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CORNELL
UNIVERSITY
LIBRARY
Cornell
University Library
RE 81.C58
The
functional
examination
of the eye
3 1924 012 164 400
Cornell University
Library
The original of this book is in
the Cornell University Library.
There are no known copyright restrictions in
the United States on the use of the text.
http://www.archive.org/details/cu31924012164400
THE
F
UNCTIONAL
EXAMINATION
OF THE
EXE.
BY
John Herbert Claiborne, Jr., M. D.,
Adjunct Professor of Ophthalmology, N. Y. Polyclinic
;
Instructor of Ophthal-
mology in the College of Physicians and Surgeons, N. Y.; Assistant
Surgeon to the New Amsterdam Eye and Ear Hospital, N. Y.
;
Formerly Attending Surgeon, North Western Dispensary,
Eye,
'
Ear and Throat Department ; Formerly
Clinical. Assistant to the Manhattan Eye
and Ear Hospital.
Author of
"
Theory and Practice of the Ophthalmoscope."
WITH TWENTY-ONE ILLUSTRATIONS
PHILADELPHIA:
THE EDWARDS & DOCKER CO.
1895
COPYRIGHT, 1895
BY THE EDWARDS & DOCKER CO.
TO
Dr. EMIL GRUENING
THIS BOOK IS DEDICATED IN GRATEFUL RECOLLECTION OF
HIS EXCELLENT TEACHING
PREFACE
A philosopher has said that the task of an author
is either to teach that which is not known or to recom-
mend known truths by his manner of adorning them.
The author presents this book to the medical pro-
fession in the hope that he has put the known facts of
a dry subject in a pleasing form.
INTRODUCTION.
""THE importance of the functional examination in the
determination of the refractive condition of the eye,
and in the determination of the necessity for wearing
glasses, cannot be over-estimated. For, whatever value
may lie in keratoscopy, the ophthalmoscope, and the oph-
thalmometer, the fact remains that, in almost all cases, the
functional examination is the crucial test. Moreover, the
widespread conceit which exists that the fitting of glasses is
an easy matter and lies within the intellectual capacity of
most any one, warrants the publication of a monograph on
this subject.
It is, indeed, difficult for any student to read the
meagre descriptions of this examination that are found in
text-books and retire with even a clear theoretical under-
standing of the subject. It is the purpose of the author to
make the subject clear beyond peradventure for those who
shall read these pages. It is his purpose, in short, to pre-
sent it in such a way that a student may follow the lines
laid down and perform the examination with scientific and
mechanical accuracy without further instruction.
A fair success in teaching the subject for a number of
years has led him to believe that he has won the right of
presenting it. The ventilation of the subject of refraction,
while it may be tedious, he believes to be essential for those
who know little of the subject, or for those who have for-
gotten what they once knew. The author desires to call
particular attention to the chapter on Presbyopia. To
judge from the frequency with which glasses are prescribed
for this condition by totally ignorant people, one might
imagine it to be a very simple affair. As a matter of fact,
it is the most difficult problem in refraction, and a thorough
knowledge of it implies a thorough knowledge of all the
anomalies of refraction.
The author also desires to call attention to the graphic
formula or cross system, by which he indicates the refrac-
tive condition of the two principal meridians of the eye.
He has reason to believe that by the use of this system he
has succeeded in making students more readily understand
the optical results of the combination of spherical with
cylindrical glasses.
He has deemed it pertinent to add a chapter on the
use of mydriatics, since, upon their use, the success in
prescribing glasses in some cases largely depends. If a
somewhat colloquial style has been adopted in the prepara-
tion of this monograph, the author would say that it has
not been unintentional. He believes that the best way to
catch and hold the attention of a student is to avoid a
didactic style and stilted phrases. The book is a result of
a course of lectures delivered for a number of years at the
New York Polyclinic, and more particularly of a course in
practical instruction given by the author in the College of
Physicians and Surgeons, New York.
CONTENTS
CHAPTER I
The Faculty of Vision ... . . 9
CHAPTER II
The Method of Conducting the Examination .
.17
CHAPTER III
Descriptions of Prisms, Lenses and the Trial Case . .20
CHAPTER IV
The Refraction of the Eye . . . . . 30
CHAPTER V
Application of the Test Card to the Errors of Refraction . . 38
CHAPTER VI
Astigmatism ... .
48
CHAPTER VII
Cases of Astigmatism . . . . , ...
59
CHAPTER VIII
Presbyopia ....
67
CHAPTER IX
Mydriatics ...
.82
Jaeger's Test Types . .
87
SnehEns Test Types . . . . .
91
CHAPTER I.
THE FACULTY OF VISION.
The faculty of vision is the physiological function of
the eye. It is needless almost for me to tell you that this
faculty does not, strictly speaking, lie within the eye. It
lies, in fact, in the brain, and the most recent researches in
the physiology of vision place the seat of this function in
the cuneus of the occipital lobe of the cerebrum. The
retina itself, then, has absolutely no power of perceiving
the light that falls upon it. In what way the retina is in-
fluenced by light, what the change in its elements is
when light falls upon it, has never been fully explained.
It seems certain, however, that some change is wrought in
it, and that this impression is conveyed through the nerve
fibres of the optic nerve upward to the centre I have men-
tioned, and that there it is interpreted as light. You
remember very well, I am sure, that the optic nerve itself,
is incapable of receiving this impression, and you remem-
ber the familiar experiment in physiology by which you
may find the
"
blind spot " in your eye. This blind spot
corresponds to the entrance of the optic nerve, or the optic
disc, as it is called. At the disc there are only optic nerve
fibres, the outer layers of the retina being entirely absent.
There is another spot of peculiar interest in the background
of the eye, and that is the macula lutea or Yellow Spot of
Sommering. This is the spot of most distinct vision in the
retina, and may be called the seeing spot as opposed to the
2
(9)
IO CLAIBORNE,
blind spot. You know that there are ten layers of the retina,
but as we come to the edge of the yellow spot, all the lay-
ers cease except that of the rods and cones, and that when
we reach the fovea centralis or central pit, nothing but the
cones remain. This pit is the point of most distinct vis-
ion, and the light that falls into it is appreciated or seen
most clearly by the visual centre in the cuneus. From
this pit outward the acuteness of vision diminishes until
we reach the confines of the retina, the ora serrata, where
the visual acuity is least. Inasmuch as there are only
cones in the macula, and their number diminishes as we
progress outward from the fovea, it is not an unreasonable
assumption that the cones are the element in the retina in
which that wondrous change is created that is interpreted
by the cuneus as light. This, at least, is the dictum of the
physiologists. It is consistent with these facts that there
are found some birds whose retinae consist entirely of
cones and that they are possessed of wonderful power of
vision. This amounts to their retinae being composed of
a number of yellow spots.
Outside of the yellow spot in man the rods predomi-
nate over the cones, but in birds the cones, as a rule, pre-
dominate. In some nocturnal birds, eminently the owl,
only rods exist.
Vision may be divided into four kinds : Central, Peri-
pheric, Distant and Near.
We have already dealt with central vision when we
pointed out the faculty or function of the macula lutea.
We have referred indirectly to the peripheric vision, when
we said that the acuteness of vision diminished from the
macula outward. The peripheric vision was doubtless
given to animals primarily for the purpose of self-protec-
tion, and for the acquisition of prey. If you wish an illus-
THF, FACULTY OF VISION.
1
1
tration of the value of peripheric vision, roll up in scroll
form two sheets of music, and holding one in front of each
eye, endeavor to cross some crowded thoroughfare. You
would find that your field of vision would be restricted to
the very small circle in front of each eye, and you would
not progress far before you would be in imminent danger.
It is through the medium of peripheric vision that
many arts can be practiced. It is through the medium of
peripheric vision that we see many of the beauties of
nature, for the world would indeed be but a small one were
we able to see only those things whose images fall within
the circle of the macula lutea. It is the peripheric vision
which enables the individuals in an orchestra to see the
baton of the leader beating time, while they keep their
central vision upon the sheet of music before them. It is
the peripheric vision which enables a pianist to see the
movements of his fingers as they pass over the keyboard,
while his central vision is cast upon the notes.
The distant vision is the faculty of the eye to recog-
nize objects at a distance, and the near vision is the faculty
of recognizing objects near. What these two terms,
"
dis-
tance
"
and
"
near
"
specially mean will be developed later.
We
shall proceed now to deal with the distant and central
vision, leave the peripheric altogether, and shall take up
the consideration of the near vision in the last lecture on
refraction.
There are few people who see well in the distance who
are not guilty of conceit about it, and it is not an unusual
thing to see a number of people comparing their vision by
looking at some distant object, such as a sign. It is ob-
vious to you that however satisfactory this may be to them,
it is not in any sense scientific, and that we must settle
upon some degree of vision as that which is normal and
12 CLAIBORNE,
physiological, in order that we may be able to determine
when the function is within and when without the limits
of proper sight. Vision is a function which is more nearly
even in man than any other function of the body. There
is a certain power of vision which is the birthright of all
men. There is the widest difference in the faculty of hear-
ing in man, and no standard has been absolutely set down
as normal. How much more true is this of taste and smell
and feeling? Yet we can make a standard in the vision,
and say that man must have vision equal to that or fall
below the standard.
It is in a high degree probable that rays of light from
two different sources or points must fall upon different
cones in order to be seen as two things or objects
;
in other
words, if rays from different objects were to fall upon one
cone, the objects would appear as one. Now the smallest
visual angle that can be perceived at the macula corre-
sponds to i'. So that our two objects must be separated
by an interval of as much as or more than i' in order to
be seen as two. If they are separated by an interval less
than i', they will appear as one.
The visual angle is the angle included between the
two lines drawn from the opposite sides of an object and
passing through the nodal point ; see figure i. CD. is an
object, and the angle formed by it with reference to the
eye is included between the lines Cc. and Dd. which meet
at the nodal point N, and the angle C.N.D. is the angle
under which the object CD. is seen.
With the view of establishing some standard test by
which the vision of all eyes can be measured, cards have
been constructed upon which the letters of the alphabet
are printed. We English-speaking people use the ordinary
English letters of course, and these are serviceable for
THE FACULTY OF VISION. 1
3
almost all cases. Nevertheless, in clinical work it becomes
sometimes necessary to have German characters at hand, be-
cause the middle class of Germans do not all recognize the
Fig. i.
English letters. A card equally good for all is that on which
figures are printed. For whatever may be the status of a
person's learning in the matter of letters, there are a few
people who know anything at all, who do not know the
meaning of figures. The Arabic figures will probably be
recognized by all the patients with whom you will come in
contact. There is also a test card on which pot-hooks are
printed. This seems to me to be of no value. It requires
more knowledge to describe a pot-hook accurately than it
does to recognize a letter or a figure. By way of using a
universal system some one has suggested and had printed
on the test card the hearts, diamonds, spades and clubs of
playing cards. I have never seen anyone who has failed
to recognize these.
By regarding the test card presented you will see that
the letters diminish in size gradually from the top to the
bottom of the card, and if you will look still more care-
fully, you will notice that over each line are inscribed cer-
tain Roman figures
;
these figures indicate the distance at
which the line over which they are written should be read
by an eye possessed of the normal acuteness or acuity of
14
CLAIBORNE,
vision. The Roman figures indicate feet in this card.
There are other cards in which the distance is indicated in
metres. Now to those of us who have been accustomed to
measure distance all our lives in feet and inches and lines,
metres mean very little until we have translated them into
feet and inches. At school you used to jump so many feet,
not so many metres. It is immaterial, however, whether
you use metres or feet, as you will see in a few minutes.
The cards usually employed are those of Snellen, and let-
ters are constructed upon the principle of the visual angle
which is formed at the nodal point by the letters when sit-
uated at the distance indicated by the Roman figures over
each line.
It has been stated that the objects must be separated
by an angle of i' in order to be seen as two. Hence, the
smallest retinal image which can be perceived at the mac-
ula corresponds to an angle of i' and each letter of the test
card
"
is so made that when at its proper distance, each
part of it is separated from the other by an interval equal
to not less than the arc subtending an angle of i' at the
nodal point," while the whole letter subtends an angle of
5'-
Fig. 2.
The letter
L,
for example, subtends an angle of 5' at
the nodal point at the distance of 6 metres (the equivalent
of our 20 feet).
THE FACULTY OF VISION. 1
5
The letter A subtends an angle of 5' at 60 m. distance,
or 200 feet on our card.
It is clearly then a matter of no concern to us whether
our patient recognizes the letter L, at twenty feet or A at
200 feet. Each letter subtends at its respective distance
the proper angle viz., 5' at the proper point,the nodal
point, and the conditions for the normal acuity of vision, so
far as the angle is concerned, are fulfilled. But the brain
must have the faculty of recognizing the letter. The
angle would be formed, if the open eye of a dead man
were placed in the track of rays emanating from the let-
ters, but, of course, they would not be seen. L,earn, there-
fore, immediately the difference between the optical condi-
tion and the function of the organ.
Although it may be the birthright of all men to be
able to appreciate the angle of 5', there may be those who
have been cheated of it. In plain words, there are those
who are not able to recognize the letter L, at 20 feet, nor
the letter A at 200 feet. Such people are said to have less
than the normal acuity of vision. If you will cast your
eye down the card we use you will observe that there are
lines for 200 feet, 100 feet,
70
feet,
50, 40,
30
and 20 feet.
So you will immediately see that it is unnecessary for
us to place our card at 200 feet or any great distance. We
may place it at 20 feet, as this card is placed, or we may
place it at 15
or 10 feet. If the 20 line is read at 20 feet, or
the 15
line at
15
feet, the 10 at 10 feet, we know that the
patient has the normal acuity of vision because his brain
has the power of knowing an angle of
5
minutes. Hence,
the acuity can be reduced to a formula, and that formula
amounts to the simple Rule of Three.
Suppose a man can read the 20 line at 20 feet, the pro-
portion is this :
1
6
CLAIBORNE,
His vision ; Normal vision =
20:20 and this, you see,
is reducible to the fraction
-f-jj-.
Hence we would say
V
=
f$,
and as the numerator and denominator of this
fraction are equal, it is equal to the integer
1,
which is per-
fection.
But suppose a man cannot read the 20 foot line at the
distance of 20 feet, and can only read the
40
foot line at
this distance, the proportion would be :
His vision
;
Normal vision =
20:40
and this is equal to
f
{}-
or
^
of the normal vision. In like
manner we would record
-^^
when a man can only read
the 200 line at 20 feet, and his acuity of vision wonld be
^
of the normal. The meaning then of
f$,
3^-, -$,
f-g-
is clear.
Sometimes you meet people who can read further
down the card than the 20 foot line at 20 feet. For exam-
ple, a man may read the 10 foot line at 20 feet. Such a
man would be said to have
V=f-
or twice the normal vis-
ion.
From all these facts we may draw this simple formula
that V=5 in which d, the numerator, equals the distance
of the patient from the card, and D, the denominator,
equals the figuring over the line read.
CHAPTER II.
THE METHOD OF CONDUCTING THE EXAMINATION.
It now becomes necessary for you to know how this
examination is conducted. This is a very important point,
and it is the simplest.
In the first place adopt a routine. Hang or place the
test card in a good light and place the chair of the patient
preferably at the distance of 20 feet. The reason of this
will be apparent in the next lecture. Let the light be be-
hind the patient if possible, at any rate, to the side.
Examine the right eye first. The left eye must be
covered, and this may be done in several ways. You your-
self may hold a card in front of it, but you soon will get
tired ; or the patient may hold a card in front of it, but
he will get tired. It is best to put on the patient a pair of
spectacle frames for testing the eyes, such as you will find
in the test case, and slip into the left side of the frame the
opaque metal disc you will find in the case. In this way
both yourself and the patient are relieved from work. This
is a decided advantage in nervous or hysterical patients.
Now tell the patient to read the card from above down-
ward carefully. You might specify from left to right, for
many stupid people will read a letter on each line in a ver-
tical series. I have even known some who attempted to
pronounce words which they supposed the letters are
intended to spell. When the lowest line possible has been
read record it mentally or otherwise, preferably on piece of
3 (17)
1
8
CLAIBORNE,
paper, and indicate that it is the vision of the right eye.
Then uncover the left eye and cover the right one with the
disc. Tell the patient now to read with the left eye as far
as possible. Then record that as the vision of the left eye.
This may be done in several ways. You may write it out
in full if you wish, but the formula is more economical.
You may write R.E.V., which means right eye vision,
or R.V., or R. You may use the L,atin abbreviations, if
you wish, O.D.V., which means oculi dextri visio; in like
manner you may write
L.E.V., L.V.,
or I,., or oculi sinistri
visio, for the vision of the left eye, for example
:
O.D.V.=f#;
O.S.V.=||;
Always use the equality marks, the periods after the ab-
breviations, and the semicolon after the fraction. The
semicolon indicates that something is to follow, and what
that is you will find out in the next lecture.
Patients are apt to close the covered eye. Advise
them to keep it open ; it is more comfortable to do so, and
there is certainly no necessity of closing it when the opaque
disc is used. By no means allow the patient to close the
eye by pressing with the hand. If this is done, the vision
of that eye is obscured for some seconds, on account of the
temporary anaemia produced in the retinal vessels by the
pressure. If the patient cannot read the first letter on the
card at the distance at which he sits, bring the card nearer,
or place him nearer the card. It is better for you to take
the card and gradually approach the patient and mark the
point at which he first sees the initial letter. When you
have found this point there is no necessity of coming
nearer. A man who cannot read the first letter at 20 feet
THE METHOD OF CONDUCTING THE EXAMINATION. 19
may be able to read it at 16 feet, if so, record his vision as
2^,
by application of the rule as directed. It is clearly
unnecessary to bring the card nearer than 16 feet if he can
read the first letter at that distance.
Suppose a patient can read only the first letter at 1 foot
his vision is of course,
^-J-g-.
If he can read it only at 6 inches,
his vision is -^--g- inches by the rule. This, however, is an
extremely vulgar fraction, and I would suggest that you
simply write the fact and not the formula. Now the terms
"fingers
"
and
"
200," are equivalent, and when a surgeon
writes that a patient counts his fingers at 1 foot, he means
T5T
by the card. The fingers are often used near-by, instead
of the card. If the patient cannot count the fingers, the
hand is moved upward and downward, outward and inward
in front of the face. If the movements are correctly seen,
it is stated that he sees "movements of the hand." If he
is able only to recognize light from dark, or can recognize
different degrees of luminosity, it is stated that he has
"
quantitative perception of light." Take care in making
this test with the hands that the source of light is behind
the patient. If the patient cannot tell the difference be-
tween day and night, his vision may be said to be O, i. e.,
he has no perception of light. In plain English you may
state that he is stone blind.
CHAPTER III.
DESCRIPTION OF PRISMS, LENSES, AND THE TRIAL-CASE.
There are two kinds of lenses used in correcting the
errors of refractionspherical and cylindrical ; these may
be convex or concave. Before passing to the consideration
of their properties, it is necessary to refer to the primary
law of refraction of light and to the behaviour of rays of
light that are incident to prisms, for upon the comprehen-
sion of these things depends the comprehension of spheri-
cal and cylindrical lenses.
Fig.
3.
Rays of light in passing from a less dense into a denser
medium are refracted toward a perpendicular drawn to the
surface of the medium at the point of entrance
;
in passing
from a denser to a less dense, they are refracted away from
a perpendicular drawn to the surface of the medium at the
(20)
PRISMS, LENSES, AND TRIAL-CASE. 21
point of emergence. If the rays be at right angles to the
surface separating the two media, they are not refracted at
all.
At B the ray A
B is refracted toward the perpendicular
PP. At C the ray B D is refracted away from the perpen-
dicular P P. The ray H K falling at a right angle to the
surface of the medium, is not refracted.
In Fig.
3,
the sides of the refracting medium are paral-
lel, but in the case of a prism the surfaces are not parallel,
and a ray can therefore be perpendicular to one surface
only at a time. A ray that falls on a prism is refracted,
and the deviation must be toward the base.
Fig.
4.
The ray D M falling upon a prism, is bent in the di-
rection M N
;
at N it is again bent, so that an observer,
catching the ray at E,
would receive it as if it came from K.
Spherical convex and concave lenses may be regarded
as being composed of prisms
;
the former with their bases,
the latter with their apices, opposed. Since rays in passing
through a prism are refracted towards its base, we can
readily comprehend the fact that convex lenses cause con-
vergence, and concave lenses divergence of rays.
A line which passes through the centre of a lens (opti-
cal centre) at right angles to the surfaces of the lens, is
22
called the principal axis.
is not refracted.
CLAIBORNE,
A ray passing through this axis
Fig.
5.
The ray B strikes the lens
L
at a right angle to its
surface, and pursues a straight course to the point H. The
ray A strikes the lens
L
obliquely at D, and is refracted
Fig. 6.
toward a perpendicular to the surface of the lens at that
point, as shown by the dotted line M K. On leaving the
lens at O, the ray is refracted away from the perpendicular
N O, and meets the central ray B at the point H. The
ray C in like manner meets the other rays at H.
Parallel rays then passing through a biconvex lens,
are rendered convergent.
PRISMS,
LENSES, AND TRIAE-CASE
23
The ray B strikes the lens L, at right angle, and is not
refracted. The ray A strikes the lens
L,
obliquely at D,
and is refracted toward the perpendicular,
G H. On emerg-
Fig.
7.
ing from the lens at K, it is bent away from the perpen-
dicular O P in the direction K M. The like takes place
with the ray C.
Parallel rays then passing through a bi-concave lens
are rendered divergent.
All rays that do not pass through the principal axis
are refracted. Those rays that pass through the optical
centre, but not through the principal axis, are termed
secondary rays.
Fig. 8.
They do undergo refraction, but in thin lenses it is so
slight that they are assumed to pass in a straight line.
24
CLAIBORNE,
Parallel rays passing through a convex lens (L,) are
brought to a focus (A) at a certain fixed distance from the
optical centre of the lens. Such a point is called the
principal focus of the lens, and the distance of this point
from the optical centre of the lens is called the focal dis-
tance of the lens.
Fig.
9.
If parallel rays, passing through a concave lens be
rendered divergent, the focus must be a virtual, negative
one, situated on the same side of the lens as the object from
which the rays proceed. If the divergent rays in Fig. 10
below, be continued backward, they will meet at F, the
principal focus.
Fig. 10.
Spherical lenses may be plano-convex (Fig. 11,
1),
that
is, having one surface plane and the other convex
;
double
convex (Fig. 11, 2)
having both surfaces convex with the
PRISMS, LENSES, AND TRIAL-CASE.
25
same radius of curvature to both
;
converging concavo-con-
vex (Fig.
11,
3)
having one surface concave and the other
convex, with the predominance of the latter, the so-called'
positive meniscus; plano-concave (Fig.
11,
4)
double or bi-
concave (Fig.
11,
5);
diverging concavo-convex (Fig. 11, 6)1
with predominance of the concavity, the negative meniscus..
123
45
Fig. 11.
Cylindrical glasses are segments of cylinders. If we
describe a circle on the outer side of an upright solid glass
cylinder, the portion included within the circle will repre-
sent the surface of a convex cylindrical glass. The trans-
verse diameter will have the greater radius of curvature,.
the vertical meridian which corresponds to the axis of the
cylinder will be plane.
If we describe a circle on the inner side of an upright
hollow glass cylinder, the portion included within the cir-
cle will represent the surface of a concave cylindrical glass.
The transverse diameter will have the greater radius of
curvature, the vertical, which corresponds to the axis of
the cylinder, will be plane.
Such
glasses, therefore, refract only those rays which
are at right angles to their axis.
Cylindrical glasses are usually made planoconvex and
plano-concave,
and parallel rays passing through them at
26 CLAIBORNE,
right angles to the axis are rendered convergent or di-
vergent respectively.
The axes of cylindrical glasses are often indicated by
ground lines, one on either side of the lens or by the glass
being ground rough on either side, so that the edges of the
ground portion are parallel with the axis.
There are two systems of numbering lenses, one is the
inch system and the other the metric system. For the
former the convex lens, which brings parallel rays of light
to a focus one inch from its optical centre, is taken as the
standard for convex, spherical, and cylindrical glasses.
Such a glass is called a convex No. i. The convex lens
which brings parallel rays of light to a focus at two inches
from its optical centre is called a convex No.
2,
and so on.
The strength of a convex number two is obviously one-half
that of a number one, and the strength of a number three
obviously one-third that of a number one. Hence the
strength of lenses is inversely as their focal distances, and
the strength is expressed in the form of a vulgar fraction,
1 ill
A.
i
ptr
>
"3")
4i 5' T5T' TEf>
CLL-
The concave lens which gives to parallel rays such a
divergence that, if prolonged backward, they will meet one
inch from the optical centre of the lens, is taken as the
standard for concave, spherical and cylindrical lenses.
Such a lens is called a concave number one. A concave
number two lens would give parallel rays such a divergence
that, if prolonged backward, they would meet two inches
from the optical centre of the lens. The strength of the
latter is obviously one-half that of the former. Convex
glasses are writen with the algebraic plus sign before them:
+
i> +T5") +Tir>
etc-
Concave glasses are written with the
algebraic minus sign before them:

x
\,
j^-,

^,
etc.
The plus and minus sign obtain also in recording convex
PRISMS,
LENSES, AND TRIAL-CASE.
2J
and concave cylindrical glasses. The standard or unit of
the metric system is a lens of one metre focal distance
;
this is called a dioptry.
In some respects the dioptric system is preferable. It
is certainly more commonly employed. The use of the
vulgar fractions gave rise to much trouble in the handling
of the common denominators. Moreover, the English and
French inch differ slightly in length. In the metric sys-
tem then we deal with integers and decimal fractions. D.
is the abbreviation for dioptry. Thus
+
1 D.
+
2 D.
3
D., etc. In fractions we write thus:
+1.5 D.

2.25
D.
+3-75,
+-25
D.
+.50
D.
This simplifies matters a good deal.
It is necessary for yon to know how to reduce the
inch system to the dioptric system and the reverse. The
English metre is
39+
inches, the French
37.
For the
sake of convenience we regard
39+
as
40
and
37
as
36.
Of course, you understand that the metre is a fixed dis-
tance
,
it is the inch of France and England that differs.
The English inch is shorter than the French, for it takes
39+
English inches and
37
French inches to make the
metre.
Let us accept
-$
as the equivalent of 1 D.
1 D.=^
,T) 2 1
1 D
3 1
4
D.=A=i-
.50
D.=-
s
-
B
-X-3r=7-y.
75
u-
TS"
X 4
TT

Tg-
.25
D. =-g-g-
X
T
=
TT-
28
CLAIBORNE,
Then
1 .
1.50
D.=^L+
1.25
D.=^V+xi
i-75
D-=W+
44
1 .
48"
-3 1
-T2"2T-
5 1 _|_.

144

HI
-
7 - _ 1
"144
20"
- 1
To get the value of the dioptres in the inch system,
multiply
^g-
or
Jg-
by the number of dioptries.
The reduction of the inch system to the dioptry is
equally simple :
-5TX36
-g-g-
1
XT
iD.
X36=4f=2
D.
^X
3
6=ff=3D.
X
36=ff=.5
oD.
1
xi4X36=
T
3
A=-25l>.
^X
3
6=^-
2-4 X36=
"4
8
- 36
"24
=75
D.
=
1.5 D.
To reduce the inch system to dioptres, multiply the
numerator of the vulgar fraction by
36
or
40.
THEO. MUNDORFF,
OPTICIAN.
NW YORK.
;
Fig. 12.
PRISMS, LENSES, AND TRIAL-CASE.
29
Fortunately, our test cases are so arranged that you
are not under the necessity of making this reduction. It
is done for you and recorded under your eyes.
The test case (see Fig. 12) contains convex and con-
cave and cylindrical glasses ; on the left are the concave
glasses, on the right the convex. In the centre are the
cylinders. The concave glasses are usually rimmed with
brass, the convex with nickel. The same thing applies to
the concave and convex cylinders. There are two of each
set, and between each row is recorded the number of each
glass in inches and dioptries, so that you can write either
you choose. The smallest number,
.25
D., is usually
placed at the bottom of the column, nearest to you. There
are not as many cylinders as there are spherical glasses.
There are usually two pairs of spectacle frames in the
case, with an opaque disc for insertion in the frame to
cover one eye while the other is under examination.
There are also prismatic glasses in the test case, but
you do not concern yourself with them in the functional
examination.
CHAPTER IV.
THE REFRACTION OF THE EYE.
The eye-ball may be considered an imperfect sphere,
composed externally of the sclera of and the cornea. The
cornea is a segment, in rough terms, of a smaller sphere,
and is inserted in the anterior aspect of the sclera. It is
the window through which the rays of light pass into the
interior of the eye.
Within the eye are found, from before backward, the
aqueous humor, the crystalline lens and the vitreous hu-
Fig.
13.
mor. At the posterior pole lies the retina, spread out
upon the choroid, which latter, in its turn, is spread out
on the sclera. The eye is indeed a photographic camera,
and may be called a camera obscura in view of the dark
pigment of the choroidal coat. This choroidal coat is in-
(3o)
THE REFRACTION OF THE EYE.
3
r
tended to absorb the rays of light, and keep them from
being reflected about within the eye. Albinos do not
possess this pigment, hence they are dazzled by light.
There are three kinds of eyes :
i. Emmetropic eyes
;
2. Hypermetropic eyes or hyperopic eyes
;
3.
Myopic eyes.
The three conditions are called emmetropia, hyperme-
tropia or hyperopia, myopia. The emmetropic eye is the
natural eye, and is about -^ of an inch in length
23
mm.,
if you wish it in the fractions of a metre. The other two
eyes differ only in that one is longer and the other shorter
Fig.
14.
than the emmetropic eye. The hypermetropic or hyper-
opic eye is shorter than
y
9
-^ of an inch, and the myopic eye
longer than
^
of an inch.
32
CLAIBORNE,
A represents the emmetropic eye, B the hyperopic, and
C the myopic eye.
The names can hardly be said to be well-chosen, as
you will soon see.
The first, emmetropia, is derived from the Greek,
meaning within the measure
of
vision. The second, hyper-
metropia or hyperopia, mean respectively over the -measure
of
vision or over-vision, while the third is a distinct anomaly,
meaningwell, it is difficult to say what. The fact is, the
word myopia is derived from the Greek word (nuetv, to
close the eyes, and &4>, the eye. Myopes, when they do not
use their proper correcting glasses, squeeze the lids together
for the purpose of seeing better, and this habit has given
them the name of myope, i. e., one who sees with the eyes
half closed. You have all doubtless observed this in
myopes. In like manner, emmetropic persons are called
emmetropes, and there is no equivalent in the English
language for this termwe are condemned to the Greek.
Hyperopic people are called hyperopes or hypermetropes
;
but for the terms hyperopia and myopia, English equiva-
lents exist. Hyperopia is
far
or long sight, and myopia is
short or near sight. Observe, now, the curious antithesis
which has worked itself outthe short eye, the hyperopic
eye, is the long- or far-sighted eye
;
and the long eye, the
myopic eye, is the short- or near-sighted eye. There is
another term for myopia, a very good term, indeed, and for
this reason it is never used, viz. : brachymetropia, which is
a literal translation into Greek of "short sight."
It becomes necessary, now, to consider these three eyes
from an optical standpoint. In order to do that, allow me a
moment's digression. When rays of light start from the same
luminous point, they are necessarily divergent, and they
continue to be so until they have traversed the distance of
THE REFRACTION OF THE EYE.
33
20 feet. At this distance and beyond it, they are prac-
tically parallel. They are, indeed, quite as parallel as
those that arrive from infinity, and the rays therefore that
come to us from the card situated on the wall 20 feet away,
have the same optical value as those that arrive from a
star or planet in the firmament. The distance of 20 feet,
then, is considered infinite distance in ophthalmology,
and it is ordinarily referred to as distance. Anything nearer
than 20 feet, is referred to as being near.
An emmetropic eye may be described as an eye which,
in a state of rest, focuses parallel rays of light upon the
macula lutea. (See A, Fig.
14.)
The parallel rays of light
from a distant source are focused upon the retina by virtue
of the refractive power of the media without an effort on
the part of the eye. A hyperopic eye is an eye which, in a
state of rest, causes parallel rays of light to be focused be-
hind the macula lutea. It is hardly necessary for me to
say to you that no focus is formed behind the eye since the
rays do not pierce the coats
;
but, since the eye is shorter
than it should be, the rays fall upon the retina in the act
of convergence before they have formed a focus. See B,
Fig. 14. A myopic eye is an eye which, in a state of rest,
focuses parallel rays of light in the vitreous humor, i. e., in
front of the macula lutea, so that the rays of light which
form a focus in the vitreous humor again diverge and fall
upon the retina in a condition of divergence. See C, Fig.
14-
An emmetropic person will therefore see distant ob-
jects because a focus is formed on the macula ; and this act
is accompanied by no effort on the part of the possessor of
this eye. It is not improbable that some of the pleasure
derived from regarding distant landscapes, apart from the
pleasing effect of the hues and tone of distance, is due to
34
CLAIBORNE,
the rest which the eye enjoys under these circumstances.
Such an eye, looking into distance, is as much a mechani-
cal instrument as the camera of a photographer.
Let us now turn our attention to the hyperopic eye.
The rays do not form a focus on the retina, as you can see
;
such an eye, therefore, cannot see distant objects well.
Instead of the points that make up a focus, circles
of
diffusion
are formed, and for every point there is a circle. An im-
perfect, enlarged, and blurred image is formed on the re-
tina, and the shorter the eye, the larger, more blurred and
more imperfect the image. You are surprised to know
that a far-sighted eye cannot see far ! From the cut it is
clear that it cannot see well in the distance, but it is a
fact that it does see distant objects well. Just
here it
is necessary to digress once more. You are surely ac-
quainted with the ciliary muscle ; if you will refer once
more to Fig.
13,
you will see it just behind the root of
the iris. This muscle runs round the eye, and depend-
ing from it is a ligament, called the ciliary ligament, one
layer of which is attached to the anterior, and the other
to the posterior, surface of the lens. The lens is elastic
and resilient, and will readily swell if pressure be taken
from it. Now this lens and muscle is in a condition of
perfect repose when the emmetropic eye is in a state of
rest, i. e., is looking at distant objects, but when the gaze is
turned upon near objects, a change takes place in this ap-
paratus. The rays coming from near objects are not paral-
lel, but are divergent, as you know, and the emmetropic
eye in a state of rest can focus only parallel rays on the
retina ; hence, this rest must be abandoned if that eye has
to see near objects. The brain gives the cue to the centres
of the third nerve that the time has come for action, and
tells them how much nerve force must be sent to the mus-
THE REFRACTION OF THE EYE.
35
cle of accomodation to accomplish the purpose of clear vis-
ion. The ring-shaped muscle then acts, and, like all mus-
cles, it shortens its origin upon its insertion. As that is
done, the tension upon the anterior surface of the lens is
relieved and the lens springs forward, thereby increasing
its antero-posterior diameter and increasing its power of
refraction. In this way the eye accommodates itself for
Fig.
15.
different distances inside of 20 feet, and the most beautiful
thing about the function is that the brain always measures
the distance accurately, and sends just the force necessary
to do the work and no more. The act of accommodation be-
longs properly to vision within 20 feet. But we have seen
that the unfortunate hyperope cannot see distant objects
well on account of the shortness of his ball. The brain
searching around for a means of forming a good focus,
turns to the accommodation, and finds that, by the use of
this function, a good focus can be formed, and its desire for
clear, distant vision be satisfied. This is an iniquitous use
of the muscle of accommodation, but it is persisted in. The
hyperope then does see clearly in the distance, but he does
so at the expense of a muscular action that is intended by
nature only for the act of near vision. Whenever a law of
nature is broken, retribution is inevitable, and the rupture
of this law constitutes no exception. The hyperope pays
36
CLAIBORNE,
for his clear vision in headache, eyeache, nausea, vomiting,
tumbling gait, and many other symptoms which are char-
acterized as those of asthenopia or weak eyes. The hyper-
opic errors are by far the greatest cause of asthenopia in
the errors of refraction.
I withdraw, then, the statement that the hyperope
does not see well in the distance.
By referring to C, Fig.
14,
you will perceive that a
myopic eye cannot possibly see distant objects well, for the
parallel rays are focused in the vitreous humor, and, hav-
ing formed a focus, again diverge, so that they arrive at
the retina in a condition of divergence. Circles of diffusion
are formed on the retina instead of points, and for every
point a circle is formed. The image of the distant objects,
therefore, is blurred and enlarged. There is no remedy
for this condition within the eye. Suppose the eye en-
deavors to remedy the defect by the act of accommodation.
The refractive power of the eye will be increased, and so
far from the eye seeing better, it will see worse, for the
focus will be formed still further forward in the vitreous
humor, and the circles of diffusion will be proportionately
larger. The trust of the myope lies in the art of man.
Pain is not so frequently caused by myopia as it is by hy-
peropia, and the reason is clear. The myopic eye has a
dreamy look, in other words, a look which is an attribute
of beauty. Myopic eyes often appear large, and this has,
from
immemorial time, been regarded as an attribute of
beauty. The expression "ox-eyed," as applied to Juno, is
familiar to many of you. This dreamy look has been
termed the
"
myopic stare." There can be little doubt
that myopia, to some extent, influences the mental quali-
ties when it develops in early life. A boy who cannot see
well in the distance is little likely to engage in field sports,
THE REFRACTION OF THE EYE.
S7
for not only would he be unsuccessful, but he would also
be in danger of injury. Consequently he would be inclined
to be a book-worm and studious, if he has brains and the
proper disposition. If naturally stupid, he is apt to become
a drone. The future of many a person could have been
altered, if their refractive error had been corrected in
youth. The world in which a myope lives is a narrow
one, and the more myopic he is, the narrower it is. His
powers of observation are limited, and his knowledge of the
wide world corresponds.
CHAPTER V.
APPLICATION OF THE TEST CARD TO THE ERRORS OF
REFRACTION.
It becomes necessary now for us to apply the test card,
and what we have learned about the acuity of vision to the
refraction of the eye. Let us take up each condition in
its turn. The term emmetropia we have seen means wtili-
in the measure
of
vision. Any eye, therefore, you would
naturally assume, that has vision within the normal meas-
ure would be emmetropic. This is not true. You must
learn for good that the term emmetropia refers by consent
to the refraction of the eye and not to the function. So
try to forget the etymological meaning of emmetropia. An
emmetropic eye, we have seen, focuses parallel rays of light
upon the retina without an effort of the accommodation.
A man may be dead and have emmetropia or his optic
nerve may be atrophic, so that he cannot tell light from
darkness, and yet be emmetropic. Conversely, because a
man has
ff
vision, it is not a necessary conclusion that he
is emmetropic.
Hypermetropia means beyond themeasure
of
vision, and
you would infer from this that any man who can see more
than
ff
is hyperopic. This also is not true. An emme-
trope
sometimes has the exceptional vision of
ff-
or
f-2-.
On
the other hand, hyperopes naturally see farther than em-
metropes, for their eyes are capable of recognizing a smaller
visual angle than emmetropes. Yet a hyperope whose fun-
dus and media are normal may not be able to see as much
(38)
ERRORS OF REFRACTION.
39
as
|$.
He may not have had that amount of acuity of vis-
ion by nature and there may be other reasons also. For ex-
ample, his muscle of accommodation may have been par-
alyzed by atropine, or as a sequella of diphtheria or syphilis.
Weakness from prolonged fever may interfere with his ac-
commodation, or what is more natural, he may not be able
to overcome the error through age. In any of these cases,
a hyperope will not be able to see -, hence the term would
appear to be an incorrect one.
A myope cannot see well in the distance, and hence,
cannot see -{}-. A man, however, who does not see |-- need
not be myopic, since we have just seen that he may be em-
metropic with function diminished from disturbance with
the perceptive apparatus or the media
;
a hyperope too, may
have less than
f
$
vision, as we have seen. So that vision
less than $ means nothing at all with reference to the re-
fraction of an eye.
Let us sum up :
If a person reads
f$
on the card, i. e., has normal vis-
ion, you have learnt one negative fact, namely, that he
cannot possibly be near-sighted. There remain two other
conditions of refraction, emmetropia and hyperopia ; he
must possess one or the other of these.
If a person reads less than
f
--, say
f$-,
you have learnt
nothing whatsoever about his refractive condition. For he
may be emmetropic with some disturbance in the fundus
or media, or he may not have his birthright of |-g- vision
;
he may be hyperopic with his accommodation weakened or
eliminated
;
or he may be myopic with an imperfect image
on his retina by reason of his elongated eyeball.
L,et us now make a practical demonstration of a few
cases.
40 CLAIBORNE,
This patient whom I now present to you I have taken
at random from among those on our benches. I shall ask
him no questions, but will proceed to take the vision first
of his right eye, and for that purpose I place this spectacle
frame on his face and cover the left eye with the metal
disc. He read
|^-
as you see. Now I shall take the vision
of his left eye
;
that also is --. What have we learned
about this man ? In the first place, he has normal acuity
of vision, his eye is capable of appreciating an angle of
5'
accurate^. So much for his function. But what have we
learned about his refraction ? Why this, that he cannot
possibly be near-sighted, for he sees well at a distance.
There are now only two other conditions of refraction left
for us to consider, namely, hyperopia and ernmetropia. To
decide between these two, we must have recourse to our
box of test glasses. I now pick out the weakest of the
convex glasses, a
+.25
D. or
y^
in the inch system, and
place it before the right eye. He tells me, as you can hear,
that he does not see so well through that glass as without
it. The conclusion from this is inevitable
;
the man can-
not be far-sighted, for if he had been, he would have been
only too glad to have relaxed his accommodation and
allowed me to represent it by my glass. He must, there-
fore, possess the only remaining condition of refraction, and
that is ernmetropia. The other eye gives the same result,
as you see. I shall now ask the man what he complains of.
He says
"
nothing whatever," and tells us that he brought
his boy for treatment. He is not a patient. When the
glass was put in front of his eye the parallel rays coming
to him from distance were focused in front of his retina, so
that he was rendered artificially near-sighted. Hence, as
an emmetrope he saw worse than before, since he had cir-
cles and not points on his macula.
ERRORS OF REFRACTION.
4
1
Let us take another patient. This boy complains of
pain over his brows and headache in the occiput when he
reads at school and when he studies at night.
Let us take his vision. With his right eye he sees -#,
and also with his left eye. You have now learnt one thing
about his refraction, namely, that he cannot be near-sighted.
So that two conditions remain for us to consider, hyperopia
and emmetropia. This boy is apparently in the same con-
dition as the man we have just examined, save that he has
pain in his eyes and head on reading. Let us now place
the weakest convex lens in front of his right eye, the
.25
D.
which I pick out of the case
;
I now ask him to read the
20 line and he does it, as you see, easily. He also tells us
that he sees it just as well. This boy has accepted a con-
vex lens, and in this respect differs from his father
whom we have just examined. What is the conclusion?
He cannot be emmetropic like his father, for if he were, he
would not see so well with as without the glass, for circles
of diffusion instead of points would be formed on his ret-
ina. There is only one other possibility for us to consider
and that is hyperopia. By exclusion then, the boy has
hyperopia. When the convex glass is put in front of his
eye he relaxes his accommodation to the extent of the value
of the convex glass and allows me to represent his effort
by my lens. He has just as good a focus as before and is
saved work. Am I content to stop here ? By no means.
He may have still more hyperopia. Hence I now place
the next strongest glass
+.50
D. in front of his eye, and he
tells me that is just as good, if not better, and, as you see,
he still reads
f-J.
This boy then has as much as
.50 D of
hyperopia. I am not yet satisfied. I go further and find
that he accepts
-f .75
D. and reads
|~|.
He says also that
it gives him a feeling of rest. I go still further and place
42
CLAIBORNE,
-f-
i D. in the frame. He shakes his head and says he does
not see quite so well. He may call off the letters for he
has learned them by heart by this time, but he is intelli-
gent enough to know that he does not see them so well.
What have we accomplished here. We have measured the
total amount of this boy's manifest hypermetropia, and
that amount is
.75
D. We continued to put glasses in
front of his eye till he saw worse. That means that we
formed a focus in front of his retina in the vitreous humor
so that the focus on his retina or macula was imperfect.
Hence the image of the letters was imperfect.
There is such a thing as an obstreperous muscle of
accommodation. A muscle that will not relax its tension
in hyperopia, but so far as you are concerned at present, a
person who will not accept a convex lens, must be considered
to be not far-sighted.
Let us draw our conclusion now from the study of this
case. A person who sees
f$
cannot be near-sighted, and
must be either hyperopic or emmetropic. If he sees equally
well with a convex glass he cannot possibly be emmetropic,
hence he must be hyperopic and the strongest convex glass
through which he sees equally as well as without it, is the
measure of his hyperopia.
We lay aside the class of cases in which the vision is
as much as
f$
and take up those in which it is less. If a
patient reads less than
f-g-,
you have learned absolutely
nothing about his refraction, and I hope you have not for-
got the reasons for this statement. I repeat them. A per-
son who reads less than
f$
may be emmetropic with some
change in the fundus or media, or as a bare possibility, may
not have the birthright of normal power of perception
;
he may be hyperopic with his accommodation limited or
ERRORS OF REFRACTION.
43
eliminated ; finally he may be myopic with an imperfect
focus due to too great length of his eyeball.
I shall now pick out some cases illustrating these con-
ditions. Here is an old man who can barely see in each
eye as much as
-^/o i
ne has opacities in his lenseshas
commencing cataract. Here is a middle-aged man who
sees still less than
2%
;
he has partial atrophy of the optic
nerve. Here is a little girl with dilated pupils, who has a
high degree of hyperopia. She sees
-^fa
in each eye be-
cause her muscle of accommodation is paralyzed, and she
has an imperfect focus in consequence. This is an old
man who reads
ff
, who is also hyperopic. No mydriatic
has been put into his eyes, but he has an imperfect focus
because he cannot use his muscle of accommodation. His
muscular strength is going fast.
This woman with the prominent eyes is near-sighted
and sees
-fg-
in each eye. She too has an imperfect focus
because the rays meet in her vitreous chamber and fall on
her retina in divergence.
The cause of the imperfect vision in the cases just
shown, I have discovered by the use of the ophthalmoscope.
But you must learn to settle on the cause by the functional
method. Here is a case to which we will apply this
method solely. The patient reads
y
2
^
in each eye as you
can see. Following the invariable rule, I place a plus
.50 D. in front of his right eye. He says he sees worse.
He cannot be hyperopiche must be either emmetropic
with disturbance in the media or fundus, or myopic. I now
place a concave glass in front of the same eye and he tells
me he can see no furtherno better. He says the letters
look a little sharper and smaller, that is all. The cause of
his poor vision is not near-sight either. He must have
44
CLAIBORNE,
some disturbance in his media or fundus, and the great
probability is that he is emmetropic.
This patient reads
|-|
with each eye. The weakest con-
vex glass makes him see worse. We exclude hyperopia.
The weakest concave glass makes him see better. He must
be near-sighted
;
he now reads
f-g-
with difficulty but he sees
better. Shall we stop here ? By no means. We increase
the strength of the glass. He now sees |-g- with

.75
D.;
with

1 D. he sees
-|$.
Are we content ? By all means
we should be. We wish no more than perfection, and that
is expressed in
|^.
You perceive that the concave glass I placed in front
of his eyes causes the rays to enter into his eye in the
condition of divergence so that the focus that was first
formed in the vitreous humor is then formed on the retina,
and the circles of diffusion are supplanted by points.
Hence, the retina has a perfect image, and as the function
is unimpaired he sees
f$.
You understand too that the
first glass that causes -- vision is the measure of the myo-
pia, for I might continue to use stronger glasses than is
necessary and the patient still see --, since he would use
his accommodation to overcome the excessive divergence
of the rays. This would be equivalent to making him
hyperopia We do not wish to do that, we merely wish to
render him emmetropic. Of course, we cannot always
give
f-
with the proper correction, so that we may formu-
late our conclusions in myopia in this wise :
If a person sees better with a concave glass he is myo-
pic, and the weakest concave glass with which he sees
-|$,
or gets the best possible vision, is the measure of his myo-
pia.
There is here too such a thing as a spasm of the ac-
commodation, so that an emmetropic person may appear
ERRORS OF REFRACTION.
45
myopic, but so far as you are concerned in the functional
method, the above conclusion is sound and good.
I^et us now sum up in as few words as possible the
propositions contained in what has been said at such great
length.
If a person reads
|~,
one thing has been learned in
regard to his refractionhe cannot be near-sighted ; he
may be emmetropic or hyperopic. If he sees worse with
the weakest convex lens in the case, he cannot be hyperopic,
hence, he must be emmetropic. If he sees equally as well
through the weakest convex lens, he cannot be emmetropic
hence, must be hyperopic, and the strongest convex glass
through which he sees equally as well or better is the
measure of his hyperopia.
Any one who sees equally as well or better through a
convex glass must be hyperopic.
If a person reads less than
-f|-,
nothing has been learned
in regard to the refractionhe may be emmetropic with
changes in media or fundus or he may not be possessed of
the proper acuity of vision naturally
;
he may be hypero-
pic with the function of accommodation eliminated or im-
paired, whereby an imperfect image is formed on the
retina
;
he may be myopic whereby an imperfect image is
formed on the retina. If he sees worse through the weak-
est convex glass he cannot be hyperopic. If he sees better
through the weakest convex glass he is hyperopic, and the
strongest convex glass through which he sees best is the
measure of his hyperopia. If he sees worse through the
weakest convex glass and better through the weakest con-
cave, he is myopic, and the weakest concave glass through
which he sees best is the measure of his myopia.
If he sees worse through the weakest convex glass,
and no better through the weakest concave, he is, in all
46 CLAIBORNE,
probability, emmetropic, with disturbance either in the
media or fundus.
Cases and Formulae.
Allow me to insist that you adopt a regular method of
recording your results. You remember how I said the
simple statement of vision was recorded. L,et us record
now the cases I have given you of
E., H. and M.
Our first patient had this vision :
R.E.V.=f;
L.E.V.=f|
;
We found this patient to be emmetropic, so we simply write
after the statement of the vision, E. thus :
R.E.V.=fi; E.
L.E.V.=||; E.
Our next patient was hyperopic to the extent of
.75
D.,
and his vision was
f|
in each eye. We record his case
thus
:
R.E.V.=f|;
hm. .75D.
L,E.V.=fi ;
hm.
.75
D.
Hm., means manifest hyperopia. Another patient
with hyperopia of 2 D. was unable to read
f$.
We record
his case thus
:
R.E.V.=f|; fw. +2 D.
L,.E.
V.=fl;
Hw.+
2D.
His hyperopia is not said to be manifest since he failed
to read
f$.
Our case of myopia is recorded in like manner :
ERRORS OF REFRACTION.
42
R.E.V.=flf; f|w.-
3
D.
Iv.E.V.=f|; fw.-
3
D.
The w. stands for with, and you observe that the two-
statements of vision are placed side by side for easy com-
parison, i. e., the vision before correction and the vision
after correction.
Do not fail to adopt this method of recording your
results. It is the plainest and simplest. There are many
irregular ways of doing it which are clear to an expert, but
nothing can be better than an unequivocally plain state-
ment.
CHAPTER VI.
ASTIGMATISM.
We come now to discuss the matter of astigmatism.
This subject is ordinarily regarded by students as extremely
difficult to comprehend. Permit me to say that the diffi-
culties lie on the surface and in the imagination. If you
have followed me so far in the description of emmetropia,
hypermetropia and myopia, and in the correction of the
latter two, you will find no difficulty in following me in
the exposition of astigmatism and its correction.
Astigmatism is the refractive condition of the eye in
which a point cannot be recognized as such. It is seen as
a line instead. The word is derived like so many terms in
ophthalmology, from the Greek a privativesignifying
not and
sri-pm
a pointnot a point.
Let me state as the initial proposition in astigmatism,
that there are but two meridians to the cornea, one being
given, the other is at a right angle. So that if you accept
90
as the first,
180
is the other. If one meridian be
45,
the other is
135 ,
or if one be
75, the other is
165
,
etc. Remember the errors we have dealt with heretofore
have been spherical errors, i. e., they have been errors of
refraction that have been common to the two meridians of
the eye.
We may refer to astigmatism also as a meridian error,
since it belongs to one or the other meridian. When an eye
is emmetropic both meridians of the cornea have the
(48)
ASTIGMATISM.
49
same radius of curvature, and the eye from before back-
wards in each meridian is
T
9
T
of an inch long. When an
eye is spherically hypermetropic, each meridian has the
same radius of curvature, but the length of the ball in each
meridian is less than -^ of an inch. When an eye is
spherically myopic each meridian has the same radius of
curvature, but the length of the ball in each meridian is
more than
^
of an inch.
When an eye is astigmatic, one meridian differs from
the other in radius of curvature and in length from before
backward.
We usually refer to the radius of curvature of the cor-
nea when we speak of astigmatism, though there is such a
thing as an astigmatism due to a prolongation of the eye-
ball at its posterior pole, as there probably is an astigmatism
due to a badly shaped crystalline lens. L,et us, however,
keep our minds upon the cornea as the seat of astigmatism.
It will be very easy for you now to call off for me the
various kinds of astigmatism.
i. Let us suppose a case in which the vertical meridian
of the eye has the radius of curvature of emmetropia, and
the horizontal meridian has the radius of curvature of
hypermetropia
;
in other words, a cornea which in its ver-
tical meridian is normally curved and in its horizontal
meridian is curved too little, i.e., is slightly flattened. The
condition is called
Simple hyperopic astigmatism.
Fig. 16.
5o
CLAIBORNE,
2. Let us suppose another case in which the horizon-
tal meridian has the radius of curvature of emmetropia and
the vertical meridian has the radius of curvature of myopia.
In other words, an eye whose horizontal meridian is nor-
mally curved and whose vertical meridian is too sharply
curved. The condition is called
Simple myopic astigmatism.
Fig.
17.
3.
There is an eye, the vertical meridian of which is
curved too little, and the horizontal meridian of which is
curved still less. It is too flat in both meridians, and one,
the horizontal, is flatter than the other, the vertical. Both
meridians have the hypermetropic length from before back-
wards, but one is more hypermetropic than the other.
The condition is called
Compound hyperopic astigmatism.
Fig. 18.
ASTIGMATISM.
5
1
4.
There is an eye, the horizontal meridian of which
is curved too much, and the vertical meridian of which is
curved still more. Both meridians have the myopic curve
and length from before backwards, but one is more myopic
than the other. The condition is called
Compound myopic astigmatism.
Fig.
19.
5.
There is an eye, the horizontal meridian of which
is less sharply curved, and the vertical meridian of which
is more sharply curved than it ought to be. There is
hypermetropia in the horizontal meridian and myopia in
the vertical meridian. The condition is called
Mixed astigmatism.
Fig. 20.
6. Occasionally the cornea of an eye may have scat-
tered over it small opacities from old inflammation or from
coal or foreign bodies which have lodged there. This con-
dition is known as
52
CLAIBORNE,
Irregular corneal astigmatism.
Occasionally the lens is badly made, so that it differs
in many places in refractive power. This is known as
Irregular lenticular astigmatism.
Irregular astigmatism, either corneal or lenticular,
cannot be corrected by glasses or any other device.
You will now see that when once you have learned
simple myopic and simple hyperopic astigmatism, you have
learned all the forms of regular astigmatism. And you have
already become convinced, I am sure, that what I said is
true, namely, that astigmatism is the refractive conditions,
E.,
H. and M., applied in combination to the two merid-
ians of the eye.
L,et us now once more sum up the various forms.
I. Regular astigatism.
i. Simple hyperopic astigmatism.
2. Simple myopic astigmatism.
3.
Compound hyperopic astigmatism.
4.
Compound myopic astigmatism.
5.
Mixed astigmatism.
II. Irregular astigmatism.
(a) corneal.
(b) lenticular.
We will now take up the consideration of astigmatism
from the standpoint of the behavior of the rays of light in
each case. This necessitates a few preliminary remarks.
From every luminous object rays of light proceed into
space in every possible direction. From the planet
Jupi-
ter, for example, as it revolves in space, rays proceed in
ASTIGMATISM.
53
all conceivable directions. From a point made by chalk
on a blackboard, rays proceed in all directions that lie
anterior to the plane of the board. They clearly cannot
pass backward owing to the imperviousness of the board
to light. But so far as the eye is concerned there are
only two sets of rays,one being given, the other lies at
a right angle to it. If I hold up this pencil in front of
you in a vertical position, you see it by virtue of the two
meridians of the cornea, the vertical and horizontal. If I
hold it at an angle of
45

to the horizon, you see it by vir-

tue of the meridian which is
45
and of that which is
135
.
If I hold it at the angle of
75 ,
you see it by virtue of the
meridians of
75
and
165
.
Let me now hold the pencil vertical. From every
luminous point on this pencil there proceed a set of verti-
cal rays and a set of horizontal rays. The horizontal rays
I indicate by the index and middle fingers between which
I stick the pencil in the vertical position. These horizon-
tal rays pass into your eye through the horizontal meridian,
and are focused on your retina as a point. From the next
luminous points above and below the first other horizontal
rays proceed and pass through other planes of the horizon-
tal meridian. Arriving at the retina they also form points,
the one below and the other above the first point, so that
there are now on your retinae
3
points arranged in a verti-
cal series, which is a line. The same thing takes place
with reference to all the other luminous points on the pen-
cil, and the result is that the vertical position of the pencil
is indicated on your retinae by a vertical line which con-
sists of luminous points arranged in a vertical series. Sup-
pose I turn the pencil to the horizontal position. From
each luminous point on the pencil there proceeds a set of
vertical rays and a set of horizontal rays. The vertical
54
CLAIBORNE,
rays I now indicate by the index and middle fingers between
which the pencil is held horizontally. These vertical rays
pass into the eye through the vertical meridian and are
formed as points on the retina. From the next luminous
points on the right and left other vertical rays proceed and
passing into the eye through other planes of the vertical
meridian are focused in a horizontal series. So that there
are now on your retinae
3
points arranged in a horizontal
series, which is a line. The same thing takes place with
reference to all the other luminous points, and the result
is that the horizontal position of the pencil is indicated on
your retinae by a horizontal line which consists of a series
of points arranged in a horizontal series.
The vertical position of the pencil then, is indicated
by the horizontal rays that pass through the various planes
of the horizontal meridian, and the horizontal position of
the pencil is indicated by the vertical rays that pass through
the various planes of the vertical meridian. In each posi-
tion, however, both sets of rays are focused on the retina at
the same time, so that the totality of the marks of the pen-
cil is recognized, and it is distinguished from some other
thing. Mark, however, that the image of a vertical object
on the retina is vertical, and the image of a horizontal object
on the retina is horizontal. Bear in mind also that there
are many planes to each meridian.
1. Simple hyperopic astigmatism, see fig. 16.
In this case the rays of one meridian are brought to a
point on the retina
;
those of the other meridian are brought
to a focus behind the retina.
2. Simple myopic astigmatism, see fig.
17.
In this case one set of rays are focused in front of the
retina, the other on the retina.
3.
Compound hyperopic astigmatism, see fig. 18.
ASTIGMATISM.
55
In this case both sets of rays are focused behind the
retina, one set being focused further behind it than the
other.
4.
Compound myopic astigmatism, see fig.
19.
Both sets are focused in front of the retina, one set be-
ing focused further in front than the other.
5.
Mixed astigmatism, see fig. 20.
One set is focused in front of the retina, the other be-
hind it.
We proceed now to the consideration of the correction
of astigmatism. Before doing so, however, allow me to
review what has been said with reference to cylindrical
glasses.
Inasmuch as the error astigmatism, is an error of a
meridian, it follows that the glass which corrects it must
be a glass that refracts light in one meridian. Cylindrical
glasses are used for this purpose. Cylindrical glasses
reflect only those rays which are at a right angle to the
axis. The axis is the plane surface which does not refract.
If I hold a convex cylinder with its axis vertical, it is
clear that only the horizontal rays are refracted
;
the ver-
tical rays are unaffected, since they pass through a plane
surface. If now, I turn the cylinder and make its axis
horizontal, the vertical rays alone are refracted. The same
thing is true of a concave cylinder.
Now a spherical convex glass is a representation of
the human eye, and there are only two meridians to it as
there are to the eye ; one being given, the other is at a right
angle. So that a convex spherical glass is composed of
two cylinders with their axes at a right angle. If I can
take two convex cylinders and place their axes at a
angle and form a spherical focus, I have proved this point.
Let us make this experiment : I take a convex cylinder of
56
CLAIBORNE,
6 D. and hold it with its axis vertical ; the horizontal rays
from our candle pass through the convex surface of the
cylinder and form points in a vertical series, making a line
of light. I turn it round at a right angle and hold the axis
horizontal. The vertical rays now passing through the
convex plane of the cylinders form points in a horizontal
series and a horizontal line of light is seen. I take another
cylinder of equal strength and place their axes at a right
angle. This gives a convex surface horizontally and a
convex surface vertically, so that both sets of rays are re-
fracted. The result is, a perfect focus of the candle is
formed. This is a typical illustration of the eye. When
there is no astigmatism, the two meridians of the eye are
equal in their refractive power and a perfect focus is formed.
Suppose now I use a cylinder of 6 D. and couple that with
a cylinder of
5
D., immediately an imperfect focus is formed
on the blackboard, and you have before you the illustration
of an astigmatic eye.
What I have said about convex cylinders applies to
concave cylinders, with this exception, that no focus is
formed by concave cylinders crossed, nor can any line of
light be seen when the cylinders are used separately.
Let me impress this point upon you indelibly. The
spherical eye is the equivalent of a spherical convex glass
both of whose meridians are equal in radius of curvature
and refractive power. If one meridian of the eye differs
from the other in radius of curvature, there is astigmatism.
Let us now apply the cylinder to the various forms of
astigmatism.
I. Regular astigmatism.
a. Simple hyperopic astigmatism.
In a very large majority of cases the erring meridian
in this form is the horizontal. The vertical meridian has
ASTIGMATISM.
5J
the normal emmetropic curve, but the horizontal is flat-
tened. It becomes necessary for us to so place the cylin-
der as that the refractive power of the horizontal meridian
is increased.
Remember now that cylinders refract those rays that
are at a right angle to the axis. We choose a convex
cylinder, of course, since the error is hyperopic, and we
place the axis vertical, thereby throwing the convex sur-
face of the cylinder in the horizontal meridian in order to
make up the deficiency there.
b. Simple myopic astigmatism.
In a very large majority of cases the erring meridian
in this form is the vertical. The horizontal meridian has
the normal curvature of emmetropia, while the vertical is
too sharply curved. The cylinder must be so placed as
that the refractive power of the vertical meridian be
diminished. A concave cylinder must be used and the
axis be placed horizontal in order to throw the concave
surface of the cylinder vertical, to diminish the refraction
in the vertical meridian.
c. Compound hyperopic astigmatism.
So far as the cylinder is concerned, the same rule ap-
plies to these cases as to simple hyperopic astigmatism.
The cylinder has to be coupled with a spherical convex
lens, and the axis of the cylinder, as a rule, is vertical.
For the horizontal meridian is less curved than the verti-
cal, and both are less curved than they should be.
d. Compound myopic astigmatism.
Both meridians are curved too sharply, and the verti-
cal more sharply than the horizontal. So that the cylinder
has to be coupled with a spherical concave glass, and the
axis of the cylinder, as a rule, is horizontal.
e. Mixed astigmatism.
58
CLAIBORNE,
One meridian has the curvature of myopia and the
other that of hyperopia.
Following out the rule in myopic astigmatism and in
hyperopic astigmatism, for you remember that mixed as-
tigmatism is a mixture of the two, the axis of the concave
cylinder lies horizontal and that of the convex cylinder
vertical. So that the cylinders are crossed at a right angle.
It must be clear to you that neither cylinder interferes
with the refraction of the other. For the rays that have
passed through the horizontal refracting surface of the con-
vex cylinder pass through the plane surface of the concave
cylinder, and the diverging rays that have passed through
the vertical refracting surface of the concave cylinder pass
through the plane surface of the convex cylinder. Neither
cylinder, therefore, interferes with the other. There are
other ways of writing this combination, which will be
shown later.
When the axes are as indicated above, namely, when
the axis of the convex cylinder is vertical and that of the
concave horizontal, the astigmatism is called astigmatism
with the rule. When the reverse is the case, it is called
astigmatism against the rule.
II. Irregular astigmatism.
There is no correction for this condition.
CHAPTER VII.
CASES OF ASTIGMATISM.
i. Simple hyperopic astigmatism.
A young woman, of delicate health and slight phy-
sique, who makes her living with her needle, complains
that for several months her head has ached, particularly
when she works or reads. The headache often reaches far
into the night. She is unable to take much exercise,
owing to her employment.
O. D.
V.=M
;
O. S.
V.=fi-;
The errors she makes in reading the card are charac-
teristic of astigmatism. She misses two or three letters in
the 30
foot line, and scarcely gets one right in the 20 foot
line. We suspect astigmatism from the start. But we
first place
+.50
D. S.
before her eye. She states that
makes it no betterbrings out some letters that were un-
clear, but obscures others ;

.50
D. makes her see worse.
We now take
+.50
D. cylinder and hold it, axis vertical,
the usual position in As. H. She immediately sees better
and expresses herself as pleased with the glass. But she is
not yet able to read the 20 foot line perfectly. We try the
next glass,
+.75
D. cylinder, axis again vertical, and she
reads the 20 foot line perfectly. Let us try the 1 D. cylin-
der now. She states that blurs the 20 foot line. We have
(59)
60 CLAIBORNE,
corrected her error, and it is
+-75
D- cylinder axis
90
.
The same is found for her other eye.
We now proceed to write the result in a formula
:
R.
E.
V.=M;
H
W.
+.75
D. c. ax. 90.
E. E.
V.=fS;
U
W.
+.75
D. c. ax. 90.
We prescribe
:
R
+.75
D. c. ax.
90
.
This method of recording is intelligible beyond per-
adventure.
2. Simple myopic astigmatism.
This case is a student of the college, one of your num-
ber. He complains of his eyes blurring after using them
for any length of time at reading. Has some headache.
Eyes occasionally water. Cannot see the black-board and
cuts well in the lecture-room. His eyes have the general
look of being strained.
R.
E. V.=
20
"40
E. E. V.
-~5T) >
He also misses a letter or two before he arrives at the
40
foot line. We suspect astigmatism from that fact.
Following the rule, we place
+.50
D. S. in front of his
eye. He sees worse. We place

.50
D. S. in front of it
;
he sees some letters better, but others worse. We try
+.50
D. c. ax.
90 ;
he sees worse still. We try

.50
D.
c. ax. 180 and he immediately sees better. We are not
content, for he has not yet reached ---. We continue using
concave cylinders, axis 180
,
till we arrive at

1.25 D.
With that he reads |-g- clearly. We are content, and leave
well enough alone. We find he requires

1.75
D. c. ax.
180
to read |-g- in the left eye.
CASES OF ASTIGMATISM. 6l
We record the result thus :
R.E.V.=H-
62 CLAIBORNE,
strength of the cylinder till we arrive at i D., when he
reads
f-g-
without an error.
We find the same condition in the left eye. We record
the result thus :
O. D.
V.=f# !
H
w.
+2
D.
S.
C
+
1 D
-
c
-
ax
-
9-
O. S.
V.=H| ; ||
w.
+2
D. S.
C
+
1 D
-
c
-
ax
-
9-
We may prescribe the glass thus :
R
+ 2 D. S.
C
+
i D. c. ax. 90.
The optician knows from the formula that both eyes
have the same correction. If the two eyes differed, we
would write the prescription for them separately.
4.
Compound myopic astigmatism.
This patient does not complain of very much headache
or pain. He simply does not see well for reading or dis-
tance, and, saving his presence, you see his eyes have a
far-away look and his whole countenance is apathetic.
O. D.V.=f
;
O. S.
V.=*a
Convex glasses make his vision worse. Concave
glasses immediately improve it. We find that

2 D. is
the weakest concave spherical glass with which the best
vision is attained, but
f
has not yet been reached. We
now couple concave cylinders with the concave spherical
and we find that with

1*50 D. cylinder, together with
the

2 D. S.,
the vision in each eye is
|-g,
so that we write:
R. E.
V.=U; U
w
-
2 D
-
s
-
C

!-5
D
-
c
-
ax
-
l8o
-
L. E.
V.=fg; f|
w.

2 D. S.
C

1.50
D. c. ax. 180 .
We prescribe thus
:

2 D. S.
C

1.50
D. c. ax. 180 .
CASES OF ASTIGMATISM.
63
5.
Mixed astigmatism.
This patient complains of constant, moderate head-
ache, weariness of the eyes, the desire to close them to get
rest, and the inability to see well near or in the distance.
R.
E.V.=fi-;
L. E.V.=f|-;
We try first convex spherical glasses which fail to
give any better vision. The same result attends the trial
of concave spherical glasses. We next place a convex
cylinder,
.50 D., axis vertical, in front of his eye. He im-
mediately sees better, and we continue to use stronger cyl-
inders. With
+ 1 D. cylinder he sees all the
40
foot line
and makes one mistake only in the
30
foot line. With
+ 1.25 D. cylinder he fails to see as well. We decide that
he has, at least, As. H., and as we have excluded spherical
hypermetropia, we turn to mixed astigmatism, as the
possible explanation of his want of proper vision. We now
couple

.50
D. c. ax. 180 with the +1 D. c. ax.
90 ,
and
immediately he says he sees better. We continue to in-
crease the strength of the concave cylinder till we arrive
at

1 D. He now reads the 20 foot line perfectly, and

expresses himself as satisfied. We conclude our patient
has mixed astigmatism, and that it is with the rule, i. e., the
axis of the convex glass is vertical and that of the concave
horizontal.
The same result is obtained in the left eye.
It is recorded thus :
R. E.
V.=f#
;
fjw.+
iD.c. ax.
90
C

1 D. c. ax. 180 .
L. E.
V.=J#; f|
w.+ 1 D. c. ax.
90 3

1 D. c. ax. 180 .
There are three ways of writing this glass for the op-
tician. First we may write it as it stands with the cylin-
der crossed
:
64
CLAIBORNE,
+
i D. c. ax.
90 3

1 D. c. ax. 180 .
Secondly, we may correct the As. H. by a spherical
convex glass of 1 D. This will obviously double the error
in the myopic meridian, so that we may also write it thus
:
+
1 D. S.
C

2 D. c. ax.
180.
Thirdly, we may correct the myopia by a spherical
glass, and that will obviously double the error in hyperopic
meridian, so that we may also write the prescription thus
:

1 D. s.
^
+
2 D. c. ax.
90
.
Any one of these writings is correct. I would sug-
gest, however, that you write it as you find the glasses in
your hands, namely, with the cylinders crossed, and let the
optician grind it his own way.
And now a word about the axis of astigmatism. I
have spoken so far only of those cases of astigmatism in
which the axis was
90
or 180 . It has, doubtless, oc-
curred to you that the axis might lie at other points than
these. It is possible for the axis of astigmatism to lie at
any point in the circle of
360
. There are, however, be-
yond a question,
"
positions of preference." In a paper in
the N. Y. Medical Journal,
June 25
and
July 2, 1892,
en-
titled
"
The Axis of Astigmatism," I propounded the prop-
osition that the axis of astigmatism does not occur at hap-
hazard
;
that there are positions of preference in hyperopic
and myopic astigmatism, and in their combinations.
Our spectacle frames, as you can see (Fig.
12),
do not
possess entire circles, but half circles. Sometimes the half
circle is below, sometimes above, so that we number only
180 for each half circle. Now you may indicate the po-
sition of the axis of the glass in two ways, either by writ-
ing out the axis of the glass, such as
75
, 105 ,
135 ,
etc.,
CASES OF ASTIGMATISM.
65
or by saying that the axis lies toward the nose or temple
so many degrees, such as 20 or
15
or 45
;
but you should
take care to observe that the upper end of the axis is to-
ward the nose or temple, for it must be plain to you that
if the upper end of the axis is 45" toward the nose, the
lower end must be
45

toward the temple. For my part,

I always write the number of degrees without referring to
nose or temple, and I think it much the best way. Inas-
much as we use semi-circles in the frames, either above or
below, the figures are invariable. Observe the two spec-
tacle frames, one above the other, Fig. 12.
In addition to the test-card, we sometimes use a figure
called Snellen's Sun-rise, or a clock-face with lines radiat-
ing toward the various hours, such as in Fig. 21.
Fig. 21.
If astigmatism be present in a case, the various lines
do not have the same degree of distinctness. Some are
gray, while others are clear, or both are grayish, and some
more gray or clear than others. If the cylinder or cylin-
ders are properly applied, the lines appear equally clear.
66
CLAIBORNE,
I think these figures of value only in very slight de-
grees of astigmatism, such as that of
.25
D. or
.50 D. For
greater errors the letters are sufficient, and, as a matter of
fact, Snellen's Sun-rise or the clock-face is rarely used.
CHAPTER VIII.
PRESBYOPIA.
The first thing I wish you to learn in regard to the
condition known as as presbyopia is that it is not an error
of refraction. It is no error at all. It is a normal physio-
logical condition to which every one comes if he lives long
enough. The derivation of the word gives a clear insight
into its meaning

itpia^
an old man, and
"><P, eyethe eye
of an old man. And that is exactly what presbyopia is.
But we must remember that it is his vision for near ob-
jects. It has nothing to do with his distant vision, strictly
speaking. I promised you in the first lecture that I would
take up the consideration of near central vision in this
lecture, and I now proceed to do so.
Refer once more to the description of the act of accom-
modation.
You remember that the accommodative apparatus con-
sisted of the lens, the muscle, and the ligament of Zinn. I
said that the legitimate function of the accommodative
apparatus was the adjusting of the refraction of the eye for
different distances within 20 feet. I wish to lay particular
stress upon that fact. That is why the act is called accom-
modation. It is accommodation of the pronounced sort to
the possessor of an eye, and it enables the eye to accommo-
date itself for different distances.
The emmetropic eye you know is focused in a state of
rest for parallel rays. If rays are divergent it is clear that
(67)
68 CLAIBORNE,
there must be an increased refractive power in the eye in
order that they may be focused upon the retina accurately.
This power lies in the accommodative apparatus. When
an object is brought nearer than 20 feet to a person, his
brain judges the distance and sends to the muscle of
accommodation a stimulus which causes it to contract. In
contracting it relieves the pressure made on the anterior
surface of the lens by the anterior layer of the ligament of
Zinn, and the lens, by virtue of its elasticity, springs for-
ward, increasing its convexity and its antero-posterior
diameter. The beautiful part of this act lies in this, that
the muscle contracts just enough to form the focus accu-
rately. In other words, when a man wishes to see an object
10 feet or 10 inches away, he focuses for the distance of 10
feet or 10 inches, and not for a less or greater distance.
This faculty of accommodation has its limitations. It is
greatest in early childhood. And this has been taken ad-
vantage of by tapestry manufacturers in Europe to set
children to work, straining their eyes at a very early age.
Owing to the fact that children are able to see smaller ob-
jects than grown people, they are enabled to use finer nee-
dles and do finer work. It has been estimated that the
accommodation has reached its acme by ten years of age,
and that thereafter it gradually decreases with advancing
years till a certain age, when the condition of presbyopia
is said to be present. Presbyopia then, is a condition in
which there is a diminution in the power of the accommo-
dative act in vision for near objects. This diminution is
due partly to imperfect muscular action and to a loss of
resiliency in the crystalline lens. When this has set in, a
man may be said to have arrived at the acme of his years
and strength. The road lies for him thereafter down-hill.
The age of presbyopia in males lies somewhere between
PRESBYOPIA.
69
40-45.
It supervenes a little earlier in women. This must
vary in a measure with a man's manner of life and employ-
ment. One who has lived an out-of-door life, free from
impure air, who has kept regular hours, avoided excesses
of all kinds, and who has not abused his eyes for reading
and study or work, must retain the power of accommoda-
tion longer than one whose life has not been modelled 0.1
these lines. It would be an interesting thing to know
when presbyopia supervenes, as an average, in a race of
savages.
I have spoken of presbyopia with reference to any ob-
ject that is nearer than 20 feet. But as a practical matter
we treat of presbyopia with reference to reading.
In order that we may have a standard for this exami-
nation, as we had a standard for the distance examination,
we take the various kinds of type that are used in printing
books. They have been arranged in order, starting with
the smallest and running to the largest. The card is
known as Jaeger's Test Types, and we speak of a person's
ability to read Jaeger No. 1 or Jaeger No.
2,
etc. Jaeger
No. 1,
the diamond type, is taken as the standard. A nor-
mal adult should be able to read Jaeger No. 1 at 8 or
9
inches. Let us accept 8 inches. If he is unable to read it
at this distance, but has to push the card further away, we
say he lacks accommodation, in other words, he is presby-
opic.
The nearest point at which a person can read Jaeger
No. 1 is called the punctum proximum or near point. We
may say that an adult's power of accommodation is the
value of a plus 8 inch lens or
5
D., since he can read Jaeger
No. 1 at eight inches. Conversely, we may say that a man
has lost his entire power of accommodation when he has
lost
5
D.
JO
CLAIBORNE,
A table has been constructed showing how much ac-
commodation is lost by the emmetropic eye at various ages :
40

o D.
45- 1
D-
50 2 D.
55-
3
D-
60 4D.
65
4-75
D.
70
5-5
D-
You see, then, that a man may be said to have lest his
entire accommodation between the ages of
6570,
for at
70
he has lost
5.5
D., or more than the value of 'an 8 inch
convex lens. But remember, we speak of his ability to
read. He has not lost all his accommodation, and he prob-
ably never entirely loses it all.
The correction of presbyopia becomes an easy matter
to restore to a man that which he has lost. We must
consider presbyopia with reference to
E.,
M., H. and astig-
matism. The list which has just been shown has been
constructed for the emmetropic eye. And allow me just
here to lay down for you this unalterable law, that every
eye has to be restored to the condition of emmetropia be-
fore the proper presbyopic glass can be prescribed for it.
The preceding examination which has been made clear to
you, I hope, must be employed invariably before the exam-
ination for presbyopia. Let us take up a few cases.
Case
1.

Emmetropia and Presbyopia.

A
gentlemen, of
45,
complains that for the last 6
months his eyes have annoyed him in reading

particu-
larly at night. They feel sandy
;
he has a slight headache
after
prolonged
reading. He has arrived at the age of
PRESBYOPIA. 71
presbyopia, but before attempting to give him a glass, we
discover the condition of his refraction. He reads
f$
in
each eye and refuses the weakest convex glass. We find
him to be emmetropic. We have plain sailing before us
now. The list tell us that an emmetrope at
45
requires
+ 1 D. to bring his
p.p.
to 8 inches, or that he has lost +
1
D. of his accommodation. We restore to him what he has
lost, and he reads, therefore, with his usual former com-
fort. If he lives long enough, he will take each correction
for the succeeding years, as it is outlined in the list.
Case 2.
Hyperopia and Presbyopia.
This gentleman is
45
years of age. He has had more
or less trouble with his eyes since boyhood, when he was
subject to occasional headaches. For some time reading
has been painful to his eyes, and it begins to dawn on him
that he is getting old. He comes to find out whether it is
true. By questioning him we find that he has been a
student all his life. We proceed to carry out the distance
examination first. We find that he reads
f
- with much
difficulty and apparent strain. We also find that he accepts
-f
1 D. in each eye as the strongest possible glass. The
man is hyperopic, and his age is that of presbyopia. If we
are to give him a reading glass, we must certainly correct
his hyperopia. We place
+
1 D in front of each eye, and
give him Jaeger's test types to read. He reads it with dif-
ficulty, as you see, at about 12 inches. He is presbyopic
as well as hyperopic. We now add + 1 D to the
+ 1 D of
his hyperopia. This makes
+
2 D and we give him that
glass. He reads Jaeger No. 1 now at 8 inches, and he can
carry the book with ease out to 12 or
14
inches, so that we
are content. We have given him a good range of accom-
72
CLAIBORNE,
modation, the distance between 8 and
14
inches, which is,
6 inches. So that you learn this fact from this case : the
hyperopia must be added to the presbyopia.
H+Pr.=Total correction.
As he waxes in years, he will have to add the presby-
opia for each age to the hyperopia which he has
;
at the
age of
50
he will require
3
D. ; at
55,
4
D., etc.
Case 3. Myopia and Presbyopia.
Here is a patient whom I have selected from the clinic
at large. He tells me he has arrived at the age of 46. I
have asked him no questions, but inasmuch as he is
46,
we
may find a case of presbyopia.
He states that he has no difficulty in reading at all,
although he is 46. He says he does not see very well in
the distance
;
he thinks he is short-sighted. His vision in
each eye is less than normal, and we find that

1 D. is the
weakest glass with which he reads
f$.
He is myopic to
the extent of 1 D.
He is
46
years of age and by rights, if he were emme-
tropic, would accept -fiD. for reading. He does not need
a convex glass to read with, because he has the value of
+
1 D. in the length of his eyeball. So that when he
comes to read, he simply lifts his distance glasses to his
brow or takes them off entirely.
Let us now give him the Jaeger Test Type. He reads
Jaeger No. 1 at 8 inches with each, and has a good range
of accommodation. Let us now put on his correction for
distance, namely,

1 D. He is now emmetropic, and we

give him Jaeger No. 1 to read once more. He is unable to
do it at 8 inches. He reads it with difficulty at 10 to
14
PRESBYOPIA.
73
inches. If we add to his distance correction, the correction
for the presbyopia of an emmetropia, i. e., +i D., the re-
sult is o, for i D and
+
1 D. cancel each other.
If this man lives to the age of
50,
he will require our
help, for at
50
years an emmetrope requires
+
2 D., and as.
our patient has a myopia of 1 D only, he will require the
difference between +2 D and

1 D., which is +1 D. At
55
he will require
+3
D

1 D=2 D., etc. A man who

has a myopia of 2 D will not require our services at
45
nor
at 50. He will simply lift his distance glasses in order to
read, but when he is
55
he will require help, and the glass
he will need will be the difference between
+3
D., an em-
metrope's loss at
55,
and 2 D., his myopia. He will then
require +iD. This method may be carried out in any
case of myopia and presbyopia combined.
When myopia and presbyopia occur in a case, subtract
the myopia from the amount of presbyopia that would exist
in a case of emmetropia of the age of the myope.
Pr.M
:
=Correction.
When a man has a myopia of as much as
3
D,= which
is
^2,
or
4
D= which is-|-, he probably never will require
a plus glass at all for reading, for his far point lies at 12 or
8 inches, and he can read with great comfort at either
point, because he does not need his accommodation at all.
But suppose a man has a myopia of
^-,
he will find it diffi-
cult to converge his visual lines for so short a distance.
We must throw his far point further out. He has a myo-
pia of 6 inches, i. e., his far point lies at 6 inches in front
of his eye. We must throw that far point out to 12 inches,
let us say for comfort. We give him

^
in order to do
so, for

iV
=
tz-
A man with a myopia of
|-
may not care to read at the distance of 8 inches. Let us
74
CLAIBORNE,
throw his far point out to 12 inches also. We give him a
i-
for
l 3- = J-
>
4
lul
8 12 2 -t

Astigmatism and Presbyopia.

I will say in the beginning, for your comfort, that
presbyopes rarely require or wish to have their astigmatism
corrected when it is slight in degree. High degrees must,
however, be noticed.
Case I. Simple hyperopic astigmatism and presbyopia.
We find that this patient has worn this glass for years.
+
1 D c. ax.
90
.
If you will allow me to employ a system of crosses this
matter can be made more graphically clear :
.H
The E
lies in the vertical meridian and the H in the
horizontal.
In other words, this glass has rendered him emmetro-
pic. Since he is now emmetropic we will apply the rule
as before for emmetropes. He is
45
years old, and is,
therefore, at the presbyopic age. At this age our list tells
us a man has lost
+ 1 D. When we give him the test card
to read he has to hold it out at a considerable distance,
even while he has on his distance glasses. We now place
over his spectacles our trial frames with +iD in it and
give him the card. He says that is better and more com-
fortable for his eyes. We have added
+ 1 D to his astig-
PRESBYOPIA.
75
matic correction, and that has to be ground as a compound
lens by the optician. We prescribe for him thus :
R
+ 1 D s.
^
+
1 D. c. ax.
90
.
Case 2. Simple myopic astigmatism and presbyopia.
Our patient has always worn

1 D. c. ax. 180 .
The graphic formula for the astigmatism is this is :
M
He is
45
years old, and commences to feel the need of help
in reading. If he takes off his distance glasses he is astig-
matic, and since he is
45
years old, let us place + 1 D. s.
over his distance glasses. We then have this combination :
+
1 D. s.
3

1 D. c. ax. 180 .
This doubtless appears to you to be a curious combi-
nation. Let us see what it really amounts to. The

1
D. c. ax. 180 neutralizes the +1 D. s. in the vertical me-
ridian, so that the covex spherical practically becomes a
convex cylinder with its refracting surface horizontal.
Now, as the patient is myopic naturally, to the extent of
1 D. in the vertical meridian, the combination really
amounts to giving him an artificial myopia of 1 D horizon-
tally. So that he has a myopia of 1 D. in each meridian,
and as he is
45
years of age, he is in the position of a
spherical myope of 1 D. The demands of his age have
been
satisfied. We may write this glass much more sim-
ply, thus
:
76
CLAIBORNE,
-+-1
D. c. ax.
90
.
For this glass gives him -fiD. s. in his horizontal
meridian and this with his natural myopia of 1 D. vertical,
puts him practically in possession of
+ 1 D- spherical.
You may write the glass either way. The optician
will select his own way of grinding it.
Case
3.
Compound hyperopic astigmatism and presbyopia.
In compound hyperopic astigmatism coupled with
presbyopia, the presbyopic correction is simply to be added
to the compound glass. This, of course, merely increases
the spherical glass, the strength of the cylinder remaining
the same.
Graphic formula for compound hyperopic astigma-
tism :
H
HH
Case
4.
Compound myopic astigmatism and presbyopia.
In this condition, the cylinder may be considered con-
stant, and the simple myopia must be subtracted from the
presbyopia.
Let us take a case of this, for it is more complicated
than the preceding.
A man of
50
wears for distance,

1 D. s.
3

1 D. c. ax. 180 .
The graphic formula for this condition of refraction is
:
PRESBYOPIA.
77
MM
-M
This combination renders him emmetropic. He is
50
years of age, and, as an emmetrope at that age requires
+2
D, we add
+2 D to the above formula :

1 D. s.
3
+2
D. s.
^

1 D. c. ax. 180 .
The result is
+1D.S.C-1
D- c. ax. 180 .
Now a man with compound myopia

1 D. s.
C

1 D- c- ax- I 8o.
has a myopia of 2 D. in the vertical meridian and 1 D. in
the horizontal. As he is
50
years old, he requires 2 D. in
each meridian according to the list, so that we prescribe :
+
1 D. c. ax.
90
.
This gives him 2 D. of myopia in the horizontal and verti-
cal meridians, and his demands are satisfied
;
e.
g.,
graphi-
cally :
MM
MM
You have doubtless observed that we have corrected a
case of simple myopic astigmatism, see case
2,
and one of
78 CLAIBORNE;
compound myopic astigmatism, with the same glass. The
explanation lies in the spherical myopia of the latter case,
and in the difference between the ages of the patient.
L,et us take the case of a man of
45,
with the correction,

1 D. s. 31 D. c. ax. 180 .
He has a compound error, and we only need to correct
the simple myopic astigmatism
;
we thus leave him with
1 D. of myopia in each meridian, which is enough for him
to read with. We give such a case,

1 D. c. ax. 180 .
M
M
Case 5.
Mixed astigmatism and presbyopia.
A patient of
50
years has worn this correction,
+ 2 D.
c. ax.
90 3

2 D. c. ax.
180.
MM
-HH
This renders him emmetropic. If we put on his spec-
tacles
and ask him to read, he is unable to do so. We
place +
2 D s. over his spectacles and he reads with ease.
PRESBYOPIA.
79
From our studies in mixed astigmatism you remember
that there are
3
ways of writing the above formula : first,
the way it is written above in crossed cylinders, secondly,
+
2 D. s.
3
4 D. c. ax. 180
or thirdly,

2 D. s.
2 +4
D. c, ax.
90
.
Now if to either of the last two we add
+
2 D, the
presbyopic correction for a man of
50
years, we write :
+4
D. s.
3

4
D. c. ax. 180 or
+ 2
D. s.
3

2
D. s.
3
+ 4
D. c. ax.
90
.
This latter formula is equal to
+4
D. c. ax.
90
.
But the great probability is that the optician prefers
to grind the second formula, i. e., a concave cylinder of
4
D. on a spherical plus glass of
4
D. Under either cir-
cumstance, the resultant value is
+4
D. c. ax.
90
.
The vertical meridian now has its natural myopia of
2 D., and the hypermetropia of 2 D of the horizontal merid-
ian has not only been corrected, but 2 D. more added to it.
Hence, each meridian has 2 D., and the demands of the
patient's age have been satisfied.
Although it is apparently easy to correct presbyopia,
the fact is that failure is more common in its correction
than in errors of refraction. The cause lies in this that
presbyopia is a matter of function. The muscle of accom-
80
CLAIBORNE,
modation has not always the same innervation. This dif-
fers with time and circumstance. In youth there is a regu-
lar tone to the muscle as a rule, but such is not the case in
presbyopia. Apatient who is satisfied with one correction
one day, will return the next and complain that the glasses
are unsatisfactory. This is particularly the case with
females. They are not able to analyze their sensations as
accurately as men.
And now, a few words of common sense about the cor-
rection of presbyopia.
Do not stick to any iron-clad rule in giving a glass.
Sometimes a stronger and sometimes a weaker glass than
apparently the correct one, is accepted.
I have stated that every adult, not presbyopic, ought
to be able to read Jaeger No. i at 8 inches. It is not im-
probable that the great majority of adults can do this for a
few seconds, but there are very few that can keep it up
longer than a minute or two. Most people read at the dis-
tance of i o or 12 inches, and books are usually printed in
type of the size of Jaeger No.
4
or
5,
at least ; more fre-
quently in type of the size of Nos. 6 or
7. So that the test
when made with Jaeger No. 1 is a test of supreme capacity,
not of ordinary working power. Try always to give your
patient as long a
"
range of accommodation
"
as possible,
that is, to give a glass that gives the greatest possible dis-
tance between the nearest point and the farthest point of
distinct vision.
After you have made your estimate of what the patient
ought to accept, try that glass, and then the glasses on
either side of it, that is, weaker and stronger glasses, and
ask the patient this question, which do you prefer ? If you
satisfy your patient you are correct. If you do not satisfy
him you need not be wrong, for there are some people who
PRESBYOPIA. 8
1
cannot be made to say that they are satisfied, and, more-
over, the case may be complicated. Do not try to force a
glass upon a person because your science tells you it is the
correct glass. Common sense should be your guide as
much as science.
CHAPTER IX.
MYDRIATICS.
Mydriatics are used for the purpose of paralyzing the
accommodation with a view to discovering the true condi-
tion of the refraction. In hypermetropia and myopia there
is probably a tonic contraction of the ciliary muscle which
is not altogether lost till advanced age. There is also an
excessive contraction of the ciliary muscle which is known
as spasm of the accommodation, and renders emmetropes
myopic, hypermetropes less hyperopic, and myopes more
myopic. The action of the mydriatic by eliminating the
action of the muscle, enables us to judge of the true refrac-
tive power of the eye.
Spasm occurs in cases in which the eyes have been
strained by excessive use, either for distance or near, but
more frequently for the latter, and is evidenced in the func-
tional examination by alternate or irregular clearness and
dimness of the letters and by the contradictory or uncer-
tain answers of the patient when glasses are put before the
eye. Headache almost invariably accompanies this condi-
tion whatever may be the refractive state.
The two agents for paralyzing the accommodation are
homatropine hydrobromate and atropine sulphate.
Homatropine hydrobromate is a derivative of atropine
and its effects are more transient than those of atropine
sulphate. The length of the duration of either depends, in
a measure, on the strength of the solution. Homatropine
(82)
MYDRIATICS.
83
is made into a
1%, 2%
or
3%
solution; that is, roughly-
speaking,
5
grains, 10 grains or
15
grains to the ounce.
For my part, I never use a greater strength than a 2
<f
solution. The
3
<f
c
solution causes the eye to be red and
congested if rapidly instilled. The redness, however, dis-
appears after a short while.
The frequency of the instillations is a matter of some
importance. In adults six or eight instillations of one or
two drops each may be used. But in children it is well to
be more careful, although I can record no case of toxic
symptoms among them from the use of homatropine. L,et
the solutions be made up with a few grains of boric acid to
keep them sweet. And do not prescribe a large amount
when you prescribe it for home use. A one drachm solution
is quite sufficient. For the drug is one of the most costly
that exist. L,et us write the formula for a two per cent,
solution for office use :
B Homatropinae hydrobromat. grs. x.
Acidi borici grs. x.
Aquae dist.
Si.
Sig. 2
f
solution of Homatropine hydrobromate.
The effect of this solution lasts about
24
hours, and
the maximum effect on the accommodation is
3
or
4
hours
after the first instillation. It is not necessary, however, to
wait for the maximum effect. When you find that the
patient cannot read any of the type on either of the first
two pages of the Jaeger Test, you may consider the accom-
modation fairly well eliminated. In cases in which the
symptoms are not grave and the asthenopia is not compli-
cated with other reflex symptoms, homatropine is satisfac-
tory. In those cases, however, in which there are symp-
toms simulating some grave nervous disturbance, or in
84
CLAIBORNE,
which the headaches and eye-pains are extraordinarly
severe, and particularly in the case of children with strabis-
mus, atropine sulphate is preferable. The paralysis of the
accommodation is more complete and lasting from this
drug. Its duration is, on an average, a weeksometimes
it is two weeks. I never use a stronger than a i
%
solution
for children. Care must be taken to watch for the point of
toleration. Some children can stand an astonishing amount
of atropine, and some exhibit toxic symptoms after one or
two instillations. It is always well to caution the parents
in regard to the possible effects, in order that they may not
persist in the use of the drug after the appearance of toxic
symptoms, and that they may not be frightened. An ordi-
nary child can stand one drop in each eye
3
times a day.
It is rare that toxic effects are seen in adults when atropine
is used for the paralysis of the accommodation. A two per
cent, solution is most satisfactory for this purpose.
R Atropinse sulphat. grs. x.
Acidi borici grs. xv.
Aquse dist. Si.
Sig. 2
%
solution of atropine sulphate.
Atropine may be kept in the eyes of children for
months without the slightest evil result to the ultimate
power of the accommodation. This is not the case in
adults and old people.
It undoubtedly impairs the accommodation in both,
and in old people particularly, when used for any length of
time. The effect of both of these drugs is accelerated by
combination with cocaine hydrochlorate in a
4
fo
solution.
For office work a mixture of cocaine and homatropine may
be kept.
Homatropinae hydrobromat.
86 CLAIBORNE,
all probability, will have to be changed to one that is
weaker after the mydriatic has disappeared. I do not rec-
ognize any other class in which the total correction, under
a mydriatic, should be given. The examination should be
made before the use of the mydriatic, during the height of
its effect, and immediately after the effect has entirely worn
off. If homatropine is used, three examinations are neces-
sary for an intelligent knowledge of the refractive condi-
tion of the eye ; if atropine sulphate is used, at least three
examinations, probably more. Under all circumstances,
the final examination should be made immediately after
the mydriatic effects disappear. This is indicated, of course,
by the patient's ability to read Jaeger No. i at the normal
distance, if he be under the age of presbyopia. During the
time the eyes are under examination, the patient should
strictly abstain from their use for near work. The tempta-
tion for patients to use their eyes, particularly when the
effect of the mydriatic has just worn off, is very great.
This inclination should be resisted, for sometimes the eyes
will relapse into the original condition of spasm, and the
examination will have to be made again.
87
No. 1.

Brilliant.
The place of our retreat wn s little neighborhood, consisting of fur men, who tilled their own grounds, and were equal atrnngem to opulence and povovlj.
As they had il ..... .1 nil the conveniences of life within themselves, the; seldom visited tonne or cities in < 1. of euperBultiea. It emote from polite, ther
still retained the primaeval simplicity of manners; and frugal by habit, they scarce knew that temperance was a virtue, They wrought with cheerfulness on
days of labor, but observed festivals sw intervals of idlunoHfl and pleasure. They kept up the Christmas carol, sent trae-love knots on Valentino morning, ate
pancakes on Shrove-tide, showed their wit an the first of April, and religiously cracked nuts on Mlahoalmas-eve. Being apprised of our approach, the whole
neighborhood came out to meet their minister, dressed in their One clothes, and preceded by a pip* and tabor; A feast also was provided for our reception, at
No. 2.Pearl.
The place of our retreat was a little neighborhood, consisting of farmers, who tilled their own grounds, and were
equal strangers to opulence and poverty. As they had almost all the conveniences of life within themselves, they
seldom visited towns or cities in search of superfluities. Remote from polite, they still retained the primaeval
simplicity of manners ; and frugal by habit, they scarce knew that temperance was a virtue. They wrought with
cheerfulness on days of labor, but observed festivals as intervals of idleness and pleasure. They kept up the
Christmas carol, sent true-love knots on Valentine morning, ate pancakes on Shrove-tide, showed their wit on the
No,
3.

NonparieL
The place of our retreat was a little neighborhood, consisting of farmers, who tilled their own
grounds, and were equal strangers to opulence and poverty As they had almost all the con-
veniences of life within themselves, they seldom visited towns or cites in search of superflu-
ities. Remote from polite, they still retained the primaeval simplicity of manners ; and
frugal by habit, they scarce knew that temperance was a virtue. They wrought with cheer-
fulness on days of labor, but observed festivals as intervals of idleness and pleasure. They
No.
4.

Minion.
The place of our retreat was a little neighborhood, consisting of farmers, who tilled
their own grounds and were equal strangers to opulence and poverty. As they had
almost all the conveniences of life within themselves, they seldom visited towns or
cities in search of superfluities. Remote from polite, they still retained the primaeval
simplicity of manners; and frugal by habit, they scarce knew that temperance was .1
virtue. They wrought with cheerfulness on days of labor, but observed festivals as
/
88
No.
5.

Bourgeois.
The place of our retreat was a little neighborhood, consisting of farm-
ers, who tilled their own grounds, and were equal strangers to opul-
ence and poverty. As they had almost all the conveniences of life
within themselves, they seldom visited towns or cities in search of
No.
6.

Long Primer.
The place of our retreat was a little neighborhood, consisting of
farmers, who tilled their own grounds, and were equal strangers to
opulence and poverty. As they had almost all the conveniences of
life within themselves, they seldom visited towns or cities in search
No.
7.

Small Pica.
The place of our retreat was a little neighborhood, consist-
ing of farmers, who tilled their own grounds, and were equal
strangers to opulence and poverty. As they had almost all
the conveniences of life within themselves, they seldom
No. 8

Pica.
The place of our retreat was a little neighborhood, con-
sisting of farmers, who tilled their own grounds, and
were equal strangers to opulence and poverty. As
they had almost all the conveniences of life within
8
9
No.
9.

English.
The place of our retreat was a little neighbor-
hood, consisting of farmers, who tilled their own
grounds, and were equal strangers to opulence
and poverty. As they had almost all the con-
No. 10.Great Primer.
The place of our retreat was a little
neighborhood, consisting of farmers,who
tilled their own grounds, and were equal
strangers to opulence and poverty. As
No.
11.Two-line Small Pica.
The place of our retreat was a
little neighborhood, consisting
of farmers, who tilled their own
grounds, and were equal stran-
90
Kb.
12. Two-lint English.
Theplace ofour retreat
was a little neighbor-
hood, consisting* of far-
mers, who tilled their
Xo. IS. Tico-linf Gnat Prin
The place of our
retreat was a little
neighborhood,
consisting of far-
9
T
SNELLEN'S TEST TYPES.
cc.
92
C.
93
LXX.
l^-
i
H !
94
XL.
XXX.
95
XX.
96
XV.
U A C
E
x.
V Z B D F