THE LIBRARY 
 
 OF 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 LOS ANGELES
 
 RETINOSCOPY 
 
 (SHADOW TEST) 
 
 THORINGTON
 
 Reviews of the 
 First Edition of 
 
 Thorington's Retinoscopy, 
 
 From "The Medical Record," New York. 
 
 "This little manual deserves a second edition, and will undoubtedly pass through 
 many more. It presents a clear, terse, and thorough exposition of an objective 
 method of determining refraction errors which is deservedly increasing in popularity. 
 In our opinion the author is amply justified in declaring that its great value in nystag- 
 mus, young children, amblyopia, aphakia, and in examining illiterates and the feeble- 
 minded can not be overestimated, and we agree with him in reminding those who 
 attempt retinoscopy, fail, and ridicule it, that the fault is behind and not in front of 
 the mirror. The book is well printed and usefully illustrated." 
 
 From "The Annals of Ophthalmology," St. Louis. Mo. 
 
 " Retinoscopy has come to stay. It is not a fad, neither a fashion. It is scientific, 
 and withal so eminently practical in its application as to commend it to every think- 
 ing worker in ophthalmology. The tendency in the medicine of to-day is toward 
 objective methods. An objective method must possess two attributes : exactness 
 and absolute independence of the patient's testimony. In addition to these qualities, 
 an objective method must, if it is to meet with general acceptance, be easy of applica- 
 tion. Ophthalmoscopy and ophthalmometry are but relatively exact in refractive 
 work, seeing which the trial-case has held its supremacy up to date; nor would we 
 wish to relegate it to the background. With a patient whose testimony is trust- 
 worthy exact results are thus obtainable, but it requires the most intelligent coopera- 
 tion on the part of the examined. If, however, there be but the least departure from 
 the conditions essential to close work with the test-lenses, as, for instance, with for- 
 eigners, illiterates, children, partial amblyopics, or mental astigmatics, retinoscopy 
 stands ready to furnish a verdict from which there can be no appeal, when one has 
 learned to properly interpret the movements observed in the pupillary area. It is to 
 the elucidation of these latter movements as observed through a plane mirror at a 
 distance of one meter that Dr. ThoriiiKton devotes himself in the volume before us. 
 The treatment of the subject is so beautifully simple that one who runs may read." 
 
 From "The Journal of the American Medical Association," Chicago, III. 
 
 " The author of this well-written little book has very satisfactorily described the 
 most approved methods of retinoscopy. The work is especially valuable in that for a 
 great part it details the results of personal investigation of so well-known an 
 authority on this subject as Dr. Thorington. Oculists accustomed to casually use 
 retinoscopy as practised in the old way, with the concave mirror or with the ophthal- 
 moscopic mirror, will be surprised to note the marked evolution of the modus oper- 
 andi of this test as developed by Drs. Jackson and Thorington. With perfected in- 
 struments and strict attention to arrangement of light, distance, and other details, a 
 surprising degree of proficiency and accuracy is possible. Any one pursuing the 
 modern methods of retinoscopy will soon be convinced of its superiority over all 
 other objective tests, and every worker in ophthalmology realizes the necessity of at 
 least one reliable objective method of refraction." 
 
 From " The New Orleans Medical and Surgical Journal," New Orleans, La. 
 
 "We have nothing but a good word for this little book. It seems to fulfil well 
 the purpose intended. It gives a brief, clear description of the means and manner of 
 retinoscopy, together with the principles or natural laws upon which it is founded. 
 The author has done well in selecting the method he thinks best and simplest, and has 
 confined himself to it, so that the student will have no difficulty or confusion in fol- 
 lowing the manual step by step, and learning to put in practice for himself what is 
 described in the pages. This once accomplished, he can readily, if he becomes con- 
 vinced of its usefulness, acquire the variations and refinement upon this mode ot 
 examination." 
 
 From "The New York Medical Journal," New York. 
 
 " This little book presents as simple and practical a description of the shadow 
 test as exists in our language."
 
 Prom "The Scottish Medical and Surgical Journal," Edinburgh, Scotland. 
 
 " Dr. Thorington's lucid text is accompanied by twenty-four good illustrations, 
 and on every page one notes that careful attention has been paid to little details of 
 manipulation which stamp the writer as a practical teacher." 
 
 Prom "The Homeopathic Eye, Ear, and Throat Journal," New York. 
 
 " A practical and useful book. This is one of the most concise and clearest ex- 
 planations of this subject we have seen. Retinoscopy is one of the most valuable aids 
 we have in refractive work." 
 
 From " The Denver Medical Times," Denver, Col. 
 
 " His directions and descriptions are exceptionally clear and concise, and the 
 little book he has written, we think, will be helpful to every physician who is inter- 
 ested in the fitting of glasses." 
 
 Prom "The Chicago Medical Recorder," Chicago, III. 
 
 " This little book is the most practical and complete exposition of the value and 
 application of the shadow test in determining refractive errors with which we have 
 any acquaintance. The illustrations, directions, advice, and general information in 
 the book are all admirable." 
 
 From "The Post-Qraduate," New York. 
 
 " This work on retinoscopy is divided into six chapters and an index. As stated 
 in the preface, it is an abstract of the author's previous writings and lectures on 
 retinoscopy, delivered at the Philadelphia Polyclinic. It is intended for college 
 students and post-graduates, yet is sufficiently complete for the use of the ophthal- 
 mologist. Retinoscopy has been selected as the name of the test, as it is the retina 
 in its relative position to the refractive media which is studied. Skiascopy and skia- 
 graphy are therefore regarded as misleading. To all those who are interested in 
 this test for the determination of refraction we commend the work." 
 
 From "The Philadelphia Polyclinic," Philadelphia. 
 
 " We take pleasure in commending this concise statement of the methods to be 
 employed in the routine use of a most valuable objective means of determining the 
 errors of refraction. The student is told in simple English how to proceed in the 
 examination." 
 
 From "The Boston Medical and Surgical Journal," Boston, Mass. 
 
 " This little manual is certainly the clearest exposition of this method of estimat- 
 ing refraction of the eye that has yet been published. The methods described are not 
 so complicated as those taught in some other handbooks. The text is clear, and the 
 illustrations serve the purposes for which they are designed admirably. Taken 
 altogether, it is the most practicable handbook on retinoscopy yet published." 
 
 From "The Journal of Ophthalmology, Otology, and Laryngology," New- 
 York. 
 
 " We most emphatically recommend this little book to the beginner in the study 
 of this method of determining refraction. The title is an index of the character of the 
 text. It is positive, exact, practical. The aim of the author has-been to present 
 facts, and in as small space as possible. He has succeeded absolutely. The average 
 work on this subject is, to the beginner, somewhat confusing, from the amount of 
 theory presented theory which is not a'ways clear to the student. This has been 
 avoided in the present case. Little, if any, theory is included, and the monograph is 
 a series of categorical statements clear, precise, and sufficient." 
 
 # * * The price of this book (third edition, revised 
 and enlarged) is $J.OO net, upon receipt of which it will 
 be sent postpaid to any address. It may be obtained from 
 the publishers or through any bookseller or dealer in 
 opticians' supplies.
 
 RETINOSCOPY 
 
 (OR SHADOW TEST) 
 
 DETERMINATION OF REFRACTION AT ONE METER 
 DISTANCE, WITH THE PLANE MIRROR 
 
 JAMES THORINGTON, M. D. 
 
 ADJUNCT PROFESSOR OF DISEASES OF THE EYE IN THE PHILADELPHIA POLYCLINIC AND 
 COLLEGE FOR GRADUATES IN MEDICINE; ASSISTANT SURGEON TO WILL'S EYE HOS- 
 PITAL; OPHTHALMOLOGIST TO THE ELWYN AND VINELAND TRAINING SCHOOL FOR 
 FEEBLE-MINDED CHILDREN; OPHTHALMOLOGIST TO THE M. E. ORPHANAGE; 
 LECTURER IN THE PHILADELPHIA MANUAL TRAINING SCHOOLS, 1896-97. 
 ON THE ANATOMY, PHYSIOLOGY, AND CARE OF THE EYES; RESIDENT 
 PHYSICIAN AND SURGEON PANAMA RAILROAD CO. AT COLON 
 (ASPINWALL), ISTHMUS OF PANAMA, 1882-1889, ETC. 
 
 THIRD EDITION, REVISED AND ENLARGED 
 
 FORTY-THREE ILLUSTRATIONS 
 
 TWELVE OF WHICH ARE COLORED 
 
 PHILADELPHIA 
 
 P. BLAKISTON'S SON & CO 
 
 1012 WALNUT STREET 
 1899
 
 COPYRIGHT, 1899, BY JAMES THORINGTON, M.D. 
 
 PRESS or WM. F. FELL ft Co.. 
 I22O-24 SANSOM ST.. 
 
 PHILADELPHIA.
 
 BOOK IS AFFECTIONATELY DEDICATED TO THE 
 MEMORY OF 
 
 FELIX A. BETTELHEIM, PH.D., M.D., 
 
 MY FRIEND AND ASSOCIATE DURING HIS SIX YEARS' RESI- 
 DENCE, AS SURGEON OF THE PANAMA RAILROAD 
 COMPANY, AT PANAMA.
 
 PREFACE TO THIRD EDITION. 
 
 The first edition of " Retinoscopy " was published 
 in March, 1897, and it is most gratifying to the 
 author that the subject continues to merit sufficient 
 attention to call for a third edition in less than 
 two years. Endeavoring to make the book more 
 worthy of the favor with which it has been re- 
 ceived and for a clearer understanding of the sub- 
 ject, some few changes in phraseology have been 
 made and five additional illustrations incorporated. 
 
 120 S. EIGHTEENTH ST., PHILADELPHIA, PA., 
 
 February, f8qg.
 
 PREFACE TO THE SECOND EDITION. 
 
 The first edition of this book was published in 
 March, 1897, and it is indeed gratifying to the 
 author that the work has found such favor as to 
 call for a second in so short a time. 
 
 To make this edition more lucid than the first, 
 the writer has carefully reviewed the original text 
 and made some changes in the phraseology, and at 
 the same time has added many new illustrations, 
 twelve of which are in colors. 
 
 A description and drawings of three lenses, sug- 
 gested by the author for the study of the scissor 
 movement, conic cornea, and spheric aberration on 
 the schematic eye, have also been inserted. 
 
 1 20 S. EIGHTEENTH ST., PHILADELPHIA, PA., 
 February, 1898.
 
 PREFACE TO THE FIRST EDITION. 
 
 At the earnest solicitation of many students and 
 friends, this book is presented as an abstract of the 
 author's previous writings and lectures on Retinos- 
 copy, delivered during the winter course on Oph- 
 thalmology, at the Philadelphia Polyclinic. 
 
 In presenting a manual of this kind the writer 
 does not presume to detract from the writings or 
 teachings of others, or the excellent work on Skia- 
 scopy, by his friend and colleague. Dr. E. Jackson ; 
 but wishes to elucidate in as concise a manner and 
 few words as possible the method of applying 
 retinoscopy, which has given most satisfaction at 
 his hands. 
 
 While intended for college students and post- 
 graduates, yet there is ample material given where- 
 by the ophthalmologist at a distance may acquire a 
 working knowledge of the method, by study and 
 practice in his own office.
 
 xiv PREFACE TO THE FIRST EDITION. 
 
 For three reasons Retinoscopy, in preference to 
 Skiascopy, has been chosen as the title : 
 
 First, that it may not be confounded with Skia- 
 graphy. 
 
 Second, that it is the name by which the test is 
 universally known ; and 
 
 Third, that it is the retina in its relative position 
 to the dioptric media which we study. 
 
 120 S. EIGHTEENTH ST., PHILADELPHIA, PA., 
 March ,
 
 CONTENTS. 
 
 CHAPTER I. 
 
 PAGE 
 
 DEFINITION. NAMES. PRINCIPLE AND VALUE OF RETINOSCOPY 
 
 SUGGESTIONS TO THE BEGINNER, '9- 2 3 
 
 CHAPTER II. 
 
 RETINOSCOPE. LIGHT. LIGHT-SCREEN. DARK ROOM. SOURCE OF 
 
 LIGHT AND POSITION OF MIRROR. OBSERVER AND PATIENT, . 24-30 
 
 CHAPTER III. 
 
 DISTANCE OF SURGEON FROM PATIENT. ARRANGEMENT OF PATIENT, 
 LIGHT, AND OBSERVER. REFLECTION- FROM MIRROR. How 
 TO USE THE MIRROR. WHAT THE OBSERVER SEES. RETINAL 
 ILLUMINATION. SHADOW. WHERE TO LOOK AND WHAT TO 
 LOOK FOR, 3!~39 
 
 CHAPTER IV. 
 
 POINT OF REVERSAL. To FIND THE POINT OF REVERSAL. WHAT 
 TO AVOID. DIRECTION OF MOVEMENT OF RETINAL ILLUMINA- 
 TION. RATE OF MOVEMENT AND FORM OF ILLUMINATION. 
 RULES FOR LENSES. MOVEMENT OF MIRROR AND APPARATUS, 40-50 
 
 CHAPTER V. 
 
 RETINOSCOPY IN EMMETROPIA AND THE VARIOUS FORMS OF REGU- 
 LAR AMETROPIA. AXONOMETER, 51-67 
 
 CHAPTER VI. 
 
 RETINOSCOPY IN THE VARIOUS FORMS OF IRREGULAR AMETROPIA. 
 RETINOSCOPY WITHOUT A CYCLOPLEGIC. THE CONCAVE MIR- 
 ROR. DESCRIPTION OF THE AUTHOR'S SCHEMATIC EYE AND 
 LIGHT-SCREEN. LENSES FOR THE STUDY OF THE SCISSOR 
 MOVEMENT, CONIC CORNEA, AND SPHERIC ABERRATION, . . . 68-83 
 
 INDEX, 85-86
 
 LIST OF ILLUSTRATIONS. 
 
 FIG. PAGE 
 
 1 . Schematic Eye for Studying Retinoscopy, 22 
 
 2. Retinoscope, 25 
 
 3. Light-screen, or Cover Chimney, 26 
 
 4. New Light-screen, 27 
 
 5. Showing Distance from Patient's Eyes and the Equivalent in Diop- 
 
 ters, 32 
 
 6. Arrangement of Patient, Light, and Observer, 33 
 
 7. Light over Patient's Head, and the Observer with Mirror at One 
 
 Meter Distance, 34 
 
 8. Folding Mirror, 35 
 
 9. Folding Mirror with Illumination 35 
 
 10. Illumination in an Emmetropic Eye, 38 
 
 11. Illumination and Shadow in an Emmetropic Eye, 38 
 
 12. Illumination with Straight Edge, 46 
 
 13. Illumination with Crescent Edge, 46 
 
 14.' Wiirdemann's Disc, 47 
 
 15. Jennings' Skiascopic Disc, 48 
 
 16. Gray Reflex as seen in High Hyperopia, 51 
 
 17. Gray Reflex, Crescent Edge, and Shadow in High Hyperopia, ... 51 
 
 1 8. Hyperopia, 52 
 
 19. Refracted Hyperopia, 53 
 
 20. Emmetropia, 54 
 
 21. Refraction of Macular Region, 55 
 
 22. Myopia, 56 
 
 23. Refracted Myopia, 57 
 
 24. Method of Writing a Formula, 60 
 
 25. Band of Light in Astigmatism, 61 
 
 26. Band of Light and Shadow, 61 
 
 27. Band of Light, Axis 90, 62 
 
 28. Band of Light Showing Half a Diopter of Astigmatism 63 
 
 29. Axonometer, 66 
 
 30. Axonometer in Position, 66 
 
 31. 32. Irregular Lenticular Astigmatism, 69 
 
 34. Two Bands of Light, 70 
 
 33. Light Areas with Dark Interspace, . . 7 1 
 
 35. Light Areas Brought Together, 71 
 
 2 xvii
 
 LIST OF ILLUSTRATIONS. 
 
 36. Tilting of Lens, ...................... 7* 
 
 37. Scissor Movement in Refracted Aphakia, ... -73 
 
 38. Illumination Seen in Conic Cornea, .............. 75 
 
 39. Positive Aberration, ............. 7& 
 
 40. Negative Aberration, .................... 7 
 
 41. Lens for the Study of the Scissor Movement, . . 8l 
 
 42. Lens for the Study of Conic Cornea, . . . 81 
 
 43. Lens for the Study of Spheric Aberration, 81
 
 RETINOSCOPY. 
 
 CHAPTER I. 
 
 DEFINITION. NAMES. PRINCIPLE AND VALUE OF 
 
 RETINOSCOPY. SUGGESTIONS TO THE 
 
 BEGINNER. 
 
 Definition. Retinoscopy (see preface to first 
 edition) may be defined as the method of estimating 
 the refraction of an eye by reflecting into it rays of 
 light from a plane or concave mirror, and observing 
 the movement which the retinal illumination makes 
 by rotating the mirror. 
 
 Names. Dioptroscopy, fundus-reflex test,* kera- 
 toscopy, fantoscopy, pupilloscopy, retinophotoscopy, 
 retinoskiascopy, skiascopy, umbrascopy, koroscopy, 
 etc., are some of the other names given to this 
 method of refraction, and their number and greater 
 or less inappropriateness have had much to do, no 
 doubt, with keeping retinoscopy in the background 
 of ophthalmology instead of giving it the promi- 
 nence which it more justly deserved and now re- 
 ceives. 
 
 * Suggested by Dr. C. A. Oliver. 
 19
 
 20 KKTINOSCOPY. 
 
 f 
 
 The principle of retinoscopy is the finding of 
 the point of reversal (the far-point of a myopic eye), 
 and to do this, if an eye is not already sufficiently 
 myopic, it will be necessary to place in front of it 
 such a lens, or series of lenses, as will bring the 
 emergent rays of light to a focus at a certain definite 
 distance (see Point of Reversal, chap. iv). 
 
 Value of Retinoscopy. Those who would 
 criticize retinoscopy because "we see nothing and 
 think nothing of the condition of the fundus," base 
 their criticism apparently on the name, retinoscopy, 
 rather than from any great amount of practical ex- 
 perience with the method. While admitting that the 
 ophthalmoscope in front of a well-trained eye can 
 often make a close refractive estimate, yet only to 
 the few does such skill obtain, and even then there 
 is that uncertainty which does not attach itself to the 
 retinoscope in competent hands. The ophthalmolo- 
 gist who knows how to use the mirror accurately 
 has the advantage of his confreres who are ignorant 
 of the test ; it gives him a position decidedly inde- 
 pendent of his patient, and puts him above the 
 common level of the traveling " Great Doctor Eye " 
 and "refracting optician," who are tied to the trial- 
 lenses and the patient's uncertain answers. Further- 
 more, when it is remembered that from fifty to eighty 
 per cent, of the patients consulting the ophthalmolo- 
 gist do so for an error of refraction, it is well that 
 he be most capable in this important branch of the 
 subject. 
 
 The wonderful advantage ot retinoscopy over 
 other methods needs no argument to uphold it; the
 
 VALUE OF RETINOSCOPY. 21 
 
 rapidly increasing number of retinoscopists testify 
 to its merits. 
 
 The writer, from his constant use of the mirror, 
 would suggest the following axiom : That, with an 
 eye otherwise normal except for its refractive error, 
 and being under the influence of a reliable cycloplegic, 
 there is no more accurate objective method of obtaining 
 its exact correction than by retinoscopy. 
 
 Retinoscopy gives the following advantages : 
 
 The character of the refraction is quickly diag- 
 nosed. 
 
 The exact refraction is obtained without question- 
 ing the patient. 
 
 Little time is required to make the test. 
 
 No expensive apparatus is necessarily required. 
 
 Its great value can never be overestimated in 
 nystagmus, young children, amblyopia, aphakia, illit- 
 erates, and the feeble-minded. 
 
 From what has just been written, it must not be 
 understood that the patient's glasses are ordered 
 immediately from the result obtained by retinos- 
 copy ; for, on the contrary, all retinoscopic work, 
 like ophthalmometry in general, should, when possi- 
 ble, be confirmed at the trial-case. 
 
 It is only in the feeble-minded, in young children, 
 and in cases of amblyopia that glasses are ordered 
 direct from the result obtained in the dark room. 
 
 The subjective method of placing lenses before 
 the patient's eyes and letting him decide by asking 
 "is this better?" or "is this worse?" only too often 
 fatigues the examiner and worries the patient, giving 
 him or her a dread or fear of inaccuracy that does
 
 22 
 
 RETINOSCOPY. 
 
 not satisfy the surgeon or tend to inspire the patient. 
 Whereas, when the neutralizing lenses found by 
 retinoscopy are placed before the patient's eyes and 
 he reads f or f$ or more, it is easy, if there is any 
 doubt, to hold up a plus and a minus quarter diopter 
 
 FIG. i. THE AUTHOR'S SCHEMATIC EYE FOR STUDYING RETINOSCOPY. 
 (For description, see chap, vi.) 
 
 glass respectively in front of this correction, and let 
 the patient tell at once if either glass improves or 
 diminishes the vision. 
 
 The writer is not condemning the subjective or 
 other methods of refraction, or trying to extol too
 
 SUGGESTIONS TO THE BEGINNER. 23 
 
 highly the shadow test, yet he would remind those 
 who try retinoscopy, fail, and then ridicule it, that 
 the fault with them is back and not in front of the 
 mirror. 
 
 Suggestions to the Beginner. To obtain profi- 
 ciency in retinoscopy there is much to be understood. 
 Careful attention to details must be given, and not a 
 little patience possessed, as it is not a method that is 
 acquired in a day, and it is only after weeks of con- 
 stant application that accuracy is acquired. There- 
 fore the beginner is strongly advised to learn the 
 major points from one of the many schematic eyes 
 in the market before attempting the human eye. At 
 the same time he should be perfectly familiar with 
 the laws of refraction and dioptrics, as an understand- 
 ing of conjugate foci is really the underlying prin- 
 ciple of the method i. e., a point on the retina being 
 one focus and the myopic or artifically-made far- 
 point the other focus. 
 
 What is meant by major points applies more par- 
 ticularly to the study of the retinal illumination, its 
 direction and apparent rate of movement, also its 
 form, the distance between the observer and the 
 patient, how to handle the mirror, etc., all of which 
 are referred to under their special headings.
 
 CHAPTER II. 
 
 RETINOSCOPE.-LIGHT.-L1GHT-SCREEN.-DAPK ROOM. 
 
 -SOURCE OF LIGHT AND POSITION OF MIRROR.- 
 
 OBSERVER AND PATIENT. 
 
 The Retinoscope, or Mirror. Two forms of 
 the plane mirror are in use the one large, four centi- 
 meters in diameter, with a four- or five-millimeter 
 sight-hole often cut through the glass ; and the other 
 small, two centimeters in diameter, on a four-centi- 
 meter metal disc, with sight-hole two millimeters in 
 diameter, not cut through the glass, the quicksilver or 
 plating alone being removed. By thus leaving the 
 glass at the sight-hole, additional reflecting surface 
 is obtained at this point, which assists materially in 
 exact work, as it diminishes the dark central shadow 
 that shows so conspicuously at times, and particularly 
 when the sight-hole is cut through the glass. The small 
 mirror has an advantage over the large by reducing 
 the area of reflected light, as only a one-centimeter 
 area on each side of the sight-hole is of particular use. 
 The small plane mirror * is the one recommended, 
 and is made with either a straight or folding handle ; 
 the latter is for the purpose of protecting the mirror 
 when carried in the pocket. The purpose of the 
 
 * Philadelphia Pofyclinic, November, 1893. Another form is 
 described by Dr. E. Jackson, American Jmtrnal of Ophthal- 
 n.ology, April, 1896. 
 
 24
 
 THE LIGHT. 25 
 
 metal disc on which the small mirror is secured is to 
 keep the light out of the observer's eye, and enable 
 him to rest the instrument against the brow and side 
 of the nose ; but if its size should appear small, the 
 observer can easily have a larger one made to suit 
 his convenience. The plating or silvering on the 
 mirror should be of the best, and free from any 
 flaws or imperfections, for on its quality depends, in 
 part, the good reflecting power of the mirror, which 
 is very important. 
 
 FIG. 2. THE AUTHOR'S RETINOSCOPE.* 
 
 The central shadow just referred to as the result 
 of the sight-hole had best be seen by the beginner 
 by reflecting the light from the mirror onto a white 
 surface, before he begins any study, as this dark 
 area may annoy him later if he does not understand 
 its origin. 
 
 The Light. This should be steady, clear, and 
 white. The Welsbach possesses all these qualities, 
 but unfortunately its delicate mantle will not stand 
 
 * See foot-note on preceding page.
 
 26 
 
 RETINOSCOPY. 
 
 much jarring, and is easily broken in consequence, 
 causing much loss of time and annoyance. The 
 electric light with a twisted carbon and ground-glass 
 covering with a round center of clear glass is grow- 
 ing quite popular. For constant service, however, 
 the Argand burner is decidedly the best, when the 
 asbestos light-screen is used to intercept the heat. 
 Whatever light is employed, it is 
 well to have it on an extension 
 bracket, so that the observer may 
 move it toward or away from the 
 patient, as necessary. 
 
 The light-screen, or cover 
 chimney, is made of one-eighth 
 inch asbestos, and of sufficient 
 size (six centimeters in diameter 
 by twenty-one in height) to fit 
 over the glass chimney of the 
 Argand burner. 
 
 Attached to the screen are two 
 superimposed revolving discs that 
 furnish four round openings, re- 
 spectively five, ten, twenty, and 
 thirty millimeters, any one ot 
 which may be turned into place 
 as occasion may require. Care should be taken that 
 the opening used is placed opposite to the brightest, 
 and never opposite to the edge or the blue part of the 
 flame. Formerly these screens were made of sheet- 
 iron, but the asbestos has been found preferable, as 
 it does not radiate the heat to the same extent as the 
 iron. The purpose of the light-screen is to cover all 
 
 FIG. 3. THE AUTHOR'S 
 LIGHT-SCREEN, OR 
 COVER CHIMNEY. 
 
 (far a further descrip- 
 tion, see chap, vi.)
 
 DARK ROOM. 
 
 27 
 
 of the flame except the portion which presents at 
 the opening in the disc. 
 
 Ten-millimeter Opening. This will be used 
 in most all retinoscopic work by the beginner. 
 
 Five-millimeter Opening. This is used to the 
 best advantage and with no small amount of satis- 
 faction by the expert when working close to the 
 point of reversal. Figure 4 shows 
 the author's new light-screen, 
 which was described on page 
 1378 in the "Journal of the 
 American Association," Decem- 
 ber 3, 1898. This is a more 
 convenient screen for retinos- 
 copy than the one shown in 
 figure 3. It is made by attach- 
 ing an iris diaphragm to an 
 asbestos chimney. The amount 
 of light passing through the dia- 
 phragm is easily controlled by 
 an ivory-tipped lever at the left- 
 hand side ; and an index on the 
 periphery records the diameter 
 of the opening in use, from one 
 to thirty millimeters. 
 
 The room must be darkened, and the darker 
 the better, all sources of light to be excluded ex- 
 cept the one in use. It must not be supposed from 
 this that the room must have its walls and ceiling 
 blackened ; on the contrary, if the shades are drawn, 
 the room will be sufficiently dark, though of course 
 a perfectly black room would be best, as giving a 
 
 FIG. 4. THE AUTHOR'S 
 NEW LIGHT-SCREEN.
 
 28 RETINOSCOPY. 
 
 greater contrast to the condition to be studied. The 
 exclusion of other lights, or beams of light, must be 
 insisted upon, as the principal use of the darkened 
 room is to keep all light except the light in use out 
 of the eye to be examined, and also not to have 
 other lights reflected from the mirror. 
 
 As the method of using the concave mirror with 
 source of light (twenty or thirty mm. opening in 
 screen) beyond its principal focus (usually over and 
 beyond the patient's head) has been superseded by 
 the simpler and easier method of using the small plane 
 mirror with source of light (one-half or one cm. open- 
 ing in light-screen) brought as close to the mirror as 
 possible, the description of retinoscopy which follows 
 will refer to the latter. 
 
 The Source of Light and Position of the 
 Mirror. The rays of light coming out of the round 
 opening in the light-screen should be five or six 
 inches to the left and front of the observer, so that 
 they may pass in front of the left eye and fall upon 
 the mirror held before the right, thus leaving the 
 observer's left eye in comparative darkness ; or the 
 observer may use the mirror before the left eye in 
 case he is left-handed and has the light to his right. 
 It is always best for the observer to keep both eyes 
 wide open and to avoid having any light fall into 
 the unused eye, which would cause him much annoy- 
 ance. Some observers hold the mirror before the 
 eye next to the screen, but this is not recommended, 
 for the reasons just mentioned. 
 
 The observer need not make any note of his ac- 
 commodation, as in using the ophthalmoscope, but,
 
 THE SOURCE OF LIGHT AND POSITION OF MIRROR. 29 
 
 as he requires very acute vision, he should wear any 
 necessary correcting glasses. Any observer whose 
 vision does not approximate f will not get much satis- 
 faction from retinoscopy. 
 
 He should take his seat facing the patient, and, as 
 the strength of the reflected light rapidly weakens as 
 the distance between the mirror and the light-screen 
 is increased, he should have the light-screen close to 
 his face (not less than six inches) if he wishes to get 
 the fullest possible strength of light on the mirror. 
 
 As the light appears just as far back in the mirror 
 as it is in front of it, then the nearer these two 
 objects are brought together, the more nearly do 
 they become as one. When working close to the 
 point of reversal, more exact work will be accom- 
 plished if this distance between the light and mirror 
 is very short. The nearer together the light and 
 mirror, the brighter the retinal illumination, and 
 greater contrast, or sharper cut edge between illu- 
 mination and surrounding shadow. The further 
 the light from the mirror, the smaller the retinal 
 illumination, and there will appear, under certain 
 conditions, a very conspicuous central shadow as 
 the result of the sight-hole in the mirror two very 
 serious objections. 
 
 The patient must have his accommodation thor- 
 oughly relaxed with a reliable cycloplegic, and should 
 be seated comfortably, one meter distant, in front 
 of the observer, with his vision steadily fixed on the 
 observer's forehead, just above the mirror. Or, what 
 is even better, the patient may concentrate his vision 
 on the edge of the metal disc ot the mirror, but
 
 30 RETINOSCOPY. 
 
 never directly into the mirror, as that would soon 
 irritate and compel him to close his eye. 
 
 In this way the patient avoids the strain of look- 
 ing into the bright reflected light, and at the same 
 time the macular region is refracted (see Fig. 21). It 
 is customary to cover the patient's other eye while 
 its fellow is being refracted ; for obvious reasons 
 this is specially important in cases of "squint."
 
 CHAPTER III. 
 
 DISTANCE OF SURGEON FROM PATIENT.-ARRANGE- 
 MENT OF PATIENT, LIGHT, AND OBSERVER.-RE- 
 FLECTION FROM MIRROR. -HOW TO USE THE 
 MIRROR. -WHAT THE OBSERVER SEES.- RETINAL 
 ILLUMINATION. SHADOW. WHERE TO LOOK AND 
 WHAT TO LOOK FOR. 
 
 Distance of Surgeon from Patient. There is 
 no fixed rule for this, and each surgeon may select 
 his own distance. It might be well for the beginner 
 to try different distances and then choose for himself. 
 The writer prefers a one meter distance, and with 
 few exceptions adheres to it. Some prefer six 
 meters, others two meters, etc. The distance of one 
 meter has important advantages : There is no get- 
 ting up or down to place lenses in front of the 
 patient's eye, as the patient or surgeon, or both, may 
 lean forward for this purpose, if necessary. Another 
 advantage is that at one meter distance there is a 
 uniform allowance of one diopter in the estimate, 
 which will be explained more fully under Rules for 
 Retinoscopy at One Meter. To get the patient's 
 eye and the observer's forehead just one meter 
 apart, the distance may be marked off on the wall of 
 the dark room on the side where the light is secured 
 (see Fig. 6), or a meter stick for the purpose may be 
 held in the hand of the observer or his assistant. 
 
 The method of obtaining the point of reversal 
 
 31
 
 fcETINOSCOPY. 
 
 
 050 
 
 
 
 062 
 
 II 
 
 075 
 
 I 
 
 087 
 
 40 
 
 I.P 
 
 
 
 Uu 
 
 1.5 
 
 I2SD 
 
 >6?5 
 
 1501 
 
 KJ 
 
 1.75 D 
 
 20 
 
 Z.1 
 
 1750 
 
 i*s 
 
 U.7S 
 
 rs 
 
 I4J 
 O 
 
 tn 
 aj 
 
 fs 
 
 3501 
 
 10 
 
 4J> 
 
 873 
 
 jilt 
 
 4 
 
 6S 7 
 
 5D 
 550 
 
 6 ^ 
 
 =* aB 7J>7 M " 
 
 
 
 W 
 
 at points other than the regula- 
 tion one meter requires such an 
 amount of extra measuring and 
 computing that it does not meet 
 with the general favor and satis- 
 faction accorded to that found by 
 producing an artificial myopia of 
 one diopter. This can best be 
 explained by reference to figure 
 5, where, if the observer is at 
 one diopter, and the neutralizing 
 lenses in front of the patient's 
 eye focus the emergent rays at 
 about that distance, he may have 
 the liberty of moving forward five 
 inches or backward five inches (a 
 play of ten inches) in looking for 
 the point of reversal, and not 
 make a possible error in his re- 
 sult of more than twelve one- 
 hundredths (0.12) of a diopter; 
 whereas if he were working 
 closer than this, he would likely 
 make an error of 0.5 D., or even 
 more, if he were not extremely 
 careful in measuring the distance 
 at which he found the reversal 
 point. 
 
 Arrangement of Patient, 
 Light, and Observer. This 
 has already been described in 
 great part, but reference to the
 
 ARRANGEMENT OF PATIENT, LIGHT, AND OBSERVER. 33 
 
 accompanying sketch may give the student a more 
 exact appreciation of the arrangement than any 
 lengthy description could do. 
 
 For convenience of the beginner in using the 
 mirror, it is best, as here shown, to keep the sur- 
 geon's eye, the light, and the patient's eye on a 
 horizontal line, and to accomplish this in children 
 
 FIG. 6. ARRANGEMENT OF PATIENT, LIGHT, AND OBSERVER. 
 
 they will either have to stand, sit on a high stool, 
 or on the parent's lap. The beginner will find it 
 sufficiently difficult at first to keep the light on the 
 patient's eye with the mirror held perpendicularly, 
 without inclining it up or down, as he would have to 
 do if the arrangement suggested is not carried out. 
 Placing the light to one side of the patient's head, 
 or above it, and the observer seated at one meter
 
 34 RETINOSCOPY. 
 
 distance from the patient, is a convenient way of 
 working retinoscopy. It has two advantages : the 
 observer avoids the heat of the flame, and at the 
 same time does not have to move the light. But 
 the writer is not partial to this mode of procedure, 
 for various reasons of precision, explained in the 
 text. Figure 7 shows the observer's eye, one 
 meter from the patient's eye, and the light above. 
 
 I METER 
 
 \G. 7. LIGHT OVER PATIENT'S HEAD, AND THE OBSERVER WITH 
 MIRROR AT ONE METER DISTANCE. 
 
 Reflection from the Mirror. The rays of light 
 coming from the round opening in the screen to the 
 plane mirror are reflected divergently, as if they 
 came from the opening in the screen situated just as 
 far back in the mirror as they originally started from 
 in front (see Figs. 18, 20, and 22), and the patient, 
 looking into the mirror, sees a round, bright spot of 
 light, just as large as the opening in the screen. 
 
 How to Use the Mirror. It should be held 
 firmly before the right eye so that the sight-hole is
 
 HOW TO USE THE MIRROR. 
 
 35 
 
 opposite to the observer's pupil ; and that it may be 
 steady, the second phalanx of the thumb should rest 
 on the cheek just below the eye, the edge of the 
 metal disc even touching the side of the nose if the 
 observer's interpupillary distance is not too great. 
 Thus held in position, its movements should be very 
 
 FIG. 8. FIG. 9. 
 
 AUTHOR'S MIRROR WJTH FOLDING HANDLE. 
 
 FIG. 8. Showing central light C, on small mirror B. This is the light the 
 patient sees when looking into the mirror, and corresponds in size to the 
 one-centimeter opening in screen. D is the folding cap handle to pro- 
 tect B when not in use. A is the metal disc. 
 
 FIG. 9. Shows the light moved to one side as a result of tilting the mirror. 
 
 limited, though they may be slow or quick, but never, 
 at any time, should it be tilted more than one, two, or 
 even three millimeters ; for if inclined more than this, 
 the light is lost from the patient's eye. If the light, 
 the patient's, and the observer's eyes are on a
 
 36 RETINOSCOPY. 
 
 horizontal line, then to find the patient's eye with the 
 reflected light all the observer has to do is to reflect 
 the light back into the light-screen, and by rotating 
 the mirror to his right, carry the reflected light 
 around on the same line until the patient's eye is 
 reached. This may seem like a superabundance of 
 instruction, but the finding of the patient's eye, which 
 appears so easy, is an immense stumbling-block, at 
 the beginning, to most students. Another way to 
 find the eye is for the observer to hold his left hand 
 up between his and the patient's eye and reflect the 
 light on to it, and when this is done to drop his hand 
 and let the light pass into the observed eye. Hav- 
 ing succeeded in finding the patient's eye, the 
 observer, if he is not very careful in his limited 
 movements of the mirror and himself, will turn the 
 light from the eye almost before he knows it, and 
 so be compelled to start and find it again ; this 
 causes much loss of time. A little practice on the 
 schematic eye will assist the beginner wonderfully 
 and give him courage, for if he hastens to the human 
 eye, and then has to stop every minute or so to try 
 and get the light on the eye, he soon becomes 
 discouraged and shows his want of experience to 
 the patient. 
 
 What the observer sees ; or the general ap- 
 pearance of the reflection from the eye. With the 
 mirror held still before his eye, and close up to the 
 bright light coming from the ten-millimeter opening 
 in the light-screen, the observer will obtain a reflec- 
 tion from the patient's eye which varies in different 
 patients, and is subject to certain changes in the
 
 WHAT THE OBSERVER SEES. 37 
 
 same patient as the refraction is altered by correct- 
 ing lenses, or it may be changed by the turning of 
 the patient's eye, or lengthening the distance be- 
 tween the mirror and the light, or increasing or 
 diminishing the strength of the light, or increasing 
 the distance between the observer and the patient. 
 The reflection from the eye of the albino or blond is 
 much brighter than from the brunette or mulatto, in 
 whom it is not so bright, even dim. This character 
 of the reflex is controlled, of course, in great part 
 by the amount of pigment in the eye ground ; how- 
 ever, in most instances there is more or less of an 
 orange-red color to the reflex, and this is especially 
 so as the point of reversal is approached. Cases of 
 high errors of refraction give a dull reflex (see Fig. 
 1 6) as compared to low errors, where the reflex is 
 usually very bright (see Fig. 10). Should the media 
 be irregular or not perfectly clear, the reflex is altered 
 accordingly ; this will be referred to under the head 
 of Irregular Astigmatism. The observer will also 
 notice on the cornea and lens bright pin-point 
 catoptric images, and at the inner edge of the iris, 
 in many eyes, a very bright ring of light (see Fig. 10) 
 about one millimeter in width, which is due to the 
 very strong peripheral refraction ; and as the eye is 
 being refracted and the point of reversal approached, 
 this peripheral ring may develop into a broader ring 
 of aberration rays, which at times will be annoying. 
 This will be referred to under Spheric Aberration, 
 chapter vi. 
 
 Retinal Illumination. By holding a strong con- 
 vex lens closer to or further from a plane surface
 
 38 RETINOSCOPY. 
 
 than its principal focus, or at the distance of its 
 principal focus, and letting the sun's rays pass 
 through it, there will be seen on the plane surface 
 a round area of light ; it is this light area which cor- 
 responds to the illumination on the retina, seen in 
 retinoscopy by reflecting the light from the mirror 
 into the patient's eye, and hence it is spoken of as 
 the retinal illumination, the "illuminated area," "the 
 area of light," "the image," etc. 
 
 Of course, the form of this illumination is con- 
 trolled, in great part, by the refraction of the 
 patient's eye. 
 
 Shadow. This is the non-illuminated portion ol 
 the retina immediately surrounding the illumination. 
 
 FIG. 10. Fir,, ii. 
 
 FIG. io. UNIFORM ILLUMINATION IN AN EMMETROPIC EYE WITH SI.ICHT 
 
 SPHERIC ABERRATION. 
 FIG. ii. UNIFORM ILLUMINATION AS IN FIG. io, PASSED TO THE LEFT BY 
 
 ROTATING THK MlRKOR, DARKNESS OR SHADOW FOLLOWING. 
 
 The illumination and shadow are, therefore, in con- 
 tact, and the contrast is most marked and easily 
 recognized when the illumination is brightest. It is 
 by this combination of the illumination and non- 
 illumination (shadow) that we study and give the 
 "shadow test" its name. In the dark room, the 
 patient keeping his eye fixed, the retina is stationary 
 and in total darkness, except the portion illuminated
 
 WHERE TO LOOK AND WHAT TO LOOK FOR. 39 
 
 by the light from the mirror (see Fig. 10). Ii the 
 mirror be rotated, the retinal illumination changes 
 its place (see Fig. n) and darkness, or shadow, 
 appears in its stead. It is by this change of illumina- 
 tion and shadow (darkness) that we often speak of a 
 movement of the shadow. 
 
 Where to Look and What to Look For. 
 With the patient, the observer, and the source of 
 light in position as directed, the rays of light are 
 reflected into the eye from the mirror as it is gently 
 rotated in the various meridians, and the (i) form, 
 (2) direction, and (3) rate of movement of the retinal 
 illumination are carefully noted through a four- or 
 five-millimeter area at the apex of the cornea, as this 
 is the part of the refractive media in the normal eye 
 that the patient will use when the effects of the 
 cycloplegic pass away and the pupil regains its 
 normal size. 
 
 The one- or two-millimeter area at the edge of the 
 pupil should be avoided by the beginner, except in 
 special instances, as only too frequently it contains 
 a bright ring of light which may or may not give a 
 stronger refraction than the area at the apex of the 
 cornea (see Spheric Aberration, chap. vi).
 
 CHAPTER IV. 
 
 POINT OF REVERSAL.-TO FIND THE POINT OF REVER- 
 SAL.-WHAT TO AVOID.-DIRECTION OF MOVEMENT 
 OF RETINAL ILLUMINATION. RATE OF MOVEMENT 
 AND FORM OF ILLUM1NATION.-RULES FOR LENSES. 
 -MOVEMENT OF MIRROR AND APPARATUS. 
 
 Point of Reversal. This maybe stated in several 
 ways namely : It is the far-point of a myopic eye, or 
 The artificial focal point of the emergent rays of light 
 
 (Fig. 19), or 
 
 The point where the emergent rays cease to con- 
 verge and commence to diverge, or 
 The point conjugate to a point on the retina (Fig. 
 
 23), or 
 
 The point where the erect image ceases and the in- 
 verted image begins, or 
 
 The point distant from the eye under examination, 
 where the retinal illumination can not be seen to 
 move. 
 
 To Find the Point of Reversal. The recogni- 
 tion of the point of reversal is the principle of retinos- 
 copy. It is what is sought for, and, when obtained 
 under certain definite arrangements, is the correct 
 solution of the test. During the test it is easy to tell 
 when the illumination moves with or against the light 
 on the face, but to get the exact point where there 
 is no apparent movement is not always easy, and is 
 
 only acquired after careful practice. 
 
 40
 
 TO FIND THE POINT OF REVERSAL. 41 
 
 For example, having determined at one meter that 
 the retinal illumination with a -f- 1.50 D. in front of 
 the observed eye just moves with the light on the 
 face, and against with a + 1.75 D., we know that the 
 reversal point must be between the strength of the 
 two lenses, or + i .62 D. This demonstrates how we 
 arrive at the exact correction, and also the capability 
 and accuracy of retinoscopy. 
 
 Emmetropic and hyperopic eyes, in a state of 
 rest, emit parallel and divergent rays, respectively, 
 and to give such eyes a point of reversal, or a focus 
 for the emergent rays, it will be necessary to inter- 
 cept these rays with a convex lens as they leave 
 the eye. In other words, emmetropic and hyperopic 
 eyes must be made (artificially) myopic. In myopic 
 eyes, however, the emergent rays always focus at 
 some point inside of infinity, and the observer may, 
 therefore, if he is so disposed, by moving his light 
 and mirror to or from the patient's eye, as the case 
 may be, find a point where the retinal illumination 
 ceases to move. If this should be at two meters, the 
 patient would have a myopia of 0.50 D. ; if at four 
 meters, a myopia of 0.25 D. ; if at one meter, a 
 myopia of one diopter, etc. 
 
 It is well for the beginner to remember, when using 
 the plane mirror, that the illumination on the patient s 
 face always moves in the same direction the mirror 
 is tilted, but not necessarily so in the pupillary area, 
 where it may appear to move opposite ; and here it 
 is that we speak of the retinal illumination moving 
 with or against (opposite to) the movement of the 
 
 4
 
 42 RETINOSCOPY. 
 
 mirror, as the case may be, and make our diagnosis 
 accordingly. 
 
 As the rays of light from the mirror proceed di- 
 vergently to the patient's eye, as if they came from 
 a point back in the mirror equal to the distance of 
 the light (opening in light-screen) in front of it and 
 working at one meter's distance, with source of light 
 five inches in front of the mirror, the rays appear to 
 emerge from a point five inches back of the mirror, 
 or a total distance of 45 inches from the patient's eye, 
 thus giving the rays of light a divergence equal to 
 0.87 of a diopter before they reach the patient's eye, 
 and this point may be made conjugate to the retina. 
 The observer will do good work if he reduces the 
 retinal illumination to the utmost limit where it can 
 be faintly seen moving with the movement of the 
 mirror, and if this is done, the observer's eye and 
 mirror will be just inside of the point of reversal 
 where the erect image can still be recognized. In 
 doing this, however, he must allow 0.87 in his esti- 
 mate and not i.o D. 
 
 At the point of reversal no definite movement of 
 the retinal illumination is made out and the pupillary 
 area is seen to be uniformly illuminated, but not so 
 brilliantly as when within or beyond the point of 
 reversal. 
 
 If the observer's eye is, at this point, exactly con- 
 jugate to the retina, then the movement of the re- 
 flected light on the retina can not be perceived 
 (though it does move), and the retinal illumination 
 will occupy the entire pupil and the shadow will be 
 absent.
 
 WHAT TO AVOID. 43 
 
 Instead, however, of reducing the retinal illumina- 
 tion to the utmost limit (as just mentioned), where 
 it can be faintly seen moving with the movement of 
 the mirror, the writer prefers and recommends plac : 
 ing before the eye under examination such a lens or 
 series of lenses as will bring the emergent rays of 
 light to a focus on his own retina, so that no move- 
 ment of the retinal illumination can be recognized. 
 
 When the point of reversal is approached, the 
 uniform color of the retinal illumination occupies so 
 much of the pupillary area that the student may 
 think he has reached the point of reversal, and if he 
 is not careful to pass the retinal illumination slowly 
 across the pupil and get the shadow, he will find his 
 result deficient, and possibly miss seeing some small 
 amount of astigmatism. 
 
 To make sure about the point of reversal, it is al- 
 ways best, especially for the beginner, to keep put- 
 ting on stronger neutralizing lenses until he gets a 
 reversal of movement, when he knows at once that 
 the point of focus of the emergent rays has passed 
 in between the mirror and eye under examination. 
 
 The lenses which control the rays of light emerg- 
 ing from the patient's eye are spoken of as neutral- 
 izing lenses. 
 
 What to Avoid. It occasionally happens that a 
 retinal vessel or vessels or a remnant of a hyaloid 
 artery, if present, or even the nerve head, may be 
 seen when the light is reflected into the eye ; if so, 
 they are to be ignored, as they are not parts of the 
 test. If the patient's eye is turned, or the rays from 
 the mirror fall obliquely, or the neutralizing lens in
 
 44 RETINOSCOPY. 
 
 front of the eye is inclined instead of being perpen- 
 dicular, there will be seen reflections of light and 
 images upon the neutralizing lens or cornea, or both, 
 and, in consequence, the retinal illumination is more 
 or less hidden or obscured ; these images and reflec- 
 tions can be easily corrected by removing the cause. 
 The catoptric images can not be removed, but as 
 they are very small, the beginner soon learns to 
 ignore them. The retinal illumination may occasion- 
 ally contain a small dark center, which will disturb 
 the beginner unless he remembers that it is caused 
 by the sight-hole in the mirror, and that it shows 
 particularly when the sight-hole is large and cut 
 through the mirror. This same dark center in the 
 illumination is also seen at times when the light is 
 removed some distance from the mirror, and the cor- 
 recting lens almost neutralizes the refraction. The 
 neutralizing lens should never be so close to the eye 
 that the lashes touch, and, in warm weather especi- 
 ally, moisture from the patient's face may condense 
 on the trial-lens, and temporarily, until it is removed, 
 obscure the reflex. 
 
 Retinoscopy with a Plane Mirror at One 
 Meter's Distance and Source of Light close to 
 the Mirror. Direction of Movement of Retinal 
 Illumination. Rate of Movement and Form 
 of Illumination. These important points in refer- 
 ence to the retinal illumination should be decided 
 promptly and without any prolonged examination. 
 This proficiency, of course, will only come by prac- 
 tice, and if, on first examination, the observer can 
 not decide whether the retinal illumination is with or
 
 FORM OF ILLUMINATION. 45 
 
 opposite to the movement of the reflected light on 
 the face, he may approach the eye until this point is 
 determined. The three important essentials may be 
 stated in the following order and in the form of rules : 
 
 Direction. The recognition of the direction that 
 the retinal illumination takes when tilting the mirror 
 is a most important point in the study of retinoscopy. 
 
 The movement of the retinal illumination, when 
 rotating the mirror, going with the movement of the 
 light on the patient's face, signifies emmetropia, 
 hyperopia, or myopia, if the myopia be less than one 
 diopter. 
 
 The apparent movement of the retinal illumina- 
 tion going opposite to the movement of the light on 
 the face always signifies myopia of more than one 
 diopter. 
 
 Rate of Movement. This, of course, is under 
 the control and is influenced in great part by the 
 rate of movement of the mirror itself ; yet after a 
 little practice the observer will recognize the fact 
 that there is a certain slowness in the apparent rate 
 of movement of the illumination when the refractive 
 error is a high one and requires a strong lens for its 
 neutralization, whereas when the retinal illumination 
 appears to move fast, the refractive error is but 
 slight, and requires a weak lens for its correction. 
 
 Form of Illumination. A large, round illum- 
 ination, while it may signify hyperopia or myopia 
 alone, yet it does not preclude astigmatism in com- 
 bination. 
 
 When the illumination appears to move faster in 
 one meridian than the meridian at right angles to it,
 
 46 RETINOSCOPY. 
 
 astigmatism will be in the meridian of slow move- 
 ment. If the retinal illumination is a band of light 
 extending across the pupil, it signifies astigmatism. 
 
 The width of the band of light does not indicate 
 so much the strength of the correcting cylinder 
 required for its neutralization as does the apparent 
 rate of movement ; if slow, a strong, if fast, a weak, 
 cylinder is required. 
 
 The band of light that is seen when a spheric lens 
 corrects one meridian, and the meridian at right 
 angles remains partly corrected, indicates the axis of 
 the cylinder in the prescription. 
 
 FIG. 12. STRAIGHT EDGE, INUICAT- FIG. 13. CRESCENT EDCK, IM.I- 
 ING ASTIGMATISM. GATING SPHERIC CORRECTION. 
 
 Rules for Placing Neutralizing Lenses. A 
 plus lens is required when the retinal illumination 
 moves with the illumination on the face, and a minus 
 lens is required when it moves opposite to the light 
 on the face. 
 
 Movement of the Mirror. There are times 
 when a quick movement, and, at other times, a slow 
 or gradual movement, is required. A substitution of 
 the quick for the slow movement, and the result can 
 not always be correct. This is explained under 
 "slow movement." 
 
 A quick movement may be used when looking
 
 MOVEMENT OF THE MIRROR. 
 
 47 
 
 
 into the eye before any correcting lens has been 
 placed in situ. It often tells the character of the 
 refraction. 
 
 The slow movement comes into use and is of 
 the utmost importance when the eye has been cor- 
 rected to within 0.75 D. or less, as it is 
 generally at this point that so many, 
 by a quick movement, hasten the 
 peripheral rays and mask the central 
 illumination, giving the idea at once 
 of over-correction (see Spheric Aber- 
 ration, chap. vi). This is a most 
 common error with the beginner, the 
 inexperienced, and with those who 
 fail to get good results and who ridi- 
 cule retinoscopy as "not exact," or 
 as " not agreeing with the subjective 
 method." It is well in every instance, 
 when the point of reversal is ap- 
 proached, to pass the retinal illumina- 
 tion (not the light area on the face) 
 well across the pupillary area to 
 make sure in regard to the character 
 of shadow which follows or precedes 
 it. This movement, at such a point 
 in neutralization, will often give a 
 hint as to the presence of astigma- 
 tism or not, as a reference to figures 12 and 13 
 will show. The presence of astigmatism is known 
 by the straight edge of the illumination, or, in its 
 place, a crescent edge would mean a spheric cor- 
 rection. 
 
 FIG. 14. WORDE- 
 MANN'S Disc.
 
 RETINOSCOPY. 
 
 Apparatus for placing lenses in front of the 
 patient's eye. There are several different forms in 
 the market, their purpose being twofold to save 
 time and any extra movements on the part of the 
 
 FIG. 15. JENNINCS' SKIASCOPIC Disc. 
 
 surgeon. Of these, that of Wiirdemann (American 
 Journal of Ophthalmology, p. 223, 1891) seems the 
 best hand skiascope. A reference to the sketch 
 shows this instrument with its convenient handle,
 
 MOVEMENT OF THE MIRROR. 49 
 
 whereby the patient, being instructed, raises or 
 lowers the disc in front of the eye, with its smooth 
 broad edge resting against the side of the nose. 
 
 One column contains plus and the other minus 
 lenses, and as it is reversible, these may be placed 
 in front of the eye, as the surgeon directs. 
 
 The most modern and complete revolving skias- 
 copic disc is that of Jennings (American Journal of 
 Ophthalmology, November, 1896, and April, 1899), 
 and may be best understood from his own descrip- 
 tion : "It consists of an upright metal frame, 
 1 8 inches high and 7 inches wide, placed at the 
 end of a table 26^ inches long and 12 inches 
 wide. In the upright frame is an endless groove 
 containing 39 lenses and i open cell. At the lower 
 end of the frame is a strong driving wheel connected 
 with a horizontal rod running the length of the table 
 to a handle with which the operator rotates the 
 lenses. Facing the operator and close to his hand 
 is a large disc, on which is indicated the lenses pre- 
 sented at the sight-hole. The white numbers on a 
 black ground represent convex, and the black num- 
 bers on the white ground concave, lenses. The 
 lenses range from 0.25 D. to 9 D. plus, and from 0.25 
 D. to 9 D. minus. The sight-holes are -| of an inch 
 in diameter, and are placed about five inches from 
 the top of the upright frame. In front of each sight- 
 hole is a cell marked in degrees to hold stronger 
 spheres or cylinders. The central portion of the up- 
 right is cut away, leaving a space for the face of the 
 patient. A movable blinder is hung from the top 
 while the chin-rest moves up and down on two par-
 
 50 RETINOSCOPY. 
 
 allel rods and is held in place by a thumb-screw. 
 The whole is mounted on a strong adjustable stand, 
 which is raised or lowered by means of a rack and 
 pinion. The essential advantages of this skiascope 
 are as follows : 
 
 1 . It saves time and fatigue in changing lenses. 
 
 2. It is under the immediate control of the operator, 
 and indicates the lens in front of the sight-hole 
 without his getting up. 
 
 3. The mechanism is simple, durable, and easy to 
 operate. 
 
 4. The cornea is accurately centered and the lens 
 perpendicular to the front of the eye (a very im- 
 portant consideration and one not possible with every 
 kind of trial frame). 
 
 5. The instrument is of such length that the 
 operator is always one meter distant from the 
 patient. 
 
 While either the hand or the revolving disc is rec- 
 ommended, yet the writer is partial to an accurately 
 fitting trial-frame, using the lenses from the trial- 
 case, which should be conveniently at hand. The 
 following suggestions in the selection and use of 
 the trial frame are offered : The temples should rest 
 easily on the ears, the nose-piece (bridge) to have 
 a sufficiently long post to permit the eye-pieces to fit 
 high and accurately over any pair of eyes, especially 
 those of children, and have the corneae occupy the 
 center of each eye-piece. Correct results can not 
 be expected or quickly obtained unless the neutral- 
 izing lenses be placed with their centers corre- 
 sponding to corneal centers, and at the same time 
 perpendicular to the front of the eye.
 
 CHAPTER V. 
 
 RETINOSCOPY IN EMMETROPIA AND THE VARIOUS 
 FORMS OF REGULAR AMETROPIA. AXONOMETER. 
 
 Hyperopia. In this form of refraction the direc- 
 tion of the movement of the retinal illumination is 
 with the movement of the light on the patient's face. 
 By rotating the mirror in the various meridians and 
 observing the rate of movement, a strong or weak 
 plus sphere, according to the apparent rate of move- 
 
 FIG. 1 6. FIG. 17. 
 
 FIG. 16. GRAY REFLEX AS SEEN IN HIGH HYPEROPIA, EVEN DARKER 
 
 THAN THE PICTURE SHOWS IT. 
 
 FIG. 17. GRAY REFLEX, WITH CRESCENT EDGE BY TILTING MIRROR TO 
 LEFT, DARKNESS OR SHADOW FOLLOWING. 
 
 ment, is placed before the eye, and the rate of move- 
 ment of the retinal illumination is again noted. 
 
 Practice alone will guide the observer in a quick 
 appreciation of the approximate strength of neutral- 
 izing lens to thus employ. 
 
 If the movement of the illumination appears slow, 
 and the observer places a -f 2.75 D. before the eye 
 for its neutralization, and the illumination then 
 becomes brilliant and appears to move fast and 
 
 5'
 
 52 RETINOSCOPY. 
 
 with the light on the face, the hyperopia is still 
 slightly uncorrected and a stronger lens must be 
 substituted. (At this point in the examination the 
 five-millimeter opening in the light-screen may be 
 used to advantage.) 
 
 Removing the -f- 2.75 D. and placing a -f 3.25 D. 
 in its place, if the retinal illumination is found to 
 move opposite to the movement of the light on the 
 face, the refraction of the eye will then be between 
 the -f 2.75 D. and the 3.25 D., which is 3 D. (See 
 example, p. 41, chap, iv.) Now, while the +30. 
 has brought the emergent rays to a focus at one 
 
 FIG. 18. 
 
 meter, it has made the eye myopic just one diopter, 
 so that in taking the patient from the dark room to 
 test his vision at six meters, or infinity, this one 
 diopter (artificial myopia) must be subtracted from 
 the + 3 D., which would leave + 2 D., the amount 
 of the hyperopia. 
 
 A reference to figures 18 and 19 will illustrate the 
 description just given. 
 
 Figure 18 is the hyperopic eye under examina- 
 tion, and shows the mirror at one meter's distance, 
 with the light five inches from the mirror. The dot- 
 ted lines represent the rays proceeding divergently
 
 HYPEROPIA. 53 
 
 from the eye under examination ; the dark lines show 
 the reflected rays from the mirror, which illuminate 
 the retina and have an imaginary focus (dotted 
 lines) beyond the retina. 
 
 Figure 19 is a profile view showing the hyperopic 
 eye with neutralizing lens in position. The dotted 
 lines with arrow-heads indicate the direction the rays 
 would naturally take coming from the eye. The 
 lens (+3 D.) in front of the eye is just sufficiently 
 strong to bend these divergent rays and bring them 
 to a focus at one meter's distance (artificial point of 
 
 i METER. 
 
 YiG. 19. 
 
 reversal). In other words, + 2 D. of the three 
 diopters thus placed before this hyperopic eye 
 would have bent the divergent rays and made them 
 parallel, or emmetropic, but the additional one 
 diopter bends the rays still more and brings them 
 to a focus (P. R.) at one meter. If, now, the ob- 
 server approaches the eye thus refracted and ob- 
 serves the retinal illumination closer than one meter, 
 he will be inside of the point of reversal, and conse- 
 quently see an erect image moving rapidly with the 
 direction of the movement of the mirror. If beyond 
 this point of reversal, he would get an inverted
 
 54 
 
 RETINOSCOPY. 
 
 image and the retinal illumination moving rapidly in 
 a direction opposite to the movement of the mirror. 
 
 Emmetropia. The emergent rays from an em- 
 metropic eye are always parallel, and the observer 
 seated at one meter sees the pupillary area in such 
 an eye brilliantly illuminated, the illumination mov- 
 ing rapidly with the light on the face as the mirror 
 is slowly rotated. 
 
 A reference to figure 20 shows the emmetropic 
 eye under examination with the position of light, 
 mirror, and eye, as in figure 18. The dotted lines 
 
 Fir,. 20. 
 
 indicate the parallel emergent rays, and the solid 
 lines the divergent rays from the mirror with an 
 imaginary focus just beyond the retina. The pur- 
 pose in this instance, as in all others of retinoscopy, 
 is to place such a neutralizing lens before the eye 
 as will bend the emergent rays and bring them to 
 a focus at a certain definite distance, making the 
 emergent rays from a point on the retina come to 
 a focus on the observer's retina. Therefore, to 
 change this illumination so that no movement can 
 be seen to take place in the pupillary area, and at 
 the same time have the emergent rays focus on the
 
 MYOPIA. 55 
 
 observer's retina, a + i sphere must be placed 
 before the eye. 
 
 Just here the writer wishes to impress upon the 
 beginner the great importance, as mentioned on 
 page 30, of refracting the macular region. To ac- 
 complish this, the patient must fix 
 his gaze upon the metal disc of the 
 mirror. As the region of the macula 
 is departed from, the strength of 
 the neutralizing lens grows slightly 
 stronger in emmetropia and hyper- 
 opia, and diminishes in myopia. A 
 reference to figure 21 will give an 
 idea of what is meant, and show that 
 other radii are not the same length as the one at 
 the fovea. 
 
 Myopia. In myopia the emergent rays always 
 converge to the far-point (point of reversal), and the 
 observer, seated at one meter from the eye, will have 
 the apparent movement of the retinal illumination 
 going opposite to the light on the face if the myopia 
 exceeds one diopter, and zvith the light on the face if 
 the myopia is less than one diopter. If the myopia 
 should be just one diopter, then the emergent rays 
 would focus on the observer's retina at one meter, 
 and there will not be any neutralizing lens required 
 to accomplish this purpose ; but if the emergent rays 
 focus beyond one meter, the observer will be within 
 this point of reversal or focus, and will, therefore, 
 have an erect image, moving fast with the move- 
 ment of the mirror, and will have to place before 
 the eye a plus lens of less than one diopter to
 
 56 RETINOSCOPY. 
 
 bring the point of reversal up to one meter. When 
 the myopia is more than one diopter, and observer 
 at one meter, the emergent rays will have focused 
 somewhere between the observer and the patient, 
 and, as a result, the retinal illumination appears to 
 move opposite to the light upon the face, more or less 
 rapidly, according to the amount of myopia ; and a 
 concave or minus lens must be placed in front of 
 such an eye that will bring the emergent rays to a 
 focus at one meter, or, in other words, will stop all 
 apparent movement of the retinal illumination. If, 
 
 Kin. 22. 
 
 for example, a 2.75 D. has been so placed, and the 
 movement is still slightly opposite to the movement 
 of the mirror, and a 3.25 D. substituted makes 
 the retinal illumination move with the movement of 
 the mirror, then the neutralizing lens for one meter 
 would be the difference between 2.75 D. and 
 3.25 D., which will be 3 D. 
 
 Figure 22 shows the myopic eye just described, 
 with the position of the mirror, light, and eye, as in 
 figures 1 8 and 20. The solid lines represent the rays 
 reflected divergently from the mirror focusing at a 
 point in the vitreous before coming to the retina, and
 
 MYOPIA. 
 
 57 
 
 the broken lines show the rays emerging from a point 
 on the retina and then converging to the focus, far- 
 point, or point of reversal close to the eye, between 
 the eye and the mirror. The observer, seated with 
 the mirror one meter distant, gets an opposite move- 
 ment in the pupillary area from the direction in which 
 he moves his mirror, and, of course, an inverted 
 image. If the observer had his eye at the point 
 where the emergent rays focused (dotted lines cross), 
 he would not recognize any movement in the pupil- 
 lary area, and it would have a uniform reflex. The 
 amount of the myopia is equal to the distance meas- 
 
 METER 
 
 P.R. 
 
 FIG. 23. 
 
 ured from this point of reversal to the cornea ; for 
 example, if the distance (point of reversal) was 
 twenty-five cm. from the patient's eye, then the 
 amount of the myopia would be four diopters. 
 
 Figure 23 is a profile view of the myopic eye. The 
 dotted lines show the rays coming from a point on 
 the retina and focusing at the far-point (P.P.); the 
 solid lines show the emergent rays acted upon or 
 bent by a plano-concave lens of three diopters, 
 which has lessened the convergence of these emer- 
 gent rays and put the far-point farther from the eye, 
 or at a distance of one meter. The observer at
 
 58 RETIXOSCOPV. 
 
 this distance does not appreciate any movement in 
 the pupillary area, but if he moves the light and 
 mirror closer to the eye he is then inside the point 
 of reversal and gets an erect image moving with the 
 movement of the mirror; if beyond the one meter's 
 distance, an inverted image and movement against 
 the movement of the mirror will be seen. If a 4 D. 
 lens had been placed before this myopic eye, the 
 emergent rays would have proceeded from it par- 
 allel, and the observer, at one meter, would have the 
 same conditions as in the refraction of an emme- 
 tropic eye, figure 20 ; but as only a 3 D. glass was 
 used, the eye has one diopter of its myopia uncor- 
 rected. From the description of retinoscopy in 
 hyperopia, emmetropia, and myopia, just given, the 
 student will recognize at once that the hyperopic, 
 emmetropic, and myopic eye of less than one 
 diopter, working with the plane mirror at one meter's f 
 distance, are given a stronger refraction than they 
 naturally call for, or, in other words, are made, artifi- 
 cially, myopic one diopter. And the myopic eye of 
 more than one diopter, under similar conditions, 
 being already myopic, retains one diopter of its 
 myopia. To give a patient thus refracted with the 
 retinoscope his emmetropic correction (correction for 
 parallel rays of light), an allowance must always be 
 made, in all meridians, of one diopter, no matter what 
 the refraction. The artificial myopia thus produced 
 at one meter gives the following rules for glasses 
 required for infinity : 
 
 Rules. i. When the neutralizing lens employed 
 is plus, then subtract one diopter.
 
 REGULAR ASTIGMATISM. 59 
 
 2. When the neutralizing lens employed is minus, 
 then add a i D., or what is more simple, or even a 
 better rule, is, To always add a / sphere to the 
 neutralizing lens obtained in the dark room when 
 working at one meter, and the result will be the 
 emmetropic or infinity correction. 
 
 Examples : 
 
 DARK ROOM, -(-0.50 o.oo -f 1 - 00 +2.00 i.oo 
 
 ADDING, i.oo i.oo i.oo i.oo i.oo 
 
 EMMETROPIC CORRECTION, 0.50 i oo o.oo -j-i.oo 2.00 
 
 The main point in all retinoscopic work to remem- 
 ber in changing from the dark room to the six meter 
 correction, is to always alloivfor the distance from the 
 patient 's eye to the point of reversal i. e., if working 
 at half a meter, allow two diopters ; if at two meters, 
 0.50 D.; if at four meters, 0.25 D., etc. 
 
 Regular Astigmatism. When refracting with 
 the retinoscope, the observer should remember that 
 he is refracting the meridian in the direction of which 
 he moves the mirror. Particular attention is called 
 to this important fact on account of the confusion 
 sometimes arising in the student's mind from the 
 use of the ophthalmoscope, where the refractive 
 condition of a certain meridian is studied by the 
 appearance of the vessels at right angles to it. 
 Astigmatism being present in an eye, means a differ- 
 ence in the strength of the glass required for the 
 two principal meridians, which, with few exceptions, 
 are at right angles to each other, and it is to these 
 two principal meridians only that the observer pays
 
 60 RETINOSCOPY. 
 
 attention ; for example, the eye that takes the follow- 
 ing formula, 
 
 -\- i.oo D. Q -f i. oo c. axis 105, 
 
 means that in the 105 meridian there is + i D. and 
 in the 15 meridian a -f 2 D. In the dark room a 
 -f 2 sphere in front of such an eye at one meter 
 would correct the 105 meridian and partly correct 
 the 15 meridian ; or a 4- 3 D. would correct the 15 
 and over-correct (movement against) the 105 mer- 
 idian. When with -i- 2 D. the 105 meridian is cor- 
 
 +3.D 
 
 rected and the 1 5 only partly so, there is seen in the 
 1 5 meridian a band of light which stands or extends 
 across the pupil in the 105 meridian and moves 
 across the pupil from left to right with the move- 
 ment of the mirror as it is tilted in the 15 meridian. 
 The presence of this band of light after the mer- 
 idian of least ametropia has been corrected always 
 signifies astigmatism, and the axis it subtends in 
 this case 105 gives the axis of the cylinder in the 
 prescription ; and the amount of the astigmatism, or 
 the strength of the cylinder required, is the differ-
 
 REGULAR ASTIGMATISM. 61 
 
 ence between the strength of the two spheres em- 
 ployed. Figure 24 shows the method of writing 
 such a dark room correction, and adding, according 
 to our rule, a i to this dark room work, we get 
 our original formula : 
 
 -f- i.oo D. -(- i.oo c. axis 105. 
 
 The method of correcting with spheres will be found 
 much more satisfactory than by placing a -f- 2 D., 
 as called for in the 105 meridian, then adding and 
 changing cylinders until the correct one is found. 
 
 FIG. 25. FIG. 26. 
 
 FIG. 25. BAND OK LIGHT AT Axis 60, WITH THE 60 MERIDIAN NEU- 
 TRALIZED. No movement of the illumination can be recognized in this 
 meridian. 
 
 FIG. 26. Shows the same as figure 25, but the band of light with straight 
 edge has been moved upward and to the left by tilting the mirror in the 
 150 meridian. 
 
 It takes much time and care to get the cylinder axis 
 just right, and is most difficult in the dark room. 
 After the result has been obtained with spheres, the 
 observer may, if he is so disposed, prove it before 
 leaving the dark room with the sphere-cylinder 
 combination. 
 
 Astigmatism may or may not be recognized on 
 first inspection of the fundus-reflex, this depending 
 entirely on the refraction ; if it be a high astigmatism 
 with a small amount of refractive error in the op-
 
 62 RETINOSCOPY. 
 
 posite meridian, as in one of the following formulas. 
 
 + i. oo D. C + 3.00 c. axis 45, 
 
 - i. oo D. Q 4-oo c. axis 180, 
 
 then the band of light so characteristic of astigma- 
 tism will be plainly seen on first inspection, extend- 
 ing across the pupil before any neutralizing lens has 
 been placed in position ; but if the hyperopia or my- 
 opia be high and the cylinder required is low, as in 
 one of the following formulas, 
 
 + 3.00 D. O -f 0.75 c. axis 105, 
 
 - 4.00 D. Q i. oo c. axis 165, 
 
 then the band of light is not recognized on first in- 
 spection or until an approximate correction has 
 been placed before the eye. To get an idea of 
 what the band of light looks like, the beginner may 
 refer to figures 25 and 27; or focus rays of light 
 through a strong cylinder ; or 
 place a cylinder in front of the 
 schematic eye and study the 
 retinal illumination. The stu- 
 dent should bear in mind that 
 the axis of the band of light 
 appears on the meridian of 
 
 FIG. 27. BAND OF LIGHT. , . , . , . , 
 
 ASTIGMATISM AXIS 90. least ametropia, and is bright- 
 est when this meridian has re- 
 ceived its full spheric correction the opposite 
 meridian being only partly corrected. 
 
 The reason for the brightness of the band of light 
 when the meridian of its axis is corrected is that 
 any point on the retina in this meridian is conjugate 
 to the focus on the observer's retina (point of re-
 
 MIXED ASTIGMATISM. 63 
 
 versal), and any movement of the mirror in this 
 meridian is not recognized, but has a uniform color 
 and occupies the entire meridian of the pupil. To 
 recognize so small an error as a quarter diopter 
 cylinder, which is not easily detected, and the 
 observer, if he is in a hurry, might think the case 
 one of simple hyperopia or myopia, the writer 
 would suggest that when the supposed point of 
 reversal is reached the correcting sphere be in- 
 creased a quarter of a diopter, and if only one 
 meridian is found over-corrected (movement oppo- 
 site), the other remaining correct (no movement 
 
 FIG. 28. BAND OF LIGHT SHOWING HALF A DIOPTER OF ASTIGMATISM. 
 
 recognized), he then knows that a quarter cylinder 
 is required ; for example, a -f 2 D. is supposed to 
 correct all meridians, and yet by substituting a 
 -f 2.25 D., the vertical meridian moves against and 
 the horizontal remains stationary; then a -f 0.25 D. 
 cylinder is called for at axis 90. 
 
 Cases having a low astigmatic error of 0.50 D. 
 can be recognized when near the point of reversal 
 by the faint shaded area on each side of the band 
 of light, as shown in figure 28 a condition often 
 overlooked. 
 
 Mixed Astigmatism. In this condition of re- 
 fraction, where one meridian is myopic and the
 
 64 RETINOSCOPY. 
 
 meridian at right angles to it is hyperopic, the move- 
 ment of the retinal illumination in the myopic meri- 
 dian will be controlled by the amount of the myopia. 
 The illumination in the myopic meridian, if the my- 
 opia is less than one diopter, moves with the mirror, 
 and against the movement of the mirror if it is more 
 than one diopter ; in either instance the observer 
 gets a distinct band of light in the meridians alter- 
 nately as each meridian is neutralized separately with 
 a sphere. Taking the following example, 
 
 2.00 c. axis 180 Q -(- i.oc c. axis 90, 
 
 the 90 meridian shows an opposite movement, and 
 in the horizontal the movement is with the move- 
 ment of the mirror. If, now, a i D. sphere be 
 placed before the eye, the 90 meridian is neutralized 
 for one meter distance, and a bright band of light is 
 seen at 90, moving with the movement of the 
 mirror on the horizontal meridian. Removing the 
 
 i D. and placing a + 2 D. before the eye, which 
 would neutralize the horizontal meridian for one 
 meter, a bright band will be seen on the horizontal 
 axis and moving opposite to the movement of the 
 mirror in the 90 meridian. Carrying out the rule 
 of always adding a i D. sphere to the correction 
 obtained in the dark room at one meter, we have 
 
 i added to the i in the vertical meridian, 
 making 2 D., axis 180; and adding i to the 
 -f 2 D. in the horizontal, we have + i D. for axis 
 90, or our original formula : 
 
 2.00 axis 180 Q -)- i.oo c. axis 90. 
 The rule for neutralizing lenses in mixed astigma-
 
 AXONOMETER. 65 
 
 tism is the same as for any other form of refraction ; 
 namely, using a plus lens when the movement is 
 with, and a minus lens when the movement is oppo- 
 site to, the movement of the light on the face. 
 
 Axonometer. To find the exact axis subtended 
 by the band of light while studying the retinal illumi- 
 nation, when the meridian of least ametropia has 
 been corrected, the writer has suggested a small in- 
 strument which, for want of a better name, he has 
 called an axonometer. 
 
 Figure 29 shows this instrument, and figure 30 the 
 axonometer in position. 
 
 The description of this device was published in 
 The Medical News, March 3, 1894, as follows : " The 
 direction of the principal meridians of corneal curva- 
 ture is often difficult to determine, and the state- 
 ment of the patient must be accepted when confirm- 
 ing the shadow-test correction ; or, if there is still 
 uncertainty, the ophthalmometer of Javal may be of 
 service. The axonometer is a black metal disc, 
 with a milled edge, one and one-half mm. in thick- 
 ness, of the diameter of the ordinary trial-lens, and 
 mounted in a cell of the trial-set. It has a central 
 round opening 1 2 mm. in diameter the diameter 
 of the average cornea at its base. Two heavy 
 white lines, one on each side, pass from the circum- 
 ference across to the central opening, bisecting the 
 disc. To use the axonometer, place it in the front 
 opening of the trial-frame, and with the patient 
 seated erect and frame accurately adjusted so that 
 the cornea of the eye to be refracted occupies the 
 central opening, proceed as in the usual method of
 
 66 RETINOSCOPY. 
 
 making the shadow test. As soon as that lens is 
 found which corrects the meridian of least ametropia, 
 
 FIG. 29. 
 
 and the band of light appears distinct, turn the 
 axonometer slowly until the two heavy white lines 
 accurately coincide, or appear to make one continu- 
 ous line with the band of light (see Fig. 30). 
 
 FIG. 30. 
 
 " The degree marks on the trial-frame to which 
 the arrow-head at the end of the white lines then
 
 AXONOMETER. 67 
 
 points is the exact axis for the cylinder. The axo- 
 nometer possesses the following points of merit : 
 
 "Simplicity. 
 
 " Accuracy. 
 
 " Small expense. 
 
 " It covers an unnecessary part of the trial-lens 
 which too frequently gives annoying reflexes and 
 images. 
 
 " It saves time, avoids the statement of the patient, 
 and renders the ophthalmometer unnecessary. 
 
 "Its color (black) absorbs the superfluous light 
 rays from the mirror and gives a stronger contrast 
 to the reflex and central illumination. 
 
 " Limiting the field of vision in children, it permits 
 of more concentrated attention. 
 
 " For children and nervous patients, when it is 
 difficult to use the ophthalmometer, this simple 
 appliance is of great service."
 
 CHAPTER VI. 
 
 RETINOSCOPY IN THE VARIOUS FORMS OF IRREGULAR 
 AMETROPIA. RETINOSCOPY WITHOUT A CYCLO- 
 PLEGIC. THE CONCAVE MIRROR. DESCRIPTION 
 OF THE AUTHOR'S SCHEMATIC EYE AND LIGHT- 
 SCREEN.-LENSES FOR THE STUDY OF THE SCISSOR 
 MOVEMENT, CONIC CORNEA, AND SPHERIC ABERRA- 
 TION. 
 
 Irregular Astigmatism. This condition is 
 either in the cornea or in the lens ; in any instance 
 it is confusing to the beginner, and even the expert 
 must work slowly to obtain a result. The corneal 
 form is most difficult to refract, as the retinal illumi- 
 nation is more or less obscured by areas of darkness. 
 The illumination between these dark areas appears 
 to move with, in places, and in others against, the 
 movement of the mirror. By moving the mirror so 
 as to make the light describe a circle around the 
 pupillary edge, a most unique kinetoscopic picture is 
 obtained, which is quite diagnostic of the condition. 
 To refract an eye with this irregularity the observer 
 may have to change his position several times, going 
 closer to or farther away from the patient. Very 
 often these eyes are astigmatic, and the band of light 
 may be promptly noted by the observer changing 
 his position as suggested, and at the same time plac- 
 ing a neutralizing lens in position. Care must be 
 taken, also, to refract in the area of the cornea that 
 will correspond to the small pupil when the effect of 
 
 68
 
 IRREGULAR ASTIGMATISM. 69 
 
 the cycloplegie passes away. It is often best, in 
 these cases of irregular corneal astigmatism, to retain 
 the correction found and use it to assist in a post- 
 cycloplegic manifest refraction. 
 
 Irregular astigmatism of the lens is frequently 
 more or less uniform, and not so broken as in the 
 corneal variety. Figures 31 and 32 show two kinds 
 of irregular lenticular astigmatism. 
 
 Figure 31 illustrates the spicules pointing in from 
 the periphery, and so long as these do not encroach 
 upon the pupillary area, they do not usually in them- 
 selves interfere with vision ; they are not often 
 
 FIG. 31. FIG. 32. 
 
 IRREGULAR LENTICULAR ASTIGMATISM. 
 
 recognized until the pupil is dilated, are then very 
 faint, and not usually made out until the point of 
 reversal is approached. Figure 32 is another form 
 of irregular lenticular astigmatism, and a very inter- 
 esting picture as studied with the retinoscope ; and, 
 as in figure 31, zvhen very faint, is not made out 
 until close to the point of reversal. These two 
 forms of irregular lenticular astigmatism, when just 
 beginning, are very seldom seen with the ophthal- 
 moscope ; the striations are too fine to be made out 
 except under the conditions just described, and when 
 recognized are of inestimable value from a point of 
 prophylactic treatment, calling for a change of occu-
 
 70 RETINOSCOI'V. 
 
 pation, rest to the eyes, and carefully selected glasses, 
 the latter often being weak lenses. These lenticular 
 conditions not infrequently accompany the " flannel- 
 red " fundus, the "fluffy eye ground," the "shot-silk 
 retina," the " woolly choroid," etc. 
 
 Scissor Movement. Another form of astig- 
 matism that may be classed as irregular is where 
 there are two areas of light, each with a straight edge, 
 and usually seen on the horizontal meridian, or 
 inclined a few degrees therefrom either way, and 
 moving toward each other as the mirror is tilted in 
 
 FIG. 34. LIGHT AREAS CO.MIM; TOGETHER AND DARK INTERSPACE 
 
 FADING. 
 
 the opposite meridian ; in other words, as the ob- 
 server is seated at one meter he sees an area of 
 light above and an area of light below with a dark 
 interspace (Fig. 33). As the mirror is slowly tilted 
 in the vertical meridian these light areas approach 
 and are followed by darkness or shadow, and at the 
 same time the dark interspace begins to fade, giving 
 the picture as shown in figure 34. When the light 
 areas are brought together, they result in a hori- 
 zontal band of light, as seen in figure 35, and at this 
 point resemble the ordinary band of light as seen in 
 regular astigmatism. This movement of the light
 
 SCISSOR MOVEMENT. 71 
 
 areas is likened to the opening and closing of the 
 scissor blades, and hence the name of scissor move- 
 ment. 
 
 These cases are more or less difficult to refract, 
 but the presence of the two areas of light with the 
 dark interspace will often assist in a correct selec- 
 tion of glasses, for while they are generally of the 
 compound hyperopic variety, calling for a plus 
 sphere and plus cylinder, yet practice and the patient's 
 
 FIG. 33. TIG. 35. 
 
 FIG. 33. LIGHT AREA ABOVE AND BELOW, WITH DARK INTERSPACE. 
 FIG. 35. LIGHT AREAS BROUGHT TOGETHER. 
 
 statement often call for a plus sphere and minus 
 cylinder. 
 
 With the following formula, 
 
 -\- 2.00 D. Q -f- 0.75 c. axis 90, 
 
 substituting a sphere the strength of the combined 
 values of the sphere and cylinder, and using a minus 
 cylinder of the same number as the plus cylinder 
 at the opposite axis, the result will be, 
 
 -j- 2.75 D. Q 0.75 c. axis 180. 
 
 The vision with the latter formula is much better 
 in many instances than with the former, and though 
 either formula would be correct, yet the latter is 
 practically the better of the two, and should be 
 ordered when so found. The condition which may
 
 72 RETINOSCOl'Y. 
 
 be the probable cause of the scissor movement is a 
 slight tilting of the lens (see Fig. 36) that is, the 
 antero-posterior axis of the lens does not stand 
 perpendicular to the plane of the cornea, thus mak- 
 ing one portion of the pupil myopic (area of light 
 moving opposite) and the other portion hyperopic 
 (area of light moving with the movement of the 
 mirror). This condition may be simulated by plac- 
 ing a convex lens at an angle before the schematic 
 eye, or reflecting the light into the eye obliquely, 
 or by using the combination lens in front of the 
 schematic eye, as suggested on page 81. What 
 
 causes the tilting of the lens the writer is not 
 prepared to state positively ; it may be congenital, 
 and yet careful 'inquiry of the patients, in many 
 instances, has shown that it is most likely due to 
 using the eyes to excess in the recumbent posture. 
 It may be a coincidence, but most of the cases of 
 scissor movement seen by the author have been in 
 adults, and those who were in the habit of reading 
 while lying down, reading themselves to sleep at 
 night in bed.* Other cases were seen among 
 
 * The writer does not wish to be misunderstood and does not 
 say that every one who uses his eyes in this faulty position must 
 develop this form of irregular astigmatism.
 
 COMPOUND IRREGULAR ASTIGMATISM. 73 
 
 paper-hangers, whose occupation compelled them to 
 look upward much of the time. These do not seem 
 unlikely causes, especially when the anatomy of the 
 ciliary region is considered, the strain of the accom- 
 modation (possibly spasm) during the faulty position 
 of the eye tilting the lens as it rests upon the 
 vitreous body. This form of astigmatism, so far 
 as known, remains a permanent one even after a 
 cessation from the original cause and correcting 
 glasses have been ordered. The retinoscope is the 
 only instrument of precision we have in diagnosing 
 this condition. The ophthalmoscope may recognize 
 
 FIG. 37. 
 
 the presence of the astigmatism, but not its char- 
 acter, and the ophthalmometer only records the 
 corneal curvature. Cases of aphakia (following 
 cataract extraction] frequently show the scissor 
 movement during the process of retinoscopy. This 
 is undoubtedly due to the flattening of the cornea 
 corresponding to the section, making one portion 
 myopic and the other hyperopic. Figure 37 shows 
 such a condition, where the upper illumination would 
 move with and the lower, being myopic, would move 
 against the movement of the mirror. 
 
 Compound Irregular Astigmatism. This is 
 a combination of the scissor movement and regular 
 
 7
 
 74 RETINOSCOPY. 
 
 astigmatism, but they are not at right angles to each 
 other. The scissor movement may be at 180, and 
 the regular astigmatism at some point away from 
 90, but not at 90 ; or the regular astigmatism may 
 be at 90 and the scissor movement at some meri- 
 dian other than 180. 
 
 A hasty review of the literature of astigmatism 
 does not reveal any reference to this form, and the 
 name for the condition has been suggested by the 
 following picture, namely : When studying the reflex, 
 a vertical band of light will be seen passing across 
 the pupillary area from left to right as the mirror is 
 turned, and then in the vertical meridian (not at 
 right angles) the scissor movement will be recog- 
 nized also ; there is, therefore, a combination of 
 regular corneal astigmatism with the scissor move- 
 ment at an oblique angle, giving the compound 
 name suggested. This form of astigmatism is rare, 
 yet not difficult to diagnose or refract when under- 
 stood. It is hoped, however, that the beginner in 
 retinoscopy may not meet one of these on his first 
 attempt at the human eye. (See page 83.) 
 
 Conic Cornea. Reflecting the light into an eye 
 that has such a condition, the observer is impressed 
 at once with the bright central illumination that 
 moves opposite to the movement of the mirror, the 
 peripheral illumination moving with, unless perchance 
 the margin should be myopic also, but of less degree. 
 This form of illumination is seen in figure 38, showing 
 the central illumination faintly separated by a shaded 
 area or ring from the peripheral circle. The best 
 way to refract a case of this kind is to keep a record
 
 SPHERIC ABERRATION. 75 
 
 of the neutralizing- lens or lenses required for the 
 portion of the pupillary area that will correspond to 
 the size of the pupil after the effect of the cycloplegic 
 passes away, and use this record as a guide in a 
 post-cycloplegic manifest correction, as in irregular 
 corneal astigmatism. 
 
 As the apex of the cone is not always central, the 
 observer must not expect to always find the bright 
 illumination in the center of the pupillary area, as 
 just mentioned ; and it is also well to note the fact 
 that a band of light will often appear during the 
 
 FIG. 38. ILLUMINATION SEEN IN CONIC CORNEA. 
 
 process of neutralization, as astigmatism is usually 
 present. This is further described on page 82. 
 
 Spheric Aberration. This appears under two 
 forms, positive or negative, and is the condition in 
 which, during the process of neutralization, there are 
 two zones, one central and the other peripheral, 
 where the refraction is not the same. In positive 
 aberration the peripheral refraction is stronger and 
 in negative aberration the peripheral is weaker than 
 the central area ; that is to say, in the positive form, 
 when the point of reversal for the center of the pupil 
 is close to one meter, the peripheral illumination 
 grows broader and has a tendency to, and often will, 
 crowd in upon the small central illumination, giving
 
 7 6 
 
 RETINOSCOPY. 
 
 the idea of neutralization, or even the appearance 
 of over-correction, the illumination in the periphery 
 moving opposite. The observer must be on his 
 guard for this condition, and while giving the mirror 
 a slow and limited rotation must watch carefully the 
 illumination in the center of the pupil and not hasten 
 
 FIG. 39. POSITIVE AHERRATION. 
 
 the peripheral movement. (See What to Avoid, 
 p. 26, chap, iv.) The observer may have to ap- 
 proach the patient's eye closer than one meter if the 
 peripheral illumination appears to move very fast. 
 The negative form is where the peripheral refraction 
 is weak as compared to the central, which appears 
 
 FIG. 40. NEGATIVE ABERRATION. 
 
 strong, and when the neutralizing lens gives a point 
 of reversal at the center of the pupil the peripheral 
 illumination still moves with the movement of the 
 mirror. This condition is seen in cases of conic 
 cornea. 
 
 Figure 39 illustrates positive aberration where the
 
 RETINOSCOPY WITHOUT A CYCLOPLEGIC. 77 
 
 parallel rays passing through a convex lens in the 
 periphery at A A come to a focus at A', much 
 sooner than the parallel rays B B, near the center, 
 which come to a focus back of A' at B', 
 
 Figure 40 illustrates negative aberration, which is 
 the reverse of positive aberration, and the central 
 rays B B are focused at B' in front of the peripheral 
 rays A A focusing at A '. 
 
 Retinoscopy Without a Cycloplegic. Cases 
 of myopia and mixed astigmatism which have 
 large pupils can be quickly and accurately re- 
 fracted by the shadow test without the use of a 
 cycloplegic. This has been repeatedly proven by 
 comparison of the manifest and cycloplegic results ; 
 yet it is not a method to be recommended or pur- 
 sued, for two reasons : One is that these patients 
 are not annoyed, like hyperopics, by the blurred near- 
 vision incident to the cycloplegic ; and, secondly, 
 glasses ordered without the cycloplegic seldom give 
 the comfort that follows from the physiologic rest 
 the eye receives from the drug. The surgeon will 
 obtain much assistance and save time by using the 
 retinoscope in cases of aphakia, in old persons 
 especially who are very slow to answer, and will 
 insist upon a description of what they do and do 
 not see, as also in re-reading the test-card from the 
 very top each time a change of lens is put in the 
 trial-frame. Presbyopes of fifty or more years of 
 age can be quickly and not inconveniently refracted 
 by the shadow test after having their pupils dilated 
 with a weak (four per cent.) solution of cocain.
 
 78 RETINOSCOPY. 
 
 Concave Mirror. While the study of retinos- 
 copy with the concave mirror is not a part of the sub- 
 ject of this book, and allusion to it has been carefully 
 avoided up to this time, yet for the benefit of those 
 who may wish to try it, the writer would suggest 
 that it will be necessary to place the source of light 
 (20 or 30 mm. opening in light-screen) above and 
 beyond the patient's head, one meter distant, or more, 
 so that the convergent rays from the mirror come to 
 a focus and cross before entering the observed eye. 
 Then to estimate the refraction, proceed as with 
 the plane mirror, remembering, however, that the 
 movements of the retinal illumination are just the 
 reverse of those obtained when using the plane 
 mirror. 
 
 The Author's Schematic Eye for Studying 
 Retinoscopy. For illustration see figure i and the 
 Journal of the American Medical Association, Janu- 
 uary5, 1895. The eye as here shown, slightly reduced 
 in size, is made of two brass cylinders, one somewhat 
 smaller than its fellow, to permit slipping evenly into 
 the other. Both cylinders are well blackened inside, 
 and the larger is also blackened outside. The smaller 
 cylinder is closed at one end (concave surface), and 
 on its inner surface is placed a colored lithograph of 
 the normal eye ground. The larger cylinder is also 
 closed at one end, except for a central round opening 
 10 mm. in diameter, which is occupied by a + 16 D. 
 lens, and on its outer surface is a colored lithograph 
 of the normal eye and its appendages ; the pupil 
 is left dilated, and corresponds to the central open-
 
 LIGHT-SCREEN OR COVER CHIMNEY. 79 
 
 ing just referred to. In addition to the picture of 
 the eye, there is also lithographed on the upper half 
 of the periphery the degree marks similar to those 
 on a trial-frame. To the lower half of the periph- 
 ery are secured, at equal distances, three posts 
 with grooves to hold trial-lenses. On the side of 
 the small cylinder is an index which records emme- 
 tropia, and the amount of myopia and hyperopia, as 
 it is pushed into or drawn out of the large cylinder. 
 The eye is mounted on a convenient stand and up- 
 right, so that it may be moved as required. In using 
 this eye, if the red eye ground and retinal vessels 
 disturb the beginner, then he may substitute a piece 
 of white paper for the retina. To study astigmatism 
 with the model, the beginner will have to place a 
 cylinder of known strength in the groove next to 
 the eye and study the characteristic band of light 
 so diagnostic of this condition, and at the same time 
 he should learn to locate the axis of the band with 
 the axonometer. 
 
 The author's light-screen or cover chimney 
 (see figure 3 and the Annals of Ophthalmology and 
 Otology, October, 1896) is made of one-eighth inch 
 asbestos, and of sufficient size to fit easily over the 
 glass chimney of the Argand burner; attached to 
 the asbestos by means of a metal clamp are two 
 superimposed discs, which revolve independently of 
 each other. The lower disc contains a piece of white 
 porcelain, 30 mm. in diameter ; also four round open- 
 ings, respectively 5, 10, 20, and 35 mm. in diameter. 
 The upper disc contains a round 35 mm. opening, a 
 round section of blue cobalt glass, a perforated disc,
 
 8o RETINOSCOPY. 
 
 a vertical and a horizontal slit, each 2^ by 25 mm. 
 The several uses of this screen are as follows : 
 
 1 . For the ophthalmoscope a good light is obtained 
 by superimposing the two 35 mm. openings. 
 
 2. Combining the 35 mm. opening in the upper 
 with either the 5 or 10 mm. in the lower disc, a 
 source of light is produced for the small retinoscope ; 
 and, 
 
 3. By substituting the 20 mm. opening, light is had 
 for the concave mirror. 
 
 4. Placing the cobalt glass over the 5, 10, 20, or 
 35 mm. opening, and the chromo-aberration test of 
 ametropia is given. 
 
 5. To test for astigmatism at one meter while 
 using the plane mirror, or for heterophoria at six 
 meters, the perforated disc is to be turned over the 
 porcelain, the latter producing a clear white image. 
 
 6. The horizontal slit placed over the porcelain 
 glass, and the operator may exercise the oblique 
 muscles. 
 
 7. The vertical slit similarly placed gives the test 
 for paralyzed muscles. 
 
 Lenses for the Study of the Scissor Move- 
 ment, Conic Cornea, and Spheric Aberra- 
 tion. (Described by the author in the Journal 
 of the American Medical Association, December 1 8, 
 1897.) 
 
 As the scissor movement, conic cornea, and spheric 
 aberration, as recognized by the retinoscope, are so 
 difficult of demonstration, except in the individual 
 patient, the writer has suggested and had made three 
 lenses which will illustrate these conditions respec-
 
 SCISSOR MOVEMENT, CONIC CORNEA, ABERRATION. 81 
 
 tively when placed in front of his schematic eye ; 
 and thus the beginner in retinoscopy may have the 
 opportunity to see, know, and study these important 
 and interesting manifestations (and at small expense) 
 before proceeding direct and in comparative igno- 
 rance to his patient. 
 
 Figure 41 is a plano-concave cylinder of two diop- 
 ters, mounted in a cell of the trial-case, and to one- 
 half of its plane surface is cemented (at the same 
 axis) a plano-convex cylinder of four diopters, thus 
 making a combination lens, one half of which is a 
 
 FIG. 41. 
 
 -2.0) 
 
 FIG. 42. FIG. 43. 
 
 2 D. and the other half is a + 2 D. Placing this 
 lens, with its axis at 180, before the schematic eye 
 at emmetropia (zero), and the observer at one meter 
 distance with his plane mirror, the two light areas 
 characteristic of the scissor movement, with their 
 comparatively straight edges and dark interspace, 
 may be seen approaching each other from above and 
 below (and the dark interspace disappearing) as the 
 mirror is tilted in the vertical meridian. 
 
 Figure 42 is a section of thin plane glass mounted 
 as in figure 41, and has cemented at its center a
 
 82 RETINOSCOPY. 
 
 small plano-convex sphere of three diopters, whose 
 base is about four mm. in diameter. Placing this 
 lens in front of the schematic eye at emmetropia, 
 and reflecting the light from the plane mirror at one 
 meter, there will be seen in the pupillary area a 
 small central illumination, which moves against or 
 opposite to the movement of the mirror, and at the 
 same time there will also be seen a peripheral ring 
 (at the edge of the iris) which moves rapidly with 
 the movement of the mirror ; between these light 
 areas is a shaded ring of feeble illumination. This 
 is the retinoscopic picture and movement of the light 
 areas, so indicative of conic cornea. It is also an 
 exaggerated picture of negative aberration. 
 
 Figure 43 is made similar to figure 42, except that 
 at its center is ground a 2 D. sphere of about four 
 mm. in diameter. To produce spheric aberration 
 of the positive form, place this lens in front of the 
 schematic eye at emmetropia, and the observer, 
 seated at one meter distance with the plane mirror, 
 will see in the pupillary area a central illumination 
 which moves slower than the peripheral area or 
 ring (at the edge of the iris), which moves rapidly, 
 both areas moving with the movement of the mirror. 
 
 After the observer has carefully studied these pic- 
 tures, it will be obvious that changes other than those 
 mentioned can be made with these lenses, and he 
 should proceed to note them by 
 
 1. Changing the focus of the schematic eye. 
 
 2. By varying his distance from the eye. 
 
 3. By placing both the concave and convex spheres 
 in combination.
 
 SCISSOR MOVEMENT, CONIC CORNEA, ABERRATION. 83 
 
 4. By placing a concave cylinder in front of the 
 double cylinder at an oblique axis, thus getting a 
 picture of compound irregular astigmatism. 
 
 5. By placing a concave cylinder in front of the 
 convex sphere and developing astigmatism with the 
 conic cornea, which is the usual condition ; or a con- 
 vex cylinder might be used in place of the concave 
 cylinder if a higher error is desired. 
 
 6. It is obvious, also, that the scissor movement 
 can be produced by a prism which is made to cover 
 one-half of the pupillary area, but the resulting 
 picture is not so satisfactory for demonstration as 
 that given by the combination lens referred to in 
 figure 41.
 
 INDEX. 
 
 ABERRATION, 75, 76 
 Accommodation, 28, 29 
 Accuracy, 23 
 Advantages of, 20, 21 
 Albino, 37 
 Amblyopia, 21 
 Aphakia, 21, 73 
 Apparatus, 47, 48, 65, 66, 67 
 Argand burner, 26 
 Arrangement, 32, 33, 34 
 Astigmatism, 59, 60 
 Avoid, what to, 43, 44 
 Axiom, 21 
 Axonometer, 65 
 
 BAND of light, 6l, 62, 63 
 Beginner, 23 
 Brunette, 37 
 
 CATOPTRIC images, 44 
 Central shadow, 24, 25, 29 
 Compound irregular astigmatism, 73, 
 
 74 
 
 Concave mirror, 28, 78 
 Conic cornea, 74, 75, 8l, 82 
 Conjugate focus, 23, 40 
 Cover chimney, 26, 27 
 Cycloplegic, 29 
 
 DARK room, 27, 28 
 
 Definition, 19 
 
 Dioptroscopy, 19 
 
 Direction of movement, 41, 42, 44, 
 
 45. 59 
 
 Discs, 47, 48, 49, 50 
 Distance, 31 
 
 EMMETROPIA, 54 
 
 Examples, 41, 59, 60 
 
 FACIAL illumination, 41 
 
 Fantoscopy, 19 
 
 Far-point, 40 
 
 Form of retinal illumination, 45, 46 
 
 Fundus-reflex test, 19 
 
 GENERAL appearances, 36, 37 
 
 HOW to use the mirror, 34, 35 
 Hyperopia, 51, 52, 53, 54 
 
 ILLITERATES, 21 
 
 Illuminated area, 38 
 
 Illumination, facial, 41 
 
 retinal, 41,51, 54, 55 
 
 Illustrations, 22, 25, 26, 27, 32, 33, 
 34, 35, 38, 46, 47, 48, 51, 52, 53, 
 54, 55, 56, 57, 60, 61,62, 63, 66, 
 69, 70, 71, 72, 73, 75, 76, 81 
 
 Image, 38 
 
 Images, 44 
 
 Irregular astigmatism, 68, 69 
 
 JACKSON, 24 
 
 Jennings, 48 
 
 KERATOSCOPY, 19 
 
 Koroscopy, 19 
 
 LENSES, 80, 81, 82 
 Lenticular astigmatism, 69 
 Light, 25, 26, 33 
 Light-screen, 26, 27, 79, 80 
 
 MACULA, 30, 55 
 Meter distance, 31. 32, 33
 
 86 
 
 INDEX. 
 
 Mirror, 24, 25, 34, 35 
 Mixed astigmatism, 63, 64 
 Movement of light, 41, 46, 47 
 
 mirror, 46, 47 
 Mulatto, 37 
 Myopia, 55, 56, 57 
 
 NAME, 17, 19 
 Negative aberration, 76, 77 
 Neutralizing lenses, 58, 59 
 Nystagmus, 21 
 
 OBSERVER, 28, 29, 33 
 Oliver, 19 
 
 PATIENT, 29, 30, 33 
 
 Point of reversal, 40, 41, 42, 53, 56, 
 
 57 
 to find, 40, 41 
 
 Position of light, 32, 33, 34 
 
 mirror, 32, 33, 34 
 observer, 32, 33, 34 
 patient, 32, 33, 34 
 
 Positive aberration, 76, 77 
 
 Principle of retinoscopy, 20 
 
 Punctum remotum, 57 
 
 Pupillary area, 36, 39 
 
 Pupilloscopy, 19 
 
 RATE of movement, 44, 45 
 
 Reflection from lenses, 44 
 mirror, 34 
 
 Regular astigmatism, 59> 60 
 
 Retinal illumination, 37, 38 
 
 Retinophotoscopy, 19 
 
 Retinoscope, 24, 25 
 
 Retinoscopy, 19 
 
 advantages of, 21 
 without a cycloplegic, 
 77 
 
 Retinoskiascopy, 19 
 Reversal of movement, 56, 57 
 Room, 27, 28 
 Rules for distance, 58, 59 
 lenses, 46, 58, 59 
 
 SCHEMATIC eye, 22, 78, 79 
 Scissor movement, 70, 71, 72, 73, 80, 
 
 81,82 
 Shade, 26 
 Shadow, 38 
 
 test, 38 
 Sight-hole, 24 
 
 Size of mirror, 24, 25, 34, 35 
 Skiascopy, 19 
 Source of light, 28 
 Spheric aberration, 75, 76, 80, 81,82 
 Squint, 30 
 Suggestions to the beginner, 23 
 
 THORINGTON, 22, 25, 26, 27, 
 
 65, 79, 80 
 Trial- frame, 50 
 
 UMBRASCOPY, 19 
 
 VALUE of retinoscopy, 20 
 Vision of observer, 29 
 
 WELSBACH, 25 
 What the observer sees, 36 
 
 to avoid, 43, 44 
 Where to look and what to look for, 
 
 39 
 Wiirdemann, 47 
 
 YOUNG children, 21, 33, 67
 
 Catalogue No. 8. April, 1899. 
 
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 HEART. 
 
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 HISTOLOGY. 
 
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 MEDICAL BOOKS. 11 
 
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 11 SUBJECT CATALOGUE. 
 
 MASSAGE. 
 
 KLEEN. Hand-Book of Massage. Authorized translation by 
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 MURRELL. Massotherapeutics. Massage as a Mode of Treat- 
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 OSTROM. Massage and the Original Swedish Move- 
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 larged. 94 Wood Engravings, many of which are original. jh.oo 
 
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 MATERIA MEDICA AND THERA- 
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 COBLENTZ. The Newer Remedies. 3d Edition, Enlarged and 
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 DAVIS. Materia Medica and Prescription Writing. fi .50 
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 HELLER. Essentials of Materia Medica, Pharmacy, and 
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 NAPHEYS. Modern Therapeutics, gth Revised Edition, En- 
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 I. SMITH, M.D., and J. AUBREY DAVIS, M.D. 
 
 Vol. I. General Medicine and Diseases of Children. |4-oo 
 
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 POTTER. Hand-Book of Materia Medica, Pharmacy, and 
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 mulae. 7th Edition. Revised and Enlarged. With Thumb Index in 
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 POTTER. Compend of Materia Medica, Therapeutics, and 
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 MEDICAL BOOKS. 13 
 
 SAYRE. Organic Materia Medica and Pharmacognosy. An 
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 Characteristics. Source, Constituents, and Pharmacopeial Prepara- 
 tions. With chapters on Synthetic Organic Remedies, Insects In- 
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 trations, many of which are original, ad Edition. Preparing. 
 
 WARING. Practical Therapeutics. 4th Edition, Revised and 
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 MEDICAL JURISPRUDENCE AND 
 TOXICOLOGY. 
 
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 BEALE. The Use of the Microscope in Practical Medicine. 
 
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 BEALE. How to Work with the Microscope. A Complete 
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 CARPENTER. The Microscope and Its Revelations. 8th 
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 M ACDONALD. Microscopical Examinations of Water and Air. 
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 MISCELLANEOUS. 
 
 BLACK. Micro-Organisms. The Formation of Poisons. A 
 Biological Study of the Germ Theory of Disease. .75 
 
 BURNETT. Poods and Dietaries. A Manual of Clinical Diet- 
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 GOULD. Borderland Studies. Miscellaneous Addresses and 
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 QOWERS. The Dynamics of Life. .75 
 
 HAIG. Causation of Disease by Uric Acid. A Contribution to 
 the Pathology of High Arterial Tension, Headache, Epilepsy, Gout, 
 Rheumatism, Diabetes, Bright's Disease, etc. 4th Edition. 3.00 
 HAIG. Diet and Food. Considered in Relation to Strength and 
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 HARE. Mediastinal Disease. Illustrated by six Plates. $100 
 HEMMETER. Diseases of the Stomach. Their Special Path- 
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 HENRY. A Practical Treatise on Anemia. Halt Cloth, .50 
 LEPFMANN. The Coal-Tar Colors. With Special Reference to 
 their Injurious Qualities and the Restrictions of their Use. A Trans- 
 lation of THEODORE WKYL'S Monograph. $1.25 
 MARSHALL. History of Woman's Medical College of Penn- 
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 tral Nervous System. With many original Colored and other 
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 GOWERS. Epilepsy and Other Chronic Convulsive Diseases, 
 ad Edition. /* Prttt. 
 
 HOR8LEY. The Brain and Spinal Cord. The Structure and 
 Functions of. Numerous Illustrations.
 
 MEDICAL BOOKS. 15 
 
 OBERSTEINER. The Anatomy of the Central Nervous Or- 
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 ORMEROD. Diseases of the Nervous System. 66 Wood En- 
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 MEDICAL BOOKS. 21 
 
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 No. 5. LANDIS. OBSTETRICS. Sixth Edition. By HBNRT G. 
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 Enlarged. 47 Illustrations. 
 
 No. 6. POTTER. MATERIA MEDICA, THERAPEUTICS, 
 AND PRESCRIPTION WRITING. Sixth Revised Edition 
 (U. S. P. 1890). By SAMUEL O. L. POTTBK, M.D., Professor of 
 Practice, Cooper Medical College, San Francisco ; late A. A. Sur- 
 geon, U. S. Army.
 
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 PQUIZ-COMPENDS ? Continued. 
 
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 trations. 
 
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 AND REFRACTION. A New Book. Including Treatment 
 and Surgery, and a Section on Local Therapeutics. By GBORGS 
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 Philadelphia Hospital, etc. With 98 Formulae and 71 Illustrations. 
 
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 Surgery and in the Woman's Medical College, Philadelphia. 
 
 No. ii. STEWART. PHARMACY. Fifth Edition. Based upon 
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 delphia College of Pharmacy ; Lecturer at Jefferson Medical 
 College. Carefully revised in accordance with the new U. S. P. 
 
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 a Section on Emergencies. By GEO. W. WARREN, D.D.S., Chiel 
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 and while the books will be found to contain an immense amount of 
 knowledge in small space, they will likewise be found easy reading ; 
 there is no stilted repetition of words ; the style is clear, lucid, and dis- 
 tinct. The arrangement of subjects is systematic and thorough ; there 
 Is a reason for every word. They contain over 600 illustrations.
 
 Morris' 
 Anatomy 
 
 Second Edition, 
 Revised and Enlarged. 
 
 790 Illustrations, of which many 
 
 51 rp in Cnlnrs_ 
 
 are in Colors. 
 
 Royal Octavo. Cloth, $6.00 ; Sheep, $7.00 ; 
 Half Russia, $8.00. 
 
 From The Medical Record, New York. 
 
 " The reproach that the English language can boast of no 
 treatise on anatomy deserving to be ranked with the masterly 
 works of Henle, Luschka, Hyrtl, and others, is fast losing 
 its force. During the past few years several works of great 
 merit have appeared, and among these Morris's " Anatomy " 
 seems destined to take first place in disputing the palm in 
 anatomical fields with the German classics. The nomencla- 
 ture, arrangement, and entire general character resemble 
 strongly those of the above-mentioned handbooks, while in 
 the beauty and profuseness of its illustrations it surpasses 
 them. . . . The ever-growing popularity of the book 
 with teachers and students is an index of its value, and it 
 may safely be recommended to all interested." 
 
 ** Handsome Descriptive Circular, with 
 Sample Pages and Colored Illustrations, 
 will be sent free upon application.
 
 A 000414516 5