y 1 with\\nno other local symptoms except perhaps a little frontal\\nheadache, but often with nervousness, general want of\\ntone, and loss of sleep and appetite. Ophthalmoscopic\\nchanges, never pronounced, may be quite absent; at an\\nearly period the disk is often decidedly congested and\\nslightly swollen and hazy, but these changes are all so\\nill-marked that competent observers may give different\\naccounts of the same case; later, the side of the disk near\\nthe y. s., and finally in bad cases the whole papilla, become\\npale, and the diagnosis of incomplete atrophy is given.\\nThe defect of sight is described as a mist,\u00e2\u0080\u009d and is usually\\nmost troublesome in bright light and for distant objects,\\nbeing less apparent early iu the morning and toward even\u00c2\u00ac\\ning. The pupils are normal, or at most rather sluggish to", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0284.jp2"}, "285": {"fulltext": "AMBLYOPIA.\\n273\\nlight. The defect of V. is limited to, or most intense at,\\nthe central part of the field (central scotoma occupying an\\noval patch which extends from the fixation point (corre\u00c2\u00ac\\nsponding to the y. s.) outward, toward, and often as far as\\nthe blind spot, corresponding to the optic disk. The affected\\narea is also found to be color-blind for red and screen; but\\nthis loss of color perception being usually incomplete, alike\\nin degree and superficial extent. Fig. 104. will often escape\\ndetection if large color tests be used; while it will readily\\nbe found by using a small colored spot of from 5 to 15 mm.\\nFig. 104.\\nR. right, L. left, visual field in a case of central amblyopia from tobacco\\nsmoking. The shaded area is the part over which acuteness of vision and\\ncolor perception are lowered, relative central scotoma, no part of the field\\nbeing absolutely blind. The dotted line marked It. shows the boundary of\\nthe field for red (see Fig. 33).\\nsquare. The patient, closing one eye, fixes\u00e2\u0080\u009d the finger\\nor nose of the observer, who then removes the colored spot\\nfrom the fixation point in various directions toward the\\nperiphery; the color, instead of appearing brightest at the\\ncentre of the field, will be dull or unrecognizable there,\\nbecoming brighter and easily recognized toward the periph\u00c2\u00ac\\nery. There is no contraction of the field, and thus, since\\nsurrounding objects are seen as well as ever, and the\\npatient has no difficulty in going about, his manner differs\\nfrom that of one with progressive atrophy, who finds diffi-\\n18", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0285.jp2"}, "286": {"fulltext": "274\\nCLINICAL DIVISION.\\nculty in guiding himself, because his visual field is con\u00c2\u00ac\\ntracted.\\nThe patients are almost without exception males, and at\\nor beyond middle life. With very rare exceptions they are\\nsmokers, and have smoked for many years, and a large\\nnumber are also intemperate in alcohol. The exceptions\\noccur chiefly in a very few patients in whom a similar kind\\nof amblyopia is hereditary, is liable to affect the female as\\nwell as the male members, and may come on much earlier\\nin life. The etiology of such cases is obscure, and in some\\nfew of them there is no evidence of heredity.\\nIn the common cases it is now generally agreed that\\ntobacco has a large share in the causation, and in the\\nopinion of a number of observers it is the sole excitant.\\nThe direct influence of alcohol, and of the various causes\\nof general exhaustion, such as anxiety, underfeeding, and\\ngeneral dissipation, is still to some extent an open ques\u00c2\u00ac\\ntion. See Chapter XXIII., Diabetes. My own opinion,\\nbased on the examination of a large number of cases, is\\nthat tobacco is the essential agent, and that the disuse or\\ngreatly diminished use of tobacco is the one essential\\nmeasure of treatment. It is important to remember that\\nthe disease may come on when either the quantity or the\\nstrength of the tobacco is increased, or when the health\\nfails and a quantity which was formerly well borne becomes\\nexcessive. Hence cases of double central amblyopia may,\\nas a rule, except in the rare form above mentioned, be\\nnamed tobacco amblyopia. The symmetry of tobacco am\u00c2\u00ac\\nblyopia is not always precise, and it appears, in very rare\\ncases, to be delayed. 1\\nThe prognosis is good if the patient come early, and if\\nthe failure have been comparatively quick. In such cases\\nreally perfect recovery may occur, and very great improve-\\n1 J. Hutchinson, Jr.: Ophthalmic Hospital Reports, xi. 1S86.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0286.jp2"}, "287": {"fulltext": "AMBLYOPIA.\\n275\\nment is the rule. In the more chronic cases, or cases\\nwhere already the whole disk is pale, a moderate improve\u00c2\u00ac\\nment, or even an arrest of progress, is all we can expect.\\nIf smoking be persisted in, no improvement takes place,\\nand the amblyopia increases up to a certain point; but\\ncomplete blindness very seldom if ever occurs. In the\\ntreatment, disuse of tobacco is the one thing essential.\\nRelapse sometimes occurs if smoking be resumed. Drink\\nshould, of course, be moderated. It is usual to give strych\u00c2\u00ac\\nnia, subcutaneously or by mouth, for a considerable period,\\nbut whether any medicine acts otherwise than by improv\u00c2\u00ac\\ning the general tone is doubtful; subcutaneous injections\\nof strychnia, carefully carried out, have not given definite\\nresults in my own cases. Others believe that the constant\\ncurrent is useful. There is reason to believe that the dis\u00c2\u00ac\\nease depends on a chronic inflammation of the central\\nbundles of the optic nerve, beginning at, or a short dis\u00c2\u00ac\\ntance behind, the eye. 1\\nHemianopia, usually called hemiopia, denotes loss of half\\nthe field of vision. When uniocular the defect is seldom\\nquite regular, and generally depends upon detachment of\\nthe retina or a very large retinal hemorrhage. It is usu\u00c2\u00ac\\nally binocular, and then indicates disease at or behind the\\noptic cliiasma. In the great majority of cases the R. or\\nL. lateral half of each field is lost. Sometimes only a\\nquarter of each field is lost. The line of separation be\u00c2\u00ac\\ntween the blind and seeing halves is usually sharply de\u00c2\u00ac\\nfined and nearly straight, only deviating a degree or two\\nat the fixation point, so as just to leave central vision in\u00c2\u00ac\\ntact over an area about corresponding to the fovea cen\u00c2\u00ac\\ntralis. Fig. 105. In other cases the separating line is\\nundulating, and a comparatively large central area of the\\nfield remains intact. The boundary between sight and\\n1 Transactions Ophthalmic Society, vol. i. p. 124, and iii. p. 160.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0287.jp2"}, "288": {"fulltext": "276\\nCLINICAL DIVISION.\\nblindness in hemianopia, though usually abrupt, is some\u00c2\u00ac\\ntimes gradual. The retention of central vision over a\\nconsiderable central area has been explained on the\\nassumption that the y. s. area receives nerve-fibres from\\nboth optic tracts, and Bunge and others have lately found\\nmicroscopical evidence that such is really the case; in\\ncases like Fig. 105 the apparent deviation of the dividing\\nline may perhaps be explained by the difficulty which the\\nFig. 105.\\nFields of vision in a case of L. homonymous lateral hemianopia. The\\ndividing line comes within one or two degrees of the fixation point (shown\\nby the central dot) in each eye. The lesion causing this hemianopia is\\nprobably in the optic tract, or not higher than the corpora geniculata.\\npatient has in keeping the eye perfectly fixed when the\\ntest object comes close to the centre. Loss of the R. half\\nof each field meaning loss of function of the L. half of\\neach retina, points to disease of the L. optic tract 1 or its\\ncontinuations, or of some part of the L. occipital lobe or\\nangular gyrus. The hemiopic pupillary reaction (Wer\u00c2\u00ac\\nnicke) assists us in localizing the disease. If, when light is\\nthrown on the blind half of the retina, the pupil contracts\\nas well as when it is thrown on the seeing half in the two\\neyes, the lesion is in the cortex but if it does not contract,\\nthe lesion is in the optic tract. Loss of the two nasal halves\\n1 Because the L. optic tract consists chiefly of fibres which supply most of\\nthe L. half of each retina, those of them destined for the R. eye crossing\\nover at the optic commissure.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0288.jp2"}, "289": {"fulltext": "AMBLYOPIA.\\n277\\nis extremely rare. Loss of the two temporal halves (tem\u00c2\u00ac\\nporal hemianopia) points to disease at the anterior part of\\nthe chiasma. Even when hemianopia has lasted for years\\nthe optic disks seldom show any change. When the lateral\\nhemianopia co-exists with hemiplegia the loss of sight is on\\nthe paralyzed side; \u00e2\u0080\u009cthe patient cannot see to his par\u00c2\u00ac\\nalyzed side\u00e2\u0080\u009d (Hughlings Jackson). If double hemiopia\\noccurs, the patient is totally blind in both eyes. Another\\nless common affection of sight, crossed amblyopia, is be\u00c2\u00ac\\nlieved to be due to a lesion of a higher centre in the angu\u00c2\u00ac\\nlar gyrus which presides in some degree over the whole of\\nboth fields of vision, but chiefly over that of the opposite\\neye. A unilateral lesion of this kind produces amblyopia\\nwith great contraction of the field of the opposite eye,\\nand with some contraction of the field of the eye of the\\nsame side. The symptoms are much like those of hyster\u00c2\u00ac\\nical amblyopia in one eye. If such a lesion were double,\\nit would presumably produce a high degree of amblyopia,\\nwith contraction of the fields in both eyes, the activity of\\nthe pupils being retained. A few cases of hemianopia for\\ncolors alone have been recorded. 1\\nHysterical amblyopia and amaurosis take various forms,\\nand real defect may be mixed up with feigning. In hys\u00c2\u00ac\\nterical hemianaesthesia the eye on the affected side is some\u00c2\u00ac\\ntimes defective or quite blind. In other cases of hysteria\\nboth sides are defective, but one worse than the other;\\nthere is concentric contraction of the visual fields, some\u00c2\u00ac\\ntimes with, sometimes without, color-blindness, a varying\\ndegree of defective visual acuteness, and sight is often dis\u00c2\u00ac\\nproportionately bad by feeble light, hence the term anaes\u00c2\u00ac\\nthesia of the retina\u00e2\u0080\u009d is sometimes used. There may,\\nhowever, be in addition irritative symptoms\u00e2\u0080\u0094watering,\\nphotophobia, and spasm of accommodation, and then the\\n1 See exhaustive paper by Mackay British Medical Journal, November 10,\\n1888.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0289.jp2"}, "290": {"fulltext": "278\\nCLINICAL DIVISION\\nterm hypersesthesia retinre\u00e2\u0080\u009d or oculi seems more ap\u00c2\u00ac\\npropriate. Amblyopia with the above characters has been\\nknown to follow a blow upon the eye affected which was\\nso slight as not to cause the least ophthalmoscopic change;\\nagain, when one eye has been suddenly lost by wound or\\nembolism a condition indistinguishable from hysterical\\nblindness may rapidly come on in the other (compare sym\u00c2\u00ac\\npathetic irritation). It is important to note that in hyster\u00c2\u00ac\\nical amblyopia, even of high degree and long standing, the\\nreflex action of the pupil, direct as well as indirect, is fully\\npreserved, and the ophthalmoscopic appearances are quite\\nnormal. The prognosis is nearly always good, though\\nrecovery is sometimes slow, and relapses may occur. In\\nsome of the worst cases I have seen there has been consid\u00c2\u00ac\\nerable ametropia.\\nTrue hysterical amblyopia seems allied, from the ophthal\u00c2\u00ac\\nmic standpoint, with a much larger and more important\\nclass, best epitomized by the term asthenopia in which\\nphotophobia, irritability, and want of endurance of the\\nciliary muscle, accommodative asthenopia or sometimes of\\nthe internal recti, muscular asthenopia, with some conjunc\u00c2\u00ac\\ntival irritability, are the main symptoms, acuteness of sight\\nbeing usually perfect, and the refraction nearly or quite\\nnormal. Of the retinal, conjunctival, and muscular fac\u00c2\u00ac\\ntors, any one may be more marked than the others, and it\\nwould seem that, given a certain state of the nervous sys\u00c2\u00ac\\ntem, which may be described as impressionable, or hyper-\\naesthetic, over-stimulation of any one is liable to set up\\nan over-sensitive state of the other two. These patients\\noften complain also of dazzling pain at the back of the\\neyes, and headache or neuralgia in the head. All the\\nsymptoms are worse after the day\u00e2\u0080\u0099s work, and sometimes\\non first waking in the morning, and they are liable to\\nvary much with the health. Artificial light always aggra\u00c2\u00ac\\nvates them, because it is often flickering and insufficient,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0290.jp2"}, "291": {"fulltext": "AMBLYOPIA.\\n279\\nbut especially because it is hot. The symptoms often lasts\\nfor months or years, causing great discomfort and serious\\nloss of time.\\nCausation. The patients are seldom children or old\\npeople. Most are women, either young or not much past\\nmiddle life, often very excitable, and often with feeble\\ncirculation. If men, they are emotional, fussy, and often\\nhypochondriacal. Some cause, such as prolonged and in\u00c2\u00ac\\ntense application at needlework or reading, can often be\\ntraced, and in such cases the symptoms may come on so\\nsuddenly that the patient becomes within a few hours, or\\na day or two, quite incapacitated for reading. Sometimes\\nbright colors, glittering things, or exposure to kitchen fire\\nseems specially injurious. Or, again, there is a history of\\nphlyctenular ophthalmia or superficial ulcers, which have\\nleft the fifth nerve permanently unstable. Accommoda\u00c2\u00ac\\ntive asthenopia with hypermetropia or astigmatism is at\\nthe bottom of nearly all the cases in which vision is sup\u00c2\u00ac\\nposed to have been injured by railway and other accidents\\nthe lowered tone caused by the shock is often more appa\u00c2\u00ac\\nrent in the ciliary muscle, because this muscle is in almost\\nconstant action and has no substitute.\\nTreatment. The refraction and the state of the inter\u00c2\u00ac\\nnal recti should always be carefully tested, and any error\\ncorrected by lenses, which may often be combined with\\nprisms, with their bases toward the nose. Plain colored\\nglasses are sometimes useful. But glasses will not cure the\\ndisease, and we must not promise too much from their use.\\nThe patient may be assured that there is no ground for\\nalarm, and that the symptoms will probably pass off sooner\\nor later. He should be discouraged from thinking about\\nhis eyes, and he need seldom be quite idle. The artificial\\nlight used should be sufficient and steady (not flickering),\\nand should be shaded to prevent the heat and light from\\nstriking directly on the eyes. Bathing the eyes freely", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0291.jp2"}, "292": {"fulltext": "280\\nCLINICAL DIVISION.\\nwith cold water, and the occasional employment of weak\\nastringent lotions, are useful, and cold air often acts bene\u00c2\u00ac\\nficially. The eyes are often much better after a rest of a\\nday or two. Outdoor exercise, and only moderate use of\\nthe eyes, therefore, should be enjoined. General measures\\nmust be taken according to the indications, especially in\\nreference to any ovarian, uterine, or digestive troubles, or\\nto sexual exhaustion in men.\\nFunctional Diseases of the Retina.\\nFunctional night-blindness (endemic nyctalopia 1 is caused\\nby temporary exhaustion of the retinal sensibility from pro\u00c2\u00ac\\nlonged exposure to diffused bright light. The circumstances\\nunder which it occurs usually imply not only great expo\u00c2\u00ac\\nsure to bright light, but lowered general nutrition, and\\nprobably some particular defect in diet. It often co-exists\\nwith scurvy. Sleeping with the face exposed to bright\\nmoonlight is believed to bring it on. It is most common in\\nsailors after long tropical voyages under bad conditions,\\nand in soldiers after long marching in bright sun. In\\nsome countries it prevails every year in Lent when no\\nmeat is eaten, and again in harvest-time. It is now but\\nrarely endemic in our country, but scattered cases occur\\nin springtime, especially in children, and it still occasion\u00c2\u00ac\\nally prevails in large schools.\\nIn this malady two little dry films, consisting of fatty or\\nsebaceous matter and epithelial scales, often form on the\\nconjunctiva at the inner and outer border of the cornea.\\nTheir meaning is obscure. A micro-organism, the bacillus\\nxerosis has been described as peculiar to this affection,\\n1 Some confusion has arisen as to the use of the words nyctalopia and hemer\u00c2\u00ac\\nalopia; they are used by Continental writers and those who follow them in a\\nsense directly opposed to the common English use of them. It is better,\\ntherefore, to discard them for their English equivalents, night-blindness and\\nday-blindness.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0292.jp2"}, "293": {"fulltext": "FUNCTIONAL DISEASES OF THE RETINA. 281\\ngrowing in the conjunctival film; its presence seems to be\\naccidental. There are no ophthalmoscopic changes. This\\nnight-blindness is soon cured by protection from bright\\nlight and improvement of nutrition, and especially by\\ncod-liver oil. That the affection is local in the eye is\\nshown by the fact that darkening one eye with a ban\u00c2\u00ac\\ndage during the day has been found to restore its sight\\nenough for the ensuing night\u00e2\u0080\u0099s watch on board ship, the\\nunprotected eye remaining as bad as ever.\\nDay-blindness (hemeralopia) occurs in certain cases of\\ncongenital amblyopia.\\nColored vision is sometimes complained of, and red is the\\ncolor usually noticed. Red vision (erythropsia.) is most\\ncommon some time after extraction of senile cataract, and\\nis associated with fatigue; everything looks rosy-red, as\\nif there was a most beautiful sunset,\u00e2\u0080\u009d as one patient said.\\nOverworked, anxious, neurotic children sometimes com\u00c2\u00ac\\nplain that after reading or sewing \u00e2\u0080\u009ceverything turns red,\u00e2\u0080\u009d\\nor red and blue.\u00e2\u0080\u009d I have not heard green or yellow men\u00c2\u00ac\\ntioned. It has also been seen in women much exhausted\\nby fasting.\\nMicropsia. Patients sometimes complain that objects\\nlook too small. When not due to insufficiency of accom\u00c2\u00ac\\nmodative power it is generally a symptom of disease of\\nthe outer layers of the retina, especially in the central\\nregion, and syphilitic retinitis is the most common cause.\\nBoth micropsia and its opposite, megalopsia, are sometimes\\nseen in hysterical amblyopia.\\nBy muscse volitantes are understood small dots, rings,\\nthreads, etc., which move about in the field of vision, but\\ndo not actually cross the fixation point, and never inter\u00c2\u00ac\\nfere with sight. They are most easily seen against the\\nsky, or a bright background, such as the microscope field.\\nThey depend upon minute changes in the vitreous, which\\nare present in nearly all eyes, though in much greater", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0293.jp2"}, "294": {"fulltext": "282\\nCLINICAL DIVISION.\\nquantity in some than others. They vary, or seem to\\nvary, greatly with the health and state of the circulation,\\nbut are of no real importance. They are most abundant\\nand troublesome in myopic eyes.\\nDiplopia. See Chapter XXI.; also pp. 379 and 198 for\\nUniocular Diplopia.\\nFor affections of sight in Megrim and Heart Disease,\\nsee Chapter XXII.\\nMalingering. Patients now and then pretend defect or\\nblindness of one or both eyes, or exaggerate an existing\\ndefect, or sometimes secretly use atropine in order to dim\\nthe sight. The imposture is generally evident enough\\nfrom other circumstances, but detection is occasionally\\nvery difficult. Malingering and intentional injuries of\\nthe eye are very rare here, but common in countries where\\nthe conscription is in force.\\nThe pretended defect of sight is usually confined to one\\neye. If the patient be in reality using both eyes, a prism\\nheld before one, by preference the blind\u00e2\u0080\u009d one, will\\nproduce double vision. The stereoscope, and also colored\\nglasses, may be made very useful in detecting imposture.\\nAnother test, when only moderate defect is asserted, is to\\ntry the eye with various weak glasses, and note whether\\nthe replies are consistent; very probably a flat glass or a\\nweak concave may be said to improve\u00e2\u0080\u009d or magnify\u00e2\u0080\u009d\\nvery much. Again, atropine may be put into the sound\\neye, and when it has fully acted the patient be asked to\\nread small print; if he reads easily with both eyes open,\\nthe imposture is clear, for he must be reading with the\\nso-called \u00e2\u0080\u009cblind\u00e2\u0080\u009d eye. If absolute blindness of one eye\\nbe asserted, the state of the pupil will be of much help,\\nunless the patient have used atropine; for if its direct\\nreflex action be good, the retina and nerve cannot be\\nmuch diseased, but as to this point compare Hysterical\\nAmblyopia, p. 277.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0294.jp2"}, "295": {"fulltext": "FUNCTIONAL DISEASES OF THE RETINA. 983\\nPretended defect of both eyes is more difficult to expose,\\nand, indeed, it may be impossible to absolutely convict the\\npatient if he be intelligent and instructed. The state of\\nthe pupils, of the visual fields, and of color perception are\\namong the best tests.\\nPriestley Smith has recently suggested the use of a prism\\nwhich the malingerer will involuntarily overcome by moving\\nthe eye before which it is placed, alternately holding the\\nprism before the eye, and removing it. If there is good\\nvision, the eye will be seen to move back and forth to avoid\\ndiplopia, which the prism would otherwise cause. If the\\neye be really blind, no such movement will occur.\\nColor-blindness may be congenital or acquired. When\\nacquired it is symptomatic of disease of the optic nerve, or,\\nas for example in hysterical amblyopia, of some affection\\nof the visual centre.\\nCongenital color-blindness is not often found unless\\nlooked for. According to recent and extended researches\\nin various countries, a proportion varying from about 3 to\\n5 per cent, of the males are color-blind in greater or less\\ndegree, and it appears to be more common in the lower\\nthan in the upper classes. These facts show the impor\u00c2\u00ac\\ntance of carefully testing all men whose employment ren\u00c2\u00ac\\nders good perception of color indispensable, such as railway\\nsignalmen and sailors. Color-blindness is usually partial\\ni. e., for only one color or one pair of complimentary\\ncolors, but is occasionally total. The most common form\\nis that in which pure green is confused with various shades\\nof gray and of red (red-green blindness); blindness for\\nblue and yellow is very rare. The blindness may be in\u00c2\u00ac\\ncomplete, perception of very pale or very dark red or green\\ne. g., being enfeebled, while bright red and green are\\nwell recognized or it may be complete for all shades and\\ntints of those colors. Congenital color-blindness is very\\noften hereditary, but nothing further is known of its cause.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0295.jp2"}, "296": {"fulltext": "284\\nCLINICAL DIVISION.\\nIt is very rare in women (0.2 per cent.). The acuteness of\\nvision\u00e2\u0080\u0094 i. e., perception of form\u00e2\u0080\u0094is normal. Both eyes\\nare affected. 1\\nThe detection of color-blindness, either congenital or\\nacquired, is easy if, in making the examination, we bear\\nin mind the two points already referred to at p. 57, viz.:\\n(1) Many persons with perfect color perception know very\\nlittle of the names of colors, and appear color-blind if asked\\nto name them; (2) the really color-blind often do not\\nknow of their defect, having learned to compensate for it\\nby attention to differences of shade and texture. Thus a\\nsignalman may be color-blind for red and green; yet he\\nmay, as a rule, correctly distinguish the green from the\\nred light, because one appears to him \u00e2\u0080\u009cbrighter\u00e2\u0080\u009d than\\nthe other. The quickest and best way of avoiding these\\nsources of error has been mentioned at p. 57. A certain\\nstandard color is given to the patient without being named,\\nand he is asked to choose from the whole mass of skeins of\\nwool all that appear to him of nearly the same color and\\nshade\u00e2\u0080\u0094no two being really quite alike. If, for example,\\nhe cannot distinguish green from red, he will place the\\ngreen test-skein side by side with various shades of gray\\nand red. Wilful concealment of color-blindness is im\u00c2\u00ac\\npossible under this test if a sufficient number of shades be\\nused.\\nAs it is necessary to detect slight as well as high degrees,\\nthe first or preliminary test should consist of very pale\\ncolors, and a pale pure green is to be taken as the test No.\\n1 (see plate in the Appendix); Nos. 1 to 5 are liable to\\nbe confused with this color. For ascertaining whether\\nthe defect be of high degree or not, stronger colors are\\nthen used; a bright rose color\u00e2\u0080\u0094 e. g., II. a, may be con\u00c2\u00ac\\nfused with blue, purple, green, or gray of corresponding\\n1 But on this point further research is needed.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0296.jp2"}, "297": {"fulltext": "FUNCTIONAL DISEASES OF THE RETINA 285\\ndepth (Nos. 6 to 9); and a scarlet, II. b, with various\\nshades and tints of brown and green (Nos. 10 to 13).\\nIt may here be noted that the visual field is not of the\\nsame size for all colors, Fig. 33, green and red having the\\nsmallest fields, and that the perception of all colors is, like\\nperception of form, sharpest at the centre of the field.\\nWith diminished illumination some colors are less easily\\nperceived than others, red being the first to disappear, and\\nthe blue persisting longest\u00e2\u0080\u0094 i. e.., being perceived under\\nthe lowest illumination; but in dull light the colors are\\nnot confused, as in true color-blindness. In congenital\\ncolor-blindness, as we have seen, red-green blindness is the\\nmost common form; and in cases of amblyopia from com\u00c2\u00ac\\nmencing atrophy of the optic nerve, green and red are\\nalmost always the first colors to fail, blue remaining last.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0297.jp2"}, "298": {"fulltext": "1\\nCHAPTER XVI.\\nDISEASES OF THE VITREOUS.\\nThe vitreous humor is nourished by the vessels of the\\nciliary body, retina, and optic disk, and is probably influ\u00c2\u00ac\\nenced by the state of the choroid also; and in most cases\\ndisease of the vitreous is associated with, and dependent\\non, disease of one or other of the structures named.\\nThus, in connection with the various surrounding mor\u00c2\u00ac\\nbid processes, the vitreous maybe the seat of inflammation,\\nacute or chronic, general or local., and of hemorrhage. It\\nmay also degenerate, especially in old age; its cells and\\nsolid parts, undergoing fatty change, become visible as\\nopacities, while its general bulk becomes too fluid. The\\nonly alteration that we can directly prove in the vitreous\\nduring life is loss of transparency from the presence of\\nopacities moving or more rarely fixed in it, but accord\u00c2\u00ac\\ning as such opacities move quickly or slowly we infer that\\nthe humor itself is, or is not, more fluid than in health.\\nOpacities in the vitreous may take the form of large,\\ndense masses, or of membranes like muslin, crape, bees\u00e2\u0080\u0099\\nwings of wine, bands, knotted strings, or isolated dots;\\nand they may be either recent, or the remains of long ante\u00c2\u00ac\\ncedent exudation, hemorrhage, or degeneration, or newly-\\nformed bloodvessels. Again, the vitreous may become\\nuniformly misty, owing to the diffusion of numberless\\ndots, \u00e2\u0080\u009cdust-like\u00e2\u0080\u009d opacities, which need careful focussing\\nby direct examination with a convex lens (about -J- 12 D.)\\nbehind the mirror, to be separately seen.\\nOpacities in the vitreous are usually detected, with great\\n286", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0298.jp2"}, "299": {"fulltext": "DISEASES OF THE VITREOUS.\\nease, by direct ophthalmoscopic examination at about 12\\nfrom the patient, but are generally situated too far forward\\ni. e., too far within the focus of the lens system\u00e2\u0080\u0094to be\\nseen clearly at a very short distance without a lens be\u00c2\u00ac\\nhind the mirror. If the patient move his eye sharply and\\nfreely from side to side and from above downward, the\\nopacities will be seen against the red ground, as dark fig\u00c2\u00ac\\nures which continue to move after the eye has come to rest;\\nthey are thus at once distinguished from opacities in the\\ncornea or lens, or from dimly seen spots of pigment at the\\nfundus, which stop when the eye stops. The opacities in\\nthe vitreous move, just as solid particles and film move in\\na bottle after the bottle has been shaken; the quickness\\nand freedom of their movement in the one case as in the\\nother depending very much on the consistence of the fluid.\\nWhen the opacities pass across the field quickly and make\\nwide movements, we may be sure that there is synchysis or\\nfluidity of the vitreous humor; if they move very lazily,\\nits consistence is probably normal; if only one or two\\nopacities be present they may only come into view now\\nand then. Moving opacities in the vitreous obscure the\\nfundus both to the direct and indirect ophthalmoscopic\\nexamination, in proportion to their size, density, and posi\u00c2\u00ac\\ntion a few isolated dots scarcely affect the brightness of\\nthe ophthalmoscopic image.\\nThe opacities may lie quite in the cortex of the vitreous\\nand be anchored at the fundus, so as to have but little\\nmovement. Such opacities, generally single, are found\\nlying over or near to the disk, and may be the result either\\nof inflammation or of hemorrhage; they are often mem\u00c2\u00ac\\nbranous, more rarely globular, and not perfectly opaque.\\nSuch an opacity should be suspected when, by indirect\\nophthalmoscopic examination, a localized haze or blurring\\nof some part of the disk or its neighborhood is noticed.\\nThe opacity must then be searched for by the direct", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0299.jp2"}, "300": {"fulltext": "288\\nCLINICAL DIVISION.\\nmethod, the patient\u00e2\u0080\u0099s eye being at rest; by altering the\\ndistance from the patient, or by turning on various con\u00c2\u00ac\\nvex lenses (or concave, if the eye be very highly myopic)\\nthe opacity will come sharply into view. The patient\u00e2\u0080\u0099s\\nrefraction must be approximately known in order to make\\nthis examination properly. Densely opaque white mem\u00c2\u00ac\\nbranes may also form over the disk or upon the retina, the\\nnature and situation of which are diagnosed in the same\\nway.\\nDiffused haziness of the vitreous causes a corresponding\\ndegree of dimness of outline and darkening of the details\\nof the fundus, as if these were seen through a thin smoke.\\nThe disk, in particular, appears red, without really being\\nso. Much the same appearances are caused by diffused\\nhaze of the cornea or lens, but the presence of these changes\\nwill, of course, have been excluded by focal illumination.\\nThere are even cases of vitreous disease where no details\\ncan be seen, even by careful examination, though plenty\\nof light reaches and returns from the fundus. In these\\nthe light is scattered by innumerable little particles, each\\nof which is transparent, so that the light, without being\\nabsorbed, is distorted and broken up, as in passing through\\nground-glass or white fog, or a partial mixture of fluids of\\ndifferent densities, such as glycerin and water. This fine\\ngeneral haze is found chiefly in syphilitic choroido-retinitis,\\nin which infiltration of the vitreous with cells is known to\\noccur. It is not always easy, nor indeed possible, to distin\u00c2\u00ac\\nguish with certainty between diffuse haze of the vitreous\\nand diffuse haze of the retina.\\nCrystals of cholesterin sometimes form in a fluid vitreous,\\nand are seen with bright illumination as minute, dancing,\\ngolden spangles, when the eye moves about, sparkling syn-\\nchysis. They proportionately obscure the fundus. Large\\nopacities just behind the lens may be seen by focal light in\\ntheir natural colors. In rare cases of choroido-retinitis,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0300.jp2"}, "301": {"fulltext": "DISEASES OF T1IE VITREOUS.\\n289\\nminute growths, consisting chiefly of bloodvessels, form\\non the retina, and project into the vitreous; they are\\nrather curiosities than of practical importance.\\nParasites (cysticercus cellulosae) occasionally come to\\nrest in the eye, and in development penetrate into the\\nvitreous; they are rarely seen in England, but are com\u00c2\u00ac\\nparatively common in some parts of Germany. Very\\nrarely a foreign body may be visible in the vitreous.\\nThe following are the conditions in which disease of the\\nvitreous is most commonly found\\n1. Myopia of high degree and old standing; the opaci\u00c2\u00ac\\nties move very freely, showing fluidity of the humor, and\\nare sharply defined. They are often the result of former\\nhemorrhage.\\n2. After severe blows, causing hemorrhage from the ves\u00c2\u00ac\\nsels of the choroid or ciliary body. When recent and\\nsituated near the back of the lens the blood can often be\\nseen by focal light; if very abundant it so darkens the\\ninterior of the eye that nothing whatever can be seen with\\nthe mirror.\\n3. After perforating wounds. The opacity will be blood\\nif the case be quite recent. Lymph or pus in the vitreous\\ngives a yellow or greenish-yellow color, easily seen by focal\\nlight, or even by daylight, and usually most dense toward\\nthe position of the wound.\\n4. In rare cases large hemorrhages into the vitreous\\noccur spontaneously in healthy eyes, with hemorrhages\\ninto the retina (not to be confused with retinitis lnemor-\\nrhagica, p. 244). Relapses often occur, and detachment\\nof retina may ensue. The subjects are generally young\\nadult males liable to epistaxis, constipation, and irregu\u00c2\u00ac\\nlarity of circulation (Eales); gout may have some influ\u00c2\u00ac\\nence (Hutchinson). This affection seems sometimes to be\\nrelated to the form of choroiditis referred to at p. 227.\\nIn all of the above cases detachment of the retina is\\n19", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0301.jp2"}, "302": {"fulltext": "290\\nCLTNICAL DIVISION.\\nlikely to occur sooner or later, and if both be present, the\\ndifferential diagnosis may be difficult.\\n5. Syphilitic choroiditis and retinitis. There is often\\ndiffuse haze, in addition to large, slowly floating opacities.\\nThe change here is due to inflammation, and the opacities\\nmay entirely disappear under treatment. These are the\\ncases in which new vessels in the vitreous are most common.\\n6. Some cases of cyclitis and cyclo-iritis. The opacities\\nare inflammatory.\\n7. In the early stage of sympathetic ophthalmitis. The\\nopacities are inflammatory.\\n8. In various cases of old disease of choroid, usually in\\nold persons, and without proof of syphilis. No doubt many\\nof these indicate former choroidal hemorrhages.\\n9. Cases occur in which no cause, either local or general,\\ncan be assigned for the presence of opacities in the vitreous.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0302.jp2"}, "303": {"fulltext": "CHAPTER XVII.\\nGLAUCOMA.\\nIn this peculiar and very serious disease the character\u00c2\u00ac\\nistic objective symptom is increased tightness of the eye-\\ncapsule, sclerotic and cornea, \u00e2\u0080\u009cincreased tension;\u00e2\u0080\u009d all\\nthe characteristic features of the disease depend upon this.\\nThe disease is much more common after middle life, when\\nthe sclerotic becomes less distensible than before; and it\\nis more common in hypermetropic eyes, where the sclerotic\\nis thick, than in myopic eyes, where it is thinned by elon\u00c2\u00ac\\ngation of the globe.\\nGlaucoma may be primary, coming on in an eye appar\u00c2\u00ac\\nently healthy, or the subject of some disease, such as senile\\ncataract, which has no influence on the glaucoma; or it\\nmay be secondary, caused by some still active disease of\\nthe eye, or by conditions left after some previous disease,\\nsuch as iritis. It is always important and seldom difficult\\nto distinguish between primary and secondary glaucoma.\\nGlaucoma differs in severity and rate of progress from\\nthe most acute to the most chronic and insidious form but\\nin every form it is a progressive disease, and unless checked\\nby treatment goes on to permanent blindness. The disease\\nis very often symmetrical, attacking the second eye after a\\nvarying interval.\\nIt is customary and useful to speak of glaucoma as either\\nacute, subacute, or chronic. But many intermediate forms\\nare found, and the same eye may, at different stages in its\\nhistory, pass through each of the three conditions. We\\nmay, indeed, here observe that acute and subacute out-\\n291", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0303.jp2"}, "304": {"fulltext": "292\\nCLINICAL DIVISION.\\nbursts are generally preceded by a so-called premonitory\\nstage, in which, the symptoms are not only chronic and\\nmild, but remittent; the intervals of remission becoming\\nshorter and shorter, till at length the attacks become con\u00c2\u00ac\\ntinuous, and the glaucomatous state is fully established.\\nRapid increase of presbyopia (Chapter XX.), shown by the\\nneed for a frequent change of spectacles, is a common pre\u00c2\u00ac\\nmonitory sign, though it is often overlooked.\\nChronic glaucoma sets in with a cloudiness of sight, or\\nfog,\u00e2\u0080\u009d varying in density and often clearing off entirely\\nfor days or even weeks, premonitory stage.\u00e2\u0080\u009d But in\\nsome cases the failure progresses without remissions from\\nfirst to last. During the attacks of fog,\u00e2\u0080\u009d artificial lights\\nare seen surrounded by colored rings, \u00e2\u0080\u009crainbows\u00e2\u0080\u009d or\\nhalos,\u00e2\u0080\u009d due to haze of the cornea, which are to be dis\u00c2\u00ac\\ntinguished from those due to mucus on the cornea. The\\nattacks of fog are often noticed only after long use of the\\neyes, as in the evening or when exhausted, the sight being\\nbetter in the early part of the day and after food. Even\\nwhen the sight has become permanently cloudy, complete\\nrecovery no longer occurring between the attacks, varia\u00c2\u00ac\\ntions of sight still form a marked feature. There is no\\ncongestion, and neuralgic pain, though not uncommon, is\\noften entirely wanting. The disease has to be distin\u00c2\u00ac\\nguished from incipient nuclear cataract, disease of the\\noptic nerve, syphilitic retinitis, and attacks of megrim.\\nIf we see the patient during one of the brief early fits of\\ncloudy sight, or after the fog has settled down permanently,\\nthe following changes will be found: a greater or less de\u00c2\u00ac\\nfect of sight, not remedied by glasses, is present in one eye,\\nor if in both, more in one than the other; the pupil is a\\nlittle larger and less active than normal; the anterior\\nchamber may be shallow, and there is usually slight dul-\\nness of the eve from steaminess of cornea, or haze of the\\naqueous humor, and some engorgement of the large per-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0304.jp2"}, "305": {"fulltext": "GLA UCOMA.\\n293\\nforating vessels situated at a little distance from the cornea,\\nFigs. 23 and 25 the tension is somewhat increased, usu\u00c2\u00ac\\nally about 1, p. 46 and the field of vision may be con\u00c2\u00ac\\ntracted, especially on the nasal side. The optic disk will\\nbe found normal, pale, or sometimes congested in early\\ncases; pale and cupped all over at a later stage. There\\nmay be spontaneous pulsation of all the vessels on the\\ndisk; or the arteries, if not pulsating spontaneously, will\\ndo so on very slight pressure on the eyeball. If the case\\nbe of old standing, the tension will often be much increased,\\nthe pupil dilated and sluggish, though not motionless, the\\nlens hazy, the field of vision much contracted, Fig. 106,\\nacuteness of vision extremely defective, the cornea in some\\ncases clear, in others dull. In nearly all cases of glaucoma\\nthe temporal part of the field, nasal part of the retina, re\u00c2\u00ac\\ntains its function longest; and in advanced cases the patient\\nwill often show this by his manner or statements occasion\u00c2\u00ac\\nally the field becomes extremely contracted before central\\nvision fails. In some few cases of simple glaucoma scoto\u00c2\u00ac\\nmata appear at the central parts of the field without con\u00c2\u00ac\\ntraction.\\nAn eye in which the above symptoms have set in may\\nprogress to total blindness in the course of months or\\nseveral years without a single \u00e2\u0080\u0098\u00e2\u0080\u0098inflammatory\u00e2\u0080\u009d symptom,\\nwithout either pain or redness \u00e2\u0080\u0094chronic painless glaucoma\\n(simple glaucoma and since the lens often becomes par\u00c2\u00ac\\ntially opaque and of a grayish or greenish hue, cases of\\nchronic glaucoma are sometimes mistaken for senile cata\u00c2\u00ac\\nract.\\nBut more commonly, in the course of a chronic case,\\nperiods of pain and congestion occur, with more rapid\\nfailure of sight; or the disease sets in with \u00e2\u0080\u009cinflamma\u00c2\u00ac\\ntory symptoms at once. In these cases of subacute glau\u00c2\u00ac\\ncoma, besides the symptoms named above, we find dusky,\\nreticulated congestion of the small and large episcleral", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0305.jp2"}, "306": {"fulltext": "2 L J4\\nCLINICAL DIVISION.\\nvessels in the ciliary region, Fig. 25, with pain referred\\nto the eye, the side of the head, or of the nose, and rapid\\nfailure of sight. The increase of tension, steaminess, and\\npartial anaesthesia of the cornea, the enlarged and sluggish\\npupil, and the shallowness of the anterior chamber, are all\\nmore marked than is usual in chronic cases, and the media\\nare too hazy to allow a good ophthalmoscopic examination.\\nFig. 106.\\nIrregular contraction of R. and L. fields of vision in chronic glaucoma;\\nfrom two different cases. The black parts show complete loss the shaded\\narea shows partial loss. Each field remains best in the outer part. Compare\\nwith Figs. 102 and 103.\\nThese symptoms, ending after a few weeks or months in\\ncomplete blindness, may remain at about the same height\\nfor months after that event, with slight variations, the eye\\ngradually settling down into a permanent state of severe,\\nbut chronic, non-inflammatory glaucomatous tension. Short\\nattacks of subacute glaucoma, with intervals of perfect\\nrecovery, sometimes occur, remittent glaucoma; permanent\\nglaucoma usually supervenes.\\nAcute glaucoma (inflammatory or congestive glaucoma)\\ndiffers from the other forms only in suddenness of onset,\\nrapidity of loss of sight, and severity of congestion and\\npain. The congestion, both arterial and venous, is in\u00c2\u00ac\\ntense; in extreme cases the lids and conjunctiva are\\nswollen, and there is photophobia, so that the case may", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0306.jp2"}, "307": {"fulltext": "GLA UCOMA.\\n295\\nbe mistaken for an acute ophthalmia. All the specific\\nsigns of glaucoma are intensified the pupil considerably\\ndilated and motionless to light, the cornea very steamy,\\nthe anterior chamber very shallow, and tension -f- 2 or 3.\\nSight will fall in a day or two down to the power of only\\ncounting fingers, or to mere perception of light, and if the\\ncase have lasted a week or two, even p. 1. is usually abol\u00c2\u00ac\\nished. The pain is very severe in the eye, temple, back\\nof the head, and down the nose; not infrequently it is so\\nbad as to cause vomiting, and many a case has been mis\u00c2\u00ac\\ntaken for a bilious attack with a cold in the eye,\u00e2\u0080\u009d for\\nneuralgia in the head,\u00e2\u0080\u009d or rheumatic ophthalmia.\u00e2\u0080\u009d\\nSome cases, however, though very acute, are mild and re\u00c2\u00ac\\nmit spontaneously; but these, like the ones mentioned in\\nthe preceding paragraph, often pass on into the severe type\\nnow described.\\nAbsolute glaucoma is glaucoma that has gone on to per\u00c2\u00ac\\nmanent blindness. Such an eye continues to display the\\ntension and other signs of the disease, and remains liable\\nto attacks of pain and congestion for varying periods, but\\nin many \u00e2\u0080\u009cabsolute\u00e2\u0080\u009d cases, especially when the original\\nattack has been acute, changes occur sooner or later, lead\u00c2\u00ac\\ning to staphylomata, cataract, atrophy of iris, and finally\\nto softening and shrinking of the globe.\\nAs a rule glaucoma runs the same course in the second\\neye as in the first, but sometimes it will be chronic in one\\nand acute or subacute in the other.\\nExplanation of the symptoms. The causes which\\nproduce the temporary attacks or premonitory symp\u00c2\u00ac\\ntoms lead, if continued, to atrophy of the inner layers\\nof the retina and of the disk, and to consequent blindness.\\nThe increase of tension damages the retina both by direct\\ncompression and by impeding its circulation, the latter\\nbeing probably the more important factor in the early\\nstages. If the media be clear enough to allow a good", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0307.jp2"}, "308": {"fulltext": "296\\nCLINICAL DIVISION.\\nview, the retinal arteries are seen to be narrow, and often\\npulsating spontaneously, and the veins engorged. The\\nperiphery of the retina suffers first and most often\\nfrom this lowering of arterial blood-supply, and hence\\nprobably the contraction of the visual field; but the inner\\nlayers of the retina, over its whole extent, suffer if the\\npressure be kept up (1) from this same insufficiency of\\narterial blood, and the changes, including hemorrhage,\\nwhich follow impeded venous outflow; (2) from direct\\ncompression of the retina; (3) from stretching and atrophy\\nFjg. 107.\\nSection of very deep glaucoma cup. Compare Fig. 40.\\nof the nerve-fibres on the disk. The floor of the disk,\\nlamina cribrosa, being the weakest part of the eye-capsule,\\nis slowly pressed backward, the nerve-fibres being dragged\\ndown, displaced, and finally atrophied the direct pressure\\non the nerve-fibres, as they bend over the edge of the disk,\\nhelps in the same process. Hence finally the disk becomes\\nnot only atrophied, but hollowed out, Fig. 107, into the well-\\nknown glaucomatous cup.\u00e2\u0080\u009d This cup, when deep, has an\\noverhanging edge, because the border of the disk is smaller\\nat the level of the choroid than at the level of the lamina\\ncribrosa; its sides are quite steep even when the cup is\\nshallow, Fig. 108.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0308.jp2"}, "309": {"fulltext": "GLA UCOMA.\\n297\\nWith the ophthalmoscope this cupping is shown by a\\nsudden bending of the vessels just within the border of the\\nFig. 10S.\\nSection of less advanced glaucoma cup.\\ndisk, where they look darker because foreshortened if the\\ncup be deep, they may disappear beneath its edge, to reap\u00c2\u00ac\\npear on its floor, where they have a lighter shade, Fig. 109.\\nOphthalmoscopic appearance of deep cupping of the disk in glaucoma.\\nX about 15. (Altered from Liep.reich.)\\nThe vessels seldom all bend with equal abruptness, some\\nparts of the disk being more deeply hollowed than others,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0309.jp2"}, "310": {"fulltext": "298\\nCLINICAL DIVISION.\\nor some of the vessels spanning over the interval instead\\nof hugging the wall of the cup. Increase of tension must\\nbe maintained for several months to produce cupping recog\u00c2\u00ac\\nnizable by the ophthalmoscope. When recent acute glau\u00c2\u00ac\\ncoma has been cured by operation, the disk, though not\\ncupped, often becomes rather hazy and very pale. Although\\nusually the excavation extends from the first over the whole\\nsurface of the disk, it appears sometimes to begin at the\\nthinnest part, the physiological pit, and spread centrifu-\\ngally toward the border. A deep cup is sometimes partly\\nfilled up by fibrous tissue, the result of chronic inflamma\u00c2\u00ac\\ntion, and its true dimensions are not then appreciable by\\nthe ophthalmoscope.\\nThe shallowness of the anterior chamber is probably due\\nto advance of the lens; it is by no means a constant symp\u00c2\u00ac\\ntom. Compression of the ciliary nerves accounts, in early\\ncases, for the sluggish and usually dilated pupil, and for\\nthe corneal anaesthesia. In old-standing cases the iris is\\noften atrophied and shrunken to a narrow rim; in uncom\u00c2\u00ac\\nplicated glaucoma iritic adhesions are never seen. The\\ncorneal changes depend partly on \u00e2\u0080\u009csteaminess\u00e2\u0080\u009d of the\\nepithelium, partly upon haze of the corneal tissue from\\noedema (Fuchs). In recent cases, especially if acute, the\\naqueous humor and the lens appear to become somewhat\\nturbid. In old cases, as already stated, the lens often be\u00c2\u00ac\\ncomes slowly cataractous. There is some doubt whether\\nthe vitreous becomes hazy in glaucoma; it is certainly\\nvery seldom so when the cornea and lens are clear, and\\nthe point cannot be settled when these media are hazy.\\nThe internal pressure tends, in acute cases, to make the\\nglobe spherical, by reducing the curvature of the cornea\\nto that of the sclerotic; it also in all cases weakens the\\naccommodation, at first by pressing on the ciliary nerves,\\nlater by causing atrophy of the ciliary muscle these facts\\ntogether explain the rapid decrease of refractive power", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0310.jp2"}, "311": {"fulltext": "GLA UCOMA.\\n299\\nO\u00e2\u0080\u0099. c., rapid onset or increase of presbyopia) which is some\u00c2\u00ac\\ntimes noticed by the patient. The choroidal circulation is\\nobstructed by the increase of pressure, and in severe glau\u00c2\u00ac\\ncoma, especially of old standing, the anterior ciliary veins,\\nforming the episcleral plexus, Figs. 23 and 27, as well as\\nthe arteries, Fig. 26, become very much enlarged.\\nMechanism of Glaucoma. The increased tension is\\ndue to excess of fluid in the eyeball. Impeded escape is\\nprobably the chief cause of this excess, and recent research\\nFig. 110.\\nSection through the ciliary region in a healthy human eye. Co., cornea;\\nScl., sclerotic; C. M., ciliary muscle; C.P., two ciliary processes, one larger\\nthan the other Ir., iris; L., the marginal part of the crystalline lens a, angle\\nof anterior chamber d, membrane of Descemet, which ceases (as such) before\\nreaching the angle, a. The dotted line shows the course probably taken by\\nfluid from the anterior part of the vitreous into the posterior aqueous cham\u00c2\u00ac\\nber, where it is augmented by aqueous humor secreted by the anterior part\\nof the ciliary process, thence through the pupil (not shown) into the anterior\\naqueous chamber, to an angle, a. Suspensory ligament of lens not shown.\\nX 10.\\nlias proved that changes are present in nearly all glaucoma\u00c2\u00ac\\ntous eyes, which must lessen or prevent the normal out\u00c2\u00ac\\nflow. But increased secretion and internal vascular con\u00c2\u00ac\\ngestion undoubtedly play an important part in certain\\ncases. Some authorities have attributed the phenomena\\nof glaucoma to vasomotor changes in the size of the blood\u00c2\u00ac\\nvessels, but such hypotheses are wanting in proof. Both", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0311.jp2"}, "312": {"fulltext": "300\\nCLINICAL DIVISION.\\nconditions would have most effect when the sclerotic was\\nmost unyielding\u00e2\u0080\u0094 i. e., in old age and in hypermetropic\\neyes. It is probable that there is a constant movement\\nof fluid from the vitreous humor through the suspensory\\nligament of the lens, and also from the anterior part of\\nthe ciliary processes, into the anterior chamber, as shown\\nby the dotted line in Fig. 110. The fluid escapes from the\\nanterior chamber into the lymphatics and perhaps into the\\nFig. 111.\\nO\\nCiliary region from a case of acute glaucoma of one month\u00e2\u0080\u0099s duration. 1 and\\n2, situations of iridectomy wounds in two cases. X 10.\\nFig. 112.\\nCiliary region in chronic glaucoma of three years\u00e2\u0080\u0099 standing. X 10.\\nveins of the sclerotic, through the meshes of the ligamentwn\\npectination Fontana\u00e2\u0080\u0099s spaces), which close the angle a fil\u00c2\u00ac\\ntration angle) and it has been proved that very little fluid\\ncan pass through any other part of the cornea. In glau\u00c2\u00ac\\ncoma the angle a is nearly always closed, in recent cases by\\ncontact, in old cases by permanent cohesion, between the\\nperiphery of the iris and the cornea, Figs. Ill and 112.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0312.jp2"}, "313": {"fulltext": "GLA TJCOMA.\\n301\\nNo complete explanation of this advance of the iris has\\nyet been given. Adolf Weber holds that the ciliary pro\u00c2\u00ac\\ncesses becoming swollen from various causes, push the iris\\nforward, and so start the glaucomatous state. Priestley\\nSmith 1 believes that the primary obstruction is at the\\nnarrow chink between the edge of the lens and the tips\\nof the ciliary processes, circumlental space,\u00e2\u0080\u009d and that\\nthe block may depend upon one or more of three factors\\n\u00e2\u0080\u0094increase in the size of the lens due to advancing years, 2\\nabnormal smallness of the ciliary area, as in hypermetropia,\\nand abnormal enlargement of the ciliary processes. Ob\u00c2\u00ac\\nstruction of this space leads to rise of pressure in the vit\u00c2\u00ac\\nreous, followed by advance of the lens and ciliary processes\\nagainst the base of the iris, and consequent closure of the\\nangle. Brailey holds that a chronic inflammation of the\\nciliary muscle and processes, and of the iris, quickly pass\u00c2\u00ac\\ning on to atrophic shrinking, leads to narrowing of the\\nangle and initial rise of tension 3 in a later paper, how\u00c2\u00ac\\never, he agrees to some extent with the view of Weber,\\nabove referred to. 4 Cases of chronic glaucoma have been\\nseen in which the iris was congenitally absent; in some of\\nthese cases the angle of the anterior chamber has been\\nfound blocked by the rudimentary iris.\\nBut there are cases which show that the matter is not\\nalways so simple. Stilling, of Strasburg, contended that\\nthe waste fluids escape by the central canal of the vitreous\\ninto the optic nerve, and partly also by filtration through\\nthe circumpapillary portion of the sclerotic, and that a\\nsclerosis of these parts, by diminishing their permeability,\\nleads to glaucoma; Brailey 5 states from pathological re-\\n1 Priestley Smith Transactions Ophthalmic Society, vol. vi. 1886.\\n2 The increase in the size of the lens as age advances has been proved\\nbeyond doubt by Priestley Smith\u00e2\u0080\u0099s researches. Ibid., vol. iii. 1883.\\n3 Brailey: Ophthalmic Hospital Reports, 1880, vol. x., pp. 14, 89. 93.\\n4 Ibid., 1881, p. 282. 6 Ibid., pp. 86, 277, 282.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0313.jp2"}, "314": {"fulltext": "302\\nCLINICAL DIVISION.\\nsearch that inflammation of the optic nerve is always\\npresent quite early in glaucoma, and that it precedes the\\nincreased tension; ophthalmoscopic examination in cer\u00c2\u00ac\\ntain cases lends support to this statement. 1 It may be\\nadded, in support of these views, that in some cases of\\nglaucoma the angle of the anterior chamber remains freely\\nopen, and that the ophthalmoscopical appearances of glau\u00c2\u00ac\\ncoma are occasionally seen without increase of T. For\\nother causes, see Secondary Glaucoma, p. 308.\\nAn over-supply of fluid affects the tension differently in\\ndifferent cases. Congestion and ordinary inflammations\\nof the retina and uveal tract do not cause glaucoma, and\\ndilatation of the arteries by vasomotor paralysis is said to\\nbe accompanied by diminished tension. But tumors in,\\nand even upon, the eye often give rise to secondary glau\u00c2\u00ac\\ncoma, and probably the active congestion and transuda\u00c2\u00ac\\ntion of fluid and small cells, which occur near to a quickly\\ngrowing tumor, are the chief factors; certainly the glau\u00c2\u00ac\\ncoma stands in no constant relation either to the size or\\nposition of the tumor. A relation is observed in some\\ncases between glaucoma and neuralgia of the fifth nerve,\\nand T. is said to be lowered in paralysis of this nerve.\\nProbably the pain acts by causing associated congestion,\\nand thus setting up glaucoma in a predisposed eye.\\nGeneral and Diathetic Causes. In an eye predis\u00c2\u00ac\\nposed, by the changes above mentioned in the ciliary re\u00c2\u00ac\\ngion, any cause of congestion may precipitate an acute\\nattack. Congestion of the eyes in connection with disturb\u00c2\u00ac\\nances of the general circulation from heart disease, bron\u00c2\u00ac\\nchitis, or portal engorgement, or due to loss of sleep from\\ngout, neuralgia, worry, etc., or caused by the over-use of\\npresbyopic eyes without suitable glasses, or by a blow, or\\nprolonged ophthalmoscopic examination, or exposure to\\n1 Nettleship: St. Thomas\u00e2\u0080\u0099s Hospital Reports, vol. xiv.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0314.jp2"}, "315": {"fulltext": "GLA UCOMA.\\n303\\ncold wind, may all bring it about. Atropine has sometimes\\ncaused an attack, because, by lessening the width, it in\u00c2\u00ac\\ncreases the thickness of the iris, and so crowds it into the\\nangle of the anterior chamber. Iridectomy on one eye\\noccasionally sets up acute glaucoma in the other, probably\\nby causing general excitement and disturbance, and it is\\nnow customary to use eserine as a preventive in the second\\neye after iridectomy in the first. Glaucoma is uncommon\\nbefore the age of forty, and is most frequent between fifty-\\nfive and sixty-five the rare cases seen in young adults\\nand children are generally chronic and often associated\\nwith other changes in the eyes, particularly myopia. Acute\\ncases are often dated from a period of overwork of the\\neyes, or want of sleep, as from sitting up, nursing, etc.\\nPatients who have had glaucoma in one eye should be\\nemphatically warned as to the danger of over-using the\\neyes, or of working without proper glasses, and against\\ndietetic errors. Primary glaucoma is, according to the\\nlatest statistics, 2 as a whole, rather more common in women\\nthan men; and while the acute (congestive) forms are\\nmuch more common in women, very chronic glaucoma are\\nrather more common in men.\\nTreatment. Iridectomy, or an equivalent operation,\\nis, with very few exceptions, the only curative treatment.\\nEserine or pilocarpine (gr. l-ij to 5 j) used locally, how\u00c2\u00ac\\never, diminishes the tension in acute glaucoma, and a few\\nattacks seem to have been permanently cured by it. But\\nalthough seldom really curative, eserine is of great tempo\u00c2\u00ac\\nrary value in cases where an operation has to be deferred.\\nIt has little or no effect on the tension unless it cause\\nmarked contraction of the pupil. Eserine acts (1) by\\nstretching the iris and drawing it away from the angle\\n1 Statistics of 1000 cases collected by Priestley Smith, loc. cit., 1886. Gallenga\\n(Turin), in 330 cases, finds the frequency greatest between sixty and seventy.\\n2 Priestley Smith loc. cit., 1886; in 1000 cases, 569 women and 431 men.\\n3 Zentmayer and Posey: Archives of Ophthalmology, vol. xxiv., No. 3,1895.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0315.jp2"}, "316": {"fulltext": "304\\nCLINICAL DIVISION\\nof the anterior chamber; (2) by the contraction of the\\nciliary muscle which it causes, the meshes of the tissue\\nbounding this angle are more widely opened. Eserine\\ncauses congestion of the ciliary processes, and probably\\nthis explains why, if it do not soon relieve, it sometimes\\naggravates the symptoms. It is of use chiefly in recent,\\nand especially in acute cases; a solution of half a grain\\nor a grain of the sulphate to the ounce is to be used about\\nevery two hours and continued if relief be obtained. If\\nin a few hours it increase the pain and do not lessen the\\nT. it should be abandoned. The pain in acute cases may\\nbe much relieved by leeching, warmth to the eye, deriva\u00c2\u00ac\\ntive treatment, such as purgation and hot foot-baths, and\\nsoporifics. Cocaine is used with eserine by some surgeons,\\nand seems to increase its efficacy.\\nIridectomy cures glaucoma by permanently reducing the\\ntension to the normal or nearlv normal decree. It is found\\no\\nthat the best results are obtained if\u00e2\u0080\u0094(1) the path of the\\nincision lie in the sclerotic from 1 to 2 mm. from the appa\u00c2\u00ac\\nrent corneal border, Fig. Ill; (2) the wound be large, allow\u00c2\u00ac\\ning removal of about a fifth of the iris; (3) the iris be re\u00c2\u00ac\\nmoved quite up to its ciliary attachment, which is best\\ndone by first cutting one end of the drawn-out loop of iris,\\nthen tearing it from its ciliary attachment along the whole\\nextent of the wound, and cutting through the other end\\nseparately. See Operation. Puncture of the sclerotic be\u00c2\u00ac\\nhind the ciliary region has been recommended by Priestley\\nSmith to relieve the tension in the vitreous chamber before\\nproceeding to the iridectomy, or in cases where after iridec\u00c2\u00ac\\ntomy the tension in the vitreous chamber still remains ab-\\nnormally high. Evacuation of the aqueous humor by para\u00c2\u00ac\\ncentesis of the anterior chamber gives only temporary relief.\\nA mere wound in the sclerotic, differing but little in\\nposition and extent from that made for iridectomy, is suffi\u00c2\u00ac\\ncient to relieve -f- T., and to cure some cases of glaucoma", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0316.jp2"}, "317": {"fulltext": "GLA ZJCOMA.\\n305\\npermanently, and this operation, subconjunctival sclerotomy,\\nwas largely adopted by some operators a few years ago.\\nIridectomy, however, has held its ground as the more\\neffectual operation. Sclerotomy is open to objection:\\n(1) because the position and length of the wound are not\\nperfectly under control; if too far forward and too short\\nit is ineffectual, if too far back and too long there is risk\\nof wounding the ciliary processes and getting hemorrhage\\ninto the vitreous; even shrinking of the operated eye and\\nsympathetic inflammation of the other have occurred; (2)\\nbecause the iris may prolapse into the wound and need\\nremoval, and the operation then becomes an iridectomy;\\n(3) when the anterior chamber is very shallow, sclerotomy\\ncannot be supposed to aid the exit of fluid so much as the\\nremoval of a piece of the iris.\\nSeveral other operations, the principle of which is to\\nmake a puncture at the sclero-corneal junction, have been\\ntried, but have not gained general confidence.\\nWhichever operation be employed in glaucoma, the for\u00c2\u00ac\\nmation of the operation scar in the sclerotic is certainly a\\nmost important factor.\\nIridectomy in acute glaucoma no doubt acts at first by\\nremoving a portion of the iris from the blocked angle, Fig.\\n99, and thus allowing the normal escape of fluid. Some\\nhigh authorities hold, however, that its permanent effect is\\ndue to the formation at the seat of the wound of a layer\\nof tissue more pervious to the eye-fluids than the sclerotic\\n\u00e2\u0080\u009cfiltration-scar an iridectomy for glaucoma which heals\\nslowly is at any rate believed to be more favorable than\\none which heals immediately\u00e2\u0080\u0094 i. e with no new tissue, and\\na slight bulging of the scar is held by some surgeons to be\\nrather desirable than otherwise. That a mere sclerotomy\\nmay be sufficient points in the same direction. Such a\\nporous scar never forms if the incision be in the cornea.\\nAn operation, usually iridectomy, is to be done in all\\n20", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0317.jp2"}, "318": {"fulltext": "306\\nCLINICAL DIVISION.\\ncases of acute and subacute glaucoma, whether there be\\ngreat pain or not, so long as some sight still remains, and\\neven if all p. 1. be lost, provided that the blindness be of\\nonly a few days\u00e2\u0080\u0099 duration. Even if the eye be permanently\\nquite blind, iridectomy or sclerotomy is sometimes prefer\u00c2\u00ac\\nable to excision of the globe for the relief of pain.\\nChronic \u00e2\u0080\u009csimple\u00e2\u0080\u009d glaucoma should, in my opinion,\\nalways, if possible, be operated upon early, as soon as the\\ndiagnosis is certain and before the field is much damaged;\\nthe prognosis is then fairly good. In advanced chronic\\nglaucoma, when the field has become much contracted,\\nvisual acuteness much lowered, and the disk pale and\\nconsiderably cupped, the rule is less clear, for it is well\\nknown that the effect of operation in such cases is far\\nfrom constant. But as no other treatment is of use, and\\niridectomy is certainly often beneficial, it should usually\\nbe performed, especially if the disease affect both eyes.\\nThe patient\u00e2\u0080\u0099s prospect of life must be allowed for in\\nchronic glaucoma; if he be old and feeble, life may end\\nbefore the disease have progressed to blindness.\\nThere is often difficulty in deciding upon the best\\ncourse in the so-called \u00e2\u0080\u009cpremonitory\u00e2\u0080\u009d stage, which con\u00c2\u00ac\\nsists, in truth, of transient attacks of slight glaucoma.\\nWhen it is clear that attacks of temporary mistiness and\\nrainbows are glaucomatous, and that they are getting more\\nfrequent, iridectomy should seldom be deferred; but if the\\npatient can be seen at short intervals, eserine should have\\na fair trial before operation is resorted to. It is to be re\u00c2\u00ac\\nmembered that iridectomy done when sight is still good\\nmay, by allowing spherical aberration and causing corneal\\nastigmatism, increase the defect; and this, though not of\\nnecessity a contraindication, must be taken into account.\\nPrognosis. The prognosis after operation is, in gen\u00c2\u00ac\\neral terms, better in proportion as the disease is acute and\\nrecent. If operated on within a few days of the onset of", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0318.jp2"}, "319": {"fulltext": "GLA TJCOMA.\\n307\\nacute symptoms, provided that fingers can still be counted\\nat the time of operation, sight is often restored to the state\\nin which it was at the onset\u00e2\u0080\u0094 i. e., if the disease be recent\\nnearly perfect sight will be restored. Even in cases com\u00c2\u00ac\\nbining the maximum of acuteness and severity, in which\\nvision has for the last few days been reduced to mere p. 1.,\\nthe operation is often successful in restoring some degree\\nof useful sight. But the prognosis is not always so favor\u00c2\u00ac\\nable in acute glaucoma, especially if the patient\u00e2\u0080\u0099s health\\nbe much broken down and if there be, as is by no means\\nuncommon, evidence that sight had been already damaged\\nby chronic glaucoma before the acute attack set in, the\\nprognosis must be guarded. In simple chronic glaucoma\\nwe can only hope as a rule to stop the disease where it is\\nand prevent the sight from getting worse.\\nThe full effect of the operation is not seen for several\\nweeks, though a marked immediate effect is produced in\\nacute cases. In cases of long standing T. may remain\\npermanently rather -j- after operation, without bad effect,\\nprovided it be very much less than before the operation\\nthe eye tissues can in some degree adapt themselves to in\u00c2\u00ac\\ncreased pressure.\\nA second iridectomy in the opposite direction, or a scle\u00c2\u00ac\\nrotomy, should be done if T., having been reduced to\\nnormal, or very slightly after the first operation, rise\\ndefinitely, and be accompanied by a return of other symp\u00c2\u00ac\\ntoms but several weeks should generally elapse, for slight\\nwaves of glaucomatous tension may occur before the eye\\nhas fully recovered from the first operation, and these may\\noften be relieved by other means. Cases which relapse\\ndefinitely, or which steadily get worse after the first opera\u00c2\u00ac\\ntion, are always very grave, and the second operation must\\nnot be confidently expected to succeed. If after iridec\u00c2\u00ac\\ntomy in acute glaucoma the symptoms are not relieved,\\neven for a time, or become worse, some complication is to", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0319.jp2"}, "320": {"fulltext": "308\\nCLINICAL DIVISION.\\nbe suspected, such as hemorrhage from the retina or cho\u00c2\u00ac\\nroid, or a tumor. See Secondary Glaucoma.\\nOther Treatment. If we are obliged to delay the\\noperation, the other means mentioned at p. 303 should be\\nprescribed, including eserine. The diet should, as a rule,\\nbe liberal, unless the patient be plethoric. It is very im\u00c2\u00ac\\nportant to ensure sound sleep and mental calm. After\\nthe operation, until the eye has become quiet, all causes\\nlikely to induce congestion must be carefully avoided, such\\nas use of the eyes, stooping or straining, and prolonged\\nophthalmoscopic examination. Atropine must never be\\nused. We should be on the alert for the earliest symptoms\\nin the second eye after operation on the first, and the use\\nof eserine may be advisable as a prophylactic.\\nIn a few cases of very chronic or subacute character,\\nwith great increase of T., iridectomy seems to aggravate\\nthe disease, being followed not even by temporary benefit,\\nbut by persistence of -j- T., increased irritability, and still\\nfurther deterioration of sight, glaucoma malignum. Per\u00c2\u00ac\\nhaps the tilting forward of the lens, which sometimes fol\u00c2\u00ac\\nlows iridectomy, may account for the result.\\nGlaucoma may occur independently in cataractous eyes,\\nand in eyes from which the lens has been extracted, with\\nor without iridectomy.\\nSecondary glaucoma may be acute or chronic, according\\nas it is a consequence of active disease or of sequelae. It\\nmay be caused by circular iritic synechia with bulging of\\nthe iris. Various forms of chronic irido-keratitis and irido-\\nchoroiditis, especially the sympathetic form, are liable to\\nbe accompanied by it; in the former it may be due to\\nchoking of the spaces of Fontana by inflammatory pro\u00c2\u00ac\\nducts, and perhaps to excessive secretion from the ciliary\\nprocesses; in the sympathetic disease, to total posterior\\nsynechia. It may follow perforation of the cornea with\\nlarge anterior synechia. The eye often becomes temporarily", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0320.jp2"}, "321": {"fulltext": "GLA XJCOMA.\\n309\\nglaucomatous in the course of traumatic cataract from the\\npressure of the swollen lens on the iris and ciliary processes,\\nespecially in patients past middle life. In none of these\\ncases is there much danger of mistaking secondary for idio\u00c2\u00ac\\npathic glaucoma.\\nBut secondary glaucoma may result from various deeper\\nchanges. When the lens is dislocated, either behind or in\\nfront of the iris, it often sets up glaucoma, sometimes of a\\nvery severe type, apparently by pressing on the ciliary pro\u00c2\u00ac\\ncesses or iris. There is .generally the history of a blow and\\nin posterior dislocation, even if the edge of the displaced\\nlens cannot be seen, the iris is usually tremulous, and its\\nsurface concave or flat at one part, while bulging or promi\u00c2\u00ac\\nnent at another. If we are sure that a lens dislocated into\\nthe vitreous is causing the symptoms, it should be extracted\\nwith a scoop (see Operations); and if lying in the anterior\\nchamber should also usually be removed. If the eye be\u00c2\u00ac\\ncomes glaucomatous immediately after a severe blow the\\ncondition of the lens may not be ascertainable, and then\\nan iridectomy must be done and the eye be watched; vit\u00c2\u00ac\\nreous is very likely to escape at the operation if there be\\ndislocation of the lens, for the latter condition implies rup\u00c2\u00ac\\nture of the suspensory ligament. Hemorrhage into an eye\\nwhose retina is detached\u00e2\u0080\u0094 e. g., in high degrees of myopia,\\nmay give rise to acute glaucoma with severe pain. A glau\u00c2\u00ac\\ncomatous attack generally occurs during the growth of an\\nintraocular tumor. It is often impossible to distinguish\\nsuch a case, in an adult, from one of idiopathic glaucoma\\nof the same severity and standing; for even if the lens be\\nnot opaque\u00e2\u0080\u0094and it often is so\u00e2\u0080\u0094the other media will prob\u00c2\u00ac\\nably be too hazy to allow an ophthalmoscopic examination\\nthe growth itself is usually of a dark color, and both idio\u00c2\u00ac\\npathic glaucoma and choroidal sarcoma are diseases of ad\u00c2\u00ac\\nvanced life. In almost every case, however, the glaucoma\\nwill be absolute,\u00e2\u0080\u009d and will be known to have been so for", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0321.jp2"}, "322": {"fulltext": "310\\nCLINICAL DIVISION.\\nweeks or months, and there will also be the negative fact\\nthat the fellow-eye shows no signs of glaucoma. If a glau\u00c2\u00ac\\ncomatous eye, which has been absolutely blind for several\\nmonths, remain painful and congested, and its media too\\nopaque for ophthalmoscopic examination, it should be ex\u00c2\u00ac\\ncised as likely to contain a tumor. Tumors in the eyes of\\nchildren also cause secondary glaucoma, but there is seldom\\nany difficulty in making the diagnosis; the patient is far\\nbelow the age for primary glaucoma, and the growth is\\nusually conspicuous from its whitish color. Secondary\\nglaucoma now and then supervenes in cases of albumin\u00c2\u00ac\\nuric retinitis, and of embolism or thrombosis of the retinal\\nvessels, and in cases of retinal hemorrhage from other\\ncauses, hemorrhagic glaucoma. In glaucoma with hemor\u00c2\u00ac\\nrhage the diagnosis can sometimes be completed only after\\nan unsuccessful operation has shown that the case is not a\\nsimple one.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0322.jp2"}, "323": {"fulltext": "CHAPTER XVIII.\\nTUMORS AND NEW-GROWTHS OF THE EYEBALL AND\\nCONJUNCTIVA.\\nA. Tumors and Growths of the Conjunctiva and\\nFront of the Eyeball.\\nCauliflower warts with narrow pedicles like those on\\nthe glans penis, but flattened like a cock\u00e2\u0080\u0099s-comb by pres\u00c2\u00ac\\nsure, are sometimes seen on the ocular and palpebral con\u00c2\u00ac\\njunctiva. Each wart with a small portion of healthy con\u00c2\u00ac\\njunctiva around its pedicle must be snipped off, or the\\ngrowth is likely to recur.\\nTuberculosis of the conjunctiva is found in the form of\\nsmall gray miliary granulations in the conjunctiva of the\\nupper lid in late stages the surface becomes ulcerated,\\nragged, and uneven, and the eyeball itself may be attacked\\nthe gland in front of the ear at the same time frequently\\nbecomes enlarged and suppurates. The treatment should\\nbe repeated free scraping with a sharp spoon, either with\\nor without cauterization, to remove the tuberculous nodules\\nas they appear. It is scarcely necessary to make a dis\u00c2\u00ac\\ntinction between this affection and lupus, which is of the\\nsame nature, but which usually attacks the conjunctiva by\\nextension from the skin.\\nThe eyelid, especially the tarsus, is now and then the\\nseat of diffused gummatous inflammation in the tertiary\\nstage of syphilis. The infiltration gives rise to a hard, in\u00c2\u00ac\\ndolent swelling of the whole lid, syphilitic tarsitis. Chancres\\nand tertiary syphilitic ulcers may occur on the lids.\\nPapilloma of the caruncle and semilunar fold is of rare\\n311", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0323.jp2"}, "324": {"fulltext": "312\\nCLINICAL DIVISION.\\noccurrence, and takes the form of a pinkish cauliflower\u00c2\u00ac\\nlike mass, which readily bleeds. Extirpation of the growth\\nshould be thorough, as it manifests a strong tendency to\\nrecur. Adenoma, primary sarcoma, and carcinoma of the\\ncaruncle also occur.\\nPinguecula, a yellowish spot, looking like adipose tissue\\nin the conjunctiva, close to the inner or outer edge of the\\ncornea, consists of thickened conjunctiva and subconjunc\u00c2\u00ac\\ntival tissue, and contains no fat. It is most common in old\\npeople and in those whose eyes are exposed to local irri\u00c2\u00ac\\ntants. Though of no consequence, advice is often asked\\nabout it.\\nPterygium is a triangular patch of thickened ocular con\u00c2\u00ac\\njunctiva, the apex of which encroaches upon the cornea;\\nFig. 113.\\nit is almost always seated on the exposed part of the eye.\\nIt varies much in area, thickness, and vascularity, and\\nthough usually stationary may be progressive. It is to be\\ndistinguished from opacity of the cornea, and from the\\ncicatricial band, symblepharon, which often forms between\\nlid and globe after burns or wounds of the conjunctiva.\\nIt is rarely seen except in those who have spent some years", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0324.jp2"}, "325": {"fulltext": "TUMORS AND NEW-GROWTHS.\\n313\\niii hot countries. The best treatment is, after dissecting\\n7 O\\nup the growth, to double it inward upon itself, drawing its\\napex into the chink between sclerotic and conjunctiva by\\nmeans of a deep suture, which is brought out again near\\nthe caruncle; or to transplant the growth into a cleft in\\nthe conjunctiva below the cornea: excision or ligature is\\nless effectual; it is important to bring the healthy conjunc\u00c2\u00ac\\ntiva over the wound by sutures after removal of the ptery\u00c2\u00ac\\ngium. Adhesion of swollen conjunctiva to a marginal\\nulcer of cornea is the starting-point of pterygium, or it\\nmay gradually extend from the edge of a pinguecula\\n(Fuchs).\\nSmall thin cysts, sometimes elongated and beaded, with\\nclear, watery contents, are not uncommon in the ocular\\nconjunctiva near to one of the canthi. They are formed\\nby distention of valved lymphatic trunks.\\nDermoid tumors (solid) of the eyeball are less frequently\\nseen .than the cystic dermoids of the eyebrow. They are\\nwhitish, smooth, hemispherical, and firm. They gener\u00c2\u00ac\\nally lie in the palpebral fissure, and are either wholly\\nconjunctival and movable, or partly corneal and fixed.\\nThey are solid, and hairs may grow from their surface.\\nThey may be combined with other congenital anomalies\\nof the eye or lids. The corneal portion of such a tumor\\ncannot always be perfectly removed.\\nThe swelling in some cases of episcleritis syphilitic or\\nnot, may be mistaken for a tumor. A few cases of inno\u00c2\u00ac\\ncent tumor on the edge of the cornea have been described\\nas fibroma; it is not certain that some of these may not\\nhave been chronic gummata.\\nMoles or patches of pigmentation of the ocular conjunc\u00c2\u00ac\\ntiva are sometimes seen; as a rule they are of no impor\u00c2\u00ac\\ntance, but in later life they sometimes become sarcomatous.\\nA congenital fibro-fatty growth sometimes occurs in the\\nform of a yellowish, lobulated, tongue-like protrusion be-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0325.jp2"}, "326": {"fulltext": "314\\nCLINICAL DIVISION.\\ntween the lid and the globe, and usually at the outer and\\nupper side of the orbit.\\nCystic tumors may be met with beneath the palpebral\\nconjunctiva. The very rare form known as clacryops is a\\nbluish tumor caused by occlusion and distention of a duct\\nof the lachrymal gland; but other cystic conjunctival\\ntumors are met with which cannot be so explained.\\nFibrous and even bony tumors are occasionally seen in\\nthe substance of the upper lid, perhaps starting from the\\ntarsus; in one case a tooth was removed from the lower lid\\nby Carver (Nagel, p. 432), and soft polypoid growths have\\nbeen met with in the sulcus between lid and globe.\\nMalignant tumors arise much less commonly on the front\\nof the eye than in the choroid or retina. They may be\\neither epithelial or sarcomatous. An injury is often stated\\nto be the cause of the growth.\\nEpithelioma may begin on the ocular conjunctiva, in\\nwhich case it remains movable, or at the sclero-corneal\\njunction, when it quickly encroaches on the cornea, infil\u00c2\u00ac\\ntrates its superficial layers, and becomes fixed. It may be\\npigmented. When such a growth is not seen until late,\\nit may perhaps be as large as a walnut, may cover or sur\u00c2\u00ac\\nround the cornea, and present a papillary or lobulated sur\u00c2\u00ac\\nface. The glands in front of the ear may be enlarged.\\nSarcoma in this region may or may not be pigmented.\\nIt generally arises at the sclero-corneal junction, and when\\nsmall the conjunctiva is traceable over the growth. But\\nin advanced cases it may be impossible from the clinical\\nfeatures to diagnose the nature of a tumor in this part.\\nMovable tumors, epithelioma, not involving the cornea,\\nmay be cut off, but are very likely to recur; and recur\u00c2\u00ac\\nrence is still more likely in the case of growths fixed to the\\ncornea or sclerotic. Removal of the eyeball at an early\\ndate, especially in the case of sarcomata, is the best course\\nin the majority of cases.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0326.jp2"}, "327": {"fulltext": "TUMORS AND NEW-GROIVTHS.\\n315\\nThe lachrymal sac is occasionally the seat of new growth,\\nor of tubercle which may be mistaken for chronic muco\u00c2\u00ac\\ncele.\\nB. Intraocular Tumors.\\nBy far the most common forms are glioma of the retina\\nand sarcoma of the choroid.\\nGlioma of the retina is a disease of infancy or early child\u00c2\u00ac\\nhood, the patients being generally under three years old\\nwhen first brought for treatment; it may, however, be\\npresent at birth, and is said occasionally to begin as late\\nas the eleventh or twelfth year. Glioma is very soft, com\u00c2\u00ac\\nposed of small round cells which grow from the granule\\nlayers of the retina, and it either grows outward, causing\\ndetachment of the retina, or inward into the vitreous;\\noften several more or less separate lobules are present. It\\noften fills the eyeball in a few months, and then spreads\\nby contact to the choroid and to the sclerotic and orbit.\\nIt is especially prone to travel back along the optic nerve\\nto the brain; and it may cause secondary deposits in the\\nbrain and in the scalp, and more rarely in distant parts.\\nIf the eye be removed before either the optic nerve or the\\norbital tissues are infiltrated, the cure is radical; but in\\nthe more numerous cases, where the patient is not seen till\\nwhat maybe called, clinically, the second stage (see below),\\na fatal return in the orbit or within the skull is the rule.\\nGlioma sometimes occurs in both eyes, and in several chil\u00c2\u00ac\\ndren of the same joarents.\\nThe earliest symptom is a shining, whitish appearance\\ndeep in the eye, and the eye is soon noticed to be blind;\\nas there is neither pain nor redness, advice is seldom sought\\nat this stage. T. is n. or rather When the peculiar\\nappearance has become very striking, or if the eye becomes\\npainful, the child is brought to be seen. In this (the sec\u00c2\u00ac\\nond) stage there is generally some congestion of the scleral", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0327.jp2"}, "328": {"fulltext": "316\\nCLINICAL DIVISION.\\nvessels, and a white, pink, or yellowish reflection from be\u00c2\u00ac\\nhind the lens (which remains clear), steaminess of the cor\u00c2\u00ac\\nnea, mydriasis, T. -j-, anterior chamber shallow and of\\nuniform depth; there may be enlargement or prominence\\nof the eyeball. On examination by focal light some ves\u00c2\u00ac\\nsels can generally be seen on the whitish background, and\\nwhite specks, indicating degeneration, are sometimes\\npresent.\\nIn young children the above appearances are sometimes\\nsimulated by inflammatory changes in the vitreous, with\\ndetachment of the retina, the result of spontaneously\\narrested severe iridochoroiditis.\\nSarcoma of the choroid and ciliary body is a growth of\\nlate or middle life, being rarely seen below the age of thirty-\\nfive. The majority of these tumors are pigmented (melan\u00c2\u00ac\\notic), some being quite black, others mottled or streaked.\\nA few are free from pigment. Some are spindle-celled or\\nmixed, others composed of round cells; some are truly\\nalveolar, but in many specimens there is very little con\u00c2\u00ac\\nnective-tissue stroma, and no very defined arrangement of\\nthe cells. These tumors are moderately firm, but friable;\\nsome are very vascular, and hemorrhages often occur into\\nthem. The tumor grows from a broad base, and usually\\nforms a well-defined rounded prominence, pushing the\\nretina before it; blood or serous fluid is effused round its\\nbase, so that the retinal detachment is more extensive than\\nthe tumor. These tumors often grow slowly so long as\\nthey are wholly contained within the eye, and several\\nyears may elapse before the growth passes out of the eye\\nand invades the orbit. Orbital infection does not usually\\noccur till the globe is filled to distention by the growth\\nbut it may happen much earlier, the cells travelling out\\nalong the sheaths of the perforating bloodvessels and pro\u00c2\u00ac\\nducing large extraocular growths, while the primary intra\u00c2\u00ac\\nocular tumor is still quite small. The lymphatic glands do", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0328.jp2"}, "329": {"fulltext": "TUMORS AND NEW-G ROW TITS.\\n317\\nnot enlarge, but there is great danger of secondary growths\\nin distant parts, especially in the liver, a risk not entirely\\nabsent even when the eye tumor is small. Hence early re\u00c2\u00ac\\nmoval of the globe is of the utmost importance, and a good,\\nthough not too confident, prognosis may be given when the\\noptic nerve and tissues of the orbit show no signs of disease.\\nMetastatic growths. In nearly every case malignant\\ntumor of the choroid is primary, but it is important to\\nknow that growths may occur here secondary to those in\\nother parts of the body; in one case, quoted by Manz,\\nboth eyes were affected, the original growth being cancer\\nof the breast.\\nSymptoms and Course. If the case be seen early,\\nwhen defect of sight is the only symptom, the tumor can\\noften be seen and recognized by its well-defined, rounded\\noutline, some folds of detached retina often being visible\\nnear it; the pupil, cornea, and tension will probably be\\nnatural. When the tumor orginates in the central region\\nthe sight is immediately affected, and the patient seeks\\nadvice very early; the differential diagnosis then lies be\u00c2\u00ac\\ntween localized plastic choroiditis and tumor. In tumor\\nthere is often some detachment of the retina at or near the\\narea of the disease, but there is no evidence of retinitis,\\nand no patches of black pigment about the swelling. By\\nophthalmoscopic estimation the diseased area is found to\\nbe more or less raised. An inflammatory exudation of\\nsimilar size commonly causes haze of the neighboring\\nretina, and opacities in the vitreous; if of some weeks\u00e2\u0080\u0099\\nduration, part of it will usually have become absorbed,\\nleaving exposed sclerotic with accumulations of pigment.\\nSooner or later the tumor in its growth sets up symptoms\\nof acute or subacute glaucoma, and sometimes iritis; sub\u00c2\u00ac\\nsequently secondary cataract forms. It is in this glau\u00c2\u00ac\\ncomatous (second) stage that relief is usually sought.\\nUnless some part of the tumor happen to be visible out-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0329.jp2"}, "330": {"fulltext": "318\\nCLINICAL DIVISION.\\nside the sclerotic, or project into the anterior chamber, a\\npositive diagnosis will often now be impossible, owing to the\\nopacity of the media; although by exclusion we may often\\narrive at great probability. If the eye be left alone, or\\niridectomy be performed, glaucomatous attacks and pain\\nwill recur, and the eye will enlarge and gradually be dis\u00c2\u00ac\\norganized by the increasing growth, which will then\\nquickly fill the orbit and fungate. But sometimes a de\u00c2\u00ac\\nceptive period of quiet follows the glaucomatous attack\\neven decided shrinking and softening of the eye may\\noccur; but the growth will sooner or later make a fresh\\nstart and become apparent. It is chiefly in very old\\npatients that this slow course is noticed. Sarcoma is\\nespecially likely to form in eyes previously injured, or\\nalready shrunken from disease.\\nThus it is apparent that in a majority of cases of cho\u00c2\u00ac\\nroidal tumor we can only guess at the truth. We suspect\\na tumor and urge excision in the following cases 1. When\\nan eye that has been for some time failing or blind from\\ndeep-seated disease becomes painful, congested, and glau\u00c2\u00ac\\ncomatous (there being no glaucoma of the other eye), and\\nparticularly if there be secondary cataract. 2. Similar\\neyes with normal or diminished tension are best excised\\nas possibly containing tumor. 3. In extensive detach\u00c2\u00ac\\nment of retina confined to one eye, without history of\\ninjury or evidence of myopia, the patient should be\\nwarned, or the eye excised, according to circumstances.\\nIn all cases of suspected glioma or sarcoma the eye\\nshould be opened at once, and if a tumor be found, the\\ncut end of the optic nerve of the excised eye should be\\ncarefully looked at; if this be pigmented or thickened,\\nanother piece should be at once removed, and the orbit\\nsearched by the finger for evidence of growth the surface\\nof the eye should also be carefully examined for external\\ngrowths. When infection of the nerve or orbit is sus-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0330.jp2"}, "331": {"fulltext": "TUMORS AND NEW-GROWTHS.\\n319\\npec ted, the orbit should be cleared out and chloride of\\nzinc paste applied.\\nTumors of the iris are rare. Melanotic as well as unpig-\\nmented sarcomata are occasionally met with. 1 The definite\\ndevelopment of melano-sarcoma of the iris has been known\\nto be preceded for many years by an apparently innocent\\npigmented spot on the iris. In eyes blind and degenerated\\nafter iridocyclitis, the uveal pigment may increase in\\namount, and creep round the pupillary border to the\\nanterior surface of the iris; these areas of new pigment\\nmight be mistaken for melanotic growths. Sebaceous or\\nepithelial tumors are also seen; they are nearly always\\nthe result of transplantation of epithelium, or of a hair,\\ninto the iris through a perforating wound of the cornea;\\nthey are frequently cystic, implantation cysts. In rare\\ncases cystic tumors with thin walls are formed between\\nthe layers, or connected with the posterior surface of the\\niris, particularly in eyes which have been operated on or\\notherwise injured.\\nDiffuse sarcoma of iris. Sarcoma of the iris may be\\nwhite or pigmented: it usually takes the form of a single\\nlarge prominent growth. I have twice seen a sarcoma\\nof the iris take the form of a diffused thickening, with a\\nmottled or tortoise-shell aspect; such a diffuse form is more\\ndifficult to diagnose, and probably more dangerous, if left\\nalone, than a definite tumor.\\nCases of disease of the iris are seen from time to time,\\nthe special feature of which is the presence of one or more\\nnodular growths, usually of small size; iritis is generally\\npresent. It is often impossible to determine the nature of\\nthe growth until the case has been watched, or microscop\u00c2\u00ac\\nical examination or inoculation experiments have been\\n1 A well-reported case, with numerous references, is given by Little, in\\nTrans. Ophth. Soc., vol. iii. 1883.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0331.jp2"}, "332": {"fulltext": "320\\nCLINICAL DIVISION.\\nmade. These cases, which have often been described as\\ngranuloma of the iris, are certainly sometimes tubercle,\\nsometimes chronic gummata, sometimes part of a severe so-\\ncalled serous iritis, and sometimes the nature of the growth\\nis doubtful. Inoculation of tuberculous material into the\\nanterior chamber of rabbits has repeatedly been followed\\nby the formation of multiple nodules, similar in appear\u00c2\u00ac\\nance to those in some of these cases, and some of the\\ngrowths in human cases have given the microscopical\\nreactions of true tubercle. The disease is probably tuber\u00c2\u00ac\\ncular when the growths are multiple, non-vascular, and\\ngray, especially when accompanied by enlarged glands in\\nthe patient, or a family history of tubercle.\\nLarge masses of confluent tubercle occasionally form in\\nthe choroid or other parts of the uveal tract, leading to\\ndisorganization of the eye, with mixed symptoms of intra\u00c2\u00ac\\nocular growth and inflammation. As it is probable that\\nthis ocular tubercle may be a source of general tubercu\u00c2\u00ac\\nlosis, excision of the eye is the best course in any doubtful\\ncase where it is clear that the eye is lost.\\nThe cornea is much less liable to tubercular infiltration\\nthan the iris, but small growths have been observed in it,\\nboth as the result of inoculation and in the course of spon\u00c2\u00ac\\ntaneous tubercle of the iris.\\nC. Tumors of the Orbit. See Chapter XIX.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0332.jp2"}, "333": {"fulltext": "CHAPTER XIX.\\nINJURIES, DISEASES, AND TUMORS OF THE ORBIT.\\n1. Contusion and concussion injuries. Bruising of the\\neyelids from direct blows\u00e2\u0080\u0094\u00e2\u0080\u009c black eye \u00e2\u0080\u009d\u00e2\u0080\u0094may usually\\nwith care be distinguished from the deeper extravasation\\nfollowing fracture of the walls of the orbit. In ordinary\\nblack eye\u00e2\u0080\u009d the ecchymosis comes very quickly and re\u00c2\u00ac\\nmains superficial, and, if it affect either the palpebral or\\nocular conjunctiva, does not pass far back. The ecchy\u00c2\u00ac\\nmosis following fracture of the orbital plate of the frontal\\nbone comes more gradually, is deep-seated, often entirely\\nbeneath, rather than in, the skin and conjunctiva, dimin\u00c2\u00ac\\nishes in density toward the front and borders of the lids,\\nand, when considerable, causes proptosis. But if a frac\u00c2\u00ac\\nture involve the rim of the orbit, the above characters are\\nlikely to be mixed, and therefore misleading. Wasting\\nof the adipose tissue of the orbit, and consequent sinking\\nback of the eye, sometimes follow severe blows, with much\\nextravasation of blood (enophthalmos).\\nFracture of the inner wall of the orbit into the nose, the\\nsinuses opening into it, or the nasal duct, is often followed\\nby emphysema of the orbital cellular tissue. This can occur\\nonly when the mucous membrane is torn. The emphysema\\ncomes on quickly from blowing the nose,\u00e2\u0080\u009d and is shown\\nby a soft, whitish, doughy swelling of the lids, which crepi\u00c2\u00ac\\ntates finely under the finger; the globe is more or less\\nprotruded and its movements limited. The emphysema\\ndisappears in a few days if the lids be kept bandaged.\\nThese fractures are usually caused by blows over the inner\\n21 321", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0333.jp2"}, "334": {"fulltext": "322\\nCLINICAL DIVISION.\\nangle of the orbit, but occasionally by blows on the malar\\nregion.\\nPartial ptosis is an occasional result of blows upon the\\nupper lid. It is generally accompanied by paralysis of\\naccommodation and dilatation of the pupil, and it seldom\\nlasts more than a few weeks. Ocular paralysis following\\ninjury to head. See Chapter XXI.\\n2. Orbital abscess and orbital cellulitis may follow in\u00c2\u00ac\\njuries, but their origin is often obscure. Cellulitis may\\nspread to the orbit from the face in erysipelas, from the\\nthroat in severe tonsillitis, or from the socket of an in\u00c2\u00ac\\nflamed tooth. Diffused acute inflammation of the cellular\\ntissue is difficult to distinguish from acute orbital abscess,\\nsince in both there are the signs of deep inflammation,\\nwith displacement of the eye and limitation of its move\u00c2\u00ac\\nments, chemosis of the conjunctiva, and brawny swelling\\nand redness of the lids. An acute abscess soon points be\u00c2\u00ac\\ntween the globe and some part of the rim of the orbit, but\\neven in cellulitis the swelling may be greater at some one\\npart, and give rise to a feeling deceptively like fluctuation.\\nOrbital abscess may be so chronic as to simulate a solid\\ntumor until the pus nears the surface; even then an ex\u00c2\u00ac\\nploratory incision may be needed to set the question at\\nrest. Abscess of the orbit, whether acute or chronic, is\\nvery often the result of periostitis, and a large surface of\\nbare bone is often found with the probe.\\nIn acute cases, as soon as fluctuation is certain, an in\u00c2\u00ac\\ncision is to be made with a narrow, straight knife, gener\u00c2\u00ac\\nally through the skin, or, if practicable, through the\\nconjunctiva. Chronic cases of doubtful nature may be\\nwatched for a time. It may be necessary to go deeply\\ninto the orbit, either with the knife, probe, or dressing\\nforceps, before matter is reached. A drainage-tube should\\nbe inserted if the abscess be deep. The proptosis does not\\nalways disappear when the abscess is opened; it may in-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0334.jp2"}, "335": {"fulltext": "INJURIES, DISEASES, AND TUMORS OF ORBIT. 323\\ncrease owing to hemorrhage, and there may be much\\nthickening of the tissues. Sight may be injured or lost\\nby stretching of, or pressure on, the optic nerve, and the\\ncornea may lose sensation, and ulcerate from damage to\\nthe ciliary nerves behind the globe.\\nThrombosis of the cavernous sinus, which may result\\nfrom several causes, produces local symptoms which it is\\ndifficult, often impossible, to distinguish from those of cellu\u00c2\u00ac\\nlitis beginning in or limited to the orbit. The thrombosis,\\nhowever, often spreads to the other cavernous sinus and\\nthe other orbit; and in any case it produces the gravest\\nhead symptoms, which, as a rule, end fatally in a short\\ntime. 1\\n3. Wounds. Wounds of the eyelids need no special\\ntreatment beyond very careful apposition by sutures,\\nsometimes with a small harelip pin, so as to secure\\nprimary and accurate union. Lacerated wounds of the\\nocular conjunctiva, if extensive, need a few fine sutures,\\nand they seldom lead to any deformity. When a rectus\\ntendon has been torn through I have never succeeded in\\ngetting the ends to unite.\\nPenetrating wounds through the lids or conjunctiva,\\nwhich pass deeply into the orbit, may be much more\\nserious than they appear at first sight, since the wounding\\nbody may have caused fracture of the orbit and damage\\nto the brain membranes, or a piece of the wounding in\u00c2\u00ac\\nstrument may have been broken off and lie embedded in\\nthe roomy cavity of the orbit, without at first exciting\\ndisturbance or causing displacement of the eye. Some\\nextraordinary cases are on record 2 in which very large\\nforeign bodies have lain in the orbit for a long time unde\u00c2\u00ac\\ntected. The optic nerve is occasionally torn across with-\\n1 An able paper on this little-known subject has been communicated to the\\nOphthalmological Society by Dr. Sidney Coupland, October, 1886.\\n2 In Mr. Lawson\u00e2\u0080\u0099s well-known treatise and elsewhere.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0335.jp2"}, "336": {"fulltext": "324\\nCLINICAL 1)1 VISION.\\nout damage to the globe. Every wound of the eyelids or\\nconjunctiva should, therefore, be carefully explored with\\nthe probe, and, whenever possible, the instrument which\\ncaused the wound should be examined.\\nWhen a foreign body is suspected or known to be firmly\\nembedded, and is not removable through the original\\nwound, it is generally best to divide the outer canthus,\\nand prolong the incision into the conjunctiva; in some\\ncases an incision through the skin over the margin of the\\norbit, at the situation of the foreign body, will be prefer\u00c2\u00ac\\nable. Single shot, embedded and causing no symptoms,\\nshould not be interferred with unless they can be easily\\nreached.\\nWounds of the orbit, by gunshot or other explosives,\\nwhen extensive and caused by numerous shots or frag\u00c2\u00ac\\nments of sand, gravel, etc., driven into the tissues, are of\\ncourse serious, particularly if the eyeball itself be injured.\\nSuch injuries may cause tetanus.\\nTumors of the Orbit.\\nA tumor of any notable size in the orbit always causes\\nprotrusion of the eye (proptosis), with or without lateral\\ndisplacement and limitation of its movement. As a rule,\\nthere are no inflammatory symptoms. An exact diagnosis\\nof the seat, attachments, and nature of an orbital tumor\\nis, of course, often impossible before operating and it may\\nbe further observed that there has occasionally been great\\ndifficulty in deciding whether the symptoms pointed to a\\ntumor, or to some form of chronic hypertrophy of cellular\\ntissue or quiet gummatous inflammation.\\nA tumor in the orbit may originate in some of the loose\\norbital tissues, in the lachrymal gland, in the periosteum,\\nupon or within the eyeball, or from the optic nerve; or it\\nmay have encroached upon the orbit from one of the neigh-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0336.jp2"}, "337": {"fulltext": "INJURIES, DISEASES, AND TUMORS OF ORBIT. 325\\nboring cavities. Fluctuating tumors in the orbit may be\\ncystic or ill-defined, and may or may not pulsate. Solid\\ntumors in the orbit may be movable, or be fixed by broad\\nattachments to the wall of the cavity. Sight is often dam\u00c2\u00ac\\naged or destroyed in the corresponding eye by compression\\nor infiltration of the optic nerve.\\n1. Distention of the frontal sinus by retained mucus\\ncauses a well-marked, fixed, usually very chronic swelling,\\nnot adherent to the skin, at the upper inner angle of the\\norbit above the tendo oculi. Hard at first, it fluctuates\\nwhen the bony wall has been absorbed. Its course is usu\u00c2\u00ac\\nally slow, but acute suppuration may supervene, and the\\nswelling be mistaken for a lachrymal abscess (p. 97).\\nThere is generally a remote history of injury. The aim\\nof treatment is to re-establish the opening, closed probably\\nas the result of fracture, between the floor of the sinus and\\nthe nose. The most prominent part of the swelling is freely\\nopened a curved probe is then passed, if possible, from the\\nsinus through the infundibulum into the nose; if the open\u00c2\u00ac\\ning has been completely closed, it is sometimes necessary\\nto perforate the base of the sinus by a trocar. A seton or\\ndrainage-tube is then passed through the hole, brought\\nout at the nostril, and must be worn for several weeks or\\nmonths. Cases of the same nature are sometimes seen in\\nwhich the swelling is at a lower level and further back in\\nthe orbit; they are not connected with the frontal sinus,\\nbut are probably due to distention of some of the cavities\\nof the ethmoid.\\n2. Pedunculated ivory exostoses sometimes grow from the\\nwalls of the same sinus or its neighborhood; beginning\\nearly in life, they increase very slowly, cause absorption\\nof their containing walls, and often in the end undergo\\nspontaneous necrosis and fall out. Their removal while\\nstill fixed is very difficult and dangerous, owing to the\\nproximity of the dura mater.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0337.jp2"}, "338": {"fulltext": "326\\nCLINICAL DIVISION\\n3. Tumors encroaching on one or both orbits from the\\nbase of the skull, the antrum, the nasal cavity, or the\\ntemporal fossa, generally admit of correct diagnosis.\\nThe suspicion of tumor on the inner or lower wall of\\nthe orbit should always lead to an examination of the\\npalate, pharynx, and teeth, of the permeability of each\\nnostril, of the functions of the cranial nerves, of the state\\nof the glands behind the jaw on both sides, and to an\\ninquiry as to epistaxis or discharge from the nose.\\n4. Pulsating tumors of the orbit and cases of proptosis\\nwith pulsation are in most cases due to arterio-venous in\u00c2\u00ac\\ntercommunication in the cavernous sinus, in consequence\\nof which the ophthalmic vein and its branches become\\ngreatly distended with partially arterialized blood. In\\na large proportion the symptoms follow rather gradually\\nafter a severe injury to the head. In others they come on\\nsuddenly with pain and noises in the head, without appa\u00c2\u00ac\\nrent cause, and these idiopathic cases are usually in senile\\npersons. In several examples of both forms a communi\u00c2\u00ac\\ncation has been found, post mortem, between the internal\\ncarotid artery and the cavernous sinus, the result of wound\\nfrom fracture of the base of the skull in the traumatic cases,\\nand of rupture of an aneurism in the idiopathic ones. The\\ntypical symptoms are proptosis, with chemosis, pulsation of\\nthe eyeball, paralysis of orbital nerves, a soft, pulsating\\ntumor under the inner part of the orbital arch, and a\\nbruit. A bruit with proptosis and conjunctival swelling\\nmay be present without demonstrable tumor or pulsation.\\nLigature of the common carotid has been practised with\\ngood results in a large number of cases; subsequent ex\u00c2\u00ac\\ncision of the eye and evisceration of the orbit for a dan\u00c2\u00ac\\ngerous return of symptoms in one or two. An unruptured\\naneurism of the internal carotid does not cause the symp\u00c2\u00ac\\ntoms just described. Aneurism of the intra-orbital arteries\\nand arterio-venous communications in the orbit, if they", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0338.jp2"}, "339": {"fulltext": "INJURIES DISEASES, AND TUMORS OF ORBIT. 327\\noccur, are excessively rare. Erectile tumors, well defined\\naud separable, but not causing decided pulsation, are some\u00c2\u00ac\\ntimes met with in the orbit, and can be dissected out.\\n5. A fluctuating tumor which does not pulsate, is not\\ninflamed, and not connected with the frontal sinus or\\nlachrymal gland, may be a chronic orbital abscess (p.\\n322), a hydatid, or a cyst containing bloody or other\\nfluid, and of uncertain origin. An exploratory puncture\\nshould be made after sufficiently watching the case, and\\nthe further treatment must be conditional. Perfectly\\nclear, thin fluid probably indicates a hydatid, and in this\\ncase the swelling is likely to return after a puncture, and\\nthe cyst will need removal through a free opening. The\\nechinococcus hydatid often contains daughter-cysts, some\\nof which escape puncture. Suppuration may take place\\naround any species of hydatid.\\n6. Examination leads to the diagnosis of a solid tumor\\nlimited to the orbit. We must try to determine whether\\nthe growth began in the eyeball or optic nerve, or in some\\nof the surrounding tissues. We therefore examine the\\nglobe for symptoms of intraocular tumor (p. 315).\\nSolid growths independent of the eyeball may arise as\\nfollows (a) From th e periosteum; these are firmly attached\\nby a broad base, are generally malignant, and seldom admit\\nof successful removal. (5) The lachrymal gland may be the\\nseat of various morbid growths, including carcinoma; a\\ngreat part of the growth is in the position of the gland, and\\ncan be explored by the finger. Although such a growth is\\noften attached firmly to the orbital wall, its position, lobu-\\nlated outline, and well-defined boundary will often lead\\nto a correct diagnosis. Tumors of the lachrymal gland\\nshould always be removed if they are increasing, for\\nwe can never feel sure that they are innocent, (c) Solid\\ntumors originating in some of the softer orbital tissues,\\nespecially the form known as cylindroma, or plexiform sar-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0339.jp2"}, "340": {"fulltext": "328\\nCLINICAL DIVISION.\\ncoma, occur more rarely. d Tumors of the optic nerve,\\nusually myxomatous, occur, though rarely j 1 they gener\u00c2\u00ac\\nally cause neuro-retinitis and blindness, but no absolutely\\npathognomonic symptoms; they may sometimes be extir\u00c2\u00ac\\npated without removing the globe.\\nWhen an orbital tumor is found during operation to be\\nadherent to bone or to infiltrate soft parts which cannot be\\nremoved, chloride of zinc paste (F. 14) should be applied\\non strips of lint, either at once or the next day when\\noozing has ceased. If the periosteum be affected, it is to\\nbe stripped off, and the paste applied to the bare bone.\\nHemorrhage from the depth of the orbit can always be\\ncontrolled by a firm, graduated compress.\\nIn every case of suspected primary orbital tumor the\\nquestion of syphilis must be carefully gone into; although\\nneither periosteal nor cellular nodes are common in the\\norbit, both are known to occur and to disappear under\\nproper treatment.\\nNsevus may occur on the eyelids and in the orbit, and\\nimplicate the conjunctiva, both of the lids and eyeball.\\nDeep noevi may degenerate and become partly cystic.\\nSome cases of nsevus of the face are associated with\\nnsevus of the choroid; in such the eyes are generally\\nvery defective.\\nDermoid tumors cystic are not uncommon at the outer\\nend of the eyebrow; more rarely they occur near the inner\\ncanthus. Lying deeply beneath the orbicularis, they are\\nnot adherent to the skin like sebaceous cysts; the sub\u00c2\u00ac\\njacent bone is sometimes hollowed out. They often grow\\nfaster than the surrounding parts, and should then be ex\u00c2\u00ac\\ntirpated, the thin cyst-wall being carefully and completely\\nremoved through an incision parallel with, and situated\\nin, the eyebrow. They usually contain sebaceous matter\\nand short hairs; occasionally, clear oil.\\n1 For references see Knapp\u00e2\u0080\u0099s Archives of Ophthalmology, xii. 292.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0340.jp2"}, "341": {"fulltext": "CHAPTER XX.\\nERRORS OF REFRACTION AND ACCOMMODATION.\\nAs stated at p. 29, 19, when the length of the eye is\\nnormal, and the accommodation relaxed, only parallel rays\\nare focussed on the retina, and, conversely, pencils of rays\\nFig. 114.\\nPencils of parallel rays entering or emerging from an emmetropic eye.\\nemerging from the retina are parallel on leaving the eye,\\nFig. 114, and this, the condition of the normal eye in\\ndistant vision is called emmetropia (E.). All permanent\\nFig. 115.\\nEmmetropia. Distant objects (parallel rays) focussed on retina near objects\\n(divergent rays) focussed behind retina.\\ndepartures from the condition in which, with relaxed\\naccommodation, the retina lies at the principal focus, are\\nknown collectively as ametropia.\\n329", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0341.jp2"}, "342": {"fulltext": "330\\nCLINICAL DIVISION.\\nIn E. rays from any near object, e. g divergent rays\\nfrom Ob, Fig. 116, are focussed behind the retina at cf,\\nevery conjugate focus being beyond the principal focus\\n(p. 22, 13). Reaching the retina before coming to a\\nfocus, such rays will form a blurred image, and the object\\nOb will therefore be seen dimly. But by using accom\u00c2\u00ac\\nmodation the convexity of the crystalline lens can be\\nincreased and its focal length shortened, so as to make\\nthe conjugate focus of Ob coincide exactly with the retina\\n(cf, Fig. 116). Under this condition the object Ob will\\nFig. 116.\\nEye during accommodation. Near objects (divergent rays) focussed on\\nretina distant objects (parallel rays) focussed in front of retina. The dotted\\nline in front of the lens shows its increase of convexity.\\nbe clearly seen, while the focus of a distant object, which\\nin Fig. 115 was formed on the retina, will now lie in front\\nof it (f, Fig. 116), and the distant object will appear in\u00c2\u00ac\\ndistinct. The nearest point of distinct vision (p) and the\\nfarthest (r) have been defined at p. 50.\\nMyopia (M.).\\nIn Fig. 115, if the retina were at cf instead of at f, a\\nclear image would be formed of an object at Ob, without\\nany effort of accommodation, while objects farther off\\nwould be focussed in front of the retina. This state, in\\nwhich the posterior part of the eyeball is too long, so that,\\nwith the accommodation at rest, the retina lies at the con\u00c2\u00ac\\njugate focus of an object at a comparatively small distance,\\nis called short-sight or myopia (M.), axial myopia.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0342.jp2"}, "343": {"fulltext": "REFRACTION AND ACCOMMODATION. 331\\nIn Fig. 117 the inner line at r is the retina, and f the\\nprincipal focus of the lens-system\u00e2\u0080\u0094 i. e., the position of the\\nretina in the normal eye. Rays emerging from r will, on\\nleaving the eye, be convergent, and, meeting at the con\u00c2\u00ac\\njugate focus r will form a clear image in the air. Con\u00c2\u00ac\\nversely, an object at r will form a clear image on the\\nretina (r), compare Figs. 10 and 12. The image of every\\nobject at a greater distance than r will be formed more\\nor less in front of r, and every such object must, therefore,\\nbe seen indistinctly. But objects nearer than r will be\\nseen clearly by exerting accommodation, just as in the\\nnormal eye, Figs. 115 and 116.\\nFig. 117.\\nMyopia. Retina beyond principal focus, hence only near objects (divergent\\nrays) focussed on retina.\\nIn M. the indistinctness of objects beyond the far point\\n(r) is lessened by partially closing the eyelids. This habit\\nis often noticed in short-sighted people who do not wear\\nglasses, and from it the word myopia is derived.\\nThe distance of r (r Fig. 117) from the eye will depend\\non the distance of its conjugate focus r i. e., upon the\\namount of elongation of the eye. The greater the distance\\nof r beyond f, the less will be the distance of its conjugate\\nfocus r (=r); in other words, the higher will be the M.,\\nand the more indistinct will distant objects be. If the\\nelongation of the eye be very slight, r nearly coinciding\\nwith f, r r) will be at a much greater distance (com\u00c2\u00ac\\npare p. 23, 16), and distant objects will be less indistinct.\\nAs the retinal images formed in a myopic eye are larger", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0343.jp2"}, "344": {"fulltext": "332\\nCLINICAL DIVISION.\\nthan normal (p. 23), myopic persons can distinguish smaller\\nobjects at the same distance than those with normal eyes.\\nSymptoms of M. In low degrees the patient\u00e2\u0080\u0099s com\u00c2\u00ac\\nplaint is that he cannot see distant objects clearly; in\\nmoderate and high degrees it is rather that he can see\\ndistinctly only when things are held very close, for objects\\na few feet off are so indistinct that many such persons\\nneglect them. Adults often tell us that their distant sight\\nwas good till about eight or ten years of age, that it then\\nbegan to shorten, and that the defect after increasing for\\nseveral years at length became stationary.\\nIn high degrees of M. the patient is apt to complain\\nof special difficulty in seeing at night, probably because,\\n(1) the mobility of the eye being below normal, the field\\nof fixation (p. 55) is diminished, and (2) the elongation of\\nthe eye by altering the position of the retina leads to some\\nnarrowing of the field of indirect vision (p. 54). 1\\nIn many cases no other complaint is made, but in a cer\u00c2\u00ac\\ntain number complications are present. There is often in\u00c2\u00ac\\ntolerance of light, an additional cause for the half-closed\\nlids and frowning expression so often noticed. Aching of\\nthe eyes is a very common and troublesome symptom, and\\nis especially frequent if the M. is increasing; it is often\\nbrought on, and always made worse, by over-use of the\\neyes, but sometimes it is very troublesome when quite at\\nrest, and even in bed at night. One or both internal recti\\noften act defectively, so that convergence of the optic axes\\nfor near vision becomes difficult, painful, or impossible, and\\nvarious degrees of divergent strabismus result; this occurs\\noftenest, but by no means only, in the higher degree of M.\\nwhere r is so near that binocular vision involves a strong\\neffort of convergence. When this muscular asthenopia,\u00e2\u0080\u009d\\nor \u00e2\u0080\u009cinsufficiency of convergence,\u00e2\u0080\u009d is slight or intermittent\\n1 Wecker and Landolt: Traite, t. i. p. 595. Landolt: Refraction and Ac\u00c2\u00ac\\ncommodation of the Eye, p. 425.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0344.jp2"}, "345": {"fulltext": "REFRACTION AND ACCOMMODATION.\\n333\\nit causes indistinctness or dancing of the print, and\\nsometimes actual diplopia, besides the other discomforts\\nabove mentioned; but diplopia is seldom present when a\\nconstant divergent squint has been established.\\nThis tendency to divergence in M. is also partly due to the\\nnatural association between relaxation of the ciliary muscles\\nand of the internal recti\u00e2\u0080\u0094the converse of convergent squint\\nin H.\\nThe lower degrees of M. are sometimes accompanied by\\ninvoluntary contraction of the ciliary muscle spasm of\\naccommodation by which M. is temporarily increased;\\nand the habitual approximation of objects, which thus\\nbecomes necessary, is one cause of still further elougatiou\\nof the eye and increase of the structural M. Floating\\nspecks, muscce volitantes, are especially common and trouble\u00c2\u00ac\\nsome in myopia.\\nObjective Signs and Complications. In high de\u00c2\u00ac\\ngrees of M. the sclerotic is enlarged in all directions, Fig.\\n120; the eye being too large, often looks too prominent,\\nFif. 118\\nSection of a highly myopic eyeball. The retina has been removed.\\nand its movements are somewhat impeded. But apparent\\nprominence of the eye may depend on many other causes.\\nThe existence of M. is made certain by the ophthalmo\u00c2\u00ac\\nscope in four different ways:\\n1. By direct examination, the image of the fundus formed\\nin the air, Fig. 117, is clearly visible to the observer if he", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0345.jp2"}, "346": {"fulltext": "334\\nCLINICAL DIVISION.\\nbe not nearer to it than his own near point. The image\\nis inverted and magnified, the enlargement being greater\\nthe further it is formed from the patient\u00e2\u0080\u0099s eye\u00e2\u0080\u0094 i. e., the\\nlower the M. For very low degrees this test is not easy\\nto use, because of the great distance (3 or 4 e. g that must\\nintervene between observer and patient; but it is easily\\napplied if the image be not more than 2 in front of the\\npatient.\\n2. By indirect examination the disk in M. appears smaller\\nthan usual. If now the object lens be gradually withdrawn\\nfrom the patient\u00e2\u0080\u0099s eye, the disk will seem to grow larger.\\nThis appearance, which depends on a real increase in size\\nof the aerial image, is less evident the lower the M., Fig.\\n119, C.\\n3. By direct examination no clear view of the fundus is\\nobtained if the distance between patient and observer be\\nless than that between patient and inverted aerial image,\\nFig. 104, r and as r is in front of the myopic eye, the\\nimage will always be invisible if the observer go close to\\nthe patient. Hence, if on going close to the patient the\\nobserver cannot, either by relaxing or using his accommo\u00c2\u00ac\\ndation, see any details of the fundus clearly, the patient is\\nmyopic, opacities of the media being of course excluded.\\nThis test is applicable to all degrees of M., accommoda\u00c2\u00ac\\ntion being completely relaxed.\\n4. By retinoscopy with a plane mirror the shadow ob\u00c2\u00ac\\ntained on rotating the mirror moves against the direction\\nof rotation. The tests 1, 2, and 4 are, on the whole, most\\ngenerally useful for beginners.\\nIn a large proportion of cases the elongation of the eye\\ncauses atrophy of the choroid on the side of the optic disk\\nnext to the y. s., the apparent inner side in direct exami\u00c2\u00ac\\nnation. This atrophy gives rise to a crescentic patch, Fig.\\n120, of yellowish-white or grayish color, whose concavity is\\nformed by the border of the disk, while its convex side", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0346.jp2"}, "347": {"fulltext": "REFRACTION AND ACCOMMODATION.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0347.jp2"}, "348": {"fulltext": "336\\nCLINICAL DIVISION.\\ncurves toward the y. s. it is known as a myopic\\ncrescent,\u00e2\u0080\u009d also as a posterior staphyloma,\u00e2\u0080\u009d because it\\nindicates a localized bulging of the sclerotic, Fig. 118.\\nFig. 120.\\nMyopic crescent or small posterior staphyloma. (Wecker and Jaeger.)\\nIt varies in size from the narrowest rim to an area several\\ntimes that of the disk, and may form a zone entirely sur\u00c2\u00ac\\nrounding the disk, Fig. 121, instead of a crescent; there\\nDescription of Fig. 119. The figure shows the effect on the size of the in\u00c2\u00ac\\nverted image caused by withdrawing the objective lens from the eye, in the\\nindirect ophthalmoscopic examination.\\nA shows that in emmetropia the image remains of the same size on with\u00c2\u00ac\\ndrawal of the lens. Ob is the retina lying at the principal focus of the diop\u00c2\u00ac\\ntric media of the eye, represented by L; l and l show the objective lens at\\ndifferent distances from the eye; Ini and Ini the ophthalmoscopic images\\nformed in each case. Rays from any point on Ob emerge from L parallel,\\nand are united by l at the point lm (the principal focus of l for the rays indi\u00c2\u00ac\\ncated) on the secondary axis 1, -which forms with the principal axis the angle\\na. If l be removed to l it will still intercept some of the same bundle of paral\u00c2\u00ac\\nlel rays, and these will be united in lm at the same distance as before, on the\\nsecondary axis 2, which forms with the principal axis the angle 6 the angle\\na. The relative sizes of lm and lm depend on (1) their respective distances\\nd and d from the lens, and (2) on the size of the angles a and b. As in the\\npresent case d d and a b, lm must lm\\nB shows the diminution of the image in hypermetropia. The lettering is\\nas before, but f is the principal focus of l, and v. f. the virtual focus of the\\nretina Ob. The letters d and d are omitted, but can easily be supplied. The\\nangle b is now smaller than a, because the rays emerge from l divergent (as\\nif from v. f.), and hence (d and d being nearly equal) lm must be smaller\\nthan lm.\\nC shows the increase of the image in myopia the retina Ob is now beyond\\nf c. F. is the far point of the eye, conjugate to Ob. The angle b is now\\nlarger than a because the rays emerge from l convergent (toward c. F.), and\\nhence (d and d still being nearly equal) lm must be larger than lm.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0348.jp2"}, "349": {"fulltext": "REFRACTION AND ACCOMMODATION. 337\\nmay also be several spots of atrophied or thinned choroid,\\nbeyond the bounds of the crescent, and these also occur in\\nhorizontal lines near the y. s. Extensive choroidal changes\\nare generally assumed to be the result of choroiditis, \u00e2\u0080\u009cmy\u00c2\u00ac\\nopic choroiditis (p. 223). As a rule, the higher the M.\\nthe more extensive are the choroidal changes, but the rela\u00c2\u00ac\\ntion is by no means constant, and occasionally even in\\nhigh degrees we find no crescent. Hemorrhages may\\noccur from the choroid in the same region, and leave\\nsome residual pigment. Owing to the steepness of the\\nFro. 121.\\nLarge annular posterior staphyloma. (Liebreich.)\\nbulging the disk is often tilted and appears oval because\\nseen at three-quarter face\u00e2\u0080\u009d instead of full face,\u00e2\u0080\u009d Fig.\\n121. It is sometimes very pale on the side next the y. s.\\nwhen the staphyloma is large.\\nThere is in M. a great liability to liquefaction of, and\\nthe formation of opacities in, the vitreous, and, still worse,\\nto detachment of the retina. A large proportion of all\\nretinal detachments occur in myopic eyes. A blow on the\\neye sometimes appears to have caused the detachment,\\nthough often not until after a considerable interval. In\\nhigh degrees of M. the lens frequently becomes cataractous,\\n22", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0349.jp2"}, "350": {"fulltext": "338\\nCLINICAL DIVISION.\\nthe cataract generally being cortical and complicated with\\ndisease of the vitreous.\\nThus we arrive at a sum total of serious difficulties and\\nrisks to which myopic persons are subject, especially when\\nthe myopia is of high degree. It is only when the degree\\nis low (2 D. or less), and the condition stationary, that the\\npopular idea of short sight being strong sight is at\\nall borne out, or that the later onset of presbyopia (p. 362)\\ncounterbalances the disadvantages of bad distant vision.\\nCauses. M. is very rarely present at birth the elonga\u00c2\u00ac\\ntion of the globe which constitutes M. comes on gradually\\nduring the growing period of life, and especially between\\nthe ages of ten and twenty l the eye begins to elongate\\nduring childhood. Though M. is strongly hereditary, it\\nmay also begin independently, especially from the pro\u00c2\u00ac\\nlonged use of the eyes for near work. The strain on the\\ninternal recti, counterbalanced, it may be, by a corre\u00c2\u00ac\\nsponding tension on the external recti, is believed to act\\nby compressing the eyeball, and thus causing the unpro\u00c2\u00ac\\ntected posterior pole of the sclerotic to bulge. The con\u00c2\u00ac\\ncomitant tension of the ciliary muscle probably aids by\\nbringing on congestion of the uveal tract, as it certainly\\nappears to do of the disk, and thus predisposes to soften\u00c2\u00ac\\ning and yielding of the tunics; to this congestion the\\nhabit of stooping over the book or work contributes by\\nretarding the return of blood. It is evident that if such\\ncauses are able to start the disease they must constantly\\ntend to increase it. M. seldom increases after the age of\\ntwenty-five, unless under special circumstances; but gene\u00c2\u00ac\\nral enfeeblement of health, as after severe illness or pro\u00c2\u00ac\\nlonged suckling, seriously increases the risk of its progress,\\neven after middle life. Any condition in which during\\nchildhood better vision is gained by holding objects very\\n1 Recent examinations by Schleich and Germann upon several hundred\\ninfants show that the human eye is almost invariably hypermetropic at birth.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0350.jp2"}, "351": {"fulltext": "REFRACTION AND ACCOMMODATION. 339\\nclose is likely to bring on M.; and so we find it dispropor*\\ntionately common among those who from childhood have\\nsuffered from corneal nebulte, partial (especially lamellar)\\ncataract, severe choroiditis, or a high degree of astigma\u00c2\u00ac\\ntism. A bad supply, or bad arrangement, of light, bad\\nprint, and seats or desks so proportioned as to encourage\\nchildren to stoop over their lessons, are now generally\\nbelieved to be largely answerable for the production of\\nmyopia. It is, however, to be noted that some of the very\\nworst cases occur in persons who have never used their\\neyes for close observation of any kind.\\nTreatment. The treatment is divisible into (1) pro\u00c2\u00ac\\nphylactic and (2) remedial. 1. Much may be done to pre\u00c2\u00ac\\nvent M., or to check its increase when it has began, by\\nregulating the light, books, and desks used by children, so\\nas to remove the temptations to stooping. Children should\\nnot be allowed to read or work by flickering or dull light;\\nand as we write and read from L. to R., it is best, when\u00c2\u00ac\\never possible, to admit the light from the left, so that the\\nshadow of the pen is thrown toward the right, away from\\nthe object looked at. A myopic child should not be allowed\\nto fully indulge his bent, which is generally strong, for\\nexcessive reading. 2. By means of suitable glasses (a) dis\u00c2\u00ac\\ntant objects may be seen clearly\u00e2\u0080\u0094 i. e., the eye be rendered\\nemmetropic, (6) reading and working become possible at a\\ngreater distance. The strain on the internal recti usually\\nceases when the gaze is directed into the distance, whether\\nvision be distinct or not; glasses for distant vision have,\\ntherefore, no effect on the progress of the myopia, and are\\nof value only for educational purposes, that the patient\\nmay see what is about him as clearly as other people;\\ntheir use is, therefore, to a great extent optional. But if\\nwe can increase the distance of the natural far point (r)\\nfrom the eyes, we lessen the tension on the internal recti\\nin near vision, diminish the temptations to stooping and", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0351.jp2"}, "352": {"fulltext": "340\\nCLINICAL DIVISION.\\nto reading by bad light, and so help to check the progress\\nof the disease; hence glasses for near work are very impor\u00c2\u00ac\\ntant in the higher degrees of M. (3 D. and more) in early\\nlife. When M. has been stationary for years, however, the\\ndecision even on this point may be left to the patient.\\nBefore ordering glasses for either purpose we must\\nmeasure accurately the degree of M. In Fig. 122, let r\\nbe the far point, and let it be 25 cm. in front of the\\npatient\u00e2\u0080\u0099s eye, so that he can see nothing clearly at a\\ngreater distance than 25 cm.\\n(a) He is required to see distant objects (objects seen\\nunder parallel rays) clearly. A concave lens is interposed\\nof strength sufficient to give to jmrallel rays a degree of\\ndivergence, as if they came from r, Fig. 122. The focal\\nFig. 122.\\nMyopia corrected by concave lens.\\nlength of this lens will be the same as its distance from r;\\nand, as it is placed close to the eye, its focal length will be\\nvery nearly the same as (a little shorter than) the patient\u00e2\u0080\u0099s\\nfar point. Therefore, if we measure the distance of r from\\nthe patient\u00e2\u0080\u0099s eye, a lens of nearly the same focal length will\\nneutralize his M. He will choose a lens rather higher\\nthan this test would lead us to expect if the M. be uncom\u00c2\u00ac\\nplicated l while if, owing to complications, there be con-\\n1 It is sometimes stated that the glass chosen for distance is rather weaker\\nthan is indicated by the distance of r from the crystalline lens, the associated\\naccommodation having caused an apparent increase of M. This is true only\\nin low degrees of M., and not always in them most patients choose a rather\\nstronger lens than is indicated by r\u00e2\u0080\u0094 i. e., a lens whose focus is shorter by the\\ndistance between its own central point and the cornea.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0352.jp2"}, "353": {"fulltext": "REFRACTION AND ACCOMMODATION. 341\\nsiderable defect of vision, he will often choose a somewhat\\nlower glass. Hence, it is a good rule to begin the trial with\\na lens weaker than the one which, judging by the above\\ntest, we expect the patient to choose, and to try succes\u00c2\u00ac\\nsively stronger ones till the best result is reached. The\\nweakest concave glass which gives the best attainable sight\\nfor the distant test types (p. 48) is the measure of the M.,\\nand this glass, but not a stronger one may be safely worn\\nfor distant vision. Beginners often test M. patients with\\nconcave glasses for near types; neither nor glasses\\ngive any information about the refraction when used for\\nnear objects, since they merely either substitute or call\\ninto use the accommodation.\\n(6) A glass is needed with which the patient will be able\\nto read or sew at a distance greater than his natural far\\npoint. Theoretically the fully correcting glass (a) would\\nsuit, since it gives to all the rays a course which, in relation\\nto the myopic eye, is the same as that of the rays entering\\na normal eye. But this glass can seldom safely be allowed\\nin the higher degree of M. The lens which fully corrects\\nthe myopia diminishes the size of the retinal images so\\nmuch (p. 30) that the patient is tempted to enlarge them\\nagain by bringing the object nearer; again, the accommo\u00c2\u00ac\\ndation is often defective in the higher degrees of M., and,\\nas the fully correcting lens requires full accommodation,\\nit will lead to over-straining if this function be weakened,\\nand so cause discomfort, if nothing worse. For these two\\nreasons the rule is to give, for near work, a glass which\\nwill diminish the myopia, but not fully correct it. Glasses\\nfor near work are seldom needed unless M. exceed 3 D.\\nLet M. be 7 D., then r will be at 14 cm. (p. 40) from the\\neye. If a glass be required with which the patient shall\\nbe able to read at 30 cm., or which shall remove r from 14\\ncm. to 30 cm.\u00e2\u0080\u0094 i. e., shall leave the patient with M. 3 D.,\\nwe must correct the difference between 7 D. and 3 I) (7 D.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0353.jp2"}, "354": {"fulltext": "342\\nCLINICAL DIVISION.\\n3D. =4 D.); a concave lens of 4 D. will make rays\\nfrom 30 cm. diverge as if they came from 14 cm. But\\neven this partial correction may diminish the images so\\nmuch that, if vision be imperfect from extensive choroidal\\nchanges, reading at the increased distance will be difficult,\\nand the patient will prefer to bring the object nearer again\\nat the expense of his accommodation, and will thus be in\u00c2\u00ac\\nconvenienced instead of bettered; it is, therefore, often\\nadvisable, even for partial correction, to order a weaker\\nlens than is optically correct.\\nPreponderance of the external over the internal recti,\\ninsufficiency of convergence, p. 332, if not cured by par\u00c2\u00ac\\ntially correcting glasses, may be treated by division of the\\nexternal rectus of one or both eyes, but not until after an\\neffort has been made to strengthen convergence by means\\nof properly regulated prismatic exercise. For this pur\u00c2\u00ac\\npose the patient fixes his gaze upon a point of light 20\\nfeet away, while the strongest prisms, bases out, with which\\nthe patient can fuse the light are placed in a spectacle\\nframe (Fig. 123). After regarding the light a few mo-\\nFig. 123.\\nments, the eyes being still fixed upon it, the prisms are\\nraised and the convergent effort relaxed; after a few\\nmoments the prisms are again lowered before the eyes, and\\nthis alternate lowering and raising of the prisms, and the\\nconsequent stimulation and relaxation of the convergence,\\npersisted in for five minutes. These exercises should be\\nrepeated three times daily, and the strength of the prisms\\nincreased as the patient is found to be able to fuse higher", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0354.jp2"}, "355": {"fulltext": "REFRACTION AND ACCOMMODATION. 343\\nones. By this procedure the power of adduction is fre\u00c2\u00ac\\nquently carried to 100\u00c2\u00b0 within a few weeks, with great\\nrelief to the asthenopia. Marked benefit will be also\\nobtained by the internal administration of tincture of nux\\nvomica, especially if the drug be given until symptoms\\nof its physiological action appear. Tenotomy of the ex\u00c2\u00ac\\nternal rectus muscle may always be done when there is a\\nmarked divergent squint, even if the squint be variable.\\nPrismatic spectacles (p. 26), the bases of the prisms being\\ntoward the nose, are occasionally serviceable for reading in\\ncases of slight muscular insufficiency. By deflecting the\\nentering light toward their bases, Fig. 16, the prisms give\\nto rays from a certain near point a direction as if they\\ncame from a greater distance, and thus lessen the need for\\nconvergence of the optic axes. The prisms may be com\u00c2\u00ac\\nbined with concave lenses.\\nM. may also be caused by an increase of the curvature,\\nor of the refractive power of the media, myopia of curva\u00c2\u00ac\\nture. Thus in conical cornea (p. 149) the curvature of the\\ncentral part of the cornea is increased\u00e2\u0080\u0094 i. e., its focal length\\nshortened, and the principal focus of the lens-system lies\\nin front of the retina, often very far in front, without any\\nchange of place of the parts at the back of the eye. M.,\\nusually of low degree, often comes on in commencing senile\\ncataract (p. 198) from a shortening of the focal length of\\nthe crystalline lens, doubtless due to increase of refractive\\nindex (p. 17). M. is sometimes simulated in H., and actual\\nM. increased by needless and uncontrollable action of the\\nciliary muscle\u00e2\u0080\u0094spasm of accommodation. Removal of the\\nlens has lately been extensively practised in the treatment\\nof myopia of high degree, 15 D. and upward. The pub\u00c2\u00ac\\nlished results of operations show that this treatment is of\\nadvantage in preventing the progressive stretching of the\\ntunics of the eye, and in making vision more comfortable.\\nThe lens is best removed by discission, without removal", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0355.jp2"}, "356": {"fulltext": "344\\nCLINICAL DIVISION.\\nof any of the lens matter unless glaucomatous symptoms\\nsupervene. An interesting fact in regard to the extraction\\nof the lens in myopia is that the amount of reduction in\\nthe refraction of the eye is much greater than one would\\na priori expect. Thus, it is found at times that after\\nremoval of the lens the refraction has changed as much as\\n15 to 20 D., whereas one would expect but a reduction of\\n10 D., the supposed refractive power of the crystalline lens.\\nHypermetropia (H.).\\nH. is optically the reverse of M. It is one of the most\\ncommon conditions we have to treat. The eyeball is too\\nshort, axial hypermetropia so that when the accommoda\u00c2\u00ac\\ntion is relaxed the retina lies within the principal focus of\\nthe eye. As rays from an object within the principal focus\\nof a convex lens emerge from the lens divergent, Figs. 10\\nand 13, so pencils of rays leaving a hypermetropic eye are\\nFig. 124.\\nHypermetropia. Parallel rays focussed behind retina. Rays already\\nconvergent focussed on retina.\\ndivergent, Fig. 127; and, conversely, only rays already\\nconvergent can be focussed on the retina. H. always\\ndates from birth, and does not afterward increase, except\\nslightly in old age. But it may diminish and even give\\nplace to M. by elongation of the eye. Iu Fig. 124 the\\ncurved line representing the retina is in front of f, com\u00c2\u00ac\\npare Fig. 115. Parallel rays will, after passing through\\nthe lens, meet the retina before focussing and form a blurred\\nimage, while divergent rays, meeting the retina still further", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0356.jp2"}, "357": {"fulltext": "REFRACTION AND ACCOMMODATION. 345\\nfrom their focus, will form an even worse image, compare\\nFig. 116; hence neither distant nor near objects will be\\nseen clearly. But by using accommodation the focal length\\ncan be shortened until the focus falls upon the retina Fig.\\n125, and distant objects are then seen clearly; and addi-\\nFig. 125.\\nIlypermetropia corrected by accommodation. Parallel rays focussed\\non retina.\\ntional accommodation will give also distinct vision of near\\nobjects, compare Fig. 116. A little consideration will show\\nthat the competence of the ciliary muscle to give these re\u00c2\u00ac\\nsults will depend in any given case (1) on the degree of\\nadvancement of the retina in front of f\u00e2\u0080\u0094 i. e., on the de\u00c2\u00ac\\ngree of shortening of the eye; and (2) on the strength of\\nAcc.\u00e2\u0080\u0094 i. e., on the extent to which the focal length of the\\nlens can be altered.\\nFig. 126.\\nIlypermetropia corrected by a convex lens whose focus coincides with the\\nvirtual focus of the retina.\\nThe same result may be gained by placing a convex lens\\nin front of the eye, instead of using the accommodation. In\\na given case, Acc. being relaxed, let the ray, a, Fig. 126,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0357.jp2"}, "358": {"fulltext": "346\\nCLINICAL DIVISION.\\non leaving the eye diverge from the axis as if it proceeded\\nfrom a point v. f., compare Fig. 13, 25 cm. behind the\\ncornea. If the ray a parallel with the axis, pass through\\na convex lens, l, of 25 cm. focal length held close to the eye,\\nit will be made to converge toward this same point, and,\\ntherefore, in accordance with 12 (p. 22) will be focussed\\non the retina at a.\\nFig. 127 may be taken for a section of a very highly\\nhypermetropic eye, the rays emerging from which are\\ndivergent. The image formed on the retina of a hyper\u00c2\u00ac\\nmetropic eye is smaller than that of the same object placed\\nat the same distance from a normal eye (p. 30).\\nFig. 127.\\nCourse of the rays emerging from a hypermetropic eye.\\nIn old age the refractive power of the crystalline lens\\nseems normally to diminish, and, therefore, an eye origin\u00c2\u00ac\\nally emmetropic becomes unable to focus parallel rays on\\nthe retina; this condition causes slight acquired liyperme-\\ntropia, and begins at the age of sixty-five.\\nSymptoms and Results of H. The direct symptoms\\nare due to insufficiency of the accommodation for distinct\\nvision of any object, whether near or distant, requires Acc.\\nproportionate to the degree of shortening of the eye, and\\nthe absolute power (amplitude) of Acc. is not increased in\\nH., at any rate not enough to meet the demand.\\nIf H. is slight or moderate and Acc. vigorous, no incon-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0358.jp2"}, "359": {"fulltext": "REFRACTION AND ACCOMMODATION. 347\\nvenience is felt either for near or distant vision. But if\\nAcc. have been weakened by disease or ill-health, or have\\nfailed with age, the patient will complain that he can no\\nlonger see near objects clearly for long together; that the\\neyes ache or water, or that everything \u00e2\u0080\u009cswims\u00e2\u0080\u009d or be\u00c2\u00ac\\ncomes \u00e2\u0080\u009cdim\u00e2\u0080\u009d after reading or sewing for a short time,\\naccommodative asthenopia There is not usually much com\u00c2\u00ac\\nplaint of defect for distant objects. Many slight or mod\u00c2\u00ac\\nerately H. patients find no inconvenience till twenty-five\\nor thirty years of age, when Acc. has naturally declined\\nby nearly one-half. Women are often first troubled after\\na long lactation, and other persons after prolonged study\\nor desk-work, or when suffering from chronic exhausting\\ndiseases. Children often complain of watering, blinking,\\nand headaclie, rather than of dimness (see also p. 279).\\nIn very high degrees of H., as a large part of the Acc.\\nis always needed from childhood upward for distant sight,\\neven the strongest effort does not suffice to give clear\\nimages of near objects, which consequently such a person\\nnever sees well. Such patients often partially compensate\\nfor the dimness of near objects by bringing them still\\nnearer, thus enlarging the visual angle and increasing the\\nsize of the retinal images (p. 30). This symptom may be\\nmistaken for M., but can be distinguished by the want of\\nuniformity in the distance at which the patient places\\nhis book, and by his being often unable, at any dis\u00c2\u00ac\\ntance whatever, to see the print easily or to read fluently.\\nIn the highest degrees even distinct distant vision is not\\nconstantly maintained, the patient often being content to let\\nhis accommodation rest except when his attention is roused.\\nAs age advances, a point is reached, even in moderate\\ndegrees of H., at which Acc. no longer suffices even for\\ndistant, and much less for near vision. Such persons tell\\nus that they early took to glasses for near work, but add\\nthat lately the glasses have not suited, and that they are", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0359.jp2"}, "360": {"fulltext": "348\\nCLINICAL DIVISION\\nnow unable to see clearly either at long or short distances.\\nOphthalmoscopic examination shows no change except H.,\\nand suitable convex glasses at once raise distant vision to\\nthe normal. Occasionally photophobia, conjunctival irri\u00c2\u00ac\\ntation, and redness are present in H., but the first-named\\nsymptom is less common than in M. (see p. 278). The most\\nimportant indirect result of H. is convergent strabismus (see\\np. 368).\\nTreatment. The treatment of H. consists in removing\\nthe necessity for overuse of Acc. by prescribing convex\\nspectacles, which, in proportion to their strength, supply\\nthe place of the increased convexity of the crystalline lens\\ninduced by Acc. In theory, the whole Acc. ought to be\\ncorrected by glasses in every case, and the eye be rendered\\nemmetropic. But in practice we find it often better to\\ngive a weaker glass, at least for a time.\\nIf Acc. in a H. eye be in abeyance (paralyzed by atro\u00c2\u00ac\\npine) vision for distant objects will be distinct only if the\\nrays pass through a convex lens, held in front of the eye,\\nwhose focus coincides with the virtual focus of the retina\\n(p. 345, Fig. 126). The strength of this lens is the measure\\nof the H.; thus the patient has H. 2 D. if a convex lens\\nof 50 cm. focal length is necessary for this purpose.\\nBut if Acc. be intact, then, as it has constantlv to be\\nused for distant sight, the patient is often unable to relax\\nit fully, when a corresponding convex lens is placed in\\nfroat of the eye; he will relax only a part, and this part\\nwill be measured by the strongest convex lens with which\\nhe can see the distant types clearly. That part of the H.\\nwhich can be detected by this test is called manifest\u00e2\u0080\u009d\\n(m. H.). The part remaining undetected, because corrected\\nby the involuntary use of Acc., is latent (1. H.). The sum\\nof the m. H. and 1. H. is the total H.\\nNow, most H. people can habitually use some Acc. for\\ndistance, and a corresponding excess for near vision with-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0360.jp2"}, "361": {"fulltext": "REFRACTION AND ACCOMMODATION. 349\\nout inconvenience, and hence the full correction of H. is\\nby no means always needful, or even agreeable to the\\npatient. In many cases the correction of the m. H. is\\nenough to relieve the asthenopic symptoms, at any rate\\nfor a considerable time; but we often find that after wear\u00c2\u00ac\\ning these glasses for some weeks or months the symptoms\\nreturn, and a fresh trial will show a larger amount of m.\\nH., which must then again be corrected by a correspond\u00c2\u00ac\\ning increase in the strength of the glasses. This process\\nmay have to be repeated several times until after a few\\nmonths the total H. becomes manifest and may be cor\u00c2\u00ac\\nrected. This method is most suitable for adults in whom\\nthe use of atropine to paralyze Acc., and allow the imme\u00c2\u00ac\\ndiate estimation of the total H., is inconvenient or impos\u00c2\u00ac\\nsible or for whom the glasses which correct the total H.,\\nas estimated by the ophthalmoscope, without atropiniza-\\ntion are found, if ordered at once, to be inconveniently\\nstrong. But for children there is seldom any gain and\\noften no little inconvenience from following this gradual\\nplan; with them the better way is to estimate the total\\nH., and to order glasses slightly (about 1 D.) weaker than\\nthat amount.\\nTo Examine for H. 1. For m. H. Note the patient\u00e2\u0080\u0099s\\nvision for distant types at 6 m., then hold in front of his\\neyes a very weak convex lens 0.5 D.), and if he sees\\nas well, or better, with it, go to the next stronger lens,\\nand so on until the strongest has been found which allows\\nthe best attainable distant vision; this lens is the measure\\nof the m. H.\\n2. For H. (total). The easiest and most certain plan is\\nto direct the patient to use strong atropine drops (F. 33)\\nthree times a day for at least two days, and then to test his\\ndistant vision with convex glasses. As in (1), the strongest\\nlens which gives the best attainable sight is the measure of\\nthe H.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0361.jp2"}, "362": {"fulltext": "350\\nCLINICAL DIVISION.\\nOphthalmoscopic Tests. 3. The image of the disk\\nseen by the indirect method becomes smaller when the lens\\nis withdrawn from the eye, Fig. 119, B.\\n4. The shadow test is described at p. 75.\\n5. By direct examination an erect image is seen at what\u00c2\u00ac\\never distance the observer be from the patient (p. 74). The\\noberver may learn, as stated at p. 74, to estimate H. with\\nalmost as great accuracy with a refraction ophthalmoscope\\nas by trial lenses, and this plan, like the shadow test, is\\nextremely valuable with children who are too young or too\\nbackward to give good answers. The total, or nearly the\\ntotal H. may often be found in this way without atropine\\nif the examination be made in a dark room, for then Acc.\\nis generally quite relaxed, however persistently it may\\nhave acted when the patient was able to look attentively\\nat objects in the light. The objective estimates, 4 and 5,\\nhowever, are more easily made after the use of atropine.\\nThe next question is, whether the glasses are to be worn\\nalways, or only when Acc. is specially strained\u00e2\u0080\u0094 i. e., in\\nnear work. They are to be worn constantly (1) whenever\\nwe are attempting to cure a squint by their means; (2) in\\nall cases of high H. in children, wdiether with or without\\nstrabismus. But patients who come under care for the\\nfirst time, as young adults, in whom the H. is, as a rule,\\nof moderate or low degree, may generally be allowed to\\nwear them only for near work. Elderly persons require\\ntwo pairs\u00e2\u0080\u0094one for distance, neutralizing the m. H., the\\nother stronger, neutralizing the presbyopia also, for near\\nwork (p. 361) the use of the former may, however, be left\\nto the patient\u00e2\u0080\u0099s choice.\\nHypermetropia is frequently associated more or less with\\nhigh degrees of esophoria, and the oculist will labor in\\nvain who corrects the ametropia without considering the\\nmuscle error. In most cases the constant wearing of as\\nnearly a full correction as can be borne with comfort will", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0362.jp2"}, "363": {"fulltext": "REFRACTION AND ACCOMMODATION. 351\\nbe efficacious in establishing a more normal muscle-balance\\nin other instances, however, further measures will be neces\u00c2\u00ac\\nsary.\\nUnlike in exophoria, in which the Editor has had most\\nexcellent results follow strengthening convergence by\\nmeans of prismatic exercise, in esophoria, exercise for the\\ndevelopment of the externi has been without beneficial\\neffect. On the other hand, however, he has found a par\u00c2\u00ac\\ntial correction of the esophoria by means of prisms, bases\\nout, incorporated into the lenses which correct the hyper-\\nmetropia, to be most efficacious in this class of cases. In\\naddition to this, tincture of belladonna, hyoscyamus, or\\nsome of the other sedatives should be given in as large\\ndoses as can be borne, to diminish the spasm or abnormal\\ncontraction of the adductors.\\nAstigmatism (As.).\\nIn the preceding cases (M. and H.) the refracting sur\u00c2\u00ac\\nfaces of the eye (the front of the cornea and the two sur\u00c2\u00ac\\nfaces of the lens) have been regarded as segments of spheres,\\nAll the rays of a cone of light which issue from a round\\nspot and pass through such a system are, neglecting\\nspherical aberration,\u00e2\u0080\u009d Fig. 9, equally refracted, and\\nmeet one another at such a single point\u00e2\u0080\u0094the focus of the\\nsystem. For if such a cone of incident light be looked\\nupon as composed of a number of different planes of rays,\\nsituated radially around the axis of the cone, the rays situ\u00c2\u00ac\\nated in any plane, say the vertical, will, after passing\\nthrough the lens-system, meet behind it at its focus, while\\nthose forming any other plane, as the horizontal, will meet\\nat the same point.\\nBut let the curvature, and, therefore, the refractive power\\nof one of the media, for instance, the cornea, be greater in\\none meridian, say the vertical, than in the horizontal, then\\nthe vertical-plane rays will meet at their focus, while the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0363.jp2"}, "364": {"fulltext": "352\\nCLINICAL DIVISION.\\nhoizontal-plane rays at the same distance, not having yet\\nmet, will, if received on a screen, form a horizontal line\\nof light. If the intermediate meridians had regularly\\nintermediate focal lengths, they would form at the same\\nplace lines of intermediate lengths, and the image of the\\nround spot of light, if caught on a screen at this distance,\\nwould form a horizontal oval. To a retina receiving such\\nan image, the round point of light would appear drawn\\nout horizontally. Such an eye is called astigmatic, be\u00c2\u00ac\\ncause unable to see a point as such; all round points\\nappearing drawn out more or less into lines.\\nA little reflection will show that in the same case, at the\\nfocal point of the hoizontal-plane rays, the rays of the\\nvertical plane will already have met and crossed, and\\nthat the image at this point will form a vertical oval.\\nIf the screen be placed midway between these two\\nextreme points, the image will be circular, but blurred,\\nbecause the vertical-plane rays will have crossed and\\nbegan to separate, while the horizontal ones will not yet\\nhave met, and each set will be equally distant from its\\nfocus. The meridians of the astigmatic medium which\\nrefract most, shortest focus, and least, longest focus, are\\nthe principal meridians. The distance between their foci is\\nthe focal interval, and represents the degree of astigmatism.\\nThe astigmatism of the eye may be regular or irregular.\\nIn regular astigmatism, the meridians of greatest and least\\nrefractive power, principal meridians,\u00e2\u0080\u009d are always at\\nright angles to each other; and every meridian is nearly\\na segment of a circle. Of the principal meridians, the\\nmost refractive, the one with shortest focal length, is, as a\\nrule, vertical, or nearly so, and the least refractive, there\u00c2\u00ac\\nfore, horizontal, or nearly so. The cornea is the principal\\nseat of this asymmetry. The crystalline lens, however,\\nis also astigmatic to a less degree, and its meridians of\\ngreatest and least curvature are usually so arranged as", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0364.jp2"}, "365": {"fulltext": "REFRACTION AND ACCOMMODATION.\\n353\\nin some degree to neutralize those of the cornea; it thus\\npartially corrects the corneal error. Corneal astigmatism\\nis often caused by operations for cataract or iridectomy (p.\\n209).\\nRegular astigmatism is corrected by a lens which equal\u00c2\u00ac\\nizes the refraction in the two principal meridians. Such\\na lens must be a segment of a cylinder, instead of, like an\\nordinary lens, a segment of a sphere. Rays traversing a\\ncylindrical lens in the plane of the axis of the cylinder are\\nnot refracted since the surfaces of lens in this direction are\\nparallel; but rays traversing it in all other planes are re\u00c2\u00ac\\nfracted more or less, and most in the plane or meridian at\\na right angle with the axis.\\nIrregular astigmatism may be caused either by irregu\u00c2\u00ac\\nlarities of the cornea, arising from ulceration, inflamma\u00c2\u00ac\\ntion, or conicity 1 (p. 149); or by various conditions of the\\ncrystalline lens, such as differences of refraction in its\\nvarious sectors, tilting or lateral dislocation of the lens, so\\nthat its axis no longer corresponds, as it should nearly do,\\nwith the centre of the cornea. Irregular astigmatism\\ncauses much distortion of the ophthalmoscopic image,\\nespecially when the object lens is moved from side to side.\\nIt is seldom much benefited by glasses.\\nReturning to regular astigmatism it will be seen that\\nthe optical condition of the eye depends upon the position\\nof the retina in respect to the focal interval. In the fol\u00c2\u00ac\\nlowing diagram, Fig. 128, let the most refractive meridian\\nbe vertical, and its focus be called a, the least refracting\\nmeridian horizontal and its focus b. The astigmatism is\\nhere represented as caused by altered position of the retina\\nin different planes, instead of by altered curvature of the\\n1 There can be little doubt from clinical observation with a refraction oph\u00c2\u00ac\\nthalmoscope, that corneal As. is often complicated by the curvature of each\\nmeridian being naturally more or less elliptical instead of circular, and this\\nwithout any tendency toward \u00e2\u0080\u009ccouical cornea,\u00e2\u0080\u009d as commonly understood.\\n23", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0365.jp2"}, "366": {"fulltext": "354\\nCLINICAL DIVISION.\\ncornea in different planes, the diagram being, of course,\\nonly intended to aid the comprehension of the principle.\\n1. Let a fall on the retina (1, Fig. 128), and b, therefore,\\nbehind it. There is E. in the vertical meridian, and there\u00c2\u00ac\\nfore H. in the horizontal meridian; this is simple H. As.\\n2. Let b fall on the retina, 2, Fig. 128, and a in front of\\nit. The horizontal meridian is, therefore, E., and the ver\u00c2\u00ac\\ntical meridian M.; simple M. As. 3. Let a and b both\\nlie behind the retina (3, Fig. 128). There is H. in both\\nmeridians, but more in the horizontal than the vertical\\nmeridian compound H. As. 4. a and b are both in front\\nPig. 12S.\\nof the retina (4, Fig. 128). There is M. in both meridians,\\nbut more in the vertical than the horizontal; compound\\nM. As. 5. a is in front of the retina and b behind it (5,\\nFig. 128). There is M. in the vertical and IT. in the hori\u00c2\u00ac\\nzontal meridian; mixed As.\\nThe general symptoms of As. resemble those caused by\\nthe simpler defects of refraction; but attention to the\\npatient\u00e2\u0080\u0099s complaints, and to the manner in which he uses\\nhis eyes, will, in the higher degrees, often give the clue to\\nits presence. Low degrees, especially of simple TI. As.,\\noften give rise to no inconvenience till rather late in life.\\nAs. is most commonly met with in connection with H., be\u00c2\u00ac\\ncause H. is so much more common than M. But it is said to\\noccur with greater relative frequency in M., when, if com\u00c2\u00ac\\nplications be present, it may, if not of high degree, be", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0366.jp2"}, "367": {"fulltext": "REFRACTION AND ACCOMMODATION. 355\\nreadily overlooked unless specially sought for. The higher\\ngrades of As. cause much inconvenience, no objects being\\nseen clearly; and spherical glasses, though of use if the\\nAs. be compound, are nearly useless if it be simple. As.\\nis always to be suspected if, with the best attainable spher\u00c2\u00ac\\nical glasses, distant vision is less improved than it ought to\\nbe, supposing of course that no other changes are present\\nto account for the defect. No definite rule can be laid\\ndown as to the degree of defect which should raise the sus\u00c2\u00ac\\npicion of As.; indeed, in the higher degrees of even simple\\nM. and H., acuteness of vision is often below normal (pp.\\n271 and 337). It is possible that in young persons with\\nvigorous accommodation the astigmatism of the cornea is\\npartly corrected by the ciliary muscle acting unequally on\\nthe different meridians of the lens, and that the seemingly\\ngreater frequency of astigmatism in the presbyopic is due\\nto the impairment of this power.\\nAs. may be measured either by trial with glasses, by the\\nshadow test (p. 75), or by ophthalmoscopic estimation (p.\\n78) of the refraction of the retinal vessels in the two chief\\nmeridians. A comparatively easy qualitative test is found\\nin the apparent shape of the disk, which, instead of being\\nround, is more or less oval. In the erect image the long\\naxis of the oval corresponds to the meridian of greatest re\u00c2\u00ac\\nfraction. and is, therefore, as a rule, nearly vertical, Fig. 129.\\nIn the inverted image, Fig. 130, the direction of the oval\\nis at right angles to the above, provided that the object lens\\nbe nearer than its own focal length to the eye. As. is sus\u00c2\u00ac\\npected when, in the erect image, an undulating retinal\\nvessel appears clear in some parts and indistinct in others,\\nan appearance which may be taken for retinitis if the ex\u00c2\u00ac\\namination be confined to the erect image. It may be imi\u00c2\u00ac\\ntated by looking at a wavy line through a cylindrical lens.\\nIn the indirect examination the shape of the disk changes\\non withdrawing the lens from the patient\u00e2\u0080\u0099s eye. It will be", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0367.jp2"}, "368": {"fulltext": "356\\nCLINIC A L DI VISION.\\nremembered that in M. the image increases as the lens is\\nwithdrawn (p. 334, 2), that in E. its size remains the same,\\nFig. 129.\\nFig. 130.\\nErect image of disk in astigma\u00c2\u00ac\\ntism, with meridian of greatest re\u00c2\u00ac\\nfraction nearly vertical. (Wecker\\nand Jaeger.)\\nThe same disk seen by the\\nindirect method. (Wecker\\nand Jaeger.)\\nwhile in H. it diminishes, Fig. 119. Thus, in a case of\\nsimple M. As. in the vertical meridian, that dimension of\\nthe disk which is seen through the vertical meridian will\\nenlarge on distancing the lens; from being oval horizon\u00c2\u00ac\\ntally when the lens is close to the eye, it becomes first\\nround and then oval vertically on withdrawing the lens.\\nIn the other forms of As. the same holds true; the image\\nenlarges either absolutely as in M. As., or relatively as in\\nH. As., in the direction of the most refracting meridian.\\nThe subjective tests for As. are very numerous, but all\\ndepend on the fact that if an astigmatic eye look at a\\nnumber of lines drawn in different directions, some will be\\nseen more clearly than others. The form of this test is not\\na matter of great consequence, provided that the lines are\\nclear, not too fine, and are easily visible with about half the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0368.jp2"}, "369": {"fulltext": "REFRACTION AND ACCOMMODATION. 357\\nnormal V. at from 3 m. to 6 m. The forms resembling a\\nclock-face with bold Roman figures at the ends of the radii\\nare very convenient, and I prefer the pattern recommended\\nby Mr. Brudenell Carter (see Appendix) to any other that\\nI have used. On this face are three parallel black lines\\nseparated by equally wide white spaces, and which collec\u00c2\u00ac\\ntively form a hand\u00e2\u0080\u009d that can be turned round into the\\npositions of best and worst vision.\\nThe easiest case for estimation is one of simple H. As.,\\nin which the eye is under atropine. Many cases of simple\\nM. As. are almost as easy to test. In a given case let the\\neye be E. in the vertical meridian, and H. in the horizon\u00c2\u00ac\\ntal. With Acc. paralyzed, rays refracted by the vertical\\nmeridian will be accurately focussed on the retina, while\\nthe focus of those refracted by the horizontal meridian will\\nbe behind the retina, Fig. 128, 1, and consequently form\\non it a blurred image. Now the rays which strike in the\\nplane of the vertical meridian are those which come from\\nthe borders of horizontal lines; hence the patient under\\nconsideration will see the lines at a distance of 3 m. to 6\\nm. quite clearly when the \u00e2\u0080\u009chand\u00e2\u0080\u009d is horizontal, except\\ntheir ends, which will be blurred. The rays which strike\\nin the plane of the horizontal meridian are those which\\nproceed from the sides of vertical lines, and as this meri\u00c2\u00ac\\ndian is hypermetropic, the lines in the hand,\u00e2\u0080\u009d when\\nplaced vertically, will be indistinct, except their ends,\\nwhich will be sharply defined. We now leave the hand\u00e2\u0080\u009d\\nvertical, and test the refraction for the lines in this position\\n(i. e., for the horizontal meridian) in the ordinary way and\\nfind, e. g., that with -j-2 D, they are seen most clearly,\\nthough not perfectly. On substituting for the spherical\\nglass, -j- 2 D. cylinder with its curvature horizontal\u00e2\u0080\u0094 i. e.,\\nits axis vertical, the lines of the hand and all the figures\\non the clock will be seen perfectly; the vertical lines and\\nfigures will be seen through the horizontal meridian cor-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0369.jp2"}, "370": {"fulltext": "358\\nCLINIC A L I) I VISION.\\nrected by the cylinder lens, and the horizontal figures\\nthrough the unaided vertical meridian, the rays which\\npass through the cylinder in this meridian not being re\u00c2\u00ac\\nfracted.\\nIn a case of simple M. As. in the vertical meridian the\\nlines of the hand\u00e2\u0080\u009d will be dull or invisible when hori\u00c2\u00ac\\nzontal, while when vertical they will be clear. On trial a\\nconcave cylinder will be found, which with its curvature\\nvertical, axis horizontal, makes the lines of the hand quite\\nclear when horizontal, and all the figures quite plain.\\nThe cases of compound and mixed As. are less easily\\ndealt with by this test. It is generally best to find, in the\\nusual way, the spherical glass which gives the best result\\nfor the distant types, and then, arming the eye with this\\nglass, to test for As., with the clock-face and cylindrical\\nlenses, as in the simple cases described above. As the\\nletters of Snellen\u00e2\u0080\u0099s distant types are made up of lines run\u00c2\u00ac\\nning in various directions, As. can be very well tested with\\nthese, and in actual practice the clock-face is not necessary\\nin most cases.\\nWe may use, instead of a cylindrical glass, a narrow slit\\nin a round plate of metal which can be placed in the direc\u00c2\u00ac\\ntion of either of the chief meridians, the spherical glass\\nbeing then found with which, in each meridian, the patient\\nsees best. One chief meridian may be ascertained by find\u00c2\u00ac\\ning the direction of the slit which gives the best sight with\\nthe spherical glass chosen in the preliminary examination,\\nand the other meridian by finding the glass which gives\\nthe best result with the slit at a right angle to the former\\ndirection.\\nAnother method, that of Javal, consists in making the\\npatient highly myopic for the time being, by means of a\\nconvex lens, unless he be myopic already then accurately\\nfinding his far point for the least myopic meridian, and", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0370.jp2"}, "371": {"fulltext": "REFRACTION AND ACCOMMODATION. 359\\nlastly finding the concave cylinder which is needed to re\u00c2\u00ac\\nduce the opposite meridian to the same refraction.\\nOphthalmoscopic estimation and retinoscopy, however,\\nsave much time, especially in mixed As. If As. he meas\u00c2\u00ac\\nured by direct ophthalmoscopic examination, we may re\u00c2\u00ac\\nmember that the axis of the correcting cylinder will be\\nparallel to the vessel used as a guide to either of the chief\\nmeridians; and that in retinoscopy the same axis is par\u00c2\u00ac\\nallel to the edge of the shadow. Thus if a vertical vessel\\nbe clearly seen with 2 D., the horizontal vessels being\\nbest seen with no lens, retinoscopy will also show H. 2 D.\\nfor the shadow moving horizontally\u00e2\u0080\u0094 i. e., with a vertical\\nedge, and the patient will choose a cylinder of -f 2 D.\\nwith its axis vertical\u00e2\u0080\u0094 i. e., its curvature horizontal be\u00c2\u00ac\\ncause the horizontal meridian of his eye has H. 2 D., the\\nvertical meridian being E.\\nWhatever means be employed, the degree of As. is ex\u00c2\u00ac\\npressed by the difference between the glasses chosen for\\nthe two chief meridians; or by the cylindrical lens which,\\nadded to the chosen spherical, gives the best result for the\\nlines or the distant types. When cylindrical glasses are\\nordered the whole of the astigmatism should be corrected.\\nIt is not usually necessary to correct astigmatism of less\\nthan 1 D. but exceptions to this rule are not uncommon,\\nsome patients deriving marked relief from the correction\\nof lower grades.\\nVision is often defective in As., and in the high degrees\\nwe are often obliged to be content with a very moderate\\nimprovement at the time of examination. This may some\u00c2\u00ac\\ntimes be explained by the retina never having received\\nclear images\u00e2\u0080\u0094 i. e., never having been accurately practised\\n(p. 271); V. in such cases often improves after proper\\nglasses have been worn for some months. In other cases\\nirregular As. is the cause of the defect. Much also de\u00c2\u00ac\\npends on the intelligence of the patient; some persons are", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0371.jp2"}, "372": {"fulltext": "360\\nCLINICAL D T VIS TON.\\nfar more appreciative of slight changes in the power, or in\\nthe direction of the axis of the cylinder than others, and\\nthis apart from the absolute acuteness of sight.\\nUnequal refraction in the two eyes (Anisometropia). It\\nis common to find that one eye has more H., more M., or\\nmore As. than its fellow; or that one is normal while the\\nother is ametropic. When the difference is not more than\\nis represented by 1.5 D., and Y. is good in both (see p.\\n271), the refraction may with advantage be equalized by\\ngiving the glasses which correct each eye, and the devel\u00c2\u00ac\\nopment of divergent squint may sometimes be prevented\\nby the increased stimulus to binocular vision thus given.\\nBut equalization is seldom possible if the difference be\\ngreater, though, especially in myopic cases, advantage is\\nsometimes gained by partial equalization. On the other\\nhand, some patients, probably those who do not possess\\nbinocular vision, will not permit even a partial equaliza\u00c2\u00ac\\ntion. When no attempt is made to harmonize the eyes,\\nthe spectacles ordered should suit the less ametropic eye.\\nOften, when one eye is E. and the other M., each is used\\nseparately for different purposes, and both remain perfect;\\nbut if one be As. or very H., it is generally defective from\\nwant of use.\\nIn anisometropia the Editor has found that hyperphoria\\nis present in all cases in which the difference in refraction\\nbetween the eyes is at all marked, even when associated\\nwith a moderate degree of esophoria or exophoria; conse\u00c2\u00ac\\nquently if binocular vision be aimed at, a partial correc\u00c2\u00ac\\ntion of the hyperphoria should always be attempted by\\nincorporating vertical prisms into the correcting lenses.\\nContrary to what might be expected, anisometropia is\\nseldom, if ever, corrected by unequal action of the two\\nciliary muscles.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0372.jp2"}, "373": {"fulltext": "REFRACTION AND ACCOMMODATION. 3G1\\nPresbyopia (Pr.).\\nPresbyopia, old sight, often called long-sight,\u00e2\u0080\u009d is the\\nresult of gradual recession of p, which takes place as life\\nadvances, and which causes curtailment of the range or\\namplitude of Acc. (p. 50). From the age of ten (or ear\u00c2\u00ac\\nlier) onward, p is constantly receding from the eye. When\\nit has reached 9\u00e2\u0080\u009d (22 cm.)\u00e2\u0080\u0094 i. e., when clear vision is no\\nlonger possible at a shorter distance than 22 cm., Pr. is\\nsaid to have begun. The standard is arbitrary, 22 cm.\\nhaving been fixed by general agreement as the point be\u00c2\u00ac\\nyond which p cannot be removed without some inconveni\u00c2\u00ac\\nence, the point where age begins to tell on the practical\\nefficiency of the eyes unless glasses are worn. In the nor\u00c2\u00ac\\nmal eye this point is reached soon after forty, and the rate\\nof diminution is so uniform that the glasses required to\\nbring p to 22 cm. may often, if necessary, be determined\\nmerely from the patient\u00e2\u0080\u0099s age. But as there are exceptions\\nto this rule, even for normal eyes, and as allowance has to\\nbe made for any error of refraction (H. or M.), it is unsafe\\nin practice to rely upon age except as a general guide.\\nThe slow failure of Acc., causing Pr., depends upon senile\\nchanges in the lens, which render it firmer and less elastic,\\nand therefore less responsive to the action of the ciliary\\nmuscle. There can be little doubt, however, that failure\\nof the ciliary muscle itself, or of its motor nerves, also\\nforms an important factor in those cases where Pr. comes\\non earlier or more quickly than usual; but it is a curious\\nfact that in these cases of premature Pr. the mobility of\\nthe iris is not affected..\\nAs Pr. depends on a natural recession of the near point,\\nit occurs in all eyes, whether their refraction be E., M., or\\nH. In M., however, Pr. sets in later than in a normal\\neye, because for the same range of Acc. the region is always\\nnearer than in the normal eye. In H., on the contrary,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0373.jp2"}, "374": {"fulltext": "CLINICAL DIVISION.\\n362\\nPr. is reached sooner than is normal, because for the same\\nrange of Acc. the region is always further than in the nor\u00c2\u00ac\\nmal eye. Thus in an E. eye a power of Acc. 4.5 D.\\ngives a range from r infinity to p 22 cm. (the focal\\nFig. 132.\\nRegion and range of Acc. in E., M., and H. Range of Acc. diminishes\\nwith age.\\nThe numbers along the top show the range of Acc. in dioptres from infinity\\n(oo or beyond it in H., to 15 D. The numbers beyond oo represent dioptres\\nof Acc. necessary to correct H. Observe that the range of Acc. is always the\\nsame at the same age, though its region varies with the refraction of the eye.\\nlength of 4.5 D., see p. 50)\u00e2\u0080\u0094 i. e., Pr. is just about to begin\\nat set. 50, Acc. 2.5 D., and p 40 cm. (the focal length\\nof 2.5 D). In a case of M. 3 D., set. 50, the range being\\n2.5 D., the region of Acc. lies between 33 cm. (the r for\\nthis eye) and 18 cm. (\u00e2\u0080\u0094focal length of 3 2.5, or 5.5\\nD.); Pr. has not yet began. In a case of H 3 D. with\\n4.5 D. of Acc. 3 D. of it are used in correcting the H.\u00e2\u0080\u0094\\nt. e., in bringing r to infinity, and only 1.5 D. remains; p", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0374.jp2"}, "375": {"fulltext": "REFRACTION AND ACCOMMODATION. 36-3\\nis therefore at 66 cm. focal length of 4.5\u00e2\u0080\u0094 3, or 1.5\\nD.), and a -f- lens of 3 D. is needed to bring p to 22 cm.;\\nthere is Pr. 3 D. The only cases in which Pr cannot\\noccur are in M. of more than 4.5 D. Thus if M. 7 D.,\\nr is at 14 cm., and though, with advancing years, p will\\nrecede to 14 cm., it cannot go further, cannot reach 22 cm.;\\nthe patient, who never could see at a greater distance than\\n14 cm., has simply lost the power to see at a shorter dis\u00c2\u00ac\\ntance. Fig. 132 shows these facts in a graphic manner.\\nTreatment. Convex spectacles are found, by the aid*\\nof the Table at p. 364, with which the patient can read at\\n22 cm..\\nIn practice it is always advisable to examine for H. or\\nM., by taking the distant vision, and trying the patient\\nfor m. H. and M. If m. H. be found, arm the patient\\nwith the glass which neutralizes it and makes him E., and\\nthen add the convex glass that should, by the Table, be\\nrequired to bring p to 22 cm. If M. be found, subtract\\nits amount from the corresponding convex glass.\\nAs Pr. is usually associated with H., M., or As., it is\\noften necessary that the ametropia should be corrected\\nFig. 133.\\nalso; this necessitates the wearing of two sets of glasses.\\nThe inconvenience and annoyance necessitated by this have\\nbeen largely overcome by the bifocal slips, so called, which\\nare small segments of lenses cemented upon the distance\\nlenses. As these slips are somewhat unsightly, and as many\\npatients object to wearing them for cosmetic reasons, Har\u00c2\u00ac\\nlan has substituted a small lens made of flint glass for the\\nbifocal, and by sinking it into the distance lens made of", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0375.jp2"}, "376": {"fulltext": "364\\nCLINICAL DIVISION\\ncrown glass gained the increased refraction necessitated by\\nthe Pr. bv means of the higher index of refraction of the\\n%J o\\nflint glass.\\nIn prescribing for Pr. we must often order rather less\\nthan the full correction. For instance, if Acc. be almost\\nentirely lost, p is practically removed to r, and the glass\\nwhich will bring p to 22 cm. will also bring r to the same,\\nor nearly the same point, and the patient will be able to\\nsee clearly only just there. Now, 22 cm. is too near for\\nsustained vision, and such patients often prefer a glass\\nwhich gives them a near point of from 30 to 40 cm. (12\\nto 16 though in choosing it they sacrifice the power of\\neasily reading very small print. The difficulty experi\u00c2\u00ac\\nenced by these patients in reading with glasses which give\\np 22 cm. depends on the unaccustomed strain thereby\\nthrown on the internal recti; and it may be removed or\\nlessened by adding to the convex glasses, prisms, with their\\nbases toward the nose, Fig. 16; or by decentring the or\u00c2\u00ac\\ndinary convex lenses inward, Fig. 17.\\nPresbyopia Table for Emmetropic Eyes.\\nAge.\\nDistance of p.\\nPr. expressed by the lens\\nnecessary to bring p to\\n22 cm. or 9\\nCm.\\nInches.\\nDioptres.\\nParis inch\\nscale.\\n40\\n22\\n9\\n0\\n0\\n45\\n28\\n11\\n+1\\n3 V\\n50\\n43\\n17\\n2\\n1\\nTIT\\n55\\n67\\n27\\n3\\n1\\nTl?\\nCO\\n200\\n72\\n4\\n1\\n65\\nInfinity.\\n4.5\\n70\\nAcquired H 1 D.\\n5.5\\n75\\nH 1.5 I).\\n6\\n80\\nH 2.5 D.\\n7", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0376.jp2"}, "377": {"fulltext": "CHAPTER XXL\\nSTRABISMUS AND OCULAR PARALYSIS.\\nStrabismus exists whenever the two eyes are not, as\\nthey ought to be, directed toward the same object. The\\neye is \u00e2\u0080\u009cdirected toward\u00e2\u0080\u009d an object when the image is\\nformed on the most sensitive part of the retina, the yellow\\nspot; the straight line joining the centre of this image\\nwith the centre of the object is the visual axis.\u00e2\u0080\u009d 1 The\\naction of the ocular muscles is normally such as to keep\\nboth visual lines always directed to the object under re\u00c2\u00ac\\ngard, binocular but single vision being the result. Al\u00c2\u00ac\\nthough each eye receives its own image, only one object is\\nperceived by the sensorium, because the images are formed\\non parts of the retinae which correspond or are iden\u00c2\u00ac\\ntical in function\u00e2\u0080\u0094 i. e., which are so placed that they\\nalways receive identical and simultaneous stimuli.\\nBut if, owing to faulty action of one or more of the\\nmuscles, one eye deviate, and the visual lines cease to be\\ndirected toward the same object, the image will no longer\\nbe formed on the y. s. in both eyes. In one of them it\\nmust fall on some other and non-identical part of the\\nretina, and the result is that two images of the same object\\n1 We sometimes meet with an apparent squint, either external or internal.\\nThe optic axis of the eye passes from a point rather to the inner side of the\\ny. s. through the centre of the cornea, and forms a small angle angle o\u00e2\u0080\u009d)\\nwith the visual axis, the line which joins the y. s. to the object looked at, and\\nwhich commonly cuts the cornea rather within its centre. As we judge of\\nthe apparent direction of a person\u00e2\u0080\u0099s eyes by the centres of his cornese\u00e2\u0080\u0094 i. e., by\\nthe optic axes, a slight apparent outward squint will be produced if the angle,\\na, be, as in many hypermetropic eyes, larger than usual, and an apparent\\nconvergent squint if, as in myopia, it be smaller. Apparent squint is always\\nslight, and the screen test described in the text gives a negative result.\\n(365)", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0377.jp2"}, "378": {"fulltext": "366\\nCLINICAL DIVISION.\\nare seen (Diplopia, p. 379). In Fig. 134 y is the y. s. in each\\neye, and the visual line of the R. eye (the thick, dotted\\nline) deviates inward hence the image of the object (ob.)\\nwhich is formed at y in the L. eye, will in the R. eye fall\\non a non-identical part to the inner side of y. ob. will be\\nseen in its true position by the L. eye To the R. eye,\\nhowever, it will appear to be at F. ob., because the part\\nFig. 134.\\nShows the position of the double images in diplopia from convergent or\\ncrossed strabismus. The images are homonymous, or correspond in position\\nto the eyes.\\nof the R. retina which now receives the image of ob. was\\naccustomed, when the eye was normally directed, to receive\\nimages from objects in the position of F. ob and in con\u00c2\u00ac\\nsequence of this early habit F. ob. is the position to which\\nevery image formed on this part of the retina is refered.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0378.jp2"}, "379": {"fulltext": "STRABISMUS AND OCULAR PARALYSIS. 367\\nHence, if the eye deviate toward its fellow (convergent\\nsquint\u00e2\u0080\u0094as in Fig. 134). the false image will seem to the\\nsquinting eye to be in the opposite direction; the image\\n(F. ob for the R. eye being referred to the patient\u00e2\u0080\u0099s R.,\\nand that for the L. eye (ob. to his L., in convergent or\\ncrossed strabismus the double images correspond in position\\nto the eyes, or are homonymous. Similar reasoning will\\nFig. 135.\\nPosition of double images in divergent strabismus.\\nThe images are crossed.\\nshow that if the eye deviate away from its fellow, Fig. 135,\\ndivergent squint, the position of the double images must be\\nreversed, and the image belonging to the R. eye appear to\\nbe to the left of the other; hence, in divergent squint the\\ndouble images are crossed.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0379.jp2"}, "380": {"fulltext": "368\\nCLINICAL DIVISION.\\nSince the image of ob. in the squinting (R) eye is formed\\non a portion of the retina, more or less distant from the\\nmost perfect part (the y. s.), it will not appear so clear or\\nso bright as the image formed at the y. s. of the sound (or\\n\u00e2\u0080\u009cworking\u00e2\u0080\u009d) eye; it is called the \u00e2\u0080\u009cfalse\u00e2\u0080\u009d image, that\\nformed in the working eye being the \u00e2\u0080\u009ctrue\u00e2\u0080\u009d one. The\\ngreater the deviation of the visual line (i. e., the greater\\nthe squint) the wider apart will be the two images appear\\nand the less distinct will the false image be.\\nThe y. s. (y) of the squinting (R.) eye will receive an im\u00c2\u00ac\\nage of some different object lying in its visual line (shown\\nby the thick dotted line); this image, if sufficiently marked\\nto attract attention, will be seen, and will appear to lie upon\\nthe image of ob. seen by the \u00e2\u0080\u009cworking\u00e2\u0080\u009d (L.) eye; two\\nequally clear objects will be seen superimposed. But, as\\na rule, only one of these images is attended to, the percep\u00c2\u00ac\\ntion of the other being habitually suppressed, even sooner\\nthan that of the false image\u00e2\u0080\u009d (p. 269); the suppressed\\nimage always belongs to the squinting eye.\\nSquinting is not always accompanied by double vision\\nbecause: (1) if the deviation be extreme, the false image\\nis formed on a very peripheral part of the retina, and is so\\ndim as not to be noticed; conversely, the less the squint\\nthe more troublesome is the diplopia, when present; (2) as\\nalready mentioned (p. 270), after a time the fake image\\nis suppressed; or the eye may have been very defective\\nbefore the squint came on.\\nWhen a squint is well marked there is no difficulty in\\nidentifying the squinting eye as the one which is misdi\u00c2\u00ac\\nrected when an object is held up to the patient\u00e2\u0080\u0099s attention\\nin most cases the patient always squints with the same eye,\\nbut a few persons can squint with either indifferently\u00e2\u0080\u0094 alter\u00c2\u00ac\\nnating squint. Nor is there often any doubt as to whether\\nthe squint is internal (convergent) or external (divergent)\u00e2\u0080\u0094\\ni. e.. whether the axis of the squinting eye crosses that of", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0380.jp2"}, "381": {"fulltext": "STRABISMUS AND OCULAR PARALYSIS. 369\\nits fellow between the patient and the object lie looks at,\\nor crosses it beyond this object, or even positively diverges\\nfrom it; upward or downward squint, though less common,\\nis almost as evident. But to prove beyond doubt which is\\nthe squinting eye, direct the patient to look at a pencil\\nheld up in the middle line at about 18 from his face, and\\nwith a card or piece of ground-glass cover the apparently\\nsound, or working\u00e2\u0080\u009d eye; the squinting eye will at once\\nmove so as to look at, or \u00e2\u0080\u009cfix the pencil, proving that it\\nhad previously been misdirected. If the sound eye be\\nwatched behind the screen it will be seen to squint as soon\\nas the affected eye fixes the object; this is known as the\\nsecondary squint and its direction is the same as that of\\nthe original or primary squint. Thus if the primary squint\\nbe convergent, the secondary will also be convergent. In\\nsquint from overaction, or from mere disuse, of one mus\u00c2\u00ac\\ncle, the secondary and primary deviations are equal, but\\nin paralytic squint the secondary often exceeds the pri\u00c2\u00ac\\nmary. If the squinting eye retain full range of movement\u00e2\u0080\u0094\\ni. e move in companionship with its fellow in all direc\u00c2\u00ac\\ntions, the squint is termed concomitant in contradistinction\\nto paralytic; hence in every case of squint it is necessary\\nto test the mobility of the eyes. It is also important to\\nnote whether the squint is constant or only occasional peri\u00c2\u00ac\\nodic\\nIt was, until lately, usual to measure the squint, when\\nnecessary, by means of a scale placed on the lower lid and\\ngraduated in such a way as to indicate in lines (or mm.)\\nthe amount of deviation. The centre of this scale, marked\\nzero, is placed over the centre of the lid, and therefore\\ncorresponding to the centre of the pupil if there be no\\nsquint; the number which corresponds to the centre of the\\npupil of the squinting eye gives the linear measurement\\nof the deviation. A more accurate and rational method,\\nintroduced by Landolt, and known as the angular method,\\n24", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0381.jp2"}, "382": {"fulltext": "370\\nCLINICAL DIVISION.\\ndetermines the size of the angle between the positions of\\nthe visual axis of the eye when squinting and when prop\u00c2\u00ac\\nerly directed. In Fig. 136, L is the squinting left eye of the\\nFig. 136.\\nAngular measurement of squint. (After Landolt.)\\npatient placed at the centre of a perimeter Lx, the diree-\\ntion of its visual axis; L Ob, the direction its visual axis\\nshould have; Ob an object, as far off as possible, at which\\nthe patient is to look x a small candle flame which the\\nobserver, stationed close behind the perimeter, moves along\\nthe arc until he sees its image reflected from the centre of\\nthe squinting cornea; the size of the angle X L Ob, read\\noff on the perimeter, is nearly the same as that of the angle\\nof deviation. A convenient method of estimating the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0382.jp2"}, "383": {"fulltext": "STRABISMUS AND OCULAR PARALYSIS. 371\\namount of angular deviation, introduced by Hirschberg,\\nconsists in the observation of the corneal reflex from a\\ncandle or ophthalmoscope mirror held about a foot from\\nthe eye. When the eyes are properly directed, the position\\nof the reflex occupies the centre of the pupil in each eye\\nunless the angle a be very large. If the eye squint inward,\\nthe reflex falls on the outer side of the centre. The pupil\\nbeing of moderate width, 3 mm., if\u00e2\u0080\u0094\\n1. The reflex be nearer centre of p. than edge, deviation is 10\u00c2\u00b0\\n2. at edge of p. deviation is 12\u00c2\u00b0\u00e2\u0080\u009415\\n3. 11 midway between edge of p. and edge of\\nC. deviation is .25\\n4. at edge of C. deviation is .45\\nStrabismus may arise from any one of the following mus\u00c2\u00ac\\ncular conditions: (1) over-action; (2) weakness following\\nover-use; (3) disuse of an eye whose sight is imperfect;\\n(4) stretching and weakening of a tendon after tenotomy\\n(5) from paralysis of one or more of the muscles.\\nFuchs 1 has shown that considerable variations occur in the\\nattachments of the recti and obliqui to the sclerotic. Such\\nvariations in the attachment and power of the muscles probably\\noperate as predisposing causes of the squint in groups 1, 2, and 3.\\n1. Over-action of the internal recti gives rise to the con\u00c2\u00ac\\nvergent squint of hypermetropia. The association of con\u00c2\u00ac\\nvergent squint with hypermetropia was first observed by\\nBonders and explained by him in the following way The\\nrelationship between accommodation and convergence is\\na remarkably close one; most people are unable to accom\u00c2\u00ac\\nmodate without, at the same time, converging their visual\\naxes. Moreover a given degree of accommodation carries\\nwith it a constant degree of convergence. Hypermetropes\\nare obliged to use their Acc. to see even distant things\\nclearly; they are generally unable to dissociate this Acc.\\n1 Fuchs: Graefe\u00e2\u0080\u0099s Arch., xxx., abstracted in Ophth. Review, vol. iv.\\n1885, 143.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0383.jp2"}, "384": {"fulltext": "372\\nCLINICAL DIVISION.\\nfrom its usual amount of convergence. So that in fixing\\nan object at 50 cm. distance, requiring Acc. of 2 D., a\\nhypermetrope of 2 D. uses 4 D. of Acc. in order to sec it\\nclearly. But 4 D. of Acc. in the normal eye goes with\\nconvergence for a point at 25 cm. distance. Such a per\u00c2\u00ac\\nson, therefore, has to do two things at once, to look at an\\nobject distant 50 cm., and to make his visual axes meet at\\n25 cm. The former he does by directing an eye\u00e2\u0080\u0094 e. g., the\\nR.\u00e2\u0080\u0094to the object 50 cm. off; the latter by converging the\\nvisual axis of the L. so that it meets that of the R at 25.\\ncm. In this case the L. eye will squint inward, but both\\ninternal recti will act equally in bringing about the con\u00c2\u00ac\\nvergence, and both eyes will use as much accommodation\\nas a pair of normal eyes would do at 25 cm. In most cases\\nthe squint always affects the same eye, and this is gener\u00c2\u00ac\\nally accounted for by some original defect of the eye itself,\\nsuch as a higher degree of H. or As., or a corneal opacity;\\nbut people who see equally well with each eye often squint\\nwith either indifferently (alternating squint). This ex\u00c2\u00ac\\nplanation, though it accounts for a large number of the\\ncases of concomitant convergent squint, is not a complete\\none\u00e2\u0080\u0094squint is not present in every case of H.; it is not\\nalways most marked in the highest degree of squint; and\\nsome cases of convergent squint occur in E. and M.\\nSchweigger believes that a want of muscular balance is\\nthe main cause of strabismus, and that in convergent\\nsquint the internal recti preponderate over the external;\\nin H. there is a congenital tendency toward preponderance\\nof the internal recti, and in myopia of the external. Han\u00c2\u00ac\\nsen Grut thinks that the preponderance is dependent on\\nthe innervation of the muscles. In cases of lono- standing\\nthe range of movement of the squinting eye is often defi\u00c2\u00ac\\ncient.\\nThis \u00e2\u0080\u009cconcomitant\u00e2\u0080\u009d convergent strabismus generally\\ncomes on early in childhood, as soon as the child begins", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0384.jp2"}, "385": {"fulltext": "STRABISMUS AND OCULAR PARALYSIS. 373\\nto look attentively and use Acc. vigorously in regarding\\nnear objects. In examining eases we shall be struck by\\nfinding that (a) in some the squint is noticed only when Acc.\\nis in full use\u00e2\u0080\u0094that it appears and disappears under observa\u00c2\u00ac\\ntion, according as the child fixes its gaze on a near object\\nor looks into space, periodic squint.\\nPeriodic squint often occurs, chiefly when the child is nervous\\nor tired; several patients have assured me that their occasional\\nconvergent squint scarcely ever came on except when eating.\\nb In others the squint is constant, but is more marked\\nduring strong Acc.; (c) it is constant, invariable, and of\\nhigh degree; (d) in most cases patients who see equally\\nwell with each eye often squint with either indifferently,\\nalternating squint The squint causes diplopia, and to\\navoid this inconvenience patients for the most part soon\\nlearn to ignore (or suppress\u00e2\u0080\u009d the image formed in the\\nsquinting eye, the result usually being that this eye be\u00c2\u00ac\\ncomes very defective. This power of suppressing the false\\nimage is learned most easily in very early life. In alter\u00c2\u00ac\\nnating squint no permanent suppression occurs, and con\u00c2\u00ac\\nsequently both eyes remain good.\\nThe squint sometimes disappears spontaneously as the\\nchild grows up; this might be explained by an increased\\npower of dissociating Acc. from convergence, or by a\\ndiminution of H. from elongation of the eye, or by a gen\u00c2\u00ac\\neral tendency in all persons, and of this there is other\\nevidence, to weakening of the internal recti with ad\u00c2\u00ac\\nvancing age.\\nTreatment of Convergent Hypermetropic Squint.\\n(a) If the squint be periodic, it can be cured by the con\u00c2\u00ac\\nstant use of spectacles which nearly correct total H.\\n(6) The same is true in some cases where the squint,\\nthough constant, is alternating or varies in degree, being\\ngreater during Acc. for near than for distant objects.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0385.jp2"}, "386": {"fulltext": "374\\nCLINICAL DIVISION.\\n(c) If the squint be constant in amount and of some\\nyears\u00e2\u0080\u0099 standing, operation is usually necessary. As the\\nsquinting eye is then usually very defective (p. 269), the\\nremoval of the deformity is the chief object of the opera\u00c2\u00ac\\ntion, binocular vision being comparatively seldom restored.\\nHence, in view of the tendency to spontaneous cure already\\nmentioned, I think it better, as a rule, not to operate on\\nchildren below the age of six, especially as in younger chil\u00c2\u00ac\\ndren we cannot always tell whether or not the squint be\\nstill periodic. The most rational treatment for children\\nunder four, when glasses may often be began, is to cover\\nthe eyes alternately with a blind, for some hours daily, to\\nensure each eye being alternately used; but this plan can\\nseldom be carried out.\\nIn older persons orthoptic training, as suggested by\\nJaval, should be essayed. As it is necessary for this pur\u00c2\u00ac\\npose that the patient should be conscious of double images,\\nthe squinting eye must be exercised with a prism base\\ndownward, and a candle-flame as visual object. After\\ndiplopia has been obtained a large sheet of cardboard is\\nheld upright between the eyes, and the patient told to\\nregard a candle-flame several metres in front of him. The\\nscreen is now removed, and an attempt made to fuse the\\nimages by means of a stereoscope, into which S. 6 D.\\nlenses have been introduced in place of the usual prism.\\nThe distance between the pictures in the stereoscope is then\\ndiminished until the patient is just able to fuse them.\\nWhen operation is decided upon, it is a safe rule to divide\\nonly one internal rectus at a sitting. At the end of a few\\nweeks, if the squint still be considerable, the operation is\\nperformed on the other eye. 1\\nMuscular asthenopia or actual divergence is very likelv\\n1 Regulations for operating in convergent strabismus in relation to its\\ndegree have been laid down by various authors; recently by Hirschberg:\\nCentralblatt fur Augenlieilkunde, 1S96, p. 5.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0386.jp2"}, "387": {"fulltext": "STRABISMUS AND OCULAR PARALYSIS.\\n375\\nto come on some years later if both tendons are needlessly\\ndivided. It is safer to leave slight convergence than to\\nrun this risk. See also Divergent Strabismus.\\n2. Divergent squint from weakness of the internal recti,\\ninsufficiency of convergence, depends upon relaxation or ab\u00c2\u00ac\\nsolute weakening of the internal recti. It is most common\\nin M., but is not infrequent in II., and even in E. This\\nform of squint sets in gradually, with difficulty in using\\nthe eyes for long together for reading, etc., the internal\\nrecti not being able to keep up convergence, muscular\\nasthenopia; in this stage it may often be detected by\\ncovering one eye while the patient looks attentively at\\nsome near object, for the covered eye will diverge when\\nthus excluded, latent divergent squint, though in the interest\\nof binocular vision convergence may be maintained for a\\nshort time when both eyes are open. The position of the\\neyes may be more exactly ascertained by the use of Mad\u00c2\u00ac\\ndox\u00e2\u0080\u0099s rod. Latent divergent strabismus is sometimes a\\ntemporary condition due to over-use of the eyes, or want\\nof general vigor, in young adults. Anything which lessens\\nthe importance of binocular vision predisposes to divergent\\nsquint\u00e2\u0080\u0094 e. g., defective sight of one eye from anisometropia.\\nLatent divergence is extremely apt to pass gradually into\\nmanifest permanent divergent squint. In this form of\\nstrabismus the eye can be moved into the inner can thus,\\neven in extreme cases, by making the patient look side\u00c2\u00ac\\nways, though not by efforts at convergence, and it is thus\\nbut rarely that the cases simulate paralysis. Tenotomy\\nof the external rectus, and even \u00e2\u0080\u009cadvancement\u00e2\u0080\u009d of the\\nweakened muscle, are often needed. In slight cases the\\nsymptoms are sometimes quite cured by wearing prisms\\nwith their bases toward the nose; but, as far as I know,\\none can seldom predict success with any certainty from\\ntheir use. One of the most troublesome features in mus\u00c2\u00ac\\ncular asthenopia is its great variability with the patient\u00e2\u0080\u0099s", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0387.jp2"}, "388": {"fulltext": "37 6\\nCLINICAL DIVISION.\\nstate of health the symptoms sometimes disappear entirely\\nin a bracing climate, returning as soon as the patient comes\\nback to his less invigorating home air.\\n3. Strabismus from disuse is also nearly always diverg\u00c2\u00ac\\nent, depending as it does on relaxation of the internal\\nrectus. It occurs in cases where convergence is no longer\\nof service, as when one eye is blind from opacity of the\\ncornea, or other cause, or where the refraction of the two\\neyes is very different (p. 360). Tenotomy of the external,\\nwith or without advancement of the internal rectus, may\\nbe performed.\\n4. Stretching and weakening of the internal rectus after\\ndivision of its tendon for convergent squint may give rise\\nto divergence, simulating that caused by paralysis of the\\ninternal rectus. The caruncle in these cases, however, is\\ngenerally much retracted, and this, together with the his\u00c2\u00ac\\ntory of a former operation, will prevent any mistake in\\ndiagnosis. Such a squint can always be lessened, and\\noften quite removed, by an operation for readjustment or\\nadvancement of the defective muscle.\\n5. Heterophoria.\u00e2\u0080\u0094The tests for heterophoria, or latent\\nsquint, have already been given (see p. 51). Sometimes,\\nhowever, the use of the Maddox rod will not be necessary\\nto ascertain the existence of these deviations, for the sim\u00c2\u00ac\\nple holding of a colored glass before one eye will be suffi\u00c2\u00ac\\ncient to remove the inducement to binocular vision, and\\nany latent squint will at once become manifest. The\\nimages may also be separated by a prism. Thus, if a prism\\nof 10\u00c2\u00b0 be placed with its base up before one eye, any lateral\\nseparation indicates the amount of exophoria or esophoria;\\ncrossed diplopia indicating the former, homonymous diplo\u00c2\u00ac\\npia the latter (modified Graefe test).\\nIn obtaining the distance, as well as the near muscle-\\nbalance, it is essential that as much of any existing devia\u00c2\u00ac\\ntion be made manifest as possible. It suggested itself to", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0388.jp2"}, "389": {"fulltext": "STRABISMUS AND OCULAR PARALYSIS. 377\\nthe Editor that it would be well to endeavor to measure\\nthe deviation that the eye undergoes when it is screened\\noff in the ordinary refraction-test, whilst the other eye fixes\\nthe test-card sharply in the endeavor to obtain the best\\nvisual acuity. To accomplish this, the vision of the right\\neye is first obtained, the left eye being obscured by an\\nopaque metallic disc. This done, the right eye is obscured\\nby the disc and the left eye made to regard the chart. So\\nsoon as the vision of this eye has been obtained, instead\\nof removing the shield from before the right eye and per\u00c2\u00ac\\nmitting the patient to bring the eyes into a state of paral\u00c2\u00ac\\nlelism by the unconscious desire for fusion necessary for\\nbinocular vision, the patient is told to regard a bright\\nelectric light placed on a level with the line of test-letters\\nthat he has just read, and but a few inches from it, the\\nright eye still being covered. The Maddox rod is then\\nlowered before the left eye, the patient\u00e2\u0080\u0099s attention called to\\nthe streak, the disc quickly removed from before the right\\neye, and the patient requested to give the relative positions\\nof the light and the streak. Any deviation, lateral or\\nvertical, is at once measured by means of the rotary\\nprisms that are in position before the eyes. The method\\nis a rapid and satisfactory one, and has frequently revealed\\nthe existence of insufficiencies that were not rendered man\u00c2\u00ac\\nifest by the usual method of employing the rod-test. The\\nsame method has been utilized as a part of every refrac\u00c2\u00ac\\ntion-test. After the refraction of one eye has been deter\u00c2\u00ac\\nmined, the correcting lenses are allowed to remain in posi\u00c2\u00ac\\ntion back of the metallic disc that is placed before the\\neye, while the other eye is examined. So soon as this is\\naccomplished the patient is requested to transfer his gaze\\nto the light, a red Maddox rod is dropped before the eye,\\nand the shield is removed from its fellow, when the slightest\\ndeviation will be made manifest and can be accurately\\ndetermined by the prisms. This last procedure has been", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0389.jp2"}, "390": {"fulltext": "378\\nCL INTO A L 1)1 VISION.\\nof great value in many intricate cases, and has often\\ndirected the attention to the true muscle-error. It is abso\u00c2\u00ac\\nlutely essential for this test that the point of light at which\\nthe patient is requested to transfer his gaze from the letters\\non the test-chart should be bright and close to the row of\\nletters that he has just read, else the excursions of the eye\\nwill be too great, and so great a movement required that\\nimpulses will be generated in the deviating eye that will\\ndefeat the purposes of the test. This has been accom\u00c2\u00ac\\nplished by means of a simple apparatus devised by\\nMessrs. Wall Ochs, of Philadelphia, which consists ot\\nan electric light shaded by a Thorington chimney,\\nattached to a metal rod placed a few inches in advance of\\nand to the side of an ordinary test-card. The light may\\nbe adjusted to correspond to any row of letters on the\\nchart, so that in any event the eye will not have to make\\na greater movement than the few inches from the letters to\\nthe light. The light that illuminates the chart is also\\nelectric, and, in common with the light for the muscle-test,\\nis so arranged that it may be operated by the surgeon at\\nthe patient\u00e2\u0080\u0099s side by means of switches. The moment the\\nrefraction is ascertained the light in the chimney is turned\\non and that for the chart off, so that a perfect contrast is ob\u00c2\u00ac\\ntained and the double images invited to appear and persist.\\nAs a result of the muscle-tests made in this manner,\\nhyperphoria was observed to exist in many cases in which\\nit did not reveal itself to the usual tests with the Maddox\\nrod, or to the disassociation of images accomplished by the\\nuse of prisms; and furthermore it was ascertained that\\nmuscle-balance is present when the phorometer shows at\\n5 m. 2\u00c2\u00b0 or 3\u00c2\u00b0 of homonymous diplopia, and from 2\u00c2\u00b0 to 4\u00c2\u00b0\\nof crossed diplopia at the reading distance. Under such\\nconditions abduction will be found to equal 8\u00c2\u00b0 or 9\u00c2\u00b0 and\\nadduction from 18\u00c2\u00b0 to 25\u00c2\u00b0, the ratio that exists in the\\nmajority of well-balanced eyes.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0390.jp2"}, "391": {"fulltext": "STRABISMUS AND OCULAR PARALYSIS. 379\\n6. Paralytic squint. The deviation is caused by the\\nunopposed action of the sound muscles. When the palsied\\nmuscle tries to act, the eye fails, in proportion to the weak\u00c2\u00ac\\nness, to move in the required direction. In many cases\\nthere is only slight paresis, and the resulting deviation is\\ntoo little to be objectively noticeable; but in such cases\\nthe diplopia, as mentioned already, is very troublesome,\\nand it is for this symptom that the patient conies under\\ncare. Further, in these slight cases the symptoms often\\nvary with the effort made by the patient. In paralysis of\\nthe third nerve the several branches are often affected in\\ndifferent degrees, and the strabismus and diplopia are then\\ncomplex. When paralysis of any ocular muscle is of long\\nstanding, secondary contraction of the opponent seems\\nsometimes to occur, and complicates the symptoms. Fur\u00c2\u00ac\\nther difficulty in diagnosis is occasionally caused by the\\nsound yoke-fellow 1 of the paralyzed muscle acting too\\nmuch, in obedience to efforts made by the latter; when\\nthis happens the squint will sometimes, even when both\\neyes are uncovered, affect the sound instead of the par\u00c2\u00ac\\nalyzed eye\u00e2\u0080\u0094 i. e., it will alternate.\\n12. Diplopia (double sight) is almost always a result of\\nsquint, and is usually most troublesome when the deviation\\nis so slight as to be hardly perceptible. Diplopia caused\\nby squint is, of course, binocular, and disappears when\\none eye is covered. Uniocular diplopia, double sight with\\none eye, however, often occurs in commencing cataract, and\\nsometimes in healthy but astigmatic eyes; it has also been\\nmet with in some cases of cerebral tumor. In the former\\ncases it has a physical cause in the crystalline lens (see\\nCataract); in the latter it must depend upon some psychical\\nchange.\\n1 Yoked or conjugate muscles are the muscles of opposite eyes which act\\ntogether in producing lateral and vertical movements\u00e2\u0080\u0094 e. g., the internal\\nrectus of one eye acts with the external rectus of the other in movement of\\nthe eyes to the R. or L.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0391.jp2"}, "392": {"fulltext": "380\\nCLINICAL DIVISION.\\nTo find out what defect of movement is causing binoc\u00c2\u00ac\\nular diplopia, darken the room, and ask the patient to\\nfollow with his eyes a lighted candle, held about 6 from\\nhim, moved successively into different positions, and to\\ndescribe the relative places of the double images in each\\nposition. Ascertain which of the two images belongs to\\neach eye by placing before one eye a strongly colored glass,\\nor by covering one eye and asking which image disappears.\\nIn many cases the image formed in the squinting eye, the\\nfalse image, is less bright or distinct, and this difference\\ngives a valuable means of distinguishing the sound from\\nthe affected eye; but the patient does not always notice a\\ndifference between the two images, and there may then be\\ndifficulty in proving which eye is at fault. The patient\u00e2\u0080\u0099s\\nreplies may be recorded on such a diagram as Fig. 120;\\nother radii may, of course, be added for intermediate posi\u00c2\u00ac\\ntions the false image is marked by the dotted line, the\\ntrue one by the unbroken line. With this graphic repre\u00c2\u00ac\\nsentation of the candle as it appears to the patient, we can\\ndeduce from the apparent position of the false image what\\nmovements of the corresponding eye are at fault, and, con\u00c2\u00ac\\nsequently, which muscle or muscles are defective. It is\\nessential that the patient should not move his head during\\nthe examination, and that he remain throughout at the\\nsame distance from the candle. Remember that, in the\\nextreme lateral movements, the nose eclipses one image.\\nWhen the double images are very wide apart\u00e2\u0080\u0094 i. e., when\\nthere is much squint, the patient often fails to notice the\\nfalse image.\\nFor the diagnosis of a case of diplopia it is often suffi\u00c2\u00ac\\ncient to ask in which directions the double sight is most\\ntroublesome, and how the images appear in respect to\\nheight, lateral separation, and apparent distance from the\\npatient. Chapter XXI.\\nThe most common forms of paralytic squint are due to", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0392.jp2"}, "393": {"fulltext": "STRABISMUS AND OCULAR PARALYSIS. 381\\naffection, separately, of the external rectus (sixth nerve),\\nsuperior oblique (fourth nerve), or of one or all of the\\nmuscles supplied by the third nerve, internal superior and\\ninferior recti, inferior oblique, levator palpebne. 1\\nParalysis of the external rectus (sixth nerve causes a con\u00c2\u00ac\\nvergent squint, from preponderance of the internal rectus,\\nwhich, except in the slightest cases, is usually very notice\\nable. Movement straight outward is impaired, and if the\\nparalysis be complete, the eye cannot be moved outward\\nbeyond the middle line of the palpebral fissure. There is\\nhomonymous diplopia; the two images, when in the hori\u00c2\u00ac\\nzontal plane, are upright and on the same level; the dis\u00c2\u00ac\\ntance between them increases as the object is moved toward\\nthe paralyzed side, but it diminishes, or the images even\\ncoalesce, in the opposite direction. Thus in paralysis of\\nthe left external rectus, Fig. 137, uppermost figure, the\\nimages separate more as the object is moved to the patient\u00e2\u0080\u0099s\\nleft, but approach one another, and finally coalesce, as it\\nis moved over to his right. In slight cases the diplopia\\nceases when the patient looks at an object a few inches off,\\nbut reappears when he gazes straight forward at a distant\\nobject. In the upper part of the field the false image is\\nsometimes lower, and in the lower part of the field higher\\nthan the true one. I have many times noticed that the\\npupil is larger in the affected eye than in the other, a con\u00c2\u00ac\\ndition which we should not expect.\\nIn paralysis of the superior oblique (fourth nerve) there\\nis either no visible squint, or only a slight deviation upward\\nand inward. But when the eyes are directed below the\\nhorizontal, very troublesome diplopia arises from the de\u00c2\u00ac\\nfective downward and outward movement, and loss of rota\u00c2\u00ac\\ntion of the vertical meridian inward, to which the lesion\\ngives rise. In downward movements, especially downward\\n1 In 77 cases of paralysis of a single oculomotor nerve I found the third\\nnerve affected in 3L cases, the fourth in 9, and the sixth in 37.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0393.jp2"}, "394": {"fulltext": "382\\nCLINICAL DIVISION.\\nand toward the paralyzed side, the eye remains a little\\nhigher than its fellow; in trying to look straight down,\\ninferior rectus and superior oblique, the unopposed action\\nof the inferior rectus carries the cornea somewhat inward,\\nconvergent squint, and at the same time rotates the ver\u00c2\u00ac\\ntical axis outward, while the cornea remains on a rather\\nhigher level than its fellow; in following an object from\\nthe horizontal middle line down-outward, it will be seen\\nthat the vertical meridian of the cornea does not, as it\\nshould, become inclined inward.\\nIn many cases, however, the slight defects of movement\\nFig. 137.\\nChart showing position of double images, as seen by the patient in paralysis\\nof L. external rectus and R. superior oblique.\\ncaused by paralysis of the superior oblique are not clearly\\nmarked, and the diagnosis has to be based on the charac\u00c2\u00ac\\nters of the diplopia. In all positions below the horizontal\\nline the false image is below the true one, and displaced\\ntoward the paralyzed side (homonymous); thus, if the R.\\nmuscle be at fault, the false image will be below and to\\nthe patient\u00e2\u0080\u0099s R., Fig. 137, arrow-head figure; further, it is\\nnot upright, but leans toward the true image. The differ\u00c2\u00ac\\nence in height between the images is greatest in movements", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0394.jp2"}, "395": {"fulltext": "STRABISMUS AND OCULAR PARALYSIS. 383\\ntoward the sound side; the lateral separation is greater\\nthe further the object is moved downward the leaning of\\nthe false image is greatest in movements toward the par\u00c2\u00ac\\nalysed side. When the patient looks on the floor\u00e2\u0080\u0094 i. e.,\\nprojects the images on to a horizontal surface, the false\\nimage seems nearer to him than the true one. The images\\nare always near enough together to cause inconvenience,\\nand as the diplopia is confined to, or is worst in, the lower\\nhalf of the field, the half most used in daily life, paralysis\\nof the superior oblique is very annoying, especially in\\ngoing up or down stairs, in looking at the floor, counting\\nmoney, eating, etc.\\nParalysis of the third nerve, when complete, causes\\nptosis, loss of inward, upward, and downward movements,\\nloss of accommodation, and partial mydriasis, well-marked\\ndivergent strabismus from unopposed action of the external\\nrectus, and crossed diplopia. The downward and outward\\nmovement, with rotation of the vertical meridian inward\\neffected by the superior oblique, remains. The mydriasis\\nis much less than that produced by atropine. In many\\ncases the paralysis is incomplete, affecting some branches\\n(and muscles) more than others, and the symptoms are\\nthen less typical. Isolated paralysis of a single third-nerve\\nmuscle is rare.\\nThere is a peculiar form of intermittent paralysis of the\\nthird nerve, known as ophthalmoplegic migraine which\\noccurs in the young, and is associated with headache and at\\ntimes with vomiting.\\nPeculiarities of paralytic strabismus. 1. If a patient\\nsuffering\u00e2\u0080\u0094 e. g. y from paresis of one external rectus\u00e2\u0080\u0094look\\nat an object distant about two feet, and the sound eye be\\nthen covered by holding a card or a piece of ground-glass\\nbefore it, the paralyzed eye will make an attempt, more or\\nless successful according to the degree of palsy, to look at\\nthe object. The movement affected will call for a greater", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0395.jp2"}, "396": {"fulltext": "384\\nCLINICAL DIVISION.\\neffort than if the sixth nerve were healthy, and as the eye\\nmuscles always work in pairs, the same effort will be trans\u00c2\u00ac\\nmitted to the internal rectus of the healthy eye. The latter\\nwill, in consequence, describe a larger movement than the\\nparalyzed eye\u00e2\u0080\u0094 i. e., the secondary squint will be greater\\nthan the primary (p. 369). This test is sometimes of use in\\ndistinguishing which is the faulty eye in cases where the\\nsquint is slight and the patient unable to distinguish be\u00c2\u00ac\\ntween the false and true images (p. 380). 2. Giddiness is\\noften present when the patient walks with the sound eye\\nclosed. This symptom depends on an erroneous judgment of\\nthe position of surrounding objects, which is caused by the\\nweakened muscle not being able to achieve a movement\\nof the eye corresponding in magnitude to the effort made.\\nIt is absent when both eyes are open, and when the par-\\nalyzed eye is covered. It often helps us more than does\\nthe former symptom in determining which is the faulty\\neye; but it varies much in severity in different cases, and\\nmay be quite absent. Patients with ocular palsy often\\nkeep one eye closed, nearly always the paralyzed one to\\navoid diplopia.\\nParalysis of the ocular muscles is seldom symmetrical;\\nin the rare cases where it is so the disease is usually intra\u00c2\u00ac\\ncranial. In uncomplicated symmetrical ophthalmoplegia\\nexterna (paralysis of all the external muscles, the iris and\\nciliary muscles escaping) the disease is usually nuclear,\\nwhile in cases of symmetrical disease of oculomotor nerve-\\ntrunks both external and internal muscles are paralyzed;\\nbut even in nuclear ophthalmoplegia the disease may spread\\nforward and attack the centres for the iris and ciliary\\nmuscle, and the differential diagnosis may then be exceed\u00c2\u00ac\\ningly difficult to make. In the later stages of nuclear\\nophthalmoplegia other cranial nerves (especially the optic\\nand fifth) may be involved, and symptoms of spinal or\\nbulbar disease be present.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0396.jp2"}, "397": {"fulltext": "STRABISMUS AND OCULAR PARALYSIS. 385\\nThe fibres of the third and fourth nerves arise from a column\\nof nerve cells beneath the floor of the aqueduct of Sylvius. It\\nis probable that the centre for accommodation lies in front, with\\nthat for the sphincter of the pupil next, the centres for the\\nother muscles following, but their exact order is not yet known.\\nThe nuclei of the internal and external recti are in communica\u00c2\u00ac\\ntion by the posterior longitudinal fibres, so that their combined\\naction in lateral movements of the eyes is secured. There is a\\ncentre for the convergence of the eyes close to the middle line.\\nAffections of the Internal Muscles of the Eyeball.\\nPhysiological Outline. The nerves of the iris are\u00e2\u0080\u0094 a, the\\nthird for contraction of the pupil; b, the cervical sympathetic\\nfor its dilatation and c, the fifth supplying sensory fibres. The\\nsympathetic fibres b come from the cord probably through the\\nanterior root of the second dorsal nerve, and reach the eye\u00e2\u0080\u0094\\n(1) through the Gasserian ganglion from the carotid plexus;\\n(2) through the lenticular ganglion from the cavernous plexus\\n(3) it is stated that sympathetic (dilator) fibres accompany the\\nfifth nerve directly from its origin. The filaments of the fifth\\n(c) form (1) the long root of the lenticular ganglion (which gives\\noff the short ciliary nerves); (2) the long ciliaries, two or three\\nin number, independent of the ganglion. The human iris con\u00c2\u00ac\\ntains a circular (sphincter) unstriped muscle close to the pupil,\\nand a dilator muscle consisting of a thin layer of plain mus\u00c2\u00ac\\ncular tissue passing from the sphincter to the circumference of\\nthe iris.\\nIf the third nerve be divided or paralyzed, the pupil dilates\\nmoderately (never extremely) and becomes motionless to light\\nand accommodation, and accommodation is lost. Of contrac\u00c2\u00ac\\ntion of pupil and spasm of accommodation from irritation of\\nthe nerve, we have little clinical knowledge; but experimental\\nstimulation of the nerve produces those effects. Section or\\nparalysis of the cervical sympathetic causes some contraction\\nof pupil and destroys its power of dilating when shaded; stimu\u00c2\u00ac\\nlation of it, or of the anterior root of the second dorsal (in\\nmonkeys, Ferrier), causes well-marked dilatation, which, how\u00c2\u00ac\\never, is less than that due to atropine; irritation of the skin,\\n25", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0397.jp2"}, "398": {"fulltext": "386\\nCLINICAL DIVISION.\\nstimulating the dilator nerve, causes slight, momentary dila\u00c2\u00ac\\ntation.\\nAll the drugs which act upon the iris act on the ciliary muscle\\ntoo, but the iris is affected sooner, for a longer time, and by\\nweaker solutions than the ciliary muscle.\\nAtropine, and all the mydriatics except cocaine, dilate the\\npupil and paralyze the accommodation; the effect of atropine\\non the pupil in old people is often, and in children sometimes,\\nvery small; the mydriasis of atropine is greater than that due\\nto paralysis of third nerve, but is somewhat increased if the\\nthird nerve be cut. It acts in old-standing paralysis of iris\\n(third nerve) and of cervical sympathetic, but in both condi\u00c2\u00ac\\ntions the mydriasis is apt to be rather less than full; the my\u00c2\u00ac\\ndriasis is said to be rather increased by stimulating the long\\nciliary nerves, and diminished by cutting the fifth, owing to\\nthe sympathetic fibres contained in it. Atropine dilates the\\npupil of a freshly excised (rabbit\u00e2\u0080\u0099s) eye, and of the eye of an\\nanimal bled to death, and it acts a little if put on to the human\\neye very soon after death. From the above it is inferred that\\natropine acts directly upon the muscular fibres, paralyzing\\nthem, and not upon the nerve fibres. Atropine does not act\\nupon the iris of birds containing striped muscle.\\nEserine and pilocarpine contract the pupil and cause spasm\\nof accommodation they have the same action in long-standing\\nparalysis of iris (third nerve), and after section of the third\\nnerve and of the sympathetic; they have very little effect if\\natropine have been used, but they immediately overcome the\\nmydriasis of cocaine. Eserine and pilocarpine, therefore,\\nprobably act directly on the muscular fibres, stimulating them.\\nCocaine dilates the pupil, but does not prevent its action to\\nlight and accommodation, and has but little action on the ciliary\\nmuscle; hence it does not act by paralyzing either the third-\\nnerve fibres or the muscular fibres. It causes further dilatation\\nof a pupil dilated by atropine or by section of third nerve while\\nit does not dilate the pupil if the cervical sympathetic have been\\ncut or paralyzed for some little time. It also causes retraction\\nof the eyelids and contraction of the superficial bloodvessels of\\nthe eye. Hence, cocaine probably acts by stimulating the sym\u00c2\u00ac\\npathetic nerve-fibres. Consult Michael Foster\u00e2\u0080\u0099s Physiology;", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0398.jp2"}, "399": {"fulltext": "STRABISMUS AND OCULAR PARALYSIS. 387\\nFerrier, Functions of Brain, second edition, and Proc. of Roy.\\nSoc., 1883; Gowers, Diseases of Nervous System vol. i.; Jessop,\\nProc. of Roy. Soc., 1885-86; Marshall, Lancet, 1885, ii. 286;\\nAuthor\u00e2\u0080\u0099s own cases.\\nThe following forms of paralysis, or altered innervation,\\nof iris and ciliary muscle agree tolerably with the above\\nphysiological facts.\\nA. Pupil alone. 1. Paralysis of dilatation pupil in good\\nlight, equal to or smaller than the other but when shaded,\\ndilates little if at all, so that in dull light it is much the\\nsmaller, paralytic miosis; accommodation not affected. This\\nuncommon condition is, when well marked, generally one\u00c2\u00ac\\nsided, and due to paralysis of cervical sympathetic by pres\u00c2\u00ac\\nsure\u00e2\u0080\u0094 e. g., by aneurism or tumor, or enlarged glands at\\nthe root of the neck, or injury to the brachial plexus; it\\nshould, therefore, always lead to careful examination. A\\ndegree of miosis and non-dilatability of pupils is common\\nin old age. 2. The opposite state, spasmodic mydriasis, is\\nvery rare as a permanent symptom, though temporary,\\nvarying dilatation of one pupil is sometimes seen in young\\nor neurotic persons. Persistent spasmodic mydriasis is said\\nto occur in the early (irritative) stage of lesions, which\\nafterward produce paralytic miosis in this state we should\\nexpect the pupil, though dilated, to act both to light and\\nto accommodation, as after cocaine. 3. Of paralytic my\u00c2\u00ac\\ndriasis, paralysis of third-nerve fibres of the sphincter\\nmuscle, without paralysis of accommodation we know but\\nlittle, 2 except in a slight degree as a residue after recovery\\nfrom the double condition (paralysis of sphincter iridis and\\nciliary muscle), the pupil often not recovering so well or\\nso soon as the accommodation. Compare the action of the\\ndrugs above given. 4. Paralysis of iris, iricloplegia, with-\\n1 Gowers: Diseases of Nervous System, i. 152.\\n2 See several cases reported by the author in Ophth. Hospital Reports, vol.\\nxi. iii. pp. 260-264.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0399.jp2"}, "400": {"fulltext": "388\\nCLINICAL DIVISION.\\nout defect of accommodation, usually affects only the action\\nto light, reflex iridoplegia, the associated action remaining.\\nIt occurs as a very early symptom in locomotor ataxy,\\nsometimes without any other symptoms of that disease, and\\nshould always lead to full investigation. It is probably\\ndue to degeneration in that part of the nucleus of the third\\nwhich presides over the reflex action of the pupil.\\nb. Paralysis of accommodation alone (cyclop legia) is often\\nseen after diphtheria. It is often incomplete, and the pupils\\nare usually unaffected; but if the cyeloplegia be complete\\nthere is sometimes mydriasis. In ataxy there is occasion\u00c2\u00ac\\nally cyeloplegia with a pupil active to light. Accommoda\u00c2\u00ac\\ntion is sometimes quite lost without any alteration of pupil\\nin what is spoken of as premature presbyopia, but this is\\nnot called cyeloplegia, not being supposed to be paralytic.\\nc. Ciliary muscle and iris affected. 1. Cyeloplegia ivith\\nmydriasis; loss of accommodation; pupil dilated to about\\n5 mm. and motionless; the ordinary condition in complete\\nparalysis of third nerve. It is now and then seen without\\nfailure of any other part of the third nerve, and the pupil\\nmay then be quite widely dilated. When an old person gets\\nparalysis of the third, the pupil is often very little dilated.\\n2. Total iridoplegia, with cyeloplegia, ophthalmoplegia in\u00c2\u00ac\\nterna accommodation lost; pupil motionless to reflex and\\nassociated stimuli, and of medium size; this is sometimes a\\nlater stage of A (4), but it may be primary, due to nuclear\\ndisease; the paralysis, both of iris and ciliary muscle, is\\noften incomplete. In paralysis of sixth nerve the pupil of\\nthe paralyzed eye is often rather larger than that of the\\nother.\\nCauses of Ocular Paralysis. It is convenient to\\nseparate the external and mixed forms from those in which\\nonly the internal muscles are involved, since the local lesions\\nare, as a rule, different in the two groups.\\nParalysis of the third, fourth, or sixth nerve may be the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0400.jp2"}, "401": {"fulltext": "STRABISMUS AND OCULAR PARALYSIS. 389\\nresult of tumors or other growths in the orbit, but in such\\ncases, as a rule, the paralysis forms only one among other\\nwell-marked local symptoms. In the vast majority of\\nuncomplicated ocular palsies we are quite unable to de\u00c2\u00ac\\ncide, either from the state of the eye or the orbital parts,\\nwhether the lesion be in the orbit or within the cranium.\\nMeningitis, morbid growths, and syphilitic periostitis at the\\nbase of the skull, or involving the sphenoidal fissure, often\\ncause ocular palsy, seldom confined to one nerve aneurism\\nof the internal carotid in the cavernous sinus occasionally\\ndoes so. Syphilitic gumma of the nerve-trunk is probably\\nthe most common cause of single paralysis; the intracranial\\nportion of the nerves is known to be often the seat of such\\ngrowths, but small neural gummata probably occur also on\\nthe orbital part of the nerves. Injuries to the head often\\ncause ocular paralysis the paralysis is usually noticed very\\nsoon after the accident, and is probably always a sign of\\nfracture of the base involving the middle fossa, or of some\\npart of the walls of the orbit. Direct damage to, or thick\u00c2\u00ac\\nening subsequent to fracture near the pulley, seems to\\naccount for some cases of traumatic paralysis of the supe\u00c2\u00ac\\nrior oblique. Pain in the temple or front of the head is\\nvery common in ocular palsies due to periostitis and gum\u00c2\u00ac\\nmata. In certain cases neither the symptoms nor history\\nenable us to locate the seat or prove the cause of the par\u00c2\u00ac\\nalysis; the term rheumatic is often applied to such\\ncases, on the assumption that the palsy is peripheral and\\ncaused by cold\u00e2\u0080\u0094that it is in fact to be compared to\\nperipheral paralysis of the facial nerve; no doubt some\\nof these are in reality syphilitic. Paralysis, usually of\\nshort duration and affecting only one nerve, is not uncom\u00c2\u00ac\\nmon at an early stage of locomotor ataxy. Ophthalmo\u00c2\u00ac\\nplegia externa generally sets in slowly, is bilaterally sym\u00c2\u00ac\\nmetrical and permanent; it usually indicates sclerotic\\ndisease of the nerve centres, often caused by syphilis;", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0401.jp2"}, "402": {"fulltext": "390\\nCLINICAL DIVISION.\\nbut it is sometimes caused by tumor centrally placed, or\\nby symmetrical gummata on nerve-trunks. Occasionally\\nocular palsies are functional,\u00e2\u0080\u009d or occur in company with\\nsymptoms apparently of hysterical nature, and pass off.\\nParalysis of oculomotor muscles is in rare cases congen\u00c2\u00ac\\nital, occurring in several members of the same family.\\nThese cases are perhaps of the same nature as those of\\ncongenital ptosis, absence or imperfect development of\\nmuscles. Occasionally paralysis of oculomotor nerves\\nfrom birth has been attributed to instrumental labor.\\nIn respect to the causation of the purely internal par\u00c2\u00ac\\nalyses we have but little positive knowledge. Mydriasis\\nwith cycloplegia and no other paralysis would be accounted\\nfor by disease of the short (third nerve) root of the lenticu\u00c2\u00ac\\nlar ganglion. Iridoplegia and ophthalmoplegia interna are\\nprobably the result of chronic, very strictly localized dis\u00c2\u00ac\\nease of the centres for the pupil and accommodation\\n(Gowers), which have been shown to form separate parts\\nof the nucleus of the third nerve. Complete ophthalmo\u00c2\u00ac\\nplegia interna would also be expected if the lenticular\\nganglion (Hutchinson), or the intraocular ganglionic cells\\nof the choroid (Hulke), were disorganized; but such\\nchanges have not yet been proved post mortem. Paralysis\\nfrom blows on the eye is referred to on p. 182. See also\\nDiphtheria, Chapter XXIII.\\nTreatment of Ocular Paralyses. In estimating\\nthe results of treatment it is well to remember that some\\ncases recover spontaneously, that in many the defect is a\\nparesis rather than paralysis, and that in the latter cases\\nthe symptoms often vary in severity from day to day, or\\neven while under observation at a single visit, according\\nto the attention given and effort made by the patient. The\\nquestions of syphilis and of injury to the head must always\\nbe carefully inquired into, especially when only one nerve\\nis paralyzed. When several nerves are involved, tumor,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0402.jp2"}, "403": {"fulltext": "STRABISMUS AND OCULAR PARALYSIS. 39i\\naneurism, or syphilis, either gummatous inflammation at\\nthe base, or sclerotic nuclear disease, is to be suspected.\\nIodide of potassium and mercury are the only internal\\nremedies likely to be beneficial, and unless syphilis be\\nquite out of the question they should have a full trial;\\nmany cases recover quickly under moderate doses of\\niodide. Faradization of the paralyzed muscles is some\u00c2\u00ac\\ntimes used. Operation for paralytic squint of old stand\u00c2\u00ac\\ning may sometimes be undertaken. 1\\nNystagmus, involuntary oscillating movement of the eyes,\\nis generally associated with serious defect of sight dating\\nfrom very early life, such as opacity of the cornea after\\nophthalmia neonatorum, congenital cataract, choroido-\\nretinitis, or disease of the optic nerve. It is, however,\\nalso seen in young babies associated with constant rhyth\u00c2\u00ac\\nmical rolling or nodding movements of the head (spasmus\\nnutans); the nystagmus in these cases usually disappears\\nspontaneously. Nystagmus is present in cases of infantile\\namblyopia without apparent cause, and constantly in\\nalbinoes. Nystagmus is often developed during adult life\\nin coal-miners; it has been attributed to the insufficiency\\nof light furnished by the safety lamps, and with more proba\u00c2\u00ac\\nbility to the necessity which the miner is under of constantly\\nlooking in an unnatural direction, upward or sideways, for\\nexample; it is often present only when the collier takes up\\nhis mining posture. It is occasionally seen in other occu\u00c2\u00ac\\npations\u00e2\u0080\u0094e. y., among compositors. Nystagmus occurs as\\na symptom in some cases of disseminated sclerosis, and in\\nother forms of central nervous disease.\\nUsually both eyes oscillate, but when only one eye is\\ndefective, it alone may oscillate. The movements in nys\u00c2\u00ac\\ntagmus, whatever may be the cause of the condition, vary\\nmuch in rapidity, amplitude, and direction in different\\n1 Rules for operations for paralytic squint have been laid down by Alfred\\nGraefe: Arch* f. Oph., xxxiii. 3, 179.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0403.jp2"}, "404": {"fulltext": "392\\nCLINICAL DIVISION.\\ncases, and even in the same case at different times; they\\nare generally worse when the patient is nervous, and often\\nthere is a particular position of the eyes in which the oscil\u00c2\u00ac\\nlation is least. Nystagmus often becomes much less marked\\nas life advances. Treatment is useless.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0404.jp2"}, "405": {"fulltext": "CHAPTER XXII.\\nOPERATIONS.\\nA. Operations on the Eyelids.\\n1. Epilation of eyelashes. Position: patient seated sur\u00c2\u00ac\\ngeon standing behind. The forceps to be broad-ended, with\\nsmooth or very finely roughened blades, which meet accu\u00c2\u00ac\\nrately in their whole width. Stretch the lid tightly by a\\nfinger placed over each end. Pull out the lashes at first\\nquickly in bundles, and finish by carefully picking out the\\nseparate ones that are left.\\n2. Eversion of upper lid. Position as for 1, or the surgeon\\nmay stand in front. The patient looks down, a probe is\\nlaid along the lid above the upper edge of the cartil\u00c2\u00ac\\nage the lashes, or the edge of the lid, are then seized\\nby a finger and thumb of the other hand, and turned up\\nover the probe, which is simultaneously pushed down.\\nAfter a little practice the probe can be dispensed with, and\\nthe lid everted by the forefinger and thumb of one hand\\nalone, one serving to fix and depress the lid, the other to\\nturn it upward.\\nFig. 138.\\nMeibomian scoop.\\n3. Removal of Meibomian cyst. Position as for 1. In\u00c2\u00ac\\nstruments a small scalpel or Beer\u00e2\u0080\u0099s knife, Fig. 176, and\\na curette, or small scoop, Figs. 138 and 172. 1. Evert the\\nlid. 2. Make a free crucial incision into the tumor from\\n393", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0405.jp2"}, "406": {"fulltext": "394\\nCLINICAL DIVISION\\nthe conjunctival surface. 3. Remove the growth, either\\nby squeezing the lid between finger- and thumb-nail, or\\nby means of the scoop. The cavity fills with blood, and\\nmay thus for a few days be larger than before. These\\ntumors have no distinct cyst-wall.\\n4. Inspection of cornea in purulent ophthalmia, etc.\\nPosition if the patient be a baby or child, the back of\\nFig. 139.\\nits head is to be held between the surgeon s knees, its\\nbody and legs being on the nurse\u00e2\u0080\u0099s lap; if an adult, the\\nsame as for 1. If the lids cannot be easily sejiarated by a\\nfinger of each hand, enough to allow a view of the cornea,\\nretractors should be used, a convenient pattern is shown in\\nFig. 139, by which one lid, or both, can be raised and held\\nFig. 140.\\nJ\\nEntropion forceps.\\naway from the globe. If this instrument be gently used\\nwe avoid all risk of causing perforation of the cornea should\\na deep ulcer be present, an accident which may happen in\\ncases attended by much swelling or spasm of the lids if the\\nfingers be used.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0406.jp2"}, "407": {"fulltext": "OPERATIONS.\\n395\\n5. Entropion. Spasmodic entropion of the lower lid, with\\nrelaxed skin, in old people. Position as for 1. A fold of\\nskin close to the edge of the lid and of width proportionate\\nto the degree of inversion is removed the orbicularis muscle\\nis then exposed, and some of its fibres should also be re\u00c2\u00ac\\nmoved the wound is then closed with sutures. Another\\ngood plan is to enter a threaded needle close to the edge of\\nthe lid, bring it out half an inch vertically below, tie the\\nintervening skin and muscle tightly, and allow the thread\\nto cut its way out; two or three such stitches will be\\nwanted at equal distances apart; the resulting scars being\\nvertical are rather conspicuous.\\n6. Organic entropion and trichiasis. When the whole\\nrow of lashes is turned inward, and the inner surface ot\\nthe lid much shortened by scarring, radical extirpation of\\nFig. 141.\\nSnellen\u00e2\u0080\u0099s lid clamp for the R. upper lid.\\nall the lashes is the quickest and most certain means of\\ngiving permanent relief, but it leaves an unsightly bald\u00c2\u00ac\\nness, and exposes the cornea to unnatural risk from dust,\\netc. Position recumbent; the surgeon stands behind the\\npatient. Anaesthesia seldom necessary. Instruments: a\\nhorn or bone lid-spatula, Fig. 142, s, or a lid clamp, Fig.\\n141, a Beer\u00e2\u0080\u0099s knife, Fig. 176, and forceps. Make an in\u00c2\u00ac\\ncision from end to end, beginning just outside the punc-\\ntum, between the hair-follicles and Meibomian ducts, as", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0407.jp2"}, "408": {"fulltext": "396\\nCLINICAL DIVISION.\\nif to split the lid into two la} r ers. Then make a second\\nincision through the skin and tissues, about a twelfth of\\nan inch above the border of the lid, parallel with but\\nin a plane at right angles to the first. The strip of skin\\nand tissues included between these two cuts will now be\\nalmost free, except at its ends, which are to be united by\\na cross-cut, and the strip dissected off; it should include\\nthe hair-follicles in their whole depth. Examine the white\\nedge of the\u00e2\u0080\u009c cartilage,\u00e2\u0080\u009d now exposed, for any hair-follicles\\naccidentally left behind; they will appear as black dots,\\nand are to be carefully removed.\\nIn the same or slighter cases the inversion of the border\\nof the lid may be much lessened by complete division of\\nthe cartilage\u00e2\u0080\u009d from the conjunctival surface along a line\\nparallel with and 3 mm. from the free border (Burow\u00e2\u0080\u0099s\\noperation). Fig. 143, Bu. The wound gapes and the in\u00c2\u00ac\\nverted border of the lid falls forward and is kept in its\\nnatural place by the cornea. The only instruments needed\\nare a scalpel and scissors. Position as for 1, or recumbent.\\nThe lid is kept well everted while the incision is being made.\\nA puncture is made with the knife parallel to the edge of\\nthe lid, close to the inner or outer end, one blade of the\\nscissors passed through this puncture and made to run\\nalong the outer surface of the cartilage\u00e2\u0080\u009d between it and\\nthe orbicularis muscle, and then the cartilage\u00e2\u0080\u009d divided\\nby closing the blades parallel to the border. The wound\\nshould be at right angles to the surface. A bluish line\\nshould be seen through the skin on replacing the lid.\\nThis operation gives complete relief for the time, but\\nmay need repetition in a few months.\\nVarious operations are performed for transplantation of\\nthe displaced lashes forward and upward, so as to restore\\ntheir natural direction. Arlt\u00e2\u0080\u0099s operation The free border\\nof the lid is split from end to end (leaving the punctum), as\\nfor extirpation of the lashes, but more deeply, Fig. 142, a.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0408.jp2"}, "409": {"fulltext": "OPERA TIONS.\\n397\\nA second incision (6), extending beyond the ends of the\\nfirst, is now made through the skin parallel to and about\\nFig. 142.\\nArlt\u00e2\u0080\u0099s operation for trichiasis. (After Schweigger.)\\nFig. 143.\\nDiagrammatic section of upper lid showing Snellen\u00e2\u0080\u0099s operation, and line\\nof section in Burow\u00e2\u0080\u0099s operation (Bu). (Altered from Wecker.)\\ntwo lines from the border of the lid, and down to but not\\nthrough the cartilagethirdly, a curved incision (c) is", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0409.jp2"}, "410": {"fulltext": "398\\nCLINICAL DIVISION.\\nmade, joining b at each end and including a semilunar\\nflap of skin, of greater or less width according to the effect\\ndesired fourthly, this flap is dissected off without injury\\nto the orbicularis, and the wound, hounded by the lines\\nb and c, closed by sutures. The anterior layer of the lid\\nborder, which contains the lashes, is thus tilted forward\\nand drawn upward.\\nA third operation (Streatfeild\u00e2\u0080\u0099s) consists in the simple\\nremoval of a wedge-shaped strip of the cartilage\u00e2\u0080\u009d (with\\nits superjacent skin and muscle) from the whole length of\\nthe lid at a distance of a line or two from its border. No\\nsutures are used.\\nFig. 144.\\nSnellen\u00e2\u0080\u0099s operation for trichiasis, s. Edge of retracted skin and muscle.\\n(After Wecker.)\\nSnellen operates as follows: The incision, b, Fig. 142, is\\ncarried down to the tarsus, the muscle and skin separated\\nfrom it and pushed upward, and a wedge, shown by the\\ngroove in Fig. 143, cut from the exposed tarsus, as in\\nStreatfeild\u00e2\u0080\u0099s operation. The border of the lid is now\\neverted, and kept in its new position by passing two or\\nthree threads, as shown in Figs. 143 and 144, and tying\\nthem over beads. The skin wound need not be sutured.\\nVarious other operations have been introduced from time\\nto time for entropion by Spencer Watson and others by\\nwhich a flap of skin is inserted between the lashes and the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0410.jp2"}, "411": {"fulltext": "OPERATIONS.\\n309\\nedge of the lid; the cutaneous hairs on the transplanted\\nflap, however, occasionally irritate the cornea.\\nAll these operations (except l)are apt to need repetition\\nsooner or later.\\nThe above operations are most suitable when the whole\\nlength of the upper lid is affected; in most hands Arlt\u00e2\u0080\u0099s\\nproceeding probably gives better average results than any\\nother. In cases of partial trichiasis, where only a few\\nlashes are misdirected, electrolysis of the hair-follicles is a\\nvaluable proceeding a needle connected with the negative\\npole of a battery is passed into the follicle by the side of\\nthe shaft of the hair, the positive pole being applied to the\\nskin of the temple. The hair is loosened, comes away, and\\ndoes not grow again; this has to be done to each of the\\ndisplaced lashes. Where only a part of the border is\\naffected, transplantation of a strip of mucous membrane\\nfrom the patient\u00e2\u0080\u0099s lip into the gap made by splitting the\\ndiseased part of the lid, Fig. 145, is the best operation.\\nThis may be done as follows (van Millingen): 1. Split the\\naffected part of the lid as in Arlt\u00e2\u0080\u0099s operation, but turn the\\ncut forward into the skin a little at each end, as shown in\\nFig. 145. 2. Separate a strip of mucous membrane from\\nthe lower lip parallel to its length, leaving its ends at\u00c2\u00ac\\ntached the strip should be longer and wider than the gap\\nit is to fill. 3. Take two needles, each with a long thread\\nattached, and pass one through each end of the lid in\u00c2\u00ac\\ncision from the skin surface into the angle of the wound,\\ndraw the needles through, carry them down to the lip, and\\npass each one through the corresponding end of the bridge\\nof mucous membrane from the deep to the free surface.\\n4. Cut the attached ends of the bridge, turn the strip over\\non the thumb-nail, and clean its under surface with scis\u00c2\u00ac\\nsors, taking care not to cut the thread at each end.\\n5. Draw the strip up into its new position by pulling on\\nthe upper ends of the threads, and tie the threads. A", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0411.jp2"}, "412": {"fulltext": "400\\nCLINICAL DIVISION.\\nvery fine stitch may be inserted at the centre of the flap\\nif thought necessary, but this can be dispensed with. The\\nsplit in the lid should be cleaned from clot before the strip\\nis brought into position. The strip usually lives and ad\u00c2\u00ac\\nheres well under an antiseptic dressing; the stitches may\\nbe left to come out.\\n7. Ectropion. Ectropion from thickening of the con\u00c2\u00ac\\njunctiva, aided by relaxation of the tissues of the lower\\nlid, seen chiefly in old people, may be treated by the\\nremoval of a Y-shaped piece of the whole thickness of the\\nFig. 145.\\nVan Millingen\u00e2\u0080\u0099s operation. First stage the portion of lid containing mis\u00c2\u00ac\\ndirected lashes split parallel to its surfaces, leaving the lashes in the anterior\\nlayer. The incision at each end is carried a short distance into the skin at a\\nright angle with the split.\\nlid, the edges being brought together with a harelip pin.\\nIn Kuhnt\u00e2\u0080\u0099s operation the lid is split by an incision in the\\nintermarginal space, and a Y-shaped portion of the inner\\nor conjunctival half is removed, the edges being drawn\\ntogether by sutures. In Snellen\u00e2\u0080\u0099s operation the everted\\nmucous membrane is drawn back into the sulcus between\\nlid and globe by a suture, entered into the conjunctiva at\\ntwo points one-third of an inch apart, passed deeply, brought\\nout on the cheek, and tied over a bit of India-rubber tube;\\nthe thread is tightened from day to day until it has nearly\\ncut through. An operation of which the principle is nearly\\nthe same, but the execution more complicated, is described", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0412.jp2"}, "413": {"fulltext": "OPERATIONS.\\n401\\nby Argyll-Robertson. 1 Slighter cases may be satisfactorily\\ntreated by the excision, or destruction by burning deeply\\nwith a fine galvanic cautery, of a strip of the palpebral\\nconjunctiva parallel to the border of the lid the contrac\u00c2\u00ac\\ntion of the scar draws the margin of the lid into place.\\nFor ectropion from cicatricial changes in the skin a\\nplastic operation is generally needed. At the same time\\nthe eyelids should be united by fine sutures, after paring\\na narrow strip from the border of each lid just within the\\nline of the lashes (blepharoplasty), a proceeding which at\\nonce assists the restitution of the displaced lid, and gives\\nprotection to the cornea; the lids may be separated a few\\nweeks later. The operation for the cure of the ectropion\\nwill naturally vary with the seat, extent, and cause of the\\ndeformity, but we may conveniently distinguish three\\nvarieties of organic ectropion, according as the condition\\nhas followed (1) a wound of the eyelid with faulty union\\n(2) a deejdy adherent scar from abscess, disease of bone, or\\ndeep ulceration of the lid or (3) extensive scarring of the\\nface from burns, lupus, etc. When the cause is quite\\nlocalized, and there is not much loss of tissue (groups 1\\nand 2), the scar may be included in a Y-shaped incision,\\nthe flap separated and pushed up till the lid is in position,\\nand the lower part of the wound then brought together by\\nFig. 146.\\nV Y operation. (From Ritterich.)\\n1 Robertson Edinburgh Clinical and Pathological Journal, December, 1883.\\n26", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0413.jp2"}, "414": {"fulltext": "402\\nCLINICAL DIVISION.\\na pin or sutures, so that what was a V now becomes a Y,\\nthe edges of the flap being attached by sutures to the limbs\\nof the Y, Fig. 146. As the lid has generally become too\\nlong from prolonged eversion, we often have at the same\\ntime to shorten it by removing a small triangle from its\\nouter end, and uniting the edges of the gap. When the\\nposition of the deformity prevents the above operation, it\\nis necessary to introduce new skin into the gap, made by\\ndissecting out the cicatricial tissue and putting the everted\\nlid into position. This may be done by bringing a flap\\nwith a broad pedicle, either by sliding or twisting into\\nthe gap; or by the method, introduced into England by\\nDr. Wolfe, of transplanting from a distant part a single\\ngraft of skin without a pedicle, large enough to Till the\\ngap; or, again, by filling the gap with several small pieces\\nof skin. Where there is extensive destruction of skin\\n(group 3) these grafting methods seem particularly valu\u00c2\u00ac\\nable. If a single large graft be used, the important points\\nare to make it considerably larger than the deficiency it\\nis to supply, to free the under surface of the graft very\\nthoroughly of all subcutaneous tissue, and apply warm\\ndressings. The single graft operation has now been tried\\nmany times, and with a good proportion of successes.\\n8. Paralytic and congenital ptosis have often been treated\\nby the removal of an oval piece of skin from the upper lid,\\nparallel to its length, the orbicularis muscle not being\\ntouched. This simple method, however, has but little\\neffect unless the piece removed be so large as to shorten\\nthe lid materially, and thus endanger the power of com\u00c2\u00ac\\nplete closure. More complicated operations, intended to\\nraise the lid by producing contraction of the subcutaneous\\ntissues, or adhesion between these parts and the tendon of\\nthe occipito-frontalis at the eyebrow without the removal\\nof any skin, have been recommended by Pagenstecher,\\nDransart, Meyer, and Panas. I have had, and have seen", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0414.jp2"}, "415": {"fulltext": "OPERA TIG NS.\\n403\\nFig. 147.\\nPanas\u00e2\u0080\u0099 operation (after).", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0415.jp2"}, "416": {"fulltext": "404\\nCLINICAL DIVISION.\\nin the hands of others, satisfactory results from Panas\u00e2\u0080\u0099\\noperation in several cases.\\n9. Canthoplasty, for lengthening the palpebral fissure at\\nthe outer canthus. The canthus is divided by scissors or\\na knife as far as may seem necessary. The contiguous\\nocular conjunctiva is then slightly dissected up and at\u00c2\u00ac\\ntached by sutures to the cut edges of the skin, so as to\\nprevent reunion, one suture being placed in the angle of\\nthe wound, one above and one below. Fig. 148.\\nFig. 148.\\nCanthoplasty. (From Ritterich.)\\n10. Peritomy, for obstinate cases of partial pannus. An-\\nfesthesia is necessary. Instruments: speculum, fixation for\u00c2\u00ac\\nceps, scissors, and Beer\u00e2\u0080\u0099s knife. With the knife a circular\\nincision is carried through the conjunctiva, round the cor\u00c2\u00ac\\nnea, at 5 mm. or less, from its border. The zone of\\nconjunctiva so included, together with the whole of its\\nsubconjunctival tissue down to the sclerotic, is now care\u00c2\u00ac\\nfully removed by the scissors. The bare surface thus left\\ngranulates, and finally contracts to a narrow band of white\\nscar-tissue, by which the vessels running to the cornea should\\nbe obliterated. The subconjunctival fascia is often found\\nmuch thickened in these cases. Care must be taken not to\\nmake the incision too far from the cornea, lest the inser\u00c2\u00ac\\ntions of the recti be damaged. The strip removed should\\nextend completely round the cornea; removal of only a\\npart of the zone is not satisfactory. The symptoms are", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0416.jp2"}, "417": {"fulltext": "OPERATIONS.\\n405\\ngenerally made worse for a time, and the final result is\\nnot reached for several months. In some cases the opera\u00c2\u00ac\\ntion has, in my experience, been very successful; while in\\nothers, without apparent reason, it has quite failed of its\\npurpose. A similar effect may be sometimes produced by\\nmaking a small linear burn with the galvano-cautery all\\naround the cornea.\\nSymblepharon, adhesion of lid to globe after destruction\\nof conjunctiva unless very extensive, can be greatly im\u00c2\u00ac\\nproved by operations. In slight cases we have merely to\\nseparate the adhesion from the globe and bring together\\nthe edges of the ocular conjunctiva to cover the surface\\nexposed, and thus prevent reunion. But when the surface\\nexposed by the dissection is large, flaps of conjunctiva with\\nbroad pedicles must be brought down to cover the defi\u00c2\u00ac\\nciency in the manner first proposed by Teale or mucous\\nmembrane may be transferred from the lip of the patient,\\nor even from the conjunctiva of a rabbit. Snellen has\\nlately used a flap of neighboring skin with a pedicle, push\u00c2\u00ac\\ning it through a sort of button-hole in the lid, and attaching\\nit in the gap made by separating the adhesions. Harlan\\nhas devised the following operation for the relief of this\\ncondition. The adhesion is freely dissected until the upward\\nmovement of the ball is entirely unimpaired, and an external\\nincision, represented at a b in the accompanying illustra\u00c2\u00ac\\ntion, along the margin of the orbit, is carried through the\\nwhole thickness of the lid, which is thus separated from its\\nconnections except at the extremity. A thin flap, c d, is\\nthen formed from the skin below the lid, care being taken\\nto leave it attached at its base line by the tissue just\\nbeneath a b, as well as at the extremities (Fig. 149). On\\nthis attachment it is turned upward as on a hinge, bring\u00c2\u00ac\\ning its raw surface into contact with the inner surface of\\n1 Teal: Ophth. Hosp. Reports, iii. p. 253,1861.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0417.jp2"}, "418": {"fulltext": "406\\nCLINICAL DIVISION\\nthe lid, and its sound surface presenting toward the ball,\\nand held in this position by suturing its edge to the margin\\nof the lid. In dissecting up the flap the incisions are car\u00c2\u00ac\\nried more deeply into the orbicularis muscle, when the\\nbase line a b is nearly reached, to enable it to turn more\\nreadily. The bare space left by the removal of the strip\\nof skin is nearly covered without strain by making a hori-\\nFig. 149.\\nHarlan\u00e2\u0080\u0099s operation for symblepharon.\\nzontal incision, d e, at its outer extremity and forming a\\nsliding flap.\\nKnapp\u00e2\u0080\u0099s roller operation for trachoma is applicable to all\\ncases in which there is a marked development of trachoma\\ngranules; and it often proves useful when there is great\\nthickening of the lid with deposit of similar material deep\\nwithin it, but without any appearance of distinct sago-\\ngrains upon the surface. The instrument consists of a\\nforceps, in each jaw of which is fixed a corrugated roller.\\nThe upper lid should be everted, one roller thrust far into\\nthe cul-de-sac, the other placed at the ciliary margin, and\\nthe two brought together with considerable pressure and\\ndrawn toward the free folded part of the lid. This is re\u00c2\u00ac\\npeated until every portion of the lid has been thoroughly\\ngone over. The same is done for the lower lid. For the\\nlid margins one roller may be placed inside the lid, the\\nother on the cutaneous surface. For the retrotarsal folds", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0418.jp2"}, "419": {"fulltext": "OPERA TIONS.\\n407\\nas much as possible of the fold is to be grasped between\\nthe rollers, and the contents pressed out. Especial care\\nis required to the conjunctiva near the outer or the inner\\ncanthus. When bleeding ceases, the eye may be washed\\nout with an antiseptic solution. The operation is usually\\nfollowed by great swelling of the lids. But this subsides\\nspontaneously in two or three days, or it may be controlled\\nby ice applications. As the operation is painful, and should\\nbe thorough, a general anaesthetic is commonly required.\\nB. Operations on the Lachrymal Apparatus.\\n1. Lachrymal abscess. (See p. 97).\\n2. Slitting up the lower canaliculus. This is best done\\nby means of a knife with a blunt or probe point, and a\\nblade narrow enough to enter the punctum. The best\\nforms of these knives are Weber\u00e2\u0080\u0099s knife, with a probe\\nend, Fig. 151; Bowman\u00e2\u0080\u0099s, with nearly parallel borders\\nand a rounded end, Fig. 152; and Liebreich\u00e2\u0080\u0099s, Fig. 153.\\nPosition as for 1. 1. The lower lid is drawn tightly out\u00c2\u00ac\\nward and downward by the thumb. 2. The canaliculus\\nknife is passed vertically into the punctum, then turned\\nhorizontally and passed on through the neck of the canal\u00c2\u00ac\\niculus till it reaches the bony (inner) wall of the lachrymal\\nsac. It is then raised up from heel toward point, and thus\\nmade to divide the canaliculus, care being taken that the\\nneck is freely divided. Liebreich\u00e2\u0080\u0099s knife cuts its own way\\nwithout being raised. The lower canaliculus may also be\\ndivided with a Beer\u00e2\u0080\u0099s knife, Fig. 176, which is run along\\na fine grooved director, Fig. 150, previously introduced.\\nIn cases of mucocele it is good practice to divide the wall\\nof the sac freely, and some surgeons open the upper as well\\nas the lower canaliculus. The canaliculus requires to be\\nkept open every three or four days till its cut edges are\\nhealed, or they will unite again.\\n3. Probing the nasal duct. After dividing the canal-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0419.jp2"}, "420": {"fulltext": "408\\nCLINICAL DIVISION.\\niculus pass a good-sized lachrymal probe horizontally\\nalong its floor till it strikes the inner (bony)\\nfig. iso. wa p t p e sac Then raise it to the vertical\\nposition, and push it steadily down the duct,\\ndownward and a very little outward and back-\\nFig. 151.\\nWeber\u00e2\u0080\u0099s canaliculus knife.\\nward, till the floor of the nose is reached. Bow\u00c2\u00ac\\nman\u00e2\u0080\u0099s earlier probes were in six sizes, of which\\nFig. 152.\\nBowman\u00e2\u0080\u0099s canaliculus knife.\\nthe largest was one twentieth inch in diameter.\\nBowman afterward adopted much larger probes\\nFig. 153.\\nLiebreich\u00e2\u0080\u0099s knife for canaliculus and nasal duct.\\nI\\nwith bulbous ends; and several such patterns\\nare now in use. The probe used should be the\\nlargest that will pass easily.\\n4. A stricture of the duct may be incised with\\nany of the canaliculus knives, although Weber\u00e2\u0080\u0099s\\nand Bowman\u00e2\u0080\u0099s are too slender to be used with\\nsafety. Liebreich\u00e2\u0080\u0099s is intended to be so used, and a special\\nknife for the purpose had previously been introduced by\\nStilling. The knife is used as a probe, being pushed quite\\ndown the duct, then partly withdrawn, turned in another\\nCanaliculus\\ndirector.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0420.jp2"}, "421": {"fulltext": "OPERATIONS.\\n409\\ndirection, and pushed down again. There is generally\\nbleeding from the nose.\\nIn all these procedures we must be certain that the probe\\nFig. 154. Fig.155.\\nor knife rests against the bony (nasal) wall of the lachry\u00c2\u00ac\\nmal sac before it is raised into the vertical direction. If", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0421.jp2"}, "422": {"fulltext": "410\\nCLINICAL DIVISION.\\nthe probe be stopped at the entrance of the canaliculus into\\nthe sac, as may easily happen if the canal be not thoroughly\\nslit in its whole length, the lid will be pulled upon and\\npuckered whenever the instrument is pushed toward the\\nnose; but if the probe have reached the sac, backward\\nand forward movements will not usually cause puckering\\nof the lid. If in the former case the instrument be turned\\nup, and an attempt made to pass it down the duct, a false\\npassage will probably be made.\\nThe direction of the two nasal ducts is either parallel, or\\nsuch that if prolonged upward they would converge slightly;\\nthey very seldom diverge. The probe when in the duct\\nshould, even if as usual its lower end be curved forward,\\nrest against and indent the eyebrow; if it stand forward\\nfrom the brow it is usually in a false passage.\\nLachrymal syringes are of two kinds 1. Anel\u00e2\u0080\u0099s syringe,\\nwith a nozzle fine enough to pass into the unopened punc\u00c2\u00ac\\ntual, Fig. 154. By injecting a little water into the duct\\nthrough the canaliculus we can sometimes clear out slight,\\napparently mucous obstruction, and relieve epiphora with\u00c2\u00ac\\nout cutting or probing; and by the same method we can\\noften decide whether or not there is an obstruction needing\\nthe severer treatment. 2. Hollow probes attached to\\nsyringes of various patterns are used for passing down\\nthe duct and syringing at the same time. Fig. 155 shows\\na simple form sold as Bowman\u00e2\u0080\u0099s.\\nExtirpation of the lachrymal gland is indicated in cases\\nof neoplasms and extreme hypertrophy, or where there is\\nobstinate stillicidium which cannot be controlled in any\\nother way. This is accomplished by removing the gland,\\neither directly through a skin incision made over the\\ngland, or by an incision through the conjunctiva after\\nexposure of the cul-de-sac, by division of the external can-\\nthus. The latter procedure is the one usually employed,\\nas the ptosis which has a tendency to follow the first men-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0422.jp2"}, "423": {"fulltext": "OPERA TIONS.\\n411\\ntioned, due to injury of the levator, is avoided, and the\\nresultant scar is much less conspicuous.\\nC. Operations for Strabismus.\\nTenotomy. The object is to divide the tendon close to\\nits insertion into the sclerotic. Critchett\u00e2\u0080\u0099s subconjunctival\\noperation, or the operations of Yon Graefe and Von Arlt\\nare the ones commonly employed; the advantages of the\\nlatter two operations are that the tendon is exposed in its\\nwhole length, the parts to be divided can be seen, and there\\nis no risk of wounding the sclerotic. The internal and\\nexternal recti are the only tendons commonly divided, the\\ninternal far the more frequently. Anaesthesia is seldom\\nnecessary except for young children. Instruments: stop\\nspeculum, Fig. 156, straight scissors with blunted points,\\ntoothed fixation forceps, strabismus hook. There are sev\u00c2\u00ac\\neral forms of hook, differing in the length and sharpness\\nof the curve and the shape of the tip.\\nFig. 156.\\nStop-spring speculum.\\nOperations. Graefe\u00e2\u0080\u0099s. After the eye has been thor\u00c2\u00ac\\noughly cocainized the speculum is introduced, and an in\u00c2\u00ac\\ncision is made transversely over the insertion of the tendon\\nsufficient to expose its whole width; the conjunctiva being\\npushed aside, Tenon s capsule is opened below the tendon;\\nthe hook is then passed under the tendon, and the latter", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0423.jp2"}, "424": {"fulltext": "412\\nCLINICAL DIVISION.\\ndivided with the scissors. The conjunctival wound may\u00c2\u00ac\\nbe closed by a single stitch. Von Arlt\u00e2\u0080\u0099s operation differs\\nFig. 157.\\nfrom the one just described in that the squint-hook is dis\u00c2\u00ac\\npensed with; after the tendon is exposed it is grasped by\\nthe fixation forceps and divided. It certainly has the\\nmerit of being much less painful, and can be used with\\nchildren frequently without a general anaesthetic. Snellen\\nmakes the conjunctival wound parallel to the muscle to\\navoid gaping. The effect in this and all operations may\\nFig. 158.\\nbe considerably increased if the various fascial or indirect\\nconnections of the muscle be divided as well as its tendon.\\nThis is done (1) by separating the conjunctiva from the\\nfascia and its muscle by a burrowing dissection with the\\nscissors before the tendon is cut; (2) by freely dividing the\\nfascia above and below the tendon, by cutting with the\\nscissors upward and downward after having divided the\\ntendon itself; (3) by tying the eye out with a silk suture\\npassed through the conjunctiva and surface fibres of the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0424.jp2"}, "425": {"fulltext": "OPERATIONS.\\n413\\nsclerotic, close to the outer border of the cornea, and at\u00c2\u00ac\\ntaching it to the temple for two days by strapping.\\nFig. 159.\\nMEYRUWITZ.\\n3\\nStrabismus hook.\\nCritchett\u00e2\u0080\u0099s operation. In this operation a fold of conjunc\u00c2\u00ac\\ntiva is pinched up over the lower border of the tendon close\\nto its insertion and divided the exposed capsule of Tenon\\nis similarly divided. The squint-hook is next passed through\\nthe opening in the capsule with its concavity downward and\\npoint backward; the point is then made to sweep around\\nbetween the tendon and globe until its end is seen projecting\\nbeneath the conjunctiva at the upper border of the tendon.\\nThe scissors are next passed into the wound with the blades\\nslightly open between the hook and the eye and the tendon\\nsnipped across. When the whole tendon has been divided,\\nthe hook comes forward beneath the conjunctiva to the\\nedge of the cornea. It is well by introducing the hook to\\nmake sure that no small strands of the tendon have escaped,\\nfor the operation does not succeed unless the division is\\ncomplete.\\nNo after-treatment is needed, but the patient is more\\ncomfortable if the eye be tied up for a few hours.\\nThe difficulties for beginners are (1) to be sure of open\u00c2\u00ac\\ning the fascia; (2) to avoid pushing the tendon in front of\\nthe scissors, especially when only the upper part remains\\nundivided.\\nSimple division of one internal rectus without separation\\nand division of fascia diminishes the squint by about two", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0425.jp2"}, "426": {"fulltext": "414\\nCLINICAL DIVISION.\\nlines (4mm.). The effect, however, is often much less if\\nthe patient be adult or nearly so.\\nLiebreicRs operation is Critchett\u00e2\u0080\u0099s with the addition of\\nthe separation of conjunctiva from the fascia, and the divi\u00c2\u00ac\\nsion of the fascia beyond the edges of the tendon described\\nat p. 413. These additions to simple tenotomy can be more\\neasily and thoroughly applied to Graefe\u00e2\u0080\u0099s operation when\\nthe incision is over the tendon, and after a considerable\\ntrial I have ceased to use Liebreich\u00e2\u0080\u0099s method. In any\\ncase of considerable convergent squint, or squint operated\\non in an adolescent or adult, I prefer Graefe\u00e2\u0080\u0099s method,\\nwhich admits of the maximum effect being easily obtained.\\nThe immediate effect of the tenotomy of a rectus muscle is\\nlessened after a few days by the reunion of the tendon with\\nthe sclerotic, but after a few weeks or months it is some\u00c2\u00ac\\ntimes again increased by the stretching of this new tissue.\\nReadjustment or advancement consists in bringing forward\\nto a new attachment the tendon of a rectus (generally the\\ninternal) which has become attached too far back after a\\nprevious tenotomy, or is acting inefficiently, as in various\\ncases of primary divergent squint; advancement of the\\nexternal rectus is also used in simultaneous conjunction\\nwith tenotomy of the internal in high degrees of con\u00c2\u00ac\\nvergent squint, especially when the squint is of many\\nyears\u00e2\u0080\u0099 duration. Indeed, whether performed for divergent\\nor convergent strabismus, tenotomy of the opponent muscle\\nis generally needed. There are several different operations,\\nbut in all of them the tendon is held in its new position by\\nsutures. The operation is tedious, but may often be done\\nunder cocaine. The instruments are the same as for ten\u00c2\u00ac\\notomy.\\nI now generally perform the operation as follows (essen\u00c2\u00ac\\ntially the method described by Tweedy): 1 1. A stitch of\\n1 Tweedy: Lancet, March 22,1884.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0426.jp2"}, "427": {"fulltext": "OPERATIONS.\\n415\\nfine silk is first put through conjunctiva and surface fibres\\nof sclerotic close to the inner edge of the cornea and exactly\\non the horziontal line; this is to serve as a guide in case\\nthe eyeball rotates afterward. 2. The tendon is exposed\\nby a vertical wound in the conjunctiva about 5 mm. from\\nthe corneal border, the fascia opened above and below, and\\na hook passed under the tendon. 3. A stitch is passed\\nthrough the upper part of the muscle alone (not including\\nconjunctiva), some way from its attachment, and tied around\\nthe included part of the muscle, and the needle then passed\\nbeneath conjunctiva and fascia and brought out above the\\nupper edge of the cornea; the lower part of the muscle is\\ntreated in the same way; the tendon is then divided from\\nthe sclerotic with scissors, and, if thought necessary, short\u00c2\u00ac\\nened by cutting off the portion in front of the sutures. The\\nneedle carrying the central (guide) thread is now passed\\nfrom behind forward through the muscle between the other\\ntwo sutures and overlying conjunctiva and tied. The upper\\nand lower stitches are then tied tightly. The conjunctiva\\nis a good deal dragged upon above and below, but soon\\nstretches, or the sutures partly cut through. The opponent\\nrectus is divided before the sutures are tied. The eyes\\nshould both usually be kept quietly tied up for several\\ndays, and the stitches be left in for a week, or until they\\ncome away, if silk.\\nCapsular Advancement .\u00e2\u0080\u0094This operation was introduced\\nby de Wecker some years ago, and has been found by the\\nEditor to be admirably adapted to the correction of low\\ndegrees of divergence in the visual axes. The steps in the\\noperation, as described by its projector, are as follows:\\nThe conjunctiva being grasped lightly with forceps\\nslightly to the corneal side of the insertion of the muscle\\nwhich is to be advanced, an upward incision is made into\\nthe conjunctiva parallel with the corneal limbus and\\nattaining the height of the upper edge of the cornea, and", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0427.jp2"}, "428": {"fulltext": "416\\nCLINICAL DIVISION.\\na similar one is made below which reaches to the level of\\nthe lower margin of the cornea. After any bleeding has\\nbeen controlled a small buttonhole is made in the capsule\\nof Tenon above and below, and a little externally to the\\ninsertion of the muscle into the globe. The closed points\\nof the scissors are then inserted into one of these holes and\\npassed under the muscle in all directions to free the capsule\\nfrom its sublying tissue. These preliminary steps having\\nbeen performed, a delicate curved needle is passed through\\nthe episcleral tissues at the summit of the cornea, and\\nthen carried through the buttonhole in the capsule, under\\nthe capsule for several millimetres, and then finally\\nbrought out through the conjunctiva and its sublying tis\u00c2\u00ac\\nsues near the canthus. A similar suture is then passed\\nbelow from the base of the cornea through the lower but\u00c2\u00ac\\ntonhole, the eye is rotated with forceps in the direction of\\nthe muscle which is being advanced, and the ends of the\\nsutures carefully tied. De Wecker claims for this opera\u00c2\u00ac\\ntion the power to accomplish all that is gained by a direct\\nadvancement of the insertion of the muscle itself, without\\nthe risk of interfering with the axis of the traction of the\\nmuscle. The operation in the hands of the Editor, how\u00c2\u00ac\\never, has not shown such a wide range of usefulness, for he\\nhas never been able to obtain but a moderate degree of\\npermanent advancing power from it.\\nD. Excision of the Eye.\\nInstruments as for squint. The operator may stand either\\nbehind or in front. 1. Divide the ocular conjunctiva all\\naround, close to the cornea. 2. Open Tenon\u00e2\u0080\u0099s capsule, and\\ndivide each rectus tendon and the neighboring fascia on\\nthe hook the two obliques are seldom divided on the hook.\\n3. Make the eye start forward by pressing the speculum\\nback behind the equator of the globe. 4. Pass the scissors", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0428.jp2"}, "429": {"fulltext": "OPERATIONS.\\n417\\nbackward along the sclerotic till their open blades can be\\nfelt to embrace the optic nerve (recognized by its toughness\\nand thickness), and divide it by a single cut while steady\u00c2\u00ac\\ning the globe with a finger of the other hand. Finish by\\ndividing the oblique muscles and remaining soft parts\\nclose to the globe. Apply pressure for a minute or two,\\naud then tie up slightly for six or eight hours with an\\nelastic pad of small sponges overlaid by cotton-wool. There\\nis scarcely ever serious bleeding. The artificial eye may be\\nfitted in from three to four weeks. 1\\nAfter some weeks or months a button of granulation\\ntissue occasionally grows from the scar at the bottom of\\nthe conjunctival sac, and should be snipped off.\\nThe operation is more difficult when the eye is ruptured\\nor shrunken, or the surrounding parts much inflamed and\\nadherent. The order of division of the muscles is imma\u00c2\u00ac\\nterial. The important points are to leave as much con\u00c2\u00ac\\njunctiva as possible, so as to form a deep bed for the glass\\neye, and by keeping the scissors close to the globe during\\nthe whole operation to avoid unnecessary laceration of the\\ntissues.\\nWhen, as in some cases of intraocular tumor, it is de\u00c2\u00ac\\nsired to remove another piece of the optic nerve, the nerve\\nshould be felt for with the finger, seized and drawn forward\\nwith the forceps, and cut off further back with the scissors.\\nSubstitutes for excision of the eyeball. Abscission is the\\nremoval of a staphylomatous cornea with the front part of the\\nsclerotic, leaving the hinder part of the globe with the muscles\\nattached to serve as a movable stump for carrying the artificial\\neye. Four or five semicircular needles carrying sutures are made\\nto puncture and counter-puncture the sclerotic, just in front of\\nthe attachments of the recti; the part of the globe in front\\n1 The glass eye must be renewed as often as it gets rough, generally at least\\nonce a year. Some persons have much difficulty in tolerating it, and they\\nmust he content to wear it for only a part of the day. It is always to be re\u00c2\u00ac\\nmoved at bedtime.\\n27", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0429.jp2"}, "430": {"fulltext": "418\\nCLINICAL DI VISION.\\nof the needles is cut off, the needles drawn through, and the\\nsutures tied. The operation is admissible only when the ciliary\\nregion is free from disease, and has therefore a very limited\\napplication even in the most favorable cases the stump is not\\nentirely free from the risk of setting up sympathetic inflamma\u00c2\u00ac\\ntion, and I therefore never perform it. It is said that if the\\nsutures are passed only through the conjunctiva or the muscles,\\nthe risk is less than when they are passed through the sclerotic.\\nThe operation of optico-ciliary neurotomy in which the optic\\nnerve and all the ciliary nerves are divided without removal\\nof the globe, with the view of preventing sympathetic disease,\\nappears to me to be bad surgery. The sensibility of the\\ncornea, abolished by the operation, often returns, proving that\\nthe ciliary nerves have reunited. The cut ends of the optic\\nnerve have also been found reunited, and though union may\\nbe prevented by exsection of a considerable piece of the optic\\nnerve, the same cannot be done with the ciliary nerves. The\\noperation, therefore, cannot be relied upon to destroy these, nor,\\nit may be added, any of the other possible paths (p. 174) along\\nwhich sympathetic irritation and inflammation may travel;\\nindeed, sympathetic inflammation has been observed to follow\\nthe operation in at least one case.\\nEvisceration of the eye, long ago performed in certain cases\\nby sundry operators, has been systematically practised and ad\u00c2\u00ac\\nvocated by Mr. Mules, 1 of Manchester, and Professor Graefe, of\\nHalle. The front of the eye is removed at the sclero-corneal\\njunction, and the whole contents of the globe emptied out with\\nany convenient instrument, very great care being taken to re\u00c2\u00ac\\nmove every trace of choroid and ciliary body. Mr. Mules then,\\nafter enlarging the scleral opening by a vertical slit, introduces\\ninto its cavity an hermetically closed, hollow glass ball, and\\nstitches the sclerotic carefully over it with fine catgut, the con\u00c2\u00ac\\njunctiva being separately sewn afterward. The parts should\\nbe irrigated during the whole operation. There is more reac\u00c2\u00ac\\ntion than after excision, and if the sclerotic be much inflamed,\\nor if suppuration occur, the stitches may give way. The in\u00c2\u00ac\\ntroduction of the glass globe is not an essential part of the\\n1 Mules: Trans. Ophth. Soc., vol. v. p 200, 1885.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0430.jp2"}, "431": {"fulltext": "OPERATIONS.\\n419\\nproceeding, its object being merely to improve the stump.\\nGraefe advocates evisceration as less likely than excision to\\nbe followed by meningitis\u00e2\u0080\u0094a terrible accident, which every\\nnow and then occurs. Mules defends it as likely to be, equally\\nwith excision, a safeguard against sympathetic disease, while\\nallowing a better stump for the artificial eye.\\nA number of operators have sought to gain the same\\ncosmetic effect as that obtained by the Mules operation,\\nwithout exposing the patient to the danger of sympathetic\\ntrouble, by removing the eyeball in its entirety, and im\u00c2\u00ac\\nplanting a glass ball within Tenon\u00e2\u0080\u0099s capsule. The best of\\nthese procedures is that which has been lately introduced\\nby Oliver. The steps in this operation are as follows: 1\\nThe conjunctiva around the entire corneal limbus is\\nfreed from the globe and dissected sufficiently far back so\\nas to expose the tendons of the four recti muscles. The\\ntendinous extremities of the muscles are made ready for\\nseparation from the globe. A half-curved needle with its\\npoint directed toward the corneal border, and holding a\\nlong piece of catgut thread, is carried directly through the\\nbelly of the internal or the external rectus muscle, and\\nbrought out of the tendon of the muscle just behind the\\nremaining attachment to the globe. The muscle thus\\nsecured is cut loose from the globe just as in an ordinary\\ntenotomy. The catgut thread is drawn through as far as\\npracticable, and a sufficient length of the strand of gut is\\nleft untouched in order to allow a loop broad enough for\\nfree manipulation between it and the eyeball. The needle\\nis carried over to the opposite side of the cornea, and, with\\nits point directed away from the cornea, is made to trans\u00c2\u00ac\\nfix the tendinous belly of the other lateral muscle, which\\nis severed and freed from its connection with the eyeball.\\nThe vertically placed muscles are dealt with in a similar\\nmanner. The four recti muscles are thus freed from their\\n1 Philadelphia Medical Journal, May 27, 1899.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0431.jp2"}, "432": {"fulltext": "420\\nCLINICAL DIVISION.\\ntendinous attachments to the globe, and each pair of mus\u00c2\u00ac\\ncles is secured in a loose sling that can be tied the moment\\nthat this becomes necessary. Working in between the\\nbroad loops of catgut attached to the ends of the muscles\\nthat are held apart by an assistant, the eyeball is enucle\u00c2\u00ac\\nated with as much of the optic nerve as may be desired,\\nwithout any difficulty. The cavity previously occupied by\\nthe globe is thoroughly cleansed and a water-tight glass\\nball of about three-fourths the size of the normal globe is\\ndropped into place. The ends of the lateral rectus mus\u00c2\u00ac\\ncles which are held by the lower and the first placed catgut\\nthread are neatly trimmed and sutured together. The\\nsame is done with the two ends of the vertical rectus mus\u00c2\u00ac\\ncles. The circular opening made by the cut edges of the\\noverlying conjunctiva is lengthened into a lozenge by a\\ncouple of horizontal snips, and is carefully brought into\\nlinear apposition by a series of silk threads. The opera\u00c2\u00ac\\ntive field is covered by a gauze protective-bandage upon\\nwhich ice compresses are placed.\u00e2\u0080\u009d\\nE. Operations on the Cornea.\\n1. Removal of foreign bodies. Instruments: a steel spud,\\nFig. 160, or a broad needle with double cutting edge, Fig.\\n161. A 2 per cent, solution of cocaine is to be dropped in\\nFig. 160. Fig. 161.\\nCorneal spud. Broad needle.\\ntwo or three times within five minutes. The operator\\nstands behind the patient, who is seated in a chair, and\\nkeeping the lids apart with his index and ring fingers,\\nsteadies the eyeball by placing his middle finger against\\nits outer or inner side. The chip is gently picked or tilted\\noff by placing the edge of the spud beneath it, or, if firmly\\nembedded, a certain amount of scraping may be necessary.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0432.jp2"}, "433": {"fulltext": "OPERA TIONS.\\n421\\nIf the foreign body be barely embedded in the epithelium, a\\ntouch with a little roll of blotting-paper will often detach it.\\nWhen a fragment of iron has been present for more than a\\ncouple of days its corneal bed is usually stained by rust, and\\na little plate or ring of brown corneal slough can often be\\npicked off after the removal of the chip but, as a rule, this\\nminute slough may be left to separate spontaneously.\\nAfter-treatment. Tie the eye up, so as to protect the\\ncorneal surface from friction and irritation. Atropine is to\\nbe used if there be marked congestion and photophobia.\\nWhen a splinter is deeply and firmly embedded, especi\u00c2\u00ac\\nally if it have penetrated the cornea and is projecting into\\nthe anterior chamber, its removal is often very difficult.\\nUnless great care be taken the splinter in such a case may\\nbe pushed on into the chamber, and the iris or lens be\\nwounded. This may sometimes be prevented by passing\\na broad needle through the cornea at another part, and\\nlaying it against the inner surface of the wound, so as to\\nform a guard or foil to the foreign body, the latter being\\nremoved by spud or forceps from the front.\\nA foreign body in the anterior chamber should in recent\\ncases always be removed, and the piece of iris on which it\\nlies must generally be excised. In cases of old standing\\nwe may judge by the symptoms whether to operate or not.\\n2. Paracentesis of the anterior chamber. Position as for\\n1, or recumbent; general anaesthesia not necessary. In\u00c2\u00ac\\nstruments: a paracentesis needle, Fig. 162, with a very\\nFig. 162.\\nParacentesis needle and probe mounted on same handle.\\nsmall, short, triangular blade, bent at an obtuse angle, like\\na minute bent keratome or a broad needle, Fig. 161. The\\nformer is more safe, as the blade is too short to reach the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0433.jp2"}, "434": {"fulltext": "422\\nCLINICAL DIVISION.\\niris or lens, even if the patient should jerk his head. If\\nthe contents of the chamber do not follow the needle on\\nits withdrawal, a small probe, Fig. 162, is passed into the\\nwound. In cases where the operation needs repeating every\\nday or two the original wound can generally be reopened\\nwith the probe. Speculum and fixation forceps should be\\nused unless the patient has good self-control.\\n3. Corneal section for hypopyon ulcer. Position recum\u00c2\u00ac\\nbent general anaesthesia seldom needed. Instruments: a\\nGraefe\u00e2\u0080\u0099s or Beer\u00e2\u0080\u0099s cataract knife, Figs. 170 and 176, spec\u00c2\u00ac\\nulum and fixation forceps. The incision is carried through\\nthe whole thickness of the cornea from one side of the ulcer\\nto the other, being both begun and finished in sound tissue.\\nOr it may be placed entirely in sound cornea, or at the\\nsclero-corneal junction, leaving the ulcer untouched; the\\nlast position avoids all risk of wounding the lens.\\nThe knife is entered at an angle with the plane of the\\niris, its edge straight forward; when its point is seen, or\\njudged to have perforated the cornea, the handle is de\u00c2\u00ac\\npressed until the back of the knife lies parallel with the\\niris, and the blade then pushed straight across the ulcer to\\nthe point chosen for counter-puncture; often in practice\\nit is simply pushed on till it cuts out. The aqueous ought\\nnot to escape until the point of the knife is engaged in its\\ncounter-puncture, but an earlier escape cannot always be\\navoided. If it be desired to keep the wound open, its edges\\nare to be separated by a probe every second or third day.\\nThe wound closes quickly at first unless kept open, but\\nafter having been opened a few times it sometimes remains\\npatent for longer.\\n4. Cauterization of the cornea is best performed with a\\nvery fine galvano-caustic terminal. The finest terminal of\\nPaquelin\u00e2\u0080\u0099s instrument may be used, but its action cannot\\nbe so well localized owing to the greater bulk of the heated\\nmetal. If the eye be much congested, I generally apply", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0434.jp2"}, "435": {"fulltext": "OPERA TJONS.\\n423\\nsolid cocaine hydrochlorate to the part to be burnt and to\\nthe part where the fixation forceps will be applied.\\nOperations for Conical Cornea. The object is to\\nproduce a scar at the apex of the cone, which by contract\u00c2\u00ac\\ning shall reduce the curvature, and so diminish the high\\ndegree of irregular myopic astigmatism to which the con\u00c2\u00ac\\ndition gives rise.\\nThere are several methods. 1. Graefe\u00e2\u0080\u0099s treatment con\u00c2\u00ac\\nsisted in first carefully shaving off the apex of the cone\\nwithout entering the anterior chamber, and then producing\\nan ulcer by touching the raw surface with solid mitigated\\nnitrate of silver (F. 1), and so obtaining a scar. This\\nmethod is more painful and less safe than others, and is now\\nseldom used. 2. In another operation the apex of the\\ncone is cut off with a cataract knife, the anterior chamber\\nbeing entered, and the wound either left to close or united\\nby sutures; there are several different modes of removing\\nthe little piece. 3. Sir William Bowman removed the\\nouter layers of the cone by means of a very delicate cut\u00c2\u00ac\\nting trephine, and left the surface to heal and contract.\\n4. The galvanic cautery is now being a good deal used\\ninstead of the knife or trephine; I have found that the\\nopacity left by the cautery is apt to engage a larger area\\nthan that caused by the cutting operations, but more ex\u00c2\u00ac\\nperience is needed before deciding on the relative merits\\nof Nos. 2 and 4.\\nAfter-treatment. Atropine and compressive band\u00c2\u00ac\\nage until the wound has closed antiphlogistic treatment,\\nand heat locally, if inflammatory symptoms arise.\\nAll operations for conical cornea are difficult to perform\\nand somewhat uncertain in result, but in many cases vision\\nimproves, from barely seeing very large letters before oper\u00c2\u00ac\\nation to reading small print afterward. The final result is\\nnever gained for several months. An artificial pupil may\\nbe necessary if a large corneal opacity finally remain.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0435.jp2"}, "436": {"fulltext": "424\\nCLINICAL DIVISION.\\nF. Operations on the Iris.\\nportion of the iris is very often removed by operation\\n(iridectomy), with various objects. The principal of these\\nare: (1) the direct improvement of sight by altering the\\nposition and size of the pupil (artificial pupil); (2) to in\u00c2\u00ac\\nfluence the course of an active disease\u00e2\u0080\u0094glaucoma, iritis,\\nulcer of the cornea with hypopyon (3) to remove the risks\\nattending \u00e2\u0080\u009cexclusion\u00e2\u0080\u009d and occlusion\u00e2\u0080\u009d of the pupil by\\nrestoring communication between the anterior and poste\u00c2\u00ac\\nrior chambers; (4) as a stage in the extraction of cataract.\\nIridectomy often causes astigmatism by giving rise to flatten\u00c2\u00ac\\ning of that meridian of the cornea which forms a right angle\\nwith the operation wound, and by bringing the edge of the\\ncornea and lens into use permits the spherical aberration, Fig.\\n9, which the iris naturally prevents; striae, if present in the\\nlens, add to these difficulties, all of which are, cceteris paribus,\\ngreater if the artificial pupil be large and uncovered by the\\nupper lid. Thus it is evident that an artificial pupil should\\nseldom be made for the optical improvement of sight unless\\nthe opacity in or over the natural pupil be such as to interfere\\nseriously with visual acuteness.\\nArtificial pupil. The object is to remove the portion of\\niris in the position best adapted to sight; thus, in cases of\\nleucoma the iridectomy is made opposite the clearest part\\nFig. 1G3.\\nIridectomy downward and inward for artificial pupil.\\nof the cornea. When the state of the cornea allows it, the\\nnew pupil should be made down-inward or straight down\u00c2\u00ac\\nward the next best place is outward or out-upward; and\\nstraight upward is, of course, least useful, because the new\\npupil will be covered by the lid. The coloboma should", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0436.jp2"}, "437": {"fulltext": "OPERATIONS.\\n425\\ngenerally be small, and often only the inner (pupillary)\\npart of the chosen portion is to be removed, the outer\\n(ciliary) part being left, Fig. 163, so as to prevent the\\nlight passing through the margin of the lens (p. 40). After\\nsuch au operation the pupil will be oval or pear-shaped, and\\nwidest toward the centre. The incision should lie in the\\ncorneal tissue if only the pupillary part of the iris is to be\\nremoved but if only a narrow zone of cornea remain clear\\nthe incision must lie a little outside the sclero-corneal junc\u00c2\u00ac\\ntion, lest its scar should interfere with the transparency of\\nthe remaining clear cornea. The loop of iris should be cut\\noff with a single snip.\\nIn iridectomy for glaucoma the coloboma is to be large,\\nthe iris to be removed quite up to its ciliary attachment,\\nand the incision to lie as far back in the sclerotic as pos\u00c2\u00ac\\nsible 1 to 2 mm. from the border of the cornea is not too\\nfar. The coloboma should be wider toward the wound\\nthan toward the pupil, so as to form a keyhole pupil,\u00e2\u0080\u009d\\nFig. 164. The loop of iris, when drawn out, is usually cut\\nFig. 164.\\nIridectomy for glaucoma. (De Wecker\\nfirst in one angle of the wound, then torn from its ciliary\\nattachment by carefully drawing it over to the other angle\\nof the wound, and its other end cut there.\\nThe difficulty of making an artificial pupil for optical\\npurposes of the best shape\u00e2\u0080\u0094 i. e., broad toward the natural\\npupil and narrow toward the circumference, is, owing to\\nthe small size of the parts, much greater than would be at\\nfirst supposed, and several methods are in use. In Mr.\\nCritchett\u00e2\u0080\u0099s iridodesis a loop of iris is drawn out, and\\nstrangulated by a fine ligature tied around it over the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0437.jp2"}, "438": {"fulltext": "426\\nCLINIC A L I) 1 1 r IS I ON.\\nincision; the little loop soon drops off, and the result is\\na pear-shaped pupil, with its broad end toward the centre.\\nIrritation and even destructive iridocyclitis sometimes\\nfollow, and the operation has therefore been abandoned.\\nFig. 165.\\nAnother plan is to draw out a small loop of iris with a\\nblunt hook (Tyrrell\u00e2\u0080\u0099s hook), and to cut off only the pupil\u00c2\u00ac\\nlary portion this method is uncertain, but, on the whole,\\nit gives good results.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0438.jp2"}, "439": {"fulltext": "OPERATIONS.\\n427\\nIridotomy (iritomy). In this operation an artificial pupil\\nis formed by the natural gaping of a simple incision in\\nthe iris. It is only applicable when the lens is absent.\\nThrough a small incision in the cornea, between the\\ncentre and margin, the scissors (shears) shown at Fig.\\n146 are passed; the more pointed blade is passed behind\\nthe iris as far as is deemed necessary, and the iris and\\nfalse membrane divided by a single closure of the blades.\\nIt is sometimes necessary to make a second cut at an angle\\nwith the first, so as to include a V-shaped tongue of iris\\nwhich will shrink and allow a larger pupil.\\nIridotomy is most useful when the iris has become tightly\\ndrawn toward the operation scar by iritis occurring after\\ncataract extraction, Fig. 178. The line of the cut in the\\niris should lie, as nearly as may be, across the direction of\\nits fibres, and should always be as long as possible. In\\ncases of this sort, or when, even without such dragging of\\nthe iris toward the scar, the pupil is filled by iritic or\\ncyclitic membrane after cataract extraction, iridotomy\\nyields a better pupil than iridectomy, with less disturb\u00c2\u00ac\\nance of, and no dragging upon, the ciliary body.\\nThe Operation of Iridectomy. Position recumbent;\\nthe operator usually stands behind. Anaesthesia is often\\nFig. 1G6.\\nadvisable, but many operators prefer cocaine; I myself\\nprefer general anaesthesia whenever the operation is crit\u00c2\u00ac\\nical or likely to be difficult. Instruments stop speculum,\\nFig. 156, fixation forceps, bent keratome, Fig. 166, iris\\nforceps, bent at various angles according to the position of\\nthe iridectomy, Fig. 168, iris scissors, De Wecker\u00e2\u0080\u0099s or those", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0439.jp2"}, "440": {"fulltext": "428\\nCLINICAL DIVISION.\\nwith elbow bend, Fig. 167, of which some patterns have\\none or both blades probe-pointed, a curette, Fig. 172, or\\nsmall metallic spatula for replacing the cut ends of the iris,\\nFig. 167. FlG 168\\nand preventing their incarceration in the angles of the\\nwound. The iridotomy scissors, Fig. 165, are very con\u00c2\u00ac\\nvenient, especially for downward and inward operations,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0440.jp2"}, "441": {"fulltext": "OPERATIONS.\\n429\\nand for the left hand. Most operators prefer Graefe\u00e2\u0080\u0099s\\ncataract knife, Fig. 170, to the triangular keratome in\\niridectomy for glaucoma.\\nThe conjunctiva is held by the fixation forceps near the\\ncornea, at a point opposite to the place selected for punc\u00c2\u00ac\\nture. 1. The keratome is to be entered slowly, steadily\\npushed on across the anterior chamber till the wound is\\nof the desired size, then slowly withdrawn, and, in with\u00c2\u00ac\\ndrawal, its blade carefully turned to one side, so as to\\nlengthen the internal wound. Two points need attention\\nas soon as the point of the knife is visible in the anterior\\nchamber, it must be tilted slightly forward to avoid wound\u00c2\u00ac\\ning the iris and lens; and care must be taken not to tilt it\\nsideways, for if this be done the wound, instead of lying\\nparallel with the border of the cornea, will lie more or less\\nacross that line. The incision is made almost as much by\\nlifting the eye against the knife with the fixation forceps\\nas by pushing the knife against the eye. The forceps are\\nnow laid down, or if fixation be still necessary, they are\\ngiven to an assistant, who is to gently draw the eye into\\nthe position required for the next step; in so doing he is\\nto draw away from the eye, not to push the ends of the\\nforceps against the sclerotic. 2. The iris forceps are in\u00c2\u00ac\\ntroduced, closed, into the wound, and passed very nearly\\nto the pupillary border of the iris before being opened,\\nand made to grasp it. By seizing the pupillary part of\\nthe iris its inner circle is certain to be brought ouside the\\nwound, when the forceps are now withdrawn; if the iris\\nbe seized in the middle of its breadth a buttonhole may be\\ncut out, and the pupillary part left standing. Often the\\niris is carried into the wound by the gush of aqueous as\\nthe keratome is withdrawn, and it is then seized without\\npassing the forceps so far into the chamber. 3. The loop\\nof iris having been cut off, either at a single snip, or by\\ncutting first one end and then the other, as in glaucoma", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0441.jp2"}, "442": {"fulltext": "430\\nCLINICAL DIVISION.\\n(p. 425), the tip of the curette or spatula is passed into\\neach angle of the wound to free the iris should it be\\nentangled; it is important to make sure that no iris is left\\nincarcerated in the track of the wound. The speculum is\\nnow removed, and the eye, or both eyes, bandaged over\\na pad of cotton-wool, either with a four-tailed bandage of\\nknitted cotton, or two or three turns of a soft cotton or\\nflannel roller.\\nThe anterior chamber is refilled in twenty-four hours,\\nexcept in cases of glaucoma, when the wound frequently\\nleaks more or less for several days. It is as well in all\\ncases to keep the eye bandaged for a week, the wound\\nbeing but feebly united, and likely to give way from any\\nslio-ht blow or other accident. When the incision lies in\\nor partly in the sclerotic, some bleeding generally occurs;\\nwhen the eye is much congested this hemorrhage is con\u00c2\u00ac\\nsiderable, aud the blood may run into the anterior chamber\\neither during or after the excision of the iris; it can be\\ndrawn out by depressing the lip of the wound with the\\ncurette, but if the chamber again fills, no prolonged efforts\\nneed be made, since the blood is usually absorbed without\\ntrouble in a few days. In diseased, especially glaucoma\u00c2\u00ac\\ntous eyes, however, its absorption is often slow. Secondary\\nhemorrhage sometimes occurs from a diseased iris several\\ndays after the operation.\\nSclerotomy is an operation for dividing the sclerotic near\\nto the margin of the cornea. It is employed in glaucoma\\ninstead of iridectomy, or after iridectomy has failed. The\\npupil is to be contracted as much as possible by eserine before\\nthe operation. It is often performed subconjunctivally, a\\nGraefe\u00e2\u0080\u0099s cataract knife, Fig. 170, being entered through\\nthe sclerotic near the margin of the cornea, 1 passed in front\\n1 De Wecker makes it 1 mm. from the clear cornea. In my own operations\\nthe distance is generally about 2 mm.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0442.jp2"}, "443": {"fulltext": "OPERATIONS.\\n431\\nof the iris, and brought out at a corresponding point on\\nthe other side, so as to include nearly one third of the cir\u00c2\u00ac\\ncumference the puncture and counter-puncture are then\\nenlarged by slow, sawing movements; the central quarter\\nof the sclerotic flap and the whole of the conjunctiva (ex\u00c2\u00ac\\ncept at the punctures) are left undivided. The knife is\\nthen slowly withdrawn. The whole operation is to be done\\nvery slowly, that the aqueous may escape gradually any\\nrush of fluid is likely to carry the iris into the wound and\\ncause a permanent prolapse, a result to be carefully avoided.\\nIf prolapse occur the iris should be excised, and the opera\u00c2\u00ac\\ntion then becomes a very peripheral iridectomy. A moder\u00c2\u00ac\\nate degree of bulging and separation of the lips of the two\\nscleral wounds takes place for a week or two, when the scar\\nflattens down, and finally a mere bluish line is left. Scle\u00c2\u00ac\\nrotomy is also performed with a triangular keratome, Fig.\\n166, the incision being just as for a very peripheral iridec-\\nFlG. 169.\\nDiagrammatic section of ciliary region, showing path of wound in iridectomy\\nfor glaueoma (I) and in sclerotomy (S). Compare Fig. 100, 1 and 2.\\ntomy, but no iris being removed or allowed to prolapse.\\nSclerotomy is difficult to perform well, is not free from\\nrisk, and on the whole has not answered early expecta\u00c2\u00ac\\ntions; it is, however, valuable as a reserve for certain\\ncases. In Fig. 169, I shows the line of incision in iridec\u00c2\u00ac\\ntomy for glaucoma, and S the line in sclerotomy.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0443.jp2"}, "444": {"fulltext": "432\\nCLINICAL DIVISION.\\nG. Operations for Cataract.\\n1. Extraction of cataract lias been systemati\u00c2\u00ac\\ncally practised for nearly a century and a half.\\nThe operation has passed through several im\u00c2\u00ac\\nportant changes, and procedures differing more\\nor less from each other are still in use. All the\\noperations are difficult to perform well, and\\nmuch practice is needed to ensure the best pros\u00c2\u00ac\\npect of success. The sources of possible failure\\nFig. 170. Fig. 171.\\nGraefe\u00e2\u0080\u0099s cataract knife. Cataract spoon.\\nare many, and as in avoiding one we are apt\\nto fall into another, it cannot be expected that\\nany one operation will, in all its details, ever be\\nuniversally adopted. At present the majority\\nof surgeons adhere more or less closely to the\\noperation known as the modified linear\u00e2\u0080\u009d\\nmethod of von Graefe, in which iridectomy forms\\na step in the proceeding. Many operators,\\nhowever, dispense with iridectomy on account of\\nFig. 172.\\nCystitome\\n(upper end)\\nand curette\\n(lower end).", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0444.jp2"}, "445": {"fulltext": "OPERATIONS.\\n433\\nthe cosmetic and optical advantages of a round pupil. That\\nmany cataracts can be easily and safely extracted without\\niridectomy admits of no doubt; and it appears equally cer\u00c2\u00ac\\ntain that some cases, especially where the lens is very hard,\\ncannot be dealt with properly in this way. Any operator\\nof experience is fully justified in leaving the iris intact\\nunless there be difficulty in delivering the lens through\\nthe pupil, or difficulty in perfectly replacing the iris after\u00c2\u00ac\\nward, or the patient be very restless; in either of these\\nevents iridectomy should be performed at the moment\\nwhen required. Eserine used just before and a few times\\nafter the operation appears to assist in preventing prolapse\\nof the iris afterward. If prolapse occurs, as it may sev\u00c2\u00ac\\neral days after operation, it is best to remove it carefully,\\nas in a case of accidental wound (p. 190).\\nAll operations for extraction of hard cataract agree on\\nthe following points 1. An incision is made in the cornea,\\nat the junction of cornea and sclerotic, or even slightly in\\nthe sclerotic, large enough to give exit to the crystalline\\nlens unbroken and unaltered in shape. The knife now\\nalmost universally employed is the narrow, thin straight\\nknife of von Graefe, Fig. 170. 2. The capsule is freely\\nopened with a small sharp-pointed instrument, cystitome\\nor pricker, Fig. 172. 3. The lens is removed through the\\nrent in the capsule (the latter structure remaining behind),\\neither by pressure and manipulation outside the eye, or by\\nmeans of a traction instrument, scoop or spoon, Fig. 171,\\npassed into the eye just behind the lens. Few operators,\\nhowever, use the scoop, except for certain emergencies and\\nspecial cases. 4. Iridectomy is very often performed as\\nthe second stage. This part of the operation was origin\u00c2\u00ac\\nally introduced, less with the object of facilitating the exit\\nof the lens than with that of preventing prolapse of the iris\\nand lessening the after-risks of iritis. But these untoward\\nresults do not occur so often with cocaine and antiseptics\\n28", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0445.jp2"}, "446": {"fulltext": "434\\nCLINICAL I)I VISION.\\nas formerly; and, as already stated, many now omit iridec\u00c2\u00ac\\ntomy. A few of the many surgeons who adhere to iridec\u00c2\u00ac\\ntomy prefer to perform it some weeks or months before the\\nextraction of the lens, preliminary iridectomy; the theory\\nbeing that iritis is less likely to follow if the cut edges of\\nthe iris are soundly healed before the lens rubs against them\\non its way out. Patients, however, will not or cannot\\nalways submit to this subdivision of the operation for cata\u00c2\u00ac\\nract, and for this and other reasons of expediency prelim\u00c2\u00ac\\ninary iridectomy cannot be employed so largely as may,\\nperhaps, on theoretical grounds be desirable. In my own\\npractice I keep it for cases where special risks or difficul\u00c2\u00ac\\nties are present, as, e. g., where the patient has only one\\neye.\\nThe following are the chief varieties of operation for\\ncataract at present practised\\n(a) Simple linear extraction, best described here, though\\nnot applicable to hard cataract. A small incision (4 to 6\\nmm.) is made by a keratome, Fig. 166, well within the\\nmargin of the cornea, with a small iridectomy if necessary.\\nAfter opening the capsule the lens is squeezed out piece\u00c2\u00ac\\nmeal, or coaxed out by depressing the outer lip of the\\nwound with the curette, Fig. 172. Only quite soft cata\u00c2\u00ac\\nracts, or those in which the nucleus, though firm, is very\\nsmall, can be so dealt with.\\nThe wish to extend the principle of a straight wound to\\nfull-sized hard cataracts, led by von Graefe, in 1865, to in\u00c2\u00ac\\ntroduce (6) the modified linear or peripheral linear extrac\u00c2\u00ac\\ntion, in which the incision lies slightly beyond the sclero-\\ncorneal junction, Fig. 174, 2, and consequently involves the\\nconjunctiva, of which a flap is made. The incision is in\u00c2\u00ac\\ntended to form an arc of the largest possible circle\u00e2\u0080\u0094 i. e.,\\nof the scleral, not of the corneal curve; its plane, there\u00c2\u00ac\\nfore, must lie as nearly as may be in a radius of the scleral\\ncurve, and at a considerable angle with that of the iris,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0446.jp2"}, "447": {"fulltext": "OPERATIONS.\\n435\\nFig. 175, 2. A large iridectomy is performed as the second\\nstage. The incision is made with the Graefe knife, Fig.\\n170, which is at first directed toward the centre of the\\npupil and then brought up to the seat of counter-puncture.\\nThe edge is turned somewhat forward during the greater\\npart of the proceeding, and the cut completed by sawing\\nmovements if needful. The disadvantages of the periph\u00c2\u00ac\\neral linear extraction are: the frequency of bleeding from\\nthe conjunctiva into the anterior chamber, the parts being\\nthus obscured a considerable risk of loss of vitreous, owing\\nto the peripheral position of the wound and sometimes a\\ndifficulty in making the lens present well; a small but\\nappreciable risk that the operated eye will set up sympa\u00c2\u00ac\\nthetic inflammation, the wound lying in the dangerous\\nregion\u00e2\u0080\u009d (p. 173); lastly, there is a tendency to make the\\nwound rather too short in order to avoid some of these\\nrisks, and thus difficulties are introduced in the clean re\u00c2\u00ac\\nmoval of the lens. Its great advantage lies in the rapid\\nhealing and consequent small attendant risk of suppurative\\ninflammation.\\nA variety of this operation consists in placing the incision\\nrather further down, and at the same time giving it a some\u00c2\u00ac\\nwhat sharper curve, so that itr forms an arc of a smaller\\ncircle than before, but is still not concentric with the cor\u00c2\u00ac\\nnea, Fig. 174, 3, upper section. The puncture is directed\\nsomewhat downward (as at the right-hand end of the fig\u00c2\u00ac\\nure), and its plane, which at the puncture and counter\u00c2\u00ac\\npuncture is almost parallel with the iris, alters to nearly a\\nright angle at the summit of the flap. The track of the\\nwound, if shaded, would appear as in the figure.\\n(c) Short flap (De Wecker). The incision, made with\\nthe same knife, lies exactly at the sclero-corneal junction,\\nand is of such an extent that it has a height of about 3\\nmm., one-quarter of the diameter of the cornea, Fig. 173.\\nA narrow rim of conjunctiva remains attached to the flap.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0447.jp2"}, "448": {"fulltext": "436\\nCLINICAL DIVISION\\nThe iridectomy, if made, is small, as in Fig. 163. For\\nvery bulky cataracts this incision is not quite large enough.\\n(d) The incision lias nearly the same curve and plane as\\nin b, but the greater part of it lies considerably within the\\nmargin of the cornea, corneal section, and iridectomy is\\nFig. 173.\\nShort flap.\\nusually dispensed with. Liebreich and Bader made the\\nsection downward, its plane forming an angle of about\\n45\u00c2\u00b0 with that of the iris, Fig. 174, 3, lower section. In\\nLebrun\u00e2\u0080\u0099s corneal operation an almost identical section is\\nmade upward; the upper section of 3, Fig. 174, if placed\\nfurther in the cornea, would nearly represent it. The cor\u00c2\u00ac\\nneal operations, without iridectomy, are easy to perform,\\nFig. 174.\\nI 2 3\\nPaths of incision for extraction of cataract. 1, old flap; 2, peripheral\\nlinear; 3 (upper Fig.), a variety of the peripheral linear (lower Fig.) corneal\\nsection. The wound appears as a narrow slit (2) or a broad tract (1), when\\nseen from the front, according to the inclination of its plane. The doited\\ncircle shows the average outline of the lens. Compare Fig. 175.\\ncompared with those in which the section lies further back\\nthe wound, however, does not, on the whole, heal so quickly,\\nand it is more likely to reopen about the fourth or fifth day.\\n(e) Old flap extraction (Daviel, Beer, now very little\\nused). The incision was slightly within the visible margin\\nof the cornea, concentric with it, and equal to at least half\\nits circumference, 1, Fig. 174, thus forming a large arc of", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0448.jp2"}, "449": {"fulltext": "OPERATIONS.\\n437\\na small circle, the plane of the incision being parallel with\\nthat of the iris, 1, Fig. 175 no iridectomy was made. The\\nincision was made with the triangular knife of Beer, Fig.\\n176, in which the blade near its heel is somewhat wider\\nFig. 175.\\nThe same section seen in profile showing the plane of the incision in 1, 2,\\nand the lower section of 3.\\nthan the height of the flap, and section being completed\\nby simply pushing the knife across the anterior chamber\\nflat with the iris, its back corresponding to the base of the\\nintended flap. The inner length of the wound is less than\\nthe outer by the thickness of the obliquely cut cornea at\\neach end, 1, Fig. 174.\\nThe flap operation was usually done without either anaes\u00c2\u00ac\\nthesia, speculum, or fixation forceps. The after-treatment\\nwas troublesome. But the great height of the flap, in pro-\\nFig. 176.\\nportion to its width, renders it very liable to gape, or even\\nto fall forward; and this, with the fact that the whole\\nwound lies in corneal tissue, considerably increases the risks\\nof large and dangerous prolapse of the iris and of rapid\\nsuppurative inflammation of the cornea. For these reasons\\nthe old flap extraction has been almost abandoned in favor", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0449.jp2"}, "450": {"fulltext": "438\\nCLINICAL DIVISION.\\nof the peripheral linear, corneal section, and short flap oper\u00c2\u00ac\\nations, which yield a much larger average of useful eyes.\\nHistorically, the flap operation was the earliest; then\\ncame the linear operation thirdly, the modified or periph\u00c2\u00ac\\neral linear operation, with iridectomy; then the modern\\ncorneal operations and short flap, the aim of which is to\\ngain the substantial advantages both of the old flap and\\nthe modified linear methods without the great risks of the\\nformer or the imperfections of the latter; lastly, iridec\u00c2\u00ac\\ntomy has, as stated above, been again abandoned, more or\\nless completely, by many operators.\\nOf other operations the most important is Pagenstecher\u00e2\u0080\u0099s,\\nin which the lens is removed by a scoop in its unbroken\\ncapsule. It is most applicable to cataracts which are over\u00c2\u00ac\\nripe or are complicated with old iritis, and to Morgagnian\\ncataract (p. 202).\\nFor methods of dealing with unripe senile cataract see\\np. 205.\\nThe chief complications which may arise daring extraction\\nof cataract are: 1. Too short an incision this is best reme\u00c2\u00ac\\ndied by enlarging with a small bent secondary knife.\u00e2\u0080\u009d\\n2. Escape of vitreous before expulsion of the lens; this is\\na signal for the prompt removal of the lens with a scoop,\\nFig. 171, the vitreous being afterward cut off level with\\nthe wound by scissors. 3. Portions of the lens remaining\\nbehind after the chief bulk has been expelled they should\\nbe coaxed out by gentle manipulation after removal of the\\nspeculum.\\nAfter-treatment of Extraction. The patient is best\\nin bed for from four to seven days. The dressing consists\\nof a jiiece of soft linen overlaid by a pad of cotton-wool or\\nalembroth tissue, and kept in place by a four-tailed band\u00c2\u00ac\\nage of knitted cotton, or a narrow flannel or open tissue\\nroller. Both eyes are to be bandaged. It is advantageous\\nto apply outside the bandage a light shield to prevent the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0450.jp2"}, "451": {"fulltext": "OPERATIONS.\\n439\\npatient from striking or rubbing the eye during sleep. The\\nroom is usually kept partly darkened for about a week, all\\nFig. 177.\\ndressings and examinations being made by the light of a\\ncandle.\\nSome operators keep their cataract patients from the first in\\ndaylight, and with no other dressing than some strips of isin\u00c2\u00ac\\nglass plaster to maintain closure of the lids. Others bandage\\nonly the operated eye. Old people occasionally get delirious\\nif kept in bed and in the dark after extraction of cataract or\\niridectomy, and for such, at any rate, the ordinary rules as to\\nbandaging, darkness, and confinement to bed must be relaxed.\\nIn my experience the subjects of this delirium have usually\\nbeen alcoholics; but I believe that imprudent use of strong\\nmydriatics may produce it in some old persons who have not\\nbeen habitual drinkers.\\nDuring the first few hours there will be some soreness\\nand smarting, and at the first dressing, from twelve to\\ntwenty-four hours after operation, a little blood-stained", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0451.jp2"}, "452": {"fulltext": "440\\nCLINICAL DIVISION.\\nfluid; but after this there should be no material discom\u00c2\u00ac\\nfort, and nothing more than a little mucous discharge,\\nsuch as old people often have. The dressings are removed,\\nand the lids gently cleansed with warm water once or twice a\\nday, their edges being separated by gently drawing down the\\nlower lid, so as to allow any retained tears to escape: this\\ncleansing is very grateful to the patient. Some surgeons\\nopen the lids and look at the eye the day after the opera\u00c2\u00ac\\ntion but many prefer to leave them closed for several days\\nunless there are signs that the case is doing badly (p. 206).\\nIt is a good practice to use one drop of atropine daily after\\nthe third day, to prevent adhesions should iritis set in but\\nif no iridectomy have been made, I prefer not to use atro\u00c2\u00ac\\npine till about the fifth day, because if the wound should\\nreopen while the pupil is dilated prolapse of iris is more\\nlikely to occur than if the pupil be small. When first ex\u00c2\u00ac\\namined the eye is always rather congested from having\\nbeen tied up; but there should be no chemosis, the wound\\nshould be united so as to retain the aqueous, and its edges\\nshould be clear. The pupil is expected to be black unless\\nit is known that portions of lens matter have been left be\u00c2\u00ac\\nhind. If all be well the bandage may be left off during\\nthe daytime at the end of a week or ten days, a shade being\\nworn but it should be reapplied at night for the first two\\nor three weeks, to prevent accidents from movements during\\nsleep. At the end of a fortnight, if the weather be fine,\\nthe patient may begin to go out, the eyes being carefully\\nprotected from light and wind by dark goggles, and he\\nmay be out of the surgeon\u00e2\u0080\u0099s hands in from three to four\\nweeks.\\nAfter-operations. When iritis occurs (p. 207) the\\npupil becomes more or less occluded by false membrane,\\nand the subsequent contraction of this membrane may\\ndraw the iris toward the scar, so that the pupil is at once\\nblocked and displaced, Fig. 178. In slight cases, where", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0452.jp2"}, "453": {"fulltext": "OPERATIONS.\\n441\\nthe pupil is not dragged out of place, sight is greatly im\u00c2\u00ac\\nproved by simply tearing across the membrane and capsule\\nwith a fine needle, and treating the case as after discission\\nof soft cataract. In doing this the needle should be passed\\ndeeply enough to tear the posterior capsule also, so that the\\nvitreous, by bulging forward, may keep the opening in the\\ncapsule patent, compare Discission of Soft Cataract, in which\\ncare is taken not to go so deeply. But in severer cases an\\nFig. 178.\\nDiagram of occlusion and displacement of pupil from iritis after upward\\nextraction of cataract.\\nartificial pupil must be made, either by iridectomy or\\niridotomy (p. 425).\\n2. Solution (discission) operations. In these the lens is\\ngradually absorbed by the action of the aqueous humor\\nadmitted through a wound in the capsule (pp. 204 and\\n210). 1. The pupil is fully dilated by atropine. 2. The\\nlids are held open by the fingers, or a stop speculum and\\nfixation forceps used. 3. A fine cataract needle, Fig. 179,\\nis directed to a point a little within the border of the cor\u00c2\u00ac\\nnea, usually the outer border, and when close to its surface\\nis plunged quickly and rather obliquely into the anterior\\nchamber. Its point is then carried to the centre of the\\npupil, Fig. 180, dipped back through the lens-capsule, and\\na few gentle movements made so as to break up the centre\\nof the anterior layers of the lens. 4. The needle is then\\nsteadily withdrawn. Special care is taken not to wound,\\nnor even touch, the iris, either on entering or withdrawing\\nthe needle, not to stir up the lens too freely, nor to go so", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0453.jp2"}, "454": {"fulltext": "442\\nCL INICA L DI VISION.\\ndeeply as to perforate the posterior capsule and so engage\\nthe vitreous. A general anaesthetic is necessary ouly for\\nyoung children or excessively nervous patients; but it\\nshould always be in readiness and the patient prepared.\\nAfter-treatment. The pupil to be kept widely dilated\\nwith atropine (F. 33), a drop being applied after the opera-\\nFig. 179. Fig. 180.\\nCataract needle\\nDiscission of cataract,\\ntion, and at least six times a day afterward, or much oftener\\nif there be threatening of iritis.. Ice or iced water is usu\u00c2\u00ac\\nally applied constantly for twenty-four to forty-eight hours\\nafter the operation, 1 as for threatened traumatic iritis (p.\\n164), and the patient to remain in bed in a darkened room\\nfor a few days. A little ciliary congestion for two or three\\ndays need cause no uneasiness but the occurrence of pain,\\nincrease of congestion, and alteration in the color of the iris\\n(commencing iritis) are indications for the application of\\nleeches near the eye, and the more frequent use of atropine.\\nIf the cataract is complete, no marked change will be\\nseen for some weeks; if partial, e. g., lamellar, in a day\\nor two the part of the lens near the needle wound, and in\\na few days the whole lens, will become opaque. In from\\nsix to eight weeks the lens will have become notably smaller,\\nflattened or hollowed on the front surface. If the eye be\\n1 1 have to thank my colleague, Mr. Gunn, for this valuable suggestion.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0454.jp2"}, "455": {"fulltext": "OPERATIONS.\\n443\\nperfectly quiet, but not unless, the operation may now be\\nrepeated in exactly the same way, and with the same after-\\ntreatment and precautions, but the needle may be used\\nmore freely. The bulk of the lens will generally disappear\\nafter the second operation, but the needle may have to be\\nused a third or a fourth time for the disintegration of small\\nresidual pieces, or in order to tear the capsule if it have\\nnot retracted enough to leave a clear central pupil. A\\nsmall whitish dot remains in the cornea at the seat of each\\nneedle puncture.\\nExtraction by suction. This operation, like simple linear\\nextraction, p. 434, is applicable to complete soft cataracts.\\nThe pupil is to be dilated by atropine. The lens-capsule\\nis opened as in discission, but more freely. Then an incision\\nis made obliquely through the cornea, between its centre\\nand margin, with a keratome, Fig. 166, or broad needle,\\nFig. 161, and the nose of the syringe passed through the\\nwound and gently dipped into the lacerated lens-substance.\\nBy very gentle suction the semifluid lens-matter is then\\ndrawn gradually into the syringe. The instrument is not\\nto be passed behind the iris in search of fragments. Nearly\\nthe whole of the lens can thus be removed. The after-\\ntreatment is the same as for needle operations. Two forms\\nof syringe are in use Teale\u00e2\u0080\u0099s, in which the suction is made\\nby the mouth applied to a piece of flexible India-rubber\\ntubing; Bowman\u00e2\u0080\u0099s, in which the suction is obtained by a\\nsliding piston worked by the thumb moving along the\\nsyringe. It is often better, and in lamellar cataract neces\u00c2\u00ac\\nsary, to break up the lens freely with a fine needle a few days\\nbefore using the syringe, and thus allow it to be thoroughly\\nmacerated and softened in the aqueous humor; atropine\\nand ice must be used freely in the interval between this\\nneedle operation and the suction and the surgeon must\\nbe prepared to interfere before the day appointed for the\\nsuction, should severe pain or increase of tension occur", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0455.jp2"}, "456": {"fulltext": "444\\nCLINICAL DIVISION.\\nfrom the rapid swelling of the lens (p. 219). Suction is\\nmore difficult to perform, and perhaps less safe, than simple\\nlinear extraction, but I have myself no objection to make\\nagainst it.\\nAnaesthesia in ophthalmic surgery. Before the intro\u00c2\u00ac\\nduction of cocaine (October, 1884) there was much diver\u00c2\u00ac\\nsity of practice in respect to anaesthesia, many surgeons\\npreferring to perform extraction of cataract, tenotomy for\\nsquint, and simple iridectomy without anaesthesia, while\\nothers preferred ether or chloroform for nearly all opera\u00c2\u00ac\\ntions. Cocaine has immensely facilitated operating with\u00c2\u00ac\\nout general anaesthesia but of course some will continue to\\nuse ether or chloroform, where others feel able to rely solely\\non the local anaesthetic. In using cocaine for the eye we\\nhave to remember that it does not affect the sensibility of\\nthe borders of the lids, nor in any constant manner that of\\nthe iris, unless used many times for at least half an hour,\\nnor that of the muscles and deeper parts, unless injected\\nunder the conjunctiva. Hence the introduction and pres\u00c2\u00ac\\nsure of the speculum are always more or less felt, there is\\nusually some little pain when the iris is seized and drawn\\nout, and decided pain when, in tenotomy, the tendon is\\nstretched on the hook, unless subconjunctival injection\\nhave been resorted to. It must further be remembered\\nthat the patient is conscious and knows that something\\ncritical is being done, and that his good behavior depends\\nalmost as much on absence of fear as on absence of feeling\\nand, again, that the painlessness of one step of an opera\u00c2\u00ac\\ntion, e. g., the section in extraction of cataract, contrasts\\nstrongly with the sensation or pain felt in another stage,\\ne. 7 the iridectomy, and that the patient will be likely to\\nstart or jump, unless warned, at such a stage. My own\\nexperience leads me to use cocaine in all cataract extrac\u00c2\u00ac\\ntions and discissions, unless for some peculiar reason ether\\nor chloroform be needed, for nearly all tenotomies and", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0456.jp2"}, "457": {"fulltext": "OPERATIONS.\\n445\\noperations for corneal ulcer and conical cornea, and for\\nsome simple iridectomies and to avoid it usually in iridec\u00c2\u00ac\\ntomy for glaucoma and for synechise, whether anterior or\\nposterior. I have not myself used it much for lachrymal\\ncases; nor have I excised the eyeball under its influence;\\nbut it may be used for both purposes with fair success. For\\nsmall lid tumors, subcutaneous injection is very successful.\\nFor granular lids or lupus of conjunctiva, a strong solution,\\n10 to 20 per cent., may be painted on before touching with\\nactual cautery or caustics; but it is better for such cases,\\nand also whenever the eyeball is congested and painful, to\\nuse the solid cocaine salt, powdered and rubbed over the\\nsurface with a brush or the finger. For cataract a solution\\nof 2 per cent., or a single disk containing -g-J-g- grain, re\u00c2\u00ac\\npeated three times within five minutes of the operation, is\\ngenerally quite enough. Solutions should be freshly made.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0457.jp2"}, "458": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0458.jp2"}, "459": {"fulltext": "PART III.\\nDISEASES OF THE EYE IN DELATION TO\\nGENERAL DISEASES.\\nCHAPTER XXIII.\\nIn stating very shortly the most important facts bearing\\non the connection between diseases of the eye and of other\\nparts of the body, it is convenient to make the following\\nsubdivisions: (A) the eye changes as part of a general\\ndisease; (B) the ocular disease as symptomatic of some\\nlocal malady at a distance; (C) the eye sharing in a local\\nprocess, affecting the neighboring parts.\\n(For the clinical details of the various eye diseases re\u00c2\u00ac\\nferred to in this chapter, see Part II.)\\nA. General diseases, in which the eye is liable to suffer.\\nSyphilis is, directly or indirectly, the cause of a large\\nproportion of the more serious diseases of the eye.\\n1. Acquired syphilis. Primary stage: Hard chancres\\nare occasionally seen on the eyelid, and even far back on\\nthe conjunctiva (p. 94).\\nSecondary stage: Sore-throat, shedding of hair, erup\u00c2\u00ac\\ntion and condylomata. Iritis is common between two and\\neight or nine months, and does not occur later than about\\neighteen months after the contagion in from two-thirds to\\nthree-fourths of the cases both eyes suffer there is a marked\\ntendency to exudation of lymph (plastic iritis), shown by\\nkeratitis punctata, haze of cornea, and less commonly by\\nlymph-nodules on the iris. In some cases there are symp-\\n(447)", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0459.jp2"}, "460": {"fulltext": "448\\nGENERAL DISEASES OF THE EYE.\\ntoms of severe cyclitis, leading to detachment of retina and\\nsecondary cataract, with little iritis; but the cyclitis of\\nacquired syphilis does not give rise to ciliary staphyloma.\\n(Compare p. 170.) Syphilitic iritis is sometimes protracted,\\nand may relapse after complete subsidence. Choroiditis\\nand retinitis generally set in rather later, from six months\\nto about two years after the chancre; seldom as late as four\\nyears. 1 The two conditions are most often seen together,\\nbut either may appear singly; and in each the vitreous\\ngenerally becomes inflamed. These conditions are essen\u00c2\u00ac\\ntially chronic, the retinitis being often, and the choroiditis\\nsometimes, liable to repeated exacerbations or recurrences;\\nwhile in some cases the secondary atrophic changes progress\\nslowly for years, almost to blindness, often with pigmen\u00c2\u00ac\\ntation of the retina. Syphilitic choroiditis and retinitis\\nusually affect both eyes, but often in an unequal degree,\\nand even when severe the disease is occasionally limited to\\none eye. Keratitis, indistinguishable from that of inherited\\nsyphilis, is among the rarest events in the acquired dis\u00c2\u00ac\\nease when it occurs it is usually in the secondary stage\\nof the disease.\\nLater periods: Ulceration of the skin and conjunctiva\\nof the lids, gummatous infiltration of the lids and sclerotic,\\nand nodes in the orbit,,whether cellular or periosteal, occur\\nbut rarely. Oculomotor paralysis is one of the frequent ocular\\nresults of syphilis. It may depend upon gumma (syphilitic\\nneuroma) of the affected nerve or nerves in the orbit or in\\nthe skull, or upon gummatous inflammation of the dura\\nmater at the base of the skull, matting the nerves together,\\nor on disease of nerve-centres. The gummatous nerve-lesions\\nseldom occur very late in tertiary syphilis.\\nThe optic disk is often inflamed or atrophied as an indi\u00c2\u00ac\\nrect result of syphilitic disease of the eye or of the nervous\\n1 A few cases are on record in which it appeared not to have begun till\\nabout ten years after infection.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0460.jp2"}, "461": {"fulltext": "SYPHILIS.\\n449\\nsystem; but the terms syphilitic optic neuritis\u00e2\u0080\u009d and\\n\u00e2\u0080\u009csyphilitic optic atrophy\u00e2\u0080\u009d are not often applicable in\\nany more direct sense, compare p. 260. The retinitis of\\nthe secondary stage affects the disk, and, when atrophy of\\nthe retina and choroid occur, the disk becomes wasted in\\nproportion; while in rare cases the retinitis of secondary\\nsyphilis is replaced by well-marked papillitis. Such cases\\nmust not be confused with others, still more rare, in which\\ndouble papillitis, passing into atrophy, occurs with all the\\nsymptoms of severe meningitis in secondary syphilis. Ter\u00c2\u00ac\\ntiary syphilitic disease, anywhere within the cranium, com\u00c2\u00ac\\nmonly causes optic neuritis, in the same way as do other\\ncoarse intracranial lesions (p. 254) but neuritis may also\\nbe caused more directly by gummatous inflammation of\\nthe trunk of the optic nerve, or of the chiasma. Primary\\nprogressive atrophy of the disks occurs in association with\\nlocomotor ataxy and ophthalmoplegia externa of syphilitic\\norigin; probably in a few instances the optic atrophy\\noccurs alone, or for a time precedes the other changes in\\nsyphilitic, as it is known to do in non-syphilitic ataxy.\\nSight is liable to be rapidly damaged from severe acute\\nloss of blood, especially from the stomach; usually both\\neyes suffer, but often unequally. When seen quite early\\npapillitis has been found, but the cases are often not seen\\ntill the appearances of atrophy have come on.\\n2. Inherited syphilis. Iritis corresponding to that in the\\nacquired disease is seen in a small number of cases, and\\noccurs between the ages of about two and fifteen months.\\nIt often gives rise to much exudation, leading to occlusion\\nof the pupil, and is frequently accompanied by deeper\\nchanges, cyclitis and disease of vitreous. It is very often\\nsymmetrical, and is much more common in girls than in boys.\\nChoroiditis and retinitis of precisely the same forms as in\\nacquired syphilis, occur at the corresponding period of the\\ndisease\u00e2\u0080\u0094 i. e. between six months and about three years of\\n29", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0461.jp2"}, "462": {"fulltext": "450\\nGENERAL DISEASES OF THE EYE.\\nage; and they show as much, some observers think more,\\ntendency to the degenerative and atrophic results already\\ndescribed; in severe cases there are not uncommonly signs\\nof cerebral degeneration. In the later stages, keratitis\\nwhich is the most common eye disease caused by inherited\\nsyphilis, occurs. It is most common between six and fifteen\\nyears old, but is sometimes seen as early as two or three\\nyears, and is occasionally deferred till after thirty. The\\ndisease is frequently complicated with iritis and cyclitis,\\nand, though tending to recovery, shows a considerable lia\u00c2\u00ac\\nbility to relapse. It almost always attacks both eyes,\\nthough sometimes at an interval of many months. When\\nthe patient is unusually young, the disease as a rule runs a\\nmild and short course. The oculomotor palsies occur but\\nrarely in inherited syphilis, but a few well-authenticated\\ncases are on record.\\nSmallpox causes inflammation and ulceration of the cor\u00c2\u00ac\\nnea, leading, in the worst cases, to its total destruction, but\\nin a large number to nothing worse than a chronic vascular\\nulcer. The corneal disease comes on some days after the\\neruption, tenth to fourteenth day from its commencement,\\nand after the onset of the secondary fever. Iritis, uncom\u00c2\u00ac\\nplicated and showing nothing characteristic of its cause,\\nsometimes occurs some weeks after an attack of smallpox.\\nOnly in very rare cases do variolous pustules form on the\\neye, and even then they are always on the conjunctiva,\\nnot on the cornea.\\nScarlet fever, typhus, and some other exanthemata may\\nbe followed by rapid and complete loss of sight, lasting a\\nday or two, showing no ophthalmoscopic changes, and end\u00c2\u00ac\\ning in recovery. Such attacks are believed to be uraemic\\nor at any rate dependent on some toxic condition of the\\nblood. A peculiarity of these cases is the preservation of the\\naction of the pupils to light. Very severe purulent or mem\u00c2\u00ac\\nbranous ophthalmia sometimes occurs during scarlet fever.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0462.jp2"}, "463": {"fulltext": "DIPHTHERITIC OPHTHALMIA.\\n451\\nDiphtheria. By far the most common result is paralysis,\\noften incomplete, of both the ciliary muscles\u00e2\u0080\u0094 cycloplegia;\\nthe pupils are not affected except in severe cases, when\\nthey may be rather large and sluggish. 1 The symptoms\\ngenerally come on from four to six weeks after the com\u00c2\u00ac\\nmencement of the illness, last about a month, and disappear\\ncompletely. Diphtheritic cycloplegia is usually, but not\\ninvariably, accompanied by paralysis of the soft palate.\\nIn most of the cases seen by ophthalmic surgeons the\\nattack of diphtheria has been mild, sometimes extremely\\nso, the case often being described as ulcerated throat;\u00e2\u0080\u009d\\nbut inquiry often yields a history of other and severer\\ncases in the family, and of general depression and weak\u00c2\u00ac\\nness in the patient out of proportion to his throat symp\u00c2\u00ac\\ntoms. We find that most of the patients who apply with\\ndiphtheritic cycloplegia are hypermetropic, doubtless be\u00c2\u00ac\\ncause those with normal, and a fortiori, with myopic, re\u00c2\u00ac\\nfraction are much less troubled by paresis of accommoda\u00c2\u00ac\\ntion, and often do not find it necessary to seek advice.\\nConcomitant convergent squint is sometimes developed in\\nhypermetropic children during the diphtheritic paresis,\\nowing to the increased efforts at accommodation (p. 365).\\nParalysis of the external muscles is occasionally seen; I\\nhave never myself seen any except the external rectus\\naffected, and recovery has been rapid.\\nDiphtheritic and membranous ophthalmia are occasion\u00c2\u00ac\\nally caused by direct inoculation of the conjunctiva of the\\nattendant by diphtheritic material from the patient\u00e2\u0080\u0099s throat;\\nor in the patient himself by extension up the nasal duct to\\nthe conjunctiva. But in many cases of diphtheritic\\nand \u00e2\u0080\u009cmembranous\u00e2\u0080\u009d ophthalmia the disease seems to be\\nlocal, the inflammation taking on this special form with-\\n1 Further observations are wanted.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0463.jp2"}, "464": {"fulltext": "452\\nGENERAL DISEASES OF THE EYE.\\nout ascertainable relation to any infectious disease. No\\ndoubt there is often something peculiar in the patient\u00e2\u0080\u0099s\\nhealth, or in the state of his eye-tissues which gives a pro\u00c2\u00ac\\nclivity to this kind of inflammation. Thus diphtheritic\\nophthalmia of all degrees is more common in young chil\u00c2\u00ac\\ndren than in adults; the worst cases generally occur after\\nmeasles, or during or after scarlet fever, broncho-pneumo\u00c2\u00ac\\nnia, or severe infantile diarrhoea; old granular disease of\\nthe conjunctiva also confers a liability to a diphtheritic\\ntype of inflammation, and the same tendency is sometimes\\nseen in ophthalmia neonatorum and in gonorrhoeal oph\u00c2\u00ac\\nthalmia.\\nMeasles is a prolific source of ophthalmia tarsi in all its\\nforms, and of corneal ulcers, particularly of the phlycten\u00c2\u00ac\\nular forms. It also gives rise to a troublesome muco-puru-\\nlent ophthalmia, and under bad hygienic conditions this\\nmay be aggravated by cultivation and transmission into\\ndestructive disease of purulent, membranous, or diphthe\u00c2\u00ac\\nritic type. Double optic neuritis has been seen in several\\npatients after measles.\\nMumps. Enlargement of the lachrymal gland sometimes\\naccompanies or follows that of the parotid. Cases have\\nbeen reported by Hirschberg and others in which the\\nlachrymal gland, but not the parotid, was enlarged. Dr.\\nSwan M. Burnett 1 called attention to haze of disk with\\nvenous engorgement of retina and failure of sight during\\nmumps. CEdema of lids and conjunctiva, and in one case\\nparesis of third nerve, pointed to effusion into the orbit.\\nThe symptoms as a rule quickly subsided.\\nChicken-pox is sometimes followed by a transient corneal\\nattack of mild conjunctivitis.\\nWhooping-cough often, like measles, leaves a proneness to\\n1 Burnett: American Journal of the Medical Sciences, January, 1886, p. 86,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0464.jp2"}, "465": {"fulltext": "EPIDEMIC CEREBROSPINAL MENINGITIS. 453\\ncorneal ulcers. In a few rare cases the condition known\\nas ischcemia retince, sudden, temporary, arterial bloodless\u00c2\u00ac\\nness, lias occurred. Conjunctival orbital or cerebral hem\u00c2\u00ac\\norrhages may occur during the violent attacks of coughing\\nthe latter may occasion muscular paralyses.\\nInfluenza. In the epidemics of the last few years many\\nocular complications have been reported, optic neuritis,\\niritis, glaucoma, and muscular defects of various kinds;\\nbut considering the almost universal prevalence of the\\nscourge, such complications must be considered un\u00c2\u00ac\\ncommon.\\nMalarial fevers, especially the severe forms met with in\\nhot countries, are sometimes the cause of retinal and other\\nintraocular hemorrhages, and even of considerable neuro\u00c2\u00ac\\nretinitis when there is much pigment in the blood the\\nswollen disk may have a peculiar gray color. When renal\\nalbuminuria is caused by malarial disease, albuminuric reti\u00c2\u00ac\\nnitis may occur. Simple optic neuritis with failure of sight,\\nfollowed by recovery, seems to occur sometimes, and ambly\u00c2\u00ac\\nopia of more than one form is said to be produced by mala\u00c2\u00ac\\nrial poisoning; some cases have recovered under quinine.\\nLoss of sight from malarial fever must not be confused\\nwith blindness due to the quinine administered for its cure\\n(p. 457).\\nRelapsing fever is sometimes followed, during conva\u00c2\u00ac\\nlescence, by inflammatory symptoms with opacities in the\\nvitreous (cyclitis), with or without iritis; recovery takes\\nplace. These cases are more common in some epidemics than\\nin others. In a large outbreak Lubinski saw no eye cases\\nin patients under twenty years of age, and none in\\nfemales.\\nEpidemic cerebro-spinal meningitis also, in a few cases,\\ngives rise to acute choroiditis, with pain, chemosis, and\\ngreat tendency to rapid exudation of lymph into the vit-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0465.jp2"}, "466": {"fulltext": "454\\nGENERAL DISEASES OF THE EYE.\\nreous and anterior chambers, and often leading to disor\u00c2\u00ac\\nganization of the eye and blindness. 1 It is believed that the\\ninflammation may extend to the eye along the optic nerve,\\nor may occur independently in the brain and the eye.\\nDeafness from disease of the internal ear is even more com\u00c2\u00ac\\nmon than the eye disease.\\nPurpura has been observed in a few cases to be accom\u00c2\u00ac\\npanied by retinal or sub retinal hemorrhages; they are\\nsometimes perivascular and linear, and in other cases form\\nlarge blotches.\\nIn pyaemia one or both eyes may be lost by septic emboli\\nlodging in the vessels of the choroid or retina, and setting\\nup suppurative panophthalmitis. The symptoms are swell\u00c2\u00ac\\ning of the lids, loss of sight, congestion, especially of the\\nperforating ciliary vessels, Fig. 24, chemosis, discoloration,\\nand dulness of aqueous and iris. There may or may not\\nbe some protrusion and loss of mobility, and conjunctival\\ndischarge. Pain, sometimes very severe, may be almost\\nabsent; probably its presence indicates rise of tension.\\nA yellow reflex is often seen from the vitreous. The eye\u00c2\u00ac\\nball generally suppurates if the patient live long enough.\\nSometimes both eyes are affected, together or with an in\u00c2\u00ac\\nterval. In cases of septicoemia abundant retinal hemor\u00c2\u00ac\\nrhages of large size may occur in both eyes; they come on\\na few days before death, and are thus of grave significance.\\nAs they are not present in typhoid and other fevers of cor\u00c2\u00ac\\nresponding severity, their presence is sometimes an aid in\\ndifferential diagnosis. 2\\nLead-poisoning is an occasional cause of optic neuro-reti\u00c2\u00ac\\nnitis leading to atrophy, of atrophy ensuing upon chronic\\n1 Possibly a few of the cases in which similar eye conditions are seen\\nwithout apparent cause may be the accompaniments of slight and unrecog\u00c2\u00ac\\nnized meningitis. (See Pseudo-glioma, p. 226.)\\n2 Gowers: Medical Ophthalmoscopy, second edition, p. 255.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0466.jp2"}, "467": {"fulltext": "TOBACCO.\\n455\\namblyopia, and of rapid, usually transient amblyopia. The\\ntwo former are the most common; the atrophy, whether\\nprimary or consecutive to papillitis, is generally accom\u00c2\u00ac\\npanied by very marked shrinking of retinal arteries, and\\ngreat defect of sight or complete blindness; it is generally\\nsymmetrical, but one eye may precede the other. Other\\nsymptoms of lead-poisoning, usually chronic, but occasion\u00c2\u00ac\\nally acute, are nearly always present. Care must be taken\\nnot to confuse albuminuric retinitis from kidney disease\\ninduced by lead with the changes here alluded to, which\\nare due in some more direct manner to the influence of the\\nmetal.\\nThe deposition of lead upon corneal ulcers has been re\u00c2\u00ac\\nferred to at p. 152.\\nAlcohol. Some observers still hold that alcohol, especi\u00c2\u00ac\\nally in the form of distilled spirits, may cause a particular\\nform of symmetrical amblyopia, the so-called amblyopia\\npotatorum. Optic neuritis and paralyses of various single\\noculomotor nerves are described by Thomsen as occurring\\nin cases of alcoholic paralysis. The difficulty of arriving\\nat the truth depends chiefly upon the fact that most drinkers\\nare also smokers, and that tobacco, whether smoked or\\nchewed, is allowed by all authorities to be one of the\\ncauses, or, as most now hold, the sole cause, of a similar\\ndisease. The question whether alcohol directly causes disease\\nof the optic nerves will not be settled until observers are\\nmuch more careful than they have hitherto been to record\\nas typical cases of alcoholic amblyopia only those in which\\nthe patient does not use even the smallest quantity of\\ntobacco in any shape.\\nTobacco. Whatever may be the truth, and it is con\u00c2\u00ac\\nfessedly difficult to arrive at, as to the direct influence of\\nalcohol, and of the various substance often combined with\\nit, there is no doubt whatever that tobacco, whether smoked", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0467.jp2"}, "468": {"fulltext": "456\\nGENERAL DISEASES OF THE EYE.\\nor chewed, does act directly on the optic nerves, and in\\nsuch a manner as to give rise to definite, and usually very\\ncharacteristic symptoms. The amblyopia seldom comes on\\nuntil tobacco has been used for many years. The quantity\\nneeded to cause symptoms is, cceteris paribus, a matter of\\nidiosyncrasy, and very small doses may produce the dis\u00c2\u00ac\\nease in men who, in other respects also, are unable to\\ntolerate large quantities of the drug. Predisposing causes\\nexert a very important influence; among these are to be\\nspecially noted increasing age; nervous exhaustion from\\noverwork, anxiety, or loss of sleep; chronic dyspepsia,\\nwhether from drinking or other causes and probably sex\u00c2\u00ac\\nual excesses and exposure to tropical heat or light. A\\nlarge proportion of the patients drink to excess, and thus\\nmake themselves more susceptible to tobacco by injuring\\nboth the nervous system and the stomach. But some re\u00c2\u00ac\\nmarkable cases are seen in men who have for long been total\\nabstainers, in others who have lately become abstainers\\nwithout lessening their tobacco, and in yet others who are\\nstrictly moderate in alcohol, are in robust health, and in\\nwhom increasing age is the only recognizable predisposing\\ncause. The strong tobaccos produce the disease far more\\nreadily than the weaker sorts, and chewing is more dan\u00c2\u00ac\\ngerous than smoking. Probably alcohol in very moderate\\ndoses counteracts rather than increases the injurious effect\\nof tobacco upon the nervous system and optic nerves\\n(Hutchinson).\\nThe vapor of bisulphide of carbon, if inhaled in a con\u00c2\u00ac\\ncentrated form and for long periods, produces at first ex\u00c2\u00ac\\ncitement, then general and severe loss of nerve power, with\\nextreme mental and muscular debility and impotence. In\\nsome of the cases the sight fails chiefly in the centre of the\\nfield, central scotoma, with haze and pallor of the disks,\\nchronic neuritis. The cases are met with either in India-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0468.jp2"}, "469": {"fulltext": "KIDNEY DISEASE\\n457\\nrubber works or oil-mills, in both of which the bisulphide\\nis largely used. 1\\nQuinine, taken in very large doses at short intervals, has\\nin a few cases caused serious visual symptoms. Sight in\\nboth eyes may be totally lost for a time, but recovery more\\nor less perfect takes place eventually, sometimes in a few\\ndays, sometimes not for months. There is a great con\u00c2\u00ac\\ntraction of the visual field even after perfect recovery of\\ncentral vision; the disks are pale and the retinal arteries\\nextremely diminished. The symptoms are therefore those\\nof almost arrested supply of arterial blood to the retina.\\nKidney disease. The common and well-known retino-\\nneuritis associated with renal albuminuria, and of which\\nseveral clinical types are found, has been already described.\\nIt need only be noted that the disease is most common with\\nchronic granular kidneys and in the kidney disease of\\npregnancy, but that it is also seen in the chronic forms\\nfollowing acute nephritis and in lardaceous disease, and\\nthat children suffering from chronic renal disease seem as\\nliable to it as adults. Retinitis with renal albuminuria is\\nusually a sign that the kidney disease is far advanced, and\\nthe prospect of life very bad. According to Miley, hospital\\npatients seldom live more than six months after the onset\\nof the retinitis (Trans. Ophth. Soc., viii. 132). C. S. Bull\\nfinds that the average duration of life is somewhat longer,\\naccording to returns from patients of all classes. There is\\nno doubt that the prospect of life for patients who are able\\nto live carefully is considerably better than for others. It\\nseems likely that there is also a group of cases in which the\\nretinal change precedes the signs of kidney disease, these\\nsigns appearing later thickening of the coats of the smaller\\nretinal arteries, giving them when seen by the ophthalmo-\\ni For full particulars, see Trans. Ophth. Soc., vol. v. 1885, pp. 149-175.\\nAnother case is reported by Gunn Ibid., vi. 1886, 372.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0469.jp2"}, "470": {"fulltext": "458\\nGENERAL DISEASES OF THE EYE.\\nscope an appearance of bright copper wire, is not infre\u00c2\u00ac\\nquently seen associated with renal disease of the chronic\\ngranular form, as has been pointed out by Gunn T exam\u00c2\u00ac\\nination of the urine often does not reveal the presence of\\nrenal disease, and it is probable that a sclerosis of the\\nsmall arteries of the body generally may be fairly well\\nadvanced without the appearance of any signs of affection\\nof the kidney. Detachment of the retina is an occasional\\nresult in extreme cases. The prognosis as regards vision\\nis best in the cases depending on albuminuria of preg\u00c2\u00ac\\nnancy. The retinal oedema and exudation are probably\\ncaused by the blood-state; but the disease of the small\\nbloodvessels and the cardiac hypertrophy, no doubt add\\nto and complicate the changes. Indeed, the different types\\nof retinal disease which are met probably depend in great\\nmeasure on the varying parts played by the three factors\\nalluded to. The failure of sight caused by albuminuric\\nretinitis has often led to the correct diagnosis of cases\\nwhich had been treated for dyspepsia, headache,\\nbiliousness.\u00e2\u0080\u009d\\nDiabetes sometimes causes cataract. In young or middle-\\naged patients the cataract usually forms quickly, and is of\\ncourse soft. As it is always symmetrical, the rapid forma\u00c2\u00ac\\ntion of double, complete cataract, at a comparatively early\\nage, should always lead to the suspicion of diabetes. In\\nold persons the progress of diabetic cataract is much slower,\\nand often shows no peculiarities. The relation of the len\u00c2\u00ac\\nticular opacity to the diabetes has not been satisfactorily\\nexplained; the presence of sugar in the lens, the action\\nof sugar or its derivatives dissolved in the aqueous and\\nvitreous, the abstraction of water from the lens owing to\\nthe increased density of the blood, and, lastly, degenera-\\n1 Gunn Trans. Ophth. Soc., vol. .xii. p. 124.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0470.jp2"}, "471": {"fulltext": "PROGRESSIVE PERNICIOUS AN JEM I A. 459\\ntion of the lens from the general cachexia attending the\\ndisease, have all been offered in explanation. It is impor\u00c2\u00ac\\ntant to know that diabetic cataract sometimes disappears\\nentirely if the health improves, the lens completely clear\u00c2\u00ac\\ning up. 1 In a few cases retinitis occurs; sometimes with\\ngreat oedema and copious, probably capillary, hemorrhages\\ninto the retina and vitreous, in other cases with numerous\\nwhite patches, but no oedema. Plastic iritis sometimes\\noccurs in diabetes, both with and without previous opera\u00c2\u00ac\\ntion Schirmer draws attention to the importance of ex\u00c2\u00ac\\namining the urine for sugar in cases of intractable iritis.\\nCentral amblyopia from disease of the optic nerves has\\nalso been observed, even it is said in patients who were\\nnot smokers, 2 and according to Hirschberg affords a grave\\nprognosis.\\nLeucocythsemia is often accompanied by retinal hemor\u00c2\u00ac\\nrhages, less commonly by whitish spots bordered by blood,\\nand consisting of white corpuscles these spots may be thick\\nmugh to project forward. Occasionally there is general\\nhaziness of the retina. In severe cases the whole fundus is\\nremarkably pale, whether there be other changes or not. 3\\nThe changes are usually symmetrical.\\nProgressive pernicious anaemia is marked by a strong\\ntendency to retinal hemorrhages these are usually grouped\\nchiefly near the disk, and are striated (Gowers). White\\npatches are also common, and occasionally well-marked\\n1 See cases recorded in Trans. Ophth. Soc., vol. v., 1885, p. 107.\\n2 See Leber, in the Graefe-Saemisch Handbuch, and a paper by Dr.\\nEdmunds and the author, Trans. Ophth. Soc., vol. iii, 1883. A doubtful case\\nin a woman is recorded in the same paper and another, also not completely\\nsatisfactory, by Samuel, in Hirschberg\u00e2\u0080\u0099s Centralblatt, 1882, p. 202. Paper by\\nMoore New York Medical Journal, 1888.\\n3 For a full account of the changes see Gowers Medical Ophthalmoscopy.\\nDr. Sharkey has shown me a case with diffuse retinitis, very numerous puncti-\\nform hemorrhages, chiefly peripheral, and dilatation with extreme tortuosity\\nof the veins.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0471.jp2"}, "472": {"fulltext": "460\\nGENERAL DISEASES OF THE EYE.\\nneuritis occurs. The author has seen hemorrhages of dif\u00c2\u00ac\\nferent dates, and in one case, shown him by Dr. Sharkey,\\nthere had evidently been a large extravasation from the\\nchoroid at an earlier period. The disk and fundus partic\u00c2\u00ac\\nipate in the general pallor. In simple anosmia optic neu\u00c2\u00ac\\nritis or retinitis with hemorrhages is met with: the degree\\nof swelling of the nerve is sometimes very great; it may\\nresult in atrophy with permanent impairment of vision.\\nThe retinitis sometimes has the appearance of typical renal\\nretinitis it may be one-sided.\\nHemophilia. As yet, no cases have been recorded in\\nwhich there were hemorrhages into the interior of the eye\\nas a result of this disease. Disturbances of vision, how\u00c2\u00ac\\never, have been reported after profuse hemorrhages else\u00c2\u00ac\\nwhere, which were probably due to optic atrophy. Priestley-\\nSmith saw an interesting case of profuse hemorrhage into\\nthe orbit following an injury of that cavity in one of these\\nsubjects.\\nScurvy. In this disease the eyes are so deeply sunken\\nand are surrounded by such dark rings that they give an\\nappearance almost characteristic of this disease. As in\\npurpura, hemorrhages are not infrequent into the retina,\\nand these become yellower as the disease progresses. As\\na result of the impoverished supply of nutriment to the\\nretina hemeralopia and nyctalopia are occasional symp\u00c2\u00ac\\ntoms.\\nIn the rare but interesting manifestations of the disease\\nin infancy, oedema of the lids has been considered charac\u00c2\u00ac\\nteristic of the disease by some clinicians. Hemorrhages\\ninto the lids and orbit are also quite common, and are at\\ntimes very striking. Holmes Spicer has reported three\\ncases in which, as a result of profuse bleeding into the\\norbits, there were great swelling of the lids and protrusion\\nof the globes.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0472.jp2"}, "473": {"fulltext": "HEART DISEASE.\\n461\\nSecondary Anaemia. Simple loss or diminution in the\\nquality of the blood is very rarely followed by ocular\\nchanges, the additional predisposing factor of impoverished\\nblood being apparently necessary to occasion lesions within\\nthe eye.\\nHeart disease is variously related to changes in the eyes\\nand alterations of sight. Aortic incompetence often pro\u00c2\u00ac\\nduces visible pulsation of the retinal arteries. This pulsa\u00c2\u00ac\\ntion often differs from that seen in glaucoma in extending\\nfar beyond the disk, and in not being so marked as to cause\\ncomplete emptying of the larger vessels during the diastole.\\nIn glaucoma the pulsation is confined to the disk. The\\ndifference is explained by the different mode of production\\nin the two cases: in the one, incomplete closure of the\\naortic orifice lowers the pressure in the whole blood-column\\nduring the diastole, and allows a reflux of blood from the\\neye; in the other heightened intraocular tension, telling\\nchiefly on the comparatively yielding tissues of the optic\\ndisk, increases the resistance to the entrance of arterial\\nblood. Valvular disease of the heart is generally present\\nin the cases of sudden lasting blindness of one eye, clinic\u00c2\u00ac\\nally diagnosed as embolism of the arteria centralis retinae;\\nbut in some of these thrombosis of the artery or of its\\ncompanion vein, or blocking of the internal carotid 1 and\\nophthalmic arteries, has been found post mortem. Brief\\ntemporary failure, or even loss of sight may occur in the\\nsubjects of valvular heart disease, and in some persons who\\nare liable to recurring headache. See Megrim. Repeated\\nattacks of this kind sometimes lead to permanent blindness\\nof one eye, and atrophy of the disk comes on; possibly re\u00c2\u00ac\\npeated temporary failures of retinal circulation at length\\ngive rise to thrombosis. In another group of cases sight\\ni Gowers Medical Ophthalmoscopy, p. 26.\\ni", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0473.jp2"}, "474": {"fulltext": "462\\nGENERAL DISEASES OF THE EYE.\\nfails during successive pregnancies or lactations, recovering\\nbetween times; some of these may be mere accommodative\\nasthenopia; others may be due to renal retinitis. Others\\nagain are due to uraemic poisoning without ophthalmoscopic\\nsigns; in the last-named the failure affects both eyes, and\\nusually develops suddenly. The seat of the affection is\\nprobably the cerebral cortex. It is probable that high\\narterial tension predisposes to intraocular hemorrhage in\\ncases where the small vessels are unsound, and that the\\nfrequent association of retinal hemorrhage with cardiac\\ndisease is thus explained.\\nTuberculosis is sometimes accompanied by the formation\\nof tubercle in the choroid. These may occur in acute\\nmiliary tuberculosis, whether the meninges be involved or\\nnot; but owing to the difficulty of thorough ophthalmo\u00c2\u00ac\\nscopic examination in such patients, and the frequently\\nvery small size of the choroidal growths, they are much\\nmore often seen after than before death. Chronic tuber\u00c2\u00ac\\ncular tumors of the brain may be accompanied by tubercles\\nof slow growth and larger size in the choroid, and occasion\u00c2\u00ac\\nally these attain such dimensions, and cause such active\\nsymptoms, as to simulate malignant tumors 1 (p. 320). It\\nis also probable that certain cases of localized choroidal\\nexudation, not accompanied by serious general symptoms\\nor by inflammatory symptoms in the eye, may be of tuber\u00c2\u00ac\\ncular nature (p. 226, 4).\\nBarlow 2 has seen tubercles in the choroid post mortem in\\nsixteen cases; in thirteen with and three without tubercular\\nmeningitis. Sometimes they took the form of extremely\\nminute dots, \u00e2\u0080\u009ctubercular dust.\u00e2\u0080\u009d In forty-four children\\n1 For interesting cases of and remarks on choroidal tuberculosis in its\\nvarious forms and relations, see communications by Mackenzie, Barlow,\\nCoupland, and others in Trans. Opth. Soc., vol. iii. October, 1882, p. 119,\\net. seq.\\n2 Barlow Ibid., p. 132.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0474.jp2"}, "475": {"fulltext": "G ONORRH (EAR RHE UMA TISM.\\n463\\nwho died of tubercular disease, forty-two showing miliary\\ntubercles in the meninges, Dr. Money 1 found tubercles in\\nthe choroid of one or both eves in fourteen.\\nRheumatism. In acute rheumatism Dr. Barlow informs\\nme that he has more than once seen well-marked conges\u00c2\u00ac\\ntion of the eyes and photophobia; but neither iritis nor\\nother inflammatory changes occur. The subjects of chronic\\nrheumatism are, however, liable to relapsing inflammation\\nof the eye, usually taking the form of iritis, but sometimes\\nfalling entirely on the scleral or episcleral tissues; while in\\nothers less common the changes are apparently confined\\nto the conjunctiva\u00e2\u0080\u0094rheumatic conjunctivitis. But, how\u00c2\u00ac\\never superficial the inflammation or congestion may be,\\nthere is no muco-purulent discharge. Some of these\\npatients give a history of acute articular rheumatism as\\nthe starting-point of their chronic troubles, others of a\\nprolonged subacute attack, lasting for many months, while\\nin others again the articular symptoms have never been\\nsevere. In yet another series a liability to facial or mus\u00c2\u00ac\\ncular rheumatism, or to recurrent neuralgia from exposure\\nto cold or damp, is the only rheumatic symptom of\\nwhich a history is given in some of these the neuralgia is\\nprobably gouty, but we have no exact knowledge of the\\nnature of this chronic rheumatism of which complaint is\\nso commonly made. It is to be remembered that the eye\\nis now and then the first part to be attacked by an inflam\u00c2\u00ac\\nmation, which later events show to be clearly related to\\nrheumatism or to gout.\\nGonorrhoeal rheumatism is not infrequently the starting-\\npoint of relapsing iritis and the other conditions named\\nabove, as well as of chronic relapsing rheumatism. Rheu\u00c2\u00ac\\nmatic iritis occurring for the first time with gonorrhoeal\\nrheumatism is, in my experience, more often symmetrical\\n1 Money: Lancet, ii. 1883, 813.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0475.jp2"}, "476": {"fulltext": "464\\nGENERAL DISEASES OF THE EYE.\\nthan other forms of arthritic iritis, or than the later attacks\\nof iritis in the same patient\u00e2\u0080\u0094a fact which at times makes the\\ndistinction between rheumatic and syphilitic iritis difficult.\\nThis statement is based on records of 104 cases of iritis with\\nwell-marked rheumatic symptoms, and six with gonorrhoea but\\nno rheumatism, in all of which syphilis was, so far as possible,\\nexcluded, (a) In thirty-four of this series the first attack of\\niritis came on during, or very soon after, gonorrhoeal rheuma\u00c2\u00ac\\ntism and in exactly one-half of these the iritis was double.\\nIn six others, making forty in all, there were iritis and gonor\u00c2\u00ac\\nrhoea, but no rheumatism, gonorrhoeal iritis,\u00e2\u0080\u009d and here the\\nproportions were the same. b In the remaining seventy cases\\nthe first iritis had no relation to gonorrhoea; and in the sub\u00c2\u00ac\\nseries the attack was single in fifty-six and double in, at the\\nmost, thirteen, two or three being doubtful, or about one-fifth.\\nNo corresponding difference obtained in regard to relapses, the\\nvast majority of the recurrent attacks in both subgroups (a and\\nb) affecting only one eye at a time.\\nGonorrhoeal iritis. Some cases of gonorrhoeal iritis have\\nbeen described in which there is iritis due to gonorrhoea\\nwithout arthritis being actually present. Probably in these\\ncases the iritis is the first indication of gonorrhoeal rheu\u00c2\u00ac\\nmatism. A variety of quiet conjunctivitis, not due to infec\u00c2\u00ac\\ntion has also been described without pain, and hardly any\\ndischarge.\\nRheumatic inflammation of the conjunctival or scleral\\ntype occurring in gonorrhoea must be carefully distin\u00c2\u00ac\\nguished from purulent ophthalmia due to infection with\\ngonorrhoeal pus.\\nIn some cases of acute inflammation of joints in infants\\nsuffering from purulent ophthalmia, the arthritis is be\u00c2\u00ac\\nlieved to be gonorrhoeal, but derived from the conjunctiva\\ninstead of the urethra. 1 In a case of this sort fluid\\n1 Clement Lucas: Brit. Med. Journ., ii. 1885, pp. 57 and 699; Fenwick:\\nIbid., p. 830 Saswornitzky abstracted in Knapp\u00e2\u0080\u0099s Archives, xv. 1886, p. 232;\\nDeutschmann Arch. f. Ophth., xxxvi. 1, p. 109.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0476.jp2"}, "477": {"fulltext": "GOUT.\\n465\\nobtained from the knee-joint was found by Deutschmann\\nto contain gonococci.\\nIt is believed that rheumatism is the cause of some cases\\nof non-suppurating orbital cellulitis, and of relapsing epi\u00c2\u00ac\\nscleritis. Rheumatism is also believed to cause some other\\nof the ocular paralyses.\\nG-out. Gouty persons are not very infrequently the sub\u00c2\u00ac\\njects of recurrent iritis indistinguishable from that which\\noccurs in rheumatism. The pathology of rheumatism is\\nso little understood that it it is not possible to distinguish\\nit in some of its forms from gout; but that the subjects of\\ntrue chalk gout are liable to relapsing iritis is undoubted.\\nThere is, on the whole, more tendency to insidious forms of\\niritis in gout than in rheumatism. It is also generally be\u00c2\u00ac\\nlieved that the subjects of gout, or persons whose near\\nrelatives suffer from it, are particularly subject to glau\u00c2\u00ac\\ncoma acute glaucoma was, indeed, the 1 arthritic ophthal\u00c2\u00ac\\nmia of earlier authors. Hemorrhagic retinitis generally\\ndue to thrombosis of one or more of the retinal veins is\\nalso more common in gouty persons than in others; it may be\\nsingle or double, and is to be distinguished from albumin\u00c2\u00ac\\nuric retinitis. It has also been observed that the children\\nor descendants of gouty persons, without being themselves\\nsubject to gout, are liable, in early adult life, to an in\u00c2\u00ac\\nsidious form of iridocyclitis (p. 171), which sometimes\\nleads to serious consequences l both eyes are likely to be\\nattacked sooner or later. The cases in this group probably\\nseem rarer than they are, from the impossibility in many\\ninstances of getting a full family history.\\nSeveral different clinical types may be recognized in the\\nlarge group of maladies referred to in this section under\\nthe name of iritis.\u00e2\u0080\u009d Besides cases of pure iritis we meet\\nwith examples of cyclitis, in some cases with increase, in\\n1 Hutchinson Lancet, January, 1873.\\n30", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0477.jp2"}, "478": {"fulltext": "466\\nGENERAL DISEASES OF THE EYE.\\nothers with decrease of tension; in other groups either the\\nsclerotic or conjunctiva are chiefly affected, true rheu\u00c2\u00ac\\nmatic ophthalmia without iritis; a fourth group, in\\nwhich the pain is disproportionately severe, may be spoken\\nof as neuralgic, and these neuralgic cases are marked by\\nsudden onset, short duration, and great frequency. In a\\nlarge majority, however, the iris is the headquarters of the\\nmorbid action. All \u00e2\u0080\u009carthritic eye diseases tend strongly\\nto relapse; they usually attack only one eye at a time,\\nthough both suffer sooner or later; and they are all much\\ninfluenced by conditions of weather, being most common in\\nspring and autumn.\\nThe strumous condition is a fruitful source of superficial\\neye diseases, which are for the most part tedious and re\u00c2\u00ac\\nlapsing, are often accompanied by severe irritative symp\u00c2\u00ac\\ntoms, but, as a rule, do not lead to serious damage. The\\nbest types are: (1) the different varieties of ophthalmia\\ntarsi; (2) all forms of phlyctenular ophthalmia; (3) many\\nsuperficial relapsing ulcers of cornea in children and ado\u00c2\u00ac\\nlescents, though not distinctly phlyctenular in origin, are\\ncertainly strumous; (4) many of the less common but\\nvery serious varieties of cyclo-keratitis in adults occur in\\nconnection with lowered health, susceptibility to cold, and\\nsluggish but irritable circulation, if not with decidedly\\nscrofulous manifestations.\\nLeprosy may have its seat in almost any part of the eye,\\nbut it usually occurs first in the superficial parts, and leads\\nto ectropion, with exposure of the cornea, and xerosis of\\nthe conjunctiva; or there may be a deposit of lepromata\\nin the cornea leading to its perforation, and to panophthal\u00c2\u00ac\\nmitis iritis and cyclitis may also occur, and leprous inva\u00c2\u00ac\\nsion of the retina has also been seen.\\nEntozoa sometimes come to rest and develop in the eye\\nor orbit. The most common intraocular parasite is the cysti-\\ncercus celluloses; it is excessively rare in this country, but", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0478.jp2"}, "479": {"fulltext": "NEURALGIA.\\n467\\nmore common on the Continent. The cysticercus may be\\nfound either beneath the retina, in the vitreous, or upon\\nthe iris, and may sometimes be recognized in each of these\\npositions by its movements. The parasite has been success\u00c2\u00ac\\nfully extracted from the vitreous when situated on the iris\\nits removal involves an iridectomy. Sometimes it develops\\nunder the conjunctiva, where I have seen it set up suppu\u00c2\u00ac\\nrative inflammation. The echinococcus hydatid with mul\u00c2\u00ac\\ntiple cysts may develop to a large size in the orbit and\\ncause much displacement of the eyeball.\\nB. Eye disease, or eye symptoms, indicative of local dis\u00c2\u00ac\\nease at a distance.\\nMegrim is well known to be sometimes accompanied, or\\neven solely manifested, by temporary disorder of sight.\\nThis generally takes the form of a flickering cloud scin\u00c2\u00ac\\ntillating scotoma with serrated borders, which, beginning\\nnear the centre of the field, spreads eccentrically, so as to\\nproduce a large defect in the field, a sort of hemianopsia;\\nthe borders of the cloud may be brilliantly colored. It\\nis referred to both eyes, and is visible when the lids are\\nclosed. The attack lasts only a short time, and perfect\\nsight returns. In many patients this amblyopia is the pre\u00c2\u00ac\\ncursor of a severe sick headache, but in others it constitutes\\nthe whole attack; it scarcely ever follows the headache.\\nLess definite and characteristic symptoms (dimness, cloudi\u00c2\u00ac\\nness, or muscae), are complained of by some patients. (Com\u00c2\u00ac\\npare p. 444.)\\nNeuralgia of the fifth nerve, especially of its first division,\\nin a few cases precedes or accompanies failure of sight in\\nthe corresponding eye, with neuritis or atrophy of the disk.\\nA liability to neuralgia of the face and head is not infre\u00c2\u00ac\\nquently observed in persons who subsequently suffer from\\nglaucoma. Intense neuralgic pain in the face or head\\nsometimes causes dimness of sight of the same eye while\\nthe pain lasts. The old belief that injury to branches of", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0479.jp2"}, "480": {"fulltext": "468\\nGENERAL DISEASES OF THE EYE.\\nthe fifth nerve can cause amaurosis is not borne out by\\nmodern experience, 1 injury to the optic nerve by fracture\\nof the skull furnishing the true explanation of such cases.\\nSympathetic ophthalmitis is the only known instance in\\nwhich inflammation of the eyeball is caused by local dis\u00c2\u00ac\\nease of an independent part.\\nDiseases of the central nervous system may be shown in\\nthe eve either at the optic disk (papillitis and atrophy) or\\nin the muscles (strabismus and diplopia).\\nThe diseases which most often cause papillitis are intra\u00c2\u00ac\\ncranial tumors, syphilitic growths, and meningitis. Abscess\\nof the brain and softening from embolism and thrombosis\\nless commonly cause it, and cerebral hemorrhage scarcely\\never. 2 Papillitis has been found in a few cases of acute and\\nsubacute myelitis 3 it does not occur in spinal meningitis.\\nIn a very large proportion (Gowers thinks at least four-\\nfifths) of all the cases of cerebral tumor (including syphilitic\\ngrowths) optic neuritis occurs at some period. The severity\\nand duration of the neuritis vary much, and probably de\u00c2\u00ac\\npend in many cases on the rate of progress, as well as on\\nthe character of the morbid growth. It not uncommonly\\nsets in at no long interval before death, while in other cases\\nit is very chronic. There is not much in the character or\\ncourse of the papillitis to help us in the localization of in\u00c2\u00ac\\ntracranial tumor; and although a very high degree of\\npapillitis, with signs of great obstruction to the retinal\\ncirculation, generally indicates cerebral tumor, there are\\nmany cases in which the presence of papillitis does not\\nhelp us to decide the nature of the intracranial disease,\\nwhether tumor, meningitis, or syphilitic disease.\\n1 References to many of the earlier cases supposed to prove this relation\\nbetween the fifth and optic nerves are given by Brown-Sequard in Holmes\u00e2\u0080\u0099\\nSystem of Surgery, third edition, vol. ii. p. 206.\\nA case by Dr. Bristowe in Trans. Ophth. Soc., vol. vi. 1886, p. 363.\\n8 Gowers: loc. cit., p. 161; Dreschfeld: Lancet, January 17, 1882; and\\nSharkey and Lawford Trans. Ophth. Soc., vol. iv. p. 232.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0480.jp2"}, "481": {"fulltext": "MENINGITIS.\\n469\\nAnalyzing 96 cases of fatal cerebral tumor, Edmunds and\\nLawford found that optic neuritis was observed in 19 of 41\\ncases where the disease was at or toward the convexity (or\\n46 per cent.); while it was seen in 41 of 55 cases where the\\ndisease was chiefly at the base (or 75 per cent.). In 43 cases\\nthe tumor was either in the basal ganglia or the cerebellum,\\nand in 37 of these 86 per cent.) optic neuritis occured\\n(Transactions of Ophthalmic Society, vol. iv. 172, 1884).\\nTumors also sometimes cause simple optic atrophy by\\npressing upon or invading some part of the optic fibres.\\nIntracranial syphilitic disease is a common cause of\\npapillitis, the disease being either a gummatous growth in\\nthe brain, or a growth or thickening beginning in the dura\\nmater, or basilar meningitis. The prognosis is much better\\nthan in cerebral tumors if vigorous treatment be adopted\\nearly; indeed, in all cases of papillitis where intracranial\\ndisease is diagnosed, and syphilis even remotely possible,\\nmercury and iodide of potassium should be promptly given.\\nMeningitis often causes papillitis, but in this respect much\\ndepends on its position and duration. Meningitis limited\\nto the convexity, whatever its cause, is seldom accompanied\\nby ophthalmoscopic changes; on the other hand, basic\\nmeningitis very often causes neuritis.\\nAmong sixteen cases of injury to the head ending in death\\nEdmunds and Lawford never found optic neuritis without\\nbasic meningitis; while they found no neuritis when the\\ndamage was limited to the convexity Transactions of Ophthalmic\\nSociety October, 1886).\\nThe neuritis in basic meningitis is probably proportionate\\nto the duration and intensity of the intracranial mischief,\\nbeing comparatively slight in acute and rapidly fatal cases,\\nwhether tubercular or not. In tubercular meningitis,\\npapillitis is very common, 1 and its occurrence seems especi-\\n1 Garlick found it in 23 of 26 fatal cases (Med.-Chir. Trans., vol. lxii.).\\nMoney (loc. cit.) discovered it in only 16 to 42 fetal cases. Slight papillitis is\\nvery easily overlooked in delirious or fretful children.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0481.jp2"}, "482": {"fulltext": "470\\nGENERAL DISEASES OF THE EYE.\\nally related to the presence of inflammatory changes about\\nthe chiasma (Gowers); and even the neuritis occurring in\\ncases of cerebral tumor seems often to be caused by second\u00c2\u00ac\\nary meningitis set up by the growth. 1 In a form of men\u00c2\u00ac\\ningitis in young children, named by Drs. Gee and Barlow\\nposterior basic,\u00e2\u0080\u009d optic neuritis is infrequent, though the\\npatients often live some little time. When patients recover\\nfrom meningitis the neuritis may pass into atrophy and\\ncause amaurosis; such cases are well known to ophthalmic\\nsurgeons; it is probable that some of them may be instances\\nof recovery from tubercular meningitis. In rare cases\\npapillitis occurs with severe head symptoms, ending in\\ndeath, but without macroscopic changes in the brain or\\nmembranes. Microscopical changes in the brain substance,\\njustifying the term cerebritis, have been found in one\\nsuch case by Dr. Sutton, and in another by Dr. Stephen\\nMackenzie. 2 It must not be forgotten that optic neuritis\\nmay be caused by various altered conditions of the blood;\\nand that it is occasionally seen without any evidence either\\nof central nervous disease or of blood changes.\\nHydrocephalus rarely causes papillitis, but often at a late\\nstage causes atrophy of the optic nerves from the pressure\\nof the distended third ventricle on the chiasma. Dr. Bar-\\nlow informs me that he has several times seen a very gross\\nform of choroiditis ending in immense patches of atrophy;\\nI have recorded one such case and seen others.\\nThe diseases most commonly causing atrophy not preceded\\nby papillitis are the chronic progressive diseases of the spinal\\ncord, especially locomotor ataxy. The atrophy in these\\ncases is slowly progressive and double, though seldom be\u00c2\u00ac\\nginning at the same time in both eyes; it almost always\\nends in blindness, although sometimes not until after many\\nyears. Similar atrophy sometimes occurs in the early stages\\n1 Edmunds and Lavvford Trans. Ophth. Soc., iii. 1883, p. 138.\\n2 Also a case by Dr. Silk, British Med. Jouru., May 26,1883.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0482.jp2"}, "483": {"fulltext": "MOTOR DISORDERS OF THE EYES.\\n471\\nof general paralysis of the insane, but chiefly in cases com\u00c2\u00ac\\nplicated by marked ataxic symptoms. It is also, but much\\nmore rarely, seen in lateral and in insular sclerosis. In the\\nlatter amblyopia with slight neuritic changes is occasionally\\nseen, and sight may improve or almost recover after having\\nbeen defective for some time. In cases of homonymous\\nlateral hemianopia we find that sometimes the blind half\\nof the field is separated from the seeing half by a straight\\nline which seems to pass through the fixation point (Fig.\\n105); but more commonly this dividing line deviates toward\\nthe blind half in the central part of the field, thus leaving\\na small central area of perfect vision. Careful observa\u00c2\u00ac\\ntions show that the dividing line probably never actually\\npasses through the fixation point; the explanation of this\\nis that fibres from the macular region pass through both\\noptic tracts and both hemispheres, so that central vision is\\nnot destroyed by disease of either tract.\\nMotor disorders of the eyes. Some of the more common\\ncauses of ocular palsy have been already given. It may\\nbe mentioned here that basic meningitis often causes par\u00c2\u00ac\\nalysis of one or more of the ocular nerves, with squinting\\n(and double vision if the patient be conscious); and, fur\u00c2\u00ac\\nther, that the palsy in such cases often varies, or appears\\nto vary from day to day.\\nLocomotor ataxy and general paralysis of the insane are\\nsometimes preceded by paralysis (usually, but not always,\\ntemporary) of one or more of the eye muscles, causing\\ndiplopia; and there may for years be nothing else to attract\\nattention. The same diseases may also be ushered in by\\ninternal ocular paralysis. The most frequent variety is\\nloss of the reflex action of the pupils to sensory stimula\u00c2\u00ac\\ntion of the skin and to light, while their associated action\\nremains, \u00e2\u0080\u009creflex iridoplegiawhen shaded and lighted\\nthev remain absolutely motionless, but they contract with\\nconvergence of the eyes, and dilate again when the eyes", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0483.jp2"}, "484": {"fulltext": "472\\nGENERAL DISEASES OF THE EYE.\\ncease to converge Argyll-Robertson symptom\u00e2\u0080\u009d). 1 This\\nphenomenon is often, though by no means always, associ\u00c2\u00ac\\nated with a contracted state of the pupils; hence, the term\\nspinal miosis\u00e2\u0080\u009d is often but incorrectly used. This re\u00c2\u00ac\\nflex paralysis of the iris is one of the most valuable of the\\nearly signs of locomotor ataxy. We do not, however, yet\\nknow how often it may occur in healthy persons or with\u00c2\u00ac\\nout eventual spinal disease it certainly has comparatively\\nlittle significance in old persons. Recent observations show\\nthat, at least in general paralysis of the insane, loss of reflex\\ndilatation to sensory stimulation of the skin is probably the\\nearliest pupillary change. 2 The complementary symptom,\\nloss of associated with retained reflex action of the pupils,\\nhas not been fully studied. Any of the other internal paral\u00c2\u00ac\\nyses may also in certain cases occur as precursors of ataxy.\\nParalysis of one third nerve coming on with hemiplegia of\\nthe opposite side may, but does not necessarily, indicate\\ndisease of the crus cerebri on the side of the palsied third\\nnerve. 3 Ophthalmoplegia externa has been already men\u00c2\u00ac\\ntioned it may here be added that cases occur in which\\nthis condition appears to be functional,\u00e2\u0080\u009d in which, at\\nany rate, the symptoms come on quickly and pass off com\u00c2\u00ac\\npletely, recurring perhaps at a later period; of these cases\\nI have seen several in young adults.\\nDouble ophthalmoplegia externa is the extreme type\\nof a large and important class of ocular palsies, to which\\nmuch attention has been given recently, characterized by the\\nparalysis of certain movements (usually associated movements\\nof the two eyes), not of the muscles supplied by a certain\\nnerve. There may be\u00e2\u0080\u0094 e. g., loss of power of both eyes to\\nlook upward (both superior recti), or loss of power to look\\nto the right (R. external and L. internal rectus); and yet\\n1 Argyll-Robertson Edinburgh Med. Journ., 1869, p. 703.\\n2 Bevan Lewis: Trans. Ophth. Soc., vol., iii. 1883.\\n3 For exceptions see Robin: Troubles Oculaires dans les Maladies de\\nl\u00e2\u0080\u0099Encephale, 1S80, p. 95.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0484.jp2"}, "485": {"fulltext": "HYSTERICAL.\\n473\\nin the latter case the L. internal rectus, if differently asso\u00c2\u00ac\\nciated, as with the R. internal during convergence, may\\nact perfectly well. Such associated paralyses are explained\\nb) lesions (usually sclerotic, occasionally tumor) affecting\\nthe centres for certain combined movements, which are\\nmore central anatomically and higher physiologically than\\nthe centres of origin of the nerve-trunks. Cases of paral\u00c2\u00ac\\nysis of both third or both sixth nerves, and also of com\u00c2\u00ac\\nplete ophthalmoplegia, are sometimes due to symmetrical\\ncoarse disease (syphilitic gummata, for instance) of the\\naffected nerve-trunks. The symptoms in all the cases\\nreferred to in this paragraph may be temporary or perma\u00c2\u00ac\\nnent, acute or chronic, and caused by various fine or coarse\\nanatomical changes; and they are frequently associated\\nwith other and graver nervous symptoms. It is of great\\nimportance in cases of multiple and associated ocular\\nparalysis to make out if we can whether the symptoms\\npoint to peripheral disease (disease of nerve-trunks), or to\\ndisease of the nuclei of origin of the nerves, or to lesion of\\nthe centres for certain movements.\\nCases of recurrent paralysis of ocular nerves, most fre\u00c2\u00ac\\nquently of the third nerve, have been described, associated\\nwith periodic headache on the same side; from the few\\nj)ost mortem examinations that have been made, the symp\u00c2\u00ac\\ntoms appear to be due to small, innocent growths in the\\ntrunk of the affected nerve. 1\\nInsular (disseminated) sclerosis is often accompanied by\\nnystagmus, characterized by irregularity both of the am\u00c2\u00ac\\nplitude and rapidity of the movements, and by pallor and\\natrophy of the optic nerves.\\nHysterical eye symptoms. See pp. 277, 379.\\nC. Cases in which the eye shares in a local process affect\u00c2\u00ac\\ning the neighboring parts.\\n1 See Holmes Spicer and Ormerod Trans. Ophth. Soc., vol. xvi.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0485.jp2"}, "486": {"fulltext": "474\\nGENERAL DISEASES OF THE EYE.\\nIn herpes zoster of the first division of the fifth nerve\\nthe eye participates. When only the supra-orbital or supra\u00c2\u00ac\\ntrochlear branches are attacked the eyeball usually escapes,\\nor is only superficially congested. But if the eruption\\noccur on the parts supplied by the nasal branch\u00e2\u0080\u0094 i. e., if\\nthe spots extend down to the tip of the nose\u00e2\u0080\u0094there is usu\u00c2\u00ac\\nally inflammation of the proper tissues of the eyeball\\n(ulceration or infiltration of cornea and iritis); for the\\nsensitive nerves of the cornea, iris, and choroid are de\u00c2\u00ac\\nrived, through the long root of the ophthalmic ganglion,\\nfrom the nasal branch. Occasionally the eye suffers, how\u00c2\u00ac\\never, when the nasal branch escapes. The pain and swell\u00c2\u00ac\\ning of the herpetic region are often so great that the attack\\ngets the name of erysipelas.\u00e2\u0080\u009d In rare cases atrophy of\\nthe optic nerve and paralysis of the third and other neigh\u00c2\u00ac\\nboring nerves occur with the herpes. 1\\nIn paralysis of the first division of the fifth the cornea\\nand conjunctiva are anaesthetic the cornea maybe touched\\nor rubbed without the patient feeling at all. In many\\ncases ulceration of the cornea, usually uncontrollable and\\ndestructive in character, takes place. This is probably due\\nto anaesthesia of the cornea the loss of sensation (1) allows\\ninjuries and irritations to occur unperceived, and (2) by re\u00c2\u00ac\\nmoving the reflex effect of the sensory nerves on the calibre\\nof the bloodvessels, permits inflammation to go uncontrolled.\\nIn paralysis of the facial nerve the eyelids cannot be\\nshut, and the cornea remains more or less exposed. When\\na strong effort is made to close the lids the eyeball rolls\\nupward beneath the upper lid. Epiphora is a common\\nresult of facial palsy. Severe ulceration of the cornea\\nmay result from the exposure.\\nParalysis of the cervical sympathetic causes some nar\u00c2\u00ac\\nrowing of the palpebral fissure from slight drooping of the\\n1 A useful paper on facial herpes with many references by Mr. Jessop, is\\npublished in vol. vi. of the Ophthalmological Society\u00e2\u0080\u0099s Transactions, 1886.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0486.jp2"}, "487": {"fulltext": "EX 0 PHTH A LMIC G OITRE.\\n475\\nupper lid, apparent recession of the e) T e into the orbit, and\\nmore or less miosis from paralysis of the dilator of the\\npupil (p. 377). No changes are observed in the calibre of\\nthe bloodvessels of the eye, or in the secretion of tears.\\nThe pupil is said to be less contracted after division of the\\nsympathetic trunk than when the trunk of the fifth (and\\nwith it the oculo-sympathetic fibres) is cut, and knowledge\\nof this may be now and then useful in diagnosis.\\nIn exophthalmic goitre (Graves\u00e2\u0080\u0099 disease, Basedow\u00e2\u0080\u0099s dis\u00c2\u00ac\\nease) the most prominent symptoms are protrusion of the\\neye, excited action of the heart, enlargement of the thy\u00c2\u00ac\\nroid, and certain nervous phenomena; the protrusion is\\nalmost invariably bilateral, though not infrequently\\ngreater on the right side. The upper lids do not follow\\nthe eyeball in looking dowu (v. Graefe\u00e2\u0080\u0099s sign); infre\u00c2\u00ac\\nquency of involuntary winking (Stellwag\u00e2\u0080\u0099s sign) and\\nabnormal width of the palpebral aperture are also found.\\nIn severe cases the proptosis may be so great as to pre\u00c2\u00ac\\nvent full closure of the lids, and in these dangerous ulcera\u00c2\u00ac\\ntion of the cornea is to be feared. In such cases it is bene\u00c2\u00ac\\nficial to shorten the palpebral fissure by uniting the borders\\nof the lids at the outer canthus, or even to unite the lids in\\ntheir whole length (p. 387). No changes are present in\\nthe fundus, except occasional dilatation of arteries and\\nspontaneous arterial pulsation. The seat of the lesion\\ncausing this peculiar malady is not yet known; it was\\nformerly supposed to be due either to some morbid con\u00c2\u00ac\\ndition of the sympathetic, or to disease of the heart; there\\nis more to support the view that it is due to a primary\\nlocalized lesion of the medulla oblongata. More recent\\nobservations have tended to show that all the symptoms\\nmay be caused by excessive formation of thyroid secretion\\nand by its absorption by the blood. 1\\n1 See discussion, Carlisle meeting of British Medical Association, British\\nMed. Journ., 1896, ii. p. 893.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0487.jp2"}, "488": {"fulltext": "476\\nGENERAL DISEASES OF THE EYE.\\nErysipelas of the face sometimes invades the deep tissues\\nof the orbit, and causes blindness by affecting the optic\\nnerve and retina; on recovery the eye is found to be blind,\\nand the ophthalmoscope shows either simple atrophy of the\\ndisk, or signs of past retinitis also. Other forms of orbital\\ncellulitis may lead to the same result.\\nDisease of the nose and adjacent sinuses is in certain\\ncases a most important cause of ocular disease. Phlycten\u00c2\u00ac\\nular ophthalmia, particularly when rebellious to treatment,\\nwill often be found to accompany a chronic rhinitis. The\\ntreatment of the nasal mucous membrane, conjoined with\\nthe local and general measures usually recommended, leads\\nto the most prompt and complete recovery.\\nIn many cases of lachrymal obstruction an examination\\nof the nose will show that the duct has been closed at the\\nlower extremity, either by pressure of hypertrophied or\\ndistorted turbinals, the tension of cicatricial bands, or by\\nchronic inflammation in the adjoining membrane. The\\nobstruction is most perfectly and readily relieved by direct\\ntreatment of the nasal condition.\\nNot rarely, orbital cellulitis is excited by disease of one\\nor more of the cavities surrounding it. At times the in\u00c2\u00ac\\nflammatory process is so great that phlegmon of the orbit\\nand extreme proptosis of the eyeball are induced. At\\nother times, however, especially in cases of ethmoiditis, the\\nsymptoms are much milder, the most marked being the\\nswelling at the inner canthus and the outw r ard displacement\\nof the globe.\\nDisorders of the teeth, though rarely, may also induce\\nchanges, structural as well as functional. Among the latter\\nmay be mentioned restriction in the range of the accom\u00c2\u00ac\\nmodation and amblyopia, while metastatic choroiditis and\\niritis have followed dental abscesses.\\nNote on the Teeth in Inherited Syphilis, with", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0488.jp2"}, "489": {"fulltext": "TEETH IN INHERITED SYPHILIS.\\n477\\nDescription op Fig. 181. None of the first set of teeth\\nme characteristically altered, though the incisors frequently\\ndecay early.\\nFig. 181.\\nIn the permanent set only two teeth, the central upper\\nincisors, are to be relied upon; but the other incisors, both\\nupper and lower and the first molars, are often deformed", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0489.jp2"}, "490": {"fulltext": "478\\nGENERAL DISEASES OF THE EYE.\\nfrom the same cause. The characteristic change in the\\ncentral upper incisors appears to depend upon defective\\nformation of the central lobe of the tooth (Fig. 181, 2, 5,\\nand 6). Soon after the eruption of the tooth this lobe\\nwears away, leaving at the centre of the cutting edge a\\nvertical notch (No. 1). If the cause have acted so in\u00c2\u00ac\\ntensely as entirely to prevent the development of the cen\u00c2\u00ac\\ntral lobe, we find, instead of the notch, a narrowing and\\nthinning of the cutting edge in comparison with the crown,\\nand this, according to its degree, produces a resemblance\\nto a screw-driver, or to a peg (Nos. 3 and 4). The teeth\\nare also usually too small in every dimension, so that the\\nincisors are often separated from one another by consider\u00c2\u00ac\\nable spaces. In extreme cases all the incisors are peggy\\nand much dwarfed. The changes are usually symmetrical,\\nbut No. 5 shows one tooth typically deformed and the\\nother normal.\\nFig. 181 (No. 7) shows in an extreme degree the changes\\ndue to absence of enamel from the permanent teeth mer\u00c2\u00ac\\ncurial,\u00e2\u0080\u009d stomatitic,\u00e2\u0080\u009d strumous,\u00e2\u0080\u009d and rickety\u00e2\u0080\u009d\\nThe change occurs in lines running horizontally across the\\nwhole set of permanent incisors and canines. When slight\\nit affects only the part near the edge, the enamel beginning\\nas a sudden terrace or step a little distance from the edge;\\nin bad cases several such terraces\u00e2\u0080\u009d are present, and the\\nwhole tooth is rough, pitted, and discolored. The first\\npermanent molars show a corresponding change on the\\ngrinding surface. It is this imperfection that is found\\npresent in nearly all cases of lamellar cataract (p. 193),\\nthough the dental condition is common enough in persons\\nwithout that or any other form of cataract.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0490.jp2"}, "491": {"fulltext": "[SUPPLEMENT,\\nTHE PRACTICAL EXAMINATION OF RAILWAY EM\u00c2\u00ac\\nPLOYES AS TO COLOR-BLINDNESS, ACUTENESS OF\\nVISION, AND HEARING, INCLUDING THE SYSTEM\\nADOPTED IN 1881 BY THE PENNSYLVANIA RAIL\u00c2\u00ac\\nROAD, AND STILL IN USE.\\nBy William Thomson, M. D.,\\nEMERITUS PROFESSOR OF OPHTHALMOLOGY IN THE JEFFERSON MEDICAL\\nCOLLEGE, PHILADELPHIA.\\nIn accordance with a wish expressed by the President\\nin 1879, that I should suggest some practical method for\\nthe examination of the employes of the Pennsylvania\\nRailroad as to their ability to see the colored signals by day\\nand night used in the service, I devoted much time to the\\nsubject, in an effort to overcome the following difficulties:\\n1. To ascertain whether each man possesses sight enough\\nto see form at the average distance, and range of vision to\\nenable him to see near objects well enough to read written\\nor printed orders and instructions. 2. To learn if each\\nman has color-sense sufficient to judge promptly and gov\u00c2\u00ac\\nern his actions by day or night, by the colors in use for\\nsignals. 3. To determine the ability of each man to hear\\ndistinctly.\\nThe difficulties to be overcome were found in the magni\u00c2\u00ac\\ntude of the task, involving the examination of thirty-five\\nthousand men then in the service, with the necessity of\\nextending it to all who might be hereafter employed, dis\u00c2\u00ac\\ntributed over thousands of miles of road, and in the\\n(479)", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0491.jp2"}, "492": {"fulltext": "480\\nSUPPLEMENT.\\nabsence of ophthalmic experts in sufficient number, pos\u00c2\u00ac\\nsessing enough special training to fit them to decide with\\nprecision the points in issue.\\nIt soon became apparent that some system would be\\nneeded that could be put in force by each Division Super\u00c2\u00ac\\nintendent, acting through intelligent employes, under the\\ngeneral supervision of one or more ophthalmic surgeons\\nof recognized skill, to whom all information collected\\ncould be transmitted, and who would be able to decide all\\ndoubtful cases, and thus protect the road from any danger\\narising from incapable employes, and save good and faith\u00c2\u00ac\\nful men from the evil of being discharged from the com\u00c2\u00ac\\npany\u00e2\u0080\u0099s service, or prevented from being employed on other\\nroads on insufficient grounds.\\nIt was believed that the facts could be collected by non-\\nprofessional persons, and could be so clearly presented to\\nthe Division Superintendent and to the ophthalmic expert\\nas to enable a perfectly correct decision to be made in\\nevery case; and that men fit for service would be recog\u00c2\u00ac\\nnized, while those deficient in sight, color-sense, or hear\u00c2\u00ac\\ning, could be referred to the expert if they so desired, or\\ntransferred to places in the service where their defects, if\\nnot remediable by treatment, could do no harm either to\\nthe road or to the public.\\nSuch a system was submitted to the General Manager of\\nthe Pennsylvania Railroad some months later, and was\\nperfected by the labors of a special committee of the Society\\nof Transportation Officers in conjunction with the writer.\\nThe entire method was, furthermore, then submitted to a\\npractical experimental test extending over nearly two\\nthousand men, employed as conductors, engineers, firemen,\\nand brakemen, and the results have satisfied the committee\\nand myself that our object has been fully attained, and\\nthat the system proposed may now be put in force with\\nconfidence in its practical utility. As an evidence of this,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0492.jp2"}, "493": {"fulltext": "EXAMINATION OF RAILWAY EMPLOYES. 481\\nI may cite two complete detailed reports, including 1383\\nmen in all. The blanks upon which the original entries\\nwere made have all been submitted to me, and they satisfy\\nme that the results in the summary of each of these excel\u00c2\u00ac\\nlent reports maybe confidently accepted, and thus we have\\nbecome acquainted with the fact that there were in the\\nservice of the Pennsylvania Railroad, of the 1383 men\\nexamined, 246 men deficient in the full acuteness of vision,\\n55 absolutely color-blind, and 21 defective in hearing.\\nIn one of the reports, an examination not included in\\nthe instructions from the committee was made with colored\\nflags and colored lights by night, and 13 men failed to be\\nable to recognize them from a total of 24, who were color\u00c2\u00ac\\nblind to the test used for its detection; but I have little\\ndoubt whatever that the entire number of color-blind, viz.,\\n55, would also fail under a carefully-devised system of tests\\nby the usual railroad signals.\\nThe entire number reported as defective in color-sense,\\n4 T per cent., is up to the average, as reported by the best\\nauthorities in its percentage; but those absolutely color\u00c2\u00ac\\nblind, and hence unable to distinguish between a soiled\\nwhite or gray and green, or a green and red flag, are fully\\n4 per cent.; and this proves that the instrument employed\\nin this part of the examination has met our expectations\\nfully.\\nAs this was the point about which I had most doubt, a\\nword or two of explanation may be proper, more especially\\nas many great authorities declare that no examination for\\ncolor-blindness should be accepted unless made by profes\u00c2\u00ac\\nsional specialists.\\nThe examination for color-blindness now generally\\naccepted and proposed by Prof. Holmgren consists in\\ntesting the power of a person to match various colors\\nwhich are most conveniently used in the form of colored\\nyarns. Usually about 150 tints are employed, in a con-\\n31", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0493.jp2"}, "494": {"fulltext": "482\\nSUPPLEMENT.\\nfused mixture, and three test colors, viz., light green rose\\nor purple, and red are placed in the foregoing order be\u00c2\u00ac\\nfore the person examined, who is directed to select similar\\ncolors from the mass. The examiner sits then in judg\u00c2\u00ac\\nment, and decides whether the color-sense is perfect from\\nthe selections made, or from those not made, or from them\\nboth, and from the prompt or hesitating manner of the\\nexamined. It has been our effort to render this more\\nsimple, and to so arrange the colors that they may be\\nidentified by some number, so that an expert, although\\nabsent from the scene, would know by these numbers the\\nexact tints selected, and thus be fully competent to declare\\nfrom them the color perception of any person whose record\\nhad been properly made. From theory based upon scien\u00c2\u00ac\\ntific knowledge, and from much experience, I was able to\\narrange an instrument that would have the real colors and\\nthose usually confounded with them, confusion colors,\u00e2\u0080\u0099\u00e2\u0080\u0099\\nplaced in such relations to each other, and so designated by\\nnumbers, as to make an examination for color-blindness\\npossible by a non-professional person, who could conduct\\nthe testing, record it properly, and transmit it to an expert\\ncapable of deciding upon the written results. Hence there\\nis no departure from the system of matching tints already\\nestablished, the only novelty being in reducing the number\\nof colors to those similar to the test colors, and to those\\nusually chosen by color-blind persons, and so identifying\\nthem as to enable an absent expert or superintendent to\\nknow precisely what colors had been selected to match\\nthe test colors.\\nThe theory of the instrument (consisting of a stick with\\nthe yarns attached, see Plate), is that color-blindness is\\nmost promptly detected by using the light green test-skein,\\nand asking that it be matched in color from the yarns on\\nthe stick, which are arranged to be alternately green and\\nconfusion colors, and are numbered from one to twenty,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0494.jp2"}, "495": {"fulltext": "PLATE JV.\\n\u00c2\u00a3\u00c2\u00bb-M. \u00c2\u00a3u. W, vL S3\\nhnm\\nl ll \u00c2\u00bby niw wm i", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0495.jp2"}, "496": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0496.jp2"}, "497": {"fulltext": "EXAMINATION OF RAILWAY EMPLOYES. 483\\nthe person being directed to select ten tints, and the ex\u00c2\u00ac\\naminer being required to note the numbers of the tints\\nchosen. It will be seen that the odd numbers are the\\ngreen, and the even ones the confusion colors, and, that\\nif a person has a good color-sense, his record will exhibit\\nnone but odd numbers; while, if he is color-blind, the\\nmingling of even numbers betrays his defect at a glance\\nto the supervising expert or superintendent.\\nThere are forty tints on the stick, and the first twenty\\nare given to the detection of color-blindness, using the\\ngreen-test and if the color-sense is deficient, it will surely\\nbe revealed.\\nTo distinguish, however, between green-blindness and\\nred-blindness, the rose-test is used, and those color-blind\\nwill select indifferently, either the blues intermingled with\\nthe rose, between figures 20 and 30, or perhaps the blue-\\ngreen or grays from 1 to 20, and thus reveal their defect,\\nand establish either green- or red-blindness.\\nFinally, the reel-test corroborates these results, and satis\u00c2\u00ac\\nfies the most sceptical of color-defect, when the confusion\\ntints or even numbers between 30 and 40 are selected.\\nOn a suitable blank these figures are placed in the order\\nof examination, and a glance of the eye reveals the color-\\nsense of the person examined; since, if anything but odd\\nnumbers are chosen, there is a defect; or if, with test one,\\nanything beyond 20 is chosen; or if, with test two, any\u00c2\u00ac\\nthing but odd numbers between 20 and 30; or, with test\\nthree, anything but odd numbers between 30 and 40. The\\ncolor-skeins can readily be changed in the instrument, if it\\nshould be found desirable.\\nIt is theoretically and practically a fact that the tints as\\narranged on the instrument look quite the same in color to\\ncolor-blind persons, and that those having a perfect color-\\nsense can thus form an idea of this infirmity. If, then,\\ngreen and gray are indistinguishable, and green and red,", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0497.jp2"}, "498": {"fulltext": "484\\nSUPPLEMENT.\\nwhen of the same depth of color, seem to be entirely the\\nsame to the color-blind, it needs no opinion from a scien\u00c2\u00ac\\ntific expert to convince the manager of a railroad that it\\nwould be most dangerous to place the lives of people under\\nthe guidance of an engineer who could not distinguish, if\\ngreen-blind, between a soiled white and a green flag, or\\nbetween a green and red flag, or other signal of these\\ncolors.\\nIt is a fact that some of the color-blind promptly give\\nthe proper names to the flags, and answer correctly, when\\nasked what they would do in presence of such signals; but\\nit must be remembered that they may see perfectly, and\\nhave always had some perception of these colors, and do\\ngive them their conventional names, perhaps, but that they\\nare unable to distinguish them at once and infallibly, and\\nthat it will only require a further extension of our method\\nof testing to demonstrate the inability of persons color\u00c2\u00ac\\nblind to our examination to recognize the signals, by day\\nor night, which are now depended upon to prevent acci\u00c2\u00ac\\ndents of the gravest character. This must be done by de\u00c2\u00ac\\nmanding that the signals be matched, and not named, and\\nis incorporated in the instructions herewith submitted, so\\nthat the tints which color-blind men select with the rail\u00c2\u00ac\\nroad signals may hereafter be known and recorded.\\nMy conclusions from a study of the subject in connection\\nwith the railway service are\\n1. That there are many employes who have defective\\nsight, caused either by optical defects, Avliich are, perhaps,\\ncongenital, and which might be corrected with proper\\nglasses, or due to the results of injuries or diseases of the\\neyes, remediable or not by medical or surgical treatment.\\n2. That one man in twenty-five will be found color-blind\\nto a degree to render him unfit for service where prompt\\nrecognition of signals is needed, inasmuch as color-blind\u00c2\u00ac\\nness for red and green renders signals of these colors indis-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0498.jp2"}, "499": {"fulltext": "EXAMINATION OF RAILWAY EMPLOYES. 485\\ntinguishable. It is a fact in physiological optics, however,\\nthat yellow and blue are seen by those color-blind for red\\nand green, and that yellow-violet blindness is so rare that\\nit might lead to the use of these yellow and blue colors, in\\npreference to red and green, wherever possible.\\n3. That color-blindness, although mainly congenital and\\nincurable, is sometimes caused by disease or injury, and\\nthat precautions might be needed to have either periodical\\nexaminations or to insist upon it in cases where men have\\nsuffered from severe illness or injury, or when they have\\nbeen addicted to the abuse of tobacco or alcohol.\\n4. That the method, when adopted, will enable the\\nauthorities to know exactly how many of their employes\\nare \u00e2\u0080\u009csatisfactory in every particular\u00e2\u0080\u0099\u00e2\u0080\u0099 as to sight and\\nhearing; and that the examination will have the further\\nvalue of making the division superintendents acquainted\\nwith the general aptitude of the men in their divisions as to\\ngeneral intelligence.\\n5. That the entire examinations can be made at the rate\\nof at least six men an hour; while that for color-sense\\nalone can be done in a very few minutes for each man by\\nan intelligent employe.\\n6. That to secure the confidence of the employes and of\\ncompetent scientific critics, as well as of the public gener\u00c2\u00ac\\nally, it is advisable to have some official professional\\nspecialist to whom all doubtful questions could be referred,\\nand who should be held responsible for the accuracy of the\\ninstruments, test-cards, etc., to be put in use, and who\\nshould have general supervision of the entire subject of\\nsight, color-sense, and hearing.\\n7. That from the impossibility of subjecting the immense\\nnumber of employes on our large railways to the inspection\\nof the few surgical experts available, and to secure the ex\u00c2\u00ac\\namination of those hereafter to be employed, some system\\nof testing by the railway Superintendents has become a", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0499.jp2"}, "500": {"fulltext": "486\\nSUPPLEMENT.\\nnecessity, and it is believed that the one prepared will\\nanswer the purpose.\\nBy request, these views were communicated to the proper\\nofficials of the Pennsylvania Railroad Company, and on\\nJuly 1, 1881, I received a communication from the gen\u00c2\u00ac\\neral manager, from which I make the following extract:\\nDear. Sir I beg leave to inform you that the appa\u00c2\u00ac\\nratus invented by you, and the rules and regulations enti\u00c2\u00ac\\ntled Instructions for examinations as to vision, color-sense,\\nand hearing,\u00e2\u0080\u0099,.prepared by a committee of transportation\\nofficers of the Pennsylvania Railroad and yourself, for the\\nuse of our officers in examining employes for defects of\\nsight and hearing, were laid before the Board of Directors,\\nwho approved and adopted them, and authorized me to put\\nthem into effect, subject to such changes from time to time\\nas experience may prove to be necessary for the proper\\nworking of the system.\\nIn putting these rules into effect, I take pleasure in\\ndesignating you as the expert to whom, under the rules,\\nsuch cases shall be referred as may require the judgment\\nof an expert.\u00e2\u0080\u009d\\nPennsylvania Railroad Company\u00e2\u0080\u0099s Instructions\\nfor Examination of Employes as to Vision,\\nColor-blindness, and Hearing.\\nInstructions for examination as to vision, color-blindness,\\nand hearing. The examination will be made as to vision,\\ncolor-sense, and hearing, and the following apparatus will\\nbe used:\\n1. A card or disk of large letters for testing distant\\nsight. 2. A book or card of print for testing sight at a\\nshort distance. 3. An adjustable frame for supporting the\\nprint to be read, with a graduated rod attached for meas\u00c2\u00ac\\nuring the distance from the eye while reading. 4. A spec-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0500.jp2"}, "501": {"fulltext": "EX A MINA TION OF RAIL WA Y EM PL 0 YES. 48 7\\ntacle frame for obstructing the vision of either eye while\\ntesting the other. 5. An assortment of colored yarns for\\ntesting the sense of color. 6. A watch with a loud tick\\nfor testing the hearing. 7. A book or set of blanks for\\nrecording the observations. 8. A copy of an approved\\nwork on color-blindness.\u00e2\u0080\u009d\\nAcuteness of vision. For distant visiou, place the test-\\ndisk or card in a good light twenty feet distant, and ascertain\\nfor each eye separately the smallest letters that can be read\\ndistinctly, and record the same by the number of that series\\non the card.\\nRange of vision. For near vision, ascertain the least\\nnumber of inches at which type D 0.5 or 1J, can be\\nread with each eye, and record the result.\\nField of vision. Let the examiner stand in front of the\\nexamined, at a distance of three feet, and directing the\\nexamined to fix his eyes on the right eye of the examiner,\\nand keep them so fixed, let the examiner extend his arm\\nlaterally, and opening and shutting his hands, let him by\\nquestions satisfy himself that his hands are seen by the\\nexamined without changing the direction of the eyes; re\u00c2\u00ac\\ncording the result as good or defective, as the case may be.\\nColor-sense. Three test-skeins\u00e2\u0080\u0094A, light green B, rose;\\nC, red\u00e2\u0080\u0094will be used with the colored yarns attached to\\nthe stick of the latter there are forty tints, numbered\\nfrom 1 to 40, and arranged in three sets\u00e2\u0080\u0094a, b and c\\nof which the odd numbers correspond to the colors of the\\ntest-skeins, while the even numbers are different or con\u00c2\u00ac\\nfusion colors.\u00e2\u0080\u009d\\nThe first set is to test for color-blindness the second to\\ndetermine whether it be red- or green-blindness, and the\\nthird to confirm the opinion formed from the first or\\nsecond test.\\nPlace the test-skein A at a distance of not less than three\\nfeet, and without naming the color, direct the person exam-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0501.jp2"}, "502": {"fulltext": "488\\nSUPPLEMENT.\\nined to name the color, and to select from the first twenty\\ntints, or set (a), of the yarns on the stick, ten tints of the\\nsame color as skein A, stating that they do not match, but\\nare different shades of the same color. Record the number\\nof the tints so selected. Do the same with skeins B and C,\\nusing for B the tints from 21 to 30, and for C the tints\\nfrom 31 to 40. If the odd numbers are selected readily,\\nthe examination may be gone over very quickly.\\nWhen color-blindness is detected, any one of the even\\nnumbers or \u00e2\u0080\u009cconfusion colors\u00e2\u0080\u009d mav be used as a test-\\nskein, and the man may be directed to select similar tints,\\nwhen he will most probably choose odd numbers, which\\nshould be recorded, stating the number on the stick of the\\n\u00e2\u0080\u009cconfusion color\u00e2\u0080\u009d used for a test, and then giving the\\nnumbers chosen to match it.\\nThen a soiled white flag should be shown, and the man\\nbe directed to select tints to match it, which should be\\nrecorded; next a green, and finally a red flag.\\nAll of the particulars are to be recorded as the examina\u00c2\u00ac\\ntion proceeds, not leaving it to memory. Use the numbers\\nin recording. The letters indicating the set need not be\\nused. Note whether the selection is prompt or hesitating\\nby a distinct mark after the proper word on the blank\\nform. When deficient color-sense is discovered, and varia\u00c2\u00ac\\ntions in the mode of testing are made by the examiner or\\nexamined, they should be noted under remarks, or on a\\nseparate sheet to be referred to, if the blank has not room\\nenough.\\nHearing. Note the number of feet or inches distant\\nfrom each ear at which a watch, having a tick loud\\nenough to be heard at five feet, is heard distinctly, using\\na watch without a tick, or a stop-watch, to detect any\\nsupposed deception; and the number of feet at which\\nordinary conversation is heard, and the numeral figures\\ncan be repeated when spoken.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0502.jp2"}, "503": {"fulltext": "EXAMINATION OF RAILWAY EMPLOYES. 489\\nExplanations. The test-disk contains letters, numbered\\nfrom 20 (xx), or D 6, to 200 (cc), or D 60. Those\\nmeasuring three-eighths of an inch, and numbered 20 (xx)\\nor D 6, are such as a good eye of ordinary power sees\\ndistinctly twenty feet or six metres distant. If a man sees\\ndistinctly only those marked C (or 100), his acuteness of\\nvision, V., is equal to jjy$, or -J-. If he sees to XX (or 20),\\nthen V. is equal to or 1, and his sight is up to the full\\nstandard. This mode of statement indicates the relative\\nvalue of the sight examined, and should be used in the\\nrecords. If one eye is or 1, and the other not less than\\nto or with or without glasses, the sight may be con\u00c2\u00ac\\nsidered satisfactory.\\nThe power of discerning small objects at the reading dis\u00c2\u00ac\\ntance is tested by the small print, and good sight may be\\nassumed if one eye can see at twenty inches the matter\\nmarked II or D 0.5, while the other distinguishes not\\nFig. 182.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0503.jp2"}, "504": {"fulltext": "490\\nSUPPLEMENT.\\nDr. Thomson\u00e2\u0080\u0099s revolving disk of test-types consists of two superimposed\\ndisks of cardboard, twelve inches in diameter, so fastened by their centres\\nto a square of cardboard which supports them that the front disk remains\\nfixed, while the back disk may be made to revolve. Near the bottom of\\nthe front disk is one of Snellen\u00e2\u0080\u0099s test-letters, large enough to be recognized\\nat 60 meters 200 feet; over this one for 36 meters 120 feet. Above this is\\nan opening through which the letters on the back disk may be seen. On\\nthe back disk test-letters arranged in five radiating rows, either of which\\nmay be brought to the aperture, making a series of test-types from 6 meters,\\nor 20 feet to 60 meters, or 200 feet. The first figure shows the complete test,\\nthe second shows the back or revolving disk. By this arrangement, the\\nperson tested is prevented from becoming too familiar with the sequence\\nof the letters he is asked to recognize.\\nless than 4\u00c2\u00a3 or D 1.5. The small print should then be\\nbrought to the point of nearest vision for each eye, and\\nthat point mentioned in inches. A good eye should be able\\nto read No. 1 at twenty inches, and have a range of vision\\nup to ten inches.\\nThe color-test will indicate whether the man is deficient", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0504.jp2"}, "505": {"fulltext": "EXAM IN A TION OF RAIL WA Y EMPLOYES. 491\\nin color-sense. The colors are arranged in three sets, one\\nof 20 and two of 10 each\u00e2\u0080\u0094the odd numbers are the colors\\nsimilar to the test-skeins, and the even numbers are the\\nconfusion colors,\u00e2\u0080\u009d or those which the color-blind will be\\nlikely to select to match the sample skeins or colors shown\\nhim. The first 20 (a) numbered from 1 to 20, have green\\ntints for the odd numbers or test-colors. In the second\\nb 21 to 30, the test-colors are rose or purple, a combina\u00c2\u00ac\\ntion of red and blue; and in the third (c), 31 to 40, they\\nare red. Ordinarily the test will be with each set sepa\u00c2\u00ac\\nrately, but the whole 40 may be employed on any test-\\nskein. Anything but green matched with green indicates\\na defect in the color-sense, for which use set (a).\\nThe test with the second set indicates whether red or\\ngreen blindness exists. The odd numbers from 21 to 30\\nare purple. If either of these is matched with test-skein\\nB, nothing is indicated, as they must appear alike to a\\ncolor-blind person but if blue is chosen, red-blindness is\\nindicated, and if green, then green-blindness is established.\\nThe third set (c) is scarcely needed, but may be used in\\nconfirmation of, or in connection with, the last, as to red\\nor green defect.\\nWhen the numbers of the tints selected are recorded in\\nthe proper blank, color-blindness will be indicated in those\\ninstances where even numbers appear, and suspicions will\\narise where numbers beyond 20 are used with test-skein A.,\\nand under 21 or beyond 30 with B, and below 31 with C.\\nFurther tests should be made of those found to be color\u00c2\u00ac\\nblind with the usual signal flags, requesting them to name\\neach color, shown singly, and to match the colors of them\\nfrom the tints on the stick, and with colored lamps; and\\nfinally to state what they understand them to mean as sig\u00c2\u00ac\\nnals.\\nIt will be well not to dwell on the examination of a man\\nfound to be defective in color-sense or in vision, but to pass", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0505.jp2"}, "506": {"fulltext": "492\\nSUPPLEMENT.\\nover each examination with the same general care, and\\nafterward send for those giving indications of defects, to\\ncome in singly for fuller examination. The examination\\nshould be private as far as practicable, especially excluding\\npersons who are to be subsequently examined.\\nInability to name color accurately, or to distinguish\\nnicely as to difference in tint, is not to be taken as an\\nevidence of color-blindness.\\nIn testing as to hearing, if the watch used can be heard\\nat five feet distant, and the person examined hears it only\\nat one foot, his hearing would be 1-5, and may be so re\u00c2\u00ac\\ncorded in fractions. Conversation in an ordinary tone\\nshould be heard at ten feet.\\nIt should be understood that all employes examined fail\u00c2\u00ac\\ning to come up to the requirements of the above standard\\nshall be accorded the benefit of a professional examina\u00c2\u00ac\\ntion. When acuteness of vision is below the standard\\nadopted, it may be possible to restore full vision by proper\\nglasses, when it is due to optical defects known as near\u00c2\u00ac\\nsight, far-sight, or astigmatism, or by other medical or\\nsurgical treatment, and useful men may then be retained\\nin the company\u00e2\u0080\u0099s service.\\nIn order to show how the Pennsylvania Railroad Com\u00c2\u00ac\\npany keeps its records of these examinations we submit the\\nfollowing fac-simile of an actual blank used in detecting a\\ncase of color-blindness:", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0506.jp2"}, "507": {"fulltext": "EX A MINA TI ON OF RAIL WA Y EM PL 0 YES. 493\\nWest Jersey Railroad Company.\\nCamden, January 19, 1883.\\nExamination of sight and hearing of James A. Morris, aged\\ntwenty-two, employed as locomotive fireman, applicant for\\nAcuteness of Vision.\\nRange of Vision.\\nThe number of the\\nSeries seen at twenty\\nfeet distant:\\nRight eye, 20-30\\nLeft eye, 20-20\\nLeast number of\\ninches at which type\\nD\u00e2\u0080\u00940.5 in test-type\\npamphlet can be read.\\nRight eye,\\ninches.\\nLeft eye,\\n44 inches.\\nField of Vision.\\nGood or defective Good.\\nColor-seme.\\nTest-skein\\nsubmitted.\\nName\\ngiven.\\nNumbers selected to match.\\nA\u00e2\u0080\u0094Green\\nB\u00e2\u0080\u0094Rose\\nC\u00e2\u0080\u0094Red\\nGreen\\nRed\\nRed\\n3, 26, 24, 7, 11, 22, 15, 5, 1, 17, 28, 9,\\n37, 33, 29, 12, 39, 31, 21, 35, 25, 27,\\n37, 33, 31, 35, 23\\n19, 30,13\\n23\\nSecond Color-test.\\nThird Color-test.\\nNumber\\nName\\nNumbers\\nFlag\\nName and\\nNumbers\\nshown.\\ngiven.\\nselected.\\nshown.\\nuse given.\\nselected.\\n24\\nGreen.\\n26, 22\\nSoiled\\nSafety,\\n2, 4, 6\\nwhite.\\nwhite.\\n39\\nYellow\\nCould find\\nSoiled\\nCaution,\\n36, 38\\nred.\\nno match.\\ngreen.\\ngreen\\n30\\nBlue.\\n26\\nSoiled\\nDanger,\\n37, 33, 31\\nred.\\nred.\\nSelection Prompt or Hesitating:\\nPrompt.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0507.jp2"}, "508": {"fulltext": "494\\nSUPPLEMENT.\\nHearing.\\nRight Ear.\\nLeft Ear.\\nWatch.\\nConversation.\\nWatch.\\nConversation.\\n8 feet.\\n20 feet.\\n8 feet.\\n20 feet.\\nRemarks.\\nEscaping steam prevented watch-test.\\nJ. J. Burleigh, Examiner.\\nAcuteness, right eye defective. Bange, good. Field, good.\\nColor-sense, defective. Hearing, see Remarks.\\nJos. Crawford, Superintendent.\\nNote. \u00e2\u0080\u0094Those approved, marked \u00e2\u0080\u009cAppd.\u00e2\u0080\u009d\\nThose not approved, marked \u00e2\u0080\u009cNot Appd.\u00e2\u0080\u009d\\nThe color-blind and those found defective in sight and\\nhearing were soon removed from positions of danger. The\\nentire system has been continued on the Pennsylvania Rail\u00c2\u00ac\\nroad since 1881, giving full satisfaction, and is now used\\nas a barrier before every new applicant, to protect the road\\nfrom the admission of dangerous men. It has been adopted\\nby the Philadelphia and Reading Railroad Company and\\nby others, as is shown by the replies received in response\\nto a circular sent to a hundred of the most important\\nrailroad corporations of this country, controlling 129,970\\nmiles, in 1894, asking if examinations were made as to\\ncolor-blindness. Thus it was found in 1894 that\\nTwenty-four using Dr. Thomson\u00e2\u0080\u0099s test controlled 38,786 miles.\\nEleven using other methods controlled .15,679\\nThirty-one making no test controlled 29,428\\nThirty-four making no reply controlled 46,077\\nSixteen other roads having control of 12,947 miles have\\nalso adopted my color-stick, thus making a grand total of", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0508.jp2"}, "509": {"fulltext": "EX A MINA TION OF RAILWAY EMPLOYES. 495\\n51,733 miles protected by this test out of 142,917 covered\\nby the investigation. The total number of roads included\\nis 116 of these 40 use my color-stick 11 use other color-\\ntests, mainly Holmgren\u00e2\u0080\u0099s; 31 use none; 34 have made no\\nresponse. The entire system has also been in use on the\\nMidland and on the London and Southwestern in England.\\nThe example of the Pennsylvania Railroad has accom\u00c2\u00ac\\nplished much good, but there is yet much to be done to\\nbring all the roads in the country under the protection of\\nsome efficient method of testing, to secure both the roads and\\nthe public against loss of life and property from these well-\\nknown defects of their employes. The total mileage of the\\ncountry, 1894, was 175,233, and there were about 1,000,000\\nemployes.\\nAs the result of much experience, and after a study of\\nthe entire subject, I suggested in 1894 some improvements\\nthat would enable a new test to be used in connection\\nwith the color-stick or as a substitute for it. The color-\\nskeins of this New Wool Test have been most carefully\\nselected, and a standard set will be kept, so that renewals\\nmay be made of the entire set or of those skeins that may\\nbecome faded, soiled, or lost. The new set consists of a\\nlarge green and a large rose test-skein, and forty small\\nskeins, each marked with a bangle having a concealed\\nnumber, extending from 1 to 40, placed in a double box,\\nso arranged as to keep the two series apart and to permit\\neach to be exposed upon a table in a confused mass. The\\nstick is dispensed with, as giving too fixed an arrangement\\nto the skeins and not enough confusion, although the skeins\\ncan be readily removed from their hooks and changed in\\nposition for this purpose, and should be so used.\\nThe large green skein being placed near by, the small\\nskeins, from 1 to 20, are exposed in good daylight, and the\\nemploye under examination is directed to select ten shades\\nof the same color of the test-skein. One with normal vision", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0509.jp2"}, "510": {"fulltext": "496\\nSUPPLEMENT.\\nwill choose promptly and with ease the ten greens with odd\\nnumbers on the bangles. A color-blind person will hesi\u00c2\u00ac\\ntate, and his selections will contain some even numbers,\\nand the confusion colors will be shades of brown, etc., con\u00c2\u00ac\\ntaining some red, or shades of gray, and will indicate the\\ncolor-defect. These figures are to be recorded on a blank,\\nand the twenty skeins are to be removed. The large rose-\\nskein is then used and the examination repeated in like\\nmanner with skeins numbered from 21 to 40, and the re\u00c2\u00ac\\nsult recorded. The confusion skeins, which have even\\nnumbers, are blue, green, and gray. From the selections\\nmade by the man found color-defective by the green test,\\nwe are able to decide the character of his color-blindness.\\nThose selecting blues are red-blind; those taking greens\\nand grays are green-blind, according to the nomenclature\\nof Holmgren. There are ten roses and ten confusion colors\\nin the second series.\\nThe red test-skein of the stick, with its confusion-colors,\\nis omitted entirely, and the test is made to conform more\\nstrictly with Holmgren\u00e2\u0080\u0099s method, while the examiner is\\nalso provided with forty questions of decisive clearness.\\nGreater scientific accuracy is obtained by this method,\\nand with the careful selection of these confusion colors I\\nnow regard this system as an improvement upon the stick,\\nand as a safer and more simple method to be used by a\\nnon-professional examiner. The blank will also give to\\nthe division superintendent or to any supervising surgical\\nexpert a more simple report of the examination. The\\nyarns are to be kept from the light in the double box, one\\nside of which is colored green and the other rose, to aid the\\nexaminer in keeping the series separate and to save time.\\nThe test will also be a valuable addition to those to be used\\nby surgical experts and ophthalmic surgeons.\\nWhen used in addition to the stick the second and third\\ncolor-tests may be omitted.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0510.jp2"}, "511": {"fulltext": "EXAMINATION OF RAILWAY EMPLOYES. 497\\nDirections for the Use of this Test.\\n1. Examine only one eye at a time by covering the other\\neye with a handkerchief, or some other means that will\\nexclude it from vision.\\n2. Spread a white cloth, like a towel, on a table in a good\\nlight.\\n3. Take out all the worsteds from the green part of the\\nbox and put them on the cloth at random.\\n4. Take from this heap the large light green test, which\\nis marked \u00e2\u0080\u009cA,\u00e2\u0080\u009d and laying it to the side in a good light\\ndirect the man to select 10 skeins from the heap. Tell\\nhim that these are not to be exactly like it in every respect,\\nbut that they are to be of the same color, only a little\\nlighter or darker in shade.\\n5. Write down on your blank the numbers of the 10\\nskeins selected by the man to match the test-skein A. If\\nonly odd numbers appear which he selected promptly, then\\nhe is not color-blind but if even numbers have been chosen,\\nhe must be more or less color-blind.\\n6. Ask him the name of the color he has been matching,\\nor any other worsted, and register his answer on the blank.\\n7. Remove now all the worsteds and put them back into\\nthe green part of the box.\\n8. Now take out the second test and expose it on the\\ntable in the same way as before.\\n9. Show him the large rose-colored test-skein, marked\\nB,\u00e2\u0080\u009d and ask him to match this with 10 worsteds in the\\nsame sense as before with the first test.\\n10. Register his 10 selections on the blank. Now any\\neven numbers selected betray and determine definitely his\\ncolor-blindness. If the man selects blues, with the test-\\nskein B, he is red-blind if he selects grays or greens, he is\\ngreen-blind.\\n32", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0511.jp2"}, "512": {"fulltext": "Examination of sight and hearing of\\nemployed as.\\n498\\nSUPPLEMENT.\\nCi\\n00", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0512.jp2"}, "513": {"fulltext": "earing.\\nEX A MTNATTON OF BA TLWA Y EMPLOYES.\\n499\\nG\\na\\nft\\nG\\no\\nc3\\nw\\nS-i\\nu\\ng\\no\\nO\\nft!\\no\\nCS\\nt-,\\noj\\nw\\n*2\\nXI\\nbo\\n5\\nC\\nO\\nej\\ntn\\ns-\\na\\na\\no\\nO\\nX3\\no\\nc3\\nco\\nC?\\nKl\\nn\\nft\\nft\\n1\\no\\nG\\nD\\nM\\nM\\noj\\nS\\nO\\na\\no\\n\u00c2\u00ab-i\\nft\\nft\\noj\\nO\\nG\\ntn\\nO\\nft\\nH\\nT3\\nft\\nft\\nft\\nft\\naj\\na\\nft\\no\\nft\\nft\\nci\\n02\\nO\\nft\\nH\\nw\\nH\\nO\\nf-\\nCO\\nxi\\nft\\nXI\\n02\\npH\\np-H\\nX\\n3\\nft\\noj\\nft\\nO\\nO\\n\u00e2\u0080\u00a29\\nw\\nft\\nft\\nH\\nft\\nc\u00c2\u00a3\\npH\\nX\\nft", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0513.jp2"}, "514": {"fulltext": "500\\nSUPPLEMENT.\\n11. Ask him the name of the test-skein, or any other\\nskein, and register it.\\n12. Put down whether his selection was prompt or hesi\u00c2\u00ac\\ntating.\\n13. Finally, as a control upon the test and as a substi\u00c2\u00ac\\ntute for the second and third color-test of the stick system,\\nthere have been added, especially for the surgical expert,\\ntwo more large test-skeins, one, C, yellow, and the other,\\nD, blue. The test C is exposed, and you may ask the man to\\nmatch it if possible by the skeins from 1 to 20. If normal\\nin color-sense, he will decline, or at the most only take the\\nyellow-green skein, but if color-blind he will select a num\u00c2\u00ac\\nber of the green skeins, which should be recorded. Then\\nuse test D, the blue skein, and let him match it from skeins\\n21 to 40. If normal or green-blind, he will select blues\\nonly, but if red-blind he will pick out a series of roses,\\nwhich should be recorded.\\nIn 1897 it was estimated that seventy-eight corporations,\\ncontrolling 106,395 miles, have adopted the entire system.\\nIn 1900 reports show that one hundred and eleven\\ncorporations, controlling 149,151 miles, have adopted it.\\nThe Lantern.\u00e2\u0080\u0094Inasmuch as for two-fifths of his time,\\nduring the night an employe must govern his actions by\\ncolored signal lights, I have now to propose a lantern\\nwhich is to be used by or under the orders of the Division\\nSuperintendent in addition to the wool-tests, and which\\ncontains those signals universally used on railroads, and\\nadditional glasses to imitate the changes induced by rain,\\nsmoke, fog, or snow. It consists of a lamp upon which can\\nbe placed an asbestos chimney having two disks, 4 in. or 10\\ncentimeters in diameter, so arranged that thin glasses, 10\\nmm. in diameter, can be superimposed. This can be also\\nplaced over an Argand burner or other gas light, or an\\nelectric light can be employed to avoid heat, or a standard\\ncandle with a spring stick. The upper disk contains four", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0514.jp2"}, "515": {"fulltext": "EXAMINATION OF RAILWAY EMPLOYES. 501\\nopenings: one, two, five, and ten millimeters each, one\\nwhite ground glass, one London smoke dark, one Lon\u00c2\u00ac\\ndon smoke medium, one light pink, one light green, one\\ncobalt.\\nThe lower disk contains the red, green, white, and blue\\ncolors in general use. By combining these with the ground\\nor London smoke glasses of upper disk, atmospheric con\u00c2\u00ac\\nditions can be imitated. The red placed over the cobalt\\ngives a very deep red color; the green and cobalt imitate\\nthe blue green so much in use. To the color-blind cobalt\\nappears as blue with no red or violet, and when combined\\nwith the blue of the lower disk appears of a bright red, but\\nis called blue by the color-blind, blind to red.\\nThe effects of distance and size are produced by the\\nopenings from 1 to 10 mm. in the upper disk. Normal\\ncolor-sense is known by the power to recognize the signals\\nat 5 meters through the 1 mm. opening. If with the large\\none a man fails to see the signal at 5 meters or 16 feet,\\nthe color-sense is reduced to and a man placed at one\\nmeter, still failing, shows a color-sense =to and at 20\\nor a meter, 100 only. I have endeavored to provide\\nconfusion colors for both red and green and white in the\\nthree glasses in the upper disk mentioned as light red or\\npink, light green, and grey, or light smoke. Color-blind\\npersons see these as one color, white or grey, and so call\\nthem.\\nThe test should be made in a dark room the various\\nlights should be brought to view by rotating the disks, and\\nthe man be directed to call out the colors of the signals.\\nThe failures or successes should be recorded on a blank.\\nNo man should be accepted who would call the led signal\\ngreen, or white; the green one red or white; or the white\\none red or green. The blue is always seen by the color\u00c2\u00ac\\nblind, and called properly.\\nNot only congenital color-blindness but that central de-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0515.jp2"}, "516": {"fulltext": "502\\nSUPPLEMENT.\\nfeet caused by alcohol, tobacco, or other drugs, or diseases,\\nis quickly detected.\\nThe disks may be called upper aud lower. The lower is\\nfor the direct,\u00e2\u0080\u009d the upper for the cross examination.\\nFig. 183.\\nThomson\u00e2\u0080\u0099s lamp.\\nThe lower contains ten glasses, designated by the num\u00c2\u00ac\\nbers from 1 to 10. Commencing with the white ground\\nand going to the next green, then to red, etc., the tenth\\nbeing the blue. These are the signals in use on all roads,\\nand they should be named at once by a man with color-\\nsense normal placed at 5 meters, in a darkened room with", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0516.jp2"}, "517": {"fulltext": "EXAM IN A TION OF RAILWAY EMPLOYES. 503\\nthe small opening. The color-blind man may call white\\ncorrectly, and he always does see blue, hence he has few\\nchances of detection since he does see the green and red\\nlights, and tries to tell them not by their color, but by their\\nintensity. It becomes requisite to present them to his view\\nin various conditions. Should he make no mistakes in his\\nfirst testing with the lower disk, the openings from 10 mm.\\nto 1 mm. in the upper should be brought into combination,\\ndecreasing the apparent size of the light and its intensity,\\nand testing his color power as is done by test-letters. The\\nnormal eye should recognize the color through 1 mm, open\u00c2\u00ac\\ning at 5 meters.\\nThe upper disk also has ten openings: 1 mm. known as\\nA. 2. B. 5. C. 10. D. Ground white, E. London-\\nsmoke dark, F. Light London-smoke, G. Light pink, H.\\nLight green, I. Cobalt, K.\\nThe ground white may be used as a means of making\\nall glasses of the lower disk more solid in color; the dark\\nLondon-smoke combined with them imitates the effect of\\nfog, rain, or snow; or it may so change the intensity of a\\nred as to cause the color-blind to call the same red either\\ngreen or red. The light pink, a compound of red and\\nblue, the light green, and the light London-smoke, are\\nconfusion colors and appear to the color-blind alike,\\nand are called white. This is an attempt to imitate the\\nconfusion colors of the wool-tests for the first time, and it\\nrequires nice adjustment of the source of light. With the\\npink, the red-blind man sees no red, and the blue which he\\ndoes see is changed by the yellow of the light within the\\nchimney into his white; the green-blind man, in like man\u00c2\u00ac\\nner, failing to see the light green, calls that and the grey-\\nwhite, alike white. The ground glass of the lower disk\\nshould be used with these.\\nThe cobalt gives a red and blue light normally, but the\\ncolor-blind see it only as blue. It has a value also in", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0517.jp2"}, "518": {"fulltext": "504\\nSUPPLEMENT.\\ncausing the red of the lower disk to be very pure and dark\\nso that a color-blind man may call the same red, with or\\nwithout the cobalt, either red or green. The cobalt with\\nthe pure greens, gives the blue-green color adopted by\\nmany roads. Cobalt combined with blue gives a rose\\nwhich is called blue by the color-blind. The man should\\nbe asked to tell what the lights indicate as signals. They\\nmean white, safety; green, caution, run slowly; red, halt,\\ndanger; blue, inspector\u00e2\u0080\u0099s light, a train or car so guarded\\nmust not be moved.\\nThe numbers and letters used on the disks are too\\nsmall to aid those defective in the testing. Any intelligent,\\nnot color-blind, examiner can use this color-tester, and\\nreport on the present blank the results, naming the mis\u00c2\u00ac\\ntakes that have been made. The man\u00e2\u0080\u0099s quantitative color-\\nsense may be found and stated. He should be placed at 16\\nfeet or 5 meters from the lantern, the smallest 1 mm.\\nopening being used. This is sufficient for a normal eye.\\nHe may fail, and may when told to name the color call\\nred green white, green or green, red. The openings are\\nthen increased to the largest, 10 mm., and failing again he\\nhas less than of color-sense. He is then directed to\\napproach the light to 1 meter, failing here he has -fo, and\\nfinally he shows y-Jy- only of color-sense, when he fails at i\\na meter or 20 inches away.\\nA most interesting experiment can be made by placing\\nthe chimney over a lamp having some common salt mixed\\nwith the alcohol in it. The flame gives a monochromatic\\nlight, which renders all the colors alike to the observer with\\nthe normal color sense, and enables him to comprehend\\nthe defect of the color-blind. The color-stick seen with\\nthis yellow light in a dark room loses all its colored tints\\nand becomes grey to the normal eye, and should be ex\u00c2\u00ac\\nhibited to the examinees by the surgical expert.\\nThe first man tested with the lantern failed on every", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0518.jp2"}, "519": {"fulltext": "EXAMINATION OF RAILWAY EMPLOYES 505\\ncolor but the blue. Called red green, but never recognized\\ngreen. His acuteness was Rt. and Lt. Called cobalt\\nblue; called light pink or red green, and London-smoke\\nwhite. New wool-test: Shown rose called it blue, and\\nselects all the blues, saying the other pinks are shades of\\ngreen. With spectroscope: Has but two colors, blue and\\nyellow, each shading to black with a light dirty white place\\nwhere yellow and blue mingle. Stick Calls red test-skein\\nred, but picks confusion colors.\\nGreen Calls it green, selects some light green skeins, then\\nmore greys, leaving best greens behind.\\nRose: Calls it red, then green, and matches it with fine\\ngrays. Calls white three squares of color on white paper\\ncomposed of light pink, light green, and light gray. Finally\\ncalls two test glasses II inches in diameter, by day, held\\none foot away, both red, one being red the other green.\\nTypical green blind.\\nIt may be of service to present to the ophthalmic experts\\nin charge of the examinations of the various railroads the\\nmeans that I have adopted for my own guidance in giving\\nmy final decisions. From the numerous methods described\\nby scientific authorities I have selected ten that are prac\u00c2\u00ac\\ntical, simple, and especially fitted for the detection of color-\\ndefects in employes of railroads. A book of record should\\nbe kept in which each case, with the results of the testing,\\nshould be entered. The Pennsylvania Railroad system\\nprovides that the preliminary examination should be made\\nunder the direction of the Division Superintendent by non\u00c2\u00ac\\nprofessional examiners, but it is to be under the supervision\\nof one professional competent surgeon, who is known as the\\nsurgical expert, or ophthalmic surgeon, who becomes re\u00c2\u00ac\\nsponsible for the qualities of the tests, and who gives the\\nfinal decision in all cases referred to him. Thus the men\\nare protected from the errors of lay examiners, and do not\\nlose their places until pronounced defecti ve by professional", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0519.jp2"}, "520": {"fulltext": "506\\nSUPPLEMENT.\\nauthority. With ordinary care no color-blind man should\\nescape detection by the lay examiner, but men really fit\\nfor the service might be unfairly treated.\\nThe most important duty of the surgical expert is to\\nexplain the entire system to the Division Superintendents\\nand to instruct their examiners.\\nWhen referred to the expert the man found color-blind\\nwill present himself with the blank of his examination, and\\nthe surgical expert will then corroborate this by the follow\u00c2\u00ac\\ning means\\n1. The color-stick or the new wool test or both.\\n2. Holmgren\u00e2\u0080\u0099s set of one hundred of fifty various-colored\\nskeins will be used and the proportion of mistakes recorded.\\nIts main value is to preserve the record, especially of\\nthose cases of partial color-blindness so difficult to decide.\\nLet the man assort these skeins at his pleasure, placing\\nthem in various piles. He generally concludes with a red,\\nblue, green, yellow, neutral, and grey pile. A small\\npiece clipped from each skein makes a valuable record\\nwhen placed in an envelope, and marked with the name\\ngiven, and teaches much to the examiners.\\n3. Browning\u00e2\u0080\u0099s pocket spectroscope will then be used, and\\nthe man be directed to describe the colors he sees when look\u00c2\u00ac\\ning through the instrument. If color-blind he will say that\\nhe sees but two colors, yellow and blue, with a gray or a\\nneutral band between them.\\n4. The color-tables of Stilling will then be used; these\\nare so arranged that on a colored background letters and\\nfigures are printed in the confusion colors of this back\u00c2\u00ac\\nground so as to be indistinguishable by the color-blind.\\nIt now becomes requisite to test the central vision to de\u00c2\u00ac\\ntect amblyopia, whether toxic from tobacco, alcohol, drugs,\\netc., or caused by disease, heredity, or accident, as well as\\nto determine the power to perceive the signal-colors that\\nare used by night.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0520.jp2"}, "521": {"fulltext": "EXAMINATION OF RAILWAY EMPLOYES. 507\\nIn the color-blindness of tobacco, alcohol, drugs, etc.,\\nthe center of the field of vision only is rendered ambly-\\nopic, hence the skeins tail to detect it, they being properly\\nseen by the peripheral parts of the retina. It may be\\nsuspected by the loss ot acuity with the testdetters. Since\\nit is confined to the macular region only the color-test\\nmust be small. In a case of tobacco amblyopia, in the\\nabsence of a perimeter, I used recently the 5 of hearts\\nheld about one foot from the face. The patient saw\\nthe four outer hearts red, the center one black, and later\\non red after treatment by strychnine. The three of the\\nsame suit answers well to detect the defect, held hori\u00c2\u00ac\\nzontally. W ith one eye closed, the right for example, fixed\\non the center heart, the one to the right disappears, or is\\ndegraded in tone; looking with left eye the heart to the\\nleft is lost or changed in tone.\\nA red Maddox rod demonstrated an entire scotoma in an\u00c2\u00ac\\nother recent case, the red line being broken for a space in\\nits centre, to be seen later as a white portion, and finally\\nas a full red streak as the case recovered under treatment.\\nThese tests demand good faith from the patient, but they\\nshow the inability of a man with toxic amblyopia to see\\nthe signals used by night.\\nThe color defect generally affects a portion of the centre\\nof the field equal to the diameter of a test-glass held at\\none foot from the eye one and a half inches, or about 6\u00c2\u00b0.\\n5. A piece of dark cobalt-blue glass should be used in\\nthe trial-frame over each eye separately, and the man be\\ndirected to look at the flame of a candle or other small\\nlight, from a distance of twenty feet. An eye normal in\\nrefraction and color-sense sees the light colored rose or\\npink, surrounded by a blue halo. To a hypermetrope there\\nmay be a blue light, with a ruby-colored ring or halo; but\\ntwo colors will always be seen, while the color-blind man\\nsees but one color, blue, or a light spot with a blue halo.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0521.jp2"}, "522": {"fulltext": "508\\nSUPPLEMENT.\\n6. Thomson\u00e2\u0080\u0099s lantern has already been described and\\ntakes the place of Bonders\u00e2\u0080\u0099 instrument.\\n7. A tin lantern, with a switch-light condenser having\\na four-inch opening arranged so as to admit of placing\\npieces of white (ground), green, red, blue, and London-\\nsmoke glass before it, is now employed. This could also be\\nmade to take the place of Donders\u00e2\u0080\u0099 instrument, if covered\\nwith a front, and with a sliding-piece with small perfora\u00c2\u00ac\\ntions. A man failing to recognize the light from a four-\\ninch aperture leaves no possible room for doubt, and this\\nfixture is useful in convincing the friends of the man, and\\nany railroad officers who may desire a rude test. The light\\nis in diameter 100 mm., and should be seen at 500 metres.\\n8. The instrument of Mr. Carter, of London, is then\\nmade use of. This is to guard the surgical expert against\\na hasty opinion, and is to act as a check upon all -wool\\ntests. It is based upon the sensibility of the retina and its\\npower to recognize form and color in various intensities of\\nlight. The surgeon and the man examined regard the\\ntests simultaneously while the quantity of light is varied;\\nthus, possible errors with other tests, especially Holmgren\u00e2\u0080\u0099s,\\ncan be avoided.\\n9. In Br. Chibret\u00e2\u0080\u0099s instrument, by means of polarized\\nlight various colors may be produced at will. The color\u00c2\u00ac\\nblind betray themselves by placing the instrument so that\\ntwo dissimilar disks of light appear to them alike.\\n10. Finally, an assortment of flags that have been in\\nactual use new, worn and old, ten of each color, white,\\ngreen, blue, and red are used as a test. These are thrown\\ndown in a confused mass on the floor, and the man is\\ndirected to properly assort them, and to tell their color at\\na distance of twenty feet. Astounding mistakes are often\\nmade; as, for example, when a man is directed to take a\\nred flag and use it to protect the rear of a train, he may\\nselect a green one. Of two reds he may call one green.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0522.jp2"}, "523": {"fulltext": "EXAMINATION OF RAILWAY EMPLOYES. 509\\nA profound understanding of this curious defect of color-\\nperception must be acquired to enable the surgical expert\\nto make the best use of these various methods, and while\\nthey are sufficient, they are decisive and require but little\\ntime. Perhaps the transcript of one case from my record-\\nbook may illustrate these brief descriptions:\\nJ. H., employed by the Pennsylvania Railroad Com\u00c2\u00ac\\npany, forty-three years old found defective and referred\\nfor final opinion.\\nColor-stick: With green, selects Nos. 1, 2, 3, 4, 6, 7, 11,\\n13, 15, 17 with rose, selects Nos. 22, 25, 21, 27, 28 with\\nred, selects Nos. 31, 32, 33, 34, 37.\\nHolmgren: Green, selects 2 greens and 21 confusions;\\nrose, selects 5 greens, with 13 confusions; red, selects 8\\ngreens, with 9 confusions, 2 greens.\\nDonders: Fails at 5 m. on all apertures; fails at 1 m.\\non all apertures; m. on all apertures.\\nCalls, with 20 mm. opening, green red; red green and\\nw T hite, light red.\\nHe made more mistakes than successes, with gray (Lon-\\ndon-smoke glass) over white; called it red and green, as\\nlight was increased or diminished, and finally declared that\\nhe had never seen such lights on a railroad.\\nFailed with switch-light, 4 inches in diameter, at 5 m.\\nand at 1 m., and manifested a color-blindness or defect\\ngreater than as he failed to see at 1 m. what a normal\\neye would recognize infallibly at 500 metres.\\nCobalt-glass Sees white light with blue halo no red or\\nrose.\\nFlags: At 1 m. calls dirty-white green fails to distin\u00c2\u00ac\\nguish red from green. He was then told to select from a\\npile of flags the danger-signal, or red one, and to hurry\\nback and protect his train; with his own hands and delib\u00c2\u00ac\\nerately he chose six\u00e2\u0080\u0094three red, two green, and one blue-\\nstating that they would all stop trains.\u00e2\u0080\u009d", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0523.jp2"}, "524": {"fulltext": "510\\nSUPPLEMENT.\\nStilling\u00e2\u0080\u0099s tables: Fails in all but VII., which should be\\nrecognized by a color-blind.\\nPronounced color-blind and unfit for any duty in which\\nhe would govern his actions with color-signals.\\nI will conclude by a regret that space does not permit a\\nfull treatment of more than this system which seems to\\nhave gained the confidence of railroad officers, as is proved\\nby its adoption for the protection of 150,000 miles of\\ntrack. Its chief originality and merit seems to be the\\nplacing of the responsibility on the Division Superintend\u00c2\u00ac\\nent, who can know the men on his division, and can in\u00c2\u00ac\\ncrease or diminish his force without the delay of medical\\nexaminations. The system of odd and even numbers of\\nthe wool-tests enables him to supervise at a glance the\\nwork of his assistants, who make and record the exami\u00c2\u00ac\\nnations. He needs to know only that men reach a certain\\ndegree of standard in sight, hearing, and color sense. There\\nare now 78,000 men employed on the Pennsylvania railroad,\\nall of whom whose duties demand a high standard have been\\nproperly tested. The system acts as a quarantine to pre\u00c2\u00ac\\nvent admission of defective men into the service.\\nIt is understood that in youth hypermetropic men may\\ngain entrance, but as they reach middle life, the examination\\nfor promotion, if they are valuable men, indicates their\\ndefect, and they are expected to use glasses to restore nor\u00c2\u00ac\\nmal vision. Re-examinations at stated periods are strongly\\nadvised. The standard of vision is not changed. A paper\\nof Dr. A. G. Thomson in the appendix of De Schweinitz and\\nRandall\u00e2\u0080\u0099s text-book, on acuity of vision requisite, and used\\nhere and abroad, may be consulted.\\nThe New Wool-test introduced in 1894 is an improve\u00c2\u00ac\\nment upon, but does not displace the stick.\\nThe revolving test-letters prevents them from becoming\\ntoo familiar.\\nThe lantern now added to the wool-tests will cover the", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0524.jp2"}, "525": {"fulltext": "EXAMINATION OF RAILWAY EMPLOYES. 511\\ntwo-fifths of the employes\u00e2\u0080\u0099 time spent in seeing signals by\\nnight; makes the examination of color-sense complete, and\\ndetects the central blindness of disease or abuse of tobacco\\nand alcohol.\\nLike Dr. Allport\u00e2\u0080\u0099s method of examination of school-chil\u00c2\u00ac\\ndren by their teachers, it makes those defective known, ex\u00c2\u00ac\\ncludes them from the service, or enables the ophthalmic sur\u00c2\u00ac\\ngeon to use his skill in relieving them. Perhaps in the future\\nthe examinations may all be made by skillful surgeons,\\nbut the system has done much good, and has induced one\\nhundred and eleven great corporations to adopt some\\nmethod of control over 150,000 miles of track, and is now\\nrendered more complete than ever before.\\nThe tests here described can be obtained of Queen\\nCo., of Philadelphia, and with each one will be sent a cer\u00c2\u00ac\\ntificate of its accuracy signed by Dr. Thomson.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0525.jp2"}, "526": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0526.jp2"}, "527": {"fulltext": "APPENDIX.\\nFORMULAE, ETC.\\nNitrate of Silver.\\n1. Mitigated Solid Nitrate of Silver (B. P. 1885):\\nNitrate of Silver 1,\\nNitrate of Potash 2.\\nFused together and run into moulds to form short, pointed sticks.\\nUsed for granular lids and purulent ophthalmia.\\nThe strength above given is known as No. 1, and is that which I\\ngenerally use; three weaker forms are made, known as Nos. 2, 3,\\nand 4, containing respectively 3, 31, and 4 parts of nitrate of potash\\nto 1 of nitrate of silver\\nPure nitrate of silver is never to be used to the conjunctiva.\\n2. Solutions of Nitrate of Silver\\n(1) Nitrate of Silver gr. x or xx,\\nDistilled Water 3j.\\nUsed by the surgeon for purulent ophthalmia, granular lids, and\\nchronic conjunctivitis, and some cases of ulcer of the cornea.\\n3. (2) Nitrate of Silver gr. j or ij,\\nDistilled Water 5j.\\nUsed by the patient in various forms of ophthalmia, only a few\\ndrops to be used at a time, and not more than three times a day.\\nAll solutions of nitrate of silver should be kept in glass-stoppered\\nbottles; any trace of organic matter decomposes the salt, and a black\\ndeposit of metallic silver falls to the bottom; the action of light\\nfavors this decomposition: amber-tinted glass is said to counteract\\nthe chemical action of light. Dark blue bottles should not be used,\\nas they only hide the deposit of reduced silver.\\n33\\n513", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0527.jp2"}, "528": {"fulltext": "514\\nAPPENDIX.\\nSulphate of Copper.\\n4. A crystal of Pure Sulphate of Copper smoothly pointed, may\\nbe used for touching granular lids of old standing.\\n5. Lapis Divinus:\\nSulphate of Copper 1,\\nAlum 1,\\nNitrate of Potash 1.\\nFused together, and camphor equal to of the whole added.\\nThe preparation is run into moulds to form sticks. It should be\\nkept in a stoppered bottle.\\nLargely used for the treatment of chronic granular lids.\\n6. Solutions of Sulphate of Copper or of Lapis Divinus gr. j\\nin 5 j of distilled water, are also very useful for many forms of\\nchronic conjunctivitis.\\nLead Lotion\\n7. Liquor Plumbi Subacetatis (B. P.) ^j,\\nDistilled Water Oj.\\n(1 in 160.)\\nUsed in chronic conjunctivitis when the cornea is sound, and in\\ninflammation of the eyelids and lachrymal sac.\\nSpirit Lotion\\n8. Rectified (or Methylated) Spirit if iv,\\nW ater xvj.\\nUsed as an evaporatiug lotion to allay or prevent inflammation of\\nthe wound after operations on the eyelids.\\n9. Lead and Spirit Lot ion\\nSpirit Lotion Oj,\\nLiquor Plumbi Subacetatis (B. P.) ^ij.\\nUsed in the same cases when there is no fear that the cornea is\\nabraded or ulcerated. A better antiphlogistic than spirit alone.\\nMercury.\\n10. Weak Solutions of Perchloride of Mercury are extensively\\nused for cleansing the conjunctiva, eyelids, etc., before, during, and\\nafter operations. A solution of 1 grain in 6000 of water (common\\nor distilled (=gr. j in fl. if xij may be freely used for the above\\npurposes, and a stronger one (1 to 2500) gr. j in fl. 3vj) as a", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0528.jp2"}, "529": {"fulltext": "APPENDIX.\\n515\\nlotion for catarrhal ophthalmia, etc. Some surgeons use much\\nstronger solutions. The Moorfields Pharmacopoeia has a lotion\\ncontaining 1 grain in fl. 3 viij, or 1 in 3500.\\n11. Solutions of Perchloride of Mercury in glycerine and dis\u00c2\u00ac\\ntilled water of the strength of 2 or 4 per cent, have been introduced\\nfor the conjunctiva in cases of trachoma, either alone or after ex\u00c2\u00ac\\npression of the follicles; perchloride of this strength has also been\\nused for some cases of ulcer of the cornea.\\nSulphate of Zinc:\\n12. Sulphate of Zinc gr. j or ij,\\nWater or Rose Water 3 j.\\nChloride of Zinc\\n13. Chloride of Zinc gr. ij,\\nWater 3 j.\\nIf there is a deposit, add of dilute hydrochloric acid just enough\\nto make a clear solution.\\n14. Chloride of Zinc Paste Caustic)\\nThe exact composition of this paste varies in different hospitals\\nthe followiug is the formula in use at Moorfields\\nChloride of Zinc 480 grains,\\nWheat Flour 180 grains,\\nWater, or Liquor Opii Sedativus, fl. ^j.\\nAlum\\n15. A stick of pure crystalline alum forms a very useful appli\u00c2\u00ac\\ncation for mild or long-standing cases of granular conjunctiva, and\\nfor many forms of chronic palpebral conjunctivitis. It may be used\\nby the patient himself without the slightest risk.\\n16 Lotion:\\nAlum gr. iv to gr. x,\\nWater \u00c2\u00a3j.\\nThe above lotions are in common use in the milder forms of acute\\nand chronic ophthalmia. The chloride of zinc occasionally irri\u00c2\u00ac\\ntates; it is specially used in purulent and severe catarrhal ophthal\u00c2\u00ac\\nmia instead of the weak nitrate of silver lotions. The stronger\\nalum lotion is often used in the same cases. The alum and sul\u00c2\u00ac\\nphate of zinc lotions may be used unsparingly to the conjunctiva;\\nthe chloride, even in severe cases, not more than six times a day.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0529.jp2"}, "530": {"fulltext": "516\\nAPPENDIX\\nBoric Acid Lotion\\n17. Boric Acid 4.\\nWater 100 by weight.\\nUsed as an antiseptic before and after operations on the eyeball,\\nand in the treatment of conjunctivitis and of suppurating ulcers of\\nthe cornea.\\nBoric acid in very fine powder may be used for dusting on to\\nthe cornea in cases of severe suppurating ulcer; it causes scarcely\\nany pain, and may be applied as often as three times a day (p 139).\\nThe crystals are difficult to powder finely, but an almost impalpable\\namorphous powder, obtained by preventing regular crystallization,\\ncan be had.\\nMr. Martindale has made for me some soluble styles containing\\nabout 60 per cent, of boric acid for use in cases of lachrymal obstruc\u00c2\u00ac\\ntion with much secretion of mucus (p 102\\nSolutions of boric acid often tarnish steel; instruments should\\ntherefore not be left in them.\\nCarbonate of Soda\\n18. Carbonate of Soda gr. x,\\nWater 3 j.\\nUsed for softening the crusts in severe ophthalmia tarsi. A small\\nquantity of the lotion, diluted with its own bulk of hot water, to be\\nused for soaking the edges of the eyelids for ten or fifteen minutes\\nnight and morning.\\nTar and Soda\\n19. Carbonate of Soda \u00c2\u00a3jss,\\nLiquor Carbonis Detergens sjj to Jss,\\nWater to Oj.\\nUsed in the same cases as the last.\\nBorax:\\n20 Biborate of Soda gr. x to xx.\\nWater ^j.\\nUsed in the same cases as the last\\nQuinine Lotion:\\n21. Sulphate of Quinine gr. iij,\\nAcid. Sulph. dil. ^B. P.) just enough to dissolve,\\nWater 3 j.\\nUsed in diphtheritic ophthalmia.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0530.jp2"}, "531": {"fulltext": "APPENDIX.\\n517\\nCarbolic Acid Lotion:\\n22. Absolute Phenol 5,\\nWater by weight 100.\\nUsed in puruleDt ophthalmia. It is important to use absolutely\\npure carbolic acid for the conjunctiva. Severe irritation often\\nfollows if any other varieties are employed.\\n23. Pure carbolic acid is useful as an application by the surgeon\\nhimself to the surface of infective or obstinate ulcers of the cornea.\\nLotion of salicylic acid is so irritating to the surface of the eye\\nthat it can seldom be used. The same objection applies to salicylic\\nwool used for dressing the eye after operation.\\n24. Calomel Powder:\\nUsed for dusting on the cornea in some cases of ulceration. It is\\nflicked into the eye from a dry camel-hair brush.\\n25. Yellow Oxide of Mercury Yellow Ointment; Pagenstecher\u00e2\u0080\u0099s\\nOintment\\nYellow Oxide of Mercury gr. xxiv,\\nVaseline z i\\n(1 in 20.)\\n26. Weaker preparations, containing gr. viij or less of the\\nyellow oxide to 3j (1 in 60 or less), are often better borne.\\nUsed in many cases of corneal ulceration and recent corneal\\nnebulae, a morsel as large as a hemp-seed being inserted within the\\nlower lid by means of a small brush, once or twice a day. It is also\\nsuitable for ophthalmia tarsi.\\nIn some of the Continental eye hospitals, where it is the custom\\nfor this remedy, among others, to be applied by the surgeon him\\nself, stronger preparations are used.\\n27. Yellow Ointment with Atropine\\nYellow Oxide of Mercury gr. viij or less,\\nAtropine gr.\\nVaseline \u00c2\u00a3j.\\nUse in the same way as 25 and 26.\\n28. Red Oxide of Mercury\\nKed Oxide of Mercury gr. xxiv or less,\\nVaseline \u00c2\u00a3j.\\nUsed for ophthalmia tarsi, etc. Was formerly used for corneal\\nulcers and nebulae; but the yellow oxide, which being made by", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0531.jp2"}, "532": {"fulltext": "518\\nAPPENDIX.\\nprecipitation is not crystalline, is now generally preferred because\\nless irritating. 1\\n29. Nitrate of Mercury (Citrine Ointment):\\nUnguentum Hydrargyri Nitratis (B.P.) gj,\\nVaseline or Prepared Lard gvij.\\nUsed in the same cases as 28.\\n30. Iodoform:\\nIodoform may be used\u00e2\u0080\u0099either in substance, or as an ointment made\\nwith vaseline.\\nIodoform gr. x to gr. xxx or more,\\nVaseline \u00c2\u00a3j.\\nUng. Iodoformi (B.P. 1885):\\nIodoform gr. xlviij,\\nBenzoated Lard ^j.\\n30a. Iodol, which is odorless, may be used in the same way.\\nThe precipitated iodoform (impalpable powder) should be used in\\npreference to the ordinary, or crystalline, form for the eye.\\nBoric Acid Ointment (B P. 1885):\\n31. Boric Acid gr. lxviij to ^j of Paraffin.\\n32 Cocaine.\\nCocaine was brought into clinical use in September, 1884, at Vienna\\nand in London and elsewhere early in October.\\nA 2 per cent, solution of a salt of cocaine dropped into the con\u00c2\u00ac\\njunctival sae causes smarting for about half a minute, followed by\\nnumbness, rising to complete anesthesia of ocular conjunctiva and\\ncornea in about two to five minutes in three to five minutes after\\nthe maximum is reached, feeling begins to return, but slight numb\u00c2\u00ac\\nness continues for about twenty minutes. There is often a feeling\\nof coldness as sensation is returning. Cocaine also causes widening\\nof the palpebral fissure by retraction of the upper and lower lids,\\nwhitening of eyeball from contraction of bloodvessels, mydriasis,\\nvery slight weakness of Acc., and perhaps lowering of the eye\\ntension. These effects last about half an hour, except the mydriasis,\\nwhich remains in some degree about twenty-four hours. The pupil\\ndilated by cocaine remains active to light and Acc.; if atropine be\\n1 The ointnent known as Singleton\u00e2\u0080\u0099s Golden Eye Ointment appears to\\ncontain the crystalline red oxide in fine powder as its active ingredient. A\\nsample kindly analyzed for me by Mr. S. Plowman, contained 70 grains of\\nthe oxide to the ounce.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0532.jp2"}, "533": {"fulltext": "APPENDIX.\\n519\\nadded the pupil becomes larger than from either drug singly.\\nEserine quickly and fully overcomes the effect of cocaine. Acc. is\\ncompletely paralyzed for a very short time if cocaine be used every\\nfew minutes for about an hour. These effects of cocaine (except the\\nlast) are explicable on the supposition that it causes spasm of the\\nsympathetic nerve-fibres to the eyelids, iris, and superficial blood\u00c2\u00ac\\nvessels; whether a similar contraction of the arteries of the ciliary\\nmuscle, brought about by the repeated use of the drug, explains the\\nfleeting paralysis of Acc. is open to question. Cocaine has no ascer\u00c2\u00ac\\ntainable action on the vessels of the retina and choroid. Cocaine is\\nthought by some to aid the action of eserine in chronic glaucoma,\\nwhen the two are used together; this is intelligible if cocaine acts by\\ncontracting the ciliary arteries.\\nIn ophthalmology cocaine is used chiefly for anaesthesia before\\noperations on the eyeball, and painful applications to the palpebral\\nconjunctiva. For the former, a freshly made 2 per cent, solution\\nof perfectly pure hydrochlorate of cocaine in freshly boiled distilled\\nwater is the safest preparation but gelatine disks of the pure salt,\\nif free from hygroscopic tendency, may be safely used. Solutions\\nin oil or vaseline are uncleanly and not suitable for surgical purposes.\\nWatery solutions of cocaine should be used quite fresh even if made\\nwith boric acid or camphor water they often, if kept, grow fungi,\\nand are then unsafe. Cocaine if too freely used causes dryness,\\nloosening, and even separation of the corneal epithelium the desic\u00c2\u00ac\\ncation of the corneal epithelium is said to occur in direct proportion\\nto the frequency of use of the cocaine, and of exposure of the cornea\\nto the air, rather than to the strength of the solution employed.\\nNot more than three applications need be made, within five minutes,\\nbefore operations for cataract, etc. Cocaine has been accused of pro-\\nducing glaucoma, but, as far as the few recorded cases show, without\\nmuch reason. For deadening granular lids, or similar conditions,\\na much stronger solution must be painted over the affected surface\\n(I use a 20 per cent, solution or the solid salt). For small tumors\\nabout the lid, etc., a 1 or 2 per cent, solution is injected in different\\ndirections at the base of the growth.\\nIf the eye be congested or inflamed cocaine acts much less perfectly\\non the conjunctiva; but it acts as well upon an ulcerated as upon a\\nhealthy cornea. As the cocaine takes effect only on the part which\\nit touches, the solution must be made to flow all over the cornea and\\nconjunctiva; and as it penetrates little, if at all, it must be injected\\nunder the conjunctiva if we wish to render the later (tenotomy)", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0533.jp2"}, "534": {"fulltext": "520\\nAPPENDIX.\\nstage of a squint operation painless, or to excise the eyeball under\\nits influence. Cocaine as ordinarily used does not seem greatly to\\naffect the sensibility of the iris injection into the anterior chamber\\nfor this purpose is not practicable even if safe.\\nCocaine is used in acute iritis in conj unction with atropine, with the\\nidea that it will assist the anodyne and mydriatic effects of the latter.\\nMy own experience does not enable me to speak strongly on this\\npoint.\\nFaintness and other signs of nervous depression have been reported\\nas due to cocaine, even when used to the eye alone. I believe that\\nthese symptoms are generally due to reaction after the mental strain\\nattending an operation of which the patient is conscious; for before\\ncocaine was used we were familiar with the occurrence of faintness\\nand vomiting from time to time when eye operations had been under\u00c2\u00ac\\ngone without antestliesia.\\nMydriatics and Myotics:\\n33. 1 Strong Atropine Drops:\\nSulphate of Atropine gr. iv,\\nDistilled Water jjj.\\nUsed in cases where the rapid and full local action of the drug is\\nrequired. For many purposes atropine drops may be used consider\u00c2\u00ac\\nably weaker than the above. Atropine (a single drop, of 2 grains\\nto Jj, or about 0.5 per cent.) begins to dilate the pupil in about\\nfifteen minutes, and to paralyze the accommodation a few minutes\\nlater; it produces wide dilatation of the pupil (8 to 9 mm.) in thirty\\nto forty minutes, and full paralysis of accommodation in about two\\nhours. Both remain at their height for twenty-four hours, and the\\neffect does not pass off entirely till from three to seven days, the ac\u00c2\u00ac\\ncommodation recovering rather sooner than the pupil. If stronger\\nsolutions be used several times, the action continues longer. The\\neffects of atropine are only very temporarily and imperfectly over\u00c2\u00ac\\ncome by eserine. Atropine slightly lowers the tension of the\\nhealthy eye, but usually increases the tension in glaucoma.\\n2 Weak Atropine Drops:\\nSulphate of Atropine gr. to\\nDistilled Water 5 j.\\nUsed when, for optical purposes, it is desired to keep the pupil\\ndilated for a long time, as in immature nuclear cataract. A single\\ndrop about three times a week will generally suffice. Very weak\\natropine acts more on the pupil than on the accommodation.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0534.jp2"}, "535": {"fulltext": "APPENDIX.\\n521\\nSolutions of sulphate of atropine keep for an indefinite time;\\nthe flocculent sediment which often forms does not impair their\\nefficiency. The mydriatics and myotics may be used in the form of\\nointment with vaseline; a smaller percentage of the drug is then\\nnecessary, and toxic effects are less likely to follow; the alkaloids\\nthemselves must be used, their salts not being soluble in fats and\\noils.\\n(3) Ung. Atropince:\\nAtropine (Alkaloid) gr. iv,\\nPure Vaseline ^j.\\nThis ointment is needlessly strong for most purposes; 1 grain to 1\\nounce is usually enough.\\n(4) Lamella Atropina (B P. 1885) gr. in each.\\n34. Scopolamine:\\nScopolamine Hydrobromate gr. to gr. 1.\\nPure Vaseline ^j.\\nThis is a powerful mydriatic, and may be used where atropine is\\nnot tolerated; it is more powerful than the latter, and does not pro\u00c2\u00ac\\nduce local irritation so readily.\\n35. Tropacocaine. \u00e2\u0080\u0094A 3 per cent solution in normal saline solu\u00c2\u00ac\\ntion is used for anaesthesia of the cornea; its effect begins more rap\u00c2\u00ac\\nidly and lasts longer than that of cocaine, and it said to be less toxic\\nit does not produce mydriasis as a rule.\\n36. Daturine:\\nSulphate of Daturine gr. iv,\\nDistilled Water ^j.\\nUsed as a mydriatic in cases where atropine causes conjunctival\\nirritation.\\n37. Duboisine:\\nSulphate of Duboisine gr. j,\\nDistilled Water 5 j.\\nA mydriatic, acting more quickly and powerfully, and passing off\\nin a shorter time, than atropine. It is tolerated in cases where\\natropine causes conjunctivitis. To be used with caution, as well-\\nmarked toxic symptoms are sometimes caused.\\nDuboisine begins to act on the pupil and accommodation in less\\nthan ten minutes, produces full mydriasis in less than twenty min\u00c2\u00ac\\nutes, and complete cycloplegia in about one hour The maximum\\neffect does not last quite so long as, and the effect passes off com\u00c2\u00ac\\npletely rather sooner than, that of atropine. Duboisine seldom breaks", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0535.jp2"}, "536": {"fulltext": "522\\nAPPENDIX.\\ndown iritic adhesions which have already resisted atropine. Its chief\\nuse seems to be for cases in which atropine causes irritation.\\n38. Holocaine has been employed of late in 1-per-cent, solution\\nas a substitute for cocaine. It possesses the advantage of not enlarg\u00c2\u00ac\\ning the pupil nor of affecting the ciliary muscle, and lias decided\\nbactericidal properties.\\n39. Eucain hydrochlorate in a 2-per-cent, solution, is an active\\nlocal anaesthetic, but possesses the disadvantage of exciting a sharp?\\nstinging sensation, which persists for some minutes after its instilla\u00c2\u00ac\\ntion.\\n40. Ilomatropine:\\nHydrobromate of Homatropine gr. iv,\\nDistilled water ^j.\\nA mydriatic, acting rather more quickly and passing off much\\nsooner than atropine; very convenient, therefore, for dilating the\\npupil for ophthalmocopic examination.\\nHomatropine begins to act on the pupil and accommodation in\\nfrom five to fifteen minutes; the greatest dilatation of pupil (usually,\\nhowever, rather less than that obtained by atropine) is reached in\\nabout fifty minutes, and complete or nearly complete cycloplegia in\\nan hour or rather less (with the solution of gr. iv to The full\\neffect is only maintained, however, for an hour, more or less, and\\nboth pupil and accommodation usually recover completely in twenty-\\nfour hours or less. Its action is quicker and rather more powerful\\nif it be used with cocain, 2 per cent, of each in distilled water.\\nHomatropine Hydrobromate 1\\nDistilled Water 40.\\nA solution of this strength is much used to produce paralysis of\\nthe accommodation for the measurement of refraction. A drop\\nshould be distilled every five minutes until 4 or 5 drops have been\\napplied, and the refraction measured at the end of one hour.]\\nFor producing rapid but brief paralysis of Acc. (in ametropia) a\\nsolution containing 2 per cent, of cocaine and 2 per cent, of homatro\u00c2\u00ac\\npine is recommended by Mr. Lang, and is convenient in suitable\\ncases; the maximum effect is gained in from twenty to sixty min\u00c2\u00ac\\nutes, but soon begins to decline.\\n41. Eserine (Physostigmine) (Alkaloid of Calabar Bean):\\n(1) Sulphate of Eserine, gr. iv\\nDistilled Water, 5", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0536.jp2"}, "537": {"fulltext": "APPENDIX.\\n523\\nUsed in mydriasis and paralysis of the accommodation, whether\\ncaused by atropine or by nerve lesions, in some forms of corneal\\nulcer, and in acute glaucoma.\\n(2) A weaker solution (gr. j to 3 j) is often better\\nborne.\\nEserine begins to contract the pupil and cause spasm of the ac\u00c2\u00ac\\ncommodation in about five minutes; its maximum effect is reached\\nin twenty to forty-five minutes. Its full effect on the accommoda\u00c2\u00ac\\ntion lasts only an hour or two, but the pupil does not completely\\nrecover for many hours, sometimes two or three days. A very weak\\nsolution acts more on the pupil than on the accommodation. Ese\u00c2\u00ac\\nrine causes pain in the eye and head, arterial ciliary congestion, and\\ntwitching of the orbicularis; the pain, sometimes severe, seldom lasts\\nlong. Eserine lessens the tension in primary glaucoma; its effect is\\nincreased in this disease if used with cocaine, on account of the con\u00c2\u00ac\\ntraction of the ciliary arteries brought about by the latter.\\n(3) Lamellce Physostigmince (B. P. 1885) gr. xoVo i n eac h.\\nAll the mydriatics and myotics may be obtained in the form of\\nsmall gelatine disks of known strength (made by Savory and Moore,\\nand by Martindale), which are sometimes more convenient than the\\nsolutions. Of the mydriatics, homatropine, scopolamine, and duboi\u00c2\u00ac\\nsine are much the most expensive.\\n42. Belladonna Fomentations:\\nExtract of Belladonna 3 j to 3 ij,\\nWater Oj.\\nWarmed in a cup or small basin and used as a hot fomentation in\\nsuppurating and serpiginous ulcers of cornea.\\n43. Pilocarpine for Subcutaneous Injections:\\nHy dry chlorate of Pilocarpine gr v,\\nDistilled Water \u00c2\u00a3j.\\nDose, TTtiij, gradually increased, to be injected daily or less often.\\nUsed in cases of retinal detachment, choroiditis, and retinitis.\\n44. Pilocarpine Drops gr. iv to 5 J*.\\nPilocarpine is a myotic like eserine, but its action is much\\nweaker.\\n45. Fluorescine for staining the cornea.\\nFluorescine 2 per cent.,\\nBicarbonate of Soda 3 per cent., in distilled water.\\nA drop placed between the lids will stain the cornea where its", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0537.jp2"}, "538": {"fulltext": "524\\nAPPENDIX.\\ncovering epithelium is imperfect. A drop of cocaine used after the\\nfluorescine precipitates it and makes the staining more obvious.\\n46. Jequirity\u00e2\u0080\u009d seeds, obtained from a leguminous plant, are\\nused in South America for the cure of granular lids (p. 120). They\\ncan now be readily obtained in moderately fine powder. The infu\u00c2\u00ac\\nsion is made by soaking the powder in cold water for a couple of\\nhours, or better in water at 120\u00c2\u00b0 F., allowing it to stand till cool,\\nand straining through muslin; it is then ready for use, but will re\u00c2\u00ac\\nmain active for several days. When obviously decomposed (foetid)\\nit is no longer active. The simple powder dusted into the con\u00c2\u00ac\\njunctiva is said to be active, but two or three trials which I made\\nwith it were negative.\\nThe action of jequirity probably depends upon a nitrogenous\\nferment, not as was for a time believed upon a specific microbe. A\\nsubstance possessing the peculiar properties of the natural seed has\\nbeen separated by more than one experimenter, but does not appear\\nto be procurable in the market; it is difficult to make, and its com\u00c2\u00ac\\nposition seems to vary.\\nAs the intensity of action of jequirity infusions of the same\\nstrength varies very much in different persons, and is sometimes\\nvery severe, it is best to use a weak preparation (1 grain of powder\\nin 100 grains of water, or ^j to fl. xijss) for all cases at first. A\\nsingle prolonged application or several applications, within a few\\nminutes to the everted lids will suffice.\\n47. The infusion of extract of suprarenal capsules\\npossesses marked vaso-constrictor properties, and is of great service\\nin operations upon the ocular muscles in forestalling any hemor\u00c2\u00ac\\nrhage that might obstruct the field of operation. When applied\\nlocally for either therapeutic or operative purposes, it should always\\nbe preceded by a 5-per-cent, solution of cocaine, so as to secure the\\ncombined ansesthetic and enhanced effects of the cocaine and ex\u00c2\u00ac\\ntract. The astringent action of the extract begins in from thirty\\nto forty seconds, and lasts from one-half to three hours. As the\\nextract undergoes putrefactive changes very quickly, it should be\\nfreshly prepared. Vansant recommends the following solution 5\\ngrains of the capsule, 11 grains of boric acid, and ounce each of\\ncamphor and distilled water, then filter.\\n48. Subconjunctival Injections.\\nInjections beneath the conjunctiva of a solution of corrosive sub\u00c2\u00ac\\nlimate or of normal salt solution have been practised during recent", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0538.jp2"}, "539": {"fulltext": "APPENDIX.\\n525\\nyears by a number of eye surgeons, more particularly by French\\nophthalmologists. The method of procedure is as follows After\\ntwo preliminary instillations of a 2-per-cent, solution of cocaine\\ninto the conjunctival sac, of a milligramme of corrosive subli\u00c2\u00ac\\nmate, with 5 milligrammes of cocaine hydrochlorate, is injected by\\nmeans of a Pravaz syringe beneath the conjunctiva. The injection\\nis followed by pain and by marked congestion and swelling of the\\nconjunctiva, the latter symptom not usually disappearing until after\\nseveral days. These injections have been employed in all forms of\\ncorneal ulceration, in scleritis, irido-cyclitis, and choroiditis and\\nretinitis, but the results obtained from them are uncertain, except in\\nprogressive corneal ulcers, where they seem to exercise a marked\\nbeneficial action.\\n49. Leeching.\\nBlood may be withdrawn from the eye either by the application\\nof one or more leeches to the temple, or by the use of an instrument\\nnamed the artificial leech of Heurteloup. This apparatus consists\\nof a sharp rotary drill for incising the skin, and a suction cupping-\\nglass. If the natural leech be applied, it should be floated in water\\nin a test-tube and brought in contact with the skin of the temple.\\nLeeching is particularly serviceable in combating inflammations of\\nthe iris and of various deep-seated affections.\\n50. Compresses.\\nHeat and cold may be applied in either a moist or a dry form. A\\ngreater penetrating action is usually derived from the moist com\u00c2\u00ac\\npress, whether it be hot or cold and in addition it possesses the\\ngreater advantage of washing away all secretions from the conjunc\u00c2\u00ac\\ntival sac.\\nThe most effective manner of applying moist cold is by means of\\nthe ice compress. This is prepared as follows: Several pads of\\ngauze of three or four thicknesses, about the size of a silver dollar,\\nare laid on a block of ice. The ice should be suspended in a re\u00c2\u00ac\\nceptacle with perforations in its bottom, which will permit the water\\nand any secretion from the compress to drain into a jar beneath it.\\nAn ordinary kitchen cullender and wash-basin will answer very\\nwell for this apparatus. One of the pads is taken from the ice as\\nsoon as it has been saturated and is applied to the closed lids; it\\nshould be removed in a few moments and another one substituted for\\nit. Compresses of absorbent cotton which have been soaked in\\nice-water may also be used; they should be squeezed out sufficiently", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0539.jp2"}, "540": {"fulltext": "526\\nAPPENDIX.\\nto prevent any of the water trickling over the patient\u00e2\u0080\u0099s face and\\nneck. Cold may also be applied by means of the ordinary douche,\\nor by holding a small cake of ice directly to the eye; but these\\nshould be discarded for the compress, as they can only be used inter\u00c2\u00ac\\nmittently.\\nDry cold is usually applied by placing a bladder or a small ice-\\nbag filled with cracked ice directly over the lids; or a similar effect\\nmay be gained by passing a cold stream through a coil of tubing\\nwhich has been moulded to conform to the shape of the globe. Both\\nof these methods have the objection of making more or less pressure\\nupon a sensitive organ, of being less active than the moist form of\\napplication, and of not washing away the secretions.\\nMoist Heat. Hot compresses consist in several thicknesses of\\ngauze, which have been saturated in very hot water, and then\\napplied to the eye as hot as they can be borne. The same effect may\\nbe gained by placing upon the eye little muslin bags filled with\\ncamomile flowers, which have been dipped in boiling water. The\\ncontinuous application of moist heat is best accomplished by pre\u00c2\u00ac\\nparing a poultice of ground slippery-elm bark, or by bandaging a\\nhot saturated compress of spongiopiline to the eye.\\nDry Heat. This is well applied either in the form of a hot-water\\nbag or by packing a pad of heated flannel or absorbent wool into the\\nhollow over the eye and holding it in place with a flannel bandage.\\nThese compresses should be as hot as the patient can bear, and care\\nshould be exercised that they do not make too much pressure on the\\nglobe.\\nAs the prolonged action of either heat or cold is likely to excoriate\\nthe skin of the lids, it is well to keep the region about the eye\\nanointed with sweet oil or vaseline. It is also important to remem\u00c2\u00ac\\nber that the intermittent action of both agents is injurious to the\\neye, so that the attendant should be charged that the compress be\\nchanged every few minutes during the time of application.\\n51. Bandages for the eyes may be of thin flannel or soft calico.\\nA linen or cotton bandage, about ten inches long, with four tails of\\ntape, or a loop of tape embracing the back of the head (Liebreich\u00e2\u0080\u0099s\\nbandage), is very convenient after the more serious operations. An\\nordinary narrow flannel bandage is better when much pressure is\\nwanted, or if the patient be unruly. The soft, elastic, woven\\nbandage, known as the Leicester bandage, is even pleasanter than\\nflannel.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0540.jp2"}, "541": {"fulltext": "APPENDIX.\\n527\\nWhen absolute exclusion of light is desired, it is best to use a\\nbandage made of a double fold of some thin black material.\\nFine old linen is better than lint for laying next the skin in\\ndressings after operation.\\nThe Moor field s\u00e2\u0080\u0099 eye bandage is made of a double fold of linen,\\nseven or eight inches in length and three in breadth. It may be\\ndescribed as consisting of two squares joined together by a narrower\\nstrip, which fits like a spectacle-frame over the bridge of the nose.\\nThe four tapes are arranged so as to form two loops, into which the\\nears fit when the bandage is applied; these loops terminate in free\\nFig. 184.\\nends, which are crossed behind the head, brought forward, and tied\\nin a knot over the forehead.\\n52. Shades.\\nAs a rule, the shade should be large enough to cover both eyes,\\nand should be made of some dark material, either green or black,\\nand as they are readily soiled, they should be inexpensive, to per\u00c2\u00ac\\nmit of their being frequently renewed. Olive-green pasteboard or\\nstout packing-paper answers the purpose admirably. A serviceable\\npattern, as shown in Figure 185, is so arranged that it fits the bridge\\nof the nose. The band which encircles the head should also be of\\npaper, about an inch and a half broad, and attached to the shield\\nby oblique notches on its upper edge.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0541.jp2"}, "542": {"fulltext": "528\\nAPPENDIX.\\nFig. 185.\\nPaper shade: A, completed shade, which consists of a, the shield D, the\\nband. The dotted line Cis an alternate shape; B, band enlarged, showing\\noblique slit.\\n53. Protective Glasses.\\nVarious patterns of glasses are made for the purpose of protecting\\nthe eyes from wind, dust, and bright light. The glasses are either\\nflat, or hollow like a watch-glass, and are colored in various shades\\nof blue or smoke tint. The most effectual are the ones known as\\n\u00e2\u0080\u009cgogglesin these the space between the glass and the edge of the\\norbit is filled by a carefully fitting framework of fine wire gauze or\\nblack crape, by which side wind and light are excluded. A small\\nair-pad of thin India-rubber tubing makes the frame fit still more\\nclosely.\\nThe spectacles ordinarily worn to protect the eyes from light are\\ndesignated as coquilles, referring to their concave shape. They are\\nprovided, as a rule, with a non-refracting lens, of a neutral smoked\\ntint of medium intensity. As many of the glasses are imperfect and\\nhave considerable refractive power, care should always be employed\\nin their selection, to avoid irritation of the eyes from their use.\\n54. Artificial Eyes.\\nThese are best made of glass; those manufactured from celluloid\\npossess a less natural appearance and soon corrode and set up irri-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0542.jp2"}, "543": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0543.jp2"}, "544": {"fulltext": "Y P N v\\nC_|\\no\\n3\\nQ\\n\u00c2\u00a33\\n3\\ncc\\nH\\nO\\na\\nM\\n7\\no\\no\\ncr\\na\\nCD\\nCD\\nH\\nm\\nH\\nr\\nm\\nH\\nH\\nn\\n3\\n0)\\n2\\n0\\nn\\n0\\nm\\nH\\n5\\no\\nr\\nD\\n33\\n0\\n0\\nJO\\nn\\no\\nz", "height": "2828", "width": "7341", "jp2-path": "diseasesofeye00nett_0_0544.jp2"}, "545": {"fulltext": "APPENDIX.\\n529\\ntation. An artificial eye should always be removed at night,\\nwashed, dried, and placed in a safe place. All eyes create more or\\nless irritation of the mucous membrane of the orbit, but a small\\namount of vaseline introduced into the orbit will make the move-\\nFig. 186.\\nArtificial human eyes\\nments of the eye much easier and reduce the wear and tear to some\\nextent.\\nThe following are the rules adopted by the authorities of the\\nMoorfields Hospital, London, for the guidance of patients wearing\\nan artificial eye:\\n\u00e2\u0080\u009cTo take the eye out: The lower lid must be drawn downward\\nwith the middle finger of the left hand; and then, with the right\\nhand, the end of a small bodkin must be put beneath the lower edge\\nof the artificial eye, which must be raised gently forward over the\\nlower eyelid, when it will readily drop out. At this time care\\nmust be taken that the eye does not fall on the ground or other\\nhard place, as it is very brittle, and may easily be broken by a\\nfall.\\nTo put the eye in: Place the left hand flat upon the forehead,\\nand with the two middle fingers raise the upper eyelid toward the\\neyebrow then, with the right hand, push the upper edge of the\\nartificial eye beneath the upper lid, which may be allowed to drop\\nupon the eye. The eye must then be supported with the middle\\nfingers of the left hand, whilst the lower eyelid is raised over its\\nlower edge with the right hand.\u00e2\u0080\u009d\\n55. Test Types.\\nSnellen\u00e2\u0080\u0099s types for testing both near and distant vision under an\\nangle of five minutes may be obtained from any optician. A con\u00c2\u00ac\\nvenient bracket (Fig. 187) for this display of the distant type,\\ndevised by Dr. Thorington, may be obtained from Wall Ochs, of\\nPhiladelphia.\\n34", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0545.jp2"}, "546": {"fulltext": "530\\nAPPENDIX.\\nA convenient set of tests, small enough to be carried in the pocket,\\ncan be obtained through Queen Co., Philadelphia. It consists of\\ntypes for near and distant vision, a pupillometer for measuring the\\npupil, a set of colored stuffs for color-blindness, and a small series\\nof lenses for testing refraction. This case is intended chiefly for\\nFig. 187.\\nward work and general medical cases. It may also be bought with\u00c2\u00ac\\nout the lenses.\\n56. Ophthalmoscopes.\\nThe ophthalmoscopes usually employed in this country are the\\nLoring and the Morton.\\nThe Loring Ophthalmoscope. This instrument consists of a full\\ndisk and a quadrant of a disk, as shown in Fig. 188. The quadrant\\nrotates immediately over the disk and around the same centre, and\\ncontains 4 lenses, \u00e2\u0080\u0094.50 and \u00e2\u0080\u009416, and -J-.50 and -f- 16. When not in\\nuse the quadrant is beneath its cover, and the instrument then rep\u00c2\u00ac\\nresents a simple ophthalmoscope with 16 lenses, the series running\\nwith an interval of 1 D., and extending from 1 to 7 plus and from", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0546.jp2"}, "547": {"fulltext": "PLATE V.\\ni\\nII a.\\nII b.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0547.jp2"}, "548": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0548.jp2"}, "549": {"fulltext": "APPENDIX.\\n531\\n1 to 8 minus. If the higher numbers are desired, they are obtained\\nby combination with those of the quadrant. These progress regu\u00c2\u00ac\\nlarly up to 16 D., every dioptric being marked upon the disk; above\\nFig. 188.\\nThe Loring ophthalmoscope.\\nthis up to 23 D. and 24 D. it is necessary to add the glass which\\ncomes beneath the 16 D., turning always in the same direction.\\nThe Morton Ophthalmoscope. This instrument consists essentially", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0549.jp2"}, "550": {"fulltext": "532\\nAPPENDIX.\\nof 29 separate lenses, inclosed in an endless groove and propelled by\\na strong driving-wheel. In addition to the lenses just mentioned,\\nFtg. 189.\\nThe Morton ophthalmoscope.\\nare four others, set in a separate disk, and so placed tliat they can be\\ninstantly put in front of, or removed away from, the sight-hole\\nwithout rotating the whole series of convex or concave lenses. At", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0550.jp2"}, "551": {"fulltext": "APPENDIX.\\n533\\nthe same time that the driving-wheel propels the lenses it rotates a\\ndisk, on which at a certain aperture is indicated the lens presented\\nat the sight-hole. On the front of the instrument is an arrangement\\nsimilar to the nose-piece of a microscope, revolving on a central\\npivot and carrying three mirrors\u00e2\u0080\u0094one plane and one concave mirror\\nof 10-inch focus at one end, and a small concave mirror of 3-inch\\nfocus at the other. The first two, which are set back to back in one\\nmounting and are reversible, are for indirect examination and reti-\\nnoscopy. The advantages claimed for this ophthalmoscope are\\nbriefly 1. A continuous series of single lenses sufficient for all ordi\u00c2\u00ac\\nnary purposes. 2. The provision of a few separate, easily adjust\u00c2\u00ac\\nable lenses for extraordinary cases. 3. The lens in the sight-hole\\nis always shown on the indicating disk (except in the rare cases\\nin which one of the extra lenses just mentioned is used). 4. The\\nnumbers of the lenses and their relative positions being fully ex\u00c2\u00ac\\nposed on an indicating disk, the direction in which this latter has to\\nbe rotated to bring any particular lens to the sight-hole is at once\\nmade manifest. 5. There is only one driving-wheel. 6. A pupil-\\nmeter, which is set in the face of the driving-wheel. 7. The pro\u00c2\u00ac\\nvision of two mirrors revolving on a central pivot, so that either can\\nbe at once brought into position. 8. The width of the instrument\\nis only 1J inches, while the driving-wheel, being 3 inches below the\\nsight-hole, is unimpeded in its action by contact with the face of\\nthe observer or patient. 9. Lastly, the instrument balances well in\\nthe hand, is light, and packs into a small compass.\\n57. Perimeters.\\nThe McHardy Perimeter. This instrument, which is undoubtedly\\nthe most complete and accurate perimeter in use, consists of a quad\u00c2\u00ac\\nrant of 30 m. radius and 75 mm. wide. This quadrant is divided\\ninto single degrees, and carries a movable slide or carriage, which\\nis connected by clock cord to a series of pulleys. These are set in\\nmotion by a train of gear-wheels so arranged as to move a pin in\\nproportionate ratio to the motion of the slide on the quadrant.\\nThe chart is clamped in a neat holder, which is pressed against the\\npin, the range of vision being registered in each meridian. The\\nmeridian is indicated by a pointer fixed to the disk in the centre of\\nthe instrument, which is divided into five degrees. The stand holds\\nan upright bar, on which are the chin- and eye-rests; these are used\\nto keep the patient\u00e2\u0080\u0099s face and eye in a steady position, the chin-rest\\nhaving a vertical adjustment.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0551.jp2"}, "552": {"fulltext": "534\\nAPPENDIX.\\nFig. 191.\\njffi\\nIji\\njjj\\njjn\\nill\\n111\\nIII III\\nill\\nMcHardy perimeter.\\nAnother excellent and much cheaper instrument is the Meyrowitz.\\nThis instrument combines the most practical points of the Landolt\\nand the Priestley-Smith perimeters. It is light and well balanced,\\nand has the broad metal arc, with the sliding object-carrier of the\\nLandolt and the registering attachment of the Priestley Smith\\ninstrument. It has an adjustable double chin-rest, sliding upon an\\nupright bar, the end of which carries a rubber plate and determines\\nthe point of fixation. The chart is fitted to a hard rubber disk at\\nthe back of the instrument and is revolved with the arc. A sta\u00c2\u00ac\\ntionary scale, mounted upon an upright arm, is graduated to corre\u00c2\u00ac\\nspond to the divisions of the arc, and is placed immediately back\\nof the disk holding the chart. By means of this ingenious combi-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0552.jp2"}, "553": {"fulltext": "APPENDIX.\\n535\\nnation the exact position of the object point upon the arc and the\\nFig. 192.\\nAstigmatic dial.\\nmeridian of the arc itself may be pricked upon the chart by a single\\npuncture.\\n58. Type for ascertaining the range of accommodation (Wall\\nOchs).", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0553.jp2"}, "554": {"fulltext": "REQUIREMENTS OF CANDIDATES FOR ADMIS\u00c2\u00ac\\nSION INTO THE PUBLIC SERVICES IN\\nTHE UNITED STATES OF AMERICA.\\nCommission in the Army. The line corps of the army is recruited\\nfrom the Military Academy at West Point, N. Y., where at entrance\\nas well as at graduation the vision, as determined by the official test\\ntypes, must not fall below in either eye, and not below unless\\nit can be made normal by proper glasses. Color blindness is not a\\ncause for rejection, but must be noted upon the form for physical\\nexamination and the applicant so informed.\\nFor admission into the medical corps of the army, errors of refrac\u00c2\u00ac\\ntion, when not excessive and not accompanied by ocular disease, and\\nwhen correctable by appropriate glasses, are not causes for rejection.\\nRecruiting officers are guided in the examination of applicants\\nfor enlistment into the ranks of the United States Army by Tripler\u00e2\u0080\u0099s\\nManual. As specified in an epitome of this work, prepared by\\nMajor Charles R. Greenleaf, the following ocular defects are noted\\nas causes for absolute rejection:\\nLoss of either eye.\\nChronic inflammation of the lids, which may be known by their\\nbeing red and swollen, with collections of more or less dried matter\\non the edges between and around the lashes; the ball of the eye\\nwill also be \u00e2\u0080\u009cbloodshot.\u00e2\u0080\u009d\\nInability to count with facility, at twenty feet distance, the black\\nspots on the test cards. This examination requires the greatest care\\nand patience on the part of the recruiting officer it is made with\\ntest cards, ten in number, with black spots arranged like those on\\nplaying-cards, and ranging from 1 to 10 on each card. The spots\\nare circular, and each four-tenths of an inch in diameter.\u00e2\u0080\u009d The\\nrecruit must be able to count them with facility at twenty feet dis\u00c2\u00ac\\ntance. Each dot presents the same appearance, when seen by the\\nnormal eye at this distance, as a black centre three feet in diameter\\non a white ground at six hundred yards\u00e2\u0080\u0099 distance. To use these\\ncards, measure off a line twenty feet long on the floor of a well-\\n(536)", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0554.jp2"}, "555": {"fulltext": "APPENDIX.\\n537\\nlighted room. Stand the recruit with his toes at one extremity of\\nthe line. Let an assistant, holding the pack of cards in his hands,\\nstand with his toes r.t the other extremity of the line and expose\\nsuccessively the faces of two or three of the cards. The recruit\\nmust be able to state promptly the number of dots on each. This\\nexamination must be made with each eye separately. The exami\u00c2\u00ac\\nnation may be varied, by showing to the recruit one of the higher\\nnumbers, such as the nine or ten card, and covering up a part of its\\nface with another card so as to expose one or more spots at a time.\\nThe \u00e2\u0080\u009cassistant\u00e2\u0080\u009d in this case should be the recruiting-officer; and\\nthe sergeant should stand behind the recruit, covering one eye com\u00c2\u00ac\\npletely with a card. It is a custom to cover the eye with the hand\\nthis is very objectionable, because, unconsciously, more or less press\u00c2\u00ac\\nure is made upon the organ, and such a sense of discomfort, as well\\nas disorder in the circulation, produced that clearness of vision\\nwhen the eye is uncovered is much interfered with or, a designing\\nman may take advantage of an opening between the fingers of the\\nhand placed over his eye to see to read the cards, while the other\\neye may be totally defective. The applicant should stand with his\\nface to the light, because in this position the iris is contracted and\\nthe pupil becomes so small that any defect of the cornea (or glass\\nof the eye), which may be situated directly in front of the pupil,\\nwill so interfere with vision as to be discovered. If the light falls\\nfrom behind the applicant, or he is in shadow, the iris is relaxed and\\nthe pupil dilates sufficiently to allow the rays of light to enter the\\neyes by the side of a defect, and vision seems to be perfect, while in\\nreality it may be very imperfect. There is often considerable hesi\u00c2\u00ac\\ntation on the part of the applicant in counting the spots, which may\\nbe due to ignorance, and some of the low numbers should be pre\u00c2\u00ac\\nsented to him. It is better to begin the examination with the right\\neye, and the spots on at least six cards should be counted without\\nhesitation before it can be considered satisfactory failing in this, the\\napplicant should be rejected.\\nProminence of the eyeballs to such an extent as to prevent tlve\\nlids from closing (exophthalmos); drooping of the upper lids over\\nthe eyeballs, with inability to raise them (ptosis) adhesion of the\\nlids to the eyeballs scalding of the cheeks from tears, indicating\\nclosure of the tear-duct; cross-eye, or squint of the right eye, if\\npermanent or well-marked (strabismus): are all causes for disqualifi\u00c2\u00ac\\ncation.\\nThe following defects, if discovered, should be noted on the en-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0555.jp2"}, "556": {"fulltext": "538\\nAPPENDIX.\\nlistment papers of the recruit by the recruiting officer, and the\\nquestion of rejection left to the decision of the surgeon at the depot.\\nA film across the white of the eye, pyramidal in shape, the base\\nresting on or near the \u00e2\u0080\u009csight\u00e2\u0080\u009d (pterygium).\\nMilky opacities on the cornea (leucoma).\\nWavering and divergence, generally outward, of one or both eyes\\nwhen the applicant is required to look steadily at an object, say the\\nhand or fingers, held at a distance of six or eight inches from the\\nface (asthenopia).\\nA rotary or oscillating movement of one or both eyes when look\u00c2\u00ac\\ning at an object at the ordinary visual distance (nystagmus); both\\neyes are generally affected, and the nervous character of the disease\\nis shown by the increased motion during the examination.\\nDouble vision, or that condition of sight in which two images\\ninstead of one are seen when the applicant is required to look stead\u00c2\u00ac\\nily at an object (diplopia).\\nCommission in the Navy. The line corps of the navy is recruited from\\nthe Naval Academy at Annapolis, Md., where a vision below in\\neither eye is a cause for rejection. No correcting lenses may be worn\\nat the time of the test. Normal color-perception is essential. At\\ngraduation the standard for acuteness of vision is the same as at\\nentrance, and no correcting lenses are allowable.\\nVisual acuity is obtained by means of the Snellen test-types, and\\nthe Holmgren method is used for testing the color-sense.\\nMerchant Marine Masters Mates, and Pilots). There are no es\u00c2\u00ac\\ntablished rules for testing eyesight of the Board of Supervising\\nInspectors other than for color-blindness, the determination of other\\ndefects and the decision regarding the proper qualifications of each\\ncandidate being at the discretion of the local inspectors. It is gen\u00c2\u00ac\\nerally understood, however, although not rigidly insisted upon, that\\nin addition to normal color-perception, which is tested by Holmgren\u00e2\u0080\u0099s\\nskeins, there must be a visual acuity in each eye of as obtained\\nby the Snellen test-types.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0556.jp2"}, "557": {"fulltext": "METHOD OF EXAMINING THE EYES OF\\nSCHOLARS IN THE PUBLIC SCHOOLS\\nIN CERTAIN AMERICAN CITIES 1\\nThe actual tests in this method are made by the principals and\\nteachers in the various schools, upon account of the impossibility\\nof securing, as yet, the appointment of properly equipped medical\\nmen for this purpose. There should, however, be a supervisor, a\\ntrained oculist, with a competent corps of assistants, to whom all\\ndoubtful cases should be referred. He should also instruct the teach\u00c2\u00ac\\ners regarding the manner in which they should make the tests, and\\nshould explain to them briefly the salient points of ocular hygiene.\\nThe eyes of all the children should be tested at the commence\u00c2\u00ac\\nment of the school term, and if the vision or range of accommoda\u00c2\u00ac\\ntion of either eye be found below the standard, or if symptoms of\\nocular fatigue be complained of, the parents or guardian should be\\nso informed, and further examination and treatment by an oculist\\ninsisted upon.\\nAll that is required for examining the eyes are two charts ot\\nSnellen test-letters, one of large letters, for determining the degree\\nof visual acuity; the other, of small type, to ascertain the power\\nof accommodation. The practical method of using these charts is\\nas follows:\\n1. To Test the Visual Acuity. Place the large letters in a good\\nlight twenty feet away from the scholar, and ascertain the lowest\\nline of letters which can be read, each eye being tested separately.\\n2. To Test the Range of Accommodation. The nearest point at\\nwhich the finest type (that marked 0.50 V.) can be read clearly with\\neach eye separately should be ascertained, and should be compared\\nwith a table printed on the back of the card, showing the proper\\nnear point for a normal eye at all ages ranging from five to twenty\\n1 This method of examination is practically the same as that introduced\\nby Dr. Frank Allport some years ago, and which is now in successful oper\u00c2\u00ac\\nation in Chicago.\\n539", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0557.jp2"}, "558": {"fulltext": "540\\nAPPENDIX.\\nyears. Brief instructions as to the manner of obtaining the accom\u00c2\u00ac\\nmodation should also be appended.\\nThe superintending oculist with his assistants should be appointed\\nby the Board of Education, and should be required to report to that\\nbody the result of the teachers\u00e2\u0080\u0099 examinations. For professional\\nreasons, great care should be exercised regarding the manner in\\nwhich the parents or guardian are told to consult an oculist, and a\\nlist of the different eye dispensaries in the same district as that in\\nwhich the pupil lives should be furnished them.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0558.jp2"}, "559": {"fulltext": "INDEX.\\nA.\\nAbbreviations, 17\\nAbduction, measurement of, 52\\nAbscess of lachrymal sac, 97\\nAccommodation, 329\\nafter blows, 322\\namplitude of, 50\\nassociation with convergence,\\n50\\nin hypermetropia, 345\\nmicropsia due to insufficiency\\nof, 281\\nparalysis of, 388\\nin presbyopia, 361\\nrelative, 51\\nrestriction of, in dental dis\u00c2\u00ac\\norders, 476\\nspasm of, 277\\nin myopia, 333\\ntests for, 50\\nAdduction, measurement of, 53\\nAdenoma of lachrymal gland, 95\\nAlbinism, 228\\nAlbuminuric retinitis, 241, 457\\nAlum, preparation of, 515\\nAmaurosis, 269\\nhysterical, 277\\nin optic atrophy, 267\\nAmblyopia, 269\\nafter blows, 278\\nalcohol in, 274, 455\\nin anisometropia, 271\\nin astigmatism, 271\\ncentral scotoma in, 273\\ncongenital, 281\\nfrom defective retinal images,\\n271\\nsuppression of image, 269\\nin dental disorders, 476\\ndouble central in, 274\\nglasses in, 271\\nin hypermetropia, 270\\nhysterical, 277\\nophthalmoscope in, 272\\nAmblyopia in strabismus, 269\\nstrychnine in, 274\\ntobacco in, 274, 455\\nAmetropia, 329\\nhysteria in, 278\\nAmplitude of accommodation, 50\\nAmyloid conjunctivitis, 121, 122\\nAnaemia a cause of blepharitis,\\n86\\nin corneal ulceration, 128\\noptic neuritis in, 261\\npernicious, progressive, 459\\nretinitis of, 244, 246\\nsecondary, 461\\nAnaesthetics, 444\\nAneurism of intra-orhital vessels,\\n326\\nAngular gyrus, disease of, lieini-\\nanopia in, 276\\nAnisometropia, 360\\namblyopia in, 271\\nAnterior chamber in glaucoma,\\n292, 294, 295, 298\\nparacentesis of, 421\\nAqueous humor, evacuation of, in\\nglaucoma, 304\\nArcus senilis, 151\\nArgyll-Robertson symptom, 472\\nArmy, visual standard in, 535\\nArtificial eyes, 528\\nAsthenopia, 278\\naccommodation, 278\\nafter accidents, 279\\nastigmatism in, 279\\ncauses of, 279\\nfifth-nerve in, 279\\nheadache in, 278\\nhypermetropia in, 279, 347\\nmuscular, 278\\nin myopia, 332\\ntreatment of, 279\\nAstigmatism, 351\\nafter blows, 183\\nextraction of cataract, 209\\noperations, 353\\n541", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0559.jp2"}, "560": {"fulltext": "542\\nINDEX.\\nAstigmatism, amblyopia in, 271\\nasthenopia in, 279\\nin cataract, 192\\ncornea in, 352\\ndetermination of, by ophalmo-\\nscope, 73\\nby shadow-test, 76, 78\\ndisk in, 355\\nfocal interval in, 352\\nimage in, 355\\nirregular, 352\\nlenses in, 355\\nlens in, 352\\nophthalmometer in measuring,\\n54\\nophthalmoscope in, 355\\nprincipal meridians in, 352\\nregular, 352\\nretinoscopy in, 355\\nsymptoms of, 354\\ntests foi\u00e2\u0080\u0099, 355\\nAtropine, 520\\naction of, 386\\nin hypermetropia, 349\\nB.\\nBacillus of Weeks, 108\\nBandages, 526\\nBasedow\u00e2\u0080\u0099s disease, 473\\nBelladonna fomentations, 523\\nBlack eye,\u00e2\u0080\u009d 321\\nBlepharitis, 85\\nafter measles, 452\\nanremia a cause of, 86\\ncauses of, 86\\nepiphora a result of, 86\\nmeasles a cause of, 86\\nscrofula a cause of, 86\\nsequel\u00c2\u00ae of, 86\\nslitting of canaliculus in, 87\\nsymptoms of, 85\\ntreatment, of, 87\\ntypes of, 85\\nBlepharospasm, 127\\nBlindness from exposure to light,\\n124\\nred-green, 284\\nBloodvessels of eyeball, 39\\nof retina, 65, 67\\nappearance of, 68\\nobstruction of, 65\\nBoric acid, 516\\nBrain, involvement of, in glioma,\\n315\\nsyphilis of, 448\\nBrain, tumors of, in ocular paraly\u00c2\u00ac\\nsis, 389\\noptic neuritis in, 260\\nBright\u00e2\u0080\u0099s disease in retinitis, 241\\nBuller\u00e2\u0080\u0099s shield, 103\\nBuphthalmos, 150\\nc.\\nCanaliculus, Bowman\u00e2\u0080\u0099s opera\u00c2\u00ac\\ntion on, 407\\nobstruction of, 96\\nslitting the, 407\\nin blepharitis, 87\\nCancer, rodent, of eyelids, 90\\ntreatment of, 92\\nCanthoplasty, 404\\nCapsulitis after extraction of\\ncataract, 208\\nCapsulo-pupillary membrane, 163\\nCarbolic-acid lotion, 517\\nCarbon, bisulphide of, 456\\nCardiac disease in retinitis, 247\\nCaruncle, after treatment of stra\u00c2\u00ac\\nbismus, 376\\npapilloma of, 311\\ntumors of, 311, 312\\nCataract, 191\\nafter choroiditis, 197\\ndisease of vitreous, 197\\nintraocular tumors, 197\\niridocyclitis, 197\\nretinitis pigmentosa, 197\\nserous cyclitis, 171\\nulceration of cornea, 196\\namblyopia after extraction of,\\n271\\nastigmatism in, 192\\nin children, 200\\nchoroiditis as a cause of, 192\\nciliary body in, 192\\ncomplicated, 197\\nconcussion, 209\\ncongenital, 193, 201\\nconsistence of, 192\\ncortical, 192, 198\\ndotted, 193\\nin detachment of retina, 197\\ndiabetes in, 191\\ndiagnosis of, 197\\ndiscission of, 203, 441\\ndrugs as a cause of, 192\\netiology of, 191\\nexamination of, by focal illumi\u00c2\u00ac\\nnation, 198\\nextraction of, 432", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0560.jp2"}, "561": {"fulltext": "INDEX.\\n543\\nCataract, extraction of, after-treat\u00c2\u00ac\\nment of, 438\\nastigmatism after, 209\\ncapsulitis after. 208\\ncauses of failure after, 206\\ncomplications during, 438\\nconical section in, 436\\ncyclitis after, 208\\ndacryo-cystitis in, 206\\ngalvano-cautery after, 207\\nglasses after, 209\\nhemorrhage after, 181, 206\\nhypermetropia after, 209\\nincarceration of iris after, 208\\niritis after, 207\\nkeratitis after, 208\\nlens in, 203\\nmembrane in pupil after, 207\\nmodified linear, 432, 434\\nby old flap method, 436\\npanophthalmitis after, 207\\npreliminary iridectomy in,\\n434\\nprolapse of iris after, 208\\nshield after, 439\\nby short flaps, 435\\nsight after, 208\\nsimple linear, 434\\nby suction, 443\\nsuppuration after, 206\\ntreatment of, 206\\nfocal illumination in, 198-200\\nfollowing injury, 209\\nfrom diabetes, 458\\nglass-blowing in, 192\\nglaucoma complicating, 197, 308\\nhard, 193\\nheredity in, 192\\nimmature nuclear, 198\\nincipient, 198\\nlamellar, 194, 200, 209\\nteeth in, 478\\nlight perception in, 198\\nloss of sight in, 198\\nmixed, 193\\nMorgagnian, 202\\nmyopia in, 198\\nnephritis in, 192\\nnuclear, 192\\noperations after, 440\\nfor, 203\\niritis in, 160\\npartial, 191\\nperception of light in, 198\\npolar, anterior, 196\\nposterior, 196, 200\\nCataract, polyopia in, 198\\nprimary, 197\\nprognosis of, 202\\nprojection of light in, 198\\npupil in, 198\\npyramidal, 195\\nrachitis in, 192, 194\\nremoval of, by curette, 204\\nby suction syringe, 204\\nsecondary, 197\\nin cyclitis, 165\\niritis in, 160\\nsenile, erythropsia after, 281\\nskin affections in, 192\\nsoft, 192\\nsymptoms of, 197\\ntraumatic, 187, 189, 210\\nglaucoma in, 210, 309\\ntreatment of, 210\\ntreatment of, 203\\nzonular, 194, 200\\nteeth in, 194\\nCatarrh of conjunctiva, 122\\nspring, 121\\nCavernous sinus, thrombosis of,\\n323\\nCellulitis of orbit, 322\\nCentral nervous system, disease\\nof, 468\\nCerebral disease, optic neuritis in,\\n255\\ntumor, papillitis in, 468\\nChalazion, 88\\ncauses of, 88\\nsymptoms of, 88\\ntreatment of, 89\\nChancre of eyelids, 92, 311, 447\\nChiasma, diseases of, hemianopia\\nin, 275\\noptic neuritis in, 261\\ntumor of, optic atrophy in,\\n267\\nChicken-pox, 452\\nChoked disk, 255, 256\\nChorea in retinitis, 247\\nChoroid, appearance of, in health,\\n214\\natrophy of, 215\\ncomplete, 218\\npartial, 218\\nsigns of, 216, 217\\nsuperficial, 218\\ncolloid disease of, 219\\ncoloboma of, 228\\ncongestion of, 227\\ndiseases of, 213", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0561.jp2"}, "562": {"fulltext": "544\\nINDEX.\\nChoroid, diseases of, after blows,\\n227\\nhemorrhage, 227\\nclinical forms of, 221\\nin myopia, 213\\noptlialmoscopic signs of, 215\\npigment in, 213\\nretina in, 213\\nin diseases of vitreous, 286\\nelastic lamina of, 220\\nhemorrhage of, 180, 182, 220\\nmiliary tuberculosis of, 219\\nin myopia, 334\\nnsevus of, 328\\npigmentation of, after albu\u00c2\u00ac\\nminuric retinitis, 227\\nin pyeemia, 454\\nrupture of, 181, 219\\nsarcoma of, 316\\nliver in, 317\\nstructure of, 214\\nsyphilis of, 227, 448\\ntubercular growths of, 227, 462\\nChoroiditis after infection, 226\\npysemia, 226\\nanomalous forms of, 226\\nanterior, 168\\natrophy of optic nerve in, 222\\ncataract after, 197\\nas a cause of cataract, 192\\ncentral senile, 224\\ndisseminata, 221, 223\\nexudation into vitreous in, 226\\nfrom meningitis, 226, 453\\nthrombosis of orbital veins,\\n226\\nhaze of vitreous in, 223\\niritis in, 160, 223\\nmetastatic, 226, 476\\nmyopia in, 223\\npanophthalmitis after, 226\\nposterior staphyloma in, 224\\npseudo-glioma after, 226\\nrecent, 218\\nin serous cyclitis, 170\\nsuppurative, 226\\nsyphilitic, 218, 222\\nTays\u00e2\u0080\u0099, 226\\ntreatment of, 223\\nChoroido-retinitis in diseases of\\nvitreous, 288\\nCilia, misplaced, 119\\ntreatment of, 121\\nelectrolysis in, 121\\nCiliary body in cataract, 192\\nin glaucoma, 300\\nCiliary body, inflammation of,\\nafter injury, 172\\nsarcoma of, 316\\nin serous cyclitis, 170\\nin sympathetic ophthalmia,\\n173\\nsyphilis of, 448\\ncongestion, 41, 153\\nin serous cyclitis, 171\\nmuscle in hypermetropia, 345\\nin myopia, 338\\nparalysis of, after blows, 182\\nnerves, 173\\nin glaucoma, 298\\nregion, 165, 167\\ndiseases of, 165\\nstaphyloma, 169\\nCircumcorneal congestion, 153\\nCocaine, 518\\naction of, 386\\nCold, 525\\nColoboma of choroid, 228\\n/fff iris, 163\\nof* lpim 910\\nColor-blindness, 283, 479\\nacquired, 283\\nconfusion colors in, 284\\ncongenital, 283\\ndetection of, 284\\nheredity in, 283\\nHolmgren\u00e2\u0080\u0099s test for, 481\\nlantern-test for, 500\\nnew wool-test for, 495\\nin optic atrophy, 265\\npartial, 283\\nThomson\u00e2\u0080\u0099s test for, 482\\ntotal, 283\\nColor perception, tests for, 57\\nsense, tests for, 487\\nCompresses, 525\\nConcave mirrow in shadow-test,\\n76, 78\\nConical cornea, 149\\nConjunctiva, 37\\nafter chicken-pox, 452\\nmeasles, 452\\namyloid disease of, 122\\nburns of, 184\\ncauliflower warts of, 31\\nchemosis of, in cellulitis of orbit,\\n322\\ncysts of, 313, 314\\ndiphtheria of, 451\\ndiseases of, 101\\nin eczema of face, 110\\neffect of electric light on, 124", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0562.jp2"}, "563": {"fulltext": "INDEX.\\n545\\nConjunctiva, epithelioma of, 314\\nin erysipelas, 110\\nexternal examination of, 37\\nfibro-fatty tumors of, 313\\nforeign bodies in, 184\\nin glaucoma, 294\\nhemorrhage from, 108\\nin whooping-cough, 453\\nin herpes zoster, 110\\nin leprosy, 466\\nlupus of, 311\\nlymphoma of, 109\\nin measles. 110\\nmoles of, 313\\npemphigus of, 123\\nin rupture of eyeball, 180\\nscalds of, 184\\nscarlet fever in, 451\\nshrinking of, 122\\nsmallpox of, 450\\nspring catarrh of, 122\\nsyphilis of, 447\\ntubercle of, 92\\ntuberculosis of, 311\\ntreatment of, 311\\nwounds of, 323\\npenetrating, 323\\nxerosis of, 124\\nConjunctivitis, 101\\nacute contagious, zinc chloride\\nin, 109\\namyloid, 121\\ncaruncle in, 121\\ncatarrhal, 107\\nacute, 107\\nchronic, 121\\ncroupous, 111\\ndiptheritic, 111\\nantitoxin in, 113\\ntreatment of, 111\\nepidemic, 108\\ntreatment of, 108\\nfollicular, 110\\nfrom drugs, 122\\nintense light, 124\\ngonorrhoeal, 464\\ngranular, 113\\nas a cause of keratitis, 132\\nenlargement of papill\u00c2\u00ae in,\\n113\\nexpression in, 117\\ngalvano-cautery in, 117\\njeguirity in, 120\\nnitrate of silver in, 117\\nopacity of cornea in, 118\\nprevention of, 116\\n35\\nConjunctivitis, granular, results\\nof, 117\\nroller forceps in, 117\\ntreatment of, 116\\nlachrymal, 121\\nmarginal, 131\\nmembranous, 111\\ncorneal ulceration in, 111\\nnodosa, 123\\nParinaud\u00e2\u0080\u0099s, 109\\npurulent, 101\\ncold applications in, 108\\ncorneal ulceration in, 103\\ngonococcus in, 101\\nto inspect cornea in, 394\\nnitrate of silver in, 105\\nprotargol in, 105\\ntreatment of, 103\\nrheumatic, 110, 463\\nsimple acute, 107\\nConstipation in diseases of vitre\u00c2\u00ac\\nous, 289\\nConvergence, accommodation as\u00c2\u00ac\\nsociated with, 50\\ninsufficiency of, in myopia, 332\\nin strabismus, 375\\nCopper, sulphate of, 514\\nCoquelles, 528\\nCoredialysis, 181\\nCornea, 42\\nabrasions of, 183\\nhypopyon in, 164\\ntreatment of, 184\\nabscess of, 134\\nafter paralysis of fifth nerve,\\n474\\nanaesthesia of, in glaucoma, 298\\nin astigmatism, 352\\nblisters on, 132\\nbullae of, 183\\nburns of, 184\\ncauterization of, 422\\nconical, 149\\nconcave glasses in, 150\\noperations for, 423\\ndetection of irregularities in\\nsurface of, 42\\nin disease of orbit, 323\\ndiseases of, 125\\neffect of quinine lotions on, 126\\nfebrile herpes of, 136\\nfluorescence of, 126\\nforeign bodies in, 183\\ndetection of, 60\\nremoval of, 420\\nin glaucoma, 292", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0563.jp2"}, "564": {"fulltext": "546\\nINDEX.\\nCornea, hypopyon ulcer of, section\\nfor, 422\\ninflammation of, 125\\ncyclitis, 143\\ndiffuse, 142\\nfilamentary, 136\\ninterstitial, 142\\nrelapses in, 146\\nresults of, 145\\ntreatment of, 146\\niritis in, 143\\nin ophthalmitis, 176\\noyster shuckers\u00e2\u0080\u0099, 137\\nparenchymatous, 142\\nsecondary glaucoma in, 146\\nto other diseases, 148\\nsuperficial punctate, 136\\nsymptoms of, 125\\nsyphilitic, 142\\ntreatment of, 137\\ninjury of, iritis in, 184\\ninspection of, in purulect con\u00c2\u00ac\\njunctivitis, 394\\ninvolvement of, in glaucoma.\\n149\\nnutrition of, 125\\nopacities of, 126\\ncongenital, 149\\nin granular conjunctivitis,\\n118\\nin myopia, 339\\nresults of, 126\\ntreatment of, 126\\ncalomel, 126\\nelectrolysis, 126\\nmassage, 126\\ntattooing, 126\\ntransplantation, 126\\nyellow oxide of mercury,\\n126\\nperforation of, secondary glau\u00c2\u00ac\\ncoma after, 308\\npunctate, deposits on back of,\\n171\\nscalds of, 184\\nsyphilis of, 448\\ntransverse calcareous film of,\\n150\\nulcers of, 125, 128\\naction of lead on, 455\\nacute infective, 133\\nserpiginous, 133\\nanaemia in, 128\\ncataract after, 196\\ncauses of, 125\\nchronic serpiginous, 132\\nCornea, ulcers of, crescentic, 132\\ndendritic creeping, 136\\nexophthalmic goitre as a cause\\nof, 136\\nin facial palsy, 474\\nfrom exposure, 136\\nin Graves\u00e2\u0080\u0099 disease, 475\\nin herpes zoster, 474\\nhypopyon in, 133\\niridectomy in, 141\\nlymphatic, 128\\nmarginal, 128\\npericorneal injection in, 127\\nphlyctenular, 128, 129\\npustular, 128, 131\\nrecurrent vascular, 131\\nrelapsing bullous, 132\\nrodent, 133\\nstrumous, 128\\ntreatment of, 137\\natropine in, 141\\ncautery in, 140\\neserine in, 141\\nheat in,139\\nincision in, 140\\nseton in, 139\\nyellow oxide of mercury in,\\n138\\nvesicles of, 136\\nwounds of, 186, 189\\nCorneal opacities, examination of.\\n58-60\\nreflex, ophthalmoscope in study\\nof, 71\\nCredo\u00e2\u0080\u0099s method of prevention of\\nophthalmia neonatorum,\\n106\\nCrus cerebri, disease of, 472\\nCyclitis after extraction of cata\u00c2\u00ac\\nract, 208\\nin corneal inflammation, 143\\nin diseases of vitreous, 289\\nwith diseases of vitreous and\\nkeratitis punctata, 170\\npurulent traumatic, 172\\nin relapsing fever, 453\\nserous, 170\\nanterior chamber in, 170\\ncataract after, 171\\nchoroiditis in, 170\\nciliary body in, 170\\ncongestion in, 171\\netiology of, 171\\nglaucoma in, 170\\ngout in, 171\\niridectomy in, 172", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0564.jp2"}, "565": {"fulltext": "INDEX.\\n547\\nCyclitis, serous, iritis in, 170\\nmyopia in, 171\\nphthisis in, 171\\npupil in, 171\\nsyuecliiae in, 170\\ntension in, 170\\ntreatment of, 172\\natropine in, 172\\nvitreous in, 170\\nsyphilitic, 447\\nCycloplegia, 388\\nafter diphtheria, 451\\nwith mydriasis, 388\\nCysticercus cellulosae, 289, 466\\nCysts of conjunctiva, 313, 314\\ndermoid, of eyeball, 313\\nMeibomian (see Chalazion),\\npellucid, of eyelids, 89\\nI).\\nDacryo-adenitis, 94\\nacute, 94\\ncauses of, 94\\nchronic, 94, 97\\ncold in, 94\\nmumps in, 94\\nrheumatism in, 94\\nsepticaemia in, 94\\nsyphilis in, 94\\ntreatment of, 94\\npoultices in, 94\\nDacryocystitis in extraction of\\ncataract, 206\\nin new-born infants, 100\\nDacryoliths, 96\\nDacryops, 314\\nDay-blindness, 281\\nDiabetes, 458\\nin cataract, 191\\nretinitis in, 244\\nDiagnosis of cataract, 197\\nDial, astigmatic, 357\\nDiarrhoea in keratomalacia, 136\\nDigestion, irregularities of, as\u00c2\u00ac\\nthenopia of, 280\\nDiphtheria, 451\\nconvergent strabismus after,\\n451\\nof conjunctiva, 451\\ncycloplegia after, 451\\nextra-ocular muscles after, 451\\nDiplopia, 379\\nbinocular, 379\\ncauses of, 380\\nmonocular, 379\\nDiplopia in myopia, 333\\nin strabismus, 368\\ntests for, 380\\nDiscission operation, 441\\nDisk in astigmatism, 355\\nDistichiasis, 119\\nDuboisine, 521\\nE.\\nEchinococcus, hydatid, 467\\nEctropion, 400\\noperations for, 400\\nArgyll-Robertson\u00e2\u0080\u0099s, 401\\nKulint\u00e2\u0080\u0099s, 400\\nSnellen\u00e2\u0080\u0099s, 400\\nEczema, marginal, of eyelids, 86\\nElectrolysis for hair-follicles, 399\\nEmphysema of orbital cellular\\ntissue, 321\\nEnophthalmos, 38, 321\\nEntozoa, 466\\nEntropion, 118\\noperation for, 395\\norganic, 395\\nspasmodic, 395\\nEnucleation, 416\\nafter foreign bodies, 189, 190\\nEpicanthus, 93\\nEpilation, 393\\nEpiphora, 94\\ncauses of, 95\\nin facial palsy, 474\\nresult of blepharitis, 86\\nEpiscleral tissue, diseases of, 165\\nEpiscleritis, 132, 165\\niritis in, 166\\nphlyctenulse in, 166\\nrheumatism in, 463\\nEpistaxis in diseases of vitreous,\\n289\\nEpithelioma of conjunctiva, 314\\nErysipelas, 476\\nof conjunctiva, 110\\nin orbital disease, 321\\nErythropsia, 281\\nfasting a cause of, 281\\nsenile cataract after, 281\\nEserine, 522\\naction of, 386\\nEsophoria, 52\\nin hypermetropia, 350\\nprism exercise in, 351\\nEthmoiditis, 476\\nEthmoid sinus, distention of, 325\\nEucaine, 522", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0565.jp2"}, "566": {"fulltext": "548\\nINDEX.\\nEvisceration, 418\\nExamination, external, of con-\\njuctiva, 37\\nof eye, 37\\nof iris, 43, 58, 59, GO\\nof lens, 43, 59, 60\\nof lids, 37\\nof fundus by ophthalmoscope,\\n74\\nExanthemata, optic neuritis in,\\n261\\nin phlyctenular keratitis, 124\\nExciting eye, 173\\nExophoria, 52\\nprism exercise in, 350\\nExophthalmic goitre, 475\\nas a cause of corneal ulcera\u00c2\u00ac\\ntion, 136\\nExophthalmos, 37\\nin goitre, 475\\nExostoses, ivory, 325\\nEye, examination of deeper media.\\n60\\nby focal light, 58-60\\nby lateral illumination, 58-60\\nby oblique light, 58-60\\nsuperficial media of, 58-60\\nEyeball, abscission of, 417\\nbloodvessels of, 39, 40, 42\\nburns of, 184\\ndermoid cyst of, 313\\nenlargement of, 37\\nexcision of, 416\\nforeign bodies in, 187\\ngumma of, 313\\ninjuries of. 180\\ncontusion and concussion, 180\\ngunshot, 186, 189\\ntreatment of, 186\\noptic neuritis after, 183\\nwithout rupture, 181\\nprognosis of, 182\\ntreatment of, 183\\nmobility of, 45\\nperforating wound of, iritis in,\\n160\\nresult of blows on, 180\\nretraction of, 38\\nrupture of, 180\\nconjunctiva in, 180\\nshrinking after, 180\\ntreatment of, 180\\nscalds of, 184\\ntension of, 46\\nafter blows, 182\\nestimation of, 46, 47\\nEyeball, tumors of, enucleation in,\\n315\\nwounds of, 183\\npenetrating, 186, 189,\\ntreatment of, 186\\nEyelids, chancre of, 92, 447\\ndiseases of, 85\\neversion of upper, 393\\nlupus of, 91\\nmarginal eczema of, 86\\noperations on, 393\\nvan Millingen\u00e2\u0080\u0099s, 399\\npellucid cysts of, 89\\nrodent cancer of, 90\\nsyphilis of, 447\\nulcers of, 90\\nwarty formations on, 89\\nwounds of, 323\\npenetrating, 323\\nEye muscles, external, balance of,\\n51\\nnomenclature of, 51\\ntest for, 51\\nF.\\nFacial nerve, paralysis of, 474\\nFar-point 330\\nFifth nerve, neuralgia of, in oph\u00c2\u00ac\\nthalmitis, 176\\nparalysis of, 474\\nFistula of lachrymal sac, 97\\nFlags, use of, in testing color-\\nsense, 488\\nFluorescine, 523\\nFocal illumination, 58-60, 184\\nFoeus, conjugate, 331\\nFovea centralis, 68, 230\\nFrontal sinus, distention of, 325\\ntreatment of, 325\\nFundus, examination of, by oph\u00c2\u00ac\\nthalmoscope, 74\\nG.\\nGlassses, protective, 528\\nGlaucoma, 291\\nabsolute, 295\\nacute, 291, 294\\nsymptoms of, 294\\nafter influenza, 453\\nanterior chamber in, 292, 294,\\n295, 298\\natrophy of retina in, 294\\nblindness in, 294\\ncataract in, 197, 308", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0566.jp2"}, "567": {"fulltext": "INDEX.\\n549\\nGlaucoma, chronic, 291\\nsymptoms of, 292\\nciliary body in, 300\\nnerves in, 298\\ncomplicating cataract, 303\\nconjunctiva in, 294\\ncornea in, 292, 294, 295\\nanaesthesia of, 298\\ncorneal involvement in, 149\\nexcavation of optic nerve in,\\n296\\nfifth nerve in, 302\\nfiltration angle in, 300\\nscar in, 305\\ngeneral and diathetic causes,\\n302\\ngout in, 302, 465\\nhalos, 292\\nheart disease in, 302\\nhemorrhage in, 181, 310\\nhypermetropia in, 291\\ninfantile, 150\\ninflammation in, 293\\niridectomy for, 425\\nlens in, 293, 298, 301\\nlids in, 294\\nligamentum pectinatum in, 300\\nloss of sight in, 292, 294, 295\\nmalignum, 308\\nmechanism of, 299\\nBrailey\u00e2\u0080\u0099s theory of, 301\\nSmith\u00e2\u0080\u0099s theory of, 301\\nWeber\u00e2\u0080\u0099s theory of, 301\\nin metastatic tumors, 317\\nneuralgia in, 294, 467\\noperations for, atropine in, 308\\ndiet in, 308\\nindications, 305, 306\\nprognosis of, 306\\nsleep in, 308\\nin ophthalmitis, 176\\nof optic nerve in, 294\\npain in, 294, 295\\nparalysis in, 302\\nperforation of vessels in, 292,\\n295\\npermanent, 296\\npremonitory stage in, 292\\npresbyopia in, 292\\nprimary, 291\\npulsation of vessels in, 293\\npupil in, 292, 294, 295, 298\\nremittent, 294\\nretinal vessels in, 297\\nsclerotic in, 291\\nsclerotomy for, 430\\nGlaucoma, secondary, 291, 308\\nacute, 308\\nafter detached retina, 309\\ndislocation of lens, 309\\nintra-ocular tumors in, 309\\niritis, 157\\nhemorrhage into eye, 309\\nperforations of cornea, 308\\ntraumatic cataract, 309\\nchronic, 308\\nin corneal inflammation, 146\\nin serous cyclitis, 170\\nsimple, 293\\nsymptoms, explanation of, 295\\nsubacute, 291, 293\\nsymptoms of, 294\\ntension in, 292, 294, 295\\nin traumatic cataract, 210\\ntreatment of, 303\\ncocaine in, 304\\neserine in, 303, 308\\nevacuation of aqueous humor\\nin, 304\\niridectomy in, 303\\nleeching in, 304\\npilocarpine in, 303, 308\\npuncture of sclerotic in, 304\\ntumors in, 301\\nvessels of retina in, 297\\nvision in, 292, 294, 295\\nvisual field in, 292, 295\\nGlioma of optic nerve, 315\\nof retina, 315\\nGonorrhoeal rheumatism, 463\\nGout, 465\\nin diseases of vitreous, 289\\nin glaucoma, 302\\nin iritis, 159\\nin scleritis, 166\\nin serous cyclitis, 171\\nGraefe\u00e2\u0080\u0099s sign, 475\\nGraves\u00e2\u0080\u0099 disease, 475\\nGumma of eyeball, 313\\nintracranial, optic neuritis in,\\n261\\nof iris, 320\\nof orbit, 324\\nGummatous scleritis, 168\\nGunshot injuries, 186, 189\\nH.\\nHead, injuries of, in ocular paral\u00c2\u00ac\\nysis, 389\\nHearing, test for, in railway em\u00c2\u00ac\\nployes, 488", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0567.jp2"}, "568": {"fulltext": "550\\nINDEX.\\nHeart disease, 461\\nin glaucoma, 302\\npulsation of retinal vessels\\nfrom, 461\\nHeat, 525\\nHematropine, 522\\nHemeralopia, 281\\nin scurvy, 460\\nHemianopia, 275\\nfor colors, 277\\ncrossed, 277\\nin detachment of retina, 275\\ndouble, 277\\nfixation-point in, 275\\nin disease of angular gyrus, 276\\nof chiasma, 275\\nof occipital lobe, 276\\nof pupillary reaction in, 276\\nof tract, 276\\nhysterical, 277\\nline of separation in, 275\\nnasal, 277\\noptic disk in, 277\\nin retinal hemorrhage, 275\\ntemporal, 277\\ntransient, 467\\nwith hemiplegia, 277\\nHemiplegia with hemianopia, 277\\nHerpes of cornea, 136\\nzoster, 474\\nof conjunctiva, 110\\nHeterophoria, 52, 376\\nprism in, 376\\nMaddox rod in, 377\\nHolocaine, 522\\nHydrocephalus, 470\\nHydrophthalmos (see Buplithal-\\nmos).\\nHypermetropia, 344\\naccommodation in, 345\\nacquired, 346\\nafter extraction of cataract, 209\\namblyopia in, 270\\nasthenopia in, 279, 347\\natropine in, 349\\naxial, 344\\nciliary muscle in, 345\\nconvergent strabismus in, 348\\nconvex lenses in, 346, 348\\ndetermination of, by ophthal\u00c2\u00ac\\nmoscope, 71\\nby shadow-test, 76, 78\\nesophoria in, 350\\nglaucoma in, 291\\nimages in, 345\\nlatent, 348\\nH^ypermetropia, manifest, 348\\nophthalmoscope in, 350\\nin strabismus, 371\\nsymptoms of, 347\\ntreatment of, 348\\nHyperphoria, 52\\nHypertrophy of lachrymal gland,\\n95\\nHyphsema, 153\\nHypopyon, 153\\nin corneal ulceration, 133\\nin iritis, 159\\ntreatment of, 140\\nulcer of cornea, section for, 442\\nHysteria, 277\\nin ametropia, 278\\nanaesthesia of retina in, 277\\nin asthenopia, 278\\ncontraction of visual field in,\\n277\\nlachrymation in, 277\\nocular paralysis in, 390\\nphotophobia in, 277\\nprognosis in, 278\\npupil in, 278\\nspasm of accommodation in, 277\\nI.\\nImages, 23, 328, 329, 334\\nin astigmatism, 355\\ncrossed, 367\\nfalse, in strabismus, 368\\nin hypermetropia, 345\\nretinal, 31\\nin strabismus, 365\\nsuppression of, 270, 373\\nInflammation, sympathetic, 173\\nInfluenza, 453\\nInfraduction, measurement of, 53\\nIntracranial disease, optic neuri\u00c2\u00ac\\ntis in, 261\\nsyphilitic disease, 469\\nIntra-ocular hemorrhage, glau\u00c2\u00ac\\ncoma after, 309\\ntumors, detection of, 60\\nIridectomy in corneal ulceration,\\n141\\nin glaucoma, 303, 425, 427\\nhemorrhage after, 181, 430\\nin interstitial keratitis, 147\\nin iritis, 162\\npreliminary, in cataract extrac\u00c2\u00ac\\ntion, 434\\nin serous cyclitis, 172\\nIrideremia, 163", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0568.jp2"}, "569": {"fulltext": "INDEX.\\n551\\nIridochoroiditis, 226\\nchronic serous, 170\\nplastic, 160\\nin sympathetic inflammation,\\n176\\nIridodesis, 425\\nIridocyclitis, cataract after, 197\\ngouty, 465\\ntraumatic, 172\\nIridoplegia, 387\\nreflex, 387, 471\\nIridotomy, 427\\nIris, 43\\nabsence of, 163\\nartificial pupil, operation for,\\n424\\ncleft in, 163\\ncoloboma of, 163\\ndetachment of, 181\\nin diabetes, 459\\ndiseases of, 153\\nexamination of, 58-60\\nexternal examination of, 43\\nforeign bodies in, 187\\ngumma of, 320\\nincarceration of, after extraction\\nof cataract, 208\\niridectomy for glaucoma, 425\\niridodesis, 425\\niridotomy, 427\\noperations on, 424\\nparalysis of, after blows, 182\\nprolapse of, after extraction of\\ncataract, 208\\ntreatment of, 190\\nsarcoma of, 319\\nsyphilis of, 447\\ntremulous, 181\\ntubercle of, 320\\nwounds of, 186\\nIritis, 153\\nacute, 158\\nafter cataract operations, 160\\ncorneal abrasions, 160\\nextraction of cataract, 207\\ninfluenza, 453\\nperforating wounds, 160\\nsmallpox, 450\\natropine in, 154, 155\\ncauses of, 153, 158\\ngout, 159\\ninjuries, 160\\nrheumatism, 159\\nsyphilis, 158\\nin choroiditis, 160, 223\\nchronic, in children, 160\\nIritis in corneal inflammation, 143\\nulcers, 161\\nin deep-seated diseases of eye,\\n161\\nfor dental disorders, 476\\ndiagnosed from glaucoma. 292\\nin diseases of vitreous, 160\\nduration of, 156\\nexudation in, 153\\nin episcleritis, 166\\nexamination of iris in, 58-60\\ngonorrhoeal, 464\\ngout in, 465\\nliyphsema in, 153\\nhypopyon in, 153\\nin injury of cornea, 184\\nintra-uterine, 164\\niridectomy in, 162\\nopacities in, 161\\npain in, 156\\nin panophthalmitis, 160\\npupil in, 154\\nrelapses in, 157\\nresults of, 156\\nrheumatism in, 463\\nin seconday cataract, 160\\nsecondary glaucoma after, 157\\nserous, 155\\ncvclitis, 170\\nsuppurative, 160\\nin sympathetic ophthalmia, 153\\ntension in, 154\\ntraumatic, 160, 172\\ntreatment of, 163\\ntreatment of, 161\\ntubercular, 160\\nin wounds of eyeball, 160\\nof lens capsule, 160\\nIrritation, sympathetic, 173\\nJ.\\nJequirity, 524\\nin granular conjunctivitis, 120\\nK.\\nKeratitis (see Corneal Inflam\u00c2\u00ac\\nmation, 128 et seq.).\\nafter extraction of cataract, 208\\nmeasles, 452\\nwhooping-cough, 452\\ninterstitial, iridectomy in, 147\\nmarginal, 131\\npunctata, 148, 170\\nin ophthalmitis, 178", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0569.jp2"}, "570": {"fulltext": "552\\nINDEX.\\nKeratitis, syphilis in, 147\\nKeratomalacia, 135\\ndiarrhoea in, 136\\ntreatment of, eserine in, 141\\nKidney disease, 457\\nL.\\nLachrymal abscess, 97\\nsymptoms of, 97\\ntreatment of, 97\\nconjunctivitis, 121\\ndisease as a cause of conjuncti\u00c2\u00ac\\nvitis, 121\\nfistula, 97\\ngland, adenoma of, 95\\nafter mumps, 452\\ndiseases of [see Dacryo-ade\u00c2\u00ac\\nnitis).\\nextirpation of, 99, 410\\nhypertrophy of, 95\\nneoplasms of, 95\\nsarcoma of, 95\\ntumors of, 324\\nobstruction from nasal disease,\\n476\\nsac, distention of, 97\\nexcision of, 99\\ntumors of, 315\\nLachrymation, 94\\nLamellar cataract, 194, 200\\nLamina cribrosa, 67\\nin glaucoma, 296\\nLantern in color-blindness, 500\\nLateral illumination, 58-60\\nLead lotion, 514\\nLead-poisoning, 455\\noptic neuritis in, 261\\nLeeching, 525\\nLens in accommodation, 329\\nanterior force of, 195\\nin astigmatism, 352\\ncapsule of, 191\\ncoloboma of, 212\\ncortex of, 191\\ndislocation of, 181\\ncongenital, 212\\nsecondary glaucoma after, 309\\nequation of, 193\\nexamination of, 59, 60\\nexternal examination of, 43\\nextraction of, for cataract, 203\\nforeign bodies in, 187\\nin glaucoma, 293, 298, 301\\ngradual absorption of, 203\\nin myopia, 337\\nLens, nucleus of, 191\\nopacity of, 181, 191\\nremoval of, in myopia, 343\\nsenile changes in, 191\\nwounds of, 187, 189\\nLenses, 18, 20\\nin astigmatism, 355\\nbifocal, in presbyopia, 363\\nconvex, in hypermetropia. 346\\ndecentration of, 27\\nnumeration of spectacle, 32\\nprincipal axis of, 21\\nfocus of, 21, 23\\nprismatic effect of decentring,\\ntable showing, 27\\nrefractive index of, 18\\nsecondary axis of, 21\\nLenticular opacities, examination\\nof, 58-60\\nLeprosy, 466\\nLeucocytlnemia, 459\\nretinitis in, 244\\nLeucoma, 126\\nLeukaemia, retinitis of, 246\\nLids, 37\\nchancres of, 311\\nexternal examination of, 37\\nin glaucoma, 294\\nnsevus of, 328\\npolypoid growths of, 314\\nsyphilitic inflammation of,\\n311\\ntumors of, 314\\nulcers of, 311\\nLigament, suspensory, rupture of,\\n181\\nLigamentum pectinatum in glau\u00c2\u00ac\\ncoma, 300\\nLippitudo, 86\\nLocomotor ataxia, 449, 471\\nocular paralysis in, 389\\noptic atrophy in, 266\\npupil in, 388\\nLupus of conjunctiva, 311\\nof eyelids, 91\\nLymph-nodules in iritis, 158\\nLymphoma of conjunctiva, 109\\nM.\\nMacula, lesions of, after injuries,\\n181\\nlutea, 67. 230\\nMaddox rod, 51\\nin color-blindness, 507\\nin heterophoria, 377", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0570.jp2"}, "571": {"fulltext": "INDEX.\\n553\\nMaddox rod in strabismus, 375\\nMalaria, 453\\nMalingering, 20, 282\\nMarines, visual standard for, 537\\nMeasles, 452\\na cause of blepharitis, 80\\nin phlyctenular keratitis, 129\\nMegalopsia, 281\\nMegrim, 461, 467\\ndiagnosed from glaucoma, 292\\nMeibomian cyst {see Chalazion),\\nremoval of, 393\\ngland, diseases of, 88\\nMeningitis, 469\\ne|)idemic cerebro-spinal, 453\\noptic neuritis, 469\\nMercury, preparations of, 514\\nMicropsia, 281\\ndue to insufficiency of accom\u00c2\u00ac\\nmodation, 281\\nin retinitis, 241, 281\\nMig raine, ophthalmoscopic, 383\\nMiosis, 386\\nparalytic, 387\\nMirrors, concave, in shadow-test,\\n76, 78\\nplane, in shadow-test, 76, 79, 82\\nMobility of eye, 45\\nMolluscum contagiosum, 90\\nMorgagnian cataract, 202\\nMotor disorders, 471\\nMucocele, 97\\ntreatment of, 98\\ncurative or operative, 98\\npalliative, 98\\nby probing, 99\\nMumps, 452\\nin dacryo-adenitis, 94\\nMuscse volitantes, 281\\nMuscles, action of mydriatics on,\\n386\\nof myotics on, 386\\nconjugate, 379\\nextra-ocular, abducting, prism,\\n378\\nadducting prism, 378\\nparalysis of, 365\\nintra-ocular, 385\\nphysiological outlines of, 386\\nparalysis of external recti, 381\\noculo-motor, 383\\nsuperior oblique, 381\\nwounds of, 323\\nMuscular paralysis in whooping-\\ncough, 453\\nMyelitis, papulitis in, 468\\nMydriasis, 386\\ncycloplegia with, 388\\nparalytic, 387\\nspasmodic, 387\\nMyopia, 329\\nafter blows, 183\\nasthenopia in, 332\\naxial, 329\\nin cataract, 198\\ncauses of, 338\\nchoroid in, 334\\nchoroiditis in, 223\\nciliary muscle in, 338\\ncrescent in, 336\\nof curvature, 343\\ndetachment of retina in, 337\\ndetermination of, by ophthal\u00c2\u00ac\\nmoscope, 71\\nby shadow-test, 76, 78\\ndiplopia in, 333\\nin diseases of choroid, 213\\nof vitreous, 289\\nheredity in, 338\\nimages in, 331\\ninsufficiency of convergence in,\\n332\\nlens in, 337\\nmuscse in, 281, 333\\nobjecive signs of, 333\\nopacities of cornea in, 339\\nophthalmoscope in, 333\\npresbyopia in, 337\\nprism exercise in, 342\\nretinoscopy in, 334\\nsclera in, 333\\nin serous cyclitis, 171\\nspasm of accommodation in, 333\\nstaphyloma in, posterior, 336\\nstrabismus in, 332\\nsymptoms of, 331\\ntenotomy in, 342\\ntreatment of, 339\\nvitreous in, 337\\nMyopsia, detachment of retina in,\\n239\\nN.\\nN;evus, 328\\nNasal duct, obstruction of, 96\\nnaso-pharyngitis in, 96\\nprobing of, 407\\nstricture of, 96\\nincision of, 408\\nscarlet fever in, 97\\nsmallpox in, 97", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0571.jp2"}, "572": {"fulltext": "554\\nINDEX.\\nNasal duct, incision of stricture\\nof, syphilis in, 96\\nstye in, 99\\ntreatment of, 98\\nNasopharyngitis in obstruction of\\nnasal duct, 96\\nNavy, visual standard in, 537\\nNear-point, 331\\nNebula, 126\\nNephritis in cataract, 192\\nNerves, paralysis of, fourth, 381\\nsixth, 381\\nthird, 379, 381\\nrecurrent, paralysis of, 473\\nNeuralgia of fifth nerve, 467\\nin glaucoma, 294\\nNeuritis, retro-ocular, amblyopia\\nin, 272\\nNeuro-retinitis in mumps, 452\\nNight-blindness, 249, 280\\nbacillus xerosis in, 280\\nconjunctiva in, 280\\nduring fasting, 280\\nfrom moonlight, 280\\nin retinitis, 241\\nin sailors, 280\\nin soldiers, 280\\ntreatment of, 281\\nNose, diseases of, 476\\nin tumors of orbit, 326\\nNyctalopia, endemic, 280\\nscurvy, 460\\nNystagmus, 391, 473\\nO.\\nOblique illumination, 58-60\\nOccipital lobe, disease of, hemi-\\nanopia in, 276\\npalsies, faradization in, 390\\nOcular paralysis, causes of, 388\\nin hysteria, 390\\ninjuries of head in, 389\\nin locomotor ataxia, 389\\nrheumatism in, 389\\nsyphilis in, 389\\ntreatment of, 390\\ntumors of brain in, 389\\nOculo-motor paralysis, syphilis in,\\n448\\nOnyx, 134\\nOpacities in media, detection of, 69\\nOpaque nerve-fibres, 231\\nOphthalmia (see Conjunctivitis),\\nneonatorum,\\nprevention of, 10$. j 7\\nOphthalmia, sympathetic, 173\\naccommodation, 174\\nblindness in, 176\\ndangerous zone in, 174\\nforeign bodies in, 174\\niritis in, 174\\ntumors in, 174\\ntarsi (see Blepharitis).\\nOphthalmitis, enucleation in, 177\\nglaucoma in, 176\\ninflammation of cornea in, 176\\nlens in, 176\\nneuralgia of fifth nerve in, 176\\nneuro-retinitis in, 177\\npunctate keratitis in, 178\\nsympathetic, in diseases of vit\u00c2\u00ac\\nreous, 289\\nsynechise in, 176\\nOphthalmometer, description of,\\n53\\nin measuring corneal astigma\u00c2\u00ac\\ntism, 54\\nOphthalmoplegia externa, 384\\ninterna, 388, 390\\nOphthalmoscope, 530\\ndetermination of astigmatism\\nby, 73, 355\\nhypermetropia by, 71, 350\\nmyopia by, 71, 333\\nrefraction by, 71\\nexamination of fundus by, 74\\nhow to use, 61\\nin study of corneal reflex, 71\\nOphthalmoscopic examination, 60\\ndilatation of pupil in, 64\\ndirect method, 61, 68\\nindirect method, 61, 68\\nOptic atrophy associated with\\nneuralgia, 467\\nin heart disease, 461\\nin hydrocephalus, 470\\nin insular sclerosis, 473\\nparalysis of insane in, 266\\npupils in, 264\\nvisual fields in, 264, 267\\ndisk (see Optic Nerve).\\nappearance of, 65\\nforamen, fracture of, 267\\nnerve, atrophy of, 254, 262\\nafter fracture of optic canal,\\n267\\nhemorrhage into norve-\\nsheaths, 267\\nintracranial disease, 265\\nretinitis, 237\\ntumors of orbit, 267", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0572.jp2"}, "573": {"fulltext": "INDEX.\\n555\\nOptic nerve, clinical aspects of\\natrophy of, 263\\ncolor-blindness in, 265\\nconsecutive, 258\\nin disease of cord, 265\\nin glaucoma, 294\\nin locomotor ataxia, 266\\nin paralysis of insane, 266\\npost-papillitic, 258, 263\\nprimary, 254, 263\\npupils in, 264\\nsclerosis in, 266\\nin tumors of chiasma, 267\\nvarieties of, 263\\nvisual fields in, 264\\nwith single amaurosis, 267\\nin diabetes, 459\\nexcavation of, in glaucoma,\\n296\\nin glaucoma, 293\\nglioma of, 315\\nin hemianopia, 277\\nin orbital disease, 323\\nsheath of, 254\\nstructure of, 254\\nsyphilis of, 448\\ntumors of, 324\\nwounds of, penetrating, 323\\nneuritis, 254\\nafter influenza, 453\\ninjuries, 183\\nmeasles, 452\\nanaemia in, 261, 460\\nascending, 254\\nbrain tumors in, 260\\nin cerebral disease, 255\\nchoked disk in, 255\\ndescending, 254\\nin disease of orbit, 260\\nexanthemata in, 261\\nin erysipelas, 476\\nfrom alcohol, 455\\nbisulphide of carbon, 456\\nlead-poisoning, 455\\nquinine, 457\\ntobacco, 456\\nhemorrhage from stomach in,\\n261\\nintracranial disease in, 261\\nlead-poisoning in, 261\\nin malaria, 453\\nmeningitis in, 262, 453, 469\\nophthalmoscopic signs of, 256\\nrenal disease in, 260, 457\\nretro-bulbar, 261\\nsight in, 259\\nOptic neuritis, suppression of\\nmenses in, 261\\nsyphilis in, 260, 261\\ntheories of prevention of, 255\\ntuberculosis in, 260\\ntract, disease of, hemianopia\\nin, 276\\nneuritis in, 261\\nOptical outlines, 17\\nOptico-ciliary neurotomy, 418\\nOvaries, disease of, asthenopia in,\\n280\\nOrbit, abscess of, 322, 327\\ncellulitis of, 322\\nin erysipelas, 476\\nfrom rheumatism, 465\\ndisease of, erysipelas in, 321\\noptic atrophy after, 267\\nnerve in, 323\\nthrombosis of cavernous sinus\\nin, 323\\nechinococcus in, 467\\nforeign bodies in, 323\\nfracture of, 321\\nhemorrhage of, in scurvy, 460\\nin whooping-cough, 453\\ninjuries of, 321\\nin mumps, 452\\nsarcoma of, 316\\ntumors of, 324\\ncystic, 325\\nerectile, 327\\nfluctuating, 327\\ngummatous, 324\\nhydatid, 327\\nhypertrophy of cellular tissue,\\n324\\nivory exostoses, 325\\nof nose in, 326\\nproptosis in, 324\\npulsating, 326\\nsolid, 327\\nsyphilis in, 328\\nof teeth in, 326\\nOrbital cellulitis from inflamma\u00c2\u00ac\\ntion of adjacent sinuses, 476\\nOrthophoria, 51\\nP.\\nPannus, 119\\nin phlyctenular disease, 131\\ntreatment of, 119\\nPanophthalmitis, 172\\nafter choroiditis, 226\\nextraction of cataract, 207", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0573.jp2"}, "574": {"fulltext": "556\\nINDEX.\\nPanophthalmitis after extraction\\nof foreign bodies, 188\\nleprosy, 406\\npyaemia in, 173, 454\\nsymptoms of, 172\\nvitreous in, 172\\nPapillitis in diseases of central\\nnervous system, 468\\nPapilloma of caruncle, 311\\nPapillo-retinitis, 260\\nPapillitis, 254\\nParacentesis of anterior chamber,\\n421\\nParalysis in glaucoma, 302\\nPediculus pubis, 90\\nPellucid cyst of eyelids, 89\\nPerimeters, 533\\ntesting field of vision with, 55\\nPeriosteum, tumors of, 324\\nPeritomy, 120, 404\\nPhlyctenulae in episcleritis, 166\\nPhlyctenular disease in nasal dis\u00c2\u00ac\\norders, 476\\npannus in, 131\\ninflammation, 128\\nPhorometer, 48, 378\\nPhotophobia, 127\\nPhthisis in serous cyclitis, 171\\nPinguecula, 312\\nPhysiological cap, 66\\nPilocarpine, 523\\nPilots, visual standard for, 537\\nPink-eye, 108\\nPlane mirrow in shadow-test, 76\\nPolar cataract, 196, 200\\nPolyopia in cataract, 198\\nPresbyopia, 361\\naccommodation in, 361\\nin glaucoma, 292\\nlenses in, 363\\ntreatment of, 363\\nPrismatic exercise, 350\\nPrisms, 18, 19, 26\\ndeviation produced by, 18\\nemployment of, 26-28\\nto expose malingering, 29\\nnumeration of, 36\\nto remove double vision, 28\\nto test ocular muscles, 28\\nProptosis, 37, 321, 324\\nin goitre, 475\\nwith pulsation, 326\\nPseudo-glioma, 226\\nPterygium, 312\\noperations for, 313\\nPtosis, congenital, 93\\nPtosis, operations for, 402\\npartial, 322\\nPupils, 43\\naction of ophthalmoscope in\\ntesting, 69\\nafter blows, 322\\nparalysis of cervical sympa\u00c2\u00ac\\nthetic, 475\\ndilatation of, 387\\nartificial, operation for, 424\\nassociated action of, 44\\nin cataract, 198\\ndilatation of, after blows, 182\\nexamination of, 43\\nexclusion of, 155\\nin glaucoma, 292\\nin hysteria, 278\\nin iritis, 154\\nirregularity of, 44\\nin locomotor ataxia, 388\\nmembrane of, 163\\nocclusion of, 155\\nparalysis of, 387\\naction of, 387\\nreflex activity of, direct, 44\\nindirect, 44\\nin serous cyclitis, 171\\nsphincter of, rupture of, after\\nblows, 182\\nPunctum lachrvmalia, diseases of,\\n95\\nPupillary membrane, 163\\nreaction, hemiopic, 276\\nPurpura, 454\\nPyaemia, 454\\nchoroiditis after, 226\\nin panophthalmitis, 173\\nPyramidal cataract, 194\\nQ.\\nQuinine, 457, 516\\nR.\\nRachitis in cataract, 192, 194\\nRailway employes, examination\\nof vision of, 284, 479, 484\\nRecti, internal, in myopia, 332\\nRefraction, 329\\ndetermination of, by ophthal\u00c2\u00ac\\nmoscope, 71\\nby shadow-test, 76\\nof eye, 29-31\\nRelapsing fever, 453", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0574.jp2"}, "575": {"fulltext": "INDEX.\\n557\\nRenal disease, 457\\nin retinitis, 241\\nRetina, anaesthesia of, in hysteria,\\n277\\narteries of, 68, 229\\natrophy of, 235, 249\\nin glaucoma, 294\\nbloodvessels of, 65, 67\\ncongestion of, 231\\ncysticercus under, 466\\ndetachment of, 181, 237\\ncataract in, 197\\nin diseases of vitreous, 289\\nhemianopia in, 275\\nin myopia, 239, 337\\nsecondary glaucoma after,\\n309\\ntreatment of, 239\\nin diabetes, 459\\ndiseases of, 229\\nblindness from, 251\\nclinical forms of, 240\\nof choroid, 213\\ngout in, 465\\nophthalmoscopic signs of, 231\\nembolism of central artery of,\\n246\\nfunctional diseases of, 280\\nglioma of, 315\\nhemorrhage of, 180\\nanaemia, 459\\nin leucocythaemia, 459\\nin septicaemia, 454\\nischaemia of, 249\\nafter whooping-cough, 452\\nin malaria, 453\\nin purpura, 454\\npigmentation of, 235, 249\\nreflexes of, 230\\nin renal disease, 457\\nin scurvy, 460\\nstructure of, 229\\nsyphilis of, 448\\nthrombosis of central artery of,\\n246\\nvein of, 244\\nveins of, 68, 229\\nvessels of, in glaucoma, 297\\nRetinae commotio, 183\\nRetinal epithelium, hyaline de\u00c2\u00ac\\ngeneration of, 226\\nimages, 31\\nopacities, detection of, 60\\nvessels, pulsation in, 68\\nRetinitis, albuminuric, 232, 241\\ndetachment in, 243\\nRetinitis, albuminuric, earliest\\nchanges in, 241\\nextravasation in, 241\\nhemorrhage in, 242\\npapillitis in, 243\\nprognosis of, 244\\nsymptoms.of, 244\\nvessels in, 241\\napoplectica, 245\\nBright\u00e2\u0080\u0099s disease in, 241\\ncardiac disease in, 247\\nchorea in, 247\\ncircinata, 253\\nconsanguinity in, 251\\ndiabetes in, 244\\ndiffuse, 232\\nduring pregnancy, 244\\nextravasation in, 233\\nfrom intense light, 252\\nhemorrhage in, 232, 235, 244\\nheredity in, 251\\nof leucocythaemia, 244\\nof leukaemia, 246\\nmercury in, 241\\nmicropsia in, 241, 281\\nnight-blindness in, 241\\noedema in, 244\\noptic atrophy after, 237\\npapillo-, 241\\nof pernicious anaemia, 244, 246\\npigmentosa, 249\\nproliferans, 252\\nrenal disease in, 241\\n\u00e2\u0080\u009cring scotoma\u00e2\u0080\u009d in, 241\\nsyphilis in, 240\\nthrombosis in, 244\\nvessels in, 233\\nvitreous haze in, 232\\nRetinoscopy (see Shadow-test),\\nin astigmatism, 355\\nin myopia, 334\\nRheumatism, 463\\nin dacryo-adenitis, 94\\ngonorrhoeal, 463\\nin iritis, 158\\nin ocular paralysis, 389\\nin sclerit.is, 166\\nRickets, teeth in, 194\\nRontgen rays in detection of for\u00c2\u00ac\\neign bodies, 189\\ns.\\nSaemisch\u00e2\u0080\u0099s operation, 140\\nSalmon patch, 144\\nSarcoma of choroid, 316", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0575.jp2"}, "576": {"fulltext": "558\\nINDEX.\\nSarcoma of ciliary body, 316\\nof iris, 319\\nof lachrymal gland, 95\\nof orbit, 316\\nof sclero-corneal junction, 314\\nScarlet fever, 450\\nin stricture of nasal duct, 97\\nSchools, examination of eyes in,\\n538\\nSclera in myopia, 333\\nScleral ring, 65\\nScleritis, 165\\ngout in, 166\\nrheumatism in, 166, 463\\nsyphilis in, 167\\ntreatment of, 168\\nSclero-iritis, 168\\n-keratitis, 168\\ntreatment of, 169\\nSclerosis, insular, 473\\nSclerotic, diseases of, 165\\nin glaucoma, 291\\npuncture of, 239\\nin glaucoma, 304\\nwounds of, 180, 186, 189\\nSclerotico-cliorioditis, posterior,\\n224\\nSclerotomy, 305, 430\\nfor glaucoma, 430\\nScopilamine, 521\\nScotoma, central, in amblyopia,\\n273\\nscintillating, 467\\nScrofula, a cause of blepharitis, 86\\nScrofulous sclerotitis, 168\\nScurvy, 460\\nnight-blindness in, 280\\nSemilunar fold, papilloma of, 311\\nSepticaemia, 454\\nin dacryo-adenitis, 94\\nSexual disorders, asthenopia in,\\n280\\nShades, 527\\nShadow-test, 75\\nconcave mirror in, 76, 78\\ndetermination of astigmatism\\nby, 76, 78\\nhypermetropia by, 76, 78\\nmyopia by, 76, 78\\nrefraction by, 76\\nplane mirror in, 76, 79, 82\\nSight, loss of, after hemorrhage,\\n449\\ntemporary loss of, 461\\nSilver, nitrate of, 513\\nSinuses, nasal, diseases of, 476\\nSkiascopy {see Shadow-test).\\nSmallpox, 450\\nof conjunctiva, 450\\niritis after, 450\\nkeratitis after, 450\\nin stricture of nasal duct, 97\\nSnellen type, 529\\nSnow-blindness, 124\\nSoda, preparation of, 516\\nSpinal cord, diseases of, optic\\natrophy in, 265\\nSquint {see Strabismus).\\nparalytic, vertigo in, 384\\nStaphyloma, ciliary, 169, 176\\nposterior, 224, 334\\nStellway\u00e2\u0080\u0099s sign, 475\\nStillicidium lacrymarum, 94\\nStomach, hemorrhage from, optic\\nneuritis in, 261\\nStrabismus, 365\\nadvancement agent in, 375\\nafter operation, 376\\nalternating, 368\\namblyopia in, 269\\nconcomitant, 369\\nconvergent, 368, 373\\nafter diphtheria, 451\\nin hypermetropia, 348\\ntreatment of, 374\\ndiplopia in, 368\\ndivergent, 366, 375\\nin myopia, 332\\nprisms in, 375\\ntreatment of, 375\\nfrom disease, 376\\nimages in, 365, 368\\nin motor disorders, 471\\nMaddox rod in, 375\\nmeasurement of, 369\\ncorneal reflex in, 371\\nperimeter in, 371\\nparalytic, 369, 379, 383\\nperiodic, 369\\nprimary, 369, 384\\nsecondary, 369, 384\\ntenotomy in, 374\\ntreatment of, caruncle after,\\n376\\nvisual axis in, 365\\nStrumous diathesis, 466\\nStye, 87\\nsymptoms of, 87\\ntreatment of, 88\\nSubconjunctival injections, 524\\nSubvaginal space, 255\\nSupraduction, measurement of, 53", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0576.jp2"}, "577": {"fulltext": "INDEX.\\n559\\nSuprarenal capsules, 524\\nSycosis tarsi (see Blepharitis).\\nSymblepliaron, 184\\noperations for, 405\\nHarlan\u00e2\u0080\u0099s, 405\\nSnellen\u00e2\u0080\u0099s, 405\\nSympathetic inflammation, 176\\nprognosis in, 179\\ntreatment of, 177\\nirritation, 173, 278\\nsymptoms of, 175\\nophthalmia, 173\\nciliary body in, 173\\nparalysis of cervical, 474\\nSympathizing eye, 173\\nSymptoms of albuminuric reti\u00c2\u00ac\\nnitis, 244\\nastigmatism, 354\\nblepharitis, 85\\ncataract, 197\\nchalazion, 88\\nglaucoma, 292, 294\\nhypermetropia, 347\\ninflammation of cornea, 125\\niritis, 153\\nlachrymal abscess, 97\\nmyopia, 331\\npanophthalmitis, 172\\nstye, 87\\nsympathetic irritation, 175\\nSynchysis in diseases of vitreous,\\n287\\nSyndectomy, 120\\nSynechise, atropine in, 1G1\\nin ophthalmitis, 176\\nposterior, 153\\nas a cause of relapses in iritis,\\n158\\ntotal, 155, 157\\nin serous cyclitis, 170\\nSyphilis, acquired, 447\\nof brain, 448\\nof ciliary body, 448\\nof conjunctiva, 447\\nof cornea, 448\\nin dacryo-adenitis, 94\\nin diseases of vitreous, 289\\ninherited, 449\\nof iris, 447\\nin iritis, 158\\nin keratitis, 147\\nof lid, 311, 447\\nin ocular paralysis, 389, 448\\noptic neuritis in, 260, 448\\nin retinitis, 240, 448\\nin scleritis, 167\\nSyphilis in stricture of nasal duct,\\n96\\nin tumors of orbit, 328\\nSyphilitic choroiditis, 218, 448\\nSyringing, lachrymal, 410\\nT.\\nTeeth, caries of, in cellulitis of\\norbit, 322\\nin inherited syphilis, 476\\nin rickets, 194, 476\\nin tumors of orbit, 326\\nin zonular cataract, 194\\nTendo oculi, 325\\nTenotomy, 411\\nin myopia, 342\\nin strabismus, 374\\nTension of eyeball, 46\\nTest types, 529\\nThrombosis of orbital veins, 226\\nTinea tarsi (see Blepharitis).\\nTrachoma (see Granular conjunc\u00c2\u00ac\\ntivitis).\\noperations for, 405\\nTraumatic cataract, 210\\nTi eatment of abrasions of cornea,\\n184\\nasthenopia, 279\\nblepharitis, 87\\ncataract, 203\\nchalazion, 89\\nchoroiditis, 223\\nconjunctivitis, diphtheritic, 111\\nepidemic, 108\\ngranular, 116\\npurulent, 103\\ndacryo-adenitis, 94\\ndetachment of retina, 239\\nglaucoma, 303\\ngunshot injuries of eyeball, 186\\nhypermetropia, 348\\nhypopyon,140\\ninflammation of cornea, 137\\ninjuries of eyeball without rup\u00c2\u00ac\\nture, 183\\ninterstitial inflammation of cor\u00c2\u00ac\\nnea, 146\\niritis, 161\\nlachrymal abscess, 97\\nmisplaced cilia, 121\\nmucocele, 98\\nnight-blindness, 281\\nobstruction of nasal duct, 98\\nocular paralysis, 390\\nopacities of cornea, 126\\n\u00c2\u00bbv-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0577.jp2"}, "578": {"fulltext": "5G0\\nINDEX.\\nTreatment, pannus, 119\\npenetrating wounds of eyeball,\\n186\\npresbyopia, 363\\nprolapse of iris, 190\\nrodent cancer of eyelids, 92\\nrupture of eyeball, 180\\nscleritis, 168\\nsclero-keratitis, 169\\nserous cyclitis, 172\\nstrabismus, 374, 375\\nstye, 88\\nsympathetic inflammation, 177\\ntraumatic cataract, 210\\ntuberculosis of conjunctiva,\\n311\\nTremulous iris, 181\\nTrial frame, employment of, 35\\nTrichiasis, 119\\ncongenital, 93\\noperations for, 395\\nTropacocaine, 521\\nTubercle of conjunctiva, 92\\nof iris, 320\\nTuberculosis, 462\\nof conjunctiva, 311\\noptic neuritis in, 260\\nTumors and growths of conjunc\u00c2\u00ac\\ntiva, 311 et seq.\\nintra-ocular, 315\\ncataract after, 197\\ndetection of, 60\\nsecondary glaucoma after,\\n309\\nTyphus fever, 450\\nIT.\\nUlcers of eyelids, 90\\nUterus, disease of, asthenopia in,\\n280\\nUveal tract, inflammation of, 173\\nV.\\nVertigo in paralytic squint, 384\\nVision (see Sight),\\nacuteness of, 48\\nstandards of, 48, 49\\ntests for, 48, 479, 487\\ncolored, 281\\nfield of, 54\\ninfluence of pupil on, 32\\noptical convictions of clear, 32\\nVisual axis, 31\\nfield, colors in, 285\\nVisual field in glaucoma, 292, 295\\nin hysteria, 277\\nVitreous, blood in, 289\\ncysticercus in, 467\\ndegeneration of, 286\\ndiseases of, 286\\ncataract after, 197\\ncauses of, 289, 290\\ncholesterin in, 288\\nchoroid in, 286\\nchoroido-retinitis in, 288\\nconstipation in, 289\\ncyclitis in, 289\\ndetachment of retina in, 28y\\nepistaxis in, 289\\ngout in, 289\\nhemorrhage in, 289\\niritis in, 160\\nmuscse volitantes in, 281\\nmyopia in, 289\\nophthalmoscope in, 288\\npenetrating wounds in, 289\\nsympathetic ophthalmitis in,\\n289\\nsynchysis in, 287, 288\\nsyphilis in, 289\\nexamination of, 286\\nexudation into, in choroiditis,\\n226\\nforeign bodies in, 188, 289\\nhemorrhage into, 180, 182\\nin myopia, 337\\nopacities of, 286\\ndetection of, 60\\nin panophthalmitis, 172\\nparasites in, 289\\npus in, 289\\nin serous cyclitis, 170\\nw.\\nWeeks, bacillus of, 108\\nWernicke sign, 276\\nWhooping-cough, 452\\nX.\\nXanthelasma palpebrarum, 90\\nXerotic patches, 135\\nZ.\\nZinc, preparation of, 515\\nZone, ciliary, 165\\nZonular cataract, 194, 200 5", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0578.jp2"}, "579": {"fulltext": "CATALOGUE OF PUBLICATIONS OF\\nLEA BROTHERS COMPANY,\\n706, 708 710 Sansom St., Philadelphia.\\nIll Fifth Ave. (Cor. 18th St.), New York.\\n__ The books in the annexed list will be sent by mail, post-paid, to any Post-Office in the\\nUnited States, on receipt of the printed prices.\\nINDEX.\\nANATOMY^ Gray, p. 11 Treves, 30 Gerrish, 11; Brockway, 4.\\nDICTIONARIES. Dungli8on, p. 8; Duane, 8 National, 4\\nPHYSICS. Draper, p. 8 Robertson, 24 Martin Rockwell, 20.\\nPHYSIOLOGY. Foster, p. 10; Chapman, 5; Schofield, 25; Collins\\nRockwell, 6. [Luff, 19 Remsen, 24.\\nCHEMISTRY. Simon, p. 26 Attfield, 3 Martin Rockwell, 20;\\nPHARMACY. Caspari, p. 5. [Bruce, 4 Schleif, 25.\\nMATERIA MEDICA. Culbretb, p. 6 Maisch, 19 Farquharson, 9\\nDISPENSATORY. National, p. 21.\\nTHERAPEUTICS. Hare, p. 13 Fothergill, 10 Whitla, 31 Hayem\\nHare, 14 Bruce, 4 Schleif, 25 Cushny, 6.\\nPRACTICE. Flint, p. 9 Loomis Thompson, 19 Malsbary, 20.\\nDIAGNOSIS. Musser, p. 21; Hare, 12; Simon, 25; Herrick, 15; Hutchi\u00c2\u00ac\\nson Rainey, 16 Collins, 6.\\nCLIMATOLOGY. Solly, p. 26 Hayem Hare, 14.\\nNERVOUS DISEASES. Dercum, p. 7 Gray, 11 Potts, 23.\\nMENTAL DISEASES. Clouston, p. 5; Savage, 24 Folsom, 10.\\nBACTERIOLOGY. Abbott, p. 2; Vaughan Novy, 30; Senn\u00e2\u0080\u0099s\\n(Surgical), 25. Park, 22 Coates, 6. [Vale, 21.\\nHISTOLOGY. Klein, p. 17 Schafer\u00e2\u0080\u0099s, 25 Dunham, 8 Nichols\\nPATHOLOGY. Green, p. 12; Gibbes, 10; Coats, 6; Nichols Vale, 21\\nSURGERY. Park, p. 22; Dennis, 7; Roberts, 24; Ashhurst, 3; Treves, 29;\\nCheyne Burghard, 5 Gallaudet, 10.\\nSURGERY OPERATIVE. Stimson, p. 27 Smith, 26 Treves, 29.\\nSURGERY ORTHOPEDIC. Young, p. 31 Gibney, 10.\\nSURGERY MINOR. Wharton, p. 30. [BalleDger\\nFRACTURES and DISLOCATIONS. Stimson, p. 27. [Wippern, 3.\\nOPHTHALMOLOGY. Norris Oliver, p. 21; Nettleship, 21; Juler, 17;\\nOTOLOGY. Politzer, p. 23; Burnett, 5; Field, 9; Bacon, 4.\\nLARYNGOLOGY and RHINOLOGY. Coakley, p. 6\\nDENTISTRY. Essig (Prosthetic), p. 9 Kirk (Operative), 17 Ameri\u00c2\u00ac\\ncan System. 2 Coleman, 6; Burchard 4.\\nURINARY DISEASES. Roberts, p. 24 Black, 4.\\nVENEREAL DISEASES. Taylor, p. 28 Hayden, 14 Cornil, 6\\nSEXUAL DISORDERS. Fuller, p. 10 Taylor, 29. [Likes, 19.\\nDERMATOLOGY. Hyde, p. 16 Jackson, 16 Pye-Smith, 24 Mor\u00c2\u00ac\\nris, 20; Jamieson, 16; Hardaway, 12 Grindon, 12.\\nGYNECOLOGY. American System, p. 3 Thomas Mund6, 29\\nEmmet, 9 Davenport, 7 May, 20 Dudley, 8 Crockett, 6.\\nOBSTETRICS. American System, p. 3 Davis, 7 Parvin, 22 Play\u00c2\u00ac\\nfair, 23 King, 17 Jewett, 17 Evans, 9.\\nPEDIATRICS. Smith, p 26 Thomson, 29 Williams, 31 Tuttle, 30.\\nHYGIENE. Egbert, p. 9 Richardson, 24 Coates, 6.\\nMEDICAL JURISPRUDENCE. Taylor, p. 28.\\nQUIZ SERIES, POCKET TEXT-BOOKS and MANUALS.\\nPp. 18, 25 and 27.\\n1.15.00.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0579.jp2"}, "580": {"fulltext": "2 Lea Brothers Co., Philadelphia and New York\\nABBOTT (A. C.). PRINCIPLES OF BACTERIOLOGY: a Practical\\nManual for Students and Physicians. New (5th) edition thoroughly\\nrevised and greatly enlarged. In one handsome 12mo. vol. of 585 pages,\\nwith 109 engrav., of which 26 are colored. Just ready. Cloth, $2.75, net.\\ncessfully. To those who require a\\ncondensed yet nevertheless complete\\nwork upon Bacteriology we most\\ncordially recommend it.\u00e2\u0080\u0094 The Thera\u00c2\u00ac\\npeutic Gazette.\\nOne of its most attractive charac\u00c2\u00ac\\nteristics is that the directions are so\\nclearly given that anyone with a\\nmoderate amount of laboratory train\u00c2\u00ac\\ning can, with a little care as to\\ndetail, make his experiments suc-\\nAMERICAN SYSTEM OF PRACTICAL MEDICINE. A SYS\u00c2\u00ac\\nTEM OF PRACTICAL MEDICINE. In contributions by Various\\nAmerican Authors. Edited by Alfred L. Loomis, M.D., LL.D.,\\nand W. Gilman Thompson, M. D. In four very handsome octavo\\nvolumes of about 900 pages each, fully illustrated. Complete work\\nnow ready. Per volume, cloth, $5; leather, $6; half Morocco, $7.\\nFor sale by subscription only. Prospectus free on application.\\nEvery chapter is a masterpiece of\\ncompleteness, and is particularly ex\u00c2\u00ac\\ncellent in regard to treatment, many\\noriginal prescriptions, formulae,\\ncharts and tables being given for the\\nguidance of the practitioner.\\n\u00e2\u0080\u009cThe American System of Medi\u00c2\u00ac\\ncine\u00e2\u0080\u009d is a work of which every\\nAmerican physician may reasonably\\nfeel proud, and in which every prac\u00c2\u00ac\\ntitioner will find a safe and trust\u00c2\u00ac\\nworthy counsellor in the daily re\u00c2\u00ac\\nsponsibilities of practice.\u00e2\u0080\u0094 The Ohio\\nMedical Journal.\\nAMERICAN SYSTEM OF DENTISTRY. In treatises by various\\nauthors. Edited by Wilbur F. Litch, M.D., D.D.S. In three very\\nhandsome super-royal octavo volumes, containing about 3200 pages,\\nwith 1873 illustrations and many full-page plates. Per vol., cloth,\\n$6; leather, $7 half Morocco, $8. For sale by subscription only. Pros\u00c2\u00ac\\npectus free on application to the Publishers.\\nAMERICAN TEXT-BOOKS OF DENTISTRY. In Contribu\u00c2\u00ac\\ntions by Eminent American Authorities. In two very handsome\\noctavo volumes, richly illustrated\\nPROSTHETIC DENTISTRY. Edited by Charles J. Essig, M.D.,\\nD.D.S., Professor of Mechanical Dentistry and Metallurgy, Department\\nof Dentistry, University of Pennsylvania, Philadelphia. 760 pages,\\n983 engravings. Cloth, $6; leather, $7. Net.\\nNo more thorough production will i It is up to date in every particular,\\nbe found either in this country or in It is a practical course on prosthetics\\nany country where dentistry is un- which any student can take up dur-\\nderstood as a part of civilization.\u00e2\u0080\u0094\\nThe International Dental Journal.\\ning or after college.\u00e2\u0080\u0094 Dominion Den\u00c2\u00ac\\ntal Journal.\\nOPERATIVE DENTISTRY. Edited by Edward C. Kirk, D.D.S.,\\nProfessor of Clinical Dentistry, Department of Dentistry, University\\nof Pennsylvania. 699 pages, 751 engravings. Cloth, $5.50; leather,\\n$6.50. Net. Just ready.\\nWritten by a number of practi\u00c2\u00ac\\ntioners as well known at the chair\\nas in journalistic literature, many of\\nthem teachers of eminence in our\\ncolleges. It should be included in\\nthe list of text-books set down as\\nmost useful to the college student.\u00e2\u0080\u0094\\nThe Dental News.\\nIt is replete in every particular\\nand treats the subject in a progressive\\nmanner. It is a book that every\\nprogressive dentist should possess,\\nand we can heartily recommend it\\nto the profession.\u00e2\u0080\u0094 The Ohio Dental\\nJournal.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0580.jp2"}, "581": {"fulltext": "Lea Brothers A Co., Philadelphia and New York. 3\\nAMERICAN SYSTEMS OF GYNECOLOGY AND OBSTET\u00c2\u00ac\\nRICS. In treatises by the most eminent American specialists. Gyne\u00c2\u00ac\\ncology edited by Matthew D. Mann, A. M., M. D., and Obstetrics\\nedited by Barton C. Hirst, M. D. In four large octavo volumes\\ncomprising 3612 pages, with 1092 engravings, and 8 colored plates. Per\\nvolume, cloth, $5 leather, $6; half Russia, $7. For sale by subscrip\u00c2\u00ac\\ntion only. Prospectus free on application to the Publishers.\\nAMERICAN TEXT-BOOK OF ANATOMY. See Gerrish page 11.\\nALLEN (HARRISON). A SYSTEM OF HUMAN ANATOMY-\\nWITH AN INTRODUCTORY SECTION ON HISTOLOGY, by\\nE. O. Shakespeare, M.D. Comprising 813 double-columned quarto\\npages, with 380 engravings on stone, 109 plates, and 241 wood cuts\\nin the text. In six sections, each in a portfolio. Price per section, $3.50.\\nAlso, bound in one volume, cloth, $23. Sold by subscription only.\\nA PRACTICE OF OBSTETRICS BY AMERICAN AU\u00c2\u00ac\\nTHORS. See Jewett page 17.\\nA TREATISE ON SURGERY BY AMERICAN AUTHORS.\\nFOR STUDENTS AND PRACTITIONERS OF SURGERY AND\\nMEDICINE. Edited by Roswell Park, M.D. See page 22.\\nASHHURST (JOHN, JR.). THE PRINCIPLES AND PRACTICE\\nOF SURGERY. For the use of Students and Practitioners. Sixth\\nand revised edition. In one large and handsome octavo volume of\\n1161 pages, with 656 engravings. Cloth, $6 leather, $7.\\nAs a masterly epitome of what has\\nbeen said and done in surgery, as a\\nsuccinct and logical statement of the\\nprinciples of the subject, as a model\\ntext-book, we do not know its equal.\\nIt is the best single text-book of\\nsurgery that we have yet seen in this\\ncountry.\u00e2\u0080\u0094 New York Post-Graduate.\\nA SYSTEM OF PRACTICAL MEDICINE BY AMERICAN\\nAUTHORS. Edited by William Pepper, M.D., LL. D. In five\\nlarge octavo volumes, containing 5573 pages and 198 illustrations. Price\\nper volume, cloth, $5 leather $6 half Russia, $7. Sold by subscrip\u00c2\u00ac\\ntion only. Prospectus free on application to the Publishers.\\nATTFEELD (JOHN). CHEMISTRY; GENERAL, MEDICAL AND\\nPHARMACEUTICAL. New (16th) edition, specially revised by the\\nAuthor for America. In one handsome 12mo. volume of 784 pages,\\nwith 88 illustrations. Cloth, $2.50, net.\\nIt is replete with the latest inform- been adopted, bringing the work into\\nation, and considers the chemistry of close touch with the latest United\\nevery substance recognized officially States Pharmacopoeia of which it is\\nor in general practice. The modern a worthy companion.\u00e2\u0080\u0094 The Pittsburg\\nscientific chemical nomenclature has Medical Review.\\nBALLENGER (W. L.) AND WIPPERN (A. G.). Shortly. A\\nPOCKET TEXT-BOOK OF DISEASES OF THE EYE, EAR,\\nNOSE AND THROAT. In one handsome 12mo. volume of about\\n400 pages, with many illustrations. Lea s Series of Pocket Text-books,\\nedited by Bern B. Gallaudet, M. D. See p. 18.\\nBARNES (ROBERT AND FANCOURT). A SYSTEM OF OB\\nSTETRIC MEDICINE AND SURGERY. Octavo, 872 pages, with\\n231 illus. Cloth, $5 leather, $6.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0581.jp2"}, "582": {"fulltext": "4 Lea Brothers Co., Philadelphia and New York.\\nBACON (GORHAM). ON THE EAR. One 12mo. volume, 400 pages,\\n109 engravings and a colored plate. Cloth, net, $2.00. Just ready.\\nIt is thebest manual upon otology, dents of medicine\u00e2\u0080\u0094 Cleveland Jour-\\nAn intensely practical book for stu- nal of Medicine.\\nBARTHOLOW (ROBERTS). CHOLERA; ITS CAUSATION, PRE\u00c2\u00ac\\nVENTION AND TREATMENT. In one 12mo. volume of 127 pages,\\nwith 9 illustrations. Cloth, $1.25.\\nBARTHOLOW (ROBERTS). MEDICAL ELECTRICITY. A\\nPRACTICAL TREATISE ON THE APPLICATIONS OF ELEC\u00c2\u00ac\\nTRICITY TO MEDICINE AND SURGERY. Third edition. In\\none octavo volume of 308 pages, with 110 illustrations.\\nBILLINGS (JOHN S.). THE NATIONAL MEDICAL DICTIONARY.\\nIncluding in one alphabet English, French, German, Italian and\\nLatin Technical Terms used in Medicine and the Collateral Sciences.\\nIn two very handsome imperial octavo volumes containing 1574\\npages and two colored plates. Per volume, cloth, $6; leather, $7;\\nnaif Morocco, $8.50. For sale by subscription only. Specimen pages\\non application to the publishers.\\nBLACK (D. CAMPBELL). THE URINE IN HEALTH AND\\nDISEASE, AND URINARY ANALYSIS, PHYSIOLOGICALLY\\nAND PATHOLOGICALLY CONSIDERED. In one 12mo. volume\\nof 256 pages, with 73 engravings. Cloth, $2.75.\\nA concise, yet complete manual,\\ntreating of the subject from a prac\u00c2\u00ac\\ntical and clinical standpoint.\u00e2\u0080\u0094 The\\nOhio Medical Journal.\\nConcise, practical, clinical, well\\nillustrated and well printed.\u00e2\u0080\u0094 Mary\u00c2\u00ac\\nland Medical Journal.\\nBLOXAM (C. L.). CHEMISTRY, INORGANIC AND ORGANIC.\\nWith Experiments. New American from the fifth London edition.\\nIn one handsome octavo volume of 727 pages, with 292 illustrations.\\nCloth, $2 leather, $3.\\nBROCKWAY (F. J.). A POCKET TEXT-BOOK OF ANATOMY.\\nIn one handsome 12mo. volume of about 400 pages, with many illus\u00c2\u00ac\\ntrations. Shortly. Lea s Series of Pocket Text-books, edited by Bern\\nB. Gallaudet, M. D. See page* 18.\\nBRUCE (J. MITCHELL). MATERIA MEDICA AND THERA\u00c2\u00ac\\nPEUTICS. New (6th) edition. In one 12mo. volume of 600 pages.\\nJust ready. Cloth, $1.50, net. See Student s Series of Manuals,\\npage, 27.\\nPRINCIPLES OF TREATMENT. In one octavo volume. Pre\u00c2\u00ac\\nparing.\\nBRYANT (THOMAS). THE PRACTICE OF SURGERY. Fourth\\nAmerican from the fourth English edition. In one imperial octavo vol.\\nof 1040 pages, with 727 illustrations. Cloth, $6.50; leather, $7.50.\\nBURCHARD (HENRY H.). DENTAL PATHOLOGY AND THER\u00c2\u00ac\\nAPEUTICS. Handsome octavo, 575 pages, with 400 illustrations.\\nCloth, net, $5.00; leather, net, $6.00.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0582.jp2"}, "583": {"fulltext": "Lea Bbothers Co., Philadelphia and New Yoek\\n5\\nBURNETT (CHARLES H.p THE EAR: ITS ANATOMY, PHYSI\u00c2\u00ac\\nOLOGY AND DISEASES. A Practical Treatise for the Use of\\nStudents and Practitioners. Second edition. In one 8vo. volume of\\n580 pages, with 107 illustrations. Cloth, $4; leather, $5.\\nCARTER (R. BRUDENELL) AND FROST (W. ADAMS). OPH\u00c2\u00ac\\nTHALMIC SURGERY. In one pocket-size 12mo. volume of 559\\npages, with 91 engravings and one plate. Cloth, $2.25. See Series of\\nClinical Manuals page 25.\\nCASPARI (CHARLES JR.). A TREATISE ON PHARMACY.\\nFor Students and Pharmacists. In one handsome octavo volume of\\n680 pages, with 288 illustrations. Cloth, $4.50.\\nThe author\u00e2\u0080\u0099s duties as Professor\\nof Theory and Practice of Pharmacy\\nin the Maryland College of Phar\u00c2\u00ac\\nmacy, and his contact with students\\nmade him aware of their exact\\nwants in the matter of a manual.\\nHis work is admirable, and the\\nCHAPMAN (HENRY C.). A TREATISE ON HUMAN PHYSI\u00c2\u00ac\\nOLOGY. New (2d) edition. In one octavo volume of 921 pages,\\nwith 595 illustrations. Just ready. Cloth, $4.25 leather, $5.25, net.\\nstudent who cannot understand must\\nbe dull indeed. The book is full of\\nnew, clean, sharp illustrations,which\\ntell the story frequently at a glance.\\nThe index is full and accurate.\u00e2\u0080\u0094\\nNational Druggist.\\nIn every respect the work fulfils\\nits promise, whether as a complete\\ntreatise for the student or as an ad\u00c2\u00ac\\nmirable work of reference for the\\nphysician .\u00e2\u0080\u0094North Carolina Medical\\nJournal.\\nCHARLES (T. CRANSTOUN). THE ELEMENTS OF PHYSIO\u00c2\u00ac\\nLOGICAL AND PATHOLOGICAL CHEMISTRY. Octavo, 451\\npages, with 38 engravings and 1 colored plate. Cloth, $3.50.\\nCHEYNE (W. WATSON). THE TREATMENT OF WOUNDS,\\nULCERS AND ABSCESSES. In one 12mo. volume of 207 pages.\\nCloth, $1.25.\\nOne will be surprised at the\\namount of practical and useful in\u00c2\u00ac\\nformation it contains; information\\nthat the practitioner is likely to\\nneed at any moment. The sections\\ndevoted to ulcers and abscesses are\\nindispensable to any physician.\u00e2\u0080\u0094\\nThe Charlotte Medical Journal.\\nCHEYNE (W. W.) AND BURGHARD (F. F.). SURGICAL\\nTREATMENT. In six octavo volumes, illustrated. Now ready.\\nVolume 1, 299 pages and 66 engravings. Cloth, $3.00 net. Volume 2,\\n382 pages, 141 engravings. Cloth, $4.00 net.\\nCLARKE (W. B.) AND LOCKWOOD (C. B.). THE DISSECTOR\u00e2\u0080\u0099S\\nMANUAL. In one 12mo. volume of 396 pages, with 49 engravings.\\nCloth, $1.50. See Students\u00e2\u0080\u0099 Series of Manuals, page 27.\\nCLELAND (JOHN). A DIRECTORY FOR THE DISSECTION OF\\nTHE HUMAN BODY. In one 12mo. vol. of 178 pages. Cloth, $1.25.\\nCLINICAL MANUALS. See Series of Clinical Manuals, page 25.\\nCLOUSTON (THOMAS S.). CLINICAL LECTURES ON MENTAL\\nDISEASES. New (5th) edition. In one octavo volume of 750 pages,\\nwith 19 colored plates. Cloth, $4.25, net. Just ready.\\nFolsom\u00e2\u0080\u0099s Abstract of Laws of U. S. on Custody of Insane, octavo,\\n$1.50, is sold in conjunction with Clouston on Mental Diseases for\\n$5.00, net, for the two works.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0583.jp2"}, "584": {"fulltext": "6 Lea Brothers Co., Philadelphia i and New York.\\nCLOWES (FRANK). AN ELEMENTARY TREATISE ON PRACTI\u00c2\u00ac\\nCAL CHEMISTRY AND QUALITATIVE INORGANIC ANALY\u00c2\u00ac\\nSIS. From the fourth English edition. In one handsome 12mo.\\nvolume of 387 pages, with 55 engravings. Cloth, $2.50.\\nCOAKLEY (CORNELIUS G.). THE DIAGNOSIS AND TREAT\u00c2\u00ac\\nMENT OF DISEASES OF THE NOSE, THROAT, NASO\u00c2\u00ac\\nPHARYNX AND TRACHEA. In one 12mo. volume of 526 pages\\nwith 92 engravings and 2 colored plates. Just ready. Cloth, $2.75. net.\\nCOATES (W. E\u00e2\u0080\u009e JR.). A POCKET TEXT-BOOK OF BACTE\u00c2\u00ac\\nRIOLOGY AND HYGIENE. In one handsome 12mo. volume of\\nabout 350 pages, with many illustrations. Shortly. Leas Series of\\nPocket Text-books edited by Bern B. Gallaudet, M. D. See\\npage 18.\\nCOATS (JOSEPH). A TREATISE ON PATHOLOGY. In one vol.\\nof 829 pages, with 339 engravings. Cloth, $5.50; leather, $6.50.\\nCOLEMAN (ALFRED). A MANUAL OF DENTAL SURGERY\\nAND PATHOLOGY. With Notes and Additions to adapt it to Amer\u00c2\u00ac\\nican Practice. By Thos. C. Stellwagen, M.A., M.D., D.D.S. In one\\nhandsome octavo vol. of 412 pages, with 331 engravings. Cloth, $3.25.\\nCOLLINS (C. P.). A POCKET TEXT-BOOK OF MEDICAL\\nDIAGNOSIS. In one handsome 12mo. volume of about 350 pages,\\nwith many illustrations. Shortly. Lea\u00e2\u0080\u0099s Series of Pocket Text-books,\\nedited by Bern B. Gallaudet, M. D. See page 18.\\nCOLLINS (H. D.) AND ROCKWELL (W. H.). A POCKET\\nTEXT-BOOK OF PHYSIOLOGY. 12mo. of 316 pages, with 153\\nillustrations. Just ready. Cloth, $1.50; flexible red leather, $2.00,\\nnet. Lea\u00e2\u0080\u0099s Series of Pocket Text-books, edited by Bern B. Gallau\u00c2\u00ac\\ndet, M. D. See page 18.\\nCONDIE (D. FRANCIS). A PRACTICAL TREATISE ON THE DIS\u00c2\u00ac\\nEASES OF CHILDREN. Sixth edition, revised and enlarged. In\\none large 8vo. volume of 719 pages. Cloth, $5.25; leather, $6.25.\\nCORNIL (V.). SYPHILIS: ITS MORBID ANATOMY, DIAGNO\u00c2\u00ac\\nSIS AND TREATMENT. Translated, with Notes and Additions, by\\nJ. Henry C. Simes, M.D. and J. William White, M.D. In one\\n8vo. volume of 461 pages, with 84 illustrations. Cloth, $3.75.\\nCROCKETT (M. A.). A POCKET TEXT-BOOK OF DISEASES\\nOF WOMEN. In one handsome 12mo. volume of about 350 pages,\\nwith many illustrations. Shortly. Lea\u00e2\u0080\u0099s Series of Pocket Text-books,\\nedited by Bern B. Gallaudet, M. D. See page 18.\\nCROOK (JAMES K.) ON MINERAL WATERS OF THE\\nUNITED STATES. Octavo, 575 pages. Just ready. Cloth, $3.50, net.\\nCULBRETH (DAVID M. R.). MATERIA MEDICA AND PHAR\u00c2\u00ac\\nMACOLOGY. In one handsome octavo volume of 812 pages, with\\n445 illustrations. Cloth, $4.75.\\nCUSHNY (ARTHUR R.). TEXT-BOOK OF PHARMACOLOGY.\\nHandsome 8vo., 728 pages, with 47 illus. Just ready. Cloth, $3.75, net.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0584.jp2"}, "585": {"fulltext": "Lea Brothers Co., Philadelphia and New York.\\n7\\nDALTON (JOHN C.). A TREATISE ON HUMAN PHYSIOLOGY.\\nSeventh edition. Octavo, 722 pages, with 252 engravings. Cloth,\\n$5; leather, $6. 8\\n-DOCTRINES OF THE CIRCULATION OF THE BLOOD. In\\none handsome 12mo. volume of 293 pages. Cloth, $2.\\nDAVENPORT (F. H.). DISEASES OF WOMEN. A Manual ot\\nGynecology. For the use of Students and Practitioners. New\\n(3d) edition. In one handsome 12mo. volume of 387 pages, with 150\\nillustrations. Cloth, $1.75, net. Just ready.\\nDAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. FOR\\nSTUDENTS AND PRACTITIONERS. In one very handsome\\noctavo volume of 546 pages, with 217 engravings and 30 full-page\\nplates in colors and monochrome. Cloth, $5 leather, $6.\\nFrom a practical standpoint the thoroughly scientific and brilliant\\nwork is all that could be desired. A treatise on obstetrics. \u00e2\u0080\u0094Med. News.\\nDAVIS (F. H.). LECTURES ON CLINICAL MEDICINE. Second\\nedition. In one 12mo. volume of 287 pages. Cloth, $1.75.\\nDE LA BECHE\u00e2\u0080\u0099S GEOLOGICAL OBSERVER. In one large octavo\\nvolume of 700 pages, with 300 engravings. Cloth, $4.\\nDENNIS (FREDERIC S.) AND BILLINGS (JOHN S.). A SYS\u00c2\u00ac\\nTEM OF SURGERY. In contributions by American Authors.\\nComplete work in four very handsome octavo volumes, containing\\n3652 pages, with 1585 engravings and 45 full-page plates in colors\\nand monochrome. Per volume, cloth, $6.00; leather, $7.00; half\\nMorocco, gilt back and top, $8.50. For sale by subscription only.\\nFull prospectus free on application to the publishers.\\nIt is worthy of the position which\\nsurgery has attained in the great\\nRepublic whence it comes. The\\nLondon Lancet.\\nIt may be fairly said to represent\\nthe most advanced condition of\\nAmerican surgery and is thoroughly\\npractical.\u00e2\u0080\u0094 Annals of Surgery.\\nNo work in English can be con\u00c2\u00ac\\nsidered as the rival of this.\u00e2\u0080\u0094 The\\nAmerican Journal of the Medical\\nSciences.\\nDERCUM (FRANCIS X., EDITOR). A TEXT-BOOK ON\\nNERVOUS DISEASES. By American Authors. In one handsome\\noctavo volume of 1054 pages, with 341 engravings and 7 colored\\nplates. Cloth, $6.00 leather, $7.00. Net.\\nRepresenting the actual status of\\nour knowledge of its subjects, aud\\nthe latest and most fully up-to-date\\nof any of its class.-\u00e2\u0080\u0094 Jour, of Amer\u00c2\u00ac\\nican Med. Association.\\nThe most thoroughly up-to-date\\ntreatise that we have on this subject.\\n\u00e2\u0080\u0094American Journal of Insanity.\\nThe work is representative of the\\nbest methods of teaching, as devel\u00c2\u00ac\\noped in the leading medical colleges\\nof this country.\u00e2\u0080\u0094 Alienist and Neu\u00c2\u00ac\\nrologist.\\nThe best text-book in any lan\u00c2\u00ac\\nguage.\u00e2\u0080\u0094 The Medical Fortnightly.\\nDE SCHWEINITZ (GEORGE E.). THE TOXIC AMBLYOPIAS.\\nTheir Classification, History, Symptoms, Pathology and Treatment.\\nVery handsome octavo, 240 pages, 46 engravings, and 9 full-page\\nplates in colors. Limited edition, de luxe binding, $4. Net.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0585.jp2"}, "586": {"fulltext": "8 Lea Brothers Co., Philadelphia and New York.\\nDRAPER (JOHN C.). MEDICAL PHYSICS. A Text-book for Stu\u00c2\u00ac\\ndents and Practitioners of Medicine. In one handsome octavo volume\\nof 734 pages, with 376 engravings. Cloth, $4.\\nDRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF\\nMODERN SURGERY. A new American, from the twelfth London\\nedition, edited by Stanley Boyd, F. R. C. S. In one large octavo\\nvolume of 965 pages, with 373 engravings. Cloth, $4; leather, $5.\\nDUANE (ALEXANDER). THE STUDENT\u00e2\u0080\u0099S DICTIONARY OF\\nMEDICINE AND THE ALLIED SCIENCES. New edition. Com\u00c2\u00ac\\nprising the Pronunciation, Derivation and Full Explanation of Medi\u00c2\u00ac\\ncal Terms, with much Collateral Descriptive Matter. Numerous Tables,\\netc. Square octavo of 658 pages. Cloth, $3.00; half leather, $3.25;\\nfull sheep, $3.75. Thumb-letter Index, 50 cents extra.\\nDUDLEY (E. C.). THE PRINCIPLES AND PRACTICE OF\\nGYNECOLOGY. New (2d) edition. Handsome octavo of 717 pages,\\nwith 453 illustrations in black and colors, and 8 colored plates. Cloth,\\n$5.00 net; leather, $6.00, wet. Just ready.\\nThe book can be safely recoin- tice of modem gynecology.\u00e2\u0080\u0094 Inter\\nmended as a complete and reliable national Medical Magazine.\\nexposition of the principles and prac-\\nDIJNCAN (J. MATTHEWS). CLINICAL LECTURES ON THE\\nDISEASES OF WOMEN. Delivered in St. Bartholomew\u00e2\u0080\u0099s Hospital.\\nIn one octavo volume of 175 pages. Cloth, $1.50.\\nDUNGLISON (ROBLEY). A DICTIONARY OF MEDICAL SCI\u00c2\u00ac\\nENCE. Containing a full explanation of the various subjects and\\nterms of Anatomy, Physiology Medical Chemistry, Pharmacy, Phar\u00c2\u00ac\\nmacology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Sur\u00c2\u00ac\\ngery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecol-\\nogy, Obstetrics, Pediatrics, Medical Jurisprudence, Dentistry, etc., etc.\\nBy Robley Dunglison, M. D., LL. D., late Professor of Institutes\\nof Medicine in the Jefferson Medical College of Philadelphia. Edited\\nby Richard J. Dtjnglison, A. M., M. D. Twenty-first edition, thor\u00c2\u00ac\\noughly revised and greatly enlarged and improved, with the Pronuncia\u00c2\u00ac\\ntion, Accentuation and Derivation of the Terms. With Appendix.\\nIn one magnificent imperial octavo volume of 1225 pages. Cloth, $7\\nleather, $8 Thumb-letter Index for quick use, 75 cents extra.\\nThe most satisfactory and authori- scarcely be measured.\u00e2\u0080\u0094 Med. Record.\\nPronunciation is indicated by the\\nphonetic system. The definitions are\\nunusually clear and concise. The\\nbook is wholly satisfactory.\u00e2\u0080\u0094 Uni\u00c2\u00ac\\nversity Medical Magazine.\\ntative guide to the derivation, defini\u00c2\u00ac\\ntion and pronunciation of medical\\nterms .\u00e2\u0080\u0094The Charlotte Med. Journal.\\nCovering the entire field of medi\u00c2\u00ac\\ncine, surgery and the collateral\\nsciences, its range of usefulness can\\nDUNHAM (EDWARD K.). MORBID AND NORMAL HIS\u00c2\u00ac\\nTOLOGY. Octavo, 450 pages,with 363 illustrations. Cloth, $3.25, net.\\nThe best one-volume text or refer- i of published in America.\u00e2\u0080\u0094 Virginia\\nence book on histology that we know I Medical Semi-Monthly.\\nEDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND\\nMATERIA MEDICA. In one8vo. volume of 544 pages. Cloth, $3.50;\\nleather, $4.50.\\nEDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for\\nStudents and Practitioners. In one handsome 8vo. volume of 576 pages,\\nwith 148 engravings. Cloth, $3 leather, $4.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0586.jp2"}, "587": {"fulltext": "Lea Brothers Co., Philadelphia and New York. 9\\nEGBERT (SENECA). A MANUAL OF HYGIENE AND SANI\u00c2\u00ac\\nTATION. In one 12mo. volume of 359 pages, with 63 illustrations.\\nJust ready. Cloth, Net $2.25.\\nIt is written in plain language,\\nand, while primarily designed for\\nphysicians, it can be studied with\\nprofit by any one of ordinary intel\u00c2\u00ac\\nligence. The writer has adapted it\\nto American conditions, and his\\nsuggestions are, above all, practical.\\nThe New York Medical Journa l.\\nELLIS (GEORGE VINER). DEMONSTRATIONS IN ANATOMY.\\nEighth edition. Octavo, 716 pages, with 249 engravings. Cloth,\\n$4.25; leather, $5.25.\\nEMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC\u00c2\u00ac\\nTICE OF GYNAECOLOGY. Third edition. Octavo, 880 pages, with\\n150 original engravings. Cloth, $5; leather, $6.\\nERICHSEN (JOHN E.). THE SCIENCE AND ART OF SUR\u00c2\u00ac\\nGERY. Eighth edition. In two large octavo volumes containing\\n2316 pages, with 984 engravings. Cloth, $9 leather, $11.\\nESSIG (CHARLES J.). PROSTHETIC DENTISTRY. S ee American\\nText-Books of Dentistry page 2.\\nEVANS (DAVID J.). A POCKET TEXT-BOOK OF OBSTETRICS.\\nIn one handsome 12mo. volume of about 300 pages, with many illustra\u00c2\u00ac\\ntions. Shortly. Lea s Series of Pocket Text-books edited by Bern B.\\nGallaudet/M. D. See page 18.\\nFARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS.\\nFourth American from fourth English edition, revised by Frank\\nWoodbury, M. D. In one 12mo. volume of 581 pages. Cloth, $2.50.\\nFIELD (GEORGE P.). A MANUAL OF DISEASES OF THE\\nEAR. Fourth edition. In one octavo volume of 391 pages, with 73\\nengravings and 21 colored plates. Cloth, $3.75.\\nFLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND\\nPRACTICE OF MEDICINE. Seventh edition, thoroughly revised\\nby Frederick P. Henry, M. D. In one large 8vo. volume of 1143\\npages, with engravings. Cloth, $5.00; leather, $6.00.\\nThe work has well earned its lead- The best of American text-books\\ning place in medical literature.\u00e2\u0080\u0094 on Practice.\u00e2\u0080\u0094 Amer.Medico-Surgical\\nMedical Record. Bulletin.\\n-A MANUAL OF AUSCULTATION AND PERCUSSION; or\\nthe Physical Diagnosis of Diseases of the Lungs and Heart, and of\\nThoracic Aneurism. Fifth edition, revised by James C. Wilson, M. D.\\nIn one handsome 12mo. volume of 274 pages, with 12 engravings.\\n-A PRACTICAL TREATISE ON TIJE DIAGNOSIS AND\\nTREATMENT OF DISEASES OF THE HEART. Second edition\\nenlarged. In one octavo volume of 550 pages. Cloth, $4.\\n-A PRACTICAL TREATISE ON THE PHYSICAL EXPLO\u00c2\u00ac\\nRATION OF THE CHEST, AND THE DIAGNOSIS OF DIS\u00c2\u00ac\\nEASES AFFECTING THE RESPIRATORY ORGANS. Second\\nand revised edition. In one octavo volume of 591 pages. Cloth, $4.50.\\n-MEDICAL ESSAYS. In one 12mo. vol. of 210 pages. Cloth, $1.38.\\n_ON PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY,ETC.\\nA Series of Clinical Lectures. In one 8vo. volume of 442 pages.\\nCloth, $3.50.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0587.jp2"}, "588": {"fulltext": "10 Lea Brothers Co., Philadelphia and New York\\nFOLSOM (C. F.). AN ABSTRACT OF STATUTES OF U. S.\\nON CUSTODY OF THE INSANE. In one 8vo. vol. of 108 pages.\\nCloth, $1.50. With Clouston on Mental Diseases (new edition, see\\npage 6) $5.00, net for the two works.\\nFORMULARY, POCKET, see page 32.\\nFOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New\\n(6th) and revised American from the sixth English edition. In one\\nlarge octavo volume of 923 pages, with 257 illustrations. Cloth, $4.50;\\nleather, $5.50.\\nUnquestionably the best book that\\ncan be placed in the student\u00e2\u0080\u0099s hands,\\nand as a work of reference for the\\nbusy physician it can scarcely be\\nexcelled.\u00e2\u0080\u0094 The Phila. Polyclinic.\\nThis single volume contains all\\nthat will be necessary in a college\\ncourse, and all that the physician\\nwill need as well.\u00e2\u0080\u0094 Dominion Med.\\nMonthly.\\nFOTHERGILL (J. MILNER). THE PRACTITIONER\u00e2\u0080\u0099S HAND\u00c2\u00ac\\nBOOK OF TREATMENT. Third edition. In one handsome octavo\\nvolume of 664 pages. Cloth, $3.75; leather, $4.75.\\nFOWNES (GEORGE). A MANUAL OF ELEMENTARY CHEM\u00c2\u00ac\\nISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em\u00c2\u00ac\\nbodying Watts\u00e2\u0080\u0099 Physical and Inorganic Chemistry. In one royal\\n12mo. volume of 1061 pages, with 168 engravings, and 1 colored\\nplate. Cloth, $2.75; leather, $3.25.\\nFRANKLAND (E.) AND JAPP (F.R.). INORGANIC CHEMISTRY.\\nIn one handsome octavo volume of 677 pages, with 51 engravings and\\n2 plates. Cloth, $3.75 leather, $4.75.\\nFULLER (EUGENE). DISORDERS OF THE SEXUAL OR\u00c2\u00ac\\nGANS IN THE MALE. In one verv handsome octavo volume of\\n238 pages, with 25 engravings\\nIt is an interesting work, and one\\nwhich, in view of the large and\\nprofitable amount of work done in\\nthis field of late years, is timely and\\nwell needed.\u00e2\u0080\u0094 Medical Fortnightly.\\nThe book is valuable and instruc-\\nand 8 full-page plates. Cloth, $2.\\ntive and brings views of sound\\npathology and rational treatment to\\nmany cases of sexual disturbance\\nwhose treatment has been too often\\nfruitless for good. Annals of\\nSurgery.\\nFULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR\\nPASSAGES. Their Pathology, Physical Diagnosis, Symptoms and\\nTreatment. From second English edition. In one 8vo. volume of 475\\npages. Cloth, $3.50.\\nGALLAUDET (BERN B.). A POCKET TEXT-BOOK ON SUR\u00c2\u00ac\\nGERY. In one handsome 12mo. volume of about 400 pages, with many\\nillustrations. Shortly. Lea x s Series of Pocket Text-books, edited by\\nBern B. Gallaudet, M. D. See page 18.\\nGANT (FREDERICK JAMES). THE STUDENT\u00e2\u0080\u0099S SURGERY. A\\nMultum in Parvo. In one square octavo volume of 845 pages, with\\n159 engravings. Cloth, $3.75.\\nGIBBES (HENEAGE). PRACTICAL PATHOLOGY AND MORBID\\nHISTOLOGY. Octavo, 314 pages, with 60 illustrations. Cloth, $2.75.\\nGIBNEY (V. P.). ORTHOPEDIC SURGERY. For the use of Practi\u00c2\u00ac\\ntioners and Students. In one 8vo. vol. profusely illus. Preparing.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0588.jp2"}, "589": {"fulltext": "Lea Brothers Co., Philadelphia and New York. 11\\nGERRISH (FREDERIC H.). A TEXT-BOOK OF ANATOMY.\\nBy American Authors. Edited by Frederic H. Gerrish, M. D. In one\\nimp. octavo volume of 915 pages, with 950 illustrations in black and\\ncolors. Just ready. Clth,$6.50; flexible waterproof, $7; leath., $7.50, net.\\nIn this, the first representative treatise on Anatomy produced in America,\\nno effort or expense has been spared to unite an authoritative text with the\\nmost successful anatomical pictures which have yet appeared in the world.\\nThe editor has secured the co-operation of the professors of anatomy in\\nleading medical colleges, and with them has prepared a text conspicuous\\nfor its simplicity, unity and judicious selection of such anatomical facts as\\nbear on physiology, surgery and internal medicine in the most compre\u00c2\u00ac\\nhensive sense of those terms. The authors have endeavored to make a\\nbook which shall stand in the place of a living teacher to the student, and\\nwhich shall be of actual service to the practitioner in his clinical work,\\nemphasizing the most important subjects, clarifying obscurities, helping\\nmost in the parts most difficult to learn, and illustrating everything by all\\navailable methods.\\nGOULD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo.\\nvol. of 589 pages. Cloth, $2. See Student s Series of Manuals, p. 27.\\nGRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL.\\nNew and thoroughly revised American edition, much enlarged in text,\\nand in engravings in black and colors. In one imperial octavo volume\\nof 1239 pages, with 772 large and elaborate engravings on wood. Price\\nof edition with illustrations in colors cloth, $7; leather, $8. Price\\nof edition with illustrations in black: cloth, $6 leather, $7.\\nThis is the best single volume\\nupon Anatomy in the English\\nlanguage.\u00e2\u0080\u0094 University Medical Mag\u00c2\u00ac\\nazine.\\nGray s Anatomy affords the student\\nmore satisfaction than any other\\ntreatise with which we are familiar.\\n\u00e2\u0080\u0094Buffalo Med. Journal.\\nThe most largely used anatomical\\ntext-book published in the English\\nlanguage.\u00e2\u0080\u0094 Annals of Surgery.\\nParticular stress is laid upon the\\npractical side of anatomical teach\u00c2\u00ac\\ning, and especially the Surgical\\nAnatomy. \u00e2\u0080\u0094Chicago Med. Recorder.\\nHolds first place in the esteem of\\nboth teachers and students.\u00e2\u0080\u0094 I he\\nBrooklyn Medical Journal.\\nThe foremost of all medical text\u00c2\u00ac\\nbooks.\u00e2\u0080\u0094 Medical Fortnightly.\\nGray s Anatomy should be the\\nfirst work which a medical student\\nshould purchase, nor should he be\\nwithout a copy throughout his pro\u00c2\u00ac\\nfessional career. \u00e2\u0080\u0094Pittsburg Medical\\nReview.\\nGRAY (LANDON CARTER). A TREATISE ON NERVOUS AND\\nMENTAL DISEASES. For Students and Practitioners of Medicine.\\nNew (2d) edition. In one handsome octavo volume of 728 pages, with\\n172 engravings and 3 colored plates. Cloth, $4.75; leather, $5.75.\\nAn up-to-date text-book upon\\nnervous and mental diseases com\u00c2\u00ac\\nbined. A well-written, terse, ex\u00c2\u00ac\\nplicit, and authoritative volume\\ntreating of both subjects is a step in\\nthe direction of popular demand.\u00e2\u0080\u0094\\nThe Chicago Clinical Review.\\nThe descriptions of the various\\ndiseases are accurate and the symp\u00c2\u00ac\\ntoms and differential diagnosis are\\nset before the student in such a way\\nas to be readily comprehended. The\\nauthor\u00e2\u0080\u0099s long experience renders his\\nviews on therapeutics of great value.\\nThe Journal of Nervous and Men\u00c2\u00ac\\ntal Disease.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0589.jp2"}, "590": {"fulltext": "12 Lea Brothers Co., Philadelphia and New York\\nGREEN (T. HENRY). AN INTRODUCTION TO PATHOLOGY\\nAND MORBID ANATOMY. New (8th) American from the eighth\\nLondon edition. In one handsome octavo volume of 582 pages, with\\n216 engravings and a colored plate. Cloth, $2.50, net. Just ready.\\nA work that is the text-book of\\nprobably four-fifths of all the stu\u00c2\u00ac\\ndents of pathology in the United\\nStates and Great Britain. \u00e2\u0080\u0094The\\nAmerican Practitioner and News.\\nIt is fully up-to-date in the record\\nof fact, and so profusely illustrated\\nas to give to each detail of text\\nsufficient explanation. The work is\\nan essential to the practitioner\u00e2\u0080\u0094\\nwhether as surgeon or physician. It\\nis the best of up-to-date text-books.\\nVirginia Med. Monthly.\\nGREENE (WILLIAM H.). A MANUAL OF MEDICAL CHEM\u00c2\u00ac\\nISTRY. For the Use of Students. Based upon Bowman\u00e2\u0080\u0099s Medical\\nChemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75.\\nGROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DIS\u00c2\u00ac\\nEASES, INJURIES AND MALFORMATIONS OF THE URINARY\\nBLADDER, THE PROSTATE GLAND AND THE URETHRA.\\nThird edition. Octavo, 574 pages, with 170 illustrations Cloth, $4.50.\\nGRINDON (JOSEPH). A POCKET TEXT-BOOK OF SKIN\\nDISEASES. In one handsome 12mo. volume of 350 pages, with\\nmany illustrations. Shortly. Lea s Series of Pocket Text-books, edited\\nby Bern B. Gallaudet, M. D. See page 18.\\nHABERSHON (S. O.). ON THE DISEASES OF THE ABDOMEN\\nSecond American from the third English edition. In one octavo vol\u00c2\u00ac\\nume of 554 pages, with 11 engravings. Cloth, $3.50.\\nHALL (WINFIELD S.). TEXT-BOOK OF PHYSIOLOGY. Octavo\\nof 672 pages, with 343 engravings, and 6 full page colored plates. Just\\nready. Cloth, $4.00 leather, $5.00, net.\\nHAMILTON (ALLAN MCLANE). NERVOUS DISEASES. THEIR\\nDESCRIPTION AND TREATMENT. Second and revised edition.\\nIn one octavo volume of 598 pages, with 72 engravings. Cloth, $4.\\nHARDAWAY (W. A.). MANUAL OF SKIN DISEASES. New (2d)\\nedition. In one 12mo. volume of 560 pages, with 40 illustrations and\\n2 plates. Cloth, $2.25, net. Just ready.\\nThe best of all the small books to\\nrecommend to students and practi\u00c2\u00ac\\ntioners. Probably no one of our\\ndermatologists has had a wider every\u00c2\u00ac\\nday clinical experience. His great\\nstrength is in diagnosis, descriptions\\nof lesions and especially in treat\u00c2\u00ac\\nment. \u00e2\u0080\u0094Indiana Medical Journal.\\nHARE (HOBART AMORY). PRACTICAL DIAGNOSIS. THE\\nUSE OF SYMPTOMS IN THE DIAGNOSIS OF DISEASE. New\\n(4th) edition. In one octavo volume of 623 pages, with 205 engravings\\nand 14 full-page colored plates. Cloth, $5.00, net. Just ready.\\nIt is unique in many respects, and\\nthe author has introduced radical\\nchanges which will be welcomed by\\nall. Anyone who reads this book\\nwill become a more acute observer,\\nwill pay more attention to the simple utility .\u00e2\u0080\u0094Medical Review.\\nyet indicative signs of disease, and\\nhe will become a better diagnosti\u00c2\u00ac\\ncian. This is a companion to Prac\u00c2\u00ac\\ntical Therapeutics, by the same\\nauthor, and it is difficult to conceive\\nof any two works of greater practical", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0590.jp2"}, "591": {"fulltext": "Lea Brothers Co., Philadelphia and New York. 13\\nHARE (HOBART AMORY). A TEXT-BOOK OF PRACTICAL\\nTHERAPEUTICS, with Special Reference to the Application of Reme\u00c2\u00ac\\ndial Measures to Disease and their Employment upon a Rational\\nBasis. With articles on various subjects by well-known specialists.\\nNew (7th) and revised edition. In one octavo volume of 776 pages.\\nCloth, $3.75, net; leather, $4.50, net.\\nIts classifications are inimitable,\\nand the readiness with which any\u00c2\u00ac\\nthing can be found is the most won\u00c2\u00ac\\nderful achievement of the art of in\u00c2\u00ac\\ndexing. This edition takes in all\\nthe latest discovered remedies.\u00e2\u0080\u0094\\nThe St. Louis Clinique.\\nThe great value of the work lies\\nin the fact that precise indications\\nfor administration are given. A\\ncomplete index of diseases and\\nremedies makes it an easy reference\\nwork. It has been arranged so that\\nit can be readily used in connection\\nwith Hare\u00e2\u0080\u0099s Practical Diagnosis.\\nFor the needs of the student and\\ngeneral practitioner it has no equal.\\n\u00e2\u0080\u0094Medical Sentinel.\\nThe best planned therapeutic work\\nof the century .\u00e2\u0080\u0094American Prac\u00c2\u00ac\\ntitioner and News.\\nIt is a book precisely adapted to\\nthe needs of the busy practitioner,\\nwho can rely upon finding exactly\\nwhat he needs.\u00e2\u0080\u0094 The National Med\u00c2\u00ac\\nical Review.\\nHARE (HOBART AMORY) ON THE MEDICAL COMPLICA\u00c2\u00ac\\nTIONS AND SEQUELAE OF TYPHOID FEVER. Octavo, 276\\npages, 21 engravings and two full-page plates. Just ready. Cloth,\\n$2.40, net.\\nA very valuable production. One read with great profit.\u00e2\u0080\u0094 Cleveland.\\nof the very best products of Dr. Journal of Medicine.\\nHare and one that every man can\\nHARE (HOBART AMORY, EDITOR). A SYSTEM OF PRAC\u00c2\u00ac\\nTICAL THERAPEUTICS. In a series of contributions by eminent\\npractitioners. In four large octavo volumes comprising about 4500\\npages,with about 550 engravings. Vol. IV., just ready. For sale by sub\u00c2\u00ac\\nscription only. Full prospectus free on application to the Publishers.\\nRegular price, Vol. IV., cloth, $6; leather, $7; half Russia, $8.\\nPrice Vol. IV. to former or new subscribers to complete work, cloth,\\n$5 leather, $6; half Russia, $7. Complete work, cloth, $20; leather,\\n$24; half Russia, $28.\\nThe great value of Hare\u00e2\u0080\u0099s System of Practical Therapeutics has led to a\\nwidespread demand for a new volume to represent advances in treatment\\nmade since the publication of the first three. More than fulfilling this\\nrequest the Editor has secured contributions from practically a new coips\\nof equally eminent authors, so that entirely fresh and original mattei is\\nensured. The plan of the work, which proved so successful, has been fol\u00c2\u00ac\\nlowed in this new volume, which will be found to present the latest devel\u00c2\u00ac\\nopments and applications of this most practical branch of the medical art.\\nThe entire System is an unrivalled encyclopaedia on the practical parts of\\nmedicine, and merits the great success it has won for that reason.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0591.jp2"}, "592": {"fulltext": "14 Lea Brothers Co., Philadelphia and New York.\\nHARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES\\nAND PRACTICE OF MEDICINE. Fifth edition. In one 12mo.\\nvolume, 669 pages, with 144 engravings. Cloth, $2.75.\\n-A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one\\n12mo. volume of 310 pages, with 220 engravings. Cloth, $1.75.\\n-A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising\\nManuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac\u00c2\u00ac\\ntice of Medicine, Surgery and Obstetrics. Second edition. In one royal\\n12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25; leather, $5.\\nHAYDEN (JAMES R.). A MANUAL OF VENEREAL DISEASES.\\nNew (2d) edition. In one 12mo. volume of 304 pages, with 54 en\u00c2\u00ac\\ngravings. Cloth, $1.50, net.\\nIt is practical, concise, definite\\nand of sufficient fulness to be satis\u00c2\u00ac\\nfactory. \u00e2\u0080\u0094Chicago Clinical Review.\\nThis work gives all of the prac\u00c2\u00ac\\ntically essential information about\\nthe three venereal diseases, gon\u00c2\u00ac\\norrhoea, the chancroid and syphilis.\\nIn diagnosis and treatment it is par\u00c2\u00ac\\nticularly thorough, and may be\\nrelied upon as a guide in the man\u00c2\u00ac\\nagement of this class of diseases.\u00e2\u0080\u0094\\nNorthwestern Lancet.\\nIt is well written, up to date, and\\nwill be found very useful.\u00e2\u0080\u0094 Inter\u00c2\u00ac\\nnational Medical Magazine.\\nHAYEM (GEORGES) AND HARE (H. A PHYSICAL AND\\nNATURAL THERAPEUTICS. The Remedial Use of Heat, Elec\u00c2\u00ac\\ntricity, Modifications of Atmospheric Pressure, Climates and Mineral\\nWaters. Edited by Prof. H. A. Hare, M. D. In one octavo volume\\nof 414 pages,with 113 engravings. Cloth, $3.\\nThis well-timed up-to-date volume\\nis particularly adapted to the re\u00c2\u00ac\\nquirements of the general practi\u00c2\u00ac\\ntioner. The section on mineral\\nwaters is most scientific and prac\u00c2\u00ac\\ntical. Some 200 pages are given up\\nto electricity and evidently embody\\nthe latest scientific information on\\nthe subject. Altogether this work\\nis the clearest and most practical aid\\nto the study of nature\u00e2\u0080\u0099s therapeutics\\nthat has yet come under our obser\\nvation. \u00e2\u0080\u0094The Medical Fortnightly.\\nFor many diseases the most potent\\nremedies lie outside of the materia\\nmedica, a fact yearly receiving wider\\nrecognition. Within this large\\nrange of applicability, physical\\nagencies when compared with drugs\\nare more direct and simple in their\\nresults. Medical literature has long\\nbeen rich in treatises upon medical\\nagents, but an authoritative work\\nupon the other great branch of\\ntherapeutics has until now been a\\ndesideratum. The section on climate,\\nrewritten by Prof. Hare, will, for\\nthe first time, place the abundant\\nresources of our country at the in\u00c2\u00ac\\ntelligent command of American\\npractitioners. The Kansas City\\nMedical Index.\\nHERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In\\none 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. See\\nStudent s Series of Manuals, page 27.\\nHERMANN (Li.). EXPERIMENTAL PHARMACOLOGY. A Hand\u00c2\u00ac\\nbook of the Methods for Determining the Physiological Actions of\\nDrugs. Translated by Robert Meade Smith, M. D. In one 12mo.\\nvolume ot 199 pages, with 32 engravings. Cloth, $1.50.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0592.jp2"}, "593": {"fulltext": "Lea Brothers Co., Philadelphia and New York. 15\\nHERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In\\none handsome 12mo. volume of 429 pages, with 80 engravings and 2\\ncolored plates. Cloth, $2.50.\\nExcellently arranged, practical,\\nconcise, up-to-date, and eminently\\nwell fitted for the use of the prac\u00c2\u00ac\\ntitioner as well as of the student.\u00e2\u0080\u0094\\nChicago Med. Recorder.\\nThis volume accomplishes its ob\u00c2\u00ac\\njects more thoroughly and com\u00c2\u00ac\\npletely than any similar work yet\\npublished. Each section devoted to\\ndiseases of special systems is pre\u00c2\u00ac\\nceded with an exposition of the\\nmethods of physical, chemical and\\nmicroscopical examination to be em\u00c2\u00ac\\nployed in each class. The technique\\nof blood examination,including color\\nanalysis, is very clearly stated.\\nUranalysis receives adequate space\\nand care. \u00e2\u0080\u0094New York Med. Journal.\\nWe commend the book not only to\\nthe undergraduate, but also to the\\nphysician who desires a ready means\\nof refreshing his knowledge of diag\u00c2\u00ac\\nnosis in the exigencies of professional\\nlife.\u00e2\u0080\u0094 Memphis Medical Monthly.\\nHELL. (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS\\nDISORDERS. In one 8vo. volume of 479 pages. Cloth, $3.25.\\nHILLtER (THOMAS). A HANDBOOK OF SKIN DISEASES.\\nSecond edition. In one royal 12mo. volume of 353 pages, with two\\nplates. Cloth, $2.25.\\nHIRST (BARTON C.) AND PIERSOL (GEORGE A.). HUMAN\\nMONSTROSITIES. Magnificent folio, containing 220 pages of text\\nand illustrated with 123 engravings and 39 large photographic plates\\nfrom nature. In four parts, price each, $5. Limited edition. For sale\\nby subscription only.\\nHOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS\\nUSED IN MEDICINE AND THE COLLATERAL SCIENCES.\\nIn one 12mo. volume of 520 double-columned pages. Cloth, $1.50\\nleather, $2.\\nHODGE (HUGH L.). ON DISEASES PECULIAR TO WOMEN,\\nINCLUDING DISPLACEMENTS OF THE UTERUS. Second and\\nrevised edition. In one 8vo. vol. of 519 pp.,with illus. Cloth, $4.50\\nHOFFMANN (FREDERICK) AND POWER (FREDERICK B.).\\nA MANUAL OF CHEMICAL ANALYSIS, as Applied to the\\nExamination of Medicinal Chemicals and their Preparations. Third\\nedition, entirely rewritten and much enlarged. In one handsome octavo\\nvolume of 621 pages, with 179 engravings. Cloth, $4.25.\\nHOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Prin\u00c2\u00ac\\nciples and Practice. A new American from the fifth English edition.\\nEdited by T. Pickering Pick, F.R.C.S. In one handsome octavo vol\u00c2\u00ac\\nume of 1008jpages, with 428 engravings. Cloth, $6; leather, $7.\\n-A SYSTEM OF SURGERY. With notes and additions by various\\nAmerican authors. Edited by John H. Packard, M. D. In three\\nvery handsome 8vo. volumes containing 3137 double-columned pages,\\nwith 979 engravings and 13 lithographic plates. Per volume, cloth, $6\\nleather, $7 half Russia, $7.50. For sale by subscription only.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0593.jp2"}, "594": {"fulltext": "16 Lea Brothers Co., Philadelphia and New York.\\nHORNER (WILLIAM E.). SPECIAL ANATOMY AND HIS\u00c2\u00ac\\nTOLOGY. Eighth edition, revised and modified. In two large 8vo.\\nvolumes of 1007 pages, containing 320 engravings. Cloth, $6.\\nHUDSON (A.). LECTURES ON THE STUDY OF FEVER. In one\\noctavo volume of 308 pages. Cloth, $2.50.\\nHUTCHISON (ROBERT) AND RAINY (HARRY). CLINICAL\\nMETHODS. A GUIDE TO THE PRACTICAL STUDY OF\\nMEDICINE. In one 12mo. volume of 562 pages, with 137 engrav\u00c2\u00ac\\nings and 8 colored plates. Cloth, $3.00.\\nA comprehensive, clear and re\u00c2\u00ac\\nmarkably up-to-date guide to clinical\\ndiagnosis. The illustrations are\\nplentiful and excellent. As exam\u00c2\u00ac\\nples of the more recent additions to\\nmedical knowledge which receive\\nrecognition, we mention Widal\u00e2\u0080\u0099s\\ntest for typhoid and the Neuron\\ntheory of the nervous system.\u00e2\u0080\u0094\\nMontreal Medical Journal.\\nHUTCHINSON (JONATHAN). SYPHILIS. In one pocket-size 12mo.\\nvolume of 542 pages, with 8 chromo-lithographic plates. Cloth, $2.25.\\nSee Series of Clinical Manuals, p. 25.\\nHYDE (JAMES NEVINS). A PRACTICAL TREATISE ON DIS\u00c2\u00ac\\nEASES OF THE SKIN. New (4th) edition, thoroughly revised.\\nIn one octavo volume of 815 pages, with 110 engravings and 12 full-\\npage plates, 4 of which are colored. Cloth, $5.25; leather, $6.25.\\nThis edition has been carefully re\u00c2\u00ac\\nvised, and every real advance has\\nbeen recognized. The work answers\\nthe needs of the general practitioner,\\nthe specialist, and the student .\u00e2\u0080\u0094The\\nOhio Med. Jour.\\nA treatise of exceptional merit\\ncharacterized by conscientious care\\nand scientific accuracy. Buffalo\\nMed. Journal.\\nA complete exposition of our\\nknowledge of cutaneous medicine as\\nit exists to-day. The teaching in\u00c2\u00ac\\nculcated throughout is sound as well\\nas practical .\u00e2\u0080\u0094The American Jour\u00c2\u00ac\\nnal of the Medical Sciences.\\nIt is the best one-volume work\\nthat we know. The student who\\ngets this book will find it a useful\\ninvestment, as it will well serve him\\nwhen he goes into practice.\u00e2\u0080\u0094 Vir\u00c2\u00ac\\nginia Medical Semi-Monthly.\\nA full and thoroughly modern\\ntext-book on dermatology. The\\nPittsburg Medical Review.\\nIt is the most practical hand\u00c2\u00ac\\nbook on dermatology with which we\\nare acquainted .\u00e2\u0080\u0094The Chicago Med\u00c2\u00ac\\nical Recorder.\\nJACKSON (GEORGE THOMAS). THE READY-REFERENCE\\nHANDBOOK OF DISEASES OF THE SKIN. New (3d) edition.\\nIn one 12mo. volume of 637 pages, with 75 illustrations and a colored\\nplate. Just ready. Cloth, $2.50, net.\\nAs a student\u00e2\u0080\u0099s manual, it may be\\nconsidered beyond criticism. The\\nbook is singularly full.\u00e2\u0080\u0094 St. Louis\\nMedical and Surgical Journal.\\nWithout doubt forms one of the\\nbest guides for the beginner in der\u00c2\u00ac\\nmatology that is to be found in the\\nEnglish language.\u00e2\u0080\u0094 Medicine.\\nJAMIESON (W. ALLAN). DISEASES OF THE SKIN. Third\\nedition. In one octavo volume of 656 pages, with 1 engraving and 9\\ndouble-page chromo-lithographic plates. Cloth, $6.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0594.jp2"}, "595": {"fulltext": "Lea Brothers Co., Philadelphia and New York. 17\\nJEWETT (CHARLES). ESSENTIALS OF OBSTETRICS. In one\\n12mo. volume of 356 pages, with 80 engravings and 3 colored plates.\\nCloth, $2.25. Just ready.\\nAn exceedingly useful manual for ing it in attractive and easily tangi-\\nstudent and practitioner. The au- ble form. The book is well illus-\\nthor has succeeded unusually well trated throughout.\u00e2\u0080\u0094 Nashville Jour.\\nin condensing the text and in arrang- j of Medicine and Surgery.\\nTHE PRACTICE OF OBSTETRICS. By American Authors.\\nOne large octavo volume of 763 pages, with 441 engravings in black\\nand colors, and 22 full-page colored plates. Just ready. Cloth,\\n$5.00, net; leather, $6.00, net.\\nA clear and practical treatise upon the book abounds. The work is\\nobstetrics by well-known teachers of sure to be popular with medical\\nthe subject. A special feature of students, as well as being of extreme\\nthis work would seem to be the value to the practitioner. The\\nexcellent illustrations with which Medical Age.\\nJONES (C. HANDF1ELD CLINICAL OBSERVATIONS ON\\nFUNCTIONAL NERVOUS DISORDERS. Second American edi\u00c2\u00ac\\ntion. In one octavo volume of 340 pages. Cloth, $3.25.\\nJULER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE\\nAND PRACTICE. Second edition. In one octavo volume of 549\\npages, with 201 engravings, 17 chromo-lithographic plates, test-types of\\nJaeger and Snellen, ana Holmgren\u00e2\u0080\u0099s Color-Blindness Test. Cloth,\\n$5.50; leather, $6.50.\\nThe volume is particularly rich in\\nmatter of practical value, such as\\ndirections for diagnosing, use of\\ninstruments, testing for glasses, for\\ncolor blindness, etc. The sections\\ndevoted to treatment are singularly\\nfull and concise.\u00e2\u0080\u0094 Medical Age.\\nKING (A. F. A.). A MANUAL OF OBSTETRICS. Seventh edition.\\nIn one 12mo. volume of 573 pages, with 223 illustrations. Cloth,\\n$2.50.\\nFrom first to finish it is thoroughly\\npractical, ooncise in expression, well\\nillustrated, and includes a statement\\nof nearly every fact of importance\\ndiscussed in obstetric treatises or\\ncyclopedias. The well-arranged\\nindex renders the book useful to\\nthe practitioner who is in haste to\\nrefresh his memory. Virginia\\nMedical Semi-Monthly.\\nKIRK (EDWARD C.). OPERATIVE DENTISTRY. Handsome\\noctavo of 700 pages, with 751 illustrations. Just ready. See American\\nText-Books of Dentistry page 2.\\nWe have only the highest praise\\nfor this valuable work. It is replete\\nin every particular, and surpasses\\nanything of the kind heretofore at\u00c2\u00ac\\ntempted. We can heartily recom\u00c2\u00ac\\nmend it to the profession.\u00e2\u0080\u0094 The\\nOhio Dental Journal.\\nKLEIN (E.). ELEMENTS OF HISTOLOGY. New (5th) edition. In\\none 12mo. volume of 506 pages, with 296 engravings. Just ready.\\nCloth, $2.00, net. See Student s Series of Manuals, page 27.\\nIt is the most complete and con- I This work deservedly occupies a\\ncise work of the kind that has yet first place as a text-book on his-\\nemanated from the press.\u00e2\u0080\u0094 The Med- tology.\u00e2\u0080\u0094 Canadian Practitioner,\\nical Age.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0595.jp2"}, "596": {"fulltext": "18 Lea Brothers Co., Philadelphia and New York.\\nLANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one\\nhandsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75.\\nL/A ROCHE (R.). YELLOW FEVER. In two 8vo. volumes of 1468\\npages. Cloth, $7.\\nLAURENCE (J. Z.) AND MOON (ROBERT C.). A HANDY-\\nBOOK OF OPHTHALMIC SURGERY. Second edition. In one\\noctavo volume of 227 pages, with 66 engravings. Cloth, $2.75.\\nLEA S SERIES OF POCKET TEXT-BOOKS, edited hy Bern\\nB. Gallaudet, M. D. Covering the entire field of Medicine in a\\nseries of 16 very handsome 12mo. volumes of 350-450 pages each,\\nprofusely illustrated. Compendious, clear, trustworthy and modern.\\nThe following volumes constitute the series.\\nCoates\u00e2\u0080\u0099 Bacteriology and Hygiene. Brockway\u00e2\u0080\u0099s Anatomy. Collins\\nand Rockwell\u00e2\u0080\u0099s Physiology. Martin and Rockwell\u00e2\u0080\u0099s Chemistry\\nand Physics. Nichols and Vale\u00e2\u0080\u0099s Histology and Pathology.\\nSchleif\u00e2\u0080\u0099s Materia Medica, Therapeutics, Medical Latin, etc. Mals-\\nbary\u00e2\u0080\u0099s Practice of Medicine. Collins\u00e2\u0080\u0099 Diagnosis. Potts\u00e2\u0080\u0099 Nervous\\nand Mental Diseases. Gallaudet\u00e2\u0080\u0099s Surgery. Likes\u00e2\u0080\u0099 Genito\u00c2\u00ac\\nurinary and Venereal Diseases. Grindon\u00e2\u0080\u0099s Dermatology. Ballen-\\nGER and Wippern\u00e2\u0080\u0099s Diseases of the Eye, Ear, Throat and Nose.\\nEvans\u00e2\u0080\u0099 Obstetrics. Crockett\u00e2\u0080\u0099s Gynecology. Tuttle\u00e2\u0080\u0099s Diseases or\\nChildren.\\nFor separate notices see under various authors\u00e2\u0080\u0099 names.\\nLEA (HENRY C.). A HISTORY OF AURICULAR CONFESSION\\nAND INDULGENCES IN THE LATIN CHURCH. In three\\noctavo volumes of about 500 pages each. Per volume, cloth, $3.00.\\n-CHAPTERS FROM THE RELIGIOUS HISTORY OF SPAIN;\\nCENSORSHIP OF THE PRESS; MYSTICS AND ILLUMINATI\\nTHE ENDEMONIADAS; EL SANTO NlftO DE LA GUARDIA\\nBRIANDA DE BARDAXI. 12mo., 522 pages. Cloth, $2.50.\\n-FORMULARY OF THE PAPAL PENITENTIARY. In one\\noctavo volume of 221 pages, with frontispiece. Cloth, $2.50.\\n-SUPERSTITION AND FORCE; ESSAYS ON THE WAGER\\nOF LAW, THE WAGER OF BATTLE, THE ORDEAL AND\\nTORTURE. Fourth edition, thoroughly revised. In one hand\u00c2\u00ac\\nsome royal 12mo. volume of 629 pages. Cloth, $2.75.\\n-STUDIES IN CHURCH HISTORY. The Rise of the Temporal\\nPower\u00e2\u0080\u0094Benefit of Clergy\u00e2\u0080\u0094Excommunication. New edition. In one\\nhandsome 12mo. volume of 605 pages. Cloth, $2.50.\\n-AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY\\nIN THE CHRISTIAN CHURCH. Second edition. In one hand\u00c2\u00ac\\nsome octavo volume of 685 pages. Cloth, $4.50.\\nLEHMANN (C. G.). A MANUAL OF CHEMICAL PHYSIOLOGY.\\nIn one 8vo. volume of 327 pages, with 41 engravings. Cloth, $2.25.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0596.jp2"}, "597": {"fulltext": "Lea Brothers Co., Philadelphia and New York. 19\\nLIKES (SYLVAN H.). A POCKET TEXT-BOOK OF GENITO\u00c2\u00ac\\nURINARY AND VENEREAL DISEASES. In one handsome\\n12mo. volume of about 350 pages, with many illustrations. Shortly.\\nLea s Series of Pocket Text-books, edited by Bern B. Gallaudet,\\nM. D. See page 18.\\nLOOMIS (ALFRED L.) AND THOMPSON (W. GILMAN,\\nEDITORS). A SYSTEM OF PRACTICAL MEDICINE. In\\nContributions by Various American Authors. In four very hand\u00c2\u00ac\\nsome octavo volumes of about 900 pages each, fully illustrated in\\nin black and colors. Complete work now ready. Per volume, cloth,\\n$5; leather, $6; half Morocco, $7. For sale by subscription only.\\nFull prospectus free on application to the Publishers. See American\\nSystem of Practical Medicine, page 2.\\nLUFF (ARTHUR P.). MANUAL OF CHEMISTRY, for the use of\\nStudents of Medicine. In one 12mo. volume of 522 pages, with 36\\nengravings. Cloth, $2. See Student s Series of Manuals, page 27.\\nLYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one\\nvery handsome octavo volume of 925 pages, with 170 engravings.\\nCloth, $4.75 leather, $5.75.\\nComplete, concise, fully abreast of Practical, systematic, complete and\\nthe times and needed by all students well balanced .\u00e2\u0080\u0094Chicago Med. Re-\\nand practitioners.\u00e2\u0080\u0094 Univ. Med. Mag. corder.\\nAn exceedingly valuable text-book.\\nLYONS (ROBERT D.). A TREATISE ON FEVER. In one octavo\\nvolume of 362 pages. Cloth, $2.25.\\nMACKENZIE (JOHN NOLAND). ON THE NOSE AND THROAT.\\nHandsome octavo, about 600 pages, richly illustrated. Preparing.\\nMAISCH (JOHN M.). A MANUAL OF ORGANIC MATERIA\\nMEDICA. New (7tli) edition, thoroughly revised by H. C. C. Maisch,\\nPh. G., Ph. D. In one very handsome 12mo. volume of 512 pages, with\\n285 engravings. Just ready. Cloth, $2.50, net.\\nUsed as text-book in every college\\nof pharmacy in the United States\\nand recommended in medical col\u00c2\u00ac\\nleges .\u00e2\u0080\u0094American Therapist.\\nNoted on both sides of the Atlantic\\nand esteemed as much in Germany as\\nin America. The work has no equal.\\n\u00e2\u0080\u0094Dominion Med. Monthly.\\nThe best handbook upon phar\u00c2\u00ac\\nmacognosy of any published in this\\ncountry .\u00e2\u0080\u0094Boston Med. Sur. Jonr.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0597.jp2"}, "598": {"fulltext": "20 Lea Brothers Co., Philadelphia and New York.\\nMALSBARY (GEORGE E.). A POCKET TEXT-BOOK OF\\nTHEORY AND PRACTICE OF MEDICINE. In one handsome\\n12mo. volume of 405 pages, with 45 illustrations. Just ready.. Cloth,\\n$1.75, net; flexible redi leather, $2.25, net. Lea\u00e2\u0080\u0099s Series of Pocket\\nText-books, edited by Bern B. Gallaudet, M. D. See page 18.\\nMANUALS. See Student\u00e2\u0080\u0099s Quiz Series, page 27, Student\u00e2\u0080\u0099s Series of\\nManuals, page 27, and Series of Clinical Manuals, page 25.\\nMARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo.\\nvolume of 468 pages, with 64 engravings and a colored plate. Cloth, $2.\\nSee Series of Clinical Manuals, page 25.\\nMARTIN (EDWARD). A MANUAL OF SURGICAL DIAGNOSIS.\\nIn one 12mo. volume of about 400 pp., fully illustrated. Preparing.\\nMARTIN (WALTON) AND ROCKWELL (WM. H). A POCKET\\nTEXT-BOOK OF CHEMISTRY AND PHYSICS. In one hand\u00c2\u00ac\\nsome 12mo. volume of about 350 pages, with many illustrations.\\nShortly. Lea s Series of Pocket Text-books, edited by Bern B.\\nGallaudet, M. D. See page 18.\\nMAY (C. H.). MANUAL OF THE DISEASES OF WOMEN. For\\nthe use of Students and Practitioners. Second edition, revised by L.\\nS. Rau, M. D. In one 12mo. volume of 360 pages, with 31 engrav\u00c2\u00ac\\nings. Cloth, $1.75.\\nMEDICAL NEWS POCKET FORMULARY, see page 32.\\nMITCHELL (S. WEIR). CLINICAL LESSONS ON NERVOUS\\nDISEASES. In one 12mo. volume of 299 pages, with 19 engravings\\nand 2 colored plates. Cloth, $2.50. Of the hundred numbered copies\\nwith the Author\u00e2\u0080\u0099s signed title page a few remain; these are offered\\nin green cloth, gilt top, at $3.50, net.\\nThe booktreats of hysteria, recur\u00c2\u00ac\\nrent melancholia, disorders of sleep,\\nchoreic movements, false sensations\\nof cold, ataxia, hemiplegic pain,\\ntreatment of sciatica, ervthromelal-\\ngia, reflex ocularneurosis, hysteric\\ncontractions, rotary movements in\\nthe feeble minded, etc. Few can\\nspeak with more authority than the\\nauthor.\u00e2\u0080\u0094 The Journal of the Ameri\u00c2\u00ac\\ncan Medical Association.\\nMITCHELL (JOHN K.). REMOTE CONSEQUENCES OF IN\u00c2\u00ac\\nJURIES OF NERVES AND THEIR TREATMENT. In one\\nhandsome 12mo. volume of 239 pages,with 12 illustrations. Cloth, $1.75.\\nInjuries of the nerves are of fre\u00c2\u00ac\\nquent occurrence in private practice,\\nand often the cause of intractable\\nand painful conditions, conse\u00c2\u00ac\\nquently this volume is of especial\\ninterest. Doctor Mitchell has had\\naccess to hospital records for the last\\nthirty years, as well as to the\\ngovernment documents, and has\\nskilfully utilized his opportunities.\\nThe Med. Age.\\nMORRIS (MALCOLM). DISEASES OF THE SKIN. New (2d)\\nedition. In one 12mo. volume of 601 pages, with 10 chromo-litho-\\ngraphic plates and 26 engravings. Cloth, $3.25, net. Just ready.\\nMULLER (J.). PRINCIPLES OF PHYSICS AND METEOROL\u00c2\u00ac\\nOGY. In one large 8vo. vol. of 623 pages, with 638 cuts. Cloth, $4.60.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0598.jp2"}, "599": {"fulltext": "Lea Brothers Co., Philadelphia and New York. 21\\nMTJSSER (JOHN H.). A PRACTICAL TREATI8E ON MEDICAL\\nDIAGNOSIS, for Students and Physicians. New (3d) edition, thor\u00c2\u00ac\\noughly revised. In one octavo volume of 1082 pages, with 253 en\u00c2\u00ac\\ngravings and 48 full-page colored plates. Just ready. Cloth, $6.00,\\nnet; leather, $7.00, net.\\nNotices of previous edition are appended.\\nWe have no work of equal value\\nin English. University Medical\\nMagazine.\\nHis descriptions of the diagnostic\\nmanifestations of diseases are accu\u00c2\u00ac\\nrate. This work will meet all the\\nrequirements of student and physi\u00c2\u00ac\\ncian.\u00e2\u0080\u0094 The Medical News.\\nFrom its pages may be made the\\ndiagnosis of every malady that\\nafflicts the human body, including\\nthose which in general are dealt\\nwith only by the specialist.\u00e2\u0080\u0094 North\u00c2\u00ac\\nwestern Lancet.\\nIt so thoroughly meets the precise\\ndemands incident to modern research\\nthat it has been adopted as a leading\\ntext-book by the medical colleges\\nof this country.\u00e2\u0080\u0094 North American\\nPractitioner.\\nOccupies the foremost place as a\\nthorough, systematic treatise.\u00e2\u0080\u0094 Ohio\\nMedical Journal.\\nThe best of its kind, invaluable to\\nthe student, general practitioner and\\nteacher.\u00e2\u0080\u0094 Montrea l Medica l Journa l.\\nNATIONAL DISPENSATORY. See Stille, Maisch Campari, p. 27.\\nNATIONAL FORMULARY. See Stille, Maisch Caspar Vs National\\nDispensatory, page 27.\\nNATIONAL MEDICAL DICTIONARY. See Billings, page 4.\\nNETTLESHIP (E.). DISEASES OF THE EYE. New (5th) American\\nfrom sixth English edition, thoroughly revised. In one 12mo. volume\\nof 521 pages, with 161 engravings, and 2 colored plates, test-types,\\nformulae and color-blindness test. Cloth, $2.25. Just ready.\\nBy far the best student\u00e2\u0080\u0099s text-book English language. Journal of\\non the subject of ophthalmology and Medicine and Science.\\nis conveniently and concisely ar-1 The present edition is the result\\nranged.\u00e2\u0080\u0094 The Clinical Review. of revision both in England and\\nIt has been conceded by ophthal- America, and therefore contains the\\nmologists generally that this work latest and best ophthalmological\\nfor compactness, practicality and ideas of both continents.\u00e2\u0080\u0094 ThePliy-\\nclearness has no superior in the sician and Surgeon.\\nNICHOLS (JOHN B.) AND YALE (F. P.). A POCKET TEXT\u00c2\u00ac\\nBOOK OF HISTOLOGY AND PATHOLOGY. In one handsome\\n12mo. volume of 452 pages, Avith 213 illustrations. Just ready. Cloth,\\n$1.75, net: flexible red leather, $2.25, net.\\nLea s Series of Pocket Text-books, edited by Bern B. Gallaudet,\\nM. D. See page 18.\\nNORRIS fWM. F.) AND OLIVER (CHAS. A.). TEXT-BOOK OF\\nOPHTHALMOLOGY. In one octavo volume of 641 pages, with 357\\nengravings and 5 colored plates. Cloth, $5 leather, $6.\\nA safe and admirable guide, Avell\\nqualified to furnish a working\\nknowledge of ophthalmology.\\nJohns Hopkins Hospital Bulletin.\\nIt is practical in its teachings.\\nWe unreservedly endorse it as the\\nbest, the safest and the most compre\u00c2\u00ac\\nhensive volume upon the subject that\\nhas ever been offered to the Amer\u00c2\u00ac\\nican medical public.\u00e2\u0080\u0094 Annals of\\nOphthalmology and Otology.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0599.jp2"}, "600": {"fulltext": "22 TiicA Brothers *Co., Philadelphia and New York.\\nOWEN (EDMUND). SURGICAL DISEASES OF CHILDREN.\\nIn one 12mo. volume of 525 pages, with 85 engravings and 4 colored\\nplates. Cloth, $2. See Series of Clinical Manuals, page 25.\\nPARK (ROSWELL). A TREATISE ON SURGERY BY AMERI\u00c2\u00ac\\nCAN AUTHORS. New and condensed edition. Just ready.\\nIn one royal octavo volume of 1261 pages, with 625 engravings\\nand 37 full-page plates. Cloth, $6.00, net; leather, $7.00, net.\\njS^This work is also published in a larger edition, comprising two\\nvolumes. Volume I., General Surgery, 799 pages, with 356 engravings\\nand 21 full-page plates, in colors and monochrome. Volume II.,\\nSpecial Surgery, 800 pages, with 430 engravings and 17 full-page\\nplates, in colors and monochrome. Per volume, cloth, $4.50; leather,\\n$5.50, net.\\nThe work is fresh, clear and practi\u00c2\u00ac\\ncal, covering the ground thoroughly\\nyet briefly, and well arranged for\\nrapid reference, so that it will be of\\nspecial value to the student and busy\\nractitioner. The pathology is\\nroad, clear and scientific, while the\\nsuggestions upon treatment are\\nclear-cut, thoroughly modern and\\nadmirably resourceful.\u00e2\u0080\u0094 Johns Hop\u00c2\u00ac\\nkins Hospital Bulletin.\\nThe latest and best work written\\nupon the science and art of surgery.\\nColumbus Medical Journal.\\nThe illustrations are almost en\u00c2\u00ac\\ntirely new and executed in such a\\nway that they add great force to the\\ntext.\u00e2\u0080\u0094 The Chicago Medical Re\u00c2\u00ac\\ncorder.\\nThe various writers have em\u00c2\u00ac\\nbodied the teachings accepted at\\nthe present hour.\u00e2\u0080\u0094 The North Amer\u00c2\u00ac\\nican Practitioner.\\nBoth for the student and practi\u00c2\u00ac\\ntioner it is most valuable. It is\\nthoroughly practical and yet thor\u00c2\u00ac\\noughly scientific.\u00e2\u0080\u0094 Medical News.\\nA truly modern surgery, not only\\nin pathology, but also in sound\\nsurgical therapeutics. New Or\u00c2\u00ac\\nleans Med. and Surgical Journal.\\nPARK (WILLIAM H.). BACTERIOLOGY IN MEDICINE AND\\nSURGERY. 12mo., 688 pages, with 87 illustrations in black and\\ncolors, and 2 plates. Just ready. Cloth, $3.00 net.\\nPARRY (JOHN S.). EXTRA-UTERINE PREGNANCY, ITS\\nCLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT\u00c2\u00ac\\nMENT. In one octavo volume of 272 pages. Cloth, $2.50.\\nPARVIN (THEOPHILUS). THE SCIENCE AND ART OF OB\u00c2\u00ac\\nSTETRICS. Third edition. In one handsome octavo volume of\\n677 pages, with 267 engravings\\nleather, $5.25.\\nIn the foremost rank among the\\nmost practical and scientific medical\\nworks of the day.\u00e2\u0080\u0094 Medical News.\\nThe book is complete in every de\u00c2\u00ac\\npartment, and contains all the neces\u00c2\u00ac\\nsary detail required by the modern\\nand 2 colored plates. Cloth, $4.25;\\npractising obstetrician. Interna\u00c2\u00ac\\ntional Medical Magazine.\\nParvin\u00e2\u0080\u0099s work is practical, con\u00c2\u00ac\\ncise and comprehensive. We com\u00c2\u00ac\\nmend it as first of its class in the\\nEnglish language.\u00e2\u0080\u0094 Medical Fort\u00c2\u00ac\\nnightly.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0600.jp2"}, "601": {"fulltext": "Lea Brothers Co., Philadelphia and New York. 23\\nPEPPER\u00e2\u0080\u0099S SYSTEM OF MEDICINE. See page 3.\\nPEPPER (A. J.). FORENSIC MEDICINE. In press. See Student\u00e2\u0080\u0099s\\nSeries of Manuals, page 27.\\n-SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages,\\nwith 81 engravings. Cloth, $2. See Student\u00e2\u0080\u0099s Series of Manuals, p. 27.\\nPICK (T. PICKERING). FRACTURES AND DISLOCATIONS.\\nIn one 12mo. volume of 530 pages, with 93 engravings. Cloth, $2.\\nSee Series of Clinical Manuals, page 25.\\nPLAYFAIR (W. S.). A TREATISE ON THE SCIENCE AND\\nPRACTICE OF MIDWIFERY. Seventh American from the ninth\\nEnglish edition. In one octavo volume of 700 pages, with 207\\nengravings and 7 plates. Cloth, $3.75 net; leather, $4.75, net. Just\\nready.\\nIn the numerous editions which\\nhave appeared it has been kept con\u00c2\u00ac\\nstantly in the foremost rank. It is\\na work which can be conscientiously\\nrecommended to the profession.\u00e2\u0080\u0094\\nThe Albany Medical Annals.\\nThis work must occupy a fore\u00c2\u00ac\\nmost place in obstetric medicine as\\na safe guide to both student and\\nobstetrician. It holds a place among\\nthe ablest English-speaking authori\u00c2\u00ac\\nties on the obstetric art.\u00e2\u0080\u0094 Buffalo\\nMedical and Surgical Journal.\\nAn epitome of the science and\\npractice of midwifery, which em\u00c2\u00ac\\nbodies all recent advances. The\\nMedical Fortnightly.\\nTHE SYSTEMATIC TREATMENT OF NERVE PROSTRA\u00c2\u00ac\\nTION AND HYSTERIA. In one 12mo. volume of 97 pages.\\nCloth, $1.\\nPOCKET FORMULARY, see page 32.\\nPOCKET TEXT-BOOKS, see page 18.\\nPOLITZER (ADAM). A TEXT-BOOK OF THE DISEASES OF THE\\nEAR AND ADJACENT ORGANS. Second American from the\\nthird German edition. Translated by Oscar Dodd, M. D., and\\nedited by Sir William Dalby, F. R. C. S. In one octavo volume of\\n748 pages, with 330 original engravings. Cloth, $5.50.\\nThe anatomy and physiology of f ment are clear and reliable. We\\neach part of the organ of hearing\\ncarefully considered, and then\\nare\\nfollows an enumeration of the dis\u00c2\u00ac\\neases to which that special part of\\nthe auditory apparatus is especially\\nliable. The indications for treat-\\nare\\ncan confidently recommend it, for it\\ncontains all that is known upon the\\nsubject.\u00e2\u0080\u0094 London Lancet.\\nA safe and elaborate guide into\\nevery part of otology.\u00e2\u0080\u0094 American\\nJournal of the Medical Sciences.\\nPOTTS (CHARLES S.). A POCKET TEXT-BOOK OF NERVOUS\\nAND MENTAL DISEASES. In one handsome 12mo. volume of\\nabout 450 pages. Shortly. Lea\u00e2\u0080\u0099s Series of Pocket Text-books, edited by\\nBern B. Gallaudet, M. D. See page 18.\\nPROGRESSIVE MEDICINE, see page 32.\\nPURDY (CHARLES W.). BRIGHT\u00e2\u0080\u0099S DISEASE AND ALLIED\\nAFFECTIONS OF THE KIDNEY. In one octavo volume of 288\\npages, with 18 engravings. Cloth, $2.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0601.jp2"}, "602": {"fulltext": "24 Lea Brothers Co., Philadelphia and New York.\\nPYE-SMITH (PHILIP H.). DISEASES OF THE SKIN. In one\\n12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2.\\nQUIZ SERIES. See Student s Quiz Series page 27.\\nRALFE (CHARLES H.). CLINICAL CHEMISTRY. In one\\n12mo. volume of 314 pages, with 16 engravings. Cloth, $1.50. See\\nStudent s Series of Manuals page 27.\\nRAMSBOTHAM (FRANCIS H.). THE PRINCIPLES AND PRAC\u00c2\u00ac\\nTICE OF OBSTETRIC MEDICINE AND SURGERY. In one\\nimperial octavo volume of 640 pages, with 64 plates and numerous\\nengravings in the text. Strongly bound in leather, $7.\\nREICHERT (EDWARD T.). A TEXT-BOOK ON PHYSIOLOGY.\\nIn one handsome octavo volume of about 800 pages, richly illustrated.\\nPreparing.\\nREMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEM\u00c2\u00ac\\nISTRY. New (5th) edition, thoroughly revised. In one 12mo. vol\u00c2\u00ac\\nume of 326 pages. Cloth, $2.\\nA clear and concise explanation\\nof a difficult subject. We cordially\\nrecommend it.\u00e2\u0080\u0094 The London Lancet.\\nThe book is equally adapted to the\\nstudent of chemistry or the practi\u00c2\u00ac\\ntioner who desires to broaden his\\ntheoretical knowledge of chemistry.\\n\u00e2\u0080\u0094New Orleans Med. and Surg. Jour.\\nThe appearance of a fifth edition\\nof this treatise is in itself a guarantee\\nthat the work has met with general\\nfavor. This is further established\\nby the fact that it has been trans\u00c2\u00ac\\nlated into German and Italian. The\\ntreatise is especially adapted to the\\nlaboratory student. It ranks unusu\u00c2\u00ac\\nally high among the works of this\\nclass. This edition has been brought\\nfully up to the times.\u00e2\u0080\u0094 American\\nMedico-Surgical Bulletin.\\nRICHARDSON (BENJAMIN WARD). PREVENTIVE MEDI\u00c2\u00ac\\nCINE. In one octavo volume of 729 pages. Cloth, $4 leather, $5.\\nROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF\\nMODERN SURGERY. New (2d) edition. In one octavo volume of\\n838 pages with 473 engravings and 8 plates. Just ready. Cloth, $4.25,\\nnet; leather, $5.25, net.\\nTHE COMPEND OF ANATOMY. For use in the Dissecting\\nRoom and in preparing for Examinations. In one 16mo. volume of\\n196 pages. Limp cloth, 75 cents.\\nROBERTS (SIR WILLIAM). A PRACTICAL TREATISE ON\\nURINARY AND RENAL DISEASES, INCLUDING URINARY\\nDEPOSITS. Fourth American from the fourth London edition. In\\none very handsome 8vo. vol. of 609 pp., with 81 illus. Cloth, $3.50.\\nROBERTSON (J. MCGREGOR). PHYSIOLOGICAL PHYSICS.\\nIn one 12mo. volume of 537 pages, with 219 engravings. Cloth, $2.\\nSee Student s Series of Manuals page 27.\\nROSS (JAMES). A HANDBOOK OF THE DISEASES OF THE\\nNERVOUS SYSTEM. In one handsome octavo volume of 726 pages,\\nwith 184 engravings. Cloth, $4.50 leather, $5.50.\\nSAVAGE (GEORGE H.). INSANITY AND ALLIED NEUROSES,\\nPRACTICAL AND CLINICAL. In one 12mo. volume of 551 pages,\\nwith 18 typical engravings. Cloth, $2. See Series of Clinical Man\u00c2\u00ac\\nuals, page 25.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0602.jp2"}, "603": {"fulltext": "Lea Brothers Co., Philadelphia and New York. 25\\nSCHAFER (EDWARD A.). THE ESSENTIALS OF HISTOL\u00c2\u00ac\\nOGY, DESCRIPTIVE AND PRACTICAL. For the use of Students.\\nNew (oth) edition. In one handsome octavo volume of 359 pages,\\nwith 392 illustrations. Cloth, $3.00, net. Just ready.\\nNowhere else will the same very\\nmoderate outlay secure as thoroughly\\nuseful and interesting an atlas of\\nstructural anatomy. The American\\nJournal of the Medical Sciences.\\nThe most satisfactory elementary\\ntext-book of histology in the Eng\u00c2\u00ac\\nlish language.\u00e2\u0080\u0094 The Boston Med. and\\nSur. Jour.\\n-A COURSE OF PRACTICAL HISTOLOGY. New (2d) edition.\\nIn one 12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25.\\nSCHLEIF (WILLIAM). MATERIA MEDICA, THERAPEUTICS,\\nPRESCRIPTION WRITING, MEDICAL LATIN, ETC. 12mo.|\\n352 pages. Cloth, $1.50, net; flexible red leather, $2.00, net. Just\\nready. Lea\u00e2\u0080\u0099s Series of Pocket Text-books. Edited by Bern B.\\nGallaudet, M. D. See page 18.\\nSCHMITZ AND ZUMPT\u00e2\u0080\u0099S CLASSICAL SERIES. Advanced\\nLatin Exercises. Cloth, 60 cts. Schmidt\u00e2\u0080\u0099s Elementary Latin Exer\u00c2\u00ac\\ncises. Cloth, 50 cents. Sallust. Cloth, 60 cents. Nepos. Cloth, 60\\ncents. Virgil. Cloth, 85 cents. Curtius. Cloth, 80 cents.\\nSCHOFIELD (ALFRED T.). ELEMENTARY PHYSIOLOGY\\nFOR STUDENTS. In one 12mo. volume of 380 pages, with 227\\nengravings and 2 colored plates. Cloth, $2.\\nSCHREIBER (JOSEPH). A MANUAL OF TREATMENT BY\\nMASSAGE AND METHODICAL MUSCLE EXERCISE. Octavo\\nvolume of 274 pages, with 117 engravings.\\nSENN (NICHOLAS). SURGICAL BACTERIOLOGY. Second edi\u00c2\u00ac\\ntion. In one octavo volume of 268 pages, with 13 plates, 10 of which\\nare colored, and 9 engravings. Cloth, $2.\\nSERIES OF CLINICAL MANUALS. A Series of Authoritative\\nMonographs on Important Clinical Subjects, in 12mo. volumes of about\\n550 pages, well illustrated. The following volumes are now ready:\\nYeo on Food in Health and Disease, new (2d) edition, $2.50; Carter\\nand Frost\u00e2\u0080\u0099s Ophthalmic Surgery, $2.25; Hutchinson on Syphilis,\\n$2.25; Marsh on Diseases of the Joints, $2; Owen on SurgicalDis-\\neases of Children, $2; Pick on Fractures and Dislocations, $2; Savage\\non Insanity and Allied Neuroses, $2.\\nFor separate notices, see under various authors\u00e2\u0080\u0099 names.\\nSERIES OF STUDENT\u00e2\u0080\u0099S MANUALS. See page 27.\\nSIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICRO\u00c2\u00ac\\nSCOPICAL AND CHEMICAL METHODS. New (2d) edition. In\\none very handsome octavo volume of 530 pages, with 135 engravings\\nand 14 full-page colored plates. Cloth, $3.50. Just ready.\\nThis book thoroughly deserves its In all respects entirely up to date,\\nsuccess. It is a very complete, authen- Medical Record.\\ntic and useful manual of the micro- The chapter on examination oi\\nscopical and chemical methods the urine is the most complete and\\nwhich are employed in diagnosis.\\nVery excellent colored plates illus\u00c2\u00ac\\ntrate this work.\u00e2\u0080\u0094 New York Medical\\nJournal.\\nadvanced that we\\nEnglish language.-\\ntitioner.\\nknow of in the\\n-Canadian Prac-", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0603.jp2"}, "604": {"fulltext": "26 Lea Brothers Co., Philadelphia and New York.\\nSIMON (W.). MANUAL OF CHEMISTRY. A Guide to Lectures\\nand Laboratory Work for Beginners in Chemistry. A Text-book\\nspecially adapted for Students of Pharmacy and Medicine. New (6th)\\nedition. In one 8vo. volume of 536 pages, with 46 engravings and 8\\nplates showing colors of 64 tests. Cloth, $3.00, net. Just ready.\\nIt is difficult to see how a better\\nbook could be constructed. No man\\nwho devotes himself to the practice\\nof medicine need know more about\\nchemistry than is contained between\\nthe covers of this book.\u00e2\u0080\u0094 The North\u00c2\u00ac\\nwestern Lancet.\\nIts statements are all clear and its\\nteachings are practical.\u00e2\u0080\u0094 Virginia\\nMed. Monthly.\\nSLADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT\u00c2\u00ac\\nMENT. Second edition. In one royal 12mo. vol., 158 pp. Cloth, $1.25.\\nSMITH (EDWARD). CONSUMPTION; ITS EARLY AND REME\u00c2\u00ac\\nDIABLE STAGES. In one 8vo. volume of 253 pp. Cloth, $2.25.\\nSMITH (J. LEWIS). A TREATISE ON THE DISEASES OF IN\u00c2\u00ac\\nFANCY AND CHILDHOOD. Eighth edition, thoroughly revised\\nand rewritten and much enlarged. In one large 8vo. volume of 983\\npages, with 273 engravings ai\\nleather, $5.50.\\nA safe guide for students and phy\u00c2\u00ac\\nsicians. The Am. Jour, of Obstetrics.\\nFor years the leading text-book on\\nchildren\u00e2\u0080\u0099s diseases in America.\u00e2\u0080\u0094\\nChicago Medical Recorder.\\n1 4 full-page plates. Cloth, $4.50;\\nThe most complete and satisfac\u00c2\u00ac\\ntory text-book with which we are\\nacquainted. \u00e2\u0080\u0094American Gynecologi\u00c2\u00ac\\ncal and Obstetrical Journal.\\nSMITH (STEPHEN). OPERATIVE SURGERY. Second and thor\u00c2\u00ac\\noughly revised edition. In one octavo volume of 892 pages, with\\n1005 engravings. Cloth, $4 leather, $5.\\nOne of the most satisfactory works dium for the modern surgeon.\u00e2\u0080\u0094 Bos\u00c2\u00ac\\non modern operative surgery yet ton Medical and Surgical Journal.\\npublished. The book is a compen-\\nSOLLY (S. EDWIN). A HANDBOOK OF MEDICAL CLIMA\u00c2\u00ac\\nTOLOGY. In one handsome octavo volume of 462 pages, with en\u00c2\u00ac\\ngravings and 11 full-page plates, 5 of which are in colors. Cloth, $4.00.\\nJust ready.\\nA clear and lucid summary of\\nwhat is known of climate in relation\\nto its influence upon human beings.\\nThe Therapeutic Gazette.\\nThe book is admirably planned,\\nclearly written ,and the author speaks\\nfrom an experience of thirty years as\\nan accurate observer and practical\\ntherapeutist. \u00e2\u0080\u0094Maryland Med. Jour.\\nEvery practitioner of medicine\\nshould possess himself of a copy and\\nstudy it, and we are sure he will\\nnever regret it. St. Louis Medical\\nand Surgical Journal.\\nSTILLE (ALFRED). CHOLERA; ITS ORIGIN, HISTORY, CAUS\u00c2\u00ac\\nATION, SYMPTOMS, LESIONS, PREVENTION AND TREAT\u00c2\u00ac\\nMENT. In one 12mo. volume of 163 pages, with a chart showing\\nroutes of previous epidemics. Cloth, $1.25.\\nTHERAPEUTICS AND MATERIA MEDICA. Fourth and\\nrevised edition. In two octavo volumes, containing 1936 pages.\\nCloth, $10; leather, $12.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0604.jp2"}, "605": {"fulltext": "Lea Brothers Co., Philadelphia and New York. 27\\nSTILLE (ALFRED), MAISCH (JOHN M.) AND CASPARI\\n(CHAS. JR.). THE NATIONAL DISPENSATORY: Containing\\nthe Natural History, Chemistry, Pharmacy, Actions and Uses of\\nMedicines, including those recognized in the latest Pharmacopoeias of\\nthe United States, Great Britain and Germany, with numerous refer\u00c2\u00ac\\nences to the French Codex. Fifth edition, revised and enlarged,\\nincluding the new U. S. Pharmacopoeia, Seventh Decennial Revision.\\nWith Supplement containing the new edition of the National Formu\u00c2\u00ac\\nlary. In one magnificent imperial octavo volume of about 2025 pages,\\nwith 320 engravings. Cloth, $7.25; leather, $8. With ready reference\\nThumb-letter Index. Cloth, $7.75 leather, $8.50.\\nSTIMSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY.\\nNew (3d) edition. In one royal\\nengravings. Cloth, $3.75.\\nA useful and practical guide for\\nall students and practitioners.\u00e2\u0080\u0094 Am.\\nJournal of the Medical Sciences.\\n12mo. volume of 614 pages, with 306\\nThe book is worth the price for the\\nillustrations alone.\u00e2\u0080\u0094 Ohio Medical\\nJournal.\\nSTIMSON (LEWIS A.). A TREATISE ON FRACTURES AND\\nDISLOCATIONS. In one handsome octavo volume of 831 pages,\\nwith 326 engravings and 20 plates. Cloth, $5.00, net; leather,\\n$6.00, net.\\nPreeminently the authoritative\\ntext-book upon the subject. The\\nvast experience of the author gives\\nto his conclusions an unimpeachable\\nvalue. The work is profusely il\u00c2\u00ac\\nlustrated. It will be found indis\u00c2\u00ac\\npensable to the student and the prac\u00c2\u00ac\\ntitioner alike .\u00e2\u0080\u0094The Medical Age.\\nTaken as a whole, the work is the\\nbest one in English to-day.\u00e2\u0080\u0094 St.\\nLouis Medical and Surgical Journal.\\nPointed, practical, comprehensive,\\nexhaustive, authoritative, well writ\u00c2\u00ac\\nten and well arranged .\u00e2\u0080\u0094Denver\\nMedical Times.\\nSTUDENT\u00e2\u0080\u0099S QUIZ SERIES. Thirteen volumes, convenient, author\u00c2\u00ac\\nitative, well illustrated, handsomely bound in cloth. 1. Anatomy\\n(double number); 2. Physiology; 3. Chemistry and Physics; 4. Histol\u00c2\u00ac\\nogy, Pathology, and Bacteriology; 5. Materia Medica and Thera\u00c2\u00ac\\npeutics 6. Practice of Medicine; 7. Surgery (double number); 8. Genito\u00c2\u00ac\\nurinary and Venereal Diseases; 9. Diseases of the Skin; 10. Diseases\\nof the Eye, Ear, Throat and Nose; 11. Obstetrics; 12. Gynecology;\\n13. Diseases of Children. Price, $1 each, except Nos. 1 and 7,\\nAnatomy and Surgery, which being double numbers are priced at\\n$1.75 each. Full specimen circular on application to publishers.\\nSTUDENT\u00e2\u0080\u0099S SERIES OF MANUALS. 12mos. of from 300-540\\npages, profusely illustrated, and bound in red limp cloth. Herman\u00e2\u0080\u0099s\\nFirst Lines in Midwifery, $1.25; Luff\u00e2\u0080\u0099s Manual of Chemistry, $2;\\nBruce\u00e2\u0080\u0099s Materia Medica and Therapeutics (sixth edition), $1.50. net.\\nBell\u00e2\u0080\u0099s Comparative Anatomy and Physiology, $2; Robert\u00c2\u00ac\\nson\u00e2\u0080\u0099s Physiological Physics, $2; Gould\u00e2\u0080\u0099s Surgical Diagnosis, $2;\\nKlein\u00e2\u0080\u0099s Elements of Histology (5tb edition), $2.00, net; Peppers\\nSurgical Pathologv, $2; Treves\u00e2\u0080\u0099 Surgical Applied Anatomy, $2\\nIUlfe\u00e2\u0080\u0099s Clinical Chemistry, $1.50; and Clarke and Lockwood s\\nDissector\u00e2\u0080\u0099s Manual, $1.50. The following is in press: Peppers\\nForensic Medicine.\\nFor separate notices, see under various author s name*.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0605.jp2"}, "606": {"fulltext": "28 Lea Brothers A Co., Philadelphia and New York.\\nSTURGES (OCTAVIUS). AN INTRODUCTION TO THE STUDY\\nOF CLINICAL MEDICINE. In one 12mo. volume. Cloth, $1.25.\\nSUTTON (JOHN BLAND). SURGICAL DISEASES OF THE\\nOVARIES AND FALLOPIAN TUBES. Including Abdominal\\nPregnancy. In one 12mo. volume of 513 pages, with 119 engravings\\nand 5 colored plates. Cloth, $3.\\nTAIT (LAWSON). DISEASES OF WOMEN AND ABDOMINAL\\nSURGERY. Vol. I. contains 546 pages and 3 plates. Cloth, $3.\\nTANNER (THOMAS HAWRES) ON THE SIGNS AND DIS\u00c2\u00ac\\nEASES OF PREGNANCY. From the second English edition. In\\none octavo volume of 490 pages, with 4 colored plates and 16 engrav\u00c2\u00ac\\nings. Cloth, $4.25\\nTAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. New\\nAmerican from the twelfth English edition, specially revised by CLARK\\nBell, Esq., of the N. Y. Bar. In one 8vo. vol. of 831 pages, with 54\\nengrs. and 8 full-page plates. Cloth, $4.50; leather, $5.50 Just ready.\\nTo the student, as to the physician,\\nwe would say, get Taylor first, and\\nthen add as means and inclination\\nenable you.\u00e2\u0080\u0094 American Practitioner\\nand Neivs.\\nIt is the authority accepted as\\nfinal by the courts of all English-\\nspeaking countries. This is the im\u00c2\u00ac\\nportant consideration for medical\\nmen, since in the event of their\\nbeing summoned as experts or wit\u00c2\u00ac\\nnesses, it strongly behooves them to\\nbe prepared according to the princi\u00c2\u00ac\\nples and practice everywhere ac\u00c2\u00ac\\ncepted. The work will be found to\\nbe thorough, authoritative and\\nmodern.\u00e2\u0080\u0094 Albany Law Journal.\\nProbably the best work on the\\nsubject written in the English lan\u00c2\u00ac\\nguage. The work has been thor\u00c2\u00ac\\noughly revised and is up to date.\u00e2\u0080\u0094\\nPacific Medical Journal.\\nON POISONS IN RELATION TO MEDICINE AND MEDI\u00c2\u00ac\\nCAL JURISPRUDENCE. Third American from the third London\\nedition. In one octavo volume of 788 pages, with 104 illustrations.\\nCloth, $5.50; leather, $6.50.\\nTAYLOR (ROBERT W.). THE PATHOLOGY AND TREAT\u00c2\u00ac\\nMENT OF VENEREAL DISEASES. In one very handsome octavo\\nvolume of 1002 pages, with 230 engravings and 8 colored plates.\\nCloth, $5.00, net; leather, $6.00, net.\\nBy long odds the best work on\\nvenereal diseases.\u00e2\u0080\u0094 Louisville Medi\u00c2\u00ac\\ncal Monthly.\\nIn the observation and treatment\\nof venereal diseases his experience\\nhas been greater probably than that\\nof any other practitioner of this con\u00c2\u00ac\\ntinent.\u00e2\u0080\u0094 New York Medical Journal.\\nThe clearest, most unbiased and\\nably presented treatise as yet pub\u00c2\u00ac\\nlished on this vast subject.\u00e2\u0080\u0094 The\\nMedical News.\\nDecidedly the most important and\\nauthoritative treatise on venereal\\ndiseases that has in recent years ap\u00c2\u00ac\\npeared in English.\u00e2\u0080\u0094 American Jour\u00c2\u00ac\\nnal of the Medical Sciences.\\nIt is a veritable storehouse of our\\nknowledge of the venereal diseases.\\nIt is commended as a conservative,\\npractical, full exposition of the\\ngreatest value.\u00e2\u0080\u0094 Chicago Clinical\\nReview.\\nThe best work on venereal dis\u00c2\u00ac\\neases in the English language. It\\nis certainly above everything of the\\nkind.\u00e2\u0080\u0094 The St. Louis Medical and\\nSurgical Journal.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0606.jp2"}, "607": {"fulltext": "Lea Brothers Co., Philadelphia and New York. 29\\nTAYLOR (ROBERT W.). A PRACTICAL TREATISE ON SEX\u00c2\u00ac\\nUAL DISORDERS IN THE MALE AND FEMALE. In one\\n8vo. vol. of 448 pp., with 73 engravings and 8 colored plates.\\nThe author has presented to the followed, will be of unlimited value\\nprofession the ablest and most scien- to both physician and patient.\u00e2\u0080\u0094\\ntific work as yet published on sexual Medical News.\\ndisorders, and one which, if carefully\\n\u00e2\u0080\u0094A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES.\\nIncluding Diagnosis, Prognosis and Treatment. In eight large folio\\nparts, measuring 14 x 18 inches, and comprising 213 beautiful figures\\non 58 full-page chromo-lithographic plates, 85 fine engravings and 425\\npages of text. Complete work now ready. Price per part, sewed in\\nheavy embossed paper, $2.50. Bound in one volume, half Russia,\\n$27 half Turkey Morocco, $28. For sale by subscription only. Address\\nthe publishers. Specimen plates by mail on receipt of ten cents.\\nTAYLOR (SEYMOUR). INDEX OF MEDICINE. A Manual for\\nthe use of Senior Students and others. In one large 12mo. volume of\\n802 pages. Cloth, $3.75.\\nTHOMAS (T. GAILLARD) AND MUNDE (PAUL F.). A PRAC\u00c2\u00ac\\nTICAL TREATISE ON THE DISEASES OF WOMEN. Sixth\\nedition, thoroughly revised by Paul F. Munde, M. D. In one\\nlarge and handsome octavo volume of 824 pages, with 347 engravings.\\nCloth, $5; leather, $6.\\nThe best practical treatise on the\\nsubject in the English language.\\nIt will be of especial value to the\\ngeneral practitioner as well as to the\\nspecialist. The illustrations are very\\nsatisfactory. Many of them are new\\nand are particularly clear and attrac\u00c2\u00ac\\ntive.\u00e2\u0080\u0094 Boston Med. and Sur. Jour.\\nThis work, which has already gone\\nthrough five large editions, and has\\nbeen translated into French, Ger\u00c2\u00ac\\nman, Spanish and Italian, is the\\nmost practical and at the same time\\nthe most complete treatise upon the\\nsubject.\u00e2\u0080\u0094 The Archives of Gynecol\u00c2\u00ac\\nogy, Obstetrics and Pediatrics.\\nTHOMPSON (SIR HENRY). CLINICAL LECTURES ON DIS\u00c2\u00ac\\nEASES OF THE URINARY ORGANS. Second and revised edi\u00c2\u00ac\\ntion. In one octavo vol. of 203 pp., with 25 engravings. Cloth, $2.25*\\n-THE PATHOLOGY AND TREATMENT OF STRICTURE\\nOF THE URETHRA AND URINARY FISTULAS. From the\\nthird English edition. In one octavo volume of 359 pages, with 47\\nengravings and 3 lithographic plates. Cloth, $3.50.\\nTHOMSON (JOHN). DISEASES OF CHILDREN. In one crown\\noctavo volume of350 pages, with 52 illus. Cloth, $1.75, net. Just ready.\\nTODD (ROBERT BENTLEY). CLINICAL LECTURES ON CER\u00c2\u00ac\\nTAIN ACUTE DISEASES. In one 8vo. vol. of 320 pp., cloth, $2.50.\\nTREVES (FREDERICK). OPERATIVE SURGERY. In two\\n8vo. vols. containing 1550 pp., with 422 illus. Cloth, $9 leath., $11.\\n-A SYSTEM OF SURGERY. In Contributions by Twenty-five\\nEnglish Surgeons. In two large octavo volumes. Vol. I., 1178 pages,\\nwith 463 engravings and 2 colored plates. Vol. II., 1120 pages, with\\n487 engravings and 2 colored plates. Complete work, cloth. $16.00.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0607.jp2"}, "608": {"fulltext": "30 Lea Brothers Co., Philadelphia and New York.\\nTREVES (FREDERICK). SURGICAL APPLIED ANATOMY. In\\none 12mo. volume of 540 pages, with 61 engravings. Cloth, $2. See\\nStudent s Series of Manuals, page 27.\\nTUTTLE (GEORGE M.). A POCKET TEXT-BOOK OF DISEASES\\nOF CHILDREN. In one handsome 12mo. volume of 374 pages,\\nwith 5 plates. Just ready. Cloth, $1.50, net; flexible red leather,\\n$2.00, net. Lea s Series of Pocket Text-books, edited by Bern B.\\nGallaudet, M. D. See p. 18\\nVAUGHAN (VICTOR C.) AND NOVY (FREDERICK G.).\\nPTOMAINS, LEUCOMAINS, TOXINS AND ANTITOXINS,\\nor the Chemical Factors in the Causation of Disease. New (3d) edition.\\nIn one 12mo. volume of 603 pages. Cloth, $3.\\nThe work has been brought down\\nto date, and will be found entirely\\nsatisfactory.\u00e2\u0080\u0094 Journal of the Ameri\u00c2\u00ac\\ncan Medical Association.\\nThe most exhaustive and most re\u00c2\u00ac\\ncent presentation of the subject.\u00e2\u0080\u0094\\nAmerican Jour, of the Med. Sciences.\\nThe present edition has been not\\nonly thoroughly revised throughout\\nbut also greatly enlarged, ample\\nconsideration being given to the new\\nsubjects of toxins and antitoxins.\u00e2\u0080\u0094\\nTri-State Medical Journal.\\nVISITING LIST. THE MEDICAL NEWS VISITING LIST for 1900.\\nFour styles: Weekly (dated for 30 patients); Monthly (undated for\\n120 patients per month); Perpetual (undated for 30 patients each\\nweek); and Perpetual (undated for 60 patients each week). The 60-\\npatient book consists of 256 pages of assorted blanks. The first three\\nstyles contain 32 pages of important data, thoroughly revised, and\\n160 pages of assorted blanks. Each in one volume, price, $1.25.\\nWith thumb-letter index for quick use, 25 cents extra. Special rates\\nto advance-paying subscribers to The Medical News or The\\nAmerican Journal of the Medical Sciences, or both. See p. 32.\\nWATSON (THOMAS). LECTURES ON THE PRINCIPLES AND\\nPRACTICE OF PHYSIC. A new American from the fifth and\\nenlarged English edition, with additions by H. Hartshorne, M. D.\\nIn two large 8vo. vols. of 1840 pp., with 190 cuts. Cloth, $9 leather, $11.\\nWEST (CHARLES). LECTURES ON THE DISEASES PECULIAR\\nTO WOMEN. Third American from the third English edition. In\\none octavo volume of 543 pages. Cloth, $3.75; leather, $4.75.\\n-ON SOME DISORDERS OF THE NERVOUS SYSTEM IN\\nCHILDHOOD. In one small 12mo. volume of 127 pages. Cloth, $1.\\nWHARTON (HENRY R.). MINOR SURGERY AND BANDAG\u00c2\u00ac\\nING. New (4th) edition. In one 12mo. volume of 594 pages, with\\n502 engravings, many of which are photographic. Just ready. $3.00,\\nnet.\\nWe know of no book which more\\nthoroughly or more satisfactorily\\ncovers the ground of Minor Surgery\\nand Bandaging. \u00e2\u0080\u0094Brooklyn Medical\\nJournal.\\nWell written, conveniently ar\u00c2\u00ac\\nranged and amply illustrated. It\\ncovers the field so fully as to render\\nit a valuable text-book, as well as a\\nwork of ready reference for sur\u00c2\u00ac\\ngeons. \u00e2\u0080\u0094North Amer. Practitioner.\\nThe part devoted to bandaging is\\nperhaps the best exposition of the\\nsubject in the English language. It\\ncan be highly commended to the\\nstudent, the practitioner and the\\nspecialist.\u00e2\u0080\u0094 The Chicago Medical\\nRecorder.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0608.jp2"}, "609": {"fulltext": "Lea Brothers Co., Philadelphia and New York. 31\\nWHITLA (WILLIAM). DICTIONARY OF TREATMENT, OR\\nTHERAPEUTIC INDEX. Including Medical and Surgical Thera\u00c2\u00ac\\npeutics. In one square octavo volume of 917 pages. Cloth, $4.\\nWILLIAMS (DAWSON). THE\\nDREN. In one 12mo. volume\\nJust ready. Cloth, $2.50, net.\\nThe descriptions of symptoms are\\nfull, and the treatment recommended\\nwill meet general approval. Under\\neach disease are given the symptoms,\\nMEDICAL DISEASES OF CHIL-\\nof 629 pages, with 18 illustrations.\\ndiagnoses, prognosis, complications,\\nand treatment. The work is up to\\ndate in every sense.\u00e2\u0080\u0094 The Charlotte\\nMedical Journal.\\nWILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY.\\nA new and revised American from the last English edition. Illustrated\\nwith 397 engravings. In one octavo volume of 616 pages. Cloth, $4;\\nleather, $5.\\n-THE STUDENT\u00e2\u0080\u0099S BOOK OF CUTANEOUS MEDICINE. In\\none 12mo. volume. Cloth, $3.50.\\nWINCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED.\\nTranslated by James R. Chadwick, A. M., M. D. With additions\\nby the Author. In one octavo volume of 484 pages. Cloth, $4.\\nWOHLER\u00e2\u0080\u0099S OUTLINES OF ORGANIC CHEMISTRY. Translated\\nfrom the eighth German edition, by Ira Remsen, M. D. In one\\n12mo. volume of 550 pages. Cloth, $3.\\nYEAR-BOOK OF TREATMENT FOR 1892, 1893, 1896,1897 and 1898.\\nCritical Reviews for Practitioners of Medicine and Surgery. In con\u00c2\u00ac\\ntributions by 25 well-known medical writers. 12mos., about 500 pages\\neach. Cloth, $1.50. In combination with The Medical News and\\nThe American Journal of the Medical Sciences, 75 cents.\\nYEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New\\n(2d) edition. In one 12mo. volume of 592 pages, with 4 engravings.\\nCloth, $2.50. See Series of Clinical Manuals page 26.\\nWe doubt whether any book on\\ndietetics has been of greater or more\\nwidespread usefulness than has this\\nmuch-quoted and much-consulted\\nwork of Dr. Yeo\u00e2\u0080\u0099s. The value of\\nthe work is not to be overestimated.\\n\u00e2\u0080\u0094New York Medical Journal.\\nA MANUAL OF MEDICAL TREATMENT, OR CLINICAL\\nTHERAPEUTICS. Two volumes containing 1275 pages. Cloth, $5.50.\\nYOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo.\\nvolume of 475 pages, with 286 illustrations. Cloth, $4; leather, $5.\\nIn studying the different chapters, surgical specialty and every page\\none is impressed with the thorough- abounds with evidences of prac-\\nness of the work. The illustrations ticality. It is the clearest and most\\nare numerous\u00e2\u0080\u0094the book thoroughly modern work upon this growing de-\\npractical\u00e2\u0080\u0094 Medical News. partment of surgery.\u00e2\u0080\u0094 The Chicago\\nIt is a thorough, a very compre- Clinical Review.\\nhensive work upon this legitimate", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0609.jp2"}, "610": {"fulltext": "PERIODICALS.\\nPROGRESSIVE MEDICINE.\\nA Quarterly Digest of New Methods, Discoveries, and Improvements\\nin the Medical and Surgical Sciences by Eminent Authorities. Edited by\\nDr. Hobart Amory Hare. In four abundantly illustrated, cloth bound,\\noctavo volumes, of 400-500 pages each, issued quarterly, commencing\\nMarch 1st, 1899. Per annum (4 volumes), $10.00 delivered.\\nTHE MEDICAL NEWS.\\nWeekly, #4.00 per Annum.\\nEach number contains 32 quarto pages, abundantly illustrated. A\\ncrisp, fresh weekly professional newspaper.\\nTHE AMERICAN JOURNAL OF THE MEDICAL SCIENCES.\\nMonthly, #4.00 Per Annum.\\nEach issue contains 128 octavo pages, fully illustrated. The most\\nadvanced and enterprising American exponent of scientific medicine.\\nTHE MEDICAL NEWS VISITING LIST.\\nFour styles, Weekly (dated for 30 patients); Monthly (undated, for\\n120 patients per month); Perpetual (undated, for 30 patients weekly per\\nyear); and Perpetual (undated, for 60 patients per year). Each style in\\none wallet-shaped book, leather bound, with pocket, pencil and rubber.\\nPrice, each, $1.25. Thumb-letter index, 25 cents extra.\\nTHE MEDICAL NEWS POCKET FORMULARY.\\nContaining 1600 prescriptions representing the latest and most ap\u00c2\u00ac\\nproved methods of administering remedial agents. Strongly bound in\\nleather with pocket and pencil. Price, $1.50, net.\\nCOMBINATION RATES:\\nAmerican Journal of the\\nMedical Sciences,\\nz Medical News\\nz\\nProgressive Medicine\\ng- Medical News Visiting List\\nMedical News Formulary\\nAlone. In Combination.\\n4.00 __ l\\n4.00 j $7.50 j $15.00\\n10.00 J\\n1.25\\n1.50 net.\\nIn all #20.75 for #16.00\\nFirst four above publications in combination #15.75\\nAll above publications in combination 16.00\\nOther Combinations will be quoted on request.\\nFull Circulars and Specimens free.\\ni\\nLEA BROTHERS CO., Publishers,\\n706, 708 710 Sansom St., Philadelphia.\\nIll Fifth Avenue, New York.", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0610.jp2"}, "611": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0611.jp2"}, "612": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0612.jp2"}, "613": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0613.jp2"}, "614": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0614.jp2"}, "615": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0615.jp2"}, "616": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0616.jp2"}, "617": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0617.jp2"}, "618": {"fulltext": "", "height": "3609", "width": "2146", "jp2-path": "diseasesofeye00nett_0_0618.jp2"}}