THE OPHTHALMOSCOPE
By the same Author.
THE REFRACTION OF THE EYE.
Eighth Edition, with 100 illustrations, crown 8vo., Qs.
THE
OPHTHALMOSCOPE
A MANUAL FOR STUDENTS
BY
aiTSTAVTJS HARTRIDaE, F.R.C.S.
SURGEON TO TUE HOVAL WKSTMIXSTKR OFHTUALMIC UdSPITAL; OPHTHALMIC SfllGEOX AND
LECTURER ON OPUTUAl.MIC SL'KGKRY TO THK WESTMINSTER HOSPITAL; OPHTHALMIC
3UBGEO.N TO ST. BARTHOLOMEW'S HOSPITAL, CHATHAM; COXSfLTIXG
OPHTHALMIC SURGEON TO ST. GEOUGK's DISPENSARY,
HANOVF.R sqUABK, ETC.
WITH SIXTY.EIGHI ILLUSTR.\.TI0X3 AND FOUR PLA.TES
THIRD EDITION
LONDON
J. & A. CHURCHILL
7, GREAT MARLBOROUGH STRKET
1897
OPTO- -TRY
UB.xARY
PREFACE TO THIRD EDITION
In preparing a third edition of ' The Ophthalmo-
scope ^ for the press_, every page has been carefully
revised^ and a few additions made which will, I
trust, enhance the value of the book as a guide to
ophthalmoscopic work.
G. H.
12, WlMPOLE StEEET, \V.;
Jul I/, 1897.
M675i:i8
PREFACE
The subject of this volume is one that has made
great progress during the last few years, not only in
the mechanism of the instrument, but also in the
methods of using it to the best advantage. In the
present day the ophthalmoscope is almost as neces-
sary to the physician as it is to the ophthalmic sur-
geon, since many serious general diseases may first
be detected by changes taking place in the fundus,
frequently without any subjective symptoms; thus
the importance and usefulness of the instrument is
greatly extended.
In introducing this small work to the profession, I
do so in the hope that it may be found useful not
only to the ophthalmic students who, in London and
other large medical schools, have the advantage of
practical demonstrations on the subject, but also to
the large class of practitioners whose opportunities of
seeing cases are few and far between, and who may
desire to learn the use of the ophthalmoscope when
practical instruction is out of their reach.
Vlll PHEFACK
While hoping that the description given will be
found sufficiently clear and elementary to enable the
most inexperienced to understand it^ I trust that
even the advanced student may find some help and
instruction.
The arrangement of the book is simple and syste-
matic, and an endeavour has been made to keep it
small, so that it may be conveniently carried in the
pocket for reference in the out-patient room ; and
this, perhaps, constitutes one of its chief advantages.
The work is profusely illustrated with woodcuts — a
matter of some importance, as it is almost impossible
to make the subject clear without them, especially to
those of my readers who may not have access to an
instructor ; illustrations, although in many instances
conveying only a somewhat imperfect idea, certainly
impress the subject on the studeut^s mind. A slight
knowledge of optics is essential, and therefore the
first chapter from my work on the ' Refraction of the
Eye ^ is reproduced, and several of the woodcuts
from that book are doing duty again.
a. H.
65, Geeen Street, Park Lane, W.;
August, 1891.
] I ^-pvy nf the Alame(Ta
^i optometrists
CONTENTS
CHAPTER I
PAGE
Optical Principles involved in the Use of the
Ophthalmoscope . . . . 1
CHAPTER II
The Ophthalmoscope . . . .21
CHAPTER III
Methods of Examination . . .32
CHAPTER IV
The Appearances of the Normal Fundus . 81
CHAPTER V
The Cornea, Anterior Chamber, Iris, and Lens . 92
h
CONTENTS
CHAPTER VI
PAGE
The Vitreous . . . .99
CHAPTER VII
The Choroid ..... 105
CHAPTER VIII
The Retina . . . . .116
CHAPTER IX
The Optic Nerve .... 136
Appendix . . . . .151
LIST OF ILLUSTRATIONS
No. PAGE
1. Reflection by a plane surface . . . .2
2. Virtual image formed by a plane mirror . . 3
'S. Reflection by a concave surface . . .4
4. Ditto ditto . . . .5
5. Reflection by a convex surface . . .6
6. Refraction by a plane surface . . .7
7. Refraction by a prism . . .8
8. Ditto ditto . . . .8
9. Refraction by a spherical surface . . 9
10. Ditto ditto . .10
11. Formation of a convex lens . . . .11
12. Different forms of lenses . . . .12
13. Refraction of secondary axes by a biconvex lens . . 12
14. Refraction of parallel rays by a convex lens . . 13
15. Ditto ditto . . .14
16. Properties of a biconvex lens . . . .14
17. Ditto ditto . . . .15
18. Properties of a biconcave lens . , .16
19. Refraction of parallel rays by a concave lens . . 16
20. Formation of an inverted image . . .17
21. Real inverted image formed by a convex lens . . 18
22. Virtual image formed by a convex lens , . .19
23. Virtual image formed by a concave lens . . 19
24. Light entering the eye and returning by tlie same path . 21
xu
LIST OF ILLUSTRATIONS
No.
25. Light returning from hypermetropic eye
20. Liglit returning from inyo})ic eye
27. Hehnholtz's first ophthalmoscope
28. Tlie ophthalmoscope
29. Morton's refracting ophthalmoscope
30. Concave mirror for retinoscopy
31. Frost's artificial eye
32. The ohlique illumination
33. Oblique illumination with magnifying glass
34. Rays coming from emmetropic eye
35. Rays coming from hypermetropic eye .
30. Rays coming from myopic eye
37. Position for the indirect examination .
38. Formation of image in indii*ect examination
39. Indirect examination in emmetropia
40. Indirect examination in hypermetropia .
41. Indirect examination in myopia
42. Size of the image in emmetropia
43. Size of the image in hypermetropia
44. Size of the image in hypermetropia
45. Diagram showing the real size^of the disc and
the images in the indirect and direct methods
46. Position for the direct examination
47. Formation of image in direct examination
48. Size of image on retina in emmetropia .
49. Determination of size of image by coin .
50. Method of estimating enlargement
51. Direct examination in emmetropia
52. Direct examination in hypermetropia .
53. Direct examination in myopia
54. Method of retinoscopy
55. Shadow in retinoscopy
56. Movement of shadow
57. Formation of image in myopia
58. Formation of image in hypermetropia .
59. Oblique shadows
60. Method of recording the chief meridians
61. Diagram of the normal disc and nerve .
PAGE
22
23
24
25
29
31
34
30
37
38
39
39
42
43
46
46
47
48
48
49
the size of
LIST OF ILLUSTRATIONS
xni
No.
62. Position of opacities
63. Movements of vitreous opacit
64. Physiological cup
65. Atrophic cup
66. Glaucoma cup
67. Parallax .
68. Papillitis .
es
PAGE
97
102
140
141
142
143
145
Coloured Plates (between pages 82 and 83) :
I. — Fig. 1. Fundus of a child of medium complexion.
Left eye. Direct.
Fig. 2. Albino. Right eye. Indirect.
II. — Fig. 1. Dark fundus. Left eye. Direct.
Fig. 2. Choroid tigre. Right eye. Indirect.
III. — Fig. 1. Choroiditis in the exudative stage'
Fie:. 2. Disseminated choroiditis . ( opposite
Fig. 3. Senile choroidal change
Fig. 4. Coloboma of the choroid
IV. — Fig. 1. Retinitis pigmentosa .
Fig. 2. Thrombosis of central vein
Fig. 3. Atrophy of the optic disc
Fig. 4. Albuminuric retinitis .
page 106
opposite
page 118
THE OPHTHALMOSCOPE
CHAPTER I
OPTICAL PRINCIPLES INVOLVED IN THE USE OF THE
OPHTHALMOSCOPE
Light is propagated from a luminous point in every
plane and in all directions in straight lines ; these
lines of direction are called rays. Rays travel with
the same rapidity so long as they remain in the same
medium.
The denser the medium the less rapidly does the
ray of light pass through it.
Rays of light diverge, and the amount of diver-
gence is proportionate to the distance of the point
from which they come ; the nearer the source of the
rays the more they diverge.
When rays proceed from a distant point such as the
sun, it is impossible to show that they are not parallel,
and in dealing with rays which enter the eye, it will
be sufficiently accurate to assume them to be parallel
when they proceed from a point at a greater distance
than 6 metres.
1
)i THE OrHTHALMOSCOPE
A ray of liglit meeting with a body, may be absorbed;
reflected ; or if it is able to pass tlirough this body, it
may be refracted.
Reflection
Reflection by a Plane Surface
"Reflection takes place from any polished surface,
and according to two laws :
1st. The angle of reflection is equal to the angle
of incidence.
2nd. The reflected and incident rays are both in
the same plane, which is perpendicular to the reflect-
ing surface.
Fig. 1.
Thus, if A B be the ray incident at b, on the mirror
c D, and B E the ray reflected, the perpendicular p b,
will divide the angle a b e into two equal parts; the
angle a b p is equal to the angle p b e ; and A b, p b,
and E B lie in the same plane.
When reflection takes place from a plane surface,
the image is projected backwards to a distance behind
the mirror, equal to the distance of the object in front
of it, the image being of the same size as the object.
Thus in Fig. 2, the image of the candle c is formed
behind the mirror m, at c', a distance behind the
EEFLECTION
mirror equal to the distance of the candle in front of
it, and an observer's eye placed at E would receive
the rays from c as if they came from c'.
Fio. 2.
M. The mirror, c. The candle, c'. The virtual image of the candle.
E. The eye of the observer receiving rays from mirror.
The image of the candle so formed by a plane
mirror is called a virtual image.
Reflection by a Concave Surface
A concave surface may be looked upon as made up
of a number of planes inclined to each other.
Parallel rays falling on a concave mirror are
reflected as convergent rays, which meet on the axis
at a point (f, Fig. 3} called the princijml focus j about
equally distant from the mirror and its centre c. The
distance of the principal focus from the mirror is
called the focal length of the mirror.
4 TIIR OPITTHALMOSCOPE
If the luminous point be situated at f, then the
diverging rays would be reflected as parallel to each
other and to the axis.
If the point is at the centre of the concavity of the
mirror (c), the rays return along the same lines, so
that the point is its own image.
If the point be at a the focus will be at a, and it
Fro. 3.
will be obvious that if the point be moved to a, its
focus will be at A; these two points, therefore, a and
a, bear a reciprocal relation to each other, and are
called conjugate foci.
If the luminous point is beyond the centre, its
conjugate focus is between the principal focus and
the centre.
If the luminous point is between the principal
focus and the centre, then its conjugate is beyond
the centre; so that the nearer the luminous point
approaches the principal focus, the greater is the
distance at which the reflected rays meet.
If the point be nearer the mirror than (f) the prin-
cipal focus, the rays will be reflected as divergent,
RKFLKCTION
and will therefore never meet; if, however, we con-
tinue these diverging rays backwards, they will unite
at a point (h) behind the mirror; this point is called
Fia. 4.
the virtual focus, and an observer situated in the path
of reflected rays will receive them as if they came
from this point.
Thus it follows that —
Concave mirrors produce two kinds of images or
none at all, according to the distance of the object, as
may be seen by looking at oneself in a concave mirror.
If the mirror be placed nearer than its principal focus,
then one sees an enlarged erect virtual image, which
increases slightly in size as the mirror is made to
recede ; this image becomes confused and disappears
as the principal focus of the mirror is reached ; on
moving the mirror still further away (that is,
beyond its focus) one obtains an enlarged inverted
image, which diminishes as the mirror is still further
withdrawn.
6
THE OPHTHALMOSCOPE
Reflection hi/ a Coiivejc Surface
Parallel rays falling on sucli a surface become
divergent, hence never meet; but if the diverging
rays thus formed are carried backwards by Hups,
then an imaginary image is formed which is called
negative, and at a point called the principal focus (f).
Foci of convex mirrors are virtual; and the image,
whatever the position of the object, is always virtual,
erect, and smaller than the object.
Fig. 5.
The radius of the mirror is double the principal focus.
Refraction
Refraction hy a Plane Surface
A ray of light passing through a transparent
medium into another of a different density is refracted,
unless the ray fall perpendicular to the surface
separating' the two media, when it continues its course
without undergoing any refraction (Fig. 6, h k).
KE FRACTION 7
A ray is called incident before passing into the
second medium, emergent after it has penetrated it.
A ray passing from a rarer to a denser medium is
refracted towards the perpendicular; as shown in Fig.
6, the ray A b is refracted at b, towards the perpen-
dicular p p.
In passing from the denser to the rarer medium the
ray is refracted from the perpendicular, b D is refracted
at c from p p (Fig. 6).
Reflection accompanies refraction, the ray dividing
itself at the point of incidence into a refracted portion
(b c) and a reflected portion (b e).
FiG.G.
The amount of refraction is the same for any medium
at the same obliquity, and is called the index of
refraction ; air is taken as the standard, and is called
1 ; the index of refraction of water is 1*3, that of glass
1*5. The diamond has almost the highest refractive
power of any transparent substance, and has an index
8
Tiiy OrUTHALMOSCOPli;
of refraction of 2"4. The cornea has an index of
refraction of 1"3 and the lens 1*4.
The refractive power of a transparent substance is
not always in proportion to its density.
If the sides of the medium are parallel, then all rays
except those perpendicular to the surface which pass
through without altering their course, are refracted
twice, as at b and c (Fig. G), and continue in the same
direction after passing through the medium as they
had before entering it.
If the two sides of the refracting medium are not
parallel, as in a prism, the rays cannot be perpeudi.
cular to more than one surface at a time.
Therefore every ray falling on a prism must undergo
refraction, and the deviation is always towards the
base of the prism.
The rehitive direction of the rays is unaltered
(Fig. 7).
Fig. 7. Fia. 8.
If D M (Fig. 8) be a ray falling on a prism (a b c) at
M, it is bent towards the base of the prism, assuming
the direction m n ; on emergence it is again bent at n ;
an observer placed at e would receive the ray as if it
came from K ; the angle K H D, formed by the two lines
REFRACTION 9
at H, is called the angle of deviation, and is about half
the size of the i^incipal angle formed at A by the two
sides of the prism.
Refraction hy a Spherical Surface
Parallel rays passing through such a surface, sepa-
rating media of different densities, do not continue
parallel, but are refracted, so that they meet at a
point called the principal focus.
If parallel rays, k, d, e, fall on a b, a spherical sur-
face separating the media M and n, of which n is the
denser, ray d, which strikes the surface of A b at right
angles, passes through without refraction, and is called
the"^ principal axis ; ray k will strike the surface at an
Fig. 9.
angle, and will therefore be refracted towards the
perpendicular c J, meeting the ray d at F ; ray E will be
refracted in the same way, likewise all rays parallel
in medium M. The point f where these rays meet is
the principal focus, and the distance between the
principal focus and the curved surface is spoken of
as the principal focal distance.
10 THE OPHTHALMOSCOPE
Rays proceeding from f, will be parallel in m after
passing throngli the refracting surface. Kays parallel
in medium n will focus at f', which is called the
anterior focus.
Had the rays in medium m been more or less diver-
gent, they would focus on the principal axis at a
greater distance than the principal focus, say at h, and
conversely rays coming from h would focus at g ;
these two points are then conjugate foci.
When the divergent rays focus at a point on the
axis twice the distance of the principal focus, then its
conjugate will be at an equal distance on the other
side of the curved surface.
If rays proceed from a point o, nearer the surface
than its principal focus, they will still be divergent
after passing through A B, though less so than before.
Fro. 10.
and will therefore never meet ; by continuing these
rays backwards they will meet at L, so that the conju-
gate focus of will be at l, on the same side as the
focus ; and the conjugate focus will in this case be
spoken of as negative.
LENSES 11
Refraction hy Lenses
Refraction by lenses is somewhat more complicated.
A lens is an optical contrivance usually made of
glass, and consists of a refracting medium with two
Fio. 11.
opposite surfaces, one or both of which may be
segments of a sphere ; they are then called spherical
lenses, of which there are six varieties :
1. Plano-convex, the segments of one sphere (Fig.
11 b).
2. Biconvex, segments of two spheres (Fig. 11, a).
3. Converging concavo-convex, also called a con-
verging meniscus.
4. Plano-concave.
5. Biconcave.
6. Diverging concavo-convex, called also a diverg-
ing meniscus.
Lenses may be looked upon as made up of a number
of prisms with different refracting angles — convex
lenses, of prisms placed with their bases together,
concave lenses, of prisms with their edges together.
A ray passing from a less refracting medium (as
air) through a lens, is deviated towards the thickest
part, therefore the first three lenses, which are
12
THK OPHTHALMOSCOPE
thickest at the centre, are called converging j and the
others, which are thickest at the borders, diverging.
Fio. 12.
A line passing througli the centre of the lens (called
the optical centre) at right angles to the surfaces of
the lens is termed the principal accis, and any ray
passing through that axis is not refracted.
All other rays undergo more or less refraction.
Rays passing through the optical centre of a lens^
but not through the principal axis, suffer slight de-
viation, but emerge in the same direction as they
entered ; the deviation in thin lenses is so slight that
they are usually assumed to pass through in a straight
line; these are called secondary axes (Fig. 13).
Fig. 13.
Lenses with secondary axes undergoing slight deviation.
BICONVEX LENSES 13
Parallel rays falling on a biconvex lens are rendered
convergent ; thus in Fig. 14 the rays A, b^ c, strike the
surface of the lens (l) at the points d, b, f; the centre
Fig. 14.
ray (b) falls on the lens at E perpendicular to its sur-
face, and therefore passes through in a straight line;
it also emerges from the lens at right angles to its
opposite surface, and so continues its course without
deviation ; but the ray A strikes the surface of the lens
obliquely at D, and as the ray is passing from one
medium (air) to another (glass) which is of greater den-
sity, it is bent towards the perpendicular of the surface
of the lens, shown by the dotted line m k ; the ray after
deviation passes through the lens, striking its opposite
surface obliquely at o, and as it leaves the lens, enters
the rarer medium (air), being deflected from the per-
pendicular NO; it is now directed to H, where it meets
the central ray B H; ray c, after undergoing similar
refractions, meets the other rays at h, and so also all
parallel rays falling on the biconvex lens (l).
Parallel rays, therefore, passing through a convex
lens (l) are brought to a focus at a certain fixed point
(a) beyond the lens ; this point is called the principal
14
THE OrHTIlALMOSCOPE
focus, and the distance of this focus from the lens is
called the focal length of the lens.
Fio. 15.
Rays from a luminous point placed at the principal
focus (a) emerge as parallel after passing through
the lens.
Divergent rays from a point (b) outside the principal
focus (f. Fig. 16) meet at a distance beyond (p') the
Fig. 1(3.
principal focus on the other side of the lens (l), and
if the distance of the luminous point (b) is equal to
twice the focal length of the lens, the rays will focus
at a point (c) the same distance on the opposite side
of the lens, rays coming from c would also focus at
B ; they are therefore called conjugate foci, for we
can indifferently replace the image (c) by the object
(b) and the object (b) by the image (c).
If the luminous point (d) be between the lens and
BICONVEX LENSES
15
the principal focus (f), then the rays will issue from
the lens divergent, though less so than before enter-
ing ; and if we prolong them backwards they will meet
at a point (h) further from the lens than the point D ;
H will therefore be the virtual focus of b, and the con-
jugate focus of D may be spoken of as negative.
Biconvex lenses have therefore two principal foci,
p and f', one on either side, at an equal distance from
the centre.
In ordinary lenses, and those in which the radii of
the two surfaces are nearly equal, the principal focus
closely coincides with the centre of curvature.
We have assumed the luminous point to be situated
on the principal axis; supposing, however, it be to
one side of it as at e (Fig. 17), then the line (e f) pass-
ing through the optical centre (c) of the lens (r.) is a
Fig. 17.
secondary axis, and the focus of the point e will be
found somewhere on this line, say at f, so that what
has been said respecting the focus of a luminous
point on the principal axis (a b) is equally true for
points on a secondary axis, provided always that the
inclination of this secondary axis is not too great,
when the focus would become imperfect from much
spherical aberration.
16
THE OriTTTTALMOSCOPE
In biconcave lenses tlie foci are always virtual,
whatever the distance of the object.
Rays of light parallel to the axis diverge after
refraction^ and if their direction be continued back-
ward, they will meet at a point termed the principal
focus (Fig. 18, f).
Fro. IS.
Fig. 19 shows the refraction of parallel rays by a
biconcave lens (l) ; the centre ray b strikes the lens
at E perpendicular to its surface, passing through
without refraction, and as it emerges from the oppo-
FiG. 19.
site side of the lens perpendicular to its surface, it
continues in a straight line; the ray A strikes the
lens obliquely at d and is refracted towards the
perpendicular, shown by the dotted line a H; the ray
after deviation passes through the lens to k, where,
FORMATION OV IMAGKS
17
on entering the medium of less density obliquely, it
is refracted from the perpendicular o p, in the direc-
tion K M ; the same takes place with ray c, at f and
N, so also with all intermediate parallel rays.
Formation of images. — To illustrate the formation of
images the following simple experiment may be
carried out. Place on one side of a screen having a
small perforation, a candle, and on the other side a
sheet of white cardboard at some distance from the
screen, to receive the image formed; rays diverge
from the candle in all directions, most of those falling
on the screen are intercepted by it, but some few
rays pass through the perforation and form an image
of the candle on the cardboard, the image being
inverted because the rays cross each other at the
orifice ; it can further be shown that when the candle
Fro. 20.
-e)
and cardboard are equally distant from the perfo-
rated screen, the candle flame and its image will be
of the same size. If the cardboard be moved further
from the perforation the image is enlarged, if it be
moved nearer it is diminished ; if we make a dozen
more perforations in the screen, a dozen more images
will be formed on the cardboard, if a hundred, then
2
18
THE OPHTHALMOSCOPE
a liuiidred ; but if the apertures come so close
together that the images overlap, then instead of so
many distinct images we get a general illumination
of the cardboard.
The image of an object is the collection of the foci
of its several points ; the images formed by lenses are,
as in the case of the foci, real or virtual. Images
formed, therefore, by convex lenses, may be real or
virtual.
In Fig. 21, let A b be a candle situated at an
infinite distance ; from the extremities of A b draw
Fig. 21.
Ktiil inverted image formed by convex lens.
two lines passing through the optical centre (c) of a
biconvex lens, the image of A will be formed some-
where on this line A c a (termed a secondary axis), say
at a; the image of b will be formed on the line b c 6,
say at h ; therefore 5 a is a small inverted image of
the candle A b, formed at the principal focus of the
convex lens. Had the candle been placed at twice
the focal distance of the lens, then its image would
be formed at the same point on the opposite side
of the lens, of the same size as the object, and in-
verted.
FORMATION OP IMAGES
]9
If the candle be at the principal focus (f), then the
image is at an infinite distance, the rays after refrac-
tion being parallel.
If, however, the candle (a b) be nearer the lens
than the focus, then the rays which diverge from the
candle will, after passing through the convex lens, be
still divergent, so that no image is formed ; an eye
placed at e would receive the rays from a b as if they
Fig. 22.
Virtual image formed by convex lens.
came from ah; a 6 is therefore a virtual image of
A B, erect and larger than the object, and formed on
the same side of the lens as the object.
Images formed by biconcave lenses are always
Fig. 23.
Virtual image formed by concave lens.
virtual, erect, and smaller than the object; let A b be
a candle, and f the principal focus of a biconcave
.20 THE OPHTHALMOSCOPE
lens ; draw from A b two Hues through c^ the
optical centre of the lens, and lines also from a and
B parallel to the axis ; after passing through the lens
they diverge and have the appearance of coming from
a b, which is therefore the virtual image of A B.
A real image can be projected on to a screen, but
a virtual one can only be seen by looking through
the lens.
TFIR OPHTHAOIOSCOPE
21
CHAPTER II
THE OPHTHALMOSCOPE
When an eye is looked at, tlie pupil appears black
altliough the media are perfectly transparent ; this is
because the rays entering the eye return to the point
from which they emanate, and therefore, unless the
observing eye can be placed in the path of returning
rays, none of them will pass through the observer's
pupil, and so no illumination will be seen.
Fig 24.
In Fig. 24 rays will be seen entering the eye from
candle a, and since the refractive system of the eye
is exactly adjusted for the candle flame, the rays
returning from the eye will traverse the same path as
those entering it; if the eye be not adapted for the
candle flame, then the rays will return towards the
source of light.
22
THE OrHTflALMOSCOPE
In the albino, as in the white rabbit, the pupil may
appear illuminated ; this is due to the transparency
of the iris, so that the returning rays cover a larger
area than is the case when passing through an ordinary
pupil, then some of the outer rays may pass through
the observer's pupil, if placed nearly in the line of
light from which the observed eye receives its rays :
that this is the correct explanation can easily be
proved by covering up the part corresponding to the
iris by an opaque diaphragm, when the pupil will at
once appear black, as in the normal eye. In hyper-
m'^tropia and myopia with a dilated pupil, one fre-
quently gets a slight fundus illumination. This is
illustrated in the following figures.
In hypermetropin, Fig, 25, the returning rays,
Fio. 25.
instead of being parallel as in emmetropia, diverge
somewhat, so that the observing eye placed at b
would receive some of the returning rays.
In myopia. Fig. 26, the returning rays converge,
cross, and diverge, so that the eye placed at b would
receive some illumination.
The ophthalmoscope is a contrivance which enables
the observing eye to be placed in the path of the re-
THE OPHTHALMOSCOPE 23
turning rays, and consists of a reflector with a hole
in the centre.
Fio. 20.
Although the inveutiou of the o])litlialmoscope
is of recent date, it had long been known that the
eye was illuminated by rays entering the globe,
and it was thought that these rays were entirely
absorbed by the pigment contained in the retina and
choroid, but it was afterwards pointed out that some
parts, such as the disc, must even then reflect some
light, and that the apparent blackness of the pupil
must be due to the optical law "that rays of light
leaving the eye, return towards the source of illumi'
nation'^ so that unless the eye of the observer can be
placed in the path of the returning rays, no illumina-
tion can be obtained. Briicke was very nearly solving
the question by placing a tube through the flame of a
candle, which enabled him to catch some of the re-
turning rays of light; but it remained for Helmholtz
to overcome the difficulty by producing his first oph-
thalmoscope.
Helmholtz's ophthalmoscope, which he introduced
in 1851, was composed of three pieces of plane glass.
Fig. 27.
Rays reflected from a light A, are projected into
the eye b, by the mirror m, the light returning from
24 THE OrnTHALMOSCOrE
the observed eye by the same path will fall on the
glass Mj a part is reflected to a, and a part passes
Via. 27.
through the glass towards c ; an observing eye placed
behind the mirror will, therefore, receive some of the
returning rays.
Ophthalmoscopes have undergone numerous modi-
fications, and the iustrument with which we now
work consists of a silvered concave glass mirror, with
a central perforation.
In Fig. 28, divergent rays from a candle c, falling
on the mirror m, are rendered convergent, and when
reflected into the eye e, cross in the vitreous and
light up the fundus between the points G and d ; if
point H of this illuminated area be taken, the rays
will (in the emmetropic eye) issue parallel, and pass-
ing through the sight-hole of the mirror, will enter
the observing eye A, forming on the retina at h' an
image of h.
The amount of fundus illumination obtained will
necessarily depend upon the source and intensity of
•VUK OrnTITALMOSCOPE
25
the liglit^ the concavity of tlic mirror used, tlie dis-
tance from the eye at which the examination is made,
and the size of the pupil in the observed eye.
Modern ophthalmoscopes are fitted with a series of
26 THE OrnTHALMOSCOrE
lenses, which can bo revolved in front of the sight-
hole ; these are known as refracting ophthalmoscopes.
Many good ones have been devised, varying but
slightly in some or other minor particulars.
The essential points of a thoroughly complete
ophthalmoscope are, that it should be supplied with
three mirrors, — a small concave, a large concave, and
a plane one ; together with a fairly complete set of
lenses, which can be brought in front of the sight-hole
of the instrument as occasion requires.
(1) The small concave mirror is for the direct
examination; it should have a focus of about 7*5 cm.,
so that light reflected from it will enter the eye
as convergent rays. The sight-hole should not be
larger than 2| mm., because only that part of the
mirror which immediately surrounds the aperture
is available in the direct examination, and should
the sight-hole be larger than tlie pupil, then no
fundus illumination will be obtained. The small
mirror may be conveniently tilted about 25° ; this
allows the ophthalmoscope to be held perfectly
straight while the light is reflected into the observed
eye, enabling one to look through the lens which
may be behind the sight-hole at right angles to its
surfaces. With the old-fashioned mirror the ophthal-
moscope itself had to be tilted towards the light,
and with it, of course, the lenses, so that they were
looked through obliquely, and thus the strength of
the lens was increased and some astigmatism pro-
duced ; hence the estimation of the refraction by the
direct method was liable to be inaccurate. The
THE OPHTHALMOSCOPE 27
disadvantage of some tilted mirrors is the distance
that intervenes between the two sides of the sight-
hole, technically called "tunnelling;" this tunnelling
somewhat diminishes the size of the field seen, hut,
what is more important, prevents the eye of tlie
examiner from approaching sufficiently near that of
the person examined ; and it may be stated as an
axiom, that the nearer the observing eye can approach
the ohservedj the more accurate will he the estimation of
the refraction.
(2) The large concave mirror is for the indirect
method of examination and for retinoscopy ; it should
have a focal length of 25 cm., so that rays from a
light situated 25 cm. from the mirror will be reflected
parallel ; when the light is further off than 25 cm.
then the rays will be slightly convergent ; this mirror
may possess an aperture of 3 or 3 J mm.
(3) The plane mirror is useful for the examination
of the vitreous, and in some cases of high mjopia;
with this mirror rays of light coming from a lamp at
a finite distance, will be reflected into the eye as
divergent rays. The plane mirror may also be used
for retinoscopy.
Tlie ophthalmoscope should be supplied with a set
of lenses, which can in turn be brought behind the
sight-hole by means of a finger wheel ; this wheel
should be so made and placed, that it may be rotated
easily while the instrument is in position without
losing sight of the fundus. The lenses may be some-
what as follows: a convex series -f5 D., +1 D.,
increasing by one dioptre up to +10 D. ; and a
28 TFIE OPTTTHALMOSCOPE
concave series —'5 D., —1 D., increasing by one
dioptre up to —12 D., and then by two dioptres up
to — 20 D. Sometimes a higher glass may be re-
quired; these may be supplied on a separate disc;
the lenses in this disc may, by combination with the
other lenses, form a very large series.
The lenses should not be less than 6 mm. in
diameter, otherwisv_ they are difficult to centre pro-
perly, and cannot be easily cleaned — a point of some
importance ; they may occasionally be used for the
subjective test of estimating the visual acuteness,
should the box of trial lenses not be at hand.
It will be sufficient here to describe and to figure
one of the ophthalmoscopes in general use, though
numerous other good instruments will be found in
this country and abroad.
Morton's ophthalmoscope, shown in Fig. 29, is
a modification of an instrument introduced by Mr
Couper; it contains a series of twenty-nine lenses in
metal rings, and one metal ring without a glass ;
these run round a continuous channel, and are so
arranged that each can be brought successively in
front of the sight-hole by means of a driving wheel.
When no lens is required, then the empty ring
occupies the sight-hole ; these lenses touch each
other sideways, but are not fixed in any way ; on the
spindle that carries the driving wheel is another
wheel with teeth, which propel the lenses round the
instrument ; a spring and notch attached to the
driving wheel centres each lens as it arrives at the
sight-hole. The strength of the glass before the
THE OrilTHALMOSCOrE
29
sight-hole is recorded by an index wheel, which,
being geared to the driving wheel, keeps pace with
it, and therefore with the lens series. The minus
glasses are contained in white rings, and are in-
dicated by white numbers ; the convex glasses are
in red rings and have red numbers.
Fio. 29.
This series of lenses is usually sufficient for most
ordinary purposes, but occasionally other lenses are
required and are provided on a special disc. Some-
times a strong convex glass is required for the
examination of the cornea or lens; at other times a
strong concave lens is necessary for a case of high
myopia. This separate disc, therefore, has a + 20 D.
and a — 50 D. so placed that they can be instantly
put in front of, or removed away from, the sight-hole
30 THE OPHTHALMOSCOPE
without rotating the whole series of lenses. On this
same disc are also a + '5 D. and a — 10 D. : the
former of these enables one to estimate to within
half a dioptre in special cases ; and the latter, by use
in conjunction with other concave lenses contained in
the series, gives us from — ID. to— 20D., with in-
tervals of one dioptre, and — 20 D. to — 30 D., with
intervals of two dioptres. This disc is well shown in
the illustration. The instrument is supplied with
three mirrors ; a large concave one of 25 cm. focus,
and a small tilted one of 7' 5 cm. focus ; these are fixed
by a pivot, so that either can be turned in front of
the sight-hole as occasion requires : the large concave
mirror can be replaced, when necessary, by a plane
one.
The movement in this ophthalmoscope is a great
improvement over the method formerly employed, of
placing the lenses in a revolving wheel. The credit
of this ingenious invention is due to Mr Couper, who
was much assisted by Mr Paxton, of the firm of
Curry and Paxton.
M. Parent, of Paris, has recently brought out a
very beautiful instrument, combining the advantages
of all the recent ophthalmoscopes, and fitted with a
series of cylindrical lenses in addition to the ordinary
spherical series. M. Parent strongly advocates the
use of cylindrical lenses for the estimation of the
refraction in cases of astigmatism by the direct
method.
Lang's ophthalmoscope is also used a good deal in
this country, and is a very convenient instrument.
THE OPHTHALMOSCOPE
31
A useful mirror to carry in the waistcoat pocket
is that known by the name of Galizowski, Fig. 30;
it is convenient for the indirect examination and
for retinoscopy; its focal length is 25 cm. If the
handle be made to double over the face, no case
will be required to protect it.
Fig. 30.
The student also requires a large biconvex lens
(+13 D.), which is necessary for focal illumination
and the indirect method of examination.
A magnifying glass made of flint and crown glass
(achromatic), and having a focus of 1*5 cm., is very
convenient for examining the cornea, iris, and lens.
Demonstrating ophthalmoscopes are also made, but
need not be described.
32 THE OrilTIFALMOSCOPE
CHAPTER III
METHODS OP EXAMINATION
The incandescent electric li"lit of sixteen-candle
power contained in a ground-glass sliade, and the
ordinary gas Argand burner, are both suitable lights
for ophthahnoscope work ; they should be arranged on
a bracket which is capable of up and down as well as
lateral movement^ while the arm of the bracket should
be sufficiently long to allow the light to be placed on
either side of the patient without his having to move.
When these lights are not to be obtained_, an ordinary
oil lamp may be used, or even a candle. The patient
should be seated on a chair, while the observer may
conveniently use a music stool, the height of which
can be altered as occasion requires; some observers
prefer to stand when making an examination. A
dark room is also an advantage.
In many cases it is necessary to dilate the pupil
with a mydriatic; one that acts quickly and fully,
and the effect of which soon passes off, is to be pre-
ferred.
The most convenient combination is —
1^ Homatropinse Hydrobromatis, gr. iv.
Cocainse Hydrocliloratis, gr. x.
Acidi Salicjlici, gr. ij.
Aquae Destillatse, ^j.
Gr. guttse.
METHODS OF EXAMINATION 33
A drop of this solution produces full dilatation in
a very sliorfc time, and the effect passes off in two or
three hours. Of course in many cases no mydriatic
is required, but when a thorough examination is
necessary it is a great advantage to examine the eye
through a well-dilated pupil ; this is especially the
case when some changes have been detected in the
fundus, and further information is required by a
more searching examination, carried out under the
most favorable conditions.
But the student should learn not to rely too much
upon these minor aids, but accustom himself to
examine the fundus in various positions and uuder
different surroundings, with or without a mydriatic.
It is recommended that every opportunity be taken
to make repeated ophthalmoscopic examinations, and
where a large number of patients is not to be met
with. Frost's artificial eye (Fig. 31 ) will be of great
service in enabling the student to acquire the neces-
sary associated movements, as well as to understand
and appreciate many points of importance with regard
to the size and formation of the images in the various
conditions of refraction.
The first thing for a beginner to do is to familiarise
himself with the variations of the normal fundus.
Very great differences are met with ; as numerous
almost as the various shades of hair found in tlie
human race.
Besides, even in those cases where the visual
acuteness is normal, and no symptouis indicative of
disease are present, gross changes may be found, or
3
34
THE OrnxnALMOSCOPE
congenital peculiarities may exist wliicli ought not to
be missed.
Fig. 31.
Generally, young ophthalmologists disdain to look
at a normal fundus, caring only for pathological con-
ditions ; it would be much better for every one to
look at a certain number of normal fundi before pass-
ing on to the various diseases. Usually the reverse
is the method of procedure ; abnormal cases are
looked at first, varied only very occasionally by a
normal case.
METHODS OP EXAMINATION 35
In undertaking an ophthalmoscopic examination, it
should be conducted quietly and without hurry; a
number of students standing round anxious to look
at the same case is not conducive to a thorough exa-
mination. A regular routine is absolutely necessaiy ;
accuracy and confidence are thereby attained. First,
the cornea, iris, and lens must be examined hy focal
ilhimination ; then the large concave mirror is used at
a distance of about two thirds of a metre, and may
give an indication of the refraction of the eye, and
allow the condition of the vitreous to be ascertained ;
this should be followed by the indirect method of exa-
mination, which enables that part of the fundus which
is within reach of the ophthalmoscope to be readily
scanned ; the examination is completed by the direct
method, which gives an image magnified some eighteen
diameters, and allows minute changes, not visible by
the indirect method, to be detected, while at the same
time it allows of an estimate of the refraction beins*
made.
When any change has been detected in the cornea,
iris, or lens, this may conveniently be examined with
the oblique mirror, having a +20 D. behind the
sight-hole of the ophthalmoscope, and approaching
close to the patient as with the direct method ; when
the iris and lens are examined in this way, a some-
what weaker glass is necessary, + IG D.
36
THE OPnTITALMOSCOrE
Focal Illumination
Tlie patient being seated opposite a good artificial
light, the observer takes up the large biconvex lens
of 13 D. between the thumb and forefinger of one
hand, and concentrates the light obliquely on the
cornea, iris, and crystalline lens successiv^ely. By
this means opacities and irregularities of the cornea,
affections of the iris, opacities of the lens, and even
disease involving the anterior part of the vitreous may
be detected. To examine every part of the lens and
the vitreous, ifc is absolutely necessary that the pupil
be dilated with a mydriatic. Then, tumours of the
ciliary region, vitreous opacities, sparkling synchj^sis,
and even detached retina, may be seen.
Fig. 32.
By varying the position of the light and of the eye
ider examination, every part can be thoroughly in-
METHODS OF EXAMINATION 37
spected. Wlieu the deeper parts of tlie lens and the
vitreous are examined, the light must be thrown into
the eye in an almost perpendicular manner, as shown
in Fig. 32.
Fio. 33.
One great advantage of the focal illumination is
that everything is seen of its real colour and in its
true position.
This examination may with advantage be supple-
mented by using a second lens before the eye as a
magnifying glass, oi", still better, the small achro-
matic glass made for that purpose and referred to on
p. 31. (Fig. 33.)
38
THE OPHTHALMOSCOPE
The Large Concave Mirror at a Distance
The light shoukl now bo pbicod on one side of the
patient, on a level with the head and slightly behind,
so that no direct light falls on his face ; the observer,
sitting opposite^ places before his eye the large concave
mirror, and at a distance of about two thirds of a
metre reflects the light into the eye he wishes to exa-
mine; usually a red fundus reflex is obtained, but
no details will be visible; should any of the vessels
or a part of the disc be seen, then we shall know that
the eye under examination is ametropic.
Because in emmetropia (Fig. 34), the rajs which come from the
two extremities of the disc (a b) emerge as two sets of parallel
Fig. 34.
rajs in the same direction as the rajs a c, b d, which, having
passed through the nodal point, undergo no refraction. These
two sets of rajs soon diverge, leaving a space between them, so
that an observer, unless he be quite close to the observed eje, is
unable to bring these raj's to a focus on his retina, and therefore
at a distance from the eje the observer sees onlj a diffused and
blurred image.
In lijpermetropiu (Fig. 35) the rays from the two points (a b)
emerge from the eje in two sets of diverging rajs, in the same
direction as the rajs a c, b d, which undergo no refraction. These
THE CONCAVE MIRROR AT A DISTANCE 39
divergin<^ rays liave tlie appearance oE coining from two points
{a b) behind tlie eye, where an erect imaginary image is formed
(a 6).
Fig. 35.
Here the observer at a distance sees a clear, erect image, which
is formed behind the eye.
In myopia (Fig. 36), the rays from the two points (a b) emerge
Fig. 36.
as two converging sets of rays, whicli meet at a h on tlieir secon-
dary axes, thus forming an inverted image in front of the eye.
This image can be distinctly seen by the observer if he be at a
sufficient distance from the point, and accommodating for the
particular spot at which the aerial image is formed. The higlier
the myopia the nearer to the e^'e will tliis image be formed.
From the above observations it will be understood that if the
observer now move his head from side to side, and the vessels of
the disc are seen to move in tlie same direction, tlie case would be
one of hypermetropia, the image formed being an erect one.
40 THE OrHTOALMOSCOPE
Had tlic vessels moved in the opposite direction to the
observer's head the case would be one of myopia, the image
being an inverted one formed in the air in front of the eye.
If the vessels of one meridian only are visible, then we have a
case of astigmatism, h^^permetropic if moving in the same, and
myopic if moving in tlie opposite direction to the observer's head,
that meridian being ametropic which is at right angles to the
vessels seen.
In mixed astigmatism the vessels of one meridian move against
the observer's movements, and those of the other meridian with
them ; this is difficult to see.
Should no f Lindas reflex be obtained when the light
is thus properly reflected into the eye^ the case may
be one of haemorrhage into the vitreous, or other
serious lesion : but the reflex may be good, and yet it
may appear irregular by the presence of black spots
here or there; in this case probably some opacity
exists in the cornea, lens, or vitreous, which interferes
with the returning rays of light, and so appears
black, whatever the real colour of the opacity may
be; and if nothing was seen by careful inspection
with focal illumination, the opacity is in all proba-
bility situated in the vitreous ; this is certainly the
case if the opacity is floating. The movements of
these floating opacities will be more conspicuous if
the patient be directed to first look upwards, then
downwards, and finally straight in front of him ; the
rate of movement will be a guide as to the consis-
tency of the vitreous, and the direction of their move-
ments will depend upon their position in the vitreous,
whether they are in front of or behind the centre of
rotation of the eyeball — a point situated in the normal
THE INDIRECT METHOD 41
emmetropic eye 9*8 mm. in front of the retina
(Fig. 63).
Sometimes the vitreous opacities may be so thin
that some of the returning liglit may pass through
them ; they will then appear more or less white or
pink ; occasionally light may be reflected from the
surface of the opacity, and then it will appear white
and more or less glistening, this is the case when
cholesterine or ty rosin crystals are present.
The Indirect Method
The examination with the large concave mirror at
a distance, which has taken some time to describe,
occupies only a very short time, and we pass on
without a break to the indirect examination. With
the large concave mirror still before the observer's
eye, and lighting up the eye under examination, the
biconvex lens which was used for the focal illumina-
tion is held up between the mirror and the patient's
eye at about its focal distance from the latter ; an
inverted image of the fundus will thus be obtained,
magnified about five diameters : the amount of
magnification depends upon the strength of the
objective used ; the stronger the lens, the less is the
image magnified, and therefore the greater the field
that comes into view. The size of the field that can
be seen at once will depend upon the strengtli and
size of the object-glass : thus, with a dilated ])upil
and a lens of + 13 D., having a diameter of about 5
cm..j the size of the field will be about 8 mm., or four
42
THE OPHTHALMOSCOPE
times as large a field as will be seen by the direct
method.
The image formed by the lens will in the case of
emmetropia be at the focus of the convex glass,
between it and the observing eye, so that the learner
has to remember to accommodate for the image at
this distance.
It is convenient to use the mirror before the right
eye with the right hand when examining the patient's
Fig. 37.
right eye, and before the left eye with the left hand
when examining the patient's left eye; then the
objective will be held between the finger and thumb
of the opposite hand. This may be steadied if neces-
sary by resting the little finger against the forehead.
By adopting this procedure the hand holding the
THE INDIRECT METHOD
43
c « o d >< ^" 2
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44 THE OPHTHALMOSCOPE
objective is not over the patient's face. Some ob-
servers, however, always use the same eye for the
indirect examination ; thus if the right be the one
preferred, tlic observer will always hold the ophthal-
moscope in his right hand, using the objective with
the left : this is simply a matter of individual con-
venience. The eye of the observer not in use may
with advantage be kept open.
Although not necessary it is an advantage to use a
+ 4 D. behind the ophthalmoscope ; one thus obtains
a somewhat larger image, which can be seen without
accommodatiug, at the focus of the biconvex lens used.
Thus when examining the fundus of an emmetrope,
the aerial inverted image will be formed at the focus
of the objective, which in the case of a + 13 D. lens
will be a little less than 8 cm., the observer (with a
+ 4 D. behind his mirror) situated at 25 cm. from
this image will see it clearly and well defined at this
distance without any accommodation : the advantage
of this plan is that the observer sits nearer the patient
than when the examination is made without the -f 4 D.,
and does not have to stretch his arm out so far when
holding up the objective.
The first part to which attention should be directed
is the disc. If one is examining the right eye, the
patient should be told to look towards one's right
ear, or, what is perhaps better, at the upheld little
finger of the right hand which is holding the mirror;
the fundus reflex being obtained, it will be noticed
to be somewhat whiter when coming from the optic
disc ; the large convex glass is held between the
THE INDIRECT METHOD 45
thumb and finger of the left hand, about 3 or 4 cm.
directly in front of the observed eye; this will
form an inverted image of the disc, which should
be clearly seen by the observer. The beginner will
find some difficulty at first in performing these asso-
ciated movements of lighting up the fundus with the
mirror, and keeping the light steadily on the eye
while the objective is held in the other hand and
moved about backwards and forwards, and from side
to side.
The next part to examine is the periphery ; this
must be gone over systematically by directing the
patient to look up, then down, then to the right, and
finally to the left. By this means the posterior
hemisphere of the eyeball may be thoroughly in-
spected, especially when the pupil has been dilated
with a mydriatic.
A still more peripheral part of the fundus can be
seen by using an objective glass which is composed
of two elements, a biconvex lens and a prism ; such a
glass is called a prismosphere.
Finally the macula region demands attention. This
part is difficult to see, as the pupil contracts vigorously
when the light is directed on this, the most sensitive
part of tlie fundus; besides, the corneal reflex comes
directly in the line of vision. The patient should be
directed to look at the sight-hole of the mirror, or
slightly to one side of it ; then with a little
manoeuvring with the mirror and lens, and a certain
amount of practice, a fairly good view of this part
may be obtained.
46 THE OPnTKALMOSCOPE
Tlie reflections formed by the cornea and by the
objective are always somewhat troublesome to the
Le<>^inner ; by tiltini^ the lens slightly these images
will bo thrown out of the line of vision.
Variations in the Size of the Image in Ametropia. —
The contlition of tlie refraction of the eye under examination will
cause some variation in the size of the images obtained ; thus in
emmetropia, rajs coming from a, Fig. 39, emerge from the eye
parallel, and are focussed by the biconvex lens at a, and rays
Fig. 39.
coming from B are focussed at 6 ; so also vs^ith rays coming from
every part of A B, forming an inverted image of A b at h a,
situated in the air at the principal focus of the biconvex lens.
In hypermetropia (Fig. 40) the rays from A emerge divergent,
Fig. 40.
so also, of course, those from b ; if these rays are continued back-
ward, they will meet behind the eye, and there form an enlarged
THE INDIRECT METHOD 47
upright image (a /3) of a b ; it is of this imaginary projected
image that we obtain, by the help of the biconvex lens, a final
inverted image {b a), situated in front of the lens beyond its
principal focus.
In myopia (Fig. 41) the rays from A and b emerge from the eye
Fig. 41.
convergent, forming an inverted aerial image in front of the eye
at /3 a, its punctum remotum. It is of this image we obtain, with
a biconvex lens placed between it and the eye, a final image (b a)
situated within the focus of the biconvex lens.
Tiie inverted image of the disc, produced by a convex lens at a
certain fixed distance from the cornea, is larger in hypermetropia,
and smaller in myopia, than in emmetropia. The lens should
next be held close to the patient's eye, and then gradually with-
drawn, while the aerial image of the disc is steadily kept in view;
if any increase or decrease take place in the size of this image, we
shall know that the eye is ametropic.
If no change take place in the size of the image on thus with-
drawing the objective the case is one of emmetropia, because rays
issue from such an eye parallel, and the image formed by the
object-glass will always be situated at its principal focus, no
matter at what distance the glass is from the observed eye
(Fig. 42). As the distance of the image from the object-lens is
always the same, the size of the image will also be the same.
If diminution take place in the size of the image the case is
one of hypermetropia, and the greater the diminution the higher
is the hypermetropia.
This change in size may be explained by remembering that in
48
THE OPHTHALMOSCOPE
hypernictropia the imajj^e of the disc formed by the object-glass is
situated beyond its principal focus, owing to the rays issuing from
Fig. 42.
E. Emmetropic eye. Kays issuing parallel, image formed at
the principal focus of the lens, no matter at what distance
the lens is from the eye.
the eye being divergent ; the relative size of the final image (3 a
to the object a b will therefore vary directly as the length c a,
and inversel}" as the length c a ; so that on withdrawing the lens
c from the observed eye, c a diminishes and c a increases ; there-
fore the ratio of a h io a 13 diminishes, i.e. the size of the image
diminishes. The two diagrams 43 and 44 show images formed by
Fig. 43.
Lens at 4 cm. from the curuea.
the object-glass when held at 4 cm. and at 12 cm. from the
cornea, the latter image being the smaller.
If the image become larger on withdrawing the object-glass, the
case is one of myopia ; the greater the increase of the image, the
higher the myopia.
THE INDIRECT METHOD 49
Tliis increase in tlie size of the image can also be explained
with the help of mathematics, remembering that, in myopia, an
Via. 44,
Lens at 12 cm. from the cornea.
H. Hypermetropic eye. c. The centre of the lens. A b.
Image on the retina, a h. Projected image. /3 a. The final
image formed by the objective.
inverted image is formed in front of the eye (Fig. 36), and it is of
this we obtain a final image, with a convex glass placed between
the eye and the inverted image, which we must regard as the
object, the object and its image being both on the same side of
the lens.
In astigmatism the disc, Instead of appearing round, is frequently
oval. If one meridian decrease in size, while the other remain
stationary as the objective is withdrawn, it is a case of simple
hypermetropic astigmatism. If the whole disc decrease in size,
one meridian diminishing more than the other, it is compound
hypermetropic astigmatism, the meridian being most hypermetropic
which diminishes most.
Increase in one meridian, the other remaining stationary, indi-
cates simple m^'opic astigmatism.
Increase in the size of the disc, but one meridian increasing
more than the other, indicates compound myopic astigmatism,
that meridian being most myopic which increases most.
If one meridian increase while the other decrease the case is one
of mixed astigmatism.
It must be remembered that by the indirect method
everything is inverted ; thus the apparent position of
4
50
THE OPHTHALMOSCOPE
Fig. 45.
B
The above figure is intended to represent, by means of A, the
real size of the optic disc; by means of b, the size of the
image formed by the indirect method; and by c, the size
of the image formed by the direct method. It also shows
in the case b the effect of the inversion ; this effect is
rendered more apparent by the patch of choroiditis shown
in the figure.
THE INDIEECT METHOD 51
the macula is to the inner side, when of course its
real position is outside, the apparent upper edge of
the disc is the lower, and so on. Fig. 45 b represents
this inversion.
Magnification of the image seen by the indirect method.
— To estimate the degree of enlargement obtained by
the inverted image we must recall to our minds the
fact, that the image we see in this method of examina-
tiou is a real image formed in the air by the union of
the rays coming from the eye and passing through
the convex lens. This image can be received upon a
screen and measured exactly ; therefore to estimate
the degree of enlargement, we have only to measure
the size of the inverted image of the disc and com-
pare it with the size of the disc itself.
We are at once met by the difficulty that the size
of the disc varies in different individuals, so that
we do not know its exact size in any particular
case.
If the biconvex lens with which we obtain the
inverted image be placed at such a distance from the
eye that its focus coincides with the nodal point of
the observed eye, a point situated in the emmetropic
eye 15 mm. in front of the retina; then the enlarge-
ment may be expressed by the simple formula —
n
of which X equals the amount of enlargement of
the image ; / equals the focal distance of the lens
52 THE OPHTHALMOSCOPE
used to produce the inverted image ; while u is the
distance between the nodal point and the retina.
Suppose, for example, we wish to know the amount
of cnlarcrement of the ima":e in the case of an emme-
trope with a ghiss of 13 D. Then /equals the focal
distance of the lens 13 D., which is 77 mm. ; and u
equals 15 mm., that is the distance between the nodal
point and the retina; we shall then have for our
formula —
77
X = -- = ^ tmies.
15
Therefore the enlargement will be five times, and
if on measuring the image thus obtained we find it to
be 7*5 mm., then we shall know that the real size of
the disc was 1*5 mm.
In hypermetropia we must find the amount of
shortening of the eyeball (3 D. = l mm.), and deduct
this from the 15 mm. which is the distance between
the nodal point and the retina, and then proceed as
before.
In myopia the increase in length of the eyeball
must be added on to the 15 mm.
To carry out this experiment practically a demon-
strating ophthalmoscope such as Beale's is necessary,
provided with a screen marked out in millimetre
squares on which the image is received. With
Frost's artificial eye the experiment can be easily
demonstrated.
The large lens used as a condenser and magnifier.
— The indirect examination being completed, before
TFIE DIRECT METHOD 53
laying down the mirror and lens a further method
of examination may be briefly mentioned. The ob-
server approaching to a short distance from the
patient (about 15 or 20 cm.), reflects the light into
the eye by means of the mirror, and having illumi-
nated the eye he then interposes the convex lens,
which is now used not to obtain an image, but to
condense the light from the mirror, while at the same
time the cornea, iris, and lens are seen under its
magnifying influence ; opacities of the cornea, in-
juries or affections of the iris or lens are often con-
veniently examined in this way ; by slightly moving
the lens backwards and forwards the light is focussed
on the different planes. This method of examination,
though very useful in many cases, must never be
used to the exclusion of the focal illumination.
The Direct Method
The direct method of examination is next employed.
This method has the advantage of enabling us to
see the parts in their true position, and gives us an
image magnified some 16 to 18 diameters, though, of
course, a much smaller part of the fundus is seen at
once. The amount of fundus which will be visible
depends chiefly upon the size of the pupil, but partly
also upon .the size of the light used ; with a pupil
of 4 mm. and a large gas flame, one gets a field little
bigger than 2 mm. ; although only this small part can
be seen at once, yet by varying the position of the
head and ophthalmoscope one is able to look over a
54
THE OPHTHALMOSCOPE
consitlorable part of tlie posterior hemisphere of the
eye. A strong prism placed behind the ophthalmo-
scope will allow a still more peripheral part of the
fundus to be seen.
Fig. 46.
For the direct examination the tilted short focnssed
mirror is used ; it may be quite small, as only those
rays reflected from the part immediately around the
sight-hole enter the pupil, — this is especially the case
when the pupil is small ; the sight-hole should not be
larger than about 2J mm., for if the sight-hole be
larger than the pupil, then no rays may enter the eye,
and we shall fail to get any illuinination. The ob-
server first corrects any ametropia that he may have,
either by having the proper correction in a suitable
clip behind the sight-hole of his ophthalmoscope, or
he may deduct his own ametropia from the glass
THE DIRECT METHOD
55
which corrects the refraction of the patient and
himself in the manner to be presently described ; he
•S s ^ s
^ <i> o ,• o
"- ^ ^ o:^
2 oj ^ c: o
-»^ ^ 'fcC « a>
_ 3 c tc
o 2 I -^ g
> O CI "Vrf r5
aj o aJ .Sr
ai gj o. X ...
^ S ^ tc^
M J K o J
>> - 2 "<
•= p^ fee's
;» C -^-^ '' ^
OJ .X "^ >
"* C (1 > '^
o « O '^ w
2 »; « ee
<; c^ ft j; « 'S
^ tc 'w 2 2 ?*
t^ cs 03 *" +^ C>
ji* <y S^ ;' 3 ,^
C gj fi t, ^j .X
»— I > -*J 2 G -^
.C o vr O «
then sits or stands as he may prefer on the same side
as the eye he is about to examine, so that the observer
50 THE OPHTHALMOSCOPE
uses his right oyo for the patient's right and his left
for the patient's left.
The light is placed on the side to be examined a
little behind and on a level with the patient's ear;
the examinee's head may with advantage be inclined
slightly towards the observer, while the observer
inclines his own head slightlj in the reverse direction ;
1. e. in examining the right eye the patient iticlines
his head slightly to the right, while the observer
inclines his slightly to his own right, so that the two
eyes may come very close together, the brows even
may touch, while the respiratory orifices of patient
and observer are away from each other.
The patient is directed to look straight in front
of him, and take as little notice as possible of the
examiner,, the surgeon resting the edge of the
ophthalmoscope against his brow, reflects the light
into the eye, and approaching close to the patient,
first looks for the disc; then scans the periphery by
directing the patient to look in different directions;
and finally examines the macula region.
The great difficulty which the beginner finds with
this method is to keep his accommodation passive ;
usually some practice is required before this can be
managed, so that a concave glass has to be used
before a clear view of the fundus can be obtained. By
using a weaker concave glass eadi time, the accommo-
dation will be gradually relaxed. Should the disc,
when first seen, appear quite clear and distinct, one
must not at once assume that the patient is emme-
tropic, bnt onl}^ on finding that the weakest convex
THE DIRECT METHOD
57
glass behind the oplitlialmoscopc impairs the clear-
ness of the image. Another difficult}^ the beginner
has, is to disregard the corneal reflex, which is most
troublesome when the macula region is inspected.
Magnification of the image seen by the direct method.
— The estimation of the amount of enlargement by
means of the direct method of examination is more
difficult and less exact than with the indirect method.
The size of the image of the disc of an emmetrope
formed on the retina of the emmetropic observer will
be exactly the same size as the disc itself,
clearly shown in Fig. 48.
This is
KiG. -JS.
The image is therefore of considerable size, and
covers a good many retinal elements ; and to find out
the magnification, we have only to consider some
external object which^ placed at a certain distance
from the eye, forms a retinal image of the same size,
viz. 1*75 mm.; half-a-crown held 25 cm. from the
eye will produce a retinal image of about this size.
If we divide the distance nt which the coin is
58
THE OrnTnALMOSCOPE
placed (25 cm.) by tlie distance from the retina to
the nodal point, 15 mm., we shall arrive at the
amount of enlargement :
25 cm. 250 ram.
15 mm.
= 17.
15 mm.
The diameter of our coin should therefore be 17
times larger than its retinal image ; we know the
size of the retinal image is 1*75 mm., therefore the
diameter of the half-crown should be about 30 mm. ;
on measuring it this will be found to be the case.
Fig. 49.
It is obvious that the disc or any part of the fundus
will appear more magnified, the greater the distance
to which its image is projected.
Hence the ophthalmoscopic image of the same disc
does not alwa^^s appear of the same size to different
observers, owing to the varying distance to which
the image is mentally projected by them. To still
further elucidate the subject, the following explana-
tion may be of service.
Every student is familiar with the plan sometimes
THE DIRECT METHOD 59
adopted in the case of the microsco}3e ; when making
a drawing of a specimen, the observer looks with one
eye, we will assume the left, down the tube of the
microscope, while with the right he looks by the side
of the tube on to apiece of drawing-paper placed on a
level with the stage of the instrument. The specimen,
seen by the left eye, is projected upon the paper with
the right, and can there be drawn ; or if it is wished
to estimate the magnifying power of the microscope,
a scale divided into hundredths of a millimetre is
placed under the eye-piece, while beside it on the
stage, or on the same level, is placed a scale divided
into millimetres, so that the image seen in this case
with the left eye is projected on to the scale placed
at the side of the instrument ; thus the two scales
are superimposed, and a comparison can be made ;
if the squares on the two scales exactly cover each
other, then we should know that the microscope mag-
nified one hundred times.
This experiment will also enable anyone to under-
stand what is intended by the expression ^^ projecting
a retinal image/'
A somewhat similar plan is adopted with the oph-
thalmoscope, but it must be slightly modified since
the conditions are different.
For with the ophthalmoscope, using the direct
method, we approach so near to the observed eye
that it would be impossible to see it at the same dis-
tance with the eye alone ; it is just the same as looking
through a strong convex lens. For this reason it is
obvious that we must place the standard scale at a
60
THE OPHTHALMOSCOPE
greater distance from the eye, and since the apparent
size of the image is larger in proportion to the dis-
tance to which it is projected, it is necessary to fix
some distance at whicli tlie measuring scale shall be
placed so as to render this method of any value;
33 centimetres has been decided upon, a distance at
whicli we ordinarily look at near objects.
Therefore, to estimate the amount of enlargement
by the direct method of examination, we look with
one eye through the ophthalmoscope at the disc of
the observed eye, while with the other we look at
Fig. 50.
a sheet of paper on which is ruled a millimetre
scale placed 33 cm. away ; with a little practice the
student will be able to project upon this scale the
image of the disc which he sees with the other e^^e,
and, by counting the number of squares on the scale
THE DIRECT MKTIIOD 61
that is covered by the iaiage^ the amount of enlarge-
ment can be estimated.
We encounter here the same difficulty that was re-
ferred to on page 51, that the size of the disc may
vary in different individuals.
If the observer be emmetropic, then it is necessary
for him to put on —3D. behind his ophthalmoscope, so
that he may accommodate 3 D. with each eye ; he
wouki then see clearly the disc of the eye under
observation, while the other eye will be adapted for
the distance at which the scale is placed, 33 cm. ;
were this proceeding not adopted, the eyes would have
to accommodate in unequal degrees in order that both
the disc and the scale may be seen clearly.
Another plan of estimating the enlargement by
the direct method is to place behind the sight-hole
of the ophthalmoscope a plain mirror from which a
good deal of the silvering has been scratched away, to
receive an image of the scale which is placed behind
the observer's head and a little to one side, and thus
the image of the disc and the scale will be super-
imposed, and the two will be seen by the one eye.
This plan is useful when the observer's eyes are not of
equal value.
Both the indirect and direct examituitions should
always be employed, each method has its own special
advantages ; thus the indirect method gives us a large
field and allows us quickly to scan over the whole of the
posterior part of the fundus, while the patient's re-
fraction need not be corrected, and the observer may
disregard his own ametropia provided he can adapt his
62 THE OPHTHALMOSCOPE
eye for the distance at which the aerial image will be
formed.
The direct method gives a smaller field but greatly
magnified, so that minute changes which are not
visible by the indirect method can be detected ; it also
gives us more accurate information of any lesion with
regard to its level, &c., being an upright image every-
thing is seen in its proper position, whereas with the
indirect method the image is inverted ; and finally with
the direct, the refraction of the observer and observed
must be corrected.
To the experienced ophthalmoscopist this becomes
an advantage, as an estimate of the patient's refrac-
tion can thus be made. One really wishes to estimate
the refraction at the macula, but this region is not suit-
able, partly because there are no convenient vessels,
and partly because it is very sensitive to light, and
therefore causes the pupil to contract vigorously, hence
one usually selects the disc as the most favorable part
for our purpose ; occasionally the refraction at the
macula differs considerably from that at the disc, but
usually little difference exists.
The estimation of the refraction by the direct method.
— To estimate the refraction of the patient by the
direct method, it is necessary that the patient's
accommodation should be relaxed; this will generally
be the case when the examination is made in a dark
room, or atropine may be used ; then if the observer's
own accommodation be suspended, and the image of
the disc appear quite clear and distinct, the case is
one of emmetropia ; because rays coming from an
THE DIRECT METHOD
63
emmetropic eye (Fig. 51, e) issue parallel, and the
observing eye receiving these rays will, if emmetropic
with its accommodation suspended, be adapted for
Fig. 51.
parallel rays, so that a clear image of a in the ob-
served eye will be formed at h on the retina of the
observing eye.
Supposing the image does not appear clear and
distinct without an effort of the accommodation, then
we turn on convex glasses behind the sight-hole of
the ophthalmoscope.
The strongest positive glass with which we are able
to get a perfectly clear image is a measure of the
hypermetropia, because rays coming from a (Fig. 52)
Ftq. 52.
in the hypermetropic eye (h) issue in a divergent
direction as though coming from u, the punctum re-
motum behind the eye. The convex lens (l) renders
64
TirK OrilTIIALMOSCOPE
tliein parallel, and they then focus at h^ on the retina
of the observing emmetropic eye (e).
If, however, the image of the disc appear indistinct,
and the convex glass, instead of rendering the image
clearer, have the opposite effect, we mnst turn the
wheel of the ophthalmoscope in the other direction,
and so bring forward the concave glasses. The weakest
with which we can see the details of the fundus clearly
is a measure of the myopia, because any stronger
glass merely brings into play the accommodation of
the observer. Rays from a (Fig. 53) leave the myopic
eye (m) so convergent, tliat they would meet at (li) the
punctum remotum. The concave lens (l) renders them
parallel before falling on the relaxed eye (e) of the
observer.
Fto. .^3.
If the ophthalmoscope is not held very close to
the eye, we must deduct from the focal distance of
the lens the distance between the cornea and the in-
strument in hypermetropia, adding them together in
myopia.
If astigmatism exist the proceeding is more difficult,
because one wishes to find out not only the refraction
of the two chief meridians, but also the axis of these
meridians. To discover the meridian of greatest re-
THE DIRECT METHOD 65
fraction, and to estimate it by the direct method, we
keep in view the disc, then if the case be one of hyper-
metropic or mixed astigmatism, we find the strongest
convex lens thronsrh which one of the vessels still
remains distinct (vessels going in other directions
will be indistinct) ; this lens will be the measure of
the refraction of that chief meridian which is at right
angles to the vessel. To estimate the other chief
meridian we select a vessel whose course is at right
angles to that first chosen, the strongest convex glass
through which this vessel is seen distinctly will give
us the measure we require.
Had the case been one of myopic astigmatism, then
the weakest concave glass with which any vessel is
first clearly defined will indicate the strength of one
meridian ; to estimate the other meridian we must as
before select a vessel which is at right angles to that
first clearly seen, then the weakest concave lens which
allows us to see it well defined, will indicate the refrac-
tion of the other chief meridian. The estimate is
more easy to make, when the chief meridians are
vertical and horizontal ; but unfortunately many
cases occur in which they are more or less oblique,
and it is not always easy to find a vessel whose course
exactly coincides with these oblique meridians.
The essential point to remember in estimating
astigmatism by this method is, that the glass with
which the vessels in one direction are clearly seen, is
the measure of the refraction of that meridian which
is at right angles to the vessels ; the student needs
only to recall to his mind the principles of the per-
5
66 THE OPHTHALMOSCOPE
ception of a lino by an astigmatic eye to understand
this.
Tlie subject may possibly be made clear by quoting
a few examples ; we will take a case in whicli the
vertical vessels and lateral sides of the disc appear
distinct without any lens, and which the weakest
convex glass renders indistinct, then the horizontal
meridian, i. e. the meridian at right angles to the
vessels clearly seen, is emmetropic ; and suppose, also,
that the horizontal vessels with the upper and lower
borders of the discs, require a convex or concave glass
to render them clear and distinct, then the vertical
meridian is hypermetropic or myopic, and the case
is one of simple hypermetropic or myopic astigma-
tism.
If both the vertical and horizontal vessels can be
seen through a convex glass, but a stronger one is
required for the horizontal than for the vertical, then
the case is one of compound hypermetropic astig-
matism, the vertical meridian being the more hyper-
metropic.
If both meridians had required concave glasses, but
of different strengths, then the case would be one of
compound myopic astigmatism.
If the vertical vessels and the lateral sides of the
disc can be seen clearly defined through a convex
glass, while the horizontal vessels require a concave
glass to render them distinct, the case is one of
mixed astigmatism, the horizontal meridian being
hypermetropic, the vertical meridian myopic.
The estimation of the refraction by the direct
THE DIRECT METHOD. G7
method is exceedingly valuable, ])nt requires great
practice. lu cases of hypermetropia and low
myopia, one is able to estimate the amount of error
within half a dioptre, and in cases of astigmatism
where the chief meridians are horizontal and ver-
tical, one can come very near the exact correction,
and without subjecting the patient to the inconveni-
ence of having his accommodation paralysed with
atropine.
The comparison of the direct and indirect methods
of examination is also very useful in astigmatism. If,
for instance, the disc is elongated horizontally in the
erect, and oval vertically in the inverted image, we
know that the curvature of the cornea is greater in
the horizontal than in the vertical meridian.
The ametropic observer must always remember,
when using the direct method for the estimation of
errors of refraction, that he must correct his own
defect, either by wearing spectacles or by having a
suitable glass in a clip behind his ophthalmoscope ;
he is then in the position of an emmetrope : but, if he
prefer it, he may subtract the amount of his own
hypermetropia or myopia from the glass with which
he sees clearly the patient's discs. Thus, if the
observer have 2 D. of hypermetropia and require +3
D. to see the fundus clearly, ( + 3 D.) - ( + 2 D.) =
-I- 1 D., the patient would have 1 D. of hypermetropia.
Had he required -2D. then (— 2 D.) - ( + 2D.) =:
( — 4D.) the observed would have 4 D. of myopia.
The same with the myopic observer; if his myopia
amount to 3 D., then he will require — 3 D. to see
68 THE OPHTHALMOSCOPE
clearly tlio emmetropic fundus ; if he sees well with-
out a glass, then the eye under examination has 3 D.
of hypermetropia ; if he require a + 2 D., then the
hj^permetropia will be 5 D., and so on.
Retinoscopy
Retinoscopy, or the shadow test, may conclude our
ophthalmoscopic examination ; this is especially neces-
sary when the vision has been found defective, and
nothing has been detected by the indirect and direct
methods.
Retinoscopy is carried out by means of the large
concave mirror used in the indirect method, or by a
plane mirror ; the following description refers to the
method carried out with the concave mirror.
The light is placed over the patient's head, and the
observer sitting at one and a quarter metres away,
reflects the light into the eye he wishes to examine ; the
converging rays of light reflected from the mirror
focus in front of it, cross and diverge. Some of these
rays passing through the pupil of the eye under
observation, form a cone of light, which in the case of
emmetropia would come to an exact focus on the
retina.
When the observer looks through the sight-hole
of the mirror, he will obtain the ordinary red fundus
reflex ; on slightly rotating the mirror the illuminated
area of the pupil may disappear (or, what may be
more easily seen, the edge of the shadow bounding
KETINOSCOPY
69
tliis illiuuinated area may appear) on tlio same .side
as the rotation or in the opposite direction, according
to the refraction of the eye under observation ; thus
if the mirror be rotated to the right and the edge of
the shadow move across the pupil also to the right,
i. e. in the same direction as the rotation of the mirror,
the case is one of myopia, whereas if the shadow had
moved in the opposite direction to the mirror, the case
would be one of hypermetropia.
If we place before a screen a convex lens, at such
a distance from it that converging rays from a con-
cave mirror, having crossed and become divergent,
are brought to an exact focus, a small, erect, well-
defined image will be formed on the screen of the lamp
from which the concave mirror received its rays ;
erect, because it has suffered two inversions.
Fig. 54.
a. The concave mirror, h. The candle, c. The lens. tf. The
screen, d. Small image of candle formed on tl>c screen.
f. Dense shadow around.
This image of the lamp is surrounded by a sharply
defined and dark shadow.
If we move the lens nearer to, or further from, the
70 TFIE OrFITlTALMOSCOPE
screeu, a circle of diffusion and not an accurate image
is formed, as shown in Fig. 55.
Fig. 55.
At e a suiiill image of the candle is formed; at d and/", circles
of diffusion.
The mirror being rotated on its vertical axis, the
imnge of the candle, with the surrounding shadow,
will always be found to move in the opposite direction
to the mirror, whatever be the distance of the lens
from the screen.
Fig. 56.
31. The mirror, ai'. The mirror after rotation. The ex-
tremities of the dotted line have moved iu the opposite
direction to the rotation of the mirror.
This is exactly what takes place in the eye, of which
our screen and lens are a representation.
Therefore the illumination and shadows which we
RETINOSCOPY 71
see iu retinoscopy are the enlarged image of the lamp
with the surrounding shadow, brought more or less
to a focus on the retina according to the refraction of
the eye. They always move against the mirror, but
as these movements are seen through the transparent
media of the eye, and thereby undergo refraction, the
" apparent " may differ from the "real '* movements.
The image we see of the lamp, and its surrounding
shadows, are formed in the same manner as all other
images.
In emmetropia the image is formed at infinity; and
therefore, at a distance from the eye, the observer
sees only a diffused and blurred image (Fig. 34).
In hypermetropia the final image of the candle and
its surrounding shadow, produced by the concave
mirror, is an erect one formed behind the e^^e, and as
it is viewed through the dioptric system of the eye, it
therefore moves against the mirror (Fig. 35).
In myopia the final image is an inverted one, pro-
jected forwards. This, therefore, moves with the
mirror, it having undergone one more inversion
(Fig. 30).
Therefore, if the image move with the mirror, the
case is certainly one of myopia. If it move against
the mirror, it is most likely one of hypermetropia ;
but it may be emmetropia, or a low degree of myopia.
The movements tell us the form of ametropia we
have to deal with. The extent of the movements on
rotation of the mirror, the clearness of the image and
the brightiiess of its edge, enable us to judge approxi-
mately the amount of ametropia to be corrected ;
72
THE OPHTHALMOSCOPE
some practice, liowcver, is required befoie we can
form au opinion with anything like accuracy.
The extent and rate of movement is always in
inverse proportion to the ametropia ; the greater the
error of refraction, the less the movement and the
slower does it take place. This may be explained in
the following way :
Suppose A to be the image of a luminous point
formed on the retina, and that a line be drawn from A
througli the nodal point B to c. Now, if the case be
one of myopia (Fig. 57), an inverted projected image
Fio. 57.
of A is formed somewhere on this line, say at c. The
higher the myopia, the nearer to the nodal point will
this image be; and hence we may suppose it formed
as near as d. If the mirror be now rotated, so that it
takes up the position of the dotted line m', c will have
moved to c, and J) to d ; hence it is clear that c has
made a greater movement than d.
Had the case been one of hypermetropia (Fig. 58),
the image would have been projected backwards, and
as in myopia, the higher the degree of hypermetropia,
the nearer to the nodal point is the image formed.
KETINOSCOPY
73
In this case, the line from the nodal point b to A is
prolonged backwards, and the image of the luminous
point in a low degree of hypermetropia is formed,
say at c, and in a higher degree, say at i). On moving
the mirror into the position of the dotted line m', c
moves to c and b to d ; whence it is clear that c has
made a greater movement than D.
Fig. 58.
Therefore, as the ametropia increases, the extent of
the movement of the imaofe decreases. The clearness
of the image and the brightness of its edge decrease
as the ametropia increases.
It was shown in Fig. 55, that on placing before a
screen a convex lens at such a distance that converg-
ing rays from a concave mirror cross and become
divergent, they are brought to an exact focus, forming
a small, erect, well-defined image on the screen of the
lamp from which the concave mirror received its rays.
On moving the lens nearer to or further from the
screen, the larger becomes the area of light, and the
feebler the illumination, owing to the circles of diffu-
sion formed on the screen.
Therefore, in the case of the eye, the greater the
74 THE Ol'HTHALMOSCOrE
ametropia, the larger is the circle of diffusion and the
weaker the illumination, so that the image we see is
less bright and its edge less distinct.
It is, therefore, in the lower degrees of ametropia
that we get the brightest and best-defined shadows;
and when we thus see them, we may assume that we
are approaching the stage of correction.
The patient, then, being seated in the dark room,
the pupils dilated, and the lamp over his head, as
before described, we take up our position 120 cm.
in front, with a concave mirror of 25 cm. focus. The
patient is then directed to look at the centre of the
mirror, so that the light from the lamp may be re-
flected along the visual axis. On looking through the
perforation of the mirror, we get the ordinary fundus
reflex, bright if the patient be emmetropic, less so if
he be ametropic ; and the greater the ametropia, the
less bright will the fundus reflex be. We now rotate
the mirror on its vertical axis to the right. If a vertical
shadow come across the pupil from the patient's right,
i. e. in the same direction as the movement of the
mirror, or what is the same thing, if the shadow move
in the same direction as the circle of light on the
patient's face^ the case is one of myopia. Should
the edge of the image appear well defined and move
quickly, in addition to a bright fundus reflex, we
infer that the myopia is of low degree and proceed to
correct it.
Each eye must of course be tried separately.
The patient having put on a pair of trial spectacle-
frames, we place a weak concave glass, say —ID.
RETINOSCOPY 75
before the eye we are about to correct. If the image
still move with the mirror, we place in the frame
— TS D, then —2 D., and so on, until we find the
point at which no distinct shadow can be seen. Sup-
posing this to be —2 D. and that on trying — 2'5 D.
the image move against the mirror, — 2 D. is assumed
to be the correcting-glass. This, however, will be
found not to be the full correction of the myopia,
because, being situated at 120 cm. from the patient,
when his far point approaches that distance, we are
unable to distinguish the movements of the shadow ;
and when the far point of the observed, though not
situated at infinity, is still at a greater distance
than the observer, we get a shadow moving in the
opposite direction. Hence it is customary in cases of
myopia to add on —'5 U. to the correcting-glass, aud
this would give us —2-5 D. as the proper glass for
our case.
In correcting myopia, it is a convenient and reli-
able plan to stop at the weakest concave glass which
makes the image move against the mirror^ and put
that down as the correcting-glass.
When the myopia is of high degree, and a strong
concave glass has to be used for its correction, the
light reflected from the mirror is so spread out by the
concave ghiss, that fewer rays pass into the eye, and
therefore the illumination is not so good as in other
states of refraction.
Had we obtained a reverse sliaduw, we should then
try convex glasses, when, if -f *5 D. neutralised it, we
should assume the case to have been one oi low
70 TIIK Ol'irrilALMOSCOI'K
myopia. Had it required + 1 D. then it would be cue
of emmetropia ; above this, bypermetropia. We pro-
ceed exactly as before, putting up stronger and
stronger glasses, until we are unable to make out the
movements of the image. This is assumed to be the
correcting-glass, and just as in the above case the
myopia was under-corrected, so in this, the byperme-
tropia is slightly over-corrected ; and hence it is usual
to deduct from this glass + 1 D., or we may stop at
the strongest convex glass with which we still get a
reverse shadow.
To sum up, therefore, if the shadow move with the
mirror, it is a case of " myopia ; ^^ if against, it may be
weak myopia if +*5 D. cause tlie image to move with
the mirror ; emmetropia if + 1 D. neutralise it ;
bypermetropia if a stronger glass is required.
The points to be observed are — (1) the direction of
the movement of the image, as indicating the kind of
ametropia; (2) the rate and amount of movement, (3)
the brightness of the edge of the image, and (4) the
amount of fundus reflex ; all indicate the degree of
ametropia.
We have taken notice only of the horizontal axis,
but any other meridian will, of course, do equally
well, if the case be one of bypermetropia or myopia
simply. If, however, the case be one of astigmatism,
then the refraction of the two chief meridians will
differ.
In astigmatism, the diffusion patch on the retina is
more or less of an oval, instead of being cither a
small well-defined image of the candle, or a circle,
RETINOSCOPY 77
according to whether the eye be emmetropic, myopic,
or hypermetropic. This oval may have its edges
horizontal and vertical ; frequently, however, they
are more or less oblique.
The oblique movements of the shadow are inde-
pendent of the direction in which the mirror is
rotated.
This obliquity is produced thus : (Fig. 59) if
behind a circular opening, which is to represent the
pupil, we place obliquely an oval piece of card, which
is to represent the image on the retina ; on moving
the card across in the direction o d, it has the appear-
ance of moving in the direction o c, at right angles to
the edge of the card. Hence the direction of the
shadow's movement is deceiving, and its oblique edge
is due to the fact that only that edge which coincides
in direction with one of the principal meridians is
seen well defined by the observer. Therefore the
Fig. 59.
apparent movements are always at right angles to the
edgfe of the shadow.
The same takes place in astigmatism, the two chief
meridians of which are parallel and perpendicular to
78 THE OPHTHALMOSCOPE
the shadows in retinoscopy ; therefore when the edge
of the image is oblique, we know at once that the
case is one of astigmatism. If, however, it should
be liorizontal or vertical, we judge if one shadow be
more distinct or quicker in its movements than the
other, though we are not always able to say at once
that astigQiatism exists. We therefore proceed to
correct one meridian. If the shadow move against
in all meridians, we first take the vertical, and put
up in front of the patient, in a spectacle-frame,
convex spherical glasses, until we find the strongest
with which the shadow still moves against the mirror.
We put this down as the correcting-glass for the
vertical meridian, and let us suppose that glass to be
-f 2 D. We next take notice of the horizontal meri-
dian, and if -f-2D. is also the highest glass with which
we still get a reverse shadow, then, of course, we know
the case is one of siuiple hypermetropia. But sup-
posing the highest convex glass had been + 4 D., we
indicate it conveniently thus :
+ 2 D.
+ 4D.
The case is one of compound hypermetropic astigma-
tism, and will require for its correction + 2 D.
sphere combined with -f 2 D. cylinder axis vertical.
We will take another case — that in which the
vertical meridian requires —2D. to give a reverse
shadow, and the horizontal + 2 D., this being the
highest glass with which we still obtain a reverse
shadow. Here we have a case of mixed astigmatism
RETINOSCOPY 79
which can be corrected by a +2 D. sphere combined
with — 4 D. cylinder axis horizontal.
Supposing the axis of the shadow to be oblique, we
know at once that astigmatism exists, and we proceed
to correct each meridian separately, moving the mirror
at right angles to the edge of the shadow, not hori-
zontally and vertically. We judge of the amount of
obliquity by the eye, and can frequently tell within
a few degrees. If the vertical meridian be 20° out,
and require for its correction —2 D., and the axis at
right angles to this (which will be therefore at 110°)
require — 3D., we express it as in Fig. GO, and correct
it with sphere —2D. combined with cylinder — ID.
axis 20°, the case being one of compound myopic
astigmatism.
Fig. 60.
Often one is able to put up the cylinder in the
spectacle-frame with the exact degree of obliquity.
Having found the glasses which correct the two
meridians, we put up the combination in a spectacle
trial frame, and if we now get only a slightly reversed
shadow in every direction, the glasses are assumed to
be the right ones, and we proceed to confirm it by
80 THE OPHTHALMOSCOPE
tryinpf the patient at the distant test typo, making any
slight alterations that may be required.
In most cases it is necessary to dilate the pupils for
retinoscopy, the refraction at the macula can then be
obtained ; without a mydriatic one would only be
able to estimate the refraction at the disc.
When the plane mirror is used for retinoscopy, then
the movements of the shadow are the reverse of those
obtained with the concave mirror.
ArPEARANCES OF THE NORMAL FUNDUS 81
CHAPTER IV
THE APPEARANCES OF THE NORMAL FUNDUS
It is essential that the learner should become
familiar with the different varieties of the normal
fundus before passing on to the various pathological
conditions. The beginner may thiuk this a very easy
matter, but he will soon discover that it is far
from being so ; for instance, in cases of slight indis-
tinctness of tlie margin of the disc, it may sometimes
be exceedingly difficult for even the most experienced
and skilful ophthalmoscopist to know exactly when
this slight blurring has passed the border line of
health and become pathological.
As the complexion and the colour of the hair varies
greatly in the human race, it is not to be wondered
at, that the colour and appearance of the back of the
eye, which depend in great measure on the amount
of pigment contained in the tissues, should also show
great variations. Plates I and II are intended to
illustrate some of the types of the normal fundus ;
and when we consider that no distinct line separates
these different varieties, but that one type passes
imperceptibly into another, it will be realised what
great differences may be met with.
6
82 THE OrHTHALMOSCOl'E
Tlieso variations depend in great measure upon
tlie auiouut of pigment eontained in the hexagonal
cells of the epithelial layer of the retina, and upon
the stellate pigment present in the tissue of the
choroid.
The pigmentation varies greatly in different people,
as a rule the lighter the complexion the less pigment
is found in the retina and choroid; the albino may
be taken as the specimen at one end of the scale, in
which the least pigment is found, while the negro
represents the other end of the scale,, in which there
is the greatest amount" of pigment. Plate I, fig. 2,
represents the right fundus of an albino, as seen by
the indirect examination; Plate II, fig. 1, the left
eye of a very dark English child, seen by the direct
method.
The ordinary red fundus reflex is due to the highly
vascular choroid, modified more or less according to
the amount of pigment present; the colour and
amount of light used will also have much influence
on it ; and some variations will be found in different
parts of the same eye ; thus the macula region is
somewhat darker than the rest of the fundus, shading
off gradually into the colour of the other parts. The
periphery is usually lighter and may possibly show
some of the details of the deeper parts of the choroid ;
the colour immediately round the disc may also be
somewhat lighter than the general tint of the fundus.
The retina. — The retina is a membrane of consider-
able thickness, being "4 mm. at its posterior and
thickest part, where it is four times as thick as the
PLATE I.
Fig. 1. — Fundus of a child aged 10 years; of medium complexion,
light brown hair, grey irides, fair skin. Erect image. Left eye.
The disc is not so shsirply defined as in many cases ; there is slight
pigmentation of the outer edge of the disc, \vhich indicates the edge
of the choroidal ring, and may be looked upon as physiological. There
is no physiological cup.
Fig. 2. — Fundus of an albino aged 24; white hair, eyebrows, and
eyelashes; irides light grey and translucent. Inverted image. Right
eye.
The absence of pigment is here well shown, each vessel of the deep
layer of the choroid can be seen. The disc appears darker than
normal, in contrast with the lightness of the rest of the fundus. The
light-coloured interspaces between the choroidal vessels are due to
the white of the sclerotic. On the outer side of the disc is a slight
crescent, caused by the choroidal opening being rather larger than the
sclerotic ring, so that a small portion of the sclerotic is here exposed.
Plate!.
A. W Head del.
Bale <V Dante Issan, Ltd.
PI ate II.
iz.e&Ci
Bale &" Danielsson, Ltd.
PLATE II.
Fig. 1.— Fumlus of a very dark child aged 10; skin dark, hair
black, eyebrows and eyelashes black ; irides dark brown. Erect image.
Left eye.
The striation around the disc is unusually distinct. The stippling
of the lamina cribrosa can be seen in the centre of the disc.
Fig. 2. — Right fundus of a child aged 10 years ; hair dark brown,
eyebrows brown, eyelashes black ; irides dark brown. Inverted image.
The tissue of the choroid contains a large quantity of very dark
pigment, which causes the interspaces between the choroidal vessels
to appear very dark — much darker than the vessels themselves. The
pigment in the epithelial layer of the retina must be of a lighter
colour than usual, to allow one to see through it on to the deeper layers
of the choroid. There is a well-marked physiological cup present.
The halo around the macula is due to reflection.
APPEARANCES OP THE NORMAL FUNDUS 83
choroid. At the macula^ its thinnest part, it is only
•1 mm. thick. The retina anterior to its epithelial
layer is transparent : this is necessarily the case^ since
it is so constructed, that rays of light entering the
eye have to pass through to its deeper parts in order
to reach the layer of rods and cones on which images
must be formed. In dark-complexioned persons a
sort of shimmer or bloom may be sometimes detected,
especially in the region of the macula ; occasionally a
striated appearance is visible at the upper and lower
margins of the disc, spreading a considerable way
over the retina. This is due to the nerve-fibres beiup*
slightly visible over the part where they are thickest,
and is best seen in young hypermetropic children.
The case from which Fig. 1, Plate II, was drawn,
afforded a good example of this striation. But,
speaking generally, the retina^ except for its large
vessels, is transparent, so that in most medium or
dark complexioned people one looks with the oph-
thalmoscope through the retina on to the retinal
epithelium, which, if fairly pigmented, allows the
red of the choroid to sliiue through, but effectually
hides any of the vessels or details, so that one gets
a uniform red reflex, often having a slightly granular
appearance when viewed by the direct method,
due to the pigment contained in the epithelial
layer ; this is, perhaps, the commonest type of the
normal fundus, and is shown in Fig. 1, Plate I.
When the epithelial layer contains but little pigment
or pigment of a light colour, as in fair people, then
we can see through this layer more or less of the
84 THE OrilTHALMOSCOPE
details of the choroid ; tlio cjipillaries of the chorio-
capilliiris are too small to be seen, but the large
choroidal vessels may be fairly distinct, having be-
tween them small islands of tissue, which may be
lighter than the vessels themselves in very fair indi-
viduals, where very little pigmeni} is present in the
connective tissue of the choroid (a very striking
example of this condition is seen in the albino Fig. 2,
Plate I) ; or the interspaces may be darker than the
vessels, when a good deal of pigment is present. Fig.
2, Plate II : these interspaces are small, triangular,
or irregular in shape about tlie disc ; more elongated
in the periphery. The details of the choroid are
often best seen in the peripher}^, sometimes only
there. Thus there are three distinct types of the
normal fundus.
1. The fundus having a slightly granular appear-
ance, with no choroidal details visible. Met with
chiefly in people of dark complexions, Fig. 1, Plate I,
and Fig 1, Plate II.
2. The fundus, in which the large choroidal vessels
are seen with lighter coloured interspaces ; light
complexioned people, Fig. 2, Plate I.
3. The fundus, in which the large choroidal vessels
appear with dark coloured interspaces; this is some-
times known under the name of " clioroid tigre,'^
and is found in people with medium complexions.
Fig. 2, Plate II, is intended to represent this con-
dition.
Though these are the three chief types of the
normal fundus, it will be understood that one variety
APPEARANCES OF THE NORMAL FUNDUS 85
gradually merges into the next, so that every possible
variation may be met with.
In old persons the epithelial layer may become
deprived of its pigment, and so allow the deeper
parts of the choroid to come into view.
It must be remembered that the arteries and veins
of the choroid cannot be distinguished from each
other by the ophthalmoscope.
The macula lutea, which is the part of most distinct
vision, is free from any visible vessels, nevertheless it
is exceedingly vascular, the capillary meshes being
much closer together than in any other part, except
at the fovea centralis, where they are absent. The
macula is situated about 2 mm. on the temporal side
of the disc and 1 mm. lower; it is directly in the line
of vision, and is slightly larger than the disc, being in
shape an ill-defined oval with its long diameter hori-
zontal ; the colour is darker than the rest of the fundus,
and shades off gradually into the general orange red
colour. Its centre is marked by a depressed whitish
pink spot, ilie fovea centralis. The macula is some-
times surrounded by a sort of ring or halo, which is
due to reflection from the sloping edge of the depres-
sion ; this halo is often seen in dark children with the
indirect method, and is shown in Plate II, fig. 2. It
requires some practice before this region can be satis-
factorily exatnined. The macula never appears yellow
with the ophthalmoscope.
Sometimes a good deal of reflex takes place from
other parts of the retina, and is spoken of as a
'^ watered silk " appearance ; this reflection takes place
86 THE OPHTrTALMOSCOPE
from the superficial part of the retina, and shows a ten-
dency to run along and over the vessels, shifting with
every movement of the mirror ; it is best seen in dark
hypermetropic children, and is rare after the age of
twenty. The exact cause of this retinal reflex is not
known, but it has been suggested that it may be due to
minute parallel striations of the cells of the ganglion
layer of the retina.
The optic disc or papilla is the iutra-ocular end of
the optic nerve, and consists of nerve-fibres which
spread out to form the retina, together with a certain
amount of connective tissue, and the central artery
and vein of the retina. It is situated a little to the
nasal side of the posterior pole of the eye, being a
little raised, and usually circular or slightly oval in
shape, with its long axis nearly vertical ; its real size
is about 1*75 mm., sometimes one side is slightly flat-
tened. The anatomically oval disc must not be con-
founded with the oval, due to astigmatism ; the
diagnosis between the two can easily be made, when
using the indirect method, the anatomically oval disc
will not alter its shape as the objective is gradually
withdrawn, while the astigmatic oval will undergo
considerable change in its shape as the convex glass
is moved away from the eye.
The colour of the disc varies much from the rest of
the fundus, being considerably lighter ; it also varies
at different periods of life, being rather paler in
old people. The colour of the disc is due to the
combined effect of the nerve-fibres, the blood-vessels,
and the connective tissue, the result being a pinkish
APPEARANCES OP THE NORMAL FUNDUS 87
rose tint ; considerable variations of colour are found
in different parts of the disc ; thus the pinkish colour
is often most pronounced on the nasal side, while the
whitest part of the disc is often its centre aud towards
the temporal side ; in many cases the nerve-fibres
separate immediately after perforating the lamina
cribrosa, leaving a conical depression between them,
at the bottom of which is seen the white stippling of
this lamina ; this pit is known as the ^''physiological
cuj).^' This cup may vary much in size and shape,
but alwa3\s has the one characteristic, that it never
involves the whole disc, as is the case with the glau-
coma cup. The physiological is usually a deep
shelving cup, while that due to glaucoma is over-
hanging. When the physiological cup is large and
deep, its nasal side may be steep or even excavated,
but the temporal side has almost invariably a gradual
slope, which may extend in this direction to the
margin of the disc. Frequently a stippling is seen at
the bottom of a deep cup ; this is due to the details
and perforations of the lamina cribrosa being visible.
Fig. 64 represents a deep physiological cup, and should
be compared with the figures illustrating the other
two varieties of cupping. Figs. 65 and 66.
The disc usually has a well-defined margin with
some traces of pigment ; this is known as the choroidal
ring, and is well shown in Fig. 61 {a) ; though spoken
of as an opening, it is not so in the true sense of the
word, since fibres pass into the nerve on all sides,
and cases occasionally occur in which the choroidal
tissue can be traced for some distance on to the face
88 THE OPHTHALMOSCOPE
of the nerve ; the edge of the choroidal opening is
often slightly larger than the corresponding opening
in the sclerotic, and when this is so, a small rim of this
coat ma}^ be visible just within the choroidal ring ; this
is called the sclerotic or connective-tissue ring (h). The
sclerotic ring is often partially hidden by the slight
expansion of the optic nerve, after passing through
the lamina cribrosa, though usually a trace of it can
be seen on the outer side ; so that we have from within
outwards ; (1) a white central depression, the physio-
logical cup ; (2) surrounded by a zone of a pinkish
colour, most marked usually on the nasal side : this
zone is composed chiefly of nerve-fibres and their
capillaries ; (3) outside this is a well-defined white
margin, the sclerotic ring, and, finally, (4) the slightly
pigmented margin of the choroidal ring. Great varia-
tion will be met with in different subjects ; the discs
on the two sides should always be compared. The
colour of the different parts of the disc can be best
appreciated by the direct examination, and by using
only a moderate illumination. The edges of the disc
should be clearly defined ; sometimes the upper and
lower margins are less distinct than the sides ; this
may be due to the nerve-fibres being thickest over
these parts ; this condition is most frequently met
with in cases of hypermetropia, being then due to an
excess of connective tissue about the disc and around
the vessels.
Fig. Gl is a diagrammatical representation of the
optic disc ; the choroidal and sclerotic rings are
seldom seen in the complete form as here represented,
APPEARANCES OF THE NORMAL FUNDUS
89
but it is necessary the student sliould be acquainted
with them and know how they are formed ; {a) cho-
roidal ring, (h) sclerotic ring, (c) physiological cup.
(d) The retina, (e) the choroid, (/) the sclerotic, (r)
the central vessels.
The central artery and vein of the retina are seen
issuiug from near the centre of the disc, usually a
little to the nasal side, the artery being on the inside,
the vein on the outside ; they spread out in the
nerve-fibre layers of the retina, so that when seen in a
microscopical section, they project above the surface
of this membrane. The retinal vessels are exceedingl}"
small, although, with the direct method, they give one
the idea of being of fair size ; the main divisions of the
retinal artery may be about '4 mm. in diameter, while
90 THE OPnTFTALMOSCOPE
the smallest visible vessels will be about 'OG mm.;
the capillaries being considerably smaller than this,
are necessarily invisible.
The arteries may be distinguished from the veins
(a) by their colour, {h) by their size, and (c) by their
general appearance. The vessels are really trans-
parent oval tubes, so that it would be more correct to
speak of the blood column contained in them.
The arteries are bright red in colour, about one
third smaller than the corresponding veins ; they
cross over the veins, and have a marked white central
streak. There is some difference of opinion as to the
cause of this white streak ; some observers consider
it is due to reflection from the column of blood, while
others think it is due to the refraction of the ravs of
light passing through the vessels and reflected back.
The veins are darker in colour, larger, and pass
under the arteries, the central white streak is less
marked and less regular than in the arteries ; fre-
quently pulsation may be seen in the veins, or can
be easil}^ produced by very slight pressure on the
eyeball.
The main central artery often divides just before
emerging from the disc into two branches, a superior
and inferior, these again divide into temporal and
nasal branches, other branches are given off dichoto-
mously ; sometimes the main artery divides on the
disc itself. As one would expect, the distribution
varies much in different persons, though there is fre-
quently great similarity in the circulation of the two
eyes. A separate artery is often found on the outer
APPEARANCES OP THE NORMAL FUNDUS 91
side of the disc curving outwards on to the retina,
and fulfilling the functions of a retinal artery ; this is
usually a branch of one of the posterior ciliary arteries,
and is known as a nlio-retinal vessel.
92 TFTR OPHTHALMOSCOPE
CHAPTER V
CORNEA — ANTERIOR CHAMBER — IRIS — LENS
I HAVE no intention to enter into a discussion on
the various diseases which affect the different struc-
tures of the eye, but it may be well to refer briefly
to the methods recommended for the examination of
each part in a systematic manner, while at the same
time the ophthalmoscopic appearances indicative of
disease of the various tissues of the eyeball may be
shortly described.
The cornea. — The cornea is the most important ex-
ternal part of the eye, and its prominent position
renders it especially liable to accident : the chief
pathological conditions from which this tissue may
suffer usually produce some alteration in its curvature
or some loss of transparency ; these changes are
almost invariably accompanied with a diminution of
vision, together with other symptoms.
The focal illumination is of tlie greatest value in
the examination of the cornea, — with it, everything will
be seen in its true position and of its proper colour ;
foreign bodies such as chips of metal, particles of coal,
&c., frequently become embedded in this tissue and
THE CORNEA 93
may easily escape detection when small, unless great
care is exercised; nebula3, irregularities, ulcers of
various kinds, — opaque, transparent, shallow, deep,
&c., — are very frequently met with. The curvature
of the cornea, may be mucli altered, as in conical
cornea ; this will best be seen in profile. Vessels may
be found on tlie surface as in panuus or phlyctenular
keratitis, or in the tissue of the cornea itself as in
interstitial keratitis (in this condition it is not possible
to distinguish the separate vessels, which are often
closely grouped together, forming what is known as a
"salmon patch ^'). Keratitis punctata may also be
detected by focal illumination; it consists of small
particles of lymph deposited on the posterior part of
the cornea, these small dots increase somewhat in
size by proliferation of the epithelium ; frequently the
spots are arranged in the shape of a pyramid, with
the apex to tlie centre of the cornea and the base
downwards. The focal illumination may frequently
be supplemented with advantage by the high magni-
fying glass (Fig. 33).
This examination having been extended to the ante-
rior chamber, iris, and lens, the large concave mirror
is next taken up, and light reflected into the eye from
a distance of half a metre; corneal opacities will now
appear as black spots in the red of the fundus, due
to the interruption of the returning rays of light
from the back of the eyeball. In conical cornea a
central illumination will be seen with the mirror,
surrounded by a dark, circular shadow, corresponding
to the base of the cone. On moving a little further
94 THE OPHTHALMOSCOPE
back, so as to use retinoscopy, tlie shadow will be
found to liavo a circular nioveniont. Finally the
corneal examination may be completed by using the
direct method, having behind the sight-hole of the
ophthalmoscope + 20 D. and approaching close to the
patient. By this means the various opacities may be
seen in detail. vSometimes a number of line arbo-
rescent lines may be detected; these are the trans-
parent remains of vessels which are left as permanent
evidence of previous keratitis.
Aqueous chamber and iris. — In some cases with the
oblique illumination the contents of the aqueous
chamber may be seen to be muddy; this is due to
inflammatory material poured out in iritis or cyclitis ;
here the apparent colour of the iris may be altered,
or the contents of the aqueous chamber being quite
transparent, the surface of the iris may be seen to be
dull, discoloured, and indistinct, the result of inflam-
matory exudation into its tissue ; sometimes the exuda-
tion forms a distinct gumma. Blood may be found in
the lower part of the anterior chamber and is spoken
of as hyjyhsema, it is usually due to a blow or iritis ; a
collection of leucocytes may also take place, forming
hyjpojoyon, the cause of which may be iritis or a spread-
ing corneal ulcer. When perforation of the cornea
has taken place, adhesions between the cornea and iris
may form [anterior tsynechiai) . Points of adhesion be-
tween the iris and lens may be detected (posterior
synechias). Sometimes one or two fibres may be seen
crossing the anterior chamber from one point of the
iris to another ; these fibres arise not from the extreme
TEE LENS
95
pupillary edge, but from the junction of the radiating
and circular fibres ; these fibres are the remains of the
pupillary membrane which existed during intra-
uterine life. Perforation of the iris from a penetrat-
ing wound may be readily detected with the oblique
illumination, and with the mirror the red reflex will
be seen through the opening, in these cases the lens
is usually wounded and soon becomes opaque; the
iris may have become more or less detached from its
ciliary border {irldodialy^in), as the result of a violent
blow. Atrophy of the iris and growths of the iris or
ciliary body may also be conveniently examined by
these means ; finally, the iris may be examined with
the ophthalmoscope, having a +10 D. behind the
sight-hole. Foreign bodies may occasionally be de-
tected in the anterior chamber, and now and then a
cilium is carried into this chamber by a perforating
body.
The lens. — To examine the lens thoroughly, the pupil
must first be dilated with homatropine and cocaine
(p. 32). The examination should be commenced with
the focal illumination ; and here a word of warning is
necessary — do not be too hasty to assume that the
lens is becoming opaque. This mistake is very
liable to be made by the inexperienced, especially
when light from a window is concentrated on the eye
with the biconvex lens. The reason of this apparent
opacity is, that as nge advances, the lens becomes
harder, so that a good deal of reflection takes place
from the anterior surface of the lens, and gives some-
what the appearance of diffuse opacity.
96 THE OPUTHALMOSCOPE
With the oblique illuniiuation opacities of the lens
appear in their true colour, spots of pigment may be
detected on the anterior capsule, and are evidence of
previous iritis; the iris has been adherent to the lens
at these points, and when the synechiaa was torn away
by a mydriatic the pigment was left attached to the
lens ; pigment in this position may increase by proli-
feration.
Anterior polar and pyramidal cataract may easily
be detected; the latter variety is usually due to the
cornea having been in contact with the lens owing to
perforation having taken place during an attack of
infantile purulent ophthalmia, a nebula may often be
seen in the cornea at the point where perforation took
place; anterior polar cataract may occasionally be
connected with the remains of the pupillary membrane.
Cortical, central, and posterior polar opacities may
also be seen, but when examining the latter the light
must be directed into the eye almost at right angles to
the cornea. Posterior polar cataract is frequently con-
genital, and may be connected with the remains of the
hyaloid artery ; at other times it may be secondary
to disease of the fundus, such as retinitis pigmentosa,
&c. Lamellar is a variety of cataract which is usually
congenital, and consists of a layer of opaque lens sub-
stance included between a clear nucleus and cortex.
This can be well examined by focal illumination
through a well dilated pupil.
The examination by focal illumination being com-
pleted, the ophthalmoscope mirror is next taken up,
and affords us valuable information as to the amount
THE LENS
97
of opacity present ; the opacities in this method of
examination show up as black spots, patches, or stria?,
against the ordinary red of the fundus, the return-
ing rays of light being interrupted by the opaque
portions of the lens. In lamellar cataract the opacity
will appear denser at the margin of the opaque portion
than it does in the centre. Finally the lens may be
inspected with the direct method, having a -f 16 D.
behind the sight-hole of the instrument.
Sometimes it is difficult by focal illumination to
make out the exact position of a fixed opacity in the
anterior part of the eyeball ; we may then employ the
concave mirror and notice the displacement which the
opacity makes with regard to the pupil when we move
our head slowly from one side to the other. Thus
Fig. 62.
supposing, as in Fig. 62, we have three opacities all
situated on the optic axis, A an opacity on the cornea,
B one on the anterior surface of the lens, and c one at
the posterior pole, then it is clear that the observer
looking along the optic axis will see these spots exactly
7
98 THE OPHTHALMOSCOPE
in the centre of the pupil, as at 1. If the observer
now move his eye from 1 to 2, the position of the
points with relation to the pupil will have changed^
opacity A will have moved towards the upper margin
of the pupil, opacity b will still be in the centre,
while opacity c will be nearer the lower edge of the
pupil.
Therefore we may state the following rule, that if
we look into the eye from directly in front, and the
opacity remains stationary when we move our head
to one side (the patient's eye being fixed), then we
know the opacity must be in the same plane as the iris,
probably the anterior surface of the lens ; had it been
on the cornea, then it would appear to move in the
opposite direction to the movement of the head ; had
it been at the posterior pole, then it would appear to
move in the same direction as the observer's head.
The quicker the movement that takes place, the further
is the opacity from the plane of the iris.
THE VITREOUS *^ 99
%
t
CHAPTEE YI
THE VITREOUS
The two chief indications of disease of the vitreous
are loss of trans'parenQXj and diminished consistency.
The focal illumination is sometimes useful in detect-
ing disease in the anterior part of the vitreous, but to
use this method to the best advantage it is necessary
to dilate the pupil and to place the light in front of
the patient, so that the rays may be concentrated on
the part we wish to examine, almost at right angles
to the cornea (Fig. 32). In this way blood, Inrge
vitreous opacities, or even the crystals of cholesterine
in sparkling synchysis maybe detected when near the
posterior surface of the lens ; a growth or a detached
retina projecting a long way forward may occasion-
ally be seen. This method of examination has the
distinct advantage of allowing things to be seen in
their proper colour and in their true position ; but,
as a rule, much fuller information will be gained by
the ophthalmoscope mirror, though the examination
of the cornea and lens by the focal illumination
should always extend to the vitreous before taking up
the mirror.
100 THE OTHTHALMOSCOPE
If no fundus reflex is obtained with the concave
mirror at a distance^ "svhen the light is properly
directed into the eye under observation, then the case
is probably one of profuse ha3morrhage into the
vitreous, presupposing, of course, that the cornea,
aqueous, and lens are transparent.
Vitreous opacities when of fair size are readily seen
with the large concave mirror; the patient should
be directed to look quickly upwards, then downwards,
and finally straight in front of him ; this movement
will stir up any opacities which may have gravitated
to the lower part of the vitreous chamber. When the
opacities are very fine and difficult to see, a plane
mirror and a subdued light may be an advantage.
Usually these opacities are floating, moving with
every movement of the eye, and continuing to do so
after the eye has come to rest; but sometimes the opaci-
ties may be fixed. They vary much in shape, size,
and position, sometimes being exceedingly small like
dust, and may require some trouble to detect them ;
at other times they are large and membranous, or in
shreds, or resembling the wings of insects. Their
rate of movement will give us some idea of the con-
sistency of the vitreous : when they move very quickly
the vitreous must be abnormally fluid; should the
opacity float very slowly across the field, then its con-
sistency may not be diminished.
These opacities may be — (1) Inflammatory exuda-
tion from one of the surrounding vascular structures,
as the choroid, or ciliary body. (2) Haemorrhage
from the retina, choroid, or ciliary body. (3) Coagu-
THE VITREOUS 101
latioii of the albuminous eleineuts of the vitreous
itself.
When the opacities are very fine, they may simply
cause a slight blurring of the details of the fundus,
which may easily be mistaken for papillitis. These
very fine opacities should be looked for with the
direct method of examination having a + 8 D. behind
the sight-hole ; they can usually be best seen against
the lighter coloured background of the disc. To
thoroughly examine every part of the vitreous the
observer must vary his distance from the patient as
well as the strength of the lens behind the ophthal-
moscope ; the stronger the lens used the more for-
ward will the vitreous opacity be. Fine opacities
are generally due to the migration of cells accom-
panying the exudation of inflammatory material of a
serous character from some part of the adjacent uveal
tract. When haemorrhage takes place into the vitreous,
or the exudation is rich in fibrin, the opacities are
liable to be large and membranous, and may, if very
numerous, prevent any details of the fundus from
being seen.
Opacities usually appear as black spots, whatever
their real colour may be, owing to the interruption to
the returning light, unless they happen to be partially
transparent, when they Avill appear grey. Sliould
they reflect light from their surface, as do crystals of
cholesterine and tyrosin, then they may spaikle like
particles of gold-leaf. A beautiful illustration of
this condition may be occasionally seen, and goes by
the name of sparkling synch ysia ; it is a degenerative
102
rnE OrilTIIALMOSCOPE
process, usually accompanied by great fluidity of the
vitreous.
In making a diagnosis of opacities in the vitreous,
corneal and lenticular affections should first be ex-
cluded by focal illumination ; the position of any
opacity may be judged of partly by its direction and
amount of movement, and partly also by the convex
glass through which it can best be seen.
To estimate the depth of any fixed opacity, we
illuminate the eye by the concave mirror at a distance ;
then, if the patient be directed to look upward, it will
be obvious that any opacity situated in front of the
point round which the eye turns (a. Fig. 63), will also
move upward, while if the opacity be behind this point,
it will move downward ; and the farther the opacity is
from the point of rotation, the greater will its move-
ment be, and therefore the deeper will be the position
of the body. A glance at the following drawing will
Fig. 63.
make this clear, a is the centre of rotation of the eye,
B is an opacity on the anterior surface of the lens,
THE VITREOUS. 103
which on uiovement of the eye upwards will move
with it to b'; c and d are vitreous opacities, which,
being situated behind A, will move in the opposite
direction to the eye, so that on turning the eye
upwards c will move to c', and D to d'; since d is deeper
than c, D will have made a greater change in its posi-
tion than c.
The real movement, therefore, which fixed opacities
in the media make is with the eye when the opacities
are in front of the centre of rotation, and in the re-
verse direction when behind tliis centre. Some
practice is required to enable one to correctly inter-
pret what is seen, because with an undilated pupil
when a point some distance behind the iris but in
front of the centre of rotation is watched while the
eyeball is moved in different directions, this point may
have the appearance of going against the movement
of the eyeball though really with it ; this is owing to
the greater displacement of the iris, as explained on
page 97.
Foreign bodies, such as chips of metal, may some-
times be seen in the vitreous more or less covered
with lymph according to the time which has elapsed
since the accident. Now and then a few air-bubbles
are carried in with the foreign body, which the ob-
server might easily mistake for the foreign body itself
unless aware of this possibility; air-bubbles are round,
reflect light from their centies, and have dark mar-
gins, whereas the reflex from a foreign body is chiefly
from its edges.
In the case of a perforating wound, a streak of
104 THE OrHTHALMOSCOPE
opacity may be seen extending through the vitreous
along the line taken by the penetrating substance.
I have seen cases where after a puncture of this kind
the vitreous has remained clear for several days, then
gradually an opaque line has formed, become more
marked each day, and leading eventually to shrinking
of the vitreous. Here, probably, some bacilli have
been introduced by tlie perforating body, and finding
the vitreous a suitable medium, have undergone
proliferation and growth.
Occasionally some remains of the hyaloid artery
may be seen floating about in the vitreous, one end
being attached to the disc, while the other end may
or may not be connected with the posterior surface of
the lens.
A rare condition is one in which new vessels may
be formed in the vitreous as a result of inflammation
or large vitreous hasmorrhage ; these vessels are more
or less supported by connective tissue, and when met
with are usually found in cases with a history of
syphilis ; retinitis proliferans is the name given to
this condition.
THE CHOROID 105
CHAPTER VII
THE CHOROID
The important part taken by tlie cboroid in the
ophtlialmoscopic picture of the fundus lias already
been fully described in Chapter IV. Variations from
the normal produced by disease of this structure are
frequently met with, and produce very various and
striking ophthalmoscopic appearances.
These alterations may display themselves as —
1. Changes in colour, pigmentation and level, due
to inflammatory exudation.
2. Atrophic patches and scars, the permanent
results of previous mischief.
3. Haemorrhages from one of the choroidal vessels.
Hyperaemia of the choroid, though probably fre-
quently present, is not recognisable with the ophthal-
moscope.
The choroid, owing to its great vascularity, is espe-
cially prone to inflammation; the term churoidititi
must be accepted in its widest sense, to include not
unly those cases in which the inflammation is in
actual progress, but others in which all inflammatory
symptoms have long subsided, and of which we have
10(3 THK OPHTHALMOSCOPE
puruuineut evidence in the shape of atrophic patches,
and spots variously pigmented, as well as those cases
which from the very first present more of the cha-
racters of an atrophy than an inflammation, as in
senile and myopic choroiditis.
Choroiditis may be divided into —
Plastic,
Suppurative.
Plastic choroiditis commences as an exudation into
the substance of the choroid. The exudations are
cellular in character ; they are generally numerous,
with a tendency to occur in patches or spots scattered
over the fundus. They can be seen with the ophthal-
moscope as pink-yellowish coloured spots, slightly
raised and with soft-looking edges ; they are beneath
the retinal vessels, and may appear in every possible
shape, but most frequently tend to the circular.
In some cases when the deeper part of the choroid
is primarily affected, and where no disturbance of the
retinal hexngonal epithelium has taken place, nothing
may be detected with the ophthalmoscope ; but sooner
or later this layer becomes involved, the epithelium
undergoes atrophy, and the pigment being set free
proliferates and travels forward into the retina,
accumulating there into spots having all the cha-
racteristics of retinal pigmentation, very like retinitis
pigmentosa, which will be referred to on page 122.
When the retinal epithelium is thus involved in the
inflammatory process, the condition may be spoken
of as Ghoroido-retinitis.
When the inflammatory symptoms are marked,
PLATE III.
FiQ., 1.— Choroiditis iu the exudative stage. Some of the patches are
of fair size, others are very small; uo pigmentation hai taken place
when the drawing was made, though it occurred some months later ;
the vitreous was full of fine opacities, which rendered the disc margins
very indistinct. The patient was a man of about 30 years of age, with
a very definite history of syphilis. Both eyes were affected.
Fig. 2. — Disseminated choroiditis in a child of 12, with the facial
characteristics and notched upper incisor teeti of inherited syphilis.
Fia. 3. — Senile chiuiges in an old man : there has been absorption
of the epithelial layer of the retina, witli great thinning of the super-
ficial layers of the choroid ; these changes allow the deeper vessels of the
choroid to be seai in detail. The vessels of this layer have un lergone
considerable sclerosis.
Fia. 4.— Coloboma of the choroid. The disc is very oval horizon-
tally ; the retinal vessels pass over the coloboma without interruption.
Plate III.
Pi^.l,
Pi6 2.
Fi^3
Fi^4.
HaU A^ Danielsson, Ltd.
THE CHOROID 107
vitreous opacities are usually present, and will
more or less veil the appearances of the choroidal
mischief : in some acute cases no details of the
fundus can be made out owing to the number and
density of the vitreous opacities, and it may only
be after these have partially cleared up that the
patches of choroiditis come into view. So that in
all cases of choroiditis, vitreous opacities must be
carefully looked for with the direct method and a
+ 8 D. glass behind the sight-hole of the ophthalmo-
scope, as described on page 101.
As the inflammatory symptoms diminish, the exu-
dation undergoes absorption together with destruc-
tion of the affected portions of the choroid, so that
ultimately a white patch or scar remains, surrounded
or dotted over more or less with pigment, and fre-
quently involving the retina in the cicatrix. The
pigment in many of these cases has two sources : first
and chiefly, the pigment cells contained in the tissue
of the choroid ; second, the pigment which has escaped
from the epithelium. The white patches are the
bare sclerotic, and may be described as patches of
choroidal atrophy. The time occupied from the com-
mencement of the exudative stage of choroiditis to
that of complete atrophy of the patches may extend
over many montlis, or even years; and when it is
reniembered tliat the disease gives no external sign
of its presence, and produces no subjective symptoms
so long as the retina and vitreous are not implicated,
and then makes itself known to the patient only by
the impairment of vision which results, it will not be
108 THE ornTiiALMoscoi'E
surprising that the mischief may have been in progress
a long time before it is detected, so that the ophthal-
moscopic appearance may vary very greatly according
to the stage and extent of the disease. Any part of
the choroid may be the seat of inflammation ; some-
times the periphery is chiefly affected, while in others
the region of the macula is alone involved.
One of the great difficulties that beset the beginner
is to decide whether a patch of exudation is in the
retina or choroid. When a patch of exudation is seen
surrounding or covering up one of the retinal vessels,
then it is certainly in the anterior part of the retina :
as a rule retinal exudations are whiter in colour than
choroidal, and have very soft-looking edges, with little
or no pigmentation. Experience alone can teach us
to arrive at a correct conclusion ; in some cases it is
difficult for the most expert observer to assert posi-
tively the exact situation of a given patch.
In the case of patches of pigment or hasmorrhage
the diagnosis is not so difficult ; retinal pigmentation
and haemorrhages usually have distinct retinal cha-
racteristics, which will be referred to on page 122.
Purulent choroiditis is usually due to septic emboli
in the choroidal vessels, and may sometimes be detected
by focal illumination ; as the purulent exudation
makes its way forward from the back of the fundus
violent inflammatory symptoms set in, the eye becomes
tense, and the cornea hazy^ so that little can be seen.
In young children this condition may run a very
chronic course, when the appearances might be mis-
taken for glioma (see p. 134).
THE CHOROID 109
The clinical varieties of choroiditis usually recog-
nised by the ophthalmoscope are —
Disseminated choroiditis^
Central choroiditis,
Myopic clioroiditisy
Senile choroiditis,
though many cases present mixed characters.
Disseminated choroiditis (Plate III, figs. 1 and 2) is
perhaps the most common variety of the disease, and
commences as a number of small spots or circular
patches of exudation which are scattered over the
fundus, chiefly in the periphery ; as the inflammatory
exudation becomes absorbed, the tissue of the choroid
becomes atrophied and destroyed, leaving circular
patches of bare sclerotic, surrounded more or less by
pigment. These spots of choroidal atrophy frequently
have a shai'ply defined and punched-out appearance,
with pigment surrounding them like a collar : in some
cases no white patches are seen, but spots of pig-
ment surrounded by a lighter margin; at other times
the patches may run together, forming one large
patch.
Usually both eyes are affected, though frequently
the mischief is further advanced in one eye than in
the other. Syphilis, either acquired or inherited, is
almost invariably the cause of this form of choroiditis ;
the only distinction that can be made with the ophthal-
moscope is, that usually there is a greater amount of
pigment present in the inherited form of the disease.
Vitreous opacities are frequently met with during the
exudative stage, and are then generally of a fine dust-
110 THE OPHTHALMOSCOPE
like character, slightly blurring the general details
of the fundus.
The degree of impairment of vision depends chiefly
upon the situation of the patches ; when confined to
the periphery it may be but little affected.
Central choroiditis. — In central choroiditis the mis-
chief is chiefly limited to the yellow-spot region.
There are several varieties of the disease ; in some the
changes are of a gross character, while in others they
are so extremely fine that they can only be seen by
the direct method of examination, and may even
then be easily overlooked unless the greatest care is
exercised.
In a few cases the appearances are such as would
suggest that an inflammatory exudation had taken
place at the macula, that it had afterwards become
absorbed, and with it most of the choroidal tissue in
which it was situated, leaving a considerable interval
between the retina (which in these cases may be
rendered visible by the pigment on its surface) and
the sclerotic : the retina may or may not be perfo-
rated. The ophthalmoscopic evidence of this interval
is supplied by the parallax produced, and by the dif-
ferent lens necessary to focus first the retina and
then the sclerotic.
Patients with central choroiditis often complain that
objects appear distorted (metamorphopsia) ; this is
due to displacement and separation of the cones.
Central vision is usually very defective, and when the
retina is much implicated a positive scotoma results.
Myopic choroiditis. — Choroiditis is exceedingly
THE CHOROID 111
common in high myopia ; besides the congestion and
thinning of the choroid, which takes place with tlie
formation of a large crescent and posterior sta{)hy-
loma, mischief is apt to begin in independent centres,
frequently in or about the macula, and often compli-
cated with choroidal haemorrhages ; the patient
usually complains of great impairment of vision,
together with metamorphopsia and general discomfort
of the eyes.
Senile choroiditis (Plate III, fig. 3) occurs in several
varieties; in one kind the changes are chiefly con-
fined to the superficial layers of the choroid, with
atrophy of the epithelial layer of the retina, affecting
the parts immediately around the disc or extending
over tlie greater part of the fundus. Seen by the
ophthalmoscope the choroidal vessels are unusually
distinct, with thickening of their sheaths ; some of the
epithelial pigment which has been set free may travel
forward into the retina ; the disease is usually sym-
metrical in the two eyes; vision is much reduced,
and is generally worse at night. In another variety
of senile choroiditis a central patch of an irregular or
circular form takes place at the macula of each e\'e,
producing a scotoma ; this variety of the disease
shows but little tendency to spread, so that althouo-ji
central vision is lost, absolute blindness is not to be
feared.
A third form of senile central choroiditis is that
in which a number of very small whitish-yellow spots
may be seen at the macula, with but little or no dis-
turbance of pigment ; they can be detected only by
112 THE OPHTHALMOSCOPE
the direct method of examination. These spots evi-
dently invade the retina, so that central vision is
defective.
Atrophy of the choroid. — One frequently meets with
cases in high myopia, and also in old people as a
senile change, in which the chorio-capillaris together
with the epithelial layer of the retina have undergone
almost complete atrophy, producing a very distinctive
ophthalmoscopic picture, allowing the vessels of the
deep layer of the choroid to come very clearly into
view, somewhat resembling those normal light-
coloured fundi of which the albino is so striking an
example. In the senile condition of atrophy of the
choroid the walls of the large vessels are usually
thickened. In many of these cases the retina would
seem to be included in the atrophic changes leading
to deterioration of vision.
Choroidal haemorrhages are not so frequent as re-
tinal; they are usually large, somewhat irregular, and
of a diffused character, and the retinal vessels will be
seen passing over them ; they are never flame-shaped,
as is the case with haemorrhages taking place in the
nerve-fibre layer of the retina. The most frequent
cause is a blow on the eyeball, but they are also met
with in high myopia. These choroidal haemorrhages
frequently leave behind them scars which are not to
be distinguished from those left by choroiditis.
The myopic crescent is commonly formed in medium
and high degrees of myopia, and is due to the choroid
being dragged away from the margin of the disc
together with a certain amount of choroidal atrophy ;
THE CHOROID 113
tlie crescent is almost invariably found on the temporal
side of the disc ; sometimes it completely surrounds
the disc, but even then its greatest breadth is usually
at the outer side. In high myopia, where a large
posterior staphyloma is present, a good deal of thin-
ning of the choroid may take place, the retinal epi-
thelium may be more or less atrophied, and in
addition to all this some horizontal markings may be
seen midway between the disc and yellow spot ; these
are probably slight tears in the superficial part of the
choroid and pigment layer of the retina. The myopic
crescent will be again referred to on page 147.
Rupture of the choroid occasionally takes place as
the result of a severe blow on the eye ; the rupture
is usually curved, with the concavity towards the disc.
When the case is seen early, the details of the rupture
are usually hidden by the haemorrhage that has taken
place ; later, a white curved scar will be seen having
pigmented edges. The degree of impairment of vision
of course depends upon the situation of the rupture,
and when near the macula it may be very great.
Tubercle of the choroid may occur either in the
miliary form or as a large tubercular mass; though
not very frequently met with, it probably often exists
undetected in cases of tuberculosis. The disease ap-
pears in small white or yellowish-white spots, some-
what raised; sometimes several spots become confluent,
forming a mass as large as or larger than the disc.
Coloboma of the choroid (Plate III, fig. 4) is a con-
genital condition occasionally met with, and, unless
the student is aware of its existence, he will be
8
114 TUE OPIITHALMOSCOrE
sure to confound it with some serious pathological
condition.
Coloboina of the choroid is due to imperfect closure
of the foetal ocuhir cleft ; it always occurs downwards,
and maybe associated with a similar defect of the iris,
lens, or ciliary body. The coloboma may vary much
in size, being usually very white with variations in the
colour at different parts, owing to irregularities of the
sclerotic ; sometimes there is considerable bulging
outwards of the part. The retinal vessels may be
seen coursing across the white area; when the colo-
boma extends up to the edge of the disc, the latter is
usually misshapen, being more or less of a horizontal
oval.
Colloid disease of the choroid. — Occasionally small
transparent bodies may be found growing from some
part of the choroid, especially in eyes that have been
affected with choroiditis ; these bodies may occur as
minute separate spots or arranged in a group ; each
spot grows from the lamina vitrea, at first pushing
forward the retinal epithelium, which gradually
undergoes atrophy, and finally allows the most promi-
nent part of the growth to pass through ; in this case
some pigment may be found surrounding the base of
the small transparent growth.
Sarcoma of the choroid may be met with either pig-
mented or unpigmented, and may belong to any of
the varieties — round-celled, spindle-celled, or mixed.
When seen in an early stage of the disease, it may be
difficult to distinguish from a simple detachment of
the retina (p. 123).
THE CHOROID 115
In the albino there is a congenital absence of pig-
ment both in the retinal epithelium and in the tissue
of the choroid, as well as in the iris. This condition
is shown in Plate I, fig. 2.
116 TIIK OPHTHALMOSCOPE
CHAPTER VIII
THE RETINA
When it is remembered that the retina in front of
the pigment layer is transparent^ it will be under-
stood that the appearances produced by disease of
this part may be much modified by the condition of
the choroid, &c. Affections of the retina may give
rise to —
1. A loss of transparency.
2. Swelling of the retinal tissues.
3. Inflammatory exudation into the retina.
4. Haemorrhages of various kinds.
5. Changes in pigmentation.
6. Differences in level of different parts, due to
detachment or new growth.
7. Changes in the retinal vessels.
(1) Loss of transparency is most commonly the
result of retinitis, and may vary from the slightest
haze which is found in the early stage of inflamma-
tion, and which can only be detected with difficulty
by the direct examination and by using a very sub-
dued light, to dense white patches which may conceal
everything behind them.
RETINITIS 117
(2) Swelling of the retinal tissues is generally most
marked near the disc, being due partly to increased
fulness of the capillaries with hypertrophy of the
connective-tissue elements, together with swelling of
the nerve-fibres. The most obvious ophthalmoscopic
signs of this swelling of the retina are, that the
striations of the nerve-fibres are more distinct than
normal, while the vessels are more tortuous, the
tortuosity showing itself not only in a lateral but also
in an antero-posterior plane ; this is proved by the
change of colour where the vessel bends backwards,
and signifies great irregularity of the retinal surface.
(3) Inflammatory exudation into the retina may be
serous, fibrinous, or purulent in character. Retinitis
may affect the whole retina or be limited to one part.
The clinical varieties commonly met with are —
Albuminuric retinitis,
Diabetic retinitis,
Syphilitic retinitis,
Leucocythaemic retinitis,
Septic retinitis ;
but cases are sometimes seen in which the cause is
obscure, and these are called idiopathic.
Retinitis produces no external signs of its presence
beyond impaired vision. The ophthalmoscopic sym-
ptoms are haemorrhages, white patches, increased
fulness and tortuosity of the veins, with swelling of
the retinal tissue indicated by the antero-posterior
bends in the vessels.
The white patches are usually irregular in shape,
with softish-looking edges. They consist partly of
118 THE OPHTHALMOSCOPE
inflaminatory exudation in various stages of fatty
degeneration, together with thickening and degene-
ration of the nerve-fibres. These patches may lie in
front of and partly hide the retinal vessels ; when this
is the case we know that the anterior part of the
retina must be involved in the morbid process.
Sometimes the patches are behind the vessels, which
may then be slightly lifted up by them.
These white patches are most frequently seen about
the disc and the macula, or between them ; the most
characteristic appearance is that found in alh^imimiric
retinitis^ in which the white patches may occur in a
circular form, radiating from the macula like the
spokes of a wheel, the whole forming a circle much
larger than the disc, and having a white lustrous
appearance. In these cases numerous retinal haemor-
rhages are generally present, both eyes are usually
affected, and the condition is often accompanied with
papillitis. The kidney disease which most commonly
gives rise to this form of retinitis is that known by the
name of granular kidney, this disease being then in-
variably in an advanced stage ; although it must be
borne in mind that occasionally the retinitis precedes
the presence of albumen in the urine by some months.
Tumours of the brain sometimes produce exactly the
same ophthalmoscopic appearance as the retinitis due
to kidney disease.
Diabetic retinitis presents very much the same
ophthalmoscopic signs, though there are usually more
haemorrhages and the patches appear less white and
are more scattered, having little tendency to form the
PLATE IV.
Fig. 1. — Retinitis pigmentosa. In this case a givat deal of pigment
has migrated into the superficial la^^ers of the retina. The vessels
are very fine, and the disc waxy-looking.
Fig. 2. — Tlu'ombosis of the central vein. Probably in this case the
main vein is only partially obstructed ; (me vein appears to carry no
blood; numerous haemorrhages are present, some of which are becom-
ing decolourised.
Fig. 3. — Atrophy of the optic disc The vessels are attenuated,
the disc is very white. There is a large sclerotic ring, which is
probably congenital. The choroidal vessels are to be seen with dark-
coloured interspaces.
Fig. 4. — Albuminuric retinitis. Numerous hsemorrhagfes, both
flame-shaped and punctate in character, are present; the white
patches of degeneration are very bright in the region of the macula.
The vessels are characteristic of the disease, the veins being full and
tortuous, the tortuosities being both lateral and antero-posterior.
Where the lower temporal artery crosses the vein it conceals it for a
short distance on both sides; this indicates thickening and opacity of
the arterial coats.
P] ale IV.
Yuk.l
■F16.2.
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Bale <^ DanielssoH, Ltd.
RETINAL HiTlMORRHAGES 119
stellate arrangement so characteristic of the albumi-
nuric variety. This form of retinitis may be com-
plicated with vitreous opacities.
Syi^hilitic retinitifi may occur with or without
choroiditis; when the retina is alone affected the
most marked ophthalmoscopic sign is a diffused haze
over the whole retina, which diminishes the bright red
fundus reflex.
Leucocythxmtc retinitis is characterised by the
great tortuosity and size of the retina vessels as well
as by the light yellow colour of the fundus reflex.
Sej^tic retinitis may occur in pyrcmia as a result of
septic emboli, the retinitis becoming purulent and
extending to the other tissues of the eye.
(4) Haemorrhages in the retina may take place either
from the large vessels or from the capillaries, and
are most frequently symptomatic of some general
disease. Retinal haemorrhages may be caused either
by increased pressure within the vessels, by degene-
ration of the coats of the vessels, by changes in the
blood itself, or by trauma ; they may be met with in
retinitis, papillitis, embolism of the central artery,
thrombosis of one of the veins, anaemia, pressure on
any part of the optic nerve between the disc and the
point where the vessels pierce the nerve-sheath,
cardiac disease, glaucoma, or any of the numerous
accidents to which the eye is liable. The shape and
extent of the ha)morrhages depend in great measure
upon the part of the retina in which they occur; the
most common variety is that taking place in the nerve-
fibre layer, when the haemorrhages are ^'flame-shaped, "
120 THE OPHTHALMOSCOPE
with well-marked lateral edges and feather}^ ends.
'J^hese hoomorrliages most com monl}^ take place from the
lariifcn' vessels and have a linear shape, radiating from
the disc ; they arc usually small and numerous, and
occur near and follow the course of the vessels, espe-
cially the veins, though it is rare to find any visible
rupture ; sometimes they partially cover up one of the
vessels. The next most frequent position for retinal
ha3morrhages is the inner nuclear layer. When taking
place into the deeper parts of the retina they may
occur as small spots or irregular-shaped circles, and
are usually capillary in character. If the bleeding
takes place from a large vessel and is profuse, some
may escape into the vitreous, or being effused back-
wards may separate the retina from its epithelial
layer, and so produce a detachment of the retina.
Retinitis with a large number of haemorrhages is
sometimes spoken of as hemorrhagic retinitifi.
Large haemorrhages are occasionally seen in the
macular region, and are called siih-hyaloid, because
they occur between the retina and the hyaloid mem-
brane. They are usually circular in shape, several
times as large as the disc, and are accompanied with
great loss of vision for the time being. When the
extravasated blood forms only a very thin layer over
the retina the patient may see everything of a red
colour. These haemorrhages, which are at first cir-
cular, soon become decolourised above, partly no
doubt by gravitation of the blood-corpuscles, and
partly also by absorption, so that when the case is
seen later it may have taken the form of a half-circle
RETINAL HiEMORRHAGES 121
or crescent witli its convexity downwards, tlie upper
part of the circle being of a liglit colour and the lower
part dark red, separated by a well-defined line of de-
marcation. Vision in these cases is usually completely
restored.
Eecent retinal hasmorrhages are of a bright red
colour; they may retain this colour for a long time
and then become of a dirty reddish-brown tint, ulti-
mately turning black ; or the colouring matter may
be absorbed, leaving white or yellow patches, which
gradually undergo degeneration : ultimately they may
leave no trace behind, or there maybe irregular spots
left to mark their previous position. These spots
may be white or light coloured, showing more or less
of the structure of the choroid, with some pigment
about their margins. Sometimes the spots are very
small, consisting merely of pigment, which may be
either the remains of the colouring matter of the
blood, or pigment set free from the hexagonal epithe-
lial cells. It is not always possible to make a dia-
gnosis between inflammatory and haomorrhagic scars
in the retina and choroid. The only conditions which
might be mistaken for a haemorrhage of the retina are
— (i) The cherry-coloured spot which occurs at the
macula in cases of embolism of the central .artery,
(ii) The somewhat similar appearance produced in a
detached retina in the macular reo^ion, the retina beincr
detached all round but remaining adherent at the
macula itself; this is a very rare condition, (iii)
Minute new vessels which have formed in a retinal
exudation. All these may more or less simulate a
122 THE OPHTHALMOSCOPE
retinal hnsniorrhage, and it is necessary the student
should be on his guard.
(5) Changes in pigmentation may be duo to any in-
flammatory or atropliic cliange taking place in the
retinal epithelium.
Retinitis 111 gmentoaa (Plate IV, fig. 1) is the disease
in which these changes are most frequently seen.
It consists of hypertrophy with gradual shrinking
of the connective tissue contained in the different
layers of the retina, together with atrophy of the
nerve elements and the migration of the pigment
set free from the epithelial laj^er, which travels
forwards into the anterior part of the retina, and
there undergoes proliferation. This pigment shows
a great tendency to coalesce into spots with radiating
processes, very much resembling bone-corpuscles as
seen under the microscope. As the radiating pro-
cesses from one spot join with those of adjacent
spots, a fine network is produced, somewhat resem-
bling black lace. In some cases the pigment will
be found accumulating along the sheath of one
of the retinal vessels. These pigment changes are
usually most marked in the peripherj'-, often occupying'
a circle midway between the margin of the disc and
the equator.
No satisfactory explanation has been given of this
peculiar arrangement taken up by the pigment. While
these changes are going on, the walls of the vessels
are becoming thicker at the expense of their internal
capacity, and this diminution of the blood- stream is
frequently the first ophthalmoscopic sign of the dis-
DETACHMENT OF THE EETINA 123
ease. The diameter of the vessels continues to decrease,
while the retina undergoes a gradual sclerosis until
ultimately the different layers become unrecognisable,
the rods and cones being quite destroyed. Early in
the disease the disc becomes pale, assuming gradually
a waxy opaque look ; both eyes are alwaj^s affected.
The chief symptoms which accompany this disease
are, great torpor of the retina, with decreasing vision,
concentric contraction of the visual fields, night-blind-
ness, &c. Frequently posterior polar cataract accom-
panies retinitis pigmentosa, and may be due to pig-
ment travelling forward from the retina along the
central lymph-channel to the back of the lens, where
it adheres and proliferates.
Retinitis pigmentosa may be congenital, or it ma}^
occur in early life. Some varieties of specific choroido-
retinitis present much the same ophthalmoscopic
appearances. It is most important to distinguish
retinal from choroidal pigmentation.
(6) Differences in level of different parts of the retina.
— It is essential that the student should learn to
recognise these differences, since detachments of the
retina are very common. When such detachments are
large and have become opaque, they can hardly escape
detection; but when the portion of retina detached is
small and retains its transparency, the diagnosis is by
no means so easy. In making a systematic examina-
tion, a detachment may now and then be seen with
focal illumination, when the displaced portion of the
retina is very large and lies a long way forward.
Usually, however, this is not the case, and having
124 THE OPHTHALMOSCOPE
detected nothing with the focnl illumination, one
passes on to the concave mirror held at a distance
from tlie eye, tlie patient being directed to look first
up, then down, and finally straight in front of him;
thus one is enabled to make a thorough examination
of the vitreous. Should the reflex from one part of
the fundus appear much lighter than the rest we may
suspect a detachment, especially if the reflex of the
part alters while the eye is kept in one position, as it
may do when the retina changes its position so that
the light is reflected differently. Not only is there an
alteration in the reflex of the part, especially when
the detachment is opaque, but a portion of the details
may come into view, while nothing can be seen of the
rest of the fundus ; this is because the detached
portion is very hypermetropic, so that an upright
image of it will be seen. The detached portion may,
if opaque, appear in white undulating folds, on which
some of the vessels may be clearly seen ; on movement
of the eye it may be seen to float about. When,
however, the retina retains its transparency, the
ordinary fundus reflex from the choroid will be seen,
and the diagnosis will rest upon the position of the
vessels on the detached transparent retina. When a
retinal vessel on a transparent detachment thus conies
into view it has a characteristic appearance ; it shows
up very clearly, appears smaller than normal, undu-
lates when the eye is moved, and is more tortuous
than usual. Besides all this it has a much darker look
than normallj'-, while the central light reflex on it
will have disappeared. The darker appearance is due
DETACHMENT OP THE RETINA 125
to the light reflected from the choroid being some-
what obstructed by the vessel, so that it is seen partly
by reflected and partly by transmitted light ; this
appearance is quite characteristic, and should at once
set one on the right track. Then, on putting up the
objective for the indirect method, the detached retina
or the vessels on it will appear different from the
rest of the fundus ; and on moving the lens slightly
from side to side while the image is kept in view,
the detached portion will look to slide over the
other part, and thus a " parallax '' will be produced
(p. 143).
The direct examination gives us much fuller infor-
mation ; when the detachment is thus looked at, the
vessels have a foreshortened and wavy appearance ;
the detachment and the vessels on it will also be
found to be very hypermetropic — that is, supposing
that the details of the disc are seen clearly with-
out a convex glass behind the ophthalmoscope, and
that the weakest convex glass blurs these details :
the detached portion of the retina, or if it be trans-
parent, then the vessels on it, may be seen with a
strong convex glass ; the more forward the retina, the
higher the glass through which it can be seen. If
the strongest glass be thus found out, we may esti-
mate the distance between the detachment and the
sclera; for 3 D. equals 1 mm., so that if the case in
question could be seen with a convex 12 D., while the
disc was emmetropic, then we should know that this
distance was 4 mm. Detachments are, however, most
frequently met with in myopes, so that a concave
126 THE OPHTHALMOSCOPE
glass would bo necessary to see tlie details of the
disc ; and yet perhaps the detachment may be clearly
seen with a convex glass ; the difference between the
weakest concave glass with which the disc can be
clearly seen, and the highest convex glass with which
the particular vessel can be seen, will give us the
measurement we require.
In many cases a part of the detachment is trans-
parent while a part has become opaque; sometimes
a rent can be detected, so that the fluid in front and
behind the detachment being in direct communication,
the retina can float about with every movement of
the eye. The edges of the torn retina will be found
turned in towards the vitreous.
When the detachment takes place in the macular
region, the retina usually remains adherent to the
macula itself, thus producing an ophthalmoscopic
appearance somewhat like the cherry-red spot of em-
bolism ; this red spot might also be mistaken for a
hemorrhage by an inexperienced observer.
The character of fluid behind the detachment can-
not often be diagnosed ; it is most frequently serum of
a light straw colour, but it may be blood : a more
important point, however, to arrive at is — is the de-
tachment due to fluid or is it due to a new growth ?
Other points not resting on the ophthalmoscope must
be called to our aid to enable an accurate opinion to
be formed. Thus the history of the case, the position
of the detachment, and the tension of the eyeball may
help us to arrive at a correct conclusion. In simple
detachment the tension is liable to be diminished.
RETINAL VESSELS 127
while in that due to a growth the tension is usually
above the normal at some period of its growth. As a
rule the surface of a growth is more prominent; some-
times a haemorrhage being visible upon it. No move-
ment of the detachment will be detected on moving the
eye, and if the case be watched for some weeks it may
be noticed if any increase is taking place. Detach-
ments are most frequent in myopic eyes, but a new
growth may occur in any eye, whatever its refraction.
Detachments are frequently accompanied by vitreous
opacities, which may interfere more or less with the
ophthalmoscopic picture. Posterior cortical cataract
is another complication that may arise from detached
retina.
(7) Changes in the retinal vessels.
(a) They may be increased or diminished in size.
■ (6) They may be unusually tortuous.
(c) Pulsation may be present in the veins or arteries.
(d) There may be alterations in the central light
streak on the vessels.
(e) The coats of the vessels may be thickened and
their transparency diminished.
(a) Changes in the size of the retinal vessels may
present numerous varieties, and are not always easily
detected on account of the great individual differ-
ences that are met with; but a careful comparison of
the vessels in the two eyes, together with the relative
size of the arteries and veins, may assist one in
arriving at a correct conclusion; the veins are as a
rule about one third larger than the arteries.
The comparison of the relative size of the veins
128 THE OPHTHALMOSCOPE
and arteries may be somewhat complicated if their
distribution does not correspond ; for instance, two
veins may accompany one artery, or vice versa.
Increase in the size of the arteries is not common,
and when it does occur is usually due to some affec-
tion of the coats of the artery which has impaired its
tone and contractility ; it is seldom seen as a result of
retinitis or papillitis, as might be expected, and the
most marked cases of increase in the size of the
arteries that have been met with have been in reti-
nitis due to leucocythaemia.
Decrease in the size of the arteries is much more
common than increase, and is often very marked in
optic atrophy or any disease causing atrophy of the
retina ; it is also a frequent result of the retrogressive
changes following papillitis and retinitis; other causes
are, increase in the iutra-ocular tension, embolism,
thrombosis, and anaemia.
Increase in the size of the veins is frequently met
with, and is usually due to inflammation of the retina
involving the walls of the vessel, or to some disease
producing general venous congestion, or to direct pres-
sure on the venous trunk as it leaves the eye ; the in-
crease in the size of the vein is generally accompanied
by an increase in its length, which shows itself by
greater tortuosity than normal; all the veins may be
thus affected or only one, or even only a part of one.
Decrease in the size of the veins is much less
common than increase, and may be due to atrophy
of the retina or optic disc, embolism, thrombosis, or
any degenerative process taking place in the vein
RETINAL VESSRLS 129
itself. When the veins seem slightly enlarged, espe-
cially if the disc is redder than usual^ the case may
be one of hypersemia.
In ansemia the arteries are slightly diminished, and
the discs and general fundus pale, owing to the blood
being of a lighter colour than normal from a defi-
ciency in the number of red blood-corpuscles.
In albuminuric retinitis the coats of the arteries
are always thickened and their calibre diminished.
Occasionally small aneurisms are found on some of
the arteries.
In atrophy of the papilla or retina the vessels will
be found diminished in size, and when this atrophy is
the result of inflammation a white line may frequently
be traced a good way along some of the larger arte-
ries. This white line is due to sclerosis of the middle
coat of the artery, or to an increase of the connective-
tissue elements of the arterial sheath, which not being
transparent can be easily seen by the direct method.
In rare cases not only may the sides of the vessels be
visible, but the front part also, so that no blood-stream
can be detected, the vessels appearing as white-looking
cords. The same condition may occasionally be seen
in the choroidal vessels. When the retinal vessels
are very much diminished in size they may appear as
small threads, stretching but a short distance over
the fundus.
But the most obvious change produced in the size
of the vessels is that due to cmhoUsm of the central
artery ; and since this artery has no anastomoses, the
retinal circulation can never be thoroughly re-estab-
9.
130 THE OPnTHALMOSCOPE
lislicd. The cause of embolism is usually a pluf^ of
lymph detached from oue of the cardiac valves, plug-
ging the main central artery ; there is sudden and
almost total loss of sight without pain or giddiness ;
and if the case be seen early the ophthalmoscopic
appearances are very characteristic. The embolus is
not generally visible, but there is great pallor of the
disc; the arteries are much diminished, the veins
slightly dilated, but decreasing in size towards the
disc ; sometimes the blood-stream is broken up into
segments, retinal haemorrhages are usually present,
and a white hazy, opaque appearance surrounds the
macula, the centre of which is occupied by a bright
red spot (cherry-coloured spot) . This opaque appear-
ance is due to oedema of the nerve-fibre layer. The
retina of the fovea centralis is very thin, and contains
but little connective tissue, so that no oedema takes
place here, therefore the red of the choroid shows
through ; this colour is much intensified by the white
appearance around, and possibly also by congestion
of the choroid; so that really the cherry-coloured
spot is produced chiefly as the result of contrast.
Should the embolus be too small to plug the central
artery, then it may block up one of the main branches,
and the ophthalmoscopic picture will vary accordingl3^
Later, the disc becomes atrophic, the odoema subsides,
and therefore the red spot disappears, while the
arteries will always remain very small. A similar
condition may be produced by a haBmorrhage into the
optic nerve sheath.
Thrombosis of the central vein produces somewhat
THE RETINA 131
analogous appearances, but the arteries are larger, the
veins mucli fuller, while retinal ha3niorrhages are more
numerous and larger.
{h) The vessels may he unusually tortuous, which is
expressed by their increased length ; these tortuosi-
ties when present are usually lateral. The condition
may be met with in cases where a nasvus of the
skin of the lids or brow exists, or it may be one of the
permanent remains of an attack of neuro-retinitis; it
is also occasionally found as a congenital condition,
and then usually in eyes that are highly hyperme-
tropic. The tortuosity of vessels on a portion of de-
tached retina has already been referred to, and may
then be in an antero-posterior plane, i. e. at right
angles to the surfaces of the retina, as well as lateral.
(c) Pulsation of the arteries and veins. — Arterial pul-
sation is almost always a pathological condition, and
is due either to increased tension or to heart disease;
it is most commonly seen in cases of glaucoma, and is
then an important diagnostic sign ; when due to heart
disease it is usually the result of aortic regurgitation,
the pulsation extending a considerable distance along
the artery, sometimes even to the smaller vessels, while
in glaucoma the pulsation is usually confined to the
disc. Arterial pulsation occurs in glaucoma either
spontaneously, or it may easily be produced by slight
pressure on the eye ; and since the tension of a glau-
comatous eye is liable to vary at different times, so
will the pulsation be more apparent sometimes than
at others ; it is not usually to be seen in all the
arteries at once, and is best seen on the disc. It con-
132 THE OrHTnALMOSCOPE
Rists of a very sudden dilatation, which is synchronous
with the cardiac systole, and is followed by a gradual
emptying; the rapidity of arterial pulsation being in
great contrast to the steady pulsation taking place in
the veins.
No pulsation exists in the normal eye, partly because
the arteries here are so small that the pulse -wave has
become very feeble, and partly because the intra-
ocular tension exactly balances the tension on the in-
side of the vessels, and therefore the blood passes on
in an almost continuous stream. In glaucoma the
intra- ocular tension is greater than that in the vessels,
so that the blood is able to flow along the retinal
arteries only during the systole of the heart ; when the
pressure is lowered during the diastole, the arteries
are occluded by the intra-ocular pressure.
Venous pulsation is usually physiological, but it
may occur with an increase of the intra-ocular tension.
This pulsation can best be seen on the disc, sometimes
at the point where the main vein is formed by the
junction of the upper and lower retinal veins. It
consists of a gradual emptying and refilling of the
vessel, and is possibly due to the slight increase of
the intra-ocular tension which occurs with each con-
traction of the left ventricle; this increase being trans-
mitted through the vitreous to the veins, causing
them to empty. The veins, however, quickly refill as
the tension is lowered.
(d) Alterations in the light streak of the retinal
vessels. — It must be remembered that the retinal ves-
sels on section are oval, the perpendicular diameter
THE RETINA 133
being less than the horizontal ; the fuller the vessels
the more they tend to the circular. This condition
influences considerably the breadth of the light reflex ;
the flatter the vessels, the broader the reflex. The
colour of the blood in the vessels also makes some
difference ; the lighter the colour, the better marked
is the central streak.
The light reflex is better marked and more regular
in the case of the arteries than the veins, and can be
traced further upon the former than upon the latter.
In oedema of the retina the reflex is much diminished,
while in detached retina it is usually absent.
(e) The walls of the vessels may he thicJcened and lose
their transparency, either from degeneration in one of
its various forms, or from inflammation. Inflamma-
tion of the vessel walls may produce a thickening of
the wall without any loss of transparency, causing a
diminution in the capacity of the vessel, or the
thickening may be of an opaque character, or the in-
flammation may affect the outer part of the vessel and
its sheath, causing a great increase in the connective-
tissue elements, with considerable increase in the
outside diameter of the vessel, while its carrying
capacity may be undiminished. The ophthalmoscopic
sign of this condition is a white line along the sides
of the vessels, which in extreme cases may appear
as white opaque cords.
This condition of thickening of the sheath and outer
part of the vessel is known as perivasculitis ; when
the condition exists only in the arteries it may be
spoken of as periarteritis.
134 TIIK Ol'HTIIALMOSCOrE
Commotio retinae. — Sometimes after a severe contu-
sion of the eyeball some part of the retina may
assume a white clouded appearance, which may be
accompanied by impaired vision^ ciliary redness, and
photophobia. These symptoms usually pass off in
thirty-six hours. The condition is probably one of
oedema of the retina.
Retinitis proliferans is the name given to that con-
dition in which new vessels grow out into the vitreous
supported by connective tissue. Bands may be seen
stretching from one part of the fundus to another.
Some observers think that these cases commence as
large vitreous haemorrhages.
Glioma of the retina is a very malignant disease,
commencing usually in the neuroglia of one of the
granular layers of the retina. It is most common in
infants, but may occur up to the age of ten or twelve
years. Sometimes both eyes are affected. This con-
dition is best examined by focal illumination, when the
growth w^ill be seen of a pink-whitish colour, smooth or
lobulated, and frequently with blood-vessels on its
surface.
Glioma may be mistaken for inflammatory exuda-
tion in the vitreous, a condition sometimes called
jjseudo- glioma ; the distinguishing points are, that in
pseudo-glioma the colour is usually yellow or straw-
coloured, the surface is flat, posterior synechiae fre-
quently exist, while the iris itself is pushed forwards
in the centi'e and retracted in its ciliary portion ; the
tension is usually subnormal ; whereas in glioma the
whole of the iris is pushed forward, and the tension
THK RETINA 135
may be increased duriug some part of its growth,
and is never subnormal so long as the coats of the eye
have not given way ; no posterior synechia) exist, and
the growth is of a pinkish colour and vascular.
Among ophthalmoscopic curiosities may be men-
tioned a very striking appearance ; the whole macular
region may be found dotted over with light-coloured
spots of various sizes, a condition which always exists
in both eyes, and has been described under the name
of guttate choroiditis, though it is probably not choroi-
ditis at all, but a physiological condition due to the
pigment in some of the hexagonal epithelial cells beiug
of a lighter colour than it is in the rest of the fundus,
and may be somewhat analogous to freckles on the
face ; but as no case has yet come within range of the
microscope, the exact situation and cause of these spots
is doubtful.
The vision in such cases is usually good; some having
been watched for years without uudergoiug any change.
Now and then a small row of spots may be seen,
somewhat like a row of small air-bubbles. These are
probably small transparent growths from the lamina
vitrea.
A few very bright refracting spots are occasionally
met with, usually near the vessels. Their pathology
is unknown. Cases in which they are present often
suffer from asthenopia.
Besides the conditions already mentioned, cysts of
the retina, rupture of the retina without a correspond-
ing rupture of the choroid, and congenital retinal
pigmentation may occasionally be met with.
136 THE OrilTIIAI.MOSCOrE
CHAPTER IX
THE OrTIC NERVE
The only part of the optic nerve to be seen with
the ophthalmoscope is the disc. Changes taking- phice
in the nerve may or may not cause alterations in the
disc. It is necessary to remember that the optic nerve
passes through the rigid sclerotic opening, which is
somewhat funnel-shaped^ the narrowest part being in
front ; the nerve fits it closely, so that when any swell-
*ing takes place in this part, the sclerotic opening acts
as a ligature, and may cause serious changes in the
nerve-fibres as well as considerable obstruction to the
retinal circulation. These changes may be made
apparent by swelling, &c., of the optic disc.
The central artery and vein are for the nutrition of
the retina, and have nothing^ to do with the nutrition
of the disc itself. Since no anastomoses take place
between these vessels and those of the surrounding
structures the retinal circulation is terminal.
Abnormal conditions of the disc may cause —
1. Alterations in colour and transparency.
2. Alterations in surface level.
3. Changes in the margins of the disc.
THE OPTIC NERVE 137
1. Alterations in colour. — Great variations are met
with in the colour of the discs in different subjects,
so that it is extremely difficult in many cases to
decide when any increase of the normal colour has
taken place; sometimes^ no doubt, the illumination
necessary for the examination may cause temporary
flushin*^ of the disc, hence too much reliance
must not be placed on this fact alone. A comparison
of the colour of the discs on the two sides may
help one to arrive at a correct conclusion. No doubt
hyYiercemia does frequently exist, and will cause
an increase in the normal pink colour, this increase
of colour being due to fulness of the capillaries. When
the hyperaemia is marked in character, it is usually
accompanied by some increase in size of the retinal
veins, with possibly some slight softening of the
margin of the disc ; this change will be best detected
by the direct examination.
Both eyes are usually affected. This condition of
hyperaGmia may remain for a long time and then
gradually subside, or it may pass on to inflammation,
and will be referred to later under the head of papil-
litis ; or it may pass on to the opposite condition,
atrophy of the optic disc.
Anxmia may cause the discs to look paler than
usual; whilst at the same time the retinal vessels may
be badly filled. In pernicious anaemia the red of the
choroid may be diminished, while the retinal veins
may bo almost as light-coloured as the arteries. As
age advances the disc becomes paler, so that a pale
disc, which, when seen in an old person, may be normal.
138 TUE OrHTIIALMOSCOrE
might ill a young individual indicate a condition
bordering on atrophy.
Atrophy of the optic nerve may be divided into —
Primary.
Secondary.
Consecutive.
Primary atrophy is that condition which is not
preceded by any inflammatory action ; though it must
be remembered that since failing vision is almost the
only symptom of atrophy, the disease may have been
in progress for a long time before being detected,
and any inflammatory action which may have pre-
ceded the degenerative processes may have vanished,
leaving no indication behind. This form of atrophy
may exist as a purely local disease, but is most com-
monly met with in association with locomotor ataxy
and disseminated sclerosis.
Secondary atrophy is the term used by most authors
to signify an atrophy due to some injury or disease of
the nerve or retina ; common causes being pressure on
any part of the nerve, embolism of the central artery
of the retina, retinitis pigmentosa, choroido-retinitis,
syphilitic retinitis, &c.
Consecutive or post-neuritic atrophy is due to the
gradual destruction of the nerve-fibres of the optic
nerve following upon inflammation of the papilla.
In atroj)hy the disc is usually very white, or in some
cases grey, but the ophthalmoscopic appearances will
vary considerably with the stage of the disease and
its cause. The whiteness of the disc is due to degene-
ration of the nerve-fibres, together with the capillaries
THE OPTIC NERVE 139
which supply them. If a case of primary atrophy is
seen when fairly advanced, with the indirect method
the disc will appear intensely white, with well-marked
margin ; the latter being rendered very distinct by
the shrinking of the nerve-fibres, which exposes
the sclerotic ring. With the direct method the white
may be less marked ; in fact, it may be of a bluish-
white colour or grey, the stippling produced by the
perforations of the lamina cribrosa being usually very
distinct. As the optic nerve shrinks no decrease takes
place in the size of the disc, but a depression of its
surface is gradually produced, forming what is known
as the atrophic cuf. This cup is always shallow,
while the vessels can be seen to slope gradually
down to the bottom of the disc. When the
atrophy is of a consecutive character, as in cases of
papillitis, the atrophy may be spoken of as post-
papillitic. The ophthalmoscopic signs indicating
this condition are, badly defined disc-margin, vessels
somewhat tortuous and diminished in size, with a
white line extending along some of them ; little or no
cupping is present, while some remains of organised
material may be seen about the disc, or covering some
of the vessels. With the direct method the disc has
often a strikingly opaque appearance.
Atrophy of the optic nerve may commence in any
part of its course between the optic chiasma and the
eye, extending in either direction from the point first
attacked.
Atrophy following retinitis pigmentosa produces a
waxy-looking disc, while the vessels are often very
140
THE OrilTLJALMOSCOrE
sniiill. Very great cliffcrouces in sights however, will
be found in these cases ; some may have very white
discs and yet retain fair vision, while others have ex-
tremely bad vision and yet the discs may not be
very white. Sometimes the margins of the disc are a
safe guide as to the cause of the atrophy, while at
other times this is not the case.
2. Alterations in surface level.— Although the disc is
spoken of as the papilla, it is really but very slightly
raised above the general level of the fundus. The disc
may be depressed so as to form a cup, of which there
are three kinds: (1) the 'physiological cup; (2) the
Fig. 64.
? ^!^»^5^gg%."a' !^Wi'^ -^'^ ''
Physiological cup.
atrophic cup; (3) the glaucoma cup.
also be raised as in papillitis.
The disc may
THE OPTIC NERVE
141
The physiological nip is a congenital conrlition, and
was mentioned on p. 88. This cup is cone-shaped
and is formed by the separation of the nerve-fibres
which spread out to form the retina ; its chief and
important characteristic being that it does not involve
the whole disc. The cup is usually the whitest part
of the disc, because it contains few nerve-fibres, and
is therefore less vascular; it occupies more or less the
centre, and when deep allows the details of the lamina
cribrosa to be seen.
In Fig. G4 we have a deep physiological cup reach-
ing almost to the edge of the temporal side of the disc,
while on the nasal side it is excavated ; the stippling
of the lamina cribrosa is well seen.
Fig. 05.
Atrophic cup.
142
THE OPHTfTALMOSCOPE
Tlie afropliic cnj) involves nearly the whole disc, bat
is shallow, and formed by a very gradual slope from
the disc margins. The vessels can be traced down the
cup without any interruption. This form of cup is
common in cases of primary atrophy.
The glaucoma cup is produced by an increase of the
intra-ocular pressure driving the nerve backwards,
and displacing the lamina cribrosa. The optic nerve
entrance is the weakest part of the coats of the e3^e-
ball, and is therefore the part which gives way first
Fig. G6.
Glaucoma cup.
to increased intra-ocular pressure. The essential
characteristics of this cup are^ that it involves the
whole disc, and is more or less excavated. When
these characteristics are well marked it is impossible
THE OPTIC NERVE
143
to mistake them ; but in others, when the cup is only
forming, it is very easy to mistake it for one of the two
preceding varieties. Besides, in some cases the two
conditions may co-exist; thus a case of glaucoma
occurring in an eye with a well-marked physiological
cup may be some time before it develops the charac-
teristics belonging to the glaucoma cup.
With the indirect examination one will see, on
moving the objective slightly from side to side, a
well-marked iiarallaXj i. e. the margin of the disc will
Fig. 67.
appear to slide over the bottom of the cup. This is
due to the image of the margin of the disc making a
greater movement than the image of the bottom of
the cup. Thus, in Fig. 67, let a represent the edge
of a glaucoma cup, and h the lower part of the same ;
the image of a will be formed at A, and h at b. On
moving the lens c to d, b will move to b' and a to a' ;
therefore the image a, which represents the margin
144 ruK ornTnALMOSCOPE
of the edge of the cup, will have made a greater
movement than b, which is the imago of the bottom
of the cup. With the direct method a parallax may
also be seen. We may estimate the depth of the cup
by tlie direct method, if we remember that 3 D = 1
mm. ; first find the glass through which the edge of
the disc is seen clearly, and then the glass through
which the bottom of the disc is seen well defined ;
for example, if the edge of the disc is seen clearly
with a +2 D., whilst the lowest part of the cup
requires —4 D., we should know that the cup was
2 mm. deep.
This deep excavated cup is found most marked in
cases of chronic glaucoma.
With the ophthalmoscope the vessels of the retina
will appear to stop at the edge of the disc as they
twist under the overhanging edge; they will be seen
again at the bottom of the disc, only more or less out
of focus. Another characteristic of the glaucoma
cup is, that the vessels are pushed towards the nasal
side; frequently also pulsation may be detected in
the arteries. This pulsation will be found referred to
on p. 131.
Neuritis. — Inflammation may attack any part of
the nerve between the optic chiasma and the eye,
and may, according to its location, be designated
as papillitis (choked disc) when the disc alone is
chiefly involved ; papillo -retinitis when the retina is
also implicated; neuritis when the nerve itself is
inflamed, and may then be either ascending or de-
scending ; retro-hulbar neuritis when the disease is
THE OPTIC NERVE
145
behind tlie eye, affecting chiefly the central fibres of
the nerve.
A well-marked case of papillitis produces the
most characteristic ophtluilraoscopic appearances,
the disc being swollen and raised, somewhat like the
end of a champagne cork. In a simple case of
neuritis the appearances are less marked. Neuritis
Fig. 68.
Papillitis.
may exist alone or in conjunction with retinitis, and
may be caused by pressure on any part of the optic
nerve, by brain mischief, or by some general disease
such as albuminuria, diabetes, syphilis, rheumatism,
influenza, &c.
No distinct line of demarcation exists between
hyperjemia and inflammation of the disc; the one
10
146 THE OPHTHALMOSCOPE
passing imperceptibly into the other. When the
edge of tlic disc has become slightly indistinct, ac-
companied by distinct swelling, papillitis ma}^ be said
to have commenced. Papillitis may exist in varying
degrees; it is usually manifested by increased red-
ness, with swelling of the optic nerve, which fills up
the physiological cup, and gradually raises up the
centre of the disc, sometimes to an enormous extent.
The swollen disc overlaps its edges, so that the
margins are very ill-defined or quite lost, while the
colour of the disc may be increased, being much the
same as the surrounding choroid. The disc margins
have a striated or woolly appearance, due partly
to opacity and swelling of the nerve-fibres, and
partly to exudation of inflammatory material. The
arteries may be diminished in size, and at places
hidden from view by exudation ; the veins are dilated
and tortuous, the bendings taking place not only in
a lateral direction, but often in an antero-posterior
plane, especially when the swelling is very great.
A few hsemorrhages may be seen near the disc,
radiating from it in the direction of the nerve-fibres.
This condition may be well seen by the indirect
method, but the indistinctness of the disc margins
and the difference in level of the swollen disc can
best be appreciated by the direct method. The
amount of swelling may be estimated if we remember
that every +3 D. means an increase in level of 1 mm.
As the swelling diminishes shrinkage takes place,
and the condition is liable to pass on to atrophy.
lietro-hulbar neuritis is a form of infiammation
THE OITIC NEUVE 147
affecting the orbital part of the optic nerve, in-
volving chiefly the central fibres, so that the oph-
thalmoscopic signs are but slight. Sometimes the
central part of the disc is congested and inflamed,
while the outer part seems to be passing into a con-
dition of atrophy ; the size of the large vessels is
but little affected, though the light streak on both
arteries and veins is usually diminished ; the retina
is more or less implicated, as shown by a slight
diminution in its transparency ; the vision is im-
paired, often by the presence of a scrotoma between
the macula and the disc, and even when this is not
present the central colour vision is usually affected.
Tobacco is the commonest cause, and in such cases
the prognosis is good.
3. Changes in the margin of the disc have already
been referred to under the diseases papillitis and post-
papillitic atrophy. In the first condition the margin
of the disc is often completely lost, as is shown in
Fig. 68 ; in slight cases, or in an early stage of the
inflammation, the edge of the disc can still be made
out, but it has a woolly striated appearance, more
marked at some parts than at others. In post-papil-
litic atrophy the margin of the disc is usually some-
what irregular, with disturbance and heaping up of
displaced pigment.
The most common cause of chano-e in the maro^iu
o o
of the disc is, however, that produced by myopia, a
crescent being formed on the outer edge. Myopia
is nearly always due to an increase in the antero-
posterior diameter of the eyeball. This increase
148 THE OrHTIIALMOSCOPK
ill length is usually produced by a stretching of
the tissues at the back of the eye; the sclerotic
bulges at the point of least resistance, i. e. on the
outer side of the optic nerve, between it and the
macula, while the choroid, instead of stretching with
it, becomes dragged away from the disc margin, ex-
posing a crescent-shaped portion oE the sclerotic.
In slight cases a mere increase of the sclerotic ring
will become visible on the outer side of the disc;
wliile in liigli degrees of myopia the crescent may
attain an enormous size, completely surrounding the
disc and extending a long way towards the macula,
the broadest part of the myopic crescent being in-
variably outwards. This myopic crescent is occa-
sionally seen in cases of emmetropia and even in
bypermetropia ; here probably the eye was originally
hypermetropic, and is on the high road to myopia,
but the crescent becomes formed before it has arrived
at this condition. Sometimes it is not quite easy to
distinguish the line of demarcation between tbe disc
and tlie crescent ; frequently also some traces of pig-
ment are to be seen on the outer edge of the crescent.
Congenital crescent was first accurately described
by Fuchs under the name of coloboma of the nerve-
sheath. It is not a very uncommon defect, and
consists of a pale coloured crescent, with, the broad
part downwards ; in some cases there is difficulty in
making out the demarcation between the disc and
tbe crescent. The congenital crescent is probably a
part of the disc itself and not the exposed sclerotic,
as in the case of the myopic crescent. The disc is
THE OPTIC NERVE 149
darker in colour than usual^ horizontally oval and
sometimes misshapen ; frequently the crescent is
staphylomatous; the eyes in which it is present have
usually more or less astigmatism, with a visual acute-
ness below the normal.
Opaque nerve-fibres is a congenital condition some-
times met with. As a rule, when the nerve-fibres
penetrate the lamina cribrosa they become divested
of their medulla, passing on as transparent fibres;
occasionally some of them retain their sheaths for a
time after passing into the eye, or, having lost them
at the optic nerve entrance, quickly regain them for
a short distance. The patches of opaque nerve-fibres
may be met with in various stapes and sizes ; perhaps
the commonest form met with being that in which a
tuft is present above and below the disc, extending
from near its margin upwards and downwards for some
distance on to the retina. Sometimes isolated patches
are seen a short way from the disc. They are always
white and opaque-looking*, somewhat flame-shaped
witli well-defined lateral margins and feathery ends,
shading off gradually into the normal retina. The
opacity occupies the anterior part of the retina, and
may even hide the retinal vessels more or less com-
pletely. When the patches are large, and extend a
long way over the retina, they bend out towards the
macula. Opaque nerve-fibres may exist in one or
both eyes, and when once seen are not likely to be
mistaken for a pathological condition ; their dense
white appearance, elongated shape, and feathery ends
are quite characteristic. It may be mentioned that
150 THK OrHTHALMOSCOPE
in tlie rabbit op.iqne nerve-fibres are the normal con-
dition ; hero they are arranged in two tufts, extend-
inir in a liorizontal direction on both sides of the
disc. Opaque nerve-fibres should be examined both
by the indirect and the direct methods.
Connective tissue on the disc. — Some part of the disc
or its vessels is occasionally more or less obscured by
a small shred, band, or irregular mass of connective
tissue ; sometimes resembling a very small piece of
cotton wool, just faintly blurring the vessels beneath
it, at others forming a very opaque white patch con-
cealing a good portion of the disc and vessels. The
condition is most probably a congenital one, being
the remnant of the fa3tal hyaloid artery; when not
congenital it maybe the organised remains of inflam-
matory exudation poured out in papillitis.
APPENDIX
I WILL now conclude this small volume by shortly
recapitulating the plan of examination recommended ;
which if carried out iu the systematic manner sug-
gested, should render it very difficult for any serious
lesion to escape detection.
1. With the oblique illumination inspect the cornea,
lens, iris, and the anterior part of the vitreous. Notice
if any opacity or irregularity of the cornea is present,
and if its curvature appear normal. The aqueous
should be quite transparent, the iris moveable and
free from any adhesions which may exist, either be-
tween it and the cornea as a result of perforation, or
between the iris and lens as a result of iritis. The
lens should be perfectly transparent; sometimes it will
be found dislocated, either congenitally or resulting
from an accident. Pigment may be noticed on the
anterior capsule; this has been torn from the pos-
terior surface of the iris, and is evidence of previous
inflammation of this tissue. Opacities may be de-
tected in any part of the lens ; when at the posterior
pole the opacity appears to be further back than
might be expected. The anterior part of the vitreous
may contain blood, which may thus be detected;
or a growth, or a very prominent detached retina
may come into view. This examination may be sup-
plemented by a strong magnifying glass, or the
152 APPENDIX
cornea may be fnrtlicr examined Avitli a +20 D.
behind the ophthalmoscope, the observer approach-
ing close to the patient.
2. Next take up the large concave mirror, and
reflect the light into the eye from a distance. Opaci-
ties of the cornea and lens will then appear as black
spots on a red ground. The cornea and lens being
transparent, notice if any vitreous opacities are
visible ; these are usually floating, and can best be
set in motion by directing the patient to look quickly
up, then down, and finally straight in front of him.
Should any vitreous opacities be detected, they may
be further examined with a plane mirror and a +8 D.
behind the ophthalmoscope. Nothing being detected
in the vitreous, notice if the disc or any part of the
fundus come into view. Should a vessel be seen,
note if it appear to move with the observer's head,
in which case it will be hypermetropic ; if against
it, then myopic. Should a detachment of the retina
exist, then, of course, this part will be very hyper-
metropic, and will answer the tests for that condi-
tion. Should the detachment be transparent, then a
vessel may be seen on the detached portion of retina ;
the vessel will appear darker than usual, more tortuous,
have a foreshortened appearance, and move with the
undulations of the detached retina.
3. Nothing being detected by the mirror alone, the
large biconvex lens should be held up in front of the
eye we are examining, while the light is still reflected
by the large concave mirror : thus one obtains an in-
verted image of the fundus. Notice first the shape, size,
APPENDIX 153
and edges of the disc, whether well defined or blurred,
whether cupped or otherwise. Distinguish the arteries
from the veins, and note if they be full, tortuous, or
pulsation is present, whether clearly defined, or covered
up in parts, and whether a line can be traced along the
edge of any of the arteries ; then examine the periphery
by directing the patient first to look up, then down,
and finally to either side. Attention must next be
directed to the macular region.
4. Examine the eye by the direct method, first the
disc, then the periphery, and finally the macular re-
gion; compare the result by this plan and the indi-
rect method. Estimate the refraction at the disc.
When any patches of pigment, exudation, oi* hasmor-
rhages are found, we must decide whether they are
retinal or choroidal.
5. Finally notice the refraction of the patient by
retinoscopy. When the observer has time, a sketch
may be made of the disc. Nothing improves our
poAvers of observation so much, or leads to such
accuracy, as making a drawing of what is really
seen ; every detail must then necessarily receive con-
siderable attention.
A TABLE OF THE ENLARGEMENT OF THE
OPHTHALMOSCOPIC IMAGE.
Inverted image Upright Proportion,
with + 13 D. image.
Emmetropiii ... ... ... 5*2 ... 20 ... 1 to 4
Hypermetropia(uxial)of 12D. 7 ... 18-4 ... 1 to 26
Myopia (axial) of 12 D. ... 4-3 ... 30 ... 1 to 7
y of the Ahmerfa
uouiib ooaiation
of upU.metrists
INDEX
Albino, 22, 82
Albuminuric retinitis, 117
Anaemia of discs, 137
Angle of deviation, 9
principal, 9
Anterior chamber, 94
Appearances of normal fundus, 81
Appendix, 151
Aqueous chamber, 94
Artery, central, 89
embolism of, 129
Artificial eye, Frost's, 34
Atrophic cup, 141
Atrophy of discs, 138
of retina, 122
of the choroid, 112
Axes, secondary, 12
Axis, principal, 9
B
Biconcave lens, 11
Biconvex lenses, 11
Cataract, 9G
Central artery and vein, 89
Chamber, anterior, 94
Cherry-coloured spot, 130
Cholesterine, 101
Choroid, 105
colloid disease of, 114
colobonia of, 113
rupture of, 113
sarcoma of, 114
tubei'cle of, 113
Choroidal hajmorrhage, 112
ring, 88
Choroiditis, 106
central, 110
disseminated, 109
guttate, 135
myopic, 110
plastic, 106
purulent, 103
senile. 111
suppurative, 108
Choroido-retinitis, 106
Cilio-retinal vessel, 91
Colloid disease of choroid, 114
Coloboma of choroid, 114
Commotio retinae, 134
Concave lens, 11
mirror, 26
at a distance, 38
156
INDEX
Conc;eiiital crescent, 148
Conical cornea, 93
Connective tissue on disc, 150
Consecutive optic atrophy, 138
Convex lens, 11
Cornea, 92
Corneal opacities, 02
Couper's ophthalmoscope, 28
Crescent, congenital, 148
Crescent, myopic, 112, 147
Cribrosa, lamina, 88, 141
Cup, atrophic, 141
glaucoma, 142
physiological, 87, 141
Detachment of retina, 123
Deviation, angle of, 9
Diabetic retinitis, 117
Direct examination, 53
positions for, 54
Disc, optic, 86
hyperemia of, 137
image of, 41
inflammation of, 144
size of, 86
Disseminated choroiditis, 109
Embolism of central artery, 129
Emergent ray, 7
Estimation of refraction by reti-
noscopy, 68
by the direct, 62
Examination, methods of, 32
direct, 53
Examination, focal illumination, 36
indirect, 41
Floating opacities, 40, 100
Focal illumination, 36
Focus, anterior, 10
conjugate, 4, 10
negative, 10, 15
principal, 6
virtual, 5
Formation of images, 17
Fovea centralis, 85
Frost's artificiiil eye, 3i
Fuchs, 148
Galizowslii's ophthalmoscope, 31
Glass, index of refraction of, 7
magnifying, 31
Glaucoma cup, 142
Glioma of the retina, 134
Guttate choroiditis, 135
H
Hffiraorrhage, choroidal, 112
into nei've-sheath, 130
into vitreous, 100
macular, 120
retinal, 119
subhyaloid, 120
Helmholtz, 23
Hyaloid artery, 119
Hyperemia of choroid, 105
of disc, 137
of retina, 129
INDEX
157
I
Illumination, focal, 36
linages, formation of, 17
real, 20
virtual, 18
Incident ray, 7
Index of refraction, 7
of cornea, 7
of glass, 7
Indirect examination, 41
Inflammation of tlie choroid, 106
disc, 144
retina, 117
Inverted image, 18
Iris, 94
K
Keratitis, 93
punctata, 93
Lamellar cataract, 96
Lamina cribrosa, 88, 141
vitrea, 114
Lens, 95
Lenses, 11
biconcave, 11
biconvex, 11
converging, 11
diverging, 11
LeucocytliKmic retinitis, 117
Lutea, macula, 85
M
Macula lutea, 85
Macular Lamorrhage, 120
Magnification by the direct method,
57
by the indirect method, 51
Magnifying glass, 31
Methods of examination, 32
Mirror, concave, 26
for retinoscopy, 31, 68
plane, 26
tilted, 26
Morton's ophthalmoscope, 28
Myopia, 112
Myopic choroiditis, 110
crescent, 112
N
Nerve, optic, 86, 136
Nerve- fibres, opaque, 149
Neuritis (see Papillitis), 144
retro-bulbar, 146
New vessels in vitreous, 104
Normal fundus, appearances of, 81
varieties of, 83
Objective lens, 31
Oblique illumination, 36
Opacities, corneal, 92
floating, 40, 100
vitreous, 100
Opaque nerve-fibres, 149
Ophthalmoscope, 21
demonstrating, 31
Galizowski's, 31
Morton's, 28
Optic disc, 86
nerve, 86, 136
Optics, 1
158
INDEX
Tiipillitis, 1 14
Parallax, 143
Physiological cup, 87, 111
PigiiR'ntation, cliangcs in, 122
Pignieiitosa, rctiuitis, 122
Plane mirror, 26
Positions for direct, 53
for indirect, 42
Primary atrophy, 138
Principal angle, 8
axis, 9
focal distance, 9
focus, 9
Prisms, 8
Pulsation, arterial, 131
venous, 132
Punctata keratitis, 93
Purulent choroiditis, 108
R
Rays, 1
Real image, 20
Reflection, 2
by a concave surface, 3
by a convex surface, 6
by a plane surface, 2
Refraction, 6
by a plane surface, 6
by a prism, 8
by a spherical surface, 9
by lenses, 11
estimation of, G2
index of, 7
Retina, 82, 116
detachment of, 123
glioma of, 134
Retinal haemorrhages, 119
vessels, 127
Retinitis, 117
albuminurica, 117
diabetic, 117
leucocythajmic, 117
pigmentosa, 122
proliferans, 134
septic, 117
syphilitic, 117
Retinoscopy, 68
Ring, choroidal, 88
sclerotic, 88
Rupture of choroid, 113
Sarcoma of choroid, 114
Sclerotic ring, 88
Secondary axes, 12
optic atrophy, 138
Senile choroiditis, 111
Septic retinitis, 119
Shadows in retinoscopy, 68
Sparkling synchysis, 101
Subhyaloid hajmorrhage, 120
Suppurative choroiditis, 108
Thrombosis of central vein, 131
Tilted mirror, 2Q
Tubercle of choroid, 113
Tyrosin, 101
Variations in the size of image, 46
Varieties of the normal fundus, 82
INDEX
159
Vein, central, 89
thrombosis of, 131
Vessels, central, 89
cilio-retiual, 91
retinal, 127
Virtual focus, 5
image, 18
Vitrea lamina, 114
Vitreous, 99
air- bubbles in, 103
liajmonhage into, 100
new vessels in, 104
opacities, 100
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Analysis (if L'o.OnO Consecutive Cases and a Foriiiulary. IJy Difncan
!<;. 13'l'LKLEV, MI)., New York. Fourth Edition, royal Itwiu,, tis. <"!.
Diseases of the Skin : a Practical Treatise for
students and Practitioners. By J. N. Hvdk, M.D., Professor of
Skin and Venereal Diseases, Kush Mediwil Collcf^e, Chicaj^o. Second
Edition. 8vo, with 2 Coloured Plates and 96 Enf^ravinf^s, 20s.
Skin Diseases of Children. By Geo. H. Fox,
M.I)., Clinical Professor of Diseases of the Skin, College of Physicians
and Surgeons, New York. With 12 Photogravure antl Chroniographic
Plates and GO Illustrations in the Text. Koj'al 8vo, 12s. 6<1.
Sarcoma and Carcinoma : their Pathology,
Diagnosis, and Treatment. By Henky T. Butlin, F.Il.C.S., Assistant
Surgeon to St. Bartholomew's Hospital. 8vo, with 4 Plates, 8s.
By the same Author.
Malignant Disease of the Larynx (Sarcoma
and Carcinoma). 8vo, with 5 Engravings, 58.
Also.
Operative Surgery of Malignant Disease. 8vo,148.
Cancers and the Cancer Process : a Treatise,
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the Cancer Hospital, Brompton. Svo, with 15 Plates. 15s.
By the same Author.
The Re-appearance (Recurrence) of Cancer
after apparent Extirpation. 8vo, .^s. tjd.
Also.
The Palliative Treatment of Incurable Cancer.
Crown 8\-o, 2s. 6d.
Diagnosis and Treatment of Syphilis. By
Tom lioniNSON, M.D. St. And., Physician to the Western Skin Hos-
pital. Crown 8vo, .'Js. 6d.
By the same Author,
Eczema : its Etiology, Pathology, and Treat-
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Also.
Illustrations of Diseases of the Skin and
Syphilis, with liemarks. Fasc. I. with 3 Plates, imp. 4to, 58.
7, GREAT MARLBOROUGH STREET.
21
J. iSf A. Churchill *8 Recent Works.
Cancerous Affections of the Skin (Epithelioma
Jiiul Kdikiit Ulci'i). 13y (JkuK(;kTiii\,M.D. Tost Svo, with 8 EiiKniv-
'"^'^' •''^- By the same Author:
Pathology and Treatment of Ringworm.
Svo, w ith 21 Eii;,'r;ivinffs, "is.
On Cancer : its Allies, and other Tumours :
tlicir Medical and Surgical Treatment. Uy F. A. Puuckll, M.D.,
M.C., Surgeon to the Cancer Hospital, I3rompton. Svo, with 21
Knjjravings, 10s. (5d.
Urinary and Renal Derangements and Calcu-
lous Disorders. By Lionel S. Bealk, F.H.C.P., F.K.S., Phj'sician to
Kinjj's Collefje Hospital, Svo, 5s.
Chemistry of Urine : a Practical Guide to the
Analytical Examination of Diabetic, Albuminous, and Gouty Urine.
By Alfred H. Allen, F.I.C, F.C.S., Public Analj'st for the West
Hiding of Yorkshire, &c. Svo, with Engravings, 7s. 6d.
Clinical Chemistry of Urine (Outlines of the).
By C. A. MacMunn, M.A., M.D. Svo, with 64 Engravings and Plate
of Spectra, 93.
Diseases of the Male Organs of Generation.
By W. H. A. Jacobson, M.Ch.Oxon., P.E.C.S., Assistant-Surgeou to
Guy's Hospital. Svo, with 88 Engravings, 223.
Atlas of Electric Cystoscopy. By Dr. Emil
Bl'RCKIIARdt, late of the Surgical Clinique of the University of
Bale, and E. Hurry Fenwiok, F.R.C.S.. Surgeon to the London
Hospital and St. Peter's Hospital for Sfone. Koyal Svo, with 34
Coloured Plates, embracing S3 Figures. 21s.
Electric Illumination of the Bladder and
Urethra, as a Means of Diagnosis of Obscure Vesico-Urethral Diseases.
By E. Hurry Fenwick, F.R.C.S., Surgeon to London Hospital and
St. Peter's Hospital for Stone. Second Edition. 8vo, with 54 En-
gravings, 6s 6d.
By the Same Author.
Tumours of the Urinary Bladder. The Jack-
son ian Prize Essay of 1887, rewritten with 200 additional cases. In
four Fasciculi. Fas. I. Itoyal Svo, 5s.
Also.
The Cardinal Symptoms of Urinary Disease :
their Diagnostic Significance and Treatment. Svo, with 36 Illustra-
tions, 8s. 6d.
7, GREAT MARLBOnOUGH STREET.
22
J. 8f A. ChurchilVs Recent Works,
By SIR HENRY THOMPSON, BART., F.R.C.S.
Diseases of the Urinary Organs. Clinical
Lectures. Eighth Edition. 8vo, with 121 En^raviiif^s, lOs. M.
Some Important Points connected with the
Surgery of the Urinary Organs. Lectures delivered in the It.C.S.
8vo, with 44 Engravings. Student's Edition, 2s. 6tl.
Practical Lithotomy and Lithotrity ; or, an
Inquiry into the Best Modes of llemoving Stone from the Bladder.
Third Edition. 8vo, with 87 Engravings, 10s.
The Preventive Treatment of Calculous Dis-
ease, and the Use of Solvent Kemedies. Third Edition. Cr. 8vo, 2s. Gd.
Tumours of the Bladder : their Nature, Sym-
ptoms, and Surgical Treatment. 8vo, with numerous Illustrations, .53.
Stricture of the Urethra, and Urinary Fistulae :
their Pathology and Treatment. Fourth E<lition. 8vo, with 74 En-
gravings, 6s.
The Suprapubic Operation of Opening the
Bladder for Stone and for Tumours. Svo, with Engravings, 38. 6d.
Introduction to the Catalogue ; being Notes
of 1,000 Cases of Calculi of the Bladder removed by the Author, and
now^ iu the Museum of K.C.S. Svo, 28.6d.
The Surgical Diseases of the Genito-Urinary
Organs, including Syphilis. By E. L. Keyes, M.D., Professor of
Genito-Urinary "Surgery, Sj^hiology, nnd Dermatology in Bellevue
Hospital Medical College, New York (a revision of Van Buken and
Keyks' Textrbook). Koy. 8vo, with 114 Engravings, 21s.
Lectures on the Surgical Disorders of the
Urinary Organs. By Keginald Hakrison, F.K.C.S., Surgeon to St.
Peter's Hospital. Fourth Edition. Svo, witli loG Eiignivings, 16s.
Syphihs. By Alfred Cooper, F.R.C.S., Con-
suiting Surgeon to the West London and the Lock Hospitals. Second
Edition. Edited by Edwakd Coxxekell, F.K.C.S., Surgeon (out-
patients) to the Loudon Lock Hospital. 8vo, with 24 Full-page
Plates (12 coloured), 188.
7, GREAT MARLBOROUGH I^TREET.
33
e/. (5r -4. Churchill^ 8 Recent Works.
On Maternal Syphilis, including the presence
ainl n-cof^iiitioii of Syphilitic Pelvic Discasf in Women. By John
A. Suaw-Mackknzik", M.D. Willi Coloured Plates, bvo, lUs. <ul.
Diseases of the Rectum and Anus. By Alfred
Cooi'KK, F.K.C.S., Senior Surj^eon to St. Mark's Hospital for
Fistula; an«l F. SwiNFOKD Edwards, P.li.C.S., Senior Assistiint
Surj^fon to St. Mark's Hospital. Second Edition, with Illustrations.
8vo, 12s.
Diseases of the Rectum and Anus. By
Hakhison Ckh'I's, F.K.C.S., Assistiint Surgeon to St. Bartholomew's
Hospital, etc. Second Edition. 8vo, with 13 Lithographic Plates and
numerous Wood Engravings, 126. 6d.
By the same Author.
Cancer of the Rectum. Especially considered
with remird to its Surgical Treatment. Jacksonian Prize Essay.
Third Edition, 8vo, with 13 Plates and several Wood Engravings, 63.
Also
The Passage of Air and Faeces from the
Urethra. 8vo, 38. 6d.
A Medical Vocabulary : an Explanation of all
Terms and Phrases used in the various Departments of Medical Science
and Practice, their Derivation, Meaning, Application, and Pronuncia-
tion. By R. G. Mayne, M.D., LL.D. Sixth Edition, by W. W.
Wagstaffe, B.A., F.R.C.S. Crown 8vo, 10s. 6d.
A Short Dictionary of Medical Terms. Being
an Abridgment of Mayne's Vocabulary. Glmo, 23. 6d.
Dunglison's Dictionary of Medical Science.
Contiiining a full Explanation of its various Subjects and Terms,
with their Pronunciation, Accentuation, and Derivation. Twenty-
first Edition. By Kichard J. Dunglison, A.M., M.D. Eoyal 8vo, 36s,
Terminologia Medica Polyglotta : a Concise
Ijiternational Dictionary of Mediciil Terms (French, Latin, English,
(terman, Italian, Spanish, and Russian). By Theodore Maxwell,
M.D., B.Sc, F.R.C.S. Edin. Royal 8vo, l(3s.
A German- English Dictionary of Medical
Terms. By Frederick Treves, F.R.C.S., Surgeon to the London
Hospital ; and Hugo Lang, B.A. Crown 8vo, half-Persian calf, 12s,
7, GBEAT MARLBOROUGH STREET.
24
J. ^ A. Churchill^ 8 Recent Works,
A Manual of Chemistry, Theoretical and Prac-
tical. By William A. Tilukn, D.Sc, F.ll.S., Professor of Chemistry
in the Koyal Collef(e of Science, London ; Examiner in Ciiemist ry to
the Department of bcience and Art. With 2 Plates and 143 Woodcuts,
crown 8vo, 10s.
Chemistry, Inorganic and Organic. With Ex-
periments. By Chaklks L. Bloxam. Eighth Edition, Ijy John
Millar Thomson, F.K.S., Professor of Chemistry in Kinj^'s Colle>/e,
London, and Arthuk G. Bloxam, Head of the Chemistry Di-piirt-
ment, tlie Goldsmiths' Institute, New Cross. 8vo, with 281 Engrav-
ings, 188. 6d.
By the same Author.
Laboratory Teaching ; or, Progressive Exer-
cises in Practical Cliemistry. Sixth Edition, by Arthur G. Bloxam.
Crown 8vo, with 80 Engravings, 68. 6d.
Watts' Organic Chemistry. Edited by William
A. TiLDKN, D.Sc, F.K.S., Professor of Chemistry, Koyal College of
Science, London. Second Edition. Crown 8vo, los.
Practical Chemistry, and Qualitative Analysis.
By Frank Clowks, D.Sc. Lond., Professor of Chemistry in the
University College, Nottingham. Sixth Edition. Post 8vo, with 84
Engravings and Frontispiece, 8s. 6d.
Quantitative Analysis. By Frank Clowes,
D.Sc. Lond., late Professor of Chemistry in the University College,
Nottingham, and J. Bkrnard Colkman, Assoc. K. C. Sci. Dublin ;
Professor of Chemistry, South-West London Polytechnic. Fourth
Edition. Post 8vo, with 117 Engravings, lOs.
By the same Authors.
Elementary Practical Chemistry and Qualita-
tive Analysis. With 5-1 Engravings, Post 8vo, 3s. Cd.
-4/50
Elementary Quantitative Analysis. With G2
Engravings, Post 8vo, 4s. Gd.
Qualitative Analysis. By R. Fresenius. Trans-
lated by Charlk.s E. Grovks, F.H.S. Tenth Edition. Svo, with
Coloured Plate of Spectra and Itj Engravings, 1.58.
By the same Author.
Quantitative Analysis. Seventh Edition.
Vol. I., Translated by A. Vacher. Svo, with
106 Engravings, 1.58.
Vol. II., Parts 1 to 5, Translated by C. E. Groves,
F.K.S. 8vo, with Engravings, 2s. 6d. each.
7, GREAT MARLBOROUGH STREET.
J. <5r A. ChurchiWs Recent Works,
Inorganic Chemistry. By Sir Edward Frank-
i,AM>, K.O.B., D.C.L., LL.D., F.li.S., and Fkancis \i. Japi', M.A.,
Ph.D., F.I.C., F.K.S., Professor of Chemistry in the University of
AlK-nieen. 8\ o, with numerous Ilhistrations on Stone and Wooii,"248.
Inorganic Chemistry (A System of). By
William Kamsay, Ph.D., F.Il.S., Professor of Chemistry in the
University College, London. 8vo, with Engravings, 158.
By the same Author.
Elementary Systematic Chemistry for the Use
of Schools and Colleges. With Engravings. Crown Svo, -is. 6d. ;
Interleaved, .5s. Gd.
Valentin's Practical Chemistry and Qualitative
and Quantitative Analysis. Edited by Dr. W. K. Hodgkinson,
F.ll.S.E., Professor of Chemistry and Ph3^8ics at the Royal Military
Academy, and Artillery College, Woolwich. Ninth Edition. 8vo, with
Engrax-tngs and Map of Spectra. 9s. (The Tal)los separately, 2s. (d.)
Practical Chemistry, Part I. Qualitative Exer-
cises and Analytical Tables for Students. By J. Campbell Browx,
Professor of Chemistry in Victoria University and University College,
Liverpool. Fourth Edition. Svo, 2s. 6d.
The Analyst's Laboratory Companion : a Col-
lection of Tal)les and Data for Chemists and Students. By Alfred
E. JOHN.SON, A.R.C.S.I., F.LC. Second Edition. Crown 8vo, cloth,
5s. ; leather, Gs. M,
Commercial Organic Analysis : a Treatise on
the Properties, Modes of Assaying, Proximate Analytical Examination,
etc., of the various Organic Chemicals and Products employed in the
Arts, Manufactures, Medicine, etc. By Alfred H. Allen, F.LC.
Third Edition.
Vol. I., 18s. ; Vol. IL, Part I., Us.
Second Edition.
Vol. III., Pt. IL, 18s.; Vol. III., Pt. III., 18s. ;
Vol. IV., completing the work, ISs.
Volumetric Analysis (A Systematic Hand-
book of) ; or the Quantitative Estimation of Chemical Substances by
Meivsure, applied to Liquids, Solids, and Gases. By Francis Sutton,
F.C.S., F.I.C, Public Analyst for the County of Norfolk. Seventh
Edition. Svo, with 112 Engravings, 18s. 6d.
7, GREAT MARLBOROUGH STREET.
J. ^ A. Churchill's Recent TForJcd.
Chemical Technology: or, Chemistry in its
Applications to Arts and Manufactures. Edited by Chahles E.
Groves, F.K.S., and Wilmam Thoup, B.Sc.
7oL. I.— Fuel and its Applications. By E.J.
Mills, D.Sc, F.R.S., and F. J. liowAy, C.E. lloyal 8vo, with
t)06 Engravings, 30s.
Vol. II.— Lighting, Fats and Oils, by W. Y.
Dent. Stearine Industky, by J. McAhthuk. Candi.k Manu-
facture, by L. FIELD an.l F. A. Field. The Petuolkl-m
IXDUSTKY AND LAMPS, by BoVEKTON UeDWOOD. MINEKS SAIEIY
Lamps, by B. Kedwood and D. A. Louis. Koyal 8vo. with 358
Engravings and Map, 20s.
Cooley's Cyclopaedia of Practical Receipts,
and Collateral Information in the Arts, Manufactures, Professions,
and Trades : including Medicine, Pharmacy, Hygiene, and Domestic
Economy. Seventh Edition, by W. North, M.A. Camb., F.C.b.
2 Vols., Hoy. 8vo, with 371 Engravings, 42s.
Chemical Technology : a Manual. By Rudolf
VON WAGNER. Translated and Edited by Sir William Crookes
F R S from the Thirteenth Enlarged German Edition as remodelled
by Dr' Ferdinand Fischer. 8vo, with 596 Engravings, 32s.
Technological Handbooks. Edited by John
Gardner, F.LC, F.C.S., and James Cameron. F.LC.
Brewing, Distilling, and Wme Manu-
facture. Crown 8vo, with Engravings, Cs. Cd.
Bleaching, Dyeing, and Calico Pnntmg.
With Formulae. Crown 8vo, with Engravnigs, os.
Oils, Resins, and Varnishes. Crown bvo,
with Engravings, 7s. 6d. ..i kj t?
Soaps and Candles. Crown 8vo, with 54 l^n-
MethodsTnd Formulae used in the Preparation
of Animal and Vegetable Tissues for Microscopiail Ex.innnation in-
cluding the Staining of Bacteria. By Pktkr Wyatt S^^uire, KL.S.
Crown 8vo, 3s. 6d. . , c? •
The Quarterly Tournalof Microscopical Science.
Edited by E. Kav Lankestkr, M.A., LL.D., ^'l^^^- =-'/'' ^J^LiT
operation of Adam Sedgwick. M.A., F.11.S.. and W. F. U. Weldon.
M.A., F.K.S. Bach Number, lOff.
7, GMEAT MARLBOROUGH STREET.
J. 8f A. ChurchilVs Recent Works,
The Microscope and its Revelations. By the
late WlLUAM B. Cakpkntku, C.B., M.I)., LL.U., F.K.S. Seventh
K.lition, by tlie Kev. W. H. Dallingkk, LL.U., F.K.S. With 21
Pliites and 800 Wooti Kiigraviugs. »vo, 2t33. Half Calf, ."iOs.
The Microtomist's Vade-Mecum : a Handbook
of the Methods of Microscopic Anatomy. By Arthur Bolles Lee.
Fourth Edition, 8vo, ITis.
Photo-Micrography (Guide to the Science of).
By Edward C. Bousfield, L.R.C.P. Lond. 8vo, with 34 Engravings
and Frontispiece, 6s.
An Introduction to Physical Measurements,
with Appendices on Absolute Electrical Measurements, etc. By Dr.
F. KoHLRAUSCH, Professor at the University of Strassburg. Third
Edition, translated from the seventh German edition, by Thomas
Hutchinson Wallkk, B.A., B.Sc, and Henry Richardson Procter,
F.LC, F.C.S. 8vo, with 91 Illustrations, 12s. 6d.
Tuson's Veterinary Pharmacopoeia, including
the Outlines of Materia Medica and Therapeutics. Fifth Edition
Edited by James Bayne, F.C.S., Professor of Chemistry and
Toxicology in the Royal Veterinary College. Crown Svo, 7s. 6d.
The Veterinarian's Pocket Remembrancer :
being Concise Directions for the Treatment of Urgent or Rare Cases,
embracing Semeiology, Diagnosis, Prognosis, Surgery, Therapeutics,
Toxicology, Detection of Poisons by their Appropriate Tests, Hygiene,
etc. By Geokge Armatage, M.R.C.V.S. Second Edition, Post
Svo, 3s.
Chauveau's Comparative Anatomy of the
Domesticated Animals. Revised and Enlarged, with the Co-operation
of S. Arloing, Director of the Lyons Veterinary School, and Edited
by George Fleming, C.B., LL.D., F.R.C.V.S., late Principal Veteri-
nary Surgeon of the British Army. Second English Edition. Svo,
with .585 Engravings, 31s. 6d.
Human Nature, its Principles and the Principles
of Physiognomy. By Physicist. Part I., Imp. l(3mo, 2s.
The Brain-Machine, its Power and Weakness.
By Albert Wilson, M.D. Edin, With 37 Illustrations, Svo, 4s. 6d.
7, GREAT MARLBOROUGH STREET.
23
Index "TO J. & A. Churchill's Cataloouk.
Allen's Chemistry of Urine, 22
Commercial Orfjanic Analy-
sis, 26
Anderson on Fingers ami Toes, IS
Armalatje's Vetei iiiiuy J'ocl<et Re-
membrancer, 2S
Barnes' (R.) Obstetric Operations, (i
Diseases of Women, (5
Beale (L. S.) on Livf^r, 12
Microscope in Medicine, 12
Sliglit Ailments, 12
Urinary and Renal Derange-
ments, 22
Beale (P. T. B.) on Elementary
Biology, 3
Beasley's Book of Prescriptions, 8
Druggists' General Receipt
Book, s
Pharmaceutical Formu-
lary, 8
Bell on"SteriIity, 6
Bellamy's Surgical Anatomy, 2
Bentley and Trimen's Medicinal
Plants, 9
Bentley's Systematic Botany, 9
Berkart's Bronchial Asthma, 13
Bernard on Stammering, 14
Bigg's Short Manual of Orthopaedy,
18
Bloxam's Chemistry, 25
Laboratory Teaching, 2o
Bousfield's Photo-Micrography, 28
Bowlby's Injuries and Diseases of
Nerves, 17
Surgical Pathology and
Morbid Anatomy, 17
Broekbank on Gallstones, 15
Brodburst's Anchylosis, 17
■ -Curvatures of Spine, 17
Dislocation of Ifip, 17
TalipesEquino-Varus,17
Brown's Midwifeiy, ti
Brown's Practical Clieniistry, 2<5
Bryant's Practice of Surgery, 17
Bu'kley on Skin, 21
Burckhardt and Fenwick's Atlas of
Electric Cystiiscopy, 22
Burdett's Hospitals and Asylums of
the World, 4
Butler-Smythe's Ovariotomies, 6
Butlin's Malignant Disease of the
Larynx, 21
Operative Surgery of Malig-
nant Disease, 21
Butlin's Sarcoma and Carcinoma, 21
Buzzard's Diseases of the Nervous
System, 14
Peripheral Neuritis, 14
Simulation of Hj-steria,
14
Cameron's Oils, Resins, and Var-
nishes, 27
Soaps and Cantlles, 27
Carpent-er ami Daliinger on the Mi-
croscope, 2K
Carpenter's Ilunian Physiology, .'J
Cautley on Feeding Infants, 7
Charteris' Practice of Medicine, 11
Chauveau's Comparative Anatomy,
28
Chevers' Diseases of India, 10
Churchill's Face and Foot Deformi-
ties, 18
Clarke's Eyestrain, 19
Clouston's Lectures on Mental
Diseases, 4
Clowes and Coleman's Quantitative
Analysis, 25
Clowes and Coleman's Elementary
Practical Chemistry, 25
Clowes' Practical Chemistry, 25
Coles on Blood, 12
Cooley's Cj'clopsedia of Practical
Receipts, 27
Cooper's Syphilis, 2.3
Cooper and Edwards' Diseases of the
Rectum, 21
Cripps' (H.) Ovariot^imy and Ab-
dominal Surgery, 17
Diseases of the Rectum
and Anus, 24
Cancer of Rectum, 21
Air and Fa'cesin Urethra,
24
Cripps' (R. A.) Galenic Pharmacy, 8
Cuff s Lectures to Nurses, 7
Cullingworth's Manual of Nursing,?
Monthly Nurses, 7
Dalby's Diseases and Injuries of the
Ear, 20
Short Ccmtributions, 20
Dana on Nervous Diseases, I I
Day on Diseases of Children, 7
on Headivches, 15
Domville's Manual for Nurses, 7
Doran's Gyna^cologicjil Oin-rations, 6
Druitt's Surgeon's Vade-Meeiini, 17
Duncan (A.) on Prevention of Dis-
ejises in Tropics, 10
[Vimthiued on next pape.
7, GREAT MARLBOROUGH STREET,
IHSKX TO J. ft A. OHUKOHTLL'S OATi-LOOUK— COntiniMt/.
Bllis's (T. S.) Human Foot, IS
Fiijjjjp's Principles and Practice of
Medicine, 10
Fay rer'6 Climate and Fevers of India,
10
Natural History, etc., of
Cholera, 10
Fenwick (E. H.). Kleetric Illumina-
tion of Blad(l<!r, 22
Symptoms of Urinary Dis-
ease, 22
Tumours of Bladder, 22
Fenwick's (S.) Medical Diafjnosis, 12
Obscure Diseases of the
Abdomen, 12
Outlines of Medical Treat-
ment, 12
The Saliva as a Test, 12
Fink's Operating for Cataract, 19
Flower's Diagrams of the Nerves, 2
Fowler's Dictionary of Practical
Medicine, 11
Fox (G. H.) on Skin Diseases of
Children, 21
Fox (Wilson), Atlas of Pathological
Anatomy of the Lvmgs, 11
Treatise on Diseases of the
Lungs, 11
Frankland and Japp's Inorganic
Chemistrj', 26
Fi-aser's Operations on the Brain, 16
Presenilis' Qualitative Analysis, 2o
Quantitative Anal3'sis, 25
Qalabin's Diseases of Women, 6
Manual of Midwifery, 5
Gardner's Bleaching, Dj'^eing, and
Calico Printing, 27
Brewing, Distilling, and
Wine Manufacture, 27
Gimlette's M^^xoedema, 12
Glassington's Dental Materia Medi-
ca, 20
Godlee's Atlas of Human Anatomy,
1
Goodhart's Diseases of Children, 7
Gowers' Diagnos is of Brain Disease,
18
Diseases of Nervous Sys-
tem, r.i
Medical Ophthalmoscopy, 13
Sj'philis and the Nervous
System, 13
Granville on Gout, 14
Green's Manual of Botany, 9
Groves and Thorp's Chemical Tech-
nology, 27
Guys Hospital Reports, 11
Habershon's Diseases of the Abdo-
men, 15
Haig's Uric Acid, 13
Diet and Food, 4
Harlev on Diseases of the Liver, 14
Harris's (V. D.) Diseases of Chest, 11
Harrison's Urinary Organs, 23
Hartridge's Kefraction of the Eye, 19
0}>htlialmoseope, 19
Hawthorne's Galenical Prepara-
tions, 8
Heath's Certain Diseases of the
Jaws, 16
Clinical Lectures on Sur-
gical Subjects, 16
Injuries and Diseases of the
Jaws, 16
Minor Surgery and Ban
daging, 16
Operative Surgery, 16
Practical Anatomy', 1
Surgical Diagnosis, 16
Hellier's Notes on Gynaecologica
Nursing, 7
Hewlett's Bacteriology, 4
Higgens' Ophthalmic Out-patient
Practice, 19
Hill on Cerebral Circulation, 2
Hillis' Leprosy in British Guiana, 20
Hirschfeld's Atlas of Central Ner-
vous System, 2
Holden's Human Osteology, I
Landmarks, 1
Holthouse on Stral)ismus, IS
Hooper's Phj^sicians' Yade Mecnm ,
10
Hovell's Diseases of the Ear, 20
Human Nature and Phj'siognomy,
28
Hyde's Diseases of the Skin, 21
Hj'slop's Mental Physiology, 5
Impey on Leprosy, 21
Ireland's Mental Affections of
Children, 5
Jacobson's Male Organs, 22
Operations of Surgery, 17
Jellett's Midwifery 5
Jessop's Ophthalmic Surgery and
Medicine. IH
Johnsons (Sir G.) Asphyxia, 12
Medical Lectures and Es-
says, 12
Cholera Controversy, 12
(A. E.) Analyst's Com-
panion, 26
{Continued on next page.
7, GREAT MARLBOROUGH STREET,
INDKX TO J. & A. Ohitbchiix's AT AijOQiTa— Continued.
Journal of Mental Science, 5
Kello}ij{ on Mental Diseases, 5
Kt^es' Cienito-Urinary Orjjans and
Syjihilis, 2."i
Kohlruuschs Physical Measure-
ments, 2.S
Lane's Kheumatio Diseases, 14
Lanj^don Dcnvn's Mental Affections
ol" Chil(iho<Hl, T
Laiarus Barlow's General Patho-
logy, 2
Lee's Microt-omists' Vade-Mecum, 28
Lescher's liecent Materia Med lea, 9
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