[Reprinted from Proceedings American Ophthalmological Society, 1890.] 
THE THERAPEUTIC EFFECT OF PRISMS IN OPH 
THAEMIC PRACTICE: A STUDY OF ONE HUND- 
RED CASES IN WTIICH THEY WERE PRE- 
SCRIBED. / 
HENRY D. NOYES, M.D., 
NEW YORK. 
Among the cases herewith presented are included both those 
in which subjective eye symptoms were the controlling element, 
those in which these were associated with headache and other 
nervous disturbances, and those likewise in which headache and 
nervous troubles were the only symptoms complained of. The 
subjective eye symptoms were of the kind commonly grouped 
as asthenopic. In making records, little effort was made to 
draw from the patient an elaborate story of his sensations ; 
only prominent features were selected both to save time and 
from a dislike to verbosity. On the contrary, the objective 
symptoms, in examination of refraction and of muscular capacity, 
were patiently investigated. The state of refraction was deter- 
mined by the ophthalmometer, by the ophthalmoscope, by test 
glasses ; and, in selected cases, by the help of full accommoda- 
tive paralysis with atropia. Every case was examined by two 
observers. Resort was had to atropia when there were signs of 
spasm of accommodation, when the finding by the ophthalmo- 
scope and the ophthalmometer did not tally with the examina- 
tion by glasses, and when no obvious reason appeared for the 
failure to procure normal visual acuity. If the question is 
asked how spasm of accommodation is to be discovered without 2 
Noyes : The Therapeutic Effect of 
employing a mydriatic, the answer is : the ophthalmometer dis- 
closes what is practically the real degree of astigmatism (admit- 
ting an occasional error of o. 5 D or i D, which belongs to the 
lens), the ophthalmoscope (carrying behind it, if needful, a cor- 
recting cylinder) will, in almost every case, disclose hyper- 
metropia; and lastly the patient is asked to read Snellen’s line 
of smallest capitals, No. 1 : nprt, etc., through a pair of convex 
prisms, consisting of -f combined with prism 50, the bases 
inwards. Emmetropic eyes see this print if there be no spasm 
at 12 inches without the prisms, provided the convergence of the 
visual lines does not induce accommodative effort. If the con- 
vergence of the visual lines be abated by prisms amounting to io°, 
this stimulus to accommodation is eliminated, and emmetropic 
eyes, with visual lines converged not to a point 12" distant but to 
one about 60" distant, will read the print at 12". Hyperopic eyes 
will read it beyond 12"; myopic eyes at less than 12". In all 
cases, having by other methods acquired an approximate idea of 
the state of refraction, the behavior of accommodation is denoted 
by the distance at which through the convex prisms the print 
is read. A variation of one inch is not important ; but if emme- 
tropic eyes can make out the print at only 10" or 9", this signifies 
spasm, and suggests atropia. I have employed this plan of pro- 
ceeding for twenty years, and am satisfied, in a general way, of 
its trustworthiness. Subjective symptoms of extreme pain, of 
frequent blur, of lachrymation, etc., will sometimes give decisive 
indications, and both the youth and sex and excitability of the 
patient will determine what should be done. This explanatory 
statement is made to vindicate the avoidance of mydriasis when 
no rational indications for it appear. 
It is proper here to remark that deficient power of abduction 
is frequently associated with spasm of A, and that it is also set 
aside by suitable prisms (viz., adductive) without mydriatics. 
Among the 100 cases to be discussed atropine was used in 
7 instances, and in all these the ametropia was 1 D or less. 
What has been remarked is intended to rebut the argument 
that if in the following cases atropia had been more extens- 
ively used, a larger amount or a larger proportion of refractive 
error would have been disclosed, whose correction would have Prisms in Ophthalmic Practice. 
3 
or might have relieved the symptoms without resorting to 
prisms. 
It is admitted that in some cases an unnoted error of 0.5 D 
or .75 D might have been brought to light, but it is not ad- 
mitted that this addition to the correcting glass would have 
furnished relief. In many instances the experiment had been 
made of using glasses to correct ametropia, and with only partial 
relief; while the full benefit was not* secured until prisms had 
been added. A very notable instance is case 5 i : the patient 
was provided with suitable cylinders for astigmatism, but did not 
get relief until she wore prisms for both insufficient abduction 
and vertical error (hyperphoria). 
This paper might be entitled a study in therapeutics. Con- 
fessedly, no chapter in medicine is beset with so many difficul 
ties. Especially is this the case when the test of our success 
or failure is the patient’s testimony about pain or improved 
function. The possibilities of mistake the experienced physi- 
cian well knows. Patients are eager to be better or are 
discouraged, and may deceive themselves and him either in 
one direction or its opposite. It is true we deal with measur- 
able factors when we test ocular muscles by prisms, but ex- 
perience shows that there is no absolute standard of normal 
capacity and comfortable use of the eye muscles. Although 
it will appear, I think, in this paper that some reliable data 
can be obtained to determine within what boundaries we are 
to look for pathological conditions, some unexplained dis- 
crepancies thrust themselves forward. We find, for example, 
that in some instances of notable relief there was very little 
corresponding change in the behavior of the ocular muscles; 
in other such instances there were improved muscular con- 
ditions. But the answer must be, that in such complex prob- 
lems we do not know all the elements. Nevertheless and in 
spite.of seeming inconsistencies, we have no other reliance 
than the persistent declaration of a patient that whereas 
once I could not work, now I can work ; whereas I once had 
pain, I now have no pain or less pain, etc., etc. The one indis- 
pensable condition for a just conclusion is, that the patient 
shall have been under observation long enough to render a judg- 4 
Noyes : The Therapeutic Effect of 
ment sound and correct. In these ico cases this condition is 
complied with. In this respect I think it may be claimed that 
they are removed from the category of imaginative cases of 
which a most signal class is found among the patients now 
being dealt with, as the French say, “by suggestion.” My 
aim has been to exclude such ; and while in all the cases pre- 
sented there seemed reason for employing prisms, in not a few 
their prescription was made as an experiment, just as, in giving 
drugs, we try this or that at a venture. These tentative cases 
are reported ; and if the result sometimes was failure, an attempt 
is made to tell why. Sometimes it is as difficult to account for 
a success as for a failure. 
The ioo cases discussed are taken consecutively as they 
occurred in private practice, and the only rule of selection has 
been, that there should be definite knowledge of the final result 
of treatment in each one. 
The cases may be classified as follows : 
Sex.— 
Males, 
60 ; females, 40 = 100. 
Age.— 
Under 
10 
years, 2 
<< 
10 to 20 
“ 32 
a 
20 “ 30 
“ 39 
a 
30 “ 40 
“ 19 
a 
40 “ 50 
“ 5 
a 
60 
“ 2 
u 
83 
“ 1 — 100 
Ocaipation.— School children, students, and teachers, 39 
Book-keepers, 8 
Lawyer, 1 
Typewriter, 1 
Mechanical draughtsman, 1 
Seamstresses, 2 
Milliner, 1 
Merchants, 4 
Physicians, 4 
Dentist, 1 
Banker, 1 
Managers, 3 
Army officer, 1 Prisms in Ophthalmic Practice. 
5 
Restaurant keeper, 
i 
Peddler, 
i 
Commercial traveler, 
i 
Not specified, and mostly married women, 
30 = 100 
In more than three-fourths of the cases the occupation was 
of a character demanding persistent and exacting eye-labor. 
Health. — In all cases where conspicuous conditions existed 
a note was made; but, when there was no evident reason for 
inquiry because manner and appearances betokened good 
health, and nothing was said to the contrary, no note was 
taken. 
Health, good in 
63 
Over-worked or exhausted, 
15 
Health, not good in 
22 - 100 
It appears that about 40 $ can be said to be in poor condition. 
Yet, by no means all of them were invalids. All were able to 
come to my office. Among the cases were not a few instances 
of persons in typical and even exuberant health. Some were 
men of large stature and great physical development. 
Ocular Symptoms may be grouped as follows : pain, in 49; 
blurring or unsteadiness of print, in 18; inability to look at 
moving objects, such as a crowd of people, scenery from a railway 
window or from a carriage, playing cards, turning leaves of a 
book, etc., in 17; inability to look fixedly at one object, as at 
a speaker in church or at a theater or in conversation, 12 
(these last two symptoms are eminently characteristic, and 
much more frequent than the record shows) ; incapacity for 
continuous reading or sewing or piano playing, etc., in 60 ; 
tendency to lose the place in reading, 2 ; troubled by seeing 
the nose, 2 ; difficulty in keeping eyes open, 2 ; occasional 
diplopia, 5 ; occasional strabismus, 2 ; photophobia, 4 ; unsteadi- 
ness of. globes, especially twitching at the outer angles in lateral 
movements, in 11 (this symptom is far more common than 
is thus indicated ; it belongs to a majority of the cases, because 
the recti externi are the muscles chiefly at fault: vide infra) ; 
spasm of accommodation, in 14 ; conjunctivitis usually slight, in 
35 ; blepharitis, in 2. 6 
Noyes: The Therapeutic Effect of 
General Symptoms. — Headache, in 57. In many instances it 
was the determining symptom which demanded relief. In most 
cases this was general; in some it was frontal or temporal or occip- 
ital or at the vertex. A singular feature of headache to which my 
attention has been called more and more of late is, that it often 
exists on first waking in the morning, and is increased during 
the day. I have come to regard this fact as indicating neu- 
rasthenia quite as much as asthenopia. But it does not always 
appear in persons of poor health. Vertigo noted in 9 ; nausea, in 
7 ; insomnia, 1 ; melancholia, 1 ; forgetfulness, 1 ; inability to 
fix mind on work, 3 ; pain in remote parts, 3 (this number 
might have been much enlarged had care been taken to make 
thorough inquiry, but lack of time usually prevented); tenderness 
over supra orbital nerves, 3. Nasal catarrh was found in 16, 
and this complication was carefully looked for. Sometimes 
it required treatment; it was always complicated with palpebral 
conjunctivitis, and often severe. It may be noted that headache 
co-existed with nasal catarrh in only 5 of the 16 cases; and n 
were free from headache. 
Passing now to the state of refraction, we have emmetropia, 
47 > hypermetropia, 25 ; myopia, o; astigmatism, 27; viz., as. 
hypermetropic, 21 ; as. myopic, 4; as. mixed, 2 ; antimetropia, r 
- 100. 
The refractive condition is certainly noteworthy, because 47$ 
were normal eyes. Moreover, the degree of ametropia was less 
than 1 D in 45 more, making the total, in whom refractive error 
was either absent or insignificant, 92. The presentation of this 
fact seems quite enough to establish the claim that the element 
of distress in the cases was not the refractive error. A further 
argument to corroborate this conclusion is found in the fact that 
in 18 cases exhibiting refractive error, correcting glasses had 
already been tried without any beneficial result, and relief was 
obtained where prisms were employed with or without what 
may be called “focalizing” glasses. 
We have next to state what muscles were chiefly affected. 
It would be most accurate to classify the cases by the functions 
of adduction and abduction and vertical movement, since in all 
of them several muscles are concerned ; but, for the sake of Prisms in Ophthalmic Practice. 
7 
simplicity, the interni and externi will represent the groups con- 
cerned in adduction and abduction. 
The number of cases of actual or supposed weakness 
of the externi was 92 
The number of cases of actual or supposed weakness 
of the interni was 7 
The number of cases of general muscular weakness 
was 1 = 100 
It must be added that among these cases were seven which 
exhibited, in addition, an error in movements up and down, 
whether the meridian was vertical or oblique. Since consider- 
able importance has been attached to the influence of this kind 
of error, reference may be made to the individual cases : they 
were numbers 10, n, 19, 26, 50, 51, and 52. 
No. 10 was a case of weakness of externi, and there was a 
vertical error of 2° for both distance and near. He was a 
medical student, aged 20; was emmetropic ; was under observa- 
tion two years. He wore prisms of 2° each with bases out- 
ward, and had complete relief and ability to work ; the vertical 
error disappeared. 
No. 11 had insufficiency of the interni, besides vertical error; 
prisms were of no use, and tenotomy was advised. 
No. 19, aged 20, was a typewriter, emmetropic, with weak 
externi, and a very slight vertical error not more than 
wore prisms 1J0 bases out constantly; was under observation 
2\ years ; while wearing glasses, had perfect relief. The re- 
mark is made that tenotomy for vertical error was suggested, 
but was never done. 
No. 26, merchant, aged 34, with weak externi, given prisms 
i£° O.U. for constant wear; under observation 6 months; was 
greatly improved, but did not get entire relief. A small vertical 
error was found, but nothing done for it. 
No. 50, male, aged 19, student, with weak externi H-fo.50, 
was given prisms i£° bases out for constant wear; was under 
observation 2 months. The existence of vertical error was pred- 
icated upon his habit of carrying the head inclined to the left 
shoulder. Moderate relief was obtained by the prisms, viz., the 8 
Noyes: The Therapeutic Effect of 
increase of reading ability from i| hours to 3 hours daily. 
This result was not esteemed satisfactory, and tenotomy was 
advised. 
No. 5 1 had proper glasses for astigmatism, but only got relief, 
by correcting errors both of abduction and of vertical deviation, 
viz., O.D. prism i° base up, O.S. prism 2° base out, added to 
cylinders. 
No. 52, female, aged 20, complains chiefly of headache, and 
had it for 2 years ; under atropine H|i D; has weak externi; 
the head inclines to the right shoulder. Left eye stands higher 
than the right; asymmetry of the bones of the face ; Ord. prisms 
bases out which she wore constantly for a month ; subse- 
quently used them only in near work; under observation 6 
months ; almost complete relief. For a time tenotomy was 
contemplated, but was not done. General health became better 
under the comforting effect of the prisms, and in the end they 
were laid aside. 
These are all the cases of vertical error included among the 
present hundred, and in only one was this corrected by prisms. 
In the remaining cases it had no special import. I can furnish 
others where prisms with bases vertical were worn to advantage, 
and in other cases I have done tenotomy of either the superior 
or inferior recti. I find vertical errors rare, and in the large 
number of cases they do not need special consideration. I do 
not omit looking for them when proper relief is not obtained, 
nor where any suspicion of their existence can arise. 
It will be seen that muscular asthenopia falls upon the 
function of abduction with an overwhelming preponderance. I 
was being led to this conclusion, in 1884, when a paper was 
read on this topic before the International Medical Congress at 
Copenhagen. Wider experience has given rise to absolute con- 
viction that the externi are at fault with far more frequency 
than the interni. But it is not claimed that the ratio is so 
high as the present cases would indicate. This fact will more 
frequently come to the surface, when investigators shall free 
their minds from the prejudice that muscular asthenopia must 
be associated with ametropia, whether myopia or hyperopia 
or astigmatism. As a fact, the number of emmetropic eyes Prisms in Ophthalmic Practice. 
9 
among the community is immensely in excess of ametropic 
eyes. They should yield the largest contingent of cases of 
muscular error, provided the searcher looks for muscular error 
habitually and apart from, as well as associated with, ametropia. 
Diagnosis and Mode of Examination. — My examinations 
have had respect to the working amplitude of convergence. 
I have not paid any heed to the so-called fusion near point 
or maximum of convergence. For emmetropic eyes I have 
taken 13" or one-third of a metre as a standard for the near 
(punctiun agendi), and the same for hypermetropia, with proper 
refractive correction. Only in myopia has a shorter distance 
been sometimes employed. I believe we can come to more 
valuable practical results by testing the patient’s capacity 
to overcome prisms at 13" than we can arrive at by employing 
the seemingly more scientific method of the nearest point of 
absolute fusion and working upon a basis of angles of converg- 
ence. We must give a patient time to learn what he is to do 
with prisms, and for facility of testing I may commend very 
strongly a simple device for holding prisms and other glasses 
which I have used for twenty years and which is figured in my text- 
book on diseases of the eye, p. 195. What we learn by prisms at 
13" is, how much is the reserve power, and what are the relations 
of opposing muscular groups at the place where the patient 
does his work. This is the real object of our inquiry, and at 
this distance should we make our investigation. I make these 
remarks, because in this I differ from Landolt and most of the 
European authorities who write on this topic. 
Neither do I lay so great stress upon the indications of the 
so-called equilibrium test of Graefe as many do. Especially do 
I insist that we ought to abandon the habit of designating the 
findings by this test as the measure and expression of the mus- 
cular insufficiency. For example, many say, and I formerly 
said, that if, in causing vertical diplopia by a prism with base 
upward, the images require a prism of 30 or of 6° to bring 
them into a plumb line with each other, this prism of 30 or 6° 
is the measure of the muscular insufficiency, and we assume 
that we have to do with exactly this amount of muscular 10 
Noyes: The Therapeutic Effect of 
debility. (The new nomenclature of Dr. G. T. Stevens gives 
special names to these deviations, — esophoria and exophoria,— 
and, by so doing, tends to fix upon them an unwarranted impor- 
tance in perpetuation of the former opinion.) I admit the great 
value of this test, and constantly reckon with it, but I shall 
show that its precision as a standard of measure is overrated ; 
that it must be taken in connection with other elements, viz., 
the power of adduction and abduction, both for near and re- 
mote points. I suggest that a correct phrase, when we make' 
this test, is to simply write in our notes how many degrees of 
displacement from the perpendicular there may be in vertical 
diplopia, whether of convergence (v. d. 30 conv.) or of diverg- 
ence (v. d. 30 div.), and leave the designation of the amount 
of actual muscular insufficiency to be estimated by all the 
findings we gather. We may be unable to state the amount in 
number of degrees with precision, but we can state it proxi- 
mately, and escape the error of a false estimate by assuming an 
unreliable standard. 
It has become my rule to regard abductive power, at 20 feet, 
of 50 or less, as sub-normal. Sometimes abduction of 6° is 
regarded with suspicion. As a rule the normal amount at 20 
feet I find to be from 6° to 8°. If adduction stands at 20° 
or 250, and after a few days rises still higher, while abduc- 
tion remains 50, and distressing symptoms exist, the indication 
for prisms with bases out is clear enough for trial. If abduction 
be 4i° or less (because half degrees are important), the indica- 
tion is conclusive. 
I do not assert that abduction less than 50, even with adduc- 
tion above 250, must always be regarded as proof of deficient 
ability for eye-work. I have examined many persons, who come 
under this category, who made no complaint of their eyes or of 
headache. My assertion is, that when complaint of eye or head 
symptoms concurs with such findings in abduction and adduc- 
tion, we then are entitled to fix upon the muscles as the probable 
factors in the trouble. In other words, to some persons very 
feeble muscles or muscles in very great disproportionate power 
do not cause distress; while to other persons they are most Prisms in Ophthalmic Practice. 
11 
manifest cause of distress. What the unnamed quantity may 
be which determines either of these results, is matter for study. 
It may reside in the muscles or in the innervation or in both 
combined. Because it is unnamed, and may be various in 
character, it does not vitiate the conclusions of a scientific in- 
duction of ascertained facts. 
Treatment. — It is almost needless to premise that any in- 
dications to be gathered from the state of health were invariably, 
and, so far as possible, efficiently, attended to. For example, 
exhausting causes, viz., over-work, extreme study, physical 
depression, mental distress, lack of suitable food and exercise, 
were so far as possible controlled. In some there was an ex- 
tremely neurotic diathesis or irritating gouty diathesis to be dealt 
with, and usually with small success. Some were instances of 
great nervous depression, to be fairly called neurasthenia. In 
some there was uterine disease; in one there was chronic 
cystitis ; in two there was chorea. Two had epilepsy. Nasal 
catarrh was noted in 16 cases, and always was attended to, and 
its influence upon the symptoms carefully discriminated. Mild 
conjunctival irritation was common, and in some cases was the 
chief source of discomfort. Usually it disappeared. But in two 
cases it proved obstinate, and the attempt to relieve it by prisms 
did not succeed. Giving heed to all that general therapeutics 
required, it is to be stated that many patients had already, at the 
hands of other physicians, been submitted to general and 
local treatment without relief; some had been seen by oculists. 
All these patients were regarded as having muscular asthe- 
nopia, and in the great majority this was counted the efficient 
factor in their trouble. In some the employment of prisms was 
tentative, and considered of uncertain value, and in some cases 
they were given to determine the diagnosis. Sometimes adduc- 
tive prisms were given when the adduction was as low as y° or 
io°; and if they were afterwards found notably useful, adduction 
materially increased. In some extremely difficult cases, with 
both abduction and adduction feeble, such prisms were employed 
as a possible relief, but proved to be of almost no benefit. I 
attach controlling importance to the results of examination at the 
far point. I order prisms with this in view, and have been taught 12 
Noyes : The Therapeutic Effect of 
by experience that errors at the near point will frequently 
disappear or be so much abated as to secure the patient’s 
comfort. Hence, I prescribe prisms to be worn continuously, 
and in exceptional cases only do I order a different kind of 
prismatic glasses for the near point. I sometimes, in a doubtful 
case, hook a pair of prisms upon the frame of the glasses which 
a patient must use for refractive error, and this permits their 
removal when desirable. Schiotz (1. c., p. 183) says: “Prisms 
are the most difficult things to order, because we can never 
predict what effect they will have. Many people cannot endure 
them; to others they are of the greatest assistance. If prisms 
seem indicated, I always tell the patient that they are chiefly 
experimental, and may be of no use to him.” My experience 
has taught me to look for benefit from prisms with much more 
certainty in properly selected cases than most oculists have 
been able to do. I always insist that the patient must persevere 
in wearing them for several hours daily until all the preliminary 
annoyances disappear, and they can wear them for the entire 
day. I usually say that they must expect to be bothered in 
crossing streets and going down stairs, etc., and they will not 
be fully used to them for a week. After that period I want 
them to report to me. My rule is, to employ prisms of low 
degree, and it will be instructive to note that in the hundred 
cases the strength of the prisms was as follows : 
Prisms 
i° 
each 
eye in 
7 
cases. 
(i 
ii° 
it 
U (( 
65 
u 
a 
2° 
H 
a a 
20 
ii 
a 
3° 
(( 
a (( 
4 
a 
ii° 
O. D., 
2° 0. S. 
i 
a 
2° 
0. D., 
I°0. s. 
i 
a 
3° 
O. D., 
2° O. S. 
I 
a 
4° 
O. D., 
2° O. S. 
I 
“ = IOO 
In 66 cases the total amount of the prisms reached only 30, 
and in 20 it reached 40. In 1 case it was 50 ; in 5 it was 
6°. In 7 cases it was only 2°. What physical effect on the 
visual lines is gained by prisms of 30 ? This amounts to a little 
less than half a metric angle (one metric angle is represented Prisms in Ophthalmic Practice. 
13 
by a prism of y° for an interocular base line of 61 mm.). The 
cases in which the total amount of the prisms was 40 and less, sum 
up 94. Of these, 88 wore prisms with bases out, 3 wore prisms 
with bases in, and nearly all wore them constantly. In 4 cases, 
Nos. 54, 65, 69, and 78, they were only used in reading, and 
there are some other partial exceptions. We find, therefore, 
that these weak prisms were used in 88 cases to relieve the 
strain on divergence; and that the abatement was about one- 
half a metric angle. The total amount of convergence called 
for in normal eyes at 13" or metre is 4 metric angles, viz., 3 
positive and 1 negative. But the cases under discussion were 
always defective in the negative metric angle, because their ab- 
duction was less than 50, and we may call it which gives 
them for a working distance of i metre a total range of active 
convergence of metric angles. An abatement of a metric 
angle is in the case of these persons a reduction of the labor of 
the adductor muscles of one-seventh. This way of presenting 
the matter seems fair, notwithstanding the total capacity of 
convergence is disregarded by leaving out that large part which 
lies between metre and the absolute near point of fusion. 
The portion considered is what we use, and the continual relief 
which is bestowed by subtraction of one-seventh the labor 
required seems to me an adequate explanation of the good 
results. A closer analysis will be made a little later. 
In a general way the results of treatment may be stated as 
follows : 
Relief of symptoms complete or very great in 
6 9 
ii ii 
moderate or partial “ 
IO 
a ii 
slight or temporary “ 
7 
ii ii 
Total, 
not attained “ 
14 
IOO 
The failures were cases u, 17, 25, 27, 34, 38, 42, 43, 58, 6i, 
66, 71, 72, 97. Of these, Nos. 11, 25, 66, 71, and 97 were 
advised to have tenotomy. No. 17 suffered severely from 
chronic cystitis; and when she made this known and was 
treated for it, her eye troubles ceased. No. 27 was a proper case 
for tenotomy, but in health too feeble and too neurotic to per- 14 
Noyes: The Therapeutic Effect of 
mit it. No. 34 had persistent follicular conjunctivitis. No. 38 
had blepharitis and conjunctivitis which were hereditary; trial 
of prisms caused headache, and he used them only a few 
times. No. 42 was a physician whose health had broken down, 
and who was extremely neurasthenic. His eye muscles were 
all weak, and the trial of prisms was made with little hope of 
good effect. No. 43 was a seamstress of unhappy temper and 
surroundings. Treatment by prisms, although correctly indi- 
cated, did no good, but at a later time, when her life became 
more comfortable, her eye troubles ceased. No. 58 was a child 
of many ailments and poor constitution. The trial of prisms 
was purely experimental, and the negative result was no disap- 
pointment to me. On the muscular findings any other result 
would not be expected. I yielded to a mother’s urgency. No. 
61 was an epileptic child for whom the trial of prisms was made 
for the general malady, and with no success. No. 66 was 60 
years old, an ardent sportsman, who practiced pigeon-shooting 
one day in the week for many hours. He had much tremor of 
the eyes when turned to the temporal angles. The abduction 
was very unsteady, giving variable findings ; neither prisms nor 
plus glasses for slight H did much good. He had to relinquish 
his favorite sport in great measure. A careful tenotomy would 
have been justifiable. 
Cases of slight or temporary relief were Nos. 33, 37, 56, 68, 
91, 93, 97. No. 37 had uterine disorder; prisms given tenta- 
tively on account of low abduction. After using prisms con- 
stantly for a month, no important change in behavior of muscles 
or symptoms. No. 56 had extreme asthenopia; tenotomy ad- 
vised. No. 68, extremely neurotic; has most severe neuralgic 
headache ; finds prisms helpful; ought to have tenotomy, but 
unwilling. No. 93, medical student, with weak interni ; prisms 
useful for two weeks, but not longer; both abduction and ad- 
duction low, and, therefore, a difficult case. 
It is important to discover what results were obtained in 
regard to headache, for which especially prisms were often 
ordered. 
In 48 cases it was severe enough to be noted, and the result 
of treatment is recorded : Prisms in OphtJialmic Practice. 
15 
Complete relief 
in 
19 
Great or very great 
relief “ 
19 
Moderate or slight 
relief “ 
6 
Temporary 
U << 
1 
No 
a u 
1 
Excited headache 
n 
00 
II 
In 79 $ the prisms had a most happy effect, and were warmly 
appreciated. There can be no doubt, of course, that the. sooth- 
ing effect was by the muscles upon the innervation. Hence, it 
is evident that for therapeutic purposes we need not trouble our- 
selves about the ultimate pathology of the condition we now 
discuss. 
In view of the fact that nearly 70$ of all the cases derived 
marked benefit from prisms, let us analyze the muscular condi- 
tions before and after treatment, in hope of discovering some 
reason for the fortunate effect. 
It is proper to remark that in some cases the beneficial effect 
was greatly aided by diminution in amount of eye-work (case 
5, et al.), by improvement in general health (cases 22, 47, 52, et 
al.), and by better surroundings. Moreover, in certain cases, as 
in 48, relief continued for a period of many months (12), and 
then trouble returned. Note is made of the instances when the 
above causes were co-operative. 
Out of 69 cases much or completely relieved, I find only 33 
in which the figures are complete for the muscular findings both 
for the near and remote distances, and both at the beginning 
and end of the observation of the case. 
After careful scrutiny, no modification in muscular conditions 
appears with sufficient uniformity to warrant any categorical 
deductions. Evidently we have to do with some factors which 
evade our inquiry, and a large allowance must be made for in- 
dividual peculiarities (the personal equation). We meet this 
fact in all living organisms ; and without attempting to reduce 
the findings by prisms to averages or any numerical statements, 
the following conclusions may be stated: 
No typical features prevail in the cases, save lozv abduction for 
distance, and in most instances this is associated with low ab- 
duction at 13". The degree of adduction is extremely variable, 16 
Noyes : The Therapeutic Effect of 
and the same relative amount does not, in all cases, hold good 
for the two ends of the region. We must not lay undue stress 
on moderate variations in adduction especially for the near. A 
fluctuation of 40 or 50 need not have great significance, unless the 
total is small. The ratio which ought to prevail between ab- 
duction and adduction cannot be deduced from examination of 
these cases, because they are all pathological. Neither can it 
be ascertained from a study of the condition of the cases which 
had experienced great or complete relief. They present at this 
stage very diverse features. We find, as the result of treatment 
of weak abduction, that in most cases abduction grows less or 
remains the same ; rarely does it increase. A change of i° for 
18' is important. The behavior of the adduction, under con- 
stant use of prisms with-bases outward, is various. First, the 
most fortunate cases are those in which it notably increases; 
bringing usually complete relief. If not fully relieved, they are 
suitable for tenotomy or may even choose it in preference to 
wearing glasses. Second, some cases of great improvement 
show little gain in adduction. In them it may be assumed 
that adduction has always been low, and the asthenopia has 
been determined by strain on both adduction and abduction, 
whose ratio to each other is such as to easily be made dis- 
cordant, because the reserve capacity in both directions is 
small. In the previous class adduction is strong and abduction 
weak; it only requires that the latter function be made able to 
care for itself and balance its antagonist for ordinary ranges. 
This being done, there arises no impluse to discordant action. 
In them it seems often true that the real condition is one of 
spasm of adduction rather than paresis of abduction. As a 
result of long continued spasm, the dominant muscles may 
ultimately become wearied, and show an abnormally low capac- 
ity. Under the soothing effect of prisms benefit accrues to all the 
muscles, and the original status is restored, viz., weak abduction 
with high adduction, and is kept harmonious by the influence of 
the prisms. Third, when we have weak externi coupled with 
weak interni, and trial by abductive prisms demonstrates that 
the weak adduction is not temporary or induced by fatigue 
as just noted, the case can derive little benefit from prisms. Prisms in Ophthalmic Practice. 
17 
We must address ourselves to the general health, and counsel 
prudence in eye-work. In these cases weak convex glasses in 
reading, will often give some aid. Resort to regulated use of 
the eyes (Dyer’s method) is very helpful; gymnastic prisms give 
only little help. 
In regard to the equilibrium test something further may be 
said. It is not rare to find that the degree of lateral displace- 
ment with the vertical prism is not fixed. For example, if at 
18' the convergence under vertical diplopia is 30, a patient may 
accept a prism of 50 or 70 by a little urgency, and the images 
continue perpendicular to each other. This means an unstable 
condition of the muscles in which they are ready for more con- 
traction. The supposition that the suspension of correct bin- 
ocular vision by a vertical prism renders all the muscles passive, 
leaves out of view the fact that muscles in tonic spasm cannot 
immediately relax. We recognize this fact elsewhere; and 
why not in the eye muscles. I call this, as Loring did, latent 
insufficiency, or still better, latent spasm of the opponents. Ad- 
mitting the general correctness of the equilibrium test, more 
consideration must be given to numerous exceptional cases. 
For example, if this test is to be our exclusive or even chief 
guide in prescribing prisms, what is to be said in view of case 
10 in which, with low abduction and good adduction, and notable 
increase of the latter by the prisms and complete relief from 
asthenopia during two years of observation, the convergence 
under vertical diplopia rose for 18' from 70 to io°, and at 13" 
from 150 to 190. This increase in convergence would denote 
a more abnormal status of muscles than before wearing prisms, 
— a conclusion completely negatived by the patients’ ex- 
perience. Almost the same remarks are pertinent to case 44, 
a case under observation nearly ten years, who wore prisms 2° 
base out constantly and with entire comfort. His abduction, 
exceptionally low, dropped from i£° to -i0, and the convergence 
on vertical diplopia rose from 8° to 120 for 18'. Again, the 
amount of lateral displacement (convergence) on vertical diplopia 
bears no constant relation either to the abduction or adduction at 
either end of the range. In case 50 at 18' we have abd. 50, add. 
450, v. d. or conv. 40. In case 89 we have at 18' abd. -£°%to 30, 18 
Noyes : The Therapeutic Effect of 
add. 440, v. d. In case 92 at 18' abd. o°, add. 250, v. d. 250 
conv. In case 87 at 18' abd. add. 150, v. d. 30 conv. 
A glance over the list of cases will verify the assertion 
that no fixed relation of this kind can be made out. It is a 
well-known fact that under vertical diplopia the images may, at 
18', be homonymous, and at 13" be heteronymous. For ex- 
ample, with vertical diplopia at 13", a divergence corrected by a 
prism of 50 is so common as to be tantamount to a normal condi- 
tion, and it need rarely be considered. On this point my views 
are supported by Schiotz (Archives of Ophthalmology, Vol. xix, 
Nos. 2, 3, p. 188, Am. edition) who says : “ All this goes to show 
that the equilibrium test sometimes gives no result at all, and 
in others an incorrect result, but still I do not believe that we are 
justified in rejecting the test entirely as some have proposed.” 
We sometimes are wholly deprived of the ability to use the 
equilibrium test, as in cases of monocular amblyopia or when 
one eye is wanting. Muscular amblyopia in persons who have 
had converging strabismus is not rare. Case 45 is an example ; 
tenotomy for converging squint had been done 11 years 
previous ; each eye had the same degree of astigmatism + 1 D, 
and in one v. = 1, in the other v. =0.1, and the defective eye 
had central scotoma. There was no binocular vision, and, 
despite thorough trial, double images could not be elicited. The 
history of the case and the jerky movements of the globes, when 
striving to reach the outer canthi, determined the diagnosis 
and treatment. Prisms 30 bases outwards gave entire relief. 
Case 73 had spontaneously recovered from converging strabis- 
mus. It was impossible to cause double images in the begin- 
ning. After wearing adductive prisms and frequently repeating 
the tests, a convergence of n° on vertical diplopia was found 
at 18'. She was much helped by the prisms. It seemed also 
that the tendency to epileptic attacks was diminished. 
A suggestion already made seems to me of eminent import- 
ance and worthy of repetition, that in many cases of low ab- 
duction the controlling circumstance is persistent spasm of the 
adductor muscles rather than paresis of abductors. This may 
either remain or pass into exhaustion. Prisms in Ophthalmic Practice. 
19 
The following conclusions may be deduced from the above 
discussion : 
1. Tests for muscular asthenopia at the punctum re- 
motum have greater value than for the punctum proximum or 
for the punctum agendi (average 13"). 
2. The equilibrium test is valuable, but not decisive, and 
should not be the measure of error. 
3. Weakness of abduction is a far more fruitful cause of 
muscular asthenopia than is weakness of adduction; the 
preponderance is not far from 3 to 1. 
4. Abduction, at 18' less than 5 °, accompanied by headache 
or eye strain justifies a trial of weak adductive prisms, which 
should be worn continuously. They may become permanently 
necessary, and carl, in many cases, be superseded by.tenotomy. 
The rules on this subject are not now considered. They may 
be only a temporary necessity, and symptoms disappear. In 
these cases we do not always find the abduction to have in- 
creased ; in other cases all the muscles show a gain in power or 
disappearance of spasm. Sometimes the prisms are worn in 
near work only (cases 54, 69, 78). Prisms, after having been 
worn with benefit, someimes lose their good influence, and in 
most cases tenotomy will give relief. 
5. Refractive errors must always be corrected; but when 
of low degree, search must also be made for muscular faults ; 
and if detected, prisms are indicated in conjunction with the 
optical correction. 
6. Many neurotic symptoms, such as headache, vertigo, 
nausea, mental disturbance, and remote neuralgic conditions, 
may be relieved by prisms. 20 
Noyes : T'/zc? Therapeutic Effect of 
No. 
Muscles. 
Sex. 
. 
V 
tc 
< 
Occupation. 
History and Symptoms. 
Refraction. 
Muse. Condition 
(Primary). 
Treatment. 
Mure. Condition 
(Ultimate). 
Results and Remarks. 
I 
Ext. 
F. 
21 
✓ 
Headache (occipital) Phlyct. 
Conj. Unable to use stereo- 
scope. Print unsteady Spasm 
A. 
0. U. + 1 D. 
V.=i+. 
18' abd. 5° add. 20° 
v. d. 5’ conv.; 
13" abd. 6° add. 
30° v. d. 10° 
conv. 
Prism 2°, base out, 
0. U with cor- 
rection of R.con- 
stantly. Local 
applications for 
conj. 
18' abd. 3° add 
26°; 13" abd. 
8° add. 43c v- d. 
ii° conv. 
Under observation 11 months. 
Headache completely relieved. 
Unable to read long. 
2 
Ext. 
M. 
16 
Student.* 
Conj. Sees nose. Nasal catarrh. 
E. 
18' abd. 2}° add. 7° 
v. d. 1° /conv.; 
13"abd. i2°add. 
17° v. d. 2i div. 
Local applications. 
Prism if°, base 
out, O. U. con- 
stantly. 
18'abd 2“ add. 200 
+ v. d. 2f conv.; 
13" abd. 10” add. 
Z5°- 
Under observation 2 years. Conj. 
and catarrh relieved. Unable 
to use eyes more than a few 
minutes with comfort. Sister 
has similar trouble. 
3 
Ext. 
M. 
12 
Sees nose. Print blurs. Pain in 
eyes. Nasal catarrh. Conj. 
E. 
18' abd. 30 add. 
240; 13" abd. 8° 
add. 50° v. d. 10° 
conv. 
Prism 2°, base out, 
O. U. constant- 
ly. 
18' abd. — i° add. 
36°; 13" abd. 
o° add. 45+v. d. 
130 conv. 
Under observation 2 years. Great 
relief. 
4 
Ext. 
F. 
8 
Eyes diverge at 4". Occasional 
diplopia. Pain in eyes, Some 
headache. 
O. U. + 1 D. 
V.=i. 
i8r abd. 3add. 
24°; 13" abd. 
io° add. 200 v d. 
30 conv. 
Prism 20, base out, 
O. U. for dis- 
tance. 
18' abd. 4° -(-add. 
240; 13" abd. 
7° add. 40° v. d. 
4° conv. 
Under observation 1 year Eyes 
comfortable. Less headache. 
5 
Ext. 
M. 
44 
Lawyer. 
Had + 1 D. 4 years ago, which 
did not relieve severe neuralgic 
pain in eyes. Conj. Photo- 
phobia. Unable to use eyes 
regularly, sometimes not over 
10 minutes. Nasal catarrh. 
Not a robust man. Occasional 
headache. 
0. D. + 1 c. 
180°. V.=i. 
O. S. + 0.75s. 
V =1. 
18'abd. 5f°add 140; 
13" abd. io° add. 
30° v. d-5° conv. 
Local applications. 
Prism if", base 
out, 0. U. for 
distance and in 
combination with 
sph ero-cy 1. glass- 
es for near work. 
18' abd. 6° add. 
30° v. d. ===; 13" 
abd. 8° add. 45° 
v. d. 17° conv. 
* Note. 
Under observation 3 years. Par- 
tial relief Much less pain. 
Obliged to spare eyes. Tenot- 
omy indicated. 
6 
Ext. 
M. 
46 
Railroad 
Manager. 
Overworked and exhausted. Ver- 
tigo. Unable to read over 15 
minutes. Eyes feel strained. 
0. U. + I c. 
180°. V.=i. 
* The sign 
iS'abd. 3°add.i5°; 
I3"abd. 15° add. 
18° v. d. 5° div. 
— signifies equilibr 
Prism 2°, base out, 
O. U. with cyl 
correction for 
constant use. 
um. 
18'abd. 2° add. 19“ 
v. d. 7° conv.; 
10° add. 
20’ v. d. 2° div. 
Under observation 8 months. 
Reads 2 hours with cylindro- 
prismatic glasses. Very com- 
fortable with glasses worn con- 
stantly. Tried cylinders alone 
without relief. Daughter sim- 
ilarly affected. 
APPENDIX. Prisms in Ophthalmic Practice. 
21 
7 
Ext. 
M. 
IO 
Pain in eyes in reading. Occa- 
sional strab conv.O. S. Can’t 
learn lessons. Teacher thinks 
him stupid. 
E. 
18' abd. 4I’ add. 
36°; 13" abd. (?) 
add. 40° v. d 10° 
conv. 
O. D. Prism 3°, 
base out. 0. S. 
Prism 2°, base 
out ■ Atrop. 
usedfirst Prisms 
worn constantly. 
i8r abd. 3° add 
47 °v d. 3°conv.; 
13" abd. 10° add. 
40° v. d 5° conv. 
Under observation 4 years. De- 
lighted with his glasses. Wears 
them constantly. Complete re- 
lief. No trouble about lessons. 
Tenotomy indicated. Heredi- 
tary tendency. 
8 
Ext 
M. 
27 
Merchant. 
Conj. No trouble in use of eyes 
until a few months ago, when 
he broke down from overwork. 
Pain in eyes after reading. 
Seldom has headache. Nasal 
catarrh. 
E. Slight spasm 
A. 
i8'abd. 3° add. 11° 
v. d. 1° conv.; 
18° add. 
20°. Slight ver- 
tical error. 
Local applications 
to lids. Dobell’s 
spray in nose. 
Prism ij°, base 
out, O. U. for 
constant use 
18' abd. 3° add. 
24°v. d-4°conv.; 
13" abd. 10’ add. 
15° v. d. i° div. 
Under observation 21 years. Able 
to use eyes in office work at 
pleasure by daylight. Irritation 
of lids much less. Unable to go 
without prisms. 
9 
Ext. 
F. 
39 
Severe pain in eyes for 2 months. 
Wakes at night with pain. Un- 
able to do near work. Sick 
headache. 
0. U. + i D. 
V.=i. 
18' abd 2$° add. 
4°; 13" abd. 150 
add. 10° v. d. 5° 
div. 
Prism 1}°, base out, 
O. U. for con- 
stant use. 
18' abd. 30 add. 6°; 
13" abd. 17° add. 
28° v. d. 4° div. 
Under observation 3 months Very 
little pain if she wears glasses 
all day. 
to 
Ext. 
M. 
20 
Medical 
Student. 
Fatigue of eyes in reading. Eyes 
unsteady in movements out- 
wards. Irregular movement of 
O. S. evidently depending on 
faulty Inf. Obi. 
E. 
i8'abd. 3* add. 24° 
v d. 7° conv ; 
13" abd. 5° add. 
30° v. d. 15 conv. 
Vert, error of 2” 
for distance and 
near. 
Prism 2°, base out, 
O. U for con- 
stant use. 
i8'abd. 1° add 37° 
v. d. ro° conv.; 
13" abd. 6° add. 
40° v.d. 19° conv. 
Under observation 2 years. Ver- 
tical error disappeared under use 
of add. prisms. Prisms give 
entire relief. 
II 
M. 
28 
Medical 
Headache, unrelieved by treat- 
0. D. + o 75s. 
18' abd 12° add. 
Prism 3”, base in, 
18' abd. 20° add. 
Under observation 2 weeks Prisms 
Int. 
♦ 
Student. 
ment, for 5 or 6 years. Unable 
to read without pain in eyes and 
headache. For a few days un- 
able to read at all. Blurring of 
print. 
V.=1. O. S. 
+ 0.75c. ioo°. 
V .=1. 
11° v. d. 14° div. 
Vertical error of 
if° for distance. 
O. U. for con- 
stant use. 
13° v. d 15° div. 
utterly inadequate. Operation 
imperative. 
12 
Ext. 
M. 
32 
Physician. 
Pain in eyes. Unable to read at 
night. Pain so severe that he 
often has to go to bed. Fron- 
tal headache. 
E. 
18' abd. add. 
20°; 13" abd. 
17° add. 30° v. d. 
4° conv. 
Prism ij°, base 
out, O. U. 
(?) 
Under observation 6J months. 
Wears prisms only part of the 
time. Puts them on when he 
has the old pain and headache, 
and is always relieved. Brother 
similarly affected. 
13 
Ext. 
M. 
22 
Book- 
keeper. 
Headache and pain in eyes. 
Obliged to give up college 
course at end of second year. 
0. U.-P0.50D. 
V.=i. 
18' abd. ij° add. 
13° v. d.i'conv.; 
13" abd. 14J0 
add. i8°. 
Prism, ij-°, base 
out, O. U. for 
constant use. 
18' abd. 2}° add. 
35°; 13" abd. 
7° add. 23°. 
Under observation 8 mos. Very 
little trouble after putting on 
prisms. Had only three or four 
slight headaches after putting 
them on. Headache if he leaves 
them off. Brother similarly 
affected. 22 
Noyes : The Therapeutic Effect of 
No. 
Muscles. 
Sex. 
Age. 
Occupation. 
History and Symptoms. 
Refraction. 
Muse. Condition 
(Primary). 
Treatment. 
Muse. Condition 
(Ultimate). 
Results and Remarks. 
*4 
Ext. 
F. 
20 
Pain in eyes, headache, and 
bleph. marg. Not relieved by 
+ 1.50 0. U. for reading. 
When first seen had had con- 
stant headache for six weeks. 
Is rather delicate. Spasm A. 
Eyes sometimes feel as if they 
would burst. 
O. D.+0.75S O 
+ 0.50C 180°. 
V.=i. O. S. 
+ 1.00s. 3 + 
0 50c. 180'. 
V.=i. 
i8'abd. 6° add. 12° 
v. d. ic div.; 13" 
abd. 22° add. 30° 
v. d. 4° div. 
Atropine. Prism 
i|°, base out, 
with + 1 D 
O. U. for read- 
ing. 
18' abd. 4° — 5° 
add. 22°. 
Under observation 6 mos. At one 
time lost glasses and was “ in 
misery ” until they were re- 
placed. Died suddenly a few 
months after last examination. 
15 
Ext. 
M. 
17 
Student. 
Eyes strained from over use. 
Conj. irritation. Eyes not pain- 
ful but feel weak. Can read 
only 15 or 20 minutes. Some 
nasal catarrh. 
E. 
18' abd. 5}° add. 
22°+; i3"abd. 
i5°(?) add. 27° 
v. d. 6° conv. 
Prism ij°, base 
out, O. U. for 
constant use, 
with additional 
+ 1 D. 0. U. 
in reading. 
i8r abd. 90 add. 
210 v. d.—5 13^ 
abd. 18° add. 350 
v. d.=^. 
Under observation i J years. Soon 
became able to read from four 
to six hours a day, reading two 
hours at a time. Ultimately 
able to discard glasses. 
l6 
Ext. 
F. 
60 
A few striae -in lenses. Nasal 
catarrh. Conj. Pain in eyes 
for several years, increasing of 
late. 
0. D. + 0 50c. 
90°. V.=i. 
O. S. — 1.50s. 
Ci+a-Soc. 80°. 
V.—O.q—. 
18' abd. 7° add. 
17° v. d =i; 13^ 
abd 20' add. 36° 
v. d. 5° div. 
Sphero-cyl. cor- 
rection for dis- 
tance with addi- 
tional -(-3D. 
forreading, with- 
out relief, fol- 
lowed by prism 
20, base out, 0. 
U. as supple- 
mentary reading 
glasses 
13" abd. 200 add. 
30 v. d. 5° div. 
Under observation one month. 
Before prisms were added could 
not use eyes at all without great 
pain. After prisms were added 
could read one-half hour at a 
time and could also read some 
in evening, a thing she said she 
had been unable to do for a long 
time. 
*7 
Ext. 
F. 
34 
General health not good. Has 
some cystitis. Conj. 
E. 
18' abd. 6° — 3° 
add. 32°; 13" 
abd. 10° + add. 
38° v. d. 6° conv. 
Prism 2°, base 
out, O. U. for 
reading. 
(?) 
Under observation nine months. 
Could not wear prisms. 
APPENDIX. — Continued. Prisms in Ophthalmic Practice. 
i8 
F. 
27 
Inherits eye trouble and has had 
it as long as she can remember. 
Pain in eyes, gums, ears, and 
back of head follows all kinds 
of eye work. Eyes twitch, and 
this is prevented only by great 
effort. Difficulty in looking at 
moving objects, and easily nau- 
seated in so doing. Sick head- 
ache. Pain in eyes, often so 
severe as to keep her awake 
nights. Has had some uterine 
trouble. Occasional attacks of 
rheumatism. Neurotic tenden- 
cies. 
O. U. + 1 D. 
V.=i. 
18' abd 3" add. 
90 v. d =2=. 
Prism ij°, base 
out, O. U. for 
constant use. 
18' abd. 1° add 
25”; 13" abd. 
14° add. 30°. 
Under observation five months. 
-)- 1 D. gave only temporary 
relief. Prisms entirely relieved 
headache. She is dizzy if she 
leaves them off, and wholly un- 
able to do without them. On 
account of neurotic tendencies, 
value of operative interference 
doubtful. 
Ext 
»9 
Ext. 
M. 
20 
Type- 
writer. 
Trouble in use of eyes for 18 
months. Can read from two to 
four hours a day. Has little 
pain or headache, but says he 
can’t use eyes. Eyes twitch, 
particularly at outer angles. 
Has very slight vertical devia- 
tion (hyperphoria). 
E. 
18' abd. add 
17° v. d.=2=; 13" 
abd. 10° add. 25° 
v. d.=2=. 
Prism if°, base 
out, O. U. for 
constant use. 
18' abd. 5° add. 
180 v d. 1° conv.; 
13" abd 15° add 
18° v. d.=2=. 
Under observation 2i years. At 
end of that time could read three 
to four hours a day. Has found 
that when he breaks prisms he 
has headache until they are 
repaired. 
20 
F. 
25 
Rather delicate, and had a very 
serious illness six months ago. 
Unable to use eyes for three 
months, and has had pain in 
using them for a longer period. 
Pain through temples and eye- 
balls, with nausea, on attempt- 
ing to use eyes. Considerable 
headache. Has trouble only in 
near work. Prism tests pro- 
voked vertigo. 
E. 
18' abd. 3U add. 
19° v. d.=2=; 13" 
abd. 16° add. 
23° v. d =2=. 
Prism i}°, base 
out, 0. U. for 
constant use. 
i8'abd. 5° add. 33° 
v d. 4° conv ; 
13" abd. 10° add. 
30° v. d. 50 conv. 
Ext. 
Able to read one-half hour 
several times a day. Use of 
eyes beyond that provokes the 
old pain, but it does not persist 
if she stops. Formerly had 
headache whenever she read, 
now about once a week only. 
Improvement in general health. 
21 
Ext 
F 
18 
Mechanical 
draughts- 
man. 
For three or four years has had 
pain around eyes, headache and 
strained feeling in use of eyes. 
Sight at times blurred. 
0. U. — 0.75s. 
C + 075c. 
90°. V.=i. 
18' abd. 5° add. 30° 
— 20°; 13" abd. 
20” add. 35° v. 
d. 2° conv. 
0 U. +0 75c 90° 
C prism iij°base 
out, for work. 
18' abd. 4” add. 
27° -f- v d 2° 
conv.; 13" abd. 
210 add. 30° + 
v. d. 3!° conv. 
Under observation two months. 
Continued to use eyes steadily 
at her work, mechanical draw- 
ing. Much less pain with 
glasses. Hardly able to work 
without them. Convex cylin- 
ders without prisms had been 
tried without benefit. 
23 24 
Noyes : The Therapeutic Effect of 
No 
Muscles. | 
Sex. 
6 
bfl 
< 
Occupation. 
History and Symptoms. 
Refraction. 
Muse. Condition. 
(Primary). 
Treatment. 
Muse Condition 
(Ultimate). 
Results and Remarks. 
22 
Ext. 
M. 
17 
Unable to use eyes for two or 
three years. Almost constant, 
severe headache. Had to give 
up school because effort of 
looking made him feel “bad.” 
Head “ seems queer ” on look- 
ing steadily at anything. Not 
a rugged boy. Some conj. 
0. D. V.=o.7; 
Oph + i D. 
CL S. E. 
18' abd. 5J" add. 
5°; 13" abd. 18° 
add. 15° v. d. 10° 
div. 
Prism ii°, base 
out, O U. for 
constant use. 
Local applica- 
tions for conj. 
i8/ abd. 6° add. 
30° + v. d =2=: 
17° add. 
23° v. d, =2=. 
Under observation four and one- 
half months. Uses eyes very 
little in reading, but has no pain 
or headache, whereas before 
wearing prisms headache was 
almost constant. 
23 
Ext. 
M. 
20 
Clerk. 
Headache for six years, increased 
by eye work. Has had to give 
up reading. Headache in 
church and theater. Severe 
nasal catarrh. 
E. 
i8r abd. 5° add. 
20°; 13" abd. 
10° add. 15°. 
Prism ij°, base 
out, O. U. for 
constant use. 
Local applica- 
tions for catarrh. 
18' abd. 3° add 
3°° • 
Under observation ten months. 
After wearing prisms a short 
time tried to leave them off for 
a day, but had headache with 
nausea, which was instantly re- 
lieved by putting on prisms. At 
end of ten months could read 
by daylight but not much in 
evening. Relief was great. 
24 
Ext. 
M. 
25 
Medical 
Student. 
Been reading late at night. Sight 
gives out suddenly after long 
reading, so that he fails to rec- 
ognize a person across lecture 
room. No trouble until* a 
month ago. 
O D. + 0 75s. 
V. - 18-15. 
O. S. + 0.75s. 
O "I" 0.50c. 
180°. V. = 
18-20. 
18' abd. i$° add 
15° v.d. 2° conv.; 
13" abd. 18° add. 
15 v. d =2=. 
0. D. -(- 0.50s. 3 
prism 2°, base 
out; 0. S. + 
ic 180° 3 prism 
2°, base out; for 
constant use. 
18' abd. 1° add. 
210 v. d.—; 13" 
abd. 16° add. 
19° v. d =2=. 
Under observation one and one- 
half years. Complete relief with 
prisms. Unable to go without 
them. 
25 
Ext. 
M. 
27 
Peddler. 
Pain in eyes for ten years. In- 
ability to read long. Nasal 
catarrh. 
E. 
i8'abd. 4° add 17° 
(?); i3//abd. 20° 
add. 15° v. d. 70 
div. 
Prism base 
out, O. U. for 
constant use. 
18' abd. ij° add. 
25° v.d. 2° conv.; 
13" abd. 10° add. 
38° v, d. r° conv. 
Under observation four months. 
Little or no relief from prisms, 
but they demonstrate the true 
nature of the trouble. Tenot- 
omy advised. 
26 
Ext. 
M. 
34 
Merchant. 
Troubled with eyes for fourteen 
years. Unable to read in even- 
ing. Conjunctivitis. Nasal 
catarrh. 
E. 
18' abd. 3° add. 
7i°i 13" abd. 15° 
add. 200 v. d. 8° 
div. 
Prism ij% base 
out, O. U. for 
constant use. 
18' abd. 20 add. 
140. 
Under observation six months. 
Condition greatly improved, but 
not entire relief. Able to read 
several hours. Had tried -f- 1 
D. for reading without benefit. 
Has slight vertical error, but 
was relieved without taking this 
into consideration. 
APPENDIX. — Continued. Prisms in Ophthalmic Practice. 
25 
27 
Ext. 
F. 
l6 
Schoolgirl. 
Aching and fatigue of eyes for 
eight months. Eyes usually 
feel very tired. Is studying 
hard and is anaemic. Spasm 
A. General health poor. 
O. D. — i.c 
180°. V. — 1. 
0. S. E. 
i8'abd. 3° add. 12° 
v. d.=2=; 13" abd. 
20° add. 30° v. d. 
5° div. 
After trying rest, 
tonics and atro 
pia for a month, 
ordered prism 
20, base out, O. 
U. for constant 
use. 
18' abd. 3° 4- add 
2o°+; 13" abd. 
18° add. 40° v. 
d. =2=. 
Under observation three months. 
Unable to wear prisms with 
comfort. Often relieved by re- 
moving them. General condi- 
tion poor. 
28 
Ext. 
F. 
23 
Music 
Teacher. 
Unable to use eyes in evening; 
they feel strained and “ crazy.” 
Difficulty in keeping eyes open 
in evening. Is “ miserable ” 
the next day after going to op- 
era. Conj. and bleph. severe. 
O. U. + 1 D. 
V.=i. 
i8'abd. 30 add. 15° 
▼. d. 4° conv. ; 
13" abd. 8° add 
15° v. d. 1° div 
Prism ij°, base 
out, O. U. for 
constant use. 
After 3 months: 
18' abd. 3+° add. 
21° v. d 2i” 
conv.; 13" abd. 
50 add. 25° v. d. 
4° conv. 
Under observation six months. 
Able to read one and one-half 
hours in evening. Comfortable 
with glasses and unable to go 
without them. Bleph. cured. 
2g 
Ext. 
M 
21 
Medical 
Student. 
Bunting pain in eyes and blur- 
ring of print after reading a few 
minutes. Almost constant 
headache. 
E. 
18' abd. 3° add. 9° 
v. d =e=; 13" abd. 
15° add. 150 v. 
d. =^. 
Prism i|°, base 
out, O. U. for 
constant use, 
with + 1 D in 
addition for 
reading. 
18' abd. 1° add. 
130 v d =2=; 13" 
abd. 13° add. 20° 
v. d. 3° conv. 
Under observation three months. 
Able to study three or four hours 
daily. Cannot go without 
glasses. 
30 
jen. 
M. 
38 
Retired 
Merchant. 
Case of general prostration from 
too close application to busi- 
ness. Unable to use eyes more 
than a few minutes at a time. 
Pain in back of head and neck. 
Pain extends to arm and leg on 
mental application or use of 
eyes. Eyes tire in looking at 
pictures, etc. Difficulty in 
looking at moving objects. 
Closes eyes on Broadway and 
gets relief. 
E. 
18' abd. add. 
15° v. d. 30 
conv.; 13" abd. 
18° add. 28° v. 
d. 3° conv. 
Prism 1°, base out, 
O. U. for con- 
stant use; later 
prisms of ij°, 
and still later 
0.75s. O. U. 
in addition for 
reading. 
18' abd 4° add. 
22° v.d 3°conv.; 
13" abd. io° add. 
140 v. d 3° conv. 
Under observation nearly two and 
one-half years. Gets a certain 
amount of relief from glasses. 
Can read paper ten minutes at 
a time and can attend to personal 
business. Has had the best ad- 
vice for general condition, and 
the slight improvement in eyes 
seems due to general improve- 
ment. 
31 
Ext. 
F. 
26 
Eyes ache and she has “ dread- 
ful” headaches when she reads 
or sews. Conj. Slight spasm 
A. Very nervous woman. 
Trouble for two or three years. 
E. 
18' abd. 50 (?) add. 
17° v. d. =2=; 13" 
abd.12° add.30° 
v. d. =i. 
Prism ij°, base 
out, O. U. for 
constant use. 
18' abd. 30 add. 
I7° i 13// abd. 
8° add. 23°. 
Under observation one year. 
Prisms relieved headache al- 
most completely from the very 
first. Much less conjunctival 
irritation. Patient in much bet- 
ter spirits and very thankful 
for prisms. 26 
Noyes : The Therapeutic Effect of 
No. 
Muscles. 
K 
0> 
CO 
O 
tc 
< 
Occupation. 
History and Symptoms. 
Refraction. 
Muse. Condition 
(Primary). 
Treatment. 
Muse. Condition 
(Ultimate). 
Results and Remarks. 
32 
Ext. 
F. 
16 
Schoolgirl. 
Has been studying hard to obtain 
first place in class. Trouble 
with eyes for three or four 
months. Pain in eyes and fa- 
tigue. Photophobia. Slight 
spasm A. Eyes often feel 
tremulous Slight twitch at 
outer angles. 
E. 
18' abd. 5° add. 
35"; 13" abd. 
18° add. 45° + 
v. d. 8° conv. 
Rest of eyes, no 
glasses. At end 
of year condi- 
tion about the 
same, although 
eyes had been 
used in modera- 
tion. Ordered 
prism ip°. base 
out, O. U. for 
constant use. 
18'abd. 5° (?) add. 
45°; 13" abd 
120 add. 50° -p 
v. d. i° conv. 
Under observation one year. Two 
weeks after putting on prisms 
reported herself much relieved. 
Had been able to use her eyes 
ad libitum without pain in study- 
ing for college examinations. 
33 
Ext. 
F. 
17 
Schoolgirl. 
More or less trouble for six 
months. Conjunctivitis. Hard 
to keep eyes open. In read- 
ing apt to lose the place if she 
lifts eyes from book. Can not 
embroider. Health good. 
Light hurts eyes. 
E. 
18' abd. 4° add 
22°; i3//abd. 16° 
add. 30° + v. d. 
6° conv. 
Prism 1}°. base 
out, O. U. for 
constant use. 
18' abd. 5° -p add. 
20°; 13" abd. 
11° add. 25° v. 
d. 7° conv. 
Under observation four months. 
Used glasses with comfort for 
two months She then had pain 
in eyes and was unable to use 
them. Later had headache, but 
this stopped on leaving school. 
34 
Ext. 
F. 
15 
Has follicular conjunctivitis. 
Reading irritates eyes. Is 
made tired by prism tests. Lids 
have been treated for several 
months. Subject to headache. 
E. 
18' abd. 30 add. 
20°; i3"abd. 10° 
add. 35° v. d. 4° 
conv. 
Treatment of lids. 
Prism 1}°, base 
out, O. U. for 
constant use. 
18' abd. 4° add. 
23° v. d. ; 
13" abd. 5° add. 
40” v. d. 7° 
conv. 
Under observation nirje months. 
Wore prisms three months with- 
out benefit. Conjunctivitis per- 
sists. Headache rather worse. 
35 
Ext 
M. 
48 
Manager. 
Severe vertigo Pain in head. 
Creeping sensations for two 
weeks. Melancholia. For- 
getfulness. Sugar in urine. 
Powerful physique. 
0. U. + 1 D. 
V.=i.+ 
18' abd. 50 add. 
25° v. d. =5=; 
13" abd 2 5° add. 
35° v. d. 10° 
conv. 
0. U. + 1 D. c 
prism ip°, base 
out, distance; 
O. U.+3D.C 
prism 2°, base 
out, for reading. 
Spherical cor- 
rection later in- 
creased to + 4 
D. 0. U. 
18' abd. 30 v. d. 
30 conv. 
Under observation for nearly three 
years. At end of first month 
said he would not take a million 
dollars for his glasses. Relief 
was prompt and not dependent 
on improvement in general con- 
dition. At end of two years 
said he had “lots of fun” with 
his eyes. He shortly after this 
had another break-down from 
anxiety due to business reverses 
and death of brother. He had 
much pain in head, sugar reap- 
peared in urine, and he was un- 
able to read at all. Reading 
glasses were slightly increased 
in strength. Subsequently re- 
gained eye power. Brother had 
weak externi. 
APPENDIX. — Continued. Prisms in Ophthalmic Practice. 
27 
36 
Ext. 
M. 
28 
Physician. 
Pain in O. S., a “real ache.” 
Unable to use eyes with com 
fort Powerful man. Picture 
of health. 
0. D. +3.S.C 
+ o-75c. 75°- 
V.=i. O. S. 
+ 3-S. C + 
O.75C. 120°.V 
= 20-20- 
i8'abd 5° f add. 
33° v. d. =5=; 13" 
abd. 20° add 50° 
v d. 3° conv. 
Prism 2', base out, 
0 U. with cor- 
rection of refrac- 
tive error. 
i8r abd. 2° add. 
15° —20°. 
Under observation one and one- 
half years. Complete relief. 
Able to use eyes as much as he 
wished. Brother of preceding 
case. 
37 
Ext 
F. 
27 
Trouble with eyes for two years. 
No pain or headache, but un- 
able to read more than a few 
minutes. Under treatment for 
uterine trouble. 
E. 
18' abd 30 add 
15°; i3/r abd. 18° 
add. 20° v. d. 
2° div. 
Prism 1°, base out, 
O. U. for con- 
stant use. Dyer. 
18' abd. 40 add. 
17°; 13" abd. 
13° add. 25°. 
Under observation one month. 
Thought glasses were of some 
assistance in reading. Could 
read with them from twenty to 
thirty minutes. 
38 
Ext 
M. 
21 
Clerk. 
Irritation of lids for ten months. 
Trouble in study or work. 
Chronic conj. and bleph. marg. 
which is hereditary. 
E. 
18' abd. 4° (?) add 
22° + ; 13" abd. 
16° add. 28° v. 
d. 50 conv. 
Prism ij°. base 
out, O. U. for 
constant use. 
18' abd 4° add. 
13° v. d. =2=; 
13" abd. 16° 
add. 15° v d. 5° 
div. Prisms not 
decidedly indi- 
cated and failed. 
Under observation four months. 
Wore prisms only a few times 
and they seemed to make head 
ache. 
9 
Ext 
M. 
35 
Merchant. 
Tired feeling in eyes. Reading 
has become a burden. Has 
had considerable anxiety. Ob- 
liged to discriminate carefully 
between colors in his business 
Trouble of recent date. Pa- 
tient rather overworked and 
worried. Eyes tire on cars, etc. 
E. 
18' abd. 3f’ add 
9°: 13" abd. 18° 
add. 17°. 
0. U. 4- i-6os. 3 
prism ii% base 
out, O. U for 
reading. Two 
years later in- 
creased spheri- 
cal glass to + 
0 75s and prism 
to 2°, O. U. for 
reading and to 
use old ones for 
distance. 
18' abd. 40 add. 
15° v. d i3// 
abd. 12° add. 
18° v. d. 5° 
conv. 
Under observation three and one- 
half years. Prisms gave great 
relief although eyes were se- 
verely taxed. 
40 
Int. 
M. 
26 
Medical 
Student. 
Trouble for two years. Pain in 
lids, not in eyes, iu reading, 
etc. 
E. 
18' abd. 5° add 5° 
v. d. =2=; i3/r 
abd. 23° add. 8° 
v. d. div. 
Prism 2° base in, 
O U. for con- 
stant use. 
i8r abd. 9° add. 
130 v. d. =2=; 13" 
abd. 35°add. 150. 
• 
Under observation fourteen mos. 
Wore glasses for over a year 
with perfect comfort. At the 
end of that time eyes became a 
little fatigued from over-work, 
preparing for examination for 
degree. 
4i 
Int. 
F. 
16 
Schoolgirl. 
Trouble with eyes for a year fol- 
lowing excessive use of eyes 
while confined to bed with in- 
jured foot. Spasm A Able to 
read a short time only. No 
headache. Nasal catarrh 
E. 
i8'abd. 70 add. 13° 
v. d. =2=; 13" 
abd. 12° add. 10° 
v. d. =2=. Image 
O. D. lower 
than that of left. 
Atrop., gr. iv ad 
oz. i, followed by 
O. D. Prism 
2°, base in; O. 
S. Prism i°, 
base in She 
had already 
worn above. 
Later increased 
O. S. to 2°. 
18' abd 11° add. 
16° v. d. 1 ° conv ; 
13" abd 18° 
add. 22”. 
Under observation two and one- 
half years. Able to use eyes 
seven or eight hours a day, in- 
stead of one-half hour as for- 
merly. Occasionally goes with- 
out her prisms, but generally 
wears them constantly. Perfect- 
ly comfortable with them. 28 
Noyes : The Therapeutic Effect of 
No. 
Muscles. 
Sex. 
Age. 
Occupation. 
History and Symptoms. 
Refraction. 
Muse. Condition 
(Primary). 
Treatment. 
Muse. Condition 
(Ultimate). 
Results and Remarks. 
42 
Int. 
M. 
43 
Physician. 
Weak constitution. Not much 
physical stamina. Has large 
practice and is overworked. 
About fifteen years ago over- 
taxed eyes and they gradually 
gave out. No trouble before 
that time. Unable to read over 
fifteen minutes without great 
distress, and is obliged to wear 
prisms of from 2° to 7°, bises 
in. Does not sleep well. Dif- 
ficulty in looking from one ob- 
ject to another. Diagnosis of 
weak intemi made years ago 
by Dr. Dyer. Eyes twitch at 
outer angles Headaches dur- 
ing the last year only. 
0. U. + 0.75s. 
V—1. 
18' abd. 3° add. 3° 
v. d. 3° div.; 
13" abd. 15° add. 
0° v. d. 15° div. 
Has had tonics, 
electricity, and 
prisms. O. U. 
-f 1-60 3 prism 
i|°,base out, for 
distance; 0. U. 
4- 1-12SO prism 
6°, base in, for 
reading. To 
use gymnastic 
prisms. 
18' abd. add. 
8°; 18' 4- i-6os. 
add.^=i5°. 
Under observation eight months. 
Habitually uses but one eye in 
reading, either one. Case of 
general muscular weakness. 
Marked neurasthenia. Had con- 
sulted various oculists. Opera- 
tion suggested. Case of break- 
down from too intense applica- 
tion in a person with neurotic 
tendencies. 
43 
Ext. 
F. 
27 
Seamstress. 
Some conj. Pain in eyes in a 
warm room. Under some ner- 
vous excitement—mental worry 
— for six months. Headache 
all the time. Supra-orbital 
tenderness. 
E. 
18' abd ij° abd. 
17°; 13" abd. 18° 
add. 20°. 
Prism 2°, base out, 
O. U. for con- 
stant use. Later 
reduced prisms 
to 1°. 
18' abd. 3° add. 
20°v. d 2°conv.; 
13" abd. 8° add. 
33° v. d. 5° conv. 
Under observation three months. 
Little benefit from prisms. Te- 
notomy indicated. The causes 
of nervous tension and worry 
contihue. Is much perturbed. 
Eye treatment of doubtful value. 
44 
Ext 
M. 
3° 
Medical 
Student. 
O. U. Amblyopia from corneal 
opacities. Unable to use eyes 
with comfort. 
0. D.+05S. V. 
= 0.6—. (). 
S. + 0.75s. V. 
=0.4. 
18' abd. add. 
24°v d 8°conv ; 
i3r/ abd 
add. 48° v. d. 90 
conv. 
O. 17. + 1 D c 
prism 2°, base 
out, for constant 
use. 
18' abd. add. 
240 -t- v. d 12° 
conv.; 13" abd. 
70 add. 23° v. d. 
10° conv. 
Under treatment nearly two years. 
Has been able to use eyes fifteen 
hours a day at times with com- 
fort. Had previously tried 
spherical glasses without much 
benefit. Relief very marked in 
spite of amblyopea. 
45 
Ext. 
F. 
17 
Schoolgirl. 
Has for several months had head- 
ache after use of eyes. Move- 
ment outwards of eyes jerky 
Operation on O. S. for strab. 
conv. eleven years ago. Cen- 
tral scotoma O. S. 
O. D. + i c 1800 
V. = 1. O. S. 
4-1 c. i8o°.V. 
= 0.1. 
No binocular vis- 
ion. 
Prism 3°, base out, 
O. U. for con- 
stant use. 
Under observation six months. 
Entirely relieved by prisms. 
Able to do full work in school 
without pain. Case of special 
interest on account of monoc. 
amblyopia. 
APPENDIX. — Continued. Prisms in Ophthalmic Practice. 
29 
46 
Ext 
F. 
l6 
Schoolgirl. 
More or less headache for two 
years. Recently more pain in 
eyes and head. Strong and 
healthy. 
E. 
18' abd. 3° add. 
14" v. d. 2° 
conv ; 13" abd. 
13° add. 20° v.d. 
Rest and tonics. 
Three weeks la- 
ter, prism i|’, 
base out, O. U. 
for constant use. 
18' abd 3° add. 
15°; 13" abd 70 
add. 20° v. d. 6° 
conv. At one 
time after wear- 
ing prisms abd. 
at 18' sank to — 
1°. 
Under observation four months. 
Partial relief from rest. With 
prisms able to use eyes four or 
five hours a day. Unable to 
read without them or even to 
walk without them. No head- 
ache. 
47 
Ext. 
F. 
15 
Schoolgirl. 
Eyes have given trouble for a 
year. Eyes ache after reading 
fifteen minutes, and headache 
follows if she continues to read. 
Has headache when tired, but 
with the headache following 
bodily fatigue she does not have 
the pain in eyes which follows 
reading Under treatment for 
slight lateral curvature of spine. 
Has been too closely confined 
to her studies. 
O.U. + i. D. V. 
18' abd. 5° add. 
27°+; i3//abd. 
150 add. 30° v. 
d. 40 conv. 
Prism 1°, base out, 
O. U for con- 
stant use, later 
for near work 
only. 
18' abd. 7° +add. 
39° v. d =&.; 13" 
abd. 16° add. 
36° v. d. 
Under observation twenty months. 
No headache, no trouble of any 
kind. Has been relieved from 
pressure of all kinds, been much 
more in open air and gained 
fifteen pounds Part of tbe re- 
lief undoubtedly due to improve- 
ment in general health, but 
prisms gave relief immediately. 
Prisms to be abandoned, first for 
distance, later for near work. 
48 
Int. 
M. 
33 
Commer- 
cial 
Traveler. 
Pam in eyes in reading. Print 
unsteady. Has read much on 
cars. Much conjunctival irri- 
tation. 
0. D. + 0 50c. 
750. V.=i. 0. 
S. + 0.50c. 
105°. V. = 1. 
i8r abd. 8° add. 
7°; 13" abd. 28° 
add. 15° v. d. 
130 div. 
Prism 1}", base in, 
0. U. combined 
with cyl. correc- 
tion for constant 
use. 
abd 9' add. 
10°/.d 4°+div.; 
200 add. 
150 v. d. 8° div. 
Under observation three years 
Glasses gave almost complete 
relief for a year. Conj. irritation 
greatly diminished. At end of 
three years old trouble returned 
and he had pain in eyes after 
fifteen or twenty minutes use. 
Tenotomy advised. 
49 
Ext. 
M. 
.3 
Schoolboy. 
Trouble for six months Blurring 
of print after reading a few 
minutes, passing off with rest. 
No pain or headache. 
O U. + 0.75s. 
V. = I. 
i8r abd. 3° add. 
io°; i3// abd 
120 abd. 23° v. 
d ===. Same re- 
sult with and 
without 4- 0.75s. 
At first ordered + 
0 75s O. U., but 
their use in read- 
ing gave rise to 
pain behind 
ears. Then or- 
dered prism 2°, 
base out, O U., 
for constant use. 
18' abd. 5° add. 
27°. 
Under observation three months. 
Wore prisms all the time and 
did not like to be without them. 
No trouble in school. 
so 
Ext. 
M. 
19 
Student. 
Occasional diplopia. Occasional 
migraine. Inclines head toward 
left shoulder. Some headache, 
i. e., pain at inner angles. 
Able to read one and one-half 
hours. Some vertigo. 
0 U. + 0.50s. 
V. = 1. 
18' abd. 4° (?) add. 
36°. Images vi- 
brate 13" add 
11° add. 46° v. 
d 70 conv. 
Prism i}°, base 
out, O. U., for 
constant use. 
18' abd. 5° add. 
45°+v. d. =£=; v. 
d. 1. conv. 4°; 
i3//abd. 3° to 0° 
add. 450 + v. d. 
8° conv. 
Under observation two months. 
Able to use eyes three hours a 
day, one hour at a time. Rather 
less headache and vertigo. Ad- 
vised tenotomy. Noyes: The Therapeutic Effect of 
30 
No. 
M uscles. 1 
K 
ii 
C/3 
oJ 
< 
Occupation. 
History and Symptoms. 
Refraction. 
Muse. Condition. 
(Primary.) 
Treatment. 
Muse. Condition. 
(Ultimate.) 
Results and Remarks. 
H 
Ext. 
and 
Int 
F. 
28 
Teacher. 
Naturally nervous. All her fam- 
ily have trouble with eyes. As 
a schoolgirl always had sick 
headache after writing. Has a 
“horror” of sitting down to 
write a letter. Never able to 
read over one-half hour with- 
out pain, and writing always 
followed by “ frightful ” head- 
ache. Binocular vision not 
constant. Vertical error of ij°. 
Has had for over a year care 
fully fitted cylindric correction 
with little relief Goes home 
from school daily perfectly ex- 
hausted. 
O. D. + 0 25s. 
C+o 75c-9°'- 
V. = 1. O. S. 
— 0.50s 0 + 
1.50c. 90° V. 
i8/ abd 5° — add. 
7°v. d 
13" abd. i2°add. 
— 10° v. d. 5° 
div. 18'. vert 
error V ii° 0. D. 
Her correction 
withO D prism 
1°, base up. O. 
S. prism 20,base 
out. 
After six weeks: 
18' abd 40- add. 
27°; 13" abd. 
18° add. 30° v. 
d. 3° conv. 
Under observation four and one- 
half months. “ Is tied to glass- 
es,” and miserable without them. 
Went to church sociable without 
them and had “ terrific ” head- 
ache all next day. With glasses 
has no headache and is able to 
read and sew all day and even- 
ing and to use eyes as she 
pleases. 
*2 
Ext. 
F. 
20 
Headache for two years, now al- 
most daily. Often has vertigo. 
Difficulty in piano playing. 
Blurring of sight in looking 
steadily at objects. Reading 
increases headache and irritates 
lids. Some conjunctival irrita- 
tion. Tonics used without 
benefit. Eyes twitch at outer 
angles. Prism tests cause 
frontal headache. Inclines 
head to right shoulder. O. S. 
stands higher than 0. D. Eyes 
ache if she spends day in town 
shopping. 
Under atropine, 
O U. + i. V. 
18' abd. 3!° add. 
10-15° v. d ===; 
13" abd. 16° add 
26° v. d. 4° div. 
Prism if°, base 
out, O. U. for 
constant use. 
i8r abd 6° add. 
42° v. d 1' conv ; 
i3°add. 
40° v. d. 4° conv. 
Under observation six months. 
Wore prisms constantly for 
about a month, then for near 
work only. Able to read an 
hour fairly well. Improvement 
in general health. At end of 
six months had very little head- 
ache, whereas formerly it was so 
severe she was frequently com- 
pelled to go to bed. 
S3 
Ext. 
M. 
13 
Schoolboy. 
Pain in eyes for three months, 
even when not reading. 
O. U. + 0.50s. 
V. = I. 
18' abd 3' add. 
19° v. d. =a=; 13" 
abd. 16}° addv 
30° v. d. 1° conv 
Prism base 
out, 0. U. for 
constant use. 
18' abd. add. 
20°v. d.3° conv.; 
13" abd, 15° add. 
3o°v.d. 2i°conv. 
Under observation one year, wear- 
ing glasses all the time without 
“ a bit ” of trouble. 
APPENDIX. — Continued. Prisms in Ophthalmic Practice. 
31 
54 
Ext. 
M. 
15 
Schoolboy. 
Reads and practices on piano 
many hours a day Sometimes 
has pain in eye-balls. Pain in 
looking at distant objects. 
Eyes tire in looking at pictures. 
Spasm A. 
0. U. + 0.75s. 
V. = 1. 
18' abd. 3" add. 8° 
v. d. =2=; 13" 
abd 14° add. 
20” v. d. =2=. 
After rest, prism 
ij°, base out, 
O. U. only in 
reading. 
18' abd. 3” add. 
40° v.d. 6° conv.; 
i3/rabd. 13° add. 
250 v. d. 5° conv. 
Under observation one and one- 
half months. Wore prisms for 
near work only. Has had no 
pain in eyes, but has not been 
using eyes as much. 
55 
Ext. 
M. 
IO 
Schoolboy. 
Under treatment more or less for 
two years for dyspepsia. Much 
headache and nausea, particu- 
larly on use of eyes. Unable 
to look at moving objects with- 
out nausea. Unable to be in 
school more than one day in a 
week for several months on ac- 
count of headache. Vertigo. 
Delicate, nervous boy. 
E. 
18' abd. 3° add. 
10” v.di; 13" 
abd. 15° add. 
13° v. d.=2=. 
Prism iF°, base 
out, 0. U. for 
constant use. 
i8r abd. 5° add. 
23° v.d.2° conv.; 
i3"abd. 140 add. 
25° v. d.4° conv. 
Under observation eight and one- 
half months. Unable to get 
along without his prisms. Un- 
able to concentrate mind on les- 
son for over one half hour. If 
crowded beyond this has nausea 
and headache which last until 
following day. Has nausea if 
he leaves off prisms. Headache, 
nausea, and vertigo decidedly 
relieved by prisms. 
56 
Ext. 
M 
IO 
Schoolboy. 
Headache, vertigo, nausea, and 
distress in stomach. Unable to 
read. It distresses him to bend 
down to take off shoes. Has 
worn convex glasses without 
benefit. 
0. D. -4- 0.75s. 
V.=I. 0. s. 
-F 1.00s. V. 
i8r abdv 1° — add. 
25" v. d. 3° + 
conv.; abd. 
0° add. i2i° v. d. 
ij conv. 
Prism iF°, base 
out, O. U. for 
constant use. 
18' abd. —2° add. 
29° v. d-3°conv.; 
13" abd. 0’ add. 
15° v.d 8° conv. 
Under observation one month. 
Headache nearly every day, but 
not quite as severe as formerly. 
Complained of distress of stom- 
ache but once since first seen. 
Tenotomy advised. 
57 
Ext 
F. 
25 
Headaches for a month, attrib- 
uted to reading too many guide 
books on a recent European 
trip. Now unable to read at 
all without headache. Spasm 
A. 
Under atropine, 
O. U. + 0.75s. 
V.=i. 
18'abd 50 add. 17° 
v. d. 1° conv.; 
13" abd. 8° add. 
40° v. d. 18° 
conv. 
Prism 1}°, base 
out, O. U. for 
constant use. 
In fact wore 
them interrupt- 
edly, always for 
near work. For 
distance they 
were not always 
comfortable. 
18' abd. 6° add. 
27° v. d. 9° conv. 
(latent); 13" 
abd. 8° add. 27° 
v. d. 12” conv. 
Under observation five months. 
Gradual improvement. Com- 
plete relief of headache. Able 
to use eyes more than two hours 
a day without fatigue. 
58 
Ext. 
F. 
8 
Tendency to chorea, and has al- 
most lived on arsenic. Occip- 
ital headache, pain extending to 
neck. Never able to study. 
If she attempts it is prostrated 
and has to go to bed Is a 
bright, lively child ordinarily, 
but at times becomes moody, 
obstinate, and almost stupid. 
Spasm A. Anaemia. Child 
nervous and easily frightened. 
O.U. —1 s. V. 
= 1. under 
atropine. 
Slight H. 
18' abd. 50 add. 
150 v. d.=£=; 
abd. io° add.i8° 
v. d.^=. 
After atropine, 
prism 1°, base 
out, 0. U for 
constant use, 
without much 
expectation that 
they would be of 
benefit. 
18' abd. add. 
22°. 
Under observation one month. 
Prisms had no effect one way or 
the other. Two years later learn 
that condition has improved. 
Eyes have no bearing on symp- 
toms. Noyes : The Therapeutic Effect of 
32 
No. 
Muscles. 
j Sex. 
W) 
< 
Occupation. 
History and Symptoms. 
Refraction. 
Muse. Condition 
(Primary). 
Treatment. 
Muse. Condition 
(Ultimate). 
Results and Remarks. 
59 
Ext. 
F. 
16 
Schoolgirl. 
Formerly had malarial headaches 
which yielded to quinine. Now 
under treatment for slight lat- 
eral curvature of spine. Has 
much headache, coming on 
after school hours and passing 
off after being in open air. 
Some conjunctival irritation. 
Considerable supra-orbital ten- 
derness. For two months head- 
ache has been almost constant. 
Spasm A. Spasm Interni. 
Rather delicate. 
E. 
18' abd. 4)° add. 
25°; 13" abd. 18° 
add. 30° v. d. 3° 
conv. 
* 
Prism ii°, base 
out, O. U. for 
constant use. 
18' abd. 4° add. 
35°+ v. d 6° 
conv.; 13" abd. 
5° — 13° add. 
30°+ v. d. 5° 
conv. 
Under observation four months. 
Complete relief of headache. 
6o 
Ext. 
F. 
31 
Thrown from sleigh two years 
ago. Sun-stroke one year ago. 
Much headache. Unable to 
use eyes in reading. Nervous. 
E. 
18' abd. 40 add. 
i5°v. d i°conv.; 
I3"abd. 11° add. 
20° v. d. 2° conv. 
Prism 1°, base out, 
O. U. for con- 
stant use. 
18' abd. 20 add. 
200 v. d 2°conv.; 
13" abd. 6° add. 
23° v. d.=^. 
Under observation three months. 
Greatly relieved by prisms. Able 
to read an hour or more. 
F. 
36 
After atropine, 
O. D.+0.75c. 
105°. V. =0.9. 
O. S. —0.50s 
3+r.75c.8o°. 
V. =0.9. 
Glasses correcting 
refracting error, 
later with addi- 
tion of prism 
ij°, base out, 
O. U. 
Ext. 
gouty. She is delicate and 
nervous. She has had the best 
medical care and has had vari- 
ous glasses without relief. 
Feels completely unstrung and 
discouraged. Spasm A. 
15°; 13" abd. 9° 
add. 18° v. d. 40 
conv. 
20° v.d.2° conv.; 
13" abd. 4° v d. 
tendency to di- 
vergence. 
Poth cylindric and cylindro- 
prismatic glasses unsatisfactory. 
Before wearing them was not 
subject to headache. Since 
using them has had much occip- 
ital headache whether using 
them or not. Only comfortable 
when not using eyes, although 
cylindro-prismatic glasses are 
restful at evening and she can’t 
play cards without them. 
F. 
36 
0. D. + 0.75s. 
V. = 0.8. 0. 
S. — °-75s. V. 
= 0.5. 
18' abd. 3° add. (?) 
v. d. 2° conv ; 
13" abd. 10° add. 
(?) v. d 5° conv. 
Prism 1}°, base 
out, O. U. for 
constant use. 
Later added — 
0.50s. to O. S., 
which was after- 
wards reduced 
to —0.25s. 
Under observation one year. 
Prisms alone gave rise to diplo- 
pia, which was relieved by 
spherical correction added to O. 
S.,and glasses were then worn 
with comfort. 
Ext. 
people while driving in Park, 
and she has vertigo so severe 
on first getting out of carriage 
that for a minute she can hardly 
stand. 
APPENDIX. — Continued. Prisms in Ophthalmic Practice. 
33 
63 
Ext. 
M. 
19 
Student. 
Dull headache most of time. 
Has nasal catarrh, conjunctivi- 
tis, and malaria. Trouble in 
reading in evening, and much 
pain in eyes after reading an 
hour or two at any time. 
Under atropine, 
O. U. + 0.75s. 
V. = i. 
18' abd. 5° add. 
20° v.d 2° conv.; 
13" abd. 18-10° 
add. 20° v. d. 2° 
conv. 
Prism i|°, 
out, O. U. for 
constant use, la- 
ter +0.75S. O.U. 
added. Glasses 
in both cases 
used constantly. 
Careful atten- 
tion to general 
health, lids and 
nose. 
18' abd. 3° add. (?) 
v. d. 2° conv.; 
13" abd. i2°-i5° 
add. 15° (?) v. d. 
1° conv. 
Under observation one year. 
Glasses relieved the headache, 
and the relief was evidently due 
to the glasses rather than to any 
other line of treatment, for on 
going without them for a few 
days he again had severe head- 
ache. 
64 
Int. 
M. 
x3 
Schoolboy. 
Headache almost every day; 
often wakes with it. Has had 
chorea and still has some 
twitching of eyes. 
E. 
18' abd. 70 add. 15° 
v. d. 2° div.; 13" 
abd. 18° add. 12° 
v. d. 7° div. 
Prism 1 J°, base in, 
O. U. for con- 
stant use. Fow- 
ler’s Solution. 
18' abd. 7° add. 
22° v. d. 30 div.; 
18° add. 
20°. 
Under observation seven months. 
Glasses gave immediate and al- 
most complete relief from head- 
ache, so that after a few weeks 
he was allowed to go without 
them except in reading. At end 
of seven months did not need 
them. No headache. 
65 
Ext. 
M. 
Merchant. 
Had palp. conj. every summer 
for twelve years, especially in 
O. S. At other times is quite 
well and can use eyes perfectly. 
0 D.+0.75S. V. 
= 1. O. S. E. 
V. = 1. 
i8'abd. 3° add. 28° 
+ v. d. 30 conv.; 
13 abd 20° add. 
45° v. d. 4° conv. 
Been treated by 
astringents and 
local medication 
with little bene- 
fit. Has tried 
+60 for reading, 
without benefit. 
To have prism 
2°, base out, O. 
U. for near work 
and use Boric 
Acid for lids. 
i8'abd.4° add 20°. 
Under observation six years. Use 
of prisms one summer made 
him comfortable. The next 
year eyes were much better and 
he seldom used glasses. Since 
then, 1885, has not used glasses 
at all. 
66 
Ext. 
M. 
60 
Restaurant 
Keeper. 
“Weakness of sight,” particu- 
larly after shooting. Distressed 
by looking out of car windows. 
Tremor of eyes at outer angles. 
Photophobia. Some slight 
conjunctival irritation. Fine 
vitreous opacities not impairing 
vision seriously. 
O 
r -1- 
i8r abd. 5° add. 
30° v. d.=2=; 13" 
abd. 2o°-5° add. 
60° v. d.=^. 
Prism i£°, base 
out, 0. U. for 
constant use; la- 
ter, weak convex 
glasses substi- 
tuted. 
1 S' abd. 5° add. 
44° v.d. =2=; 13" 
abd. — i8°-i5° 
add. 60° -f-v. d. 
15° conv. With 
+ 3 D 0. U., 
1-8' abd. 23° add. 
(?) v. d. 3° conv. 
Under observation six weeks. No 
improvement except from the 
rest. 34 
Noyes : The Therapeutic Effect of 
No. 
Muscles. 
X* 
U 
C/3 
6 
to 
< 
Occupation. 
History and Symptoms. 
Refraction. 
Muse. Condition 
(Primary). 
Treatment. 
Muse. Condition 
(Ultimate). 
Results and Remarks. 
67 
Ext. 
M. 
28 
Theol. 
Student. 
Has had several pairs of glasses 
none of which satisfy him. 
Eyes feel uncomfortable with- 
out real pain. Never has dis- 
comfort in both eyes at once, 
usually only in 0. D. Spasm 
A. Excessively nervous. 
0. D. -4- 0.50c. 
100°. V. = 1. 
O S. 4- 0.50c. 
105°. V. = 1. 
18' abd. 7° add. 
15° v. d. 2° div.; 
18° add. 
200 v. d. 2° conv. 
Prism 2°, base 
out, O. U with 
cyl. correction 
for constant use. 
18' abd. 5° + add. 
(?); 13" abd. io° 
add (?) v. d. 4° 
conv. 
Under observation nearly two 
years. Wore cylindro-prismatic 
glasses for several months with 
great benefit. He then began 
to use cylinders alone for dis- 
tance and used prisms only in 
reading. Ultimately he used 
cylinders for all purposes. 
68 
Ext. 
M. 
35 
Clerk. 
For seven or eight years has had 
severe neuralgic pain in eyes 
and head. Pain so severe that 
he usually has to go to bed as 
soon as he gets home. Never 
free from pain. Has been 
under the best medical treat- 
ment without relief. Abduc- 
tion painful. Often has diplo- 
pia. 
O. D. 0 7—; 4- 
1 D V. = 1. 
O. S. 0.5; not 
improved. O. 
S. Struck by 
a piece of wood 
when he was a 
boy. No trace 
of injury visi- 
ble. 
18' abd. —3" add 
200 v. d. 8|° 
conv ; 13" abd. 
— 7° add. 30° v. 
d. 24° conv. 
Prsm 3°, base 
out, O. U. for 
constant use. 
After 10 days, 
18' abd. — 15° 
add. 37°; 13" 
abd .13° add. (?). 
Under observation two and one- 
half years, but no examination 
made after first ten days. Te- 
notomy urgently advised, but he 
has been unable to leave his 
business. He drags along and 
leads a wretched existence. He 
can’t get along without his 
prisms, but they are entirely in- 
adequate, as was to be expected. 
69 
Ext. 
M. 
47 
Banker. 
Much severe headache for two 
months, coming on at all hours 
of day; often wakes with it. 
Pain is through temples Prism 
tests bring on the headache. 
Prefers to ride backward in 
cars. Is a large man and takes 
little exercise. No diplopia. 
Is a confirmed dyspeptic and 
gouty. 
0. U. + 1.75s.- 
V. = 1. 
18' abd. 3° add. 
35°v.d.2°conv ; 
13" abd. (?)add. 
(?) v. d. 5° conv.; 
13" without 
glasses(+i.25s.) 
v. d. 10° conv. 
O. U. + 1.75s. c 
prism 2°, base 
out, for reading. 
To use his glass- 
es, +i.25S O.U. 
for distance. 
18' abd. 3°—add. 
27° v. d. 3° conv.; 
13" abd. (?) add. 
(?) v. d. 5° conv. 
Under observation five months. 
Has very little headache, but 
thinks relief is due to antipyrin 
which he began to use shortly 
after first visit because the head- 
ache continued after wearing 
glasses. Still he is very depend- 
ent on his glasses and feels that 
they help him. Is unable to 
watch a public speaker without 
them, and is unable to look at 
the miuister through a whole 
sermon even with them. Finally 
gave up prisms. 
70 
Ext. 
M. 
16 
Student. 
More or less trouble for four 
years, unrelieved by weak 
glasses. Sometimes has pain 
in eyes in looking at distant 
objects, but chiefly in reading. 
E. 
18' abd. 2°—add. 
30° v d-4° conv.; 
0 add. 
35° + v. d. 10° 
conv. 
Prism ii°, base 
out, O. U. for 
constant use. 
* 
18' abd. 30 add. 
350+v. d. 10° 
conv.; 13" abd. 
(?) add. (?) v. d. 
23° conv. 
Under observation three months. 
Much more comfortable with 
prisms, which he enjoyed and 
did not like to leave off. Te- 
notomy advised. 
APPENDIX. — Continued. Prisms in Ophthalmic Practice. 
35 
71 
Ext. 
72 
M 
M. 
32 
IO 
Dentist. 
Blurring of objects and print. If 
very tired has diplopia Slight 
trouble two or three years but 
not much until last few months. 
Never has headache. 
Epileptic convulsions for two and 
E. 
Nearly E 
18' abd. 3°—add. 
23°v d.8° conv ; 
11° add. 
20° v. d. 7° conv. 
18' abd. 5° add. 
Prism 2% base 
out, O. U. for 
constant use. 
0. D. prism 2°, 
After 1 week, 18' 
abd. o° add. 30° 
v. d. 8” conv. 
18' abd. 50 add. 
Seen one and one-half years later. 
Had been from one oculist to 
another, and was still worrying 
along. Tenotomy urgently ad- 
vised. Nothing to be expected 
from any other mode of treat- 
ment. 
Under observation nine weeks. 
one-half years. Sometimes 
Spasm A. 
r5°; 13" abd. 
base out. O. S. 
21° v. d. 
Wore glasses faithfully for one 
goes a day or two without hav- 
10° add. 25° v. 
prism 1 £ , base 
conv.; 13" abd. 
month without appreciable ben- 
mg one, but usually has from 
d. conv. 
up. 
160 add. 170 v. d. 
efit Has attacks at least every 
two to five in a day Under 
Vert error A 1 
5° conv. Vert. 
other day. 
best medical treatment. Has 
O. D. 
error only J°. 
distinct aura. Right side more 
affected than left. Some 
frontal headache. 
73 
Ext. 
74 
F. 
F. 
48 
Married. 
Had strabismus in early life, but 
eyes “suddenly” came into 
O. D. Amblyo- 
pia. O. S. E. 
O. U. 4 0.50c. 
Undetermined on 
account of mo- 
nocular amblyo- 
pia. 
18' abd. 3° add. 
0. U. prism 1°, 
base out, for 
constant use, 
followed one 
week later by 
O. D. prism 3°, 
base out. O. S. 
prism 1°, base 
out. 
O. U. 40.50c. 90° 
18' v. d. 11° conv. 
She learned to 
recognize double 
images momen- 
tarily. 
Under observation three months. 
No headache Comfortable 
with prisms, and misses them if 
she leaves them oft. Epileptic 
attacks have occurred, but have 
never been frequent. 
correct position without opera- 
tion. Can be made to see 
double images only momenta- 
rily, and prism tests show cen- 
tral blind spot O. D. For four 
years has had some headache 
following epileptiform attacks. 
Some illness (“brain fever”) 
two years ago. Has headache 
after a Park drive. 
Burning pain in eyes and head- 
18' abd. 5° add 
Under observation eight and one- 
Ext. 
ache for a week, due to excess- 
90°. V. — 1. 
120 v.d. 1° conv.; 
C prism 1°, base 
20° v. d.=£=; 13" 
half months Headache much 
ive use of eyes in China paint- 
13" abd 20'add 
out, for constant 
abd. 18° add. 
abated Health better. Can 
ing. Not subject to headache, 
20° v. d. 3° div. 
use S t r y c h . 
25° v. d.=^. 
use eyes moderately. 
but reading the paper will now 
provoke it. Considerable con- 
Sulph. 
junctival irritation. Health not 
very good; is depressed on ac- 
count of serious illness of a 
very dear friend. 
75 
M. 
20 
Clerk. 
Eyes tire quickly and print be- 
E. 
18' abd. 5° add. 
Prism i|°, base 
18' abd. 3° add. 
Under observation one month. 
Ext. 
comes blurred. After reading 
I5°v.d.=a=; 13" 
out, O. U. for 
27° 4 v. d. 2° 
With prisms works easily, both 
fifteen or twenty minutes lays 
abd.10° add. 15° 
constant use. 
conv.: i3,/ abd. 
by day and night. Eyes do not 
aside book and doesn’t feel like 
v. d.=£=. 
15° add. 28° v. d. 
become tired. No blurring of 
going on, although he has no 
50 conv. 
print. Very little irritation of 
real pain. Slight conjunctival 
lids unless provoked by smoke, 
irritation. Some nasal catarrh, 
benefited by treatment. 
etc. 36 
Noyes : The Therapeutic Effect of 
No. 
Muscles. 
I Sex. 
OJ 
tc 
< 
Occupation. 
History and Symptoms. 
Refraction. 
Muse. Condition 
(Primary). 
Treatment. 
Muse. Condition 
(Ultimate). 
Results and Remarks. 
76 
Ext. 
M. 
14 
Schoolboy. 
Trouble for six months. Unable 
to read over one-half hour with 
comfort. Eyes feel sore and 
painful, print becomes blurred, 
and frontal headache follows 
use of eyes. Follicular con- 
junctivitis. 
O. D. + 0.75s. 
V. = 1. O. S. 
E. 
i8'abd 50 add. 13° 
v. d.=5=; 
ii° add. 16° v. 
d. 2° div. 
Tannin and Glyc- 
erine locally. 
Prism if, base 
out, O. U. for 
constant use. 
18' abd. 4°-5° add. 
29° v. 13" 
abd. 6°-io° add. 
3°°-35° v. d.3°- 
7° conv. Short- 
ly before this 
abd. at 18' was 
only 3±° and at 
13" 6°. 
« 
Under observation two years. 
Pain in eyes and frontal head- 
ache continued for about six 
months with only slight im- 
provement. From one to three 
headaches a week, coming on 
after reading. Tenotomy was 
advised, but when he came a 
month later, expecting an opera- 
tion, it was deferred on account 
of the improved muscular condi- 
tion, the absence of pain and 
headache, and the marked sub- 
sidence of the conjunctival 
trouble. Continues to wear 
glasses. 
77 
Ext 
M. 
23 
Medical 
Student. 
Weariness of eyes in reading. 
Sense of strain in looking out 
of car windows. 
O. U. + 0 50c. 
go°. V. = 1. 
Under atro- 
pine. 
18' abd. 4° add. 17° 
v d. 2° conv.; 
13" abd. 150 add. 
20° v. d. 30 div. 
Prism t base 
out, O. U. to be 
worn constantly 
i n connection 
with +0 75c, 90° 
O. U. which he 
had been wear- 
ing without 
relief. 
18' abd 2i° add 
240 + v. d 4° 
conv.; 13" abd 
13° add 36° v. d. 
2° conv. 
Under observation five months. 
Sense of strain greatly dimin- 
ished by supplementary prisms. 
Reported that he could read 
twelve hours a day. 
78 
Ext. 
M. 
19 
Student. 
Complains that eyes always feel 
tired after using blow-pipe in 
laboratory. 
E. 
i8'abd. 5° add 220 
v. d. 2° conv.; 
13" abd. 13° add. 
25°v.d. 12° conv. 
Prism 2°, base 
out, O. U. for 
near work. 
Under observation five weeks. 
Uses prisms in blow pipe work 
and gets along very well. Re- 
lief permanent. 
79 
Ext. 
M. 
30 
Book- 
keeper. 
Trouble for eight or nine months. 
Pain in eyes whenever he uses 
them. Moderate conjunctival 
irritation. 
E. 
18' abd. 4° add. 7° 
v. d. =5=; 13" 
abd i2i° add. 8° 
v. d. ===. 
Prism if, base 
out, O. U. for 
constant use. 
18' abd. 2°-3° add. 
14° v d.3° conv.; 
10° add. 
20° v. d. 3° conv. 
Under observation fifteen months, 
at the end of which time he 
could read two hours without 
much trouble. Has given up 
book-keeping and is more out of 
doors. The case was at first 
thought to be one of weak in- 
tend, and prisms were ordered 
with bases in. By mistake 
prisms were set with bases out, 
with result above mentioned. 
APPENDIX. — Continued. Prisms in Ophthalmic Practice. 
37 
8o 
Ext 
M 
*3 
Schoolboy. 
Frontal headache and sometimes 
pain in eyes in reading. Often 
wakes with headache, and read- 
ing one-half hour will bring it 
on. Conjunctival irritation. 
E. 
18'abd. 5° add. 21° 
v. d. 2° conv ; 
i3,/abd.2o°add. 
20° v. d. 7° conv. 
Prism 1}°, base 
out, O. U to be 
used constantly 
temporarily. 
Under observation ten days. Wore 
prisms eight i ays, found head- 
ache cured. Attempted to go 
without them, and headache re- 
turned. Relief known to be 
permanent. 
81 
Ext. 
F- 
42 
Married. 
Very poor health for four years, 
following attack of nervous 
prostration. Uterine trouble. 
Until recently has been able 
with care to read three or four 
hours a day, but read too long 
a few weeks ago and has been 
unable to use eyes much since. 
Has suitable convex glasses for 
distance and near work. Four 
years ago began to have “ter- 
rible ” headaches which per- 
sisted for two years. After the 
“real cure” there was relief 
for a year, but for the past year 
the headaches have occurred 
with the old frequency and se- 
verity. Riding in Park fatig- 
uing. Photophobia. Insomnia. 
O. U. + 0.75s. 
V. = 1. 
i8r abd. 4° add. 
20' v d.=2=; 13" 
abd. 15° add. 
32° v. d. 4° conv. 
After to days. 
18' abd. 4° add. 
200 v d. 4° conv.; 
13", no glasses, 
abd 20°add 230 
v. d. 7° conv.; 
13" and +1.75S. 
O. U. abd. 23° 
add. 18° v. d.=!5=. 
0. U. -(-0.50s c 
prism ij°, base 
out, for constant 
use. Later -f- 
1.50s. 3 prism 
ii°, base out, for 
reading. 
i8r gl. v. d. 2° 
conv; 13" gl. 
v. d. 8° conv. 
Under observation four months. 
Much less headache. Rest has 
been of benefit. Health some- 
what better. Finds that prisms 
give much relief for distance, but 
not for near work. 
82 
Ext. 
F. 
i5 
Schoolgirl. 
Subject to sick headache as long 
as she can remember; during 
past year has had about one a 
week. Almost constant dull 
headache for three weeks. 
Eyes feel crossed in near work, 
but she persists in spite of pain. 
0. U. + 0.50s. 
V.= I. 
18' abd. 34-° add. 
27°v.d 3° conv ; 
i3//abd. 150 add. 
30° v. d.^. 
Prism 1U, base 
out, O. U. for 
reading. 
18' abd. 3° add. 
40° v. d.6° conv.; 
i3"abd 15° add. 
30° v. d 5° conv. 
Under observation five months. 
Complete relief from pain and 
headache. Able to do all her 
school work, besides Christmas 
fancy work. Tenotomy was ad- 
vised, but deferred on account 
of improvement. 
83 
Ext. 
M. 
22 
U. S. Army 
Officer. 
No trouble until a year ago. 
During past year eyes have felt 
tired after reading a few hours. 
Recently unable to read for 
any length of time with com- 
fort. A perfect specimen of a 
man physically. First noticed 
■trouble after target practice. 
E. 
18' abd. 50 add 
24° v d .===: 13" 
abd. 8° add. 40° 
+ v. d. 7J0 conv. 
Prism ij°, base 
out, O. U. for 
constant use. 
18' abd. add. 
210 v. d.===; 13" 
abd. 17° add. 
30° v. d.=e=. 
Under observation six weeks. 
Prisms a great relief. Can read 
two hours, but mechanical draw- 
ing is hard for him. Does not 
like to be without prisms long 
enough for his morning toilet. 38 
Noy.es : The Therapeutic Effect of 
No. 
Muscles. 
X 
in 
Age. 
Occupation. 
History and Symptoms. 
Refraction. 
Muse Condition 
(Primary). 
Treatment. 
Muse. Condition 
(Ultimate) 
Results and Remarks. 
84 
Ext 
M 
28 
Manager. 
Has for three years had so much 
pain in eyes and head that he 
could read very little, and has 
not been able to read at all for 
six months. Has worn cylin- 
dric glasses without relief 
Rather run down physically. 
Appetite not good. 
O D. — 1. s. 3 
+2.25C.9o°.V. 
= 1. O. S.— 
O.75S.C + 2C. 
85°. V. = i. 
18' abd. 4° add. 
22° v. d.5° conv.; 
13" abd. 12° add 
28° v. d. 12° 
conv. 
Correction of re- 
fractive error 
with prism 2°, 
base out, O. U. 
for constant use. 
18' abd. 3° add. 
26° v. d. 8° conv.; 
13" abd. 20° 
add. 34° v. d. 
9° conv. 
Under observation sixteen months. 
Can’t get along without the 
prisms, but even with them eyes 
smart and print blurs, with sense 
of fatigue. At times perfectly 
comfortable Feels that glasses 
are decidedly beneficial. 
85 
Ext. 
M. 
35 
Medical 
Student. 
Much difficulty in use of eyes for 
over a year. Lids feel stiff; 
they twitch andfinally close in 
reading by artificial light. 
O. U. + 0.75c. 
180°. V. = 1. 
18'abd. 2° add. 13° 
v d.=2=; 13" abd. 
i6i° add. 350 v. 
d. 1° conv. 
Prism i£°, base 
out, 0. U. for 
constant use. 
18' abd. i° add. 
ig°v.d. 3° conv.; 
i3,/abd. 10° add. 
40° + v. d. 70 
conv. 
Under observation six months. 
Can read with prisms for hours. 
Benefit permanent. 
86 
M. 
27 
Physician. 
Trouble in looking at people pass- 
ing, moving objects, etc. Ob- 
jects unsteady and print blurs 
— letters run together. Eyes 
become tired in looking at dis- 
tant objects. 
E. 
18' abd. 2j° add. 
i3°v.d-3° conv ; 
13" abd. 8° add. 
38° v. d. ===. 
Prism 1J”. base 
out, 0. U. for 
constant use. 
Under observation for at least 
twelve months. Perfectly com- 
fortable with prisms, and unable 
to go without them. 
Ext. 
87 
Ext. 
M. 
35 
Book- 
keeper. 
Some headache about once a 
week, and dull headache most 
of the time. Pain frontal, about 
eyes. Has been book-keeper 
for seven years, and works from 
ten to fourteen hours a day. 
Was formerly on the western 
plains and then had headache. 
Conjunctival irritation. 
E. 
18' abd. 5° add 9° 
v. d. 1° conv.; 
18° add. 
6° v. d. 2” div. 
Prism base 
out, O. U. for 
constant use. 
Later, -+0.75S. 
additional for 
desk work. 
18' abd. 4}° add. 
i5°v. d-3°conv.; 
I3,/ abd. 6° add. 
15° v. d. 4° conv. 
Under observation six months. 
Continues to use eyes excess- 
ively. Has very little headache 
compared with what he formerly 
had. 
88 
Ext. 
M. 
29 
Medical 
Student. 
Complains only of blurring of 
print. 
Under atropine, 
H. = t D. V. 
18'abd. 30 add. 22° 
v. d. =2=; 13" 
abd. 16° add. 25° 
v. d. =2=. 
Prism i£°, base 
out, O U. for 
constant use. 
Has worn +1-42 
s. O. U. with-’ 
out relief. 
18' abd. 4° add 
150 v. d. :2=; 
abd. 13° add. 
23° v. d.=2=. 
Under observation four months. 
Prisms were of great service. 
Was able to use his eyes all win- 
ter as much as he pleased, even 
in the cramming for final exam- 
ination. 
APPENDIX. — Continued. Prisms in Ophthalmic Practice. 
39 
8g 
Ext. 
M. 
12 
Schoolboy. 
Trouble for six months. Has 
used + 0.75s. O. U. without 
relief. Has headache in after- 
noon. Some nasal catarrh. 
Slight conjunctival irritation. 
O. U. + 1 D. 
V. = i. 
18' abd. 2J0 add. 
25°; 13" abd. 
3° add. 30° v. d. 
5° conv. 
O. U. +1 D. s. C 
prism i|°, base 
out, for constant 
use. 
18' abd. J°~3° add. 
44° 4- v. d. 
13" abd. 5° add. 
38° v. d. 11° 
conv. 
Under observation six months. 
Wore glasses nearly all the time. 
Is better with glasses on and has 
very little headache, but glasses 
are inadequate. Tenotomy ad- 
vised. 
go 
Ext. 
F. 
2 i 
Unable to use eyes at night for a 
year. Trouble began after se- 
verely taxing eyes in fine paint- 
ing. Eyes feel strained. Has 
had + i.s. for a year without 
much benefit. Slight conjunc- 
tival irritation. 
O D. -1- 0.50c. 
9o°.y.=1.0. 
s. 4-0.75c. 90°. 
V. = 1. 
18' abd. 6° add. 
i2°-i7° v. d 1° 
div.; 13" abd. 
15° add 150 v. 
d. tendency to 
div. 
O. D. +0.50C. 90° 
3 prism i°, base 
out; O. S. + 
0 75c. 90° O 
prism i°, base 
out, for constant 
use After three 
mos. in reading, 
etc , only. 
18' abd. 3U add. 
220 v. d.=2=; 13" 
abd. 10° add. 
23° v. d. 3° conv. 
Under observation three months. 
Strained feeling relieved. Broke 
glasses at end of three months, 
and had to go without them for 
three days. Felt loss of glasses 
very much the first day, but 
suffered no inconvenience after 
that. Allowed to use them in 
near work only. 
9i 
Ext. 
F. 
l6 
Trouble for two years. Pain in 
eyes and inability to read much 
in evening. 
E. 
18' abd. 5° add. 
210 v. d.as; 
abd. 20° add. 
30° v. d. 10° 
conv. 
Prism 2°, base 
out, O. U. for 
near work. 
18' abd. 6° add. 
22° v. 13" 
abd. io°add.43°. 
Under observation four months. 
Prefers to use glasses in reading, 
and can do more with them than 
she could before she had them, 
but they are not of great service. 
92 
Ext. 
F. 
20 
Seamstress. 
Difficulty in use of eyes for a 
year. Eyes feel tired. Much 
pain in eyes and frontal head- 
ache. Insufficiency of externi 
so marked that in the muscular 
tests there is often convergence 
with suppression of one image. 
Pain in eyes often amounts to 
a real ache and is always worse 
in evening. Eyes become red 
and inflamed. 
E. 
18' abd. (?) add. 
(?) v. d. 20° 
conv.; 13" abd. 
15° add. 20° v. 
d. 18° conv. 
Prism 2°, base 
out, O. U. for 
constant use. 
18' abd. 0° add. 
28°v.d.25',conv.; 
13" abd. — 18° 
add. 23° v. d. 18° 
conv. With red 
gl. i8r abd —3° 
to —9°. 
Under observation two weeks. 
Wore glasses all the time, and 
had only one headache. Eyes 
feel much stronger. No pain. 
Prisms nauseated her at first. 
Relief probably due to rest, as 
eyes have not been used much. 
Tenotomy the only remedy. 
93 
Ext. 
M. 
29 
Medical 
Student. 
Complains of the inflammation 
of lids. Diagnosis of weak in- 
tend made in another city two 
years ago. Nasal obstruction. 
O. U. 4- 0.50c. 
90°. V. = 1. 
18' abd. 50 add. 7° 
v. d. =o=; 13" 
abd. 18° add. 
15° v. d. 2$° div. 
Prism 2°, base 
in, O. U. for 
constant use. 
18' abd. 50 add. 9° 
v. d. ===; 13" 
abd. 26° add. 
120 v. d. 7° div. 
Under observation three months. 
Prisms gave relief for two weeks 
and then failed. Suitable for 
operation. Probable advance- 
ment of interni. 40 
Noyes : The Therapeutic Effect of 
No. 
Muscles. 
Sex. 
<V 
tUO 
< 
Occupation. 
History and Symptoms. 
Refraction. 
Muse. Condition 
(Primary). 
Treatment. 
Muse. Condition 
(Ultimate). 
Results and Remarks. 
94 
Ext. 
M. 
18 
Bank 
Clerk. 
Trouble for two years. Great 
difficulty in looking at moving 
objects, as in playing cards, 
turning leaves of book. Trouble 
in piano and violin playing; in 
the latter the motion of the bow 
is very annoying. Can not ride 
forwards in cars and look out 
of window without great dis- 
comfort, but has no trouble in 
riding backwards. Is much 
annoyed at table looking at per- 
sons opposite. Finds it diffi- 
cult to keep face in repose 
looking steadily at anything. 
Is relieved by pressure on brow 
and temples, and by clasping 
hands behind head. 
O. D. -f 0.50c. 
90°. V. = l.O. 
S. -I-1. c. go°. 
V. = 1. 
18' abd. 4° (?) add. 
70 v. d i3r/ 
abd. 180 add. 4° 
v. d. 4° div. 
Possible vertical 
error of J°. 
Prism 1}°, base 
out, 0 U. for 
constant use, in 
comb in at ion 
with correcting 
cyl. glasses. Al- 
so given prisms 
for gymnastic 
purposes to in- 
crease adduction. 
18' abd. 20 add 
50° v. d.=£=; 13" 
abd add. (?) 
v. d 2° div. 
Under observation six months. 
Unable to get along without his 
prisms, as he found when he 
broke them. Is able to do all 
his work and gets along fairly 
well. Intemi too weak for an 
operation at first, but their power 
greatly increased under practice. 
He may finally come to an oper- 
ation. Cylinclers without prisms 
did not relieve. 
9S 
Ext. 
F. 
24 
Pain in eyes for three or four 
years, pretty severe for a year. 
After ten minutes of reading 
print blurs and pain comes on. 
Headache, frontal, temporal, 
and occipital. As a schoolgirl 
could not use eyes with comfort. 
Steady looking at anything pain- 
ful, and she has to keep eyes 
closed on cars. Often has to 
lie down and close eyes to rest 
them. Has had much care and 
anxiety, and takes little exercise. 
Considerable conjunctival irri- 
tation. Has worn weak cylin- 
ders without relief. 
E. 
18' abd. 5° add. 
17° v. d 13" 
abd. 13° add. 
150 v. d. 3° conv. 
Local applications 
to conjunctiva. 
Gr. ii Sol. Pilo- 
carpine with 
Cocaine once a 
day. After using 
Pilocarpine two 
weeks with little 
or no benefit, 
prism ij°, base 
out, O U. for 
constant use, 
and to continue 
drops as before. 
Tonics. 
18' abd. 6° add. 
25° -f v. d. slight 
conv.; 13" abd. 
io°-i5° add 35 
+ v. d. 5° conv. 
Under observation three and one- 
half months. Able to read 
nearly one-half hour with 
prisms. Still has pain in eyes 
and headache, but less than 
formerly. The state of health 
was the main feature. Glasses 
used tentatively. 
06 
Ext. 
F. 
23 
Milliner. 
Always had more or less pain in 
head, worse now than ever. 
Recently had severe pain in 
eyeballs. Trouble in riding on 
cars. 
0. D. E. O. S. 
Hm. 0.25. 
18' abd. 2° add. 
33° v.d 6° conv.; 
13" abd. 3° add. 
33°v.d. n°conv. 
Prism 1}”, base 
out, O. U. for 
constant use. 
18' abd. 1° — add. 
40° v d. io°conv. 
Under observation two weeks. 
Decidedly better. Has been 
able to work moderately, and 
with more comfort. Tenotomy 
advised. 
APPENDIX. — Continued. Prisms in Ophthalmic Practice. 
41 
97 
Ext 
O' 
M. 
32 
Three vears ago had occasional 
attacks of what he calls “spasm 
of eyes,” i. e , print became 
unsteady in reading, and he 
could see parts of words only. 
These attacks would be followed 
by intense headache. He now 
complains of pain in top of 
head. Broke down in college. 
0. D. -+0.25S.O 
-f 0.75c. 75”. 
V.= 1. O. S. 
+ 0 50s. O + 
0.50c. 105°. 
V.=i. 
Examined by ocul- 
ist of Baltimore, 
three years ago. 
Three years ago, 
sphero-cylindric 
correction as al- 
readynoted; five 
months agosame 
correction with 
prism 4°, base 
out,0 D.; prism 
2i°, base out, 
O. S. 
18' abd. — 6° add. 
23°; 13" abd. 
— 50 add. 25° 
v. d. 12° conv. 
Under observation of former ocu- 
list for three years. Since using 
prisms has had none of the 
attacks which he formerly had. 
Suitable for operation. 
q8 
Ext. 
F. 
83 
Pain in eyes and headache after 
use, for a few weeks Bright, 
vigorous, and well-preserved 
old lady. Reads and writes 
until eleven o’clock at night 
Homonymous diplopia in dis- 
tant vision. 
O. D. 4- 1.50s. 
V.=o.4. O.S. 
-(-1.50c. 180°. 
V.=o.4* 
Sclerosed len- 
ses. 
18' Homonymous 
diplopia; 13" 
abd. 25° add. 
13° v. d. 8° div. 
Prism ij°, base 
out, O. U. for 
distance; O. U. 
+ 50 for read- 
ing. 
18' abd. 0“ add 
12-15° v d. 3° 
conv.; 13" abd. 
(?) add. 5° v. d. 
10° div. 
Under observation two weeks 
Headache relieved by prisms. 
No diplopia with prisms. 
99 
Ext. 
F. 
20 
Pain in eyes; they ache most of 
the time. Much headache; 
she often wakes with it. Has 
been using -fo.7gs. 0 U. in 
reading, etc., without relief. 
Brother has weak e x t e r 11 i. 
Some conjunctival irritation. 
E. 
18' abd. 4° add. 
18° v. d. i° conv.; 
13" abd. 9° add. 
17° v. d 
Prism ij°, base 
out, O. U. for 
reading. 
18' abd. 4° add. 
22° v d. 1° conv.; 
13" abd 8° add. 
(?) v. d. 5° conv 
Under observation fifteen months 
Great relief. Continues to wear 
glasses. 
IOO 
Ext. 
M. 
22 
Student. 
* 
Eyes always feel weak. Often 
has pain in eyes after using 
them three or four hours. 
Conjunctivitis. Nasal catarrh, 
with obstruction. Has used 
-(-0.75s. for reading, without 
relief. Sister has similar 
trouble. 
0. D. —0.75c. 
180°. V.=i. 
O. S. —0.50c. 
180°. V.=i. 
18' abd. 3° add. 
18° v. d.=*=; 13" 
abd. 170 add. 35° 
v d.===. 
Prism H", base out, 
O. U. for con- 
stant use. La- 
ter, prisms com- 
bined with con- 
c a v e cylinders 
for distance, and 
convex cylinders 
for reading. 
Constant use. 
18' abd. 3° add. 
24°v.d 4° conv.; 
13" abd. 13° 
add. 23° v. d.===. 
Under observation two years. 
Prisms gave great relief at once, 
and enabled him to study eight 
or ten hours a aay, and that be- 
fore cylinders were added. 
N asal obstruction removed after 
symptoms were relieved. At 
end of two years had no cause 
to complain of eyes.