One Hundred Cases of Hypermetropic Astig- 
matism Contrary to the Rule, and 
the Associated Symptoms. 
BY 
G. E. DE SCHWEINITZ, -M.D. (Univ. of Penn.), 
OPHTHALMIC SURGEON TO THE PHILADELPHIA AND CHILDREN’S 
HOSPITALS ; OPHTHALMOLOGIST TO THE INFIR MARY FOR NER- 
VOUS DISEASES; LECTURER ON MEDICAL OPHTHALMOS- 
COPY IN THE UNIVERITY OF PENNSYLVANIA. 
Read in the Section on Ophthalmology, at the Forty-second Annual 
Meeting of the American Medical Association, held at 
Washington, D. C., May, 1891. 
Reprinted from the “Journal of the American Medical 
Association,” September 5, 1891. 
CHICAGO: 
PUBLISHED AT THE OFFICE OF THE ASSOCIATION, 
i8gi. ONE HUNDRED CASES OF HYPERMETRO- 
PIC ASTIGMATISM CONTRARY TO 
THE RULE, AND THE ASSOCI- 
ATED SYMPTOMS. 
BY G. E. DE SCHWEINITZ, M.D. (Univ. of Penn.), 
OPHTHALMIC SURGEON TO THE PHILADELPHIA AND CHILDREN’S 
HOSPITALS; OPHTHALMOLOGIST TO THE INFIRMARY FOR 
NERVOUS DISEASES ; LECTURER ON MEDICAL OPH- 
THALMOSCOPY, UNIV. OF PENNSYLVANIA. 
Ever since the days when Weir Mitchell called 
attention to the intimate connection between 
a variety of headaches and the existence of er- 
rors of refraction, before which time this close 
association had not received at the hands of neu- 
rologists extensive study, the literature of oph- 
thalmology and neurology has been burdened 
with numerous communications upon this rela- 
tionship, until now the investigation of a case of 
headache is not complete until the refraction of 
the eye and the balance of the ocular muscles 
have been carefully considered. All forms of 
refraction error are known to be the cause of 
headaches, but usually it is considered that the 
presence of astigmatism, either of the simple or 
compound type, aggravates the amount of the 
head-pain. It has been stated that when the as- 2 
tigmatism is contrary to the rule, the entire cor- 
rection of the error is more absolutely necessary 
to bring relief, and that its uncorrected presence 
is more potent in producing general nervous 
phenomena, than when the astigmatism is accord- 
ing to the rule. More than this, the researches 
of Schoen on the influence of accommodative 
strain in the production of glaucoma and catar- 
act are important additions to our knowledge of 
the influence of astigmatism, both of the usual 
and unusual varieties, upon the ultimate well- 
being of ametropic eyes. So, also, Theobald, of 
Baltimore, has studied a number of examples of 
astigmatism contrary to the rule, and adduced 
evidence to show that under certain circum- 
stances this condition of refraction may conduce 
to the development of glaucoma. 
The following cases were analyzed because 
they have been under observation for a suffi- 
cient length of time to determine in practi- 
cally all of them the exact value of their 
correction, and also to have studied the 
associated symptoms in sufficient detail to 
demonstrate whether or not they were out of 
proportion to the character or the amount of the 
refraction error. In all of the cases a mydriatic 
was employed, except in those where the use of 
such a drug was contra-indicated by glaucoma- 
tous symptoms. In patients over 45 the mydria- 
tic was homatropine; in those under 45 either 
atropine or hyoscyamine. Whenever it was ne- 
cessary the spherical lens, required by the age of 3 
the patient, was ordered for the purposes of read- 
ing and close vision. This glass is not set down 
in the notes. For the convenience of study, the 
cases may be gathered into five groups: 
/. Cases presenting themselves for treatment on 
account of optical reasons alone — beginnmg pres- 
byopia, or dissatisfaction with convex spherical 
lenses. ATo pain and no reflex symptoms. 
Case i. Beginning Presbyopia.—M. T., a man 
aged 41; no headache; no asthenopia; tricky 
close vision. Healthy fundus, with the excep- 
tion of slight absorption of the pigment epithe- 
lium of the choroid. 
O. D. + .25s C + -90caxis 15 ff. O. S. + .25s 
0+ -75c axis I5° It- These lenses were entirely 
satisfactory. 
Case 2. Un sat isfa do ry Reading Glasses (Con- 
vex).—F. E., a woman aged 57; no general dis- 
ease; no ill health or reflex neurosis traceable to 
eye-strain; reading glasses. Fun- 
dus healthy. 
O. D. + .50s O + .50c axis 15 }-f. O. S. + 
.50s O + .50c axis 165 ff. A satisfactory im- 
provement in reading power. 
Case j. Eye-tire and Blurred Vision at Close 
Work.—E. K. B., a woman aged 30; perfect gen- 
eral health; no headache but unsatisfactory en- 
durance with simple convex lenses. Normal 
fundus. 
O. D. + 2.s C + -25c axis H |f. O. S. + 
2.25SO + .50c axis 165 |f. The desired improve- 
ment resulted. 4 
Case </. High H; Blurred Vision during Read- 
ing.—A. H., a woman aged 44; perfect general 
health; eyes tire and print blurs; the convex 
reading lenses do not suffice; no headaches and 
no asthenopia. Healthy, hypermetropic fundus. 
O. D. + 4.50s C + -25c axis 15 f}}. O.S. + 5.S 
c T -25c axis H f}}. These lenses gave the 
desired relief. 
Case 5. Unsatisfactory Reading Glasses.—D. I., 
a woman aged 63; good general health with 
the exception of hay fever; glasses—convex 
spliericals corresponding to age—do not per- 
mit entirely comfortable reading, or sufficient 
eye endurance. Round, somewhat gray-red discs. 
O. D. + i.s 0 + .25c axis 150 |~g. O. S. + 
2.s 3 + -6oc axis 30 Jj}. These glasses, with a 
corresponding correction for reading, were satis- 
factory. 
Case 6. No symptoms of Eye-strain; “wants 
new glasses."—C. W., a woman aged 58; perfect 
general health; has worn glasses for reading pur- 
poses for a number of years which recently have 
not permitted sufficient eye-endurance. These 
glasses are simple sphericals. There is no head- 
ache. Fundus perfectly normal. 
O. D. + .25s O + .50c axis 15 £{J. O. I). + 
•75s O + -25c axis 165 |t}. These lenses have 
answered a satisfactory purpose. 
Case y. No symptoms of Eye-strain; “wants 
new glasses."—S. W. M., a woman aged 55; per- 
fect general health; has worn glasses for reading 
for a number of years, which are simple spheri- 5 
cals and have recently not permitted comfort 
with reading. The patient states that she had 
iritis in youth, and the left pupil is slightly dis- 
torted above. In each eye the discs are rather 
gray, but there is no decided lesion of the fundus. 
O. D. + 1.25 Q + .25 axis 15 f-JJ. O. S. + 
1.25s 0 + .75C axis H |-{j. These lenses associa- 
ted with the proper presbyopic correction have 
proved entirely satisfactory. 
Case 8. Beginning Presbyopia ; No Headache. 
—M. H. T., a woman, aged 44 ; in perfect gen- 
eral health ; complains of some blur of vision at 
the near point, inability to thread the needle, and 
slight smarting of the edges of the eyelid ; has 
never worn glasses. In each eye an oval disc ; 
no conus ; a fairly healthy eyeground. 
O.D. + .25s Q + 1.25c axis 30 !§. O.S. + 
-50s O + .25c axis 150 These glasses were 
entirely satisfactory. 
Case 9. Unsatisfactory Reading Glasses; No 
Headache.—J. J. S., a man, aged 55 ; has never 
worn any glasses except those which he bought 
in stores, and is using at present a + 3. I), with 
which he sees indistinctly at times, but other- 
wise complains of no symptom at all; his gen- 
eral health is good. The ophthalmoscope shows 
in each eye an oval disc, somewhat gray in its 
deeper layers, and a slight gray haze of the 
retina. 
O.D. + 1.50s 0 + .25c axis H f£. O.S. + 
1.25s 0 -f .50c axis H !«-. These lenses, com- 6 
biued with a suitable presbyopic correction, af- 
forded the relief he desired. 
Case 10. Unsatisfactory Reading Glasses; No 
Headache.—A. B., a woman, aged 52 ; good gen- 
eral health ; complains of some mistiness while 
attempting to read, and also when looking at a 
distance ; never has had an attack of headache. 
Wears a convex spherical of + 3 D.; media clear; 
tension normal. Oval discs, with slight veiling 
of the lower and inner edges. 
O.D. +2.sQ + .25c axis H f {}. O.S. + 1.50s 
3 + 1 -25c axis H flJ. These glasses, combined 
with the necessary addition for reading, answered 
her purposes very satisfactorily. 
Case 11. Imperfect Presbyopic Correction.—A. 
W., a woman, aged 48, complains neither of pain 
in the eye nor headache, but does not see satis- 
factorily with her reading glass which is + 4 
D.; general health good; media clear, discs oval; 
eyegrounds fairly healthy. 
O.D. + 2.s O + .75c axis H f$. O.S. -f- 
1.75s O + .50c axis H fj}. These glasses, to- 
gether with a suitable presbyopic correction 
placed in bifocals, were eminently satisfactory. 
Case 12. Imperfect Presbyopic Correction.—E. 
W. a man, aged 62, in active business and per- 
fect health, never has had a headache ; complains 
that after reading for some time his vision blurs. 
He has worn presbyopic glasses, convex spher- 
icals, for a number of years, having changed 
them at suitable intervals, but until recently has 
had no feeling of disaomfort at all. Theophthal- 7 
moscope showed discs not more gray than was 
natural at his time of life, and the evegrounds 
generally healthy. 
O.D. + 1.50s O 4- .90c axis 165 f®. O.S. + 
i.sQ + .90c axis H. f|. The glasses afforded 
satisfaction. 
Case 13. ■Unsatisfactory Reading Glasses.—J. 
A., a woman, aged 50, complains that she can- 
not see distinctly with her reading glasses ( + 
3.25); there is occasional slight smarting and 
burning of the eye lids ; no headache ; the gen- 
eral health good. In each eye there is a round 
disc with a slight absorbing crescent at its outer 
side ; the general fundus in good condition. 
O.D. + i.s O + .25caxis Hf£. O.S. + 1,25s 
= + .25c axis 30 115. This correction, combined 
with a suitable spherical for reading, gave the 
desired relief and the indistinct vision disap- 
peared. 
Case 14.. Insufficient Reading Glasses ; Slight 
Ocular Pain.—C. S. B., a man aged 48, in per- 
fectly good general health, has worn glasses for 
eight or ten years, always simple, convex spher- 
icals; from time to time he has used his eyes consid- 
erably, and also has had slight pain in them, but 
never any headache or other symptoms. In each 
eye there was an oval disc ; no conus ; rather 
pallid; the fundus in fair condition. O.D. + 
1.25s Q + .25c axis 165 O.S. + .50s 0 + 
.65c axis H f|. This correction combined wTith a 
suitable spherical yielded an excellent result. 
Case 13. Imperfect Reading Glasses.—J. A., a 6 
bined with a suitable presbyopic correction, af- 
forded the relief he desired. 
Case 10. Unsatisfactory Reading Glasses; No 
Headache.—A. B., a woman, aged 52 ; good gen- 
eral health ; complains of some mistiness while 
attempting to read, and also when looking at a 
distance ; never has had an attack of headache. 
Wears a convex spherical of + 3 D.; media clear; 
tension normal. Oval discs, with slight veiling 
of the lower and inner edges. 
O.D. + 2.s O + .25c axis H f". O.S. + 1.50s 
3 + 1.25c axis H £$. These glasses, combined 
with the necessary addition for reading, answered 
her purposes very satisfactorily. 
Case 11. Imperfect Presbyopic Correction.—A. 
W., a woman, aged 48, complains neither of pain 
in the eye nor headache, but does not see satis- 
factorily with her reading glass which is -f 4 
D.; general health good; media clear, discs oval; 
eyegrounds fairly healthy. 
O.D. + 2.s O + .75c axis H f$. O.S. -f- 
1.75s O + .50c axis H §[}. These glasses, to- 
gether with a suitable presbyopic correction 
placed in bifocals, were eminently satisfactory. 
Case 12. Imperfect Presbyopic Correction.—K. 
W. a man, aged 62, in active business and per- 
fect health, never has had a headache ; complains 
that after reading for some time his vision blurs. 
He has worn presbyopic glasses, convex spher- 
icals, for a number of years, having changed 
them at suitable intervals, but until recently has 
had no feeling of disoomfort at all. Theophthal- 7 
moscope showed discs not more gray than was 
natural at his time of life, and the eyegrounds 
generally healthy. 
O.D. + 1.50s O + .90c axis 165 O.S. + 
i.s O + .90c axis H. f g. The glasses afforded 
satisfaction. 
Case 13. ■Unsatisfactory Reading Glasses.—J. 
A., a woman, aged 50, complains that she can- 
not see distinctly with her reading glasses ( + 
3.25); there is occasional slight smarting and 
burning of the eye lids ; no headache ; the gen- 
eral health good. In each eye there is a round 
disc with a slight absorbing crescent at its outer 
side ; the general fundus in good condition. 
O.D. + i.s O + .25caxis Hf£. O.S. + 1.25s 
= + .25c axis 30 f-[J. This correction, combined 
with a suitable spherical for reading, gave the 
desired relief and the indistinct vision disap- 
peared. 
Case 14. Insufficient Reading Glasses ; Slight 
Ocular Pam.—C. S. B., a man aged 48, in per- 
fectly good general health, has worn glasses for 
eight or ten years, always simple, convex spher- 
icals; from time to time he has used his eyes consid- 
erably, and also has had slight pain in them, but 
never any headache or other symptoms. In each 
eye there was an oval disc ; no conus ; rather 
pallid; the fundus in fair condition. O.D. + 
1.25s Q + .25c axis 165 ff. O.S. + .50s O + 
.65c axis H This correction combined with a 
suitable spherical yielded an excellent result. 
Case 13. Imperfect Readmg Glasses.—J. A., a 8 
woman aged 50, complains that during the act 
of reading she cannot see distinctly, but other- 
wise, with the exception of slight burning and 
smarting at the margins of the lids, has no symp- 
toms of eye-strain; the general health is perfect- 
ly good; she has worn glasses for a number of 
years, always a simple spherical. In each eye 
there was a round disc with slight crescent at the 
outer side and an absorbing pigment line be- 
yond. 
O. D. + i.s C +.25C axis H f{|-. O. S. + 1.25s 
C + .25c axis 30 f ib This correction with a 
suitable presbyopic addition proved satisfactory. 
Case 16. Unsatisfactory Reading Glasses ; 
Slightly Blurred Visio?i.—M. R. H., a woman 
aged 54, has worn glasses for mail)- years, but 
complains that after their use objects blur some- 
what; there is no pain and no headache, although 
the patient herself is a delicate woman having 
lost much sleep owing to the necessity of nurs- 
ing a case of prolonged illness in her family. In 
each eye the disc was an oval, the central lymph 
sheaths full and the color of the papilla slightly 
gray. 
O. D. + 2.s O + ,50c axis 15 §[}. O. S. + 
2.s 0 + .50c axis 165 These glasses seem to 
help her, although the eye endurance has never 
been great; they certainly proved better than sim- 
ple spliericals. 
Case 1 j. Imperfect Reading Glasses; No Pain.— 
E. J. P., a woman aged 58, for years has suffered 
with a torpid liver and symptoms called dyspeptic 9 
probabfy owing to the same condition; curiously 
enough there never has been any pain and no head- 
ache; she has worn glasses for years, simple con- 
vex sphericals for reading. In each eye an oval op- 
tic disc, and scattered through the choroid nu- 
merous yellowish dots sometimes discrete and 
sometimes gathered in clusters; the central 
lymph sheaths full and the discs rather gray, 
O. D. + 1.50s O + 2.c axis 15 O. S. + 
i.sQ + .50c axis H -fjf. These glasses and the 
additional lenses suitable for reading purposes 
gave entire satisfaction; indeed the patient com- 
plained of no special symptoms, and except for 
indistinct vision was reasonably well satisfied with 
glasses that paid no attention to her astigmatism. 
Of these seventeen cases one was under thirty, 
seven between forty and fifty, and the remaining 
nine between fifty and sixty-three. In general 
terms the patients complained very slightly, 
the chief disability being lack of eye endurance, 
although in many instances they were people 
who, glassed as they were with simple convex 
lenses, yet read and worked at close ranges with 
comparative comfort. The desired increase in 
eye endurance came with the addition of the cyl- 
inders. It is noteworthy that in fourteen out of 
the thirty-four eyes examined the correcting cyl- 
inder w’as as low as 0.25 dioptry; its absence was 
missed and its presence a relief. The eyegrounds 
in these cases presented no unusual features, and 
require no comment. 
III. Cases characterized by blepharospasm, 10 
symptomatic conjunctivitis, ccdcma of the ltds, epi- 
phora, photophobia, <?r muscce. 
Case i. Blepharospasm.—M. A., a boy aged 
9 years; perfect general health; no headache; 
constant blepharospasm. Oval, over-capillarv 
discs; tine retinal striation. 
O. D. + .6oc axis H ff. O. S. + .25s 0 + 
.60c axis H Complete relief of the symp- 
toms. 
Case 2. Epiphora a?id Ocular Pain.—S. E., 
a man aged 62; very gouty; one attack of iritis; 
ocular pain and lachrymation with eye use. 
Gray-red discs and remains of former iritis. 
. O. D. + .75s Q + .75c axis H ff. O. S. 
+ .90c axis H ff. These glasses afforded relief. 
In addition the patient took anti-gout diet and 
iodide of soda. 
Case j. Recurring Attacks oj Conjunctivitis; 
Occasional Temple Headache.-—C. T., a woman 
aged 33; general health good; recurring attacks 
of conjunctivitis and coarse bulbar injection; 
some temple headache. No fundus lesion except 
retinal striation. 
O. D. -f 1.25s O + 1.50c axis 165 |f. O. S. + 
3.50s 0 + .75c axis 150 ff. These glasses af- 
forded entire relief. 
Case 4. Epiphora.—C. I J., a man aged 46; 
good general health; cannot read at night, and 
all reading produces epiphora. Fundus normal 
except slight blurring of the nasal edges of the 
discs. 
O. D. + .50c axis H ff. O. S. + .25c axis 15 11 
yf. The epiphora entirely ceased with the use 
of this correction added to a corresponding read- 
ing lens. 
Case 5. Muscce and Photophobia.—M. L., a 
woman aged 67; feeble general health without 
definite disease; reading produces photophobia 
with web-like film rising before the eyes, the 
center of the film dotted with darker points. 
Media clear; gray-red discs, edges slightly mel- 
lowed. 
O. D. + i.sQ + .60caxis H yf. O. S. -f i.s 
C + -25c axis 30 yf. These glasses relieved- 
the photophobia, but did not at last accounts re- 
move the muscae. 
Case 6. Photophobia and Ocular Pain.—B. 
L. J., a woman aged 52; has been the subject of 
nervous exhaustion and recently underwent the 
rest cure; now considers herself well; reading 
produces eye-pain and photophobia. Round 
discs with slight retinal haze. 
O. D. + .25s O +.50C axis H ff. O. S. + 
•25s O + .50c axis 15 The result was good. 
Case 7. Muscce; Occasional Supraorbital Neu- 
ralgia.—C. T. A., a woman aged 56; subject to 
rheumatism; loses much sleep; muscae, supraor- 
bital neuralgia and ocular pain; each lens nucleus 
strongly marked. Oval, rather gray discs and 
hazy retinas. 
O. D. + .60c axis H f$. O. S. + .25s Q + 
.25c axis H fy. These glasses markedly reliev- 
ed the muscae and the ocular pain, but not the 12 
supraorbital neuralgia. This was modified by 
anti-rheumatic treatment. 
Case 8. Blepharospasm and Left Headache.— 
A. C. B., a man aged 18; general health good; 
has blepharospasm, blepharitis and headache 
chiefly on the leftside; the left eye is amblyopic. 
There are no lesions of the fundus except that the 
disc on the left side is grayer than normal at his 
age of life. 
O. D. + 1.25s 0 + .25c axis H f$. O. S. + 
2.s 0 + 1.25c axis H fj}. Complete relief of 
the symptoms. 
Case 9. CEdema of Lids; Some General Head- 
ache.—S. C. a woman aged 20; in poor general 
health; subject to tonsillitis; has had several at- 
tacks of catarrhal jaundice; eyes troublesome 
since childhood on account of recurring oedema 
of the lids. The margins of the disc are veiled; 
tortuous transverse vessels and woolly choroids. 
O. D. -f 2.s 0 + .90c axis 15 fj}. O. S. 4~ 
i-5°s 0 + 1.25c axis 165 f$. Relief followed. 
An attack of typhoid fever shortly afterward, 
prolonged in its course, rendered it difficult to 
of estimate the value the correction. 
Case 10. Chronic Hypercemia; Epiphora.—M. 
M., a woman aged 47, in good general health, 
constantly using her eyes, complains of burning, 
lachrymation, and heaviness of the lids. Inspec- 
tion of the conjunctiva reveals the somewhat 
characteristic tear-soaked appearance of chronic 
hypersemia. In each eye the disc is gray-red, 13 
and there is undue amount of retinal haze and 
opacity of the fibre layer. 
O. D. + .25s O + .37c axis 15 |$. O. S. + 
•75s C + -25c axis 165 fir- The use °f these 
glasses with the proper reading correction and a 
local astringent wash produced great relief. 
Case 11. Vaso-motor Blepharitis; Asthenopia.— 
C. A. Y., a woman aged 25, excessively nervous; 
imagines she is going blind; worried about slight 
redness of the ciliary margins which grows worse 
after eye use; states that she cannot read or sew 
with any comfort; has worn for some time a cor- 
rection very similar to the one given below. Eye- 
grounds present oval discs; fairly healthy retinas; 
no conus. 
O. D. + 2.25s O + .60c axis H O. S. + 
3.25s O + .90c axis 165 |-J}. The eyelids im- 
proved very considerably under the use of these 
glasses, although the patient’s asthenopia, ac- 
cording to her own statement, did not improve. 
The field of vision in this case presented more or 
less the typical characteristics seen in hysterical 
eyes. 
Case 12. Chronic Ilyperannia of the Con- 
junctiva.—P. S., a man aged 42, complains of 
some epiphora and smarting of the the 
conjunctiva of which presents the appearances of 
hyperaemia ; he never has had a headache and 
has no asthenopia. In each eye the lymph 
sheaths are full and there is undue broadening 
of the scleral ring with haziness of the retinas. 
The patient uses tobacco and alcohol injudi- 14 
ciously, and has done enormous amounts of eye 
work. 
O.D. + 1.75s Q + .75c axis H O.S. + 
1.50s Q + .75c axis H f$. These glasses to- 
gether with an antiseptic wash afforded re- 
lief ; the patient was not, however, under obser- 
vation very long. 
Case 13. Epiphora; Slight Ocular Pain.—J. 
R., a boy aged 8, complains of slight pain in 
his eyes and constant watering, especially after 
the act of reading; scarlet fever in youth, but 
no recent illness ; headaches practically never 
present. In each eye an oval, unduly capillary 
disc and typical shot-silk retina. 
O.D. + 1.50s 0 + .90c axis 45 O.S. 4- 
1.25s 0 + .60c axis 165 f-jy. One month later 
reports himself better, though the eyes occasion- 
ally grow red ; watering has stopped; there are a 
few swollen lymph follicles on theretrotarsal folds. 
These thirteen cases varied in age from eight to 
sixty-seven years, and presented as their most 
prominent complaint one or other of the symp- 
toms noted in the group heading—symptoms 
commonly seen in all forms of refraction error, 
and occurring quite as frequently in cases of 
usual astigmatism, and even in simple hyper- 
metropia and myopia. In two of the cases evi- 
dence of general disease required appropriate 
constitutional remedies, and in one hysteria was 
a strong factor. It is again noteworthy in four 
of the cases that the addition of a weak cylinder 
to a spherical glass which previously had been 15 
worn for reading produced a result not attained 
by the former correction, and that in six of the 
examined eyes the astigmatism was neutralized 
by a 0.25 I) cylinder. 
III. Cases characterized by various types of 
headaches aggravated by the use of the eyes. 
Case 1. Peri-ocular Pain and Occipital Head- 
ache.—L,. M., a woman aged 56 ; in delicate 
health; nausea and backache; peri-ocular, 
frontal and occipital headache. Grey-red discs, 
distended lymph sheaths, areas of fine, yellowish- 
white spots in macula. Urine slightly albumin- 
ous and containing hyaline tube casts. 
O.D. + .25s Q + .90c axis H yf. O.S. + 
• 5°s O + -75c axis H yf. The presence of 
Bright’s disease in this case rendered it impossi- 
ble to judge of the value of the glasses in re- 
lieving the headache. 
Case 2. Nocturnal Headache.—B. C., a woman 
aged 40 ; general health good ; misty vision and 
a feeling of fulness in head ; nocturnal headaches 
after evening use of eyes ; discs too capillary, 
and faint retinal haze. 
O.D. + 1.25s O + .90c axis 10yf. O.S. + 1.25s 
O + .50c axis 165 yf. Kntire relief resulted. 
Case j>. Severe Supraorbital Neuralgia.—D. 
\V., a man aged 61 ; chronic rheumatism ; gouty 
ancestry ; severe supraorbital neuralgia ; failing 
vision especially in O.D. 
O.D. + i.s O + .50c axis 15 §f. O.S. -f- 1. 
s O + .50c axis H |f. In the right eye grey- 
red disc and unduly prominent scleral ring ; field 16 
contracted. In left eye fundus normal except 
broadening of the scleral ring. Reading power 
improved ; supraorbital neuralgia not relieved ; 
this was probably rheumatic. 
Case 4. Severe Frontal Headache.—J. M., a 
girl aged 17 ; general health usually good ; slight 
menstrual derangement; frontal headache se- 
verely aggravated by eye use. Fundus normal. 
O D. + 1.25s C + -6oc axis H O.S. -f- 
1.25s Q + .60c axis 165 These glasses 
afforded entire relief except during the menstrual 
epoch when considerable asthenopia appeared. 
Case 5. Frontal Headache.—S. W., a young 
man aged 18 ; general health good ; no complaint 
except frontal headache after reading or study ; 
discs normal in color ; scleral rings unduly broad; 
veins and lymph sheaths distended. 
O. D. + i.s 0 +.90C axis H O. S. + i.s 
0 + 1.25c axis 165 yf. The result was entirely 
satisfactory. 
Case 6. Right-sided Headache, Neuralgic in 
Type.—M.D., a woman aged 59; delicate health, 
the result of a long standing fistula in ano and a 
severe attack of typhoid fever; cannot read with 
any comfort, severe headache the invariable re- 
sult ; is wearing simple sphericals. 
O. D. + i.s 0 + .50 c axis H O. S. + 
1.25s 0 + .25c axis H y-f. Much relief followed 
the use of the new glasses. 
Case 7. Peri-orbital Pain and General Head- 
ache.—P. D. E., a woman aged 30, feeble general 
health without definite disease; severe general 17 
headaches and photophobia aggravated by eye use. 
Oval discs, nasal edges veiled, choroids woolly. 
O. D. +.25S C + -5oc axis H ff. O. S. + 
.50s C + .50c axis H ff. Greatly improved in 
all respects without the use of general medication. 
Case 8. Consta?it Temple Headache.—M. D. G., 
a boy aged 18, general health good; constant 
temple headache with some lachrymation. Oval, 
over-capillary discs, with veiling of the nasal edges, 
O. D. + .50s C + .50c axis 15 |f, O. S. + 
• 5°s O + .25c axis 165 |f. Satisfactory result. 
Case g. Constant Left-sided Head-Pain.—H. 
R. C., a man aged go, general health perfectly 
good; dull ocular pain and sharp left-sided head- 
ache, with some photophobia. In the right eye 
round disc, color good, but scleral ring too plain- 
ly marked; left eye, oval disc, gray, veins and 
lymph sheaths full. 
O. D. + .90s 0 .50c axis H ff. O. S. + i.s 
0 + .50c axis 165 f§. There was entire relief. 
Case ig. “ Sick Headache.”—M. A., a woman 
aged 50, good general health; numerous sick 
headaches brought on by eye use, with unsatis- 
factory reading power. Oval, healthy discs. 
O. D. + 1.50s 0 + .50c axis 150 ff. O. S. 
+ 1.50s 0 + .50c axis 30 |f. These glasses af- 
forded relief when combined with proper reading 
lenses. 
Case 11. OccipialHeadache.—S. M., woman aged 
47, cardiac asthma from mitral disease, has had 
rheumatism; severe occipital headache aggravated 
by eye use, ordinary convex sphericals useless. 18 
O. D. + .50s C + -6oc axis 15 |£. O. S- + .50s 
O + i-c axis 1 65 f £. The occipital headache 
had disappeared when the patient was last seen. 
Case 12. Occipital Headache.—J. H. T., a man 
aged 38, general health good; has worn glasses 
for four years (+ 1.5) ; recently complains of not 
seeing well and pain in the occiput after eye use. 
In each eye an oval disc, with a slight patch of 
choroiditis at the outer margin ; central lymph 
sheaths full. O. D. + 1.50s Q .50c axis H 
f$. O. S. + 1.50s C .50c axis H The re- 
sult was perfectly satisfactory. 
Case 13. Severe Brow Pain.—M. L,., a girl 
aged 16, slender, anaemic, occasional dysmenor- 
rhoea; for two years has suffered with violent at- 
tacks of brow pain, slight ache being more or 
less constant, and the explosions of headache 
being severe enough to put the patient to bed. 
They were often noted on Saturday or Sunday. 
The ophthalmoscope reveals in each eye an oval 
optic disc, unduly capillary, and all the edges 
blurred by a hazy retina; in other words, a typi- 
cal eye-strain eye ground. 
O. D. + .75s Q + .60c axis 15 f$. O. S. + 
•75s O + -75c axis H -f$. These glasses, together 
with discontinuance of the studies, the adminis- 
tration of iron and occasional doses of bromide 
of lithium, revolutionized this girl. She is to-day 
practically free from headaches, or at least they 
come with great rarity. Her color has improved, 
her haemoglobin has mounted to normal, and the 
eye grounds have vastly improved. It should be 19 
noted, however, that with the glasses there was 
careful regulation of her habit of life, and the 
almost continuous use of iron in the form of 
Blaud’s pills. 
Case 14. Severe General Headache.—H. F., a 
woman aged 30, from early childhood has been 
subject to violent general headaches, considering 
herself fortunate if she passed a day without some 
pain in the head ; this was invariably brought on 
in a violent degree by use of the eyes. In girl- 
hood she was removed from school on this ac- 
count. With this exception, there is no general 
disturbance. Curiously enough, her eyes were 
never examined. Kach eye presented an oval 
optic disc of fairly good color, and no changes 
in the fundus. O. D. 4- 2.75s Q + .50c axis H 
f$. O. S. + 4.50s C + -5°c axis H f-g-. Very 
marked relief followed the use of these glasses. 
Case 15. Violent Headaches of the Migrainal 
Type.—A. J., a woman aged 50, had for years 
suffered with violent headache, worse in the eye, 
top of the'head and back of the ear, generally 
one-sided, without positive prodromes, and some- 
times followed by nausea; has tried all manner 
of medication, and on the examinations of very 
competent general practitioners was pronounced 
to be free from constitutional reasons for such 
headache. She is, however, an anaemic woman, 
slender, and readily worried, having met with 
considerable business reverses. The eye-grounds 
were healthy; in each eye an oval optic disc of 
about normal color. 20 
O. D. + .75s C + -75C axis 30 O. S. 4- 
•75s O + -75c axis 165 §■$. These glasses did 
not cure the headache; in fact, at the last account 
she was not relieved by them except as aids to 
reading. She was a peculiar, somewhat vain, 
old maid, and declined to wear the distance 
glasses. It is possible that had she consented to 
the constant use of glasses the result might have 
been better. 
Case 16. Violent Temple and Brow Headache.— 
W. J., a woman aged 35, except for occasional 
attacks of gastralgia, probably a symptom of 
one of the types of dyspepsia, usually induced by 
imprudence in eating, is in good general health. 
She suffers from violent temple and brow head- 
ache, and is subject to excessive exacerbations of 
these pains. In each eye a slightly oval, unduly 
capillary optic disc; the retinas fairly good. She 
has worn + 4.50 D without relief. 
O. D. + 5.50s O + -5oc axis 15 O. S. + 
7.50s O + -6oc axis 165 f$. These glasses cured 
the headaches. 
Case 17. ■ Typical School Headaches.—A girl 
aged 13, in good general health, complains of 
brow pain at the end of each school hour, and 
that the eyes feel as if they were being pushed in- 
ward. Oval discs, slight crescents and some 
retinal haze. 
O. D. + 1.75s O + .25c axis 150 f$. O. S. -f 
1.75s G + .25c axis H No headaches oc- 
'curred unless she laid aside her glasses. 
Case 18. Constant Headaches.— S. E. C., a 21 
woman aged 45, states that since her 15th year 
she has had constant headache, its chief location 
being in the brow and temple; she is fairly well 
nourished without constitutional taint, but with 
a neurasthenic tendency and a habit of trying all 
manner of doctors. Remedies have proved un- 
availing in her headache; five graduated tenoto- 
mies have been done; these, she states, relieved 
for a time the headaches which now, however, 
are constant and severe. She wears for distance 
+ .50s and for reading + 2.50s. Each disc an 
oval, its surface slightly cedematous and all edges 
hazy; numerous lymph reflexes. 
O. D. + i.s O + .25c axis 15 f-g-. O. S. + i.s 
O + -50c axis 165 After wearing these 
glasses for some time she states that they help 
her eyes but the headache continues to be pres- 
ent, although not so severe, in the brow and 
temple. She has undergone careful six-weeks 
rest-cure and is generally much improved. 
Case 19. Violent Scattered Head pain; No Re- 
lief from Drugs.—A. B. H., a man aged 35, has 
had no serious illness since his 17th year, when 
he suffered from scarlet fever, but had a slight 
heat stroke eight years ago. He is very bilious; 
works in tobacco, but uses the drug moderately. 
His present trouble began five years ago in the 
form of shooting pains in the head, previous to 
which time he suffered from sick headaches. 
These pains locate themselves in different spots, 
and are intensely violent and neuralgic in type. 
In each eye a round disc with some patches of 22 
white over the central vessels; rather full veins, 
but otherwise normal eyegrounds. 
O. D. + .50c axis 150 O. S. + .37c axis 
30 J-£. With the exception of a few doses of 
croton chloral hydrate the patient had no reme- 
dies after the prescription of these comparatively 
weak cylinders, and yet the relief was almost 
immediate and has continued ever since, the 
treatment having been instituted many months 
ago. 
Case 20. Periorbital Pain.—G. P. S., a wom- 
an aged 49, rather delicate in constitution and yet 
without organic disease, complains of a peculiar 
pain, which is described as “drawing” in the brow 
and over the eye after reading and writing; this 
pain speedily produces nausea. In each eye an 
oval disc, the edges slightly blurred by hazy ret- 
inas. 
O. D. + 2.s O + .25c axis H f$. O. S. + 
I. O + .50c axis 150 f$. These glasses com- 
bined with suitable presbyopic correction, were 
of great assistance, and reading and writing is 
now done with comparative ease, although eye 
endurance is not great. The previous correction 
was similar except that the astigmatism had been 
unnoted. 
Case 21. Vertex a?id Occipital Headache.—M. 
J. A. a woman aged 51, is excessively anaemic, 
having had two attacks of haematemesis, in the 
last of which she nearly perished, probably de- 
pending upon ulcer of the stomach; she is deaf 
from catarrhal disease of the Eustachian tubes. 23 
Numerous muscae float before each eye. In each 
the edges of the disc slightly hazy, the choroid a 
little woolly, a few yellowish dots scattered 
through the eyeground but no haemorrhages; the 
color of the discs pallid. 
O. D. + 1.75s Q + :50c axis H f$. O. S. + 
1.75s O + -6oc axis 15 f£. These glasses and a 
suitable presbyopic correction combined in bifo- 
cals, may have produced some relief, but the eyes 
are far from comfortable and the eye endurance 
exceedingly limited. It could not reasonably be 
expected that any great impression would be 
made in a woman whose haemoglobin was so much 
below the normal from excessive haemorrhages. 
Case 22. General Headache.—A. H. T., a 
woman aged30, always complained of weak eyes; 
never has had any severe illness. In childhood 
fell upon the head, without, however, pro- 
ducing a fracture; in early childhood had 
convulsions attributed to indigestion; for years 
has suffered with violent headaches begin- 
ning in the eyes, becoming general and ending 
in nausea. Drugs have been useless. In each 
eye the disc is oval, the surrounding retina hazy 
and the surface of the papilla a little woolly. 
O. D.+ .75s Q + .25c axis 30 f$. O. S. + 
.75s -f .25c axis 150 After wearing these 
glasses for several months she reported an entire 
absence, with one exception, of headaches. 
Case 23. Brow Headache After Study.—F. R., 
a boy aged 14, had diphtheria and scarlet fever 
in infancy, but is perfectly well now; complains 24 
of the ordinary brow pain after evening study 
hour so common in children; occasionally the 
headache becomes general. With the exception 
cf unduly full veins which are slightly tortuous 
there are no changes in the eyeground. 
O. D. -f 1.25s 0 +.5oc'axis Hf$. O. S. + 1.50s 
0 + .25c axis H f-$. The relief was complete. 
Case 24. Severe Occipital Headache.—E. M., 
a woman aged 45, has had a complication of 
troubles which may briefly be stated as double 
vision from paralysis of one or other of the ocu- 
lar muscles (it is not known now which) follow- 
ed by Bell’s palsy, the remains of which are still 
apparent, and having had as her most recent illness 
a miscarriage, one other having also occurred, 
in all instances the probable result of specific 
taint. There were no changes in the eyeground 
to indicate constitutional disease and she sought 
relief for violent occipital headache. 
O. D. + i.s 0 + .50c axis 30 f$, O. S. + i.s 
0 + .75c axis 150 f$. This, or a formula very 
nearly like it, together with a suitable presbyopic 
correction, she had worn for some time and with 
some relief, but the headache continued. A slight 
change was made in the cylinders, without much 
relief to the headache, which also did not yield to 
anti-specific treatment. A thorough .examination 
of the urine revealed some albumin and here and 
there a tube cast. Under proper diet, combined 
with Basham’s mixture and small doses of bichlo- 
ride of mercury, the occipital pain was relieved. 
In this instance it is evident that the astigmatism 25 
was not the cause of the pain, and that its cor- 
rection consequently yielded no result. 
Case 25. Violent General Headache.—G. S., a 
woman aged 31, for four years has suffered with 
violent headaches, somewhat relieved but by no 
means set aside by glasses which imperfectly cor- 
rected her astigmatism. One year ago she had 
nervous prostration, and has suffered at times with 
rheumatic pains in the shoulders; otherwise the 
health appears to be good. In each eye there is 
an oval, distinctly gray optic disc. 
O. D. + 3.S Q + .75c axis H f-|. O. S. 
+ 2S. 0 + .50c axis H Three months after 
the correction the patient reported that she had 
scarcely any headache, although previous to that 
time it was rare to pass a day without one. It is 
interesting to note that in this case she previously 
wore a correction of her astigmatism, just half of 
the amount having been ordered, with almost no 
correction of the hypermetropia and with no good 
result. 
Case 26. “ Sick Headaches.”—E. E- S., a wo- 
man aged 45, some years ago had typhoid fever; 
since then has been well, but has lost much sleep 
by nursing; wears simple sphericals which are 
not satisfactory ; always has had*much headache, 
which begins over left eye, spreads through head 
to occiput, and also has many “ sick headaches,” 
beginning in the same way. The optic discs are 
pallid, with marked scleral rings surrounding 
them ; otherwise no changes. 
O. D. + .60s C -25c axis H -fj]-. O. S. + 26 
.60s C + .25c axis H §#. Three months after 
the use of these glasses, together with the neces- 
sary convex addition for reading, which was com- 
bined with a 2.50 prism base in, the patient re- 
ported herself much better. 
Case 27. Severe Frontal Headache.—W. J. S., 
a woman aged 48, with the exception of consid- 
erable nervousness and ready succumbing to fa- 
tigue, is in good general health. She has worn 
glasses for twenty-three years, always simple 
sphericals, and for years has suffered with violent 
pain beginning in the forehead and passing to the 
occiput, coming in spells sometimes lasting for 
two days at a time. These headaches are induced 
not alone by reading or eye work, but by any fa- 
tigue. There are faint strise in the far periphery 
of each lens. The discs are oval, of good color, 
maculas normal; some filling of the central lymph 
sheaths. 
O. D. + 5.S Q + .75c axis H —. O. S.-j- 
5s- O + -9°c axis r5 It—• Three months later 
this patient reported herself better in every way, 
having had only one headache and no eye pain. 
Case 28. Ordinary School Headaches.—B. B., a 
girl aged 16, has worn glasses for four years, very 
much an under-correction of her refraction error 
and without note of the astigmatism. She is 
subject to tonsillitis, has some indigestion and a 
great many comedones on her face, probably con- 
nected with the indigestion, perhaps with men- 
strual disturbance ; complains of indistinct vision 
and headache coming on after school, with ina- 27 
bility to maintain accurate close vision. In the 
right eye an oval disc, the surface a little woolly, 
and a slight crescent at the outer side. In the 
left eye an irregularly oval disc with distinctly 
mellowed edges and many lymph reflexes through 
the fundus. 
O. D. + 2.s C + .12C axis H f-g-. O. S. + 
3.25s O -f 1.25c axis 15 fg. Several months after 
this correction was ordered marked relief was re- 
ported. 
Case 29. Occasional Brow Pain; a Good Deal 
of Nervousness.—J. J. R., a woman aged 35, was 
glassed six years ago, and wears a correction sim- 
ilar to the one given below, but slightly under 
the total amount of astigmatism; declares that 
she is in good general health, a report which is 
confirmed by her physician; complains of limited 
eye endurance, headache over the brow and pain 
darting in the right eye; cannot use the eyes at 
night, and “gets nervous from her eyes.” In 
each eye a typical eye-strain appearance, name- 
ly: slightly veiled edges of the disc, full lymph 
sheaths, and fine cedematous haze of the retina. 
O. D. + 2.s Q+ 90c axis 165 fg. O. S. + 1.75s 
O + .90c axis H fg. A month later she reported 
progress, but still complained of some pain and 
the nervous feeling when she used her eyes. The 
eye-grounds were still very irritable. 
Case jo. Post-ocular Headache.—A. A., a wo- 
man aged 38, has worn glasses for ten years, re- 
cently having a correction closely similar to the 
one given below, but also an under-correction; 28 
she is much confined at her business and is in 
poor general health from lack of exercise, with- 
out any definite illness; is very nervous. The 
eyes feel strained, and their use brings on severe 
pain situated behind the orbit. In each eye a 
round disc with a shallow excavation, the papilla 
being surrounded by a somewhat hazy retina. 
O. D. + 2.s Q + .50c axis 30#$. O. S. + 1.75s 
O + -75c axis r5° It- These glasses were a help, 
but a vacation, complete rest, and some general 
medication were also used. 
Case si- Temporal Headache ; Ocular Pain.— 
A. R. L,., a man aged 29, uses his eyes a good 
deal; is a trained athlete and generally in good 
health ; formerly he was subject to vertigo which 
now has entirely subsided ; at present complains 
of pain in the eyeballs nearly constant, and when 
headaches come on, which is not infrequent, the 
pain is situated in the temples. In each eye an 
oval hyperaemic optic disc, the eyegrounds show- 
ing superficial choroidal disturbance. 
O.D. -f 1.25s 0 + .25c axis 165 O.S. + 
1.25s 0 -+- .25c axis 15 These glasses ap- 
pear to have given comfort thus far, but the eye- 
grounds are not m good condition and rest has 
been enjoined. 
In these thirty-one cases various types of 
headaches occurred, which were relieved prompt- 
ly by the correction, except when the pain 
had evident origin in some constitutional con- 
dition, namely, in cases 1 and 3; and when, 
as in cases 15, 18, and 29, although no exact 29 
constitutional reason for the headache was 
ascertained, the general system probably was at 
fault, or sufficient time for the irritability of the 
eyfcgrounds to subside had not yet elapsed. In 
other words, the relief was exactly the same as 
that which is afforded by the correction of the 
ordinary errors of refraction associated with 
headache. It did not seem in any of the cases 
that the headache was more severe than that 
often noted in cases of astigmatism according to 
the rule, nor was there in any case marked gen- 
eral disturbance, as the apparent result of the 
eve-strain, except, perhaps, in case 7, where a 
feeble young woman improved greatly in all re- 
spects without the use of any general medica- 
tion. In several cases general tonic medication 
was employed in addition to the optical thera- 
peutics—a precaution often advisable as an ad- 
junct in the treatment of “eye-strain” head- 
aches. The ages of these patients Varied from 
13 to 61 years. 
IV. Cases characterized by ocular changes — in- 
cipient cataract, with or without headache; and 
glaucoma. 
Case 1. Simple Chro?iic Glaucoma.—S. E., a 
woman aged 50 ; has had much mental worry, 
otherwise no illness ; dim vision in the right eye 
for several months ; frequent changes in glasses ; 
periods of obscuration of vision; no headache. 
Right eye, round disc excavated to margin, 
especially deep above and to nasal side, buff- 
colored rim with halo all round. T. +. 2. 30 
Left eye, round disc, small central excavation ; 
veins full and pulsating. Anterior chamber in 
both eyes shallow ; the nasal field in O.D. ab- 
sent ; in O.S. contracted. 
O.D. -f 2.s 0 4- .6oc axis 15 ff. O.S. + 
2.25s 0 + .60c axis H |f. Twenty months 
later the central vision in O.D. was ff ; in O.S. 
The patient has used continuously eserine. 
The field of vision has not materially changed. 
Case 2. Simple Chronic Glaucoma.—A. H. D., 
a woman aged 65; easily worried; a poor sleeper ; 
has chronic dyspepsia ; obscured vision in the 
right eye above the horizontal line ; pain in the 
back of neck ; many changes in glasses. In the 
right eye a narrow anterior chamber ; nerve hori- 
zontally oval ; complete, shallow, glaucomatous 
cup and halo; T + 1. In the left eye oval 
disc; partial excavation ; halo-like band. In 
the field of the right eye there was complete loss 
of the upper and inner quadrant; in the left 
contraction of the lower inner portion. 
O.D. + .50s 0 + .50c axis 15 O.S. + 
•5os 0 + -5oc axis 165 f-f. Iridectomy was 
done on the right eye when vision began to fail 
(ff), with goodresult. 
Case 3. Incipient Cataract; Ocular Pain.—C. 
S., a woman aged 70; well preserved; general 
health, except for rheumatism, good; unsatis- 
factory reading glasses—simple convex spher- 
icals; eyes pain. Oval discs; sharp scleral 
rings; choroids fair; striae in the anterior 
cortices. 31 
O.D. + 2.50s 3 + .75c axis 15 O.S. -f 
2.50s 3 + .60c axis 165 The result was in- 
creased comfort to the patient. 
Case 4. bicipient Cataract; Occipital Head- 
ache.—S. A., a man aged 54; is the subject of 
muscular rheumatism and occipital headache ; 
eyes readily tire at close work. Irregularly oval, 
gray discs ; sharply marked scleral rings ; fine, 
dust-like opacities in the periphery of each lens. 
O.D. -f .25c axis 15 ff. O.S. + .25c axis 
165 yf. These cylinders, incorporated with 
suitable convex sphericals for reading purposes, 
gave great satisfaction. Iodides, however, were 
ordered. 
Case 5. Incipieiit Cataract; Occipital Head- 
ache.—W. W. G., a woman aged 54; imperfect 
health, although complexion ruddy; asthma 
(renal?); occipital headache ; trigeminal neu- 
ralgia ; reading glasses unsatisfactory ; many 
follicular granulations in the conjunctival cul-de- 
sac. Oval, gray discs and fine striae in the an- 
terior cortex of each lens; albumin, hyaline and 
granular casts in the urine. 
O.D. -f 2.50s 3 -f- .25c axis H f$. O.S. -|- 
2.s Q + .25 c axis 165 f-j}. The result of the 
change of glasses in this case was at last ac- 
counts not an improvement. The local condi- 
tion of the conjunctiva precluded the possibility 
of any satisfactory eye work. 
Case 6. Incipient Cataract; Frontal Headache. 
—B. C. G., a woman aged 60; general health 
moderately good ; subject to “ sick headaches 32 
at times bilious ; urine normal; eye pain with 
sharp frontal headache caused by reading; glasses 
—simple convex sphericals—not satisfactory. 
Small oval discs with yellowish dots in the 
macula ; many shoots in the periphery of each 
lens. 
O.D. + 1.75s Q plus .90c axis 150!$. O.S. 
+ 2.s Q + .50c axis 60 f~jy. Distinct relief has 
followed the new correction. The patient, how- 
ever, has taken alternately iodide and bromide of 
potash, and strychnia. 
Case 7. High H As.; Incipient Cataract.—T. 
A. H., a woman aged 68 ; general health mod- 
erately good; sciatica at times and occasional 
attacks of bronchitis ; convergent squint since 
childhood ; seeks .advice for improvement in vis- 
ion ; wears sphericals only ; no headache. Oval, 
rather grey-red discs with mellow margins. In- 
cipient cataract in each eye. 
O.D. + 2.50s 3 + 2-c axis i5°t&- O.S. + 
4«s C + I-5oc axis 165 f$. The improvement 
in vision, which was considerable, afforded the 
patient great satisfaction. 
Case 8. Incipient Cataract; Pam in the Occi- 
put.—E. C., a woman aged 61, has a mitral mur- 
mur and complains of pain after reading, sewing 
and the like, with some smarting and burning of 
the eyelids and pain in the occiput. In each eye 
an oval, distinctly gray optic disc. In the right 
eye the lens hazy, in the left striae in the anterior 
cortex. 
O.D. + 4.50s C T .75c axis H f-g-. O.S. + 33 
4-5os O + .25c axis H f£. These glasses afford- 
ed her considerable relief, although prolonged 
reading still produces some burning in the eyelids. 
Case 9. Incipient Cataract; Vertigo; Occipital 
Headache.—J. V. B., a woman aged 58, suffers 
from chronic indigestion and vertigo of such a 
type that the tendency is to fall forward; occa- 
sional attacks of severe headache in the occiput; 
heart and kidneys normal. In each eye an ap- 
parently healthy optic disc, except for undue 
broadening of the scleral ring. Targe flocculent 
opacities in the anterior cortex of each lens, not 
yet encroaching upon the pupillary space. 
O. D. 4- i.s Q + .50c. axis H f$. O. S. 
+ i.s O 4- .50c axis H f$. These glasses 
afforded relief, but it should be stated that the 
patient was also under treatment for the chronic 
indigestion, and the regulated diet and medi- 
cinal measures were potent factors in reliev- 
ing the vertigo. The headache appears to have 
been due to uncorrected astigmatism. The pa- 
tient has not reported quite lately, and the present 
result is unknown. It is an interesting fact that 
through the distance glasses there was orthophoria 
for the distant point; without them a slight right 
hyperphoria. 
Case 10. hicipient Cataract; no Headache.— 
J. E. W., a woman aged 70, complains of no 
headache, but some slight pain in the eyeballs ; 
uses her eyes incessantly as an artist doing the 
finest kind of painting. With the exception of 
some dyspepsia and a recent attack of influenza, 34 
the general health is good. In each eye there 
are striae in the anterior cortex, radiating irregu- 
larly towards the pupil. Each disc is oval, gray, 
and the central lymph sheath full. The maculas 
are normal. 
O. D. + 1.25s O + .75c axis H f$. O. S. + 
2,s O + .25c axis H §#. The patient expressed 
satisfaction with the glasses. 
Case 11. Incipient Cataract; Slight Conjunctivi- 
tis.—W. T., a man aged 62, in good general health 
with the exception of an attack of influenza, from 
which the convalescence was slow, complains that 
the right eye inflames, the vision is dim and the 
glasses not clear; there is no headache. In each 
eye an oval disc, with undue broadening of the 
scleral ring, and the surface distinctly gray-red. 
In each lens small opacities down and in, in the 
anterior cortes, and the circle surrounding the 
nucleus slightly hazy. 
O. D. + .50s O + 1.25c axis H O. S. 
+ .90c axis 150 These glasses, together 
with reading sphericals, were ordered. The pa- 
tient appeared to see with satisfaction, but com- 
plained still of the irritation so common in in- 
cipient cataract. It should be stated that there 
was also some squamous blepharitis. 
Case 12. Incipient Cataract; Slight Vitreous 
Opacities; Occipital Headache.—J. A., a man aged 
61, has had rheumatism, but with the exception 
of an attack of influenza in last October, which 
much prostrated him, has been in good condition. 
Since then has complained of floating spots before 35 
the right eye; he has some headache, chiefly in 
the occiput. In the right eye an oval, rather 
gray disc, fine haze in the vitreous and some striae 
in the lens. In the left eye the conditions are 
similar, except no vitreous change was noticed. 
In each the retinas were hazy. 
O. D. + 1.25s O + .50c axis H O. 
S. + i.s Q + .50c axis H f$. The vision, liowT- 
ever, was not clear, being misty, especially 011 
the right side. 
Case 13. Incipient Cataract; Pain in the Eye- 
balls.—J. B., a man aged 58, complains of some 
pain in the eyeballs, worse upon the left side ; 
occasional brow ache. With the exception of a 
severe fall in the winter, which shocked him con- 
siderably but did not break any bones, there has 
been 110 noteworthy fact in his recent history. 
There is a slight haze around the perinuclear tis- 
sue of the lens, and a few fine opacities. Each 
disc is gray-red and contains a small central cup; 
in each macula a few fine yellowish dots. 
O. D. + i.s O + .75c axis 150 |-2-. O. S. + 
i.s O + .50c axis H f$-. These glasses were 
ordered and eye rest enjoined. 
Case 14. Incipient Cataract; Some Throbbing 
in the Temples.—P. J., a man aged 68, considers 
himself to be in good general health; has some 
post-nasal catarrh ; complains recently of throb- 
bing in the temples and insufficient eye en- 
durance. In the right eye an irregularly hori- 
zontally oval disc, with slightly mellowed edges, 
and an atrophic broadening of the scleral ring. 36 
There is superficial absorption of the choroidal 
pigment. In the left eye a rim of cortical opaci- 
ties not yet encroaching upon the pupil, an oval 
disc which is very gray, and considerable epithe- 
lial choroidal change. 
O. D. + i.s O + .6oc axis 165 O. S. + 
1.50s O + .50c axis 15 f£. 
Case 15. Incipient Cataract; Headache and Nau- 
sea.—J. A. T., a woman aged 55, six years ago 
had nervous prostration, since then has been 
exceedingly nervous and suffered from flitting 
neuralgic pains; the nervousness is increased 
by reading, which also brings on headache asso- 
ciated with nausea. In the right eye there is a 
slightly gray, oval disc, without conus; small, 
fluffy opacities in the lens. In the left eye a sim- 
ilar oval disc and similar opacities, one spear- 
shaped stria passing towards the pupil space. 
Here and there in the choroid are fine yellowish 
dots. 
O. D. + .25c axis H O. S. + .50c axis 
165 ff. This was added to a suitable pres- 
byopic correction and worn with a good deal of 
satisfaction—the patient, however, was restricted 
in reading and given alteratives, chiefly in the 
form of bichloride of mercury. 
The two cases of glaucoma are interesting in 
connection with Dr. Theobald’s investigations as 
to the possibility of astigmatism being a factor 
in the development of this disease. They are 
further interesting because; of the sharp central 
vision which was obtained by a correction of the 37 
astigmatism, and the influence of instillations of 
eserine. Both of these cases had been entirely 
unconscious of any serious eye trouble, and won- 
dered why the frequent glasses which they pur- 
chased without consultation had never permitted 
them to see well or comfortably. The thirteen 
cases of incipient cataract were all, up to the 
present date, relieved by the addition of the cyl- 
inders to their reading glasses and the use of the 
correction for constant wear, with the single ex- 
ception of the case associated with Bright’s dis- 
ease and granular lids, although in three of them 
no marked change for the better can be recorded. 
The importance of the correction of the entire 
error of refraction in incipient cataract has been 
dwelt upon frequently, especially in the able com- 
munication of Dr. S. D. Risley1 upon this topic. 
It is, perhaps, worth while to emphasize the 
fact that the very presence of striae in the 
lens determines an astigmatism, and that this 
should be searched for and corrected; and 
moreover, that these corrections should be the 
subject of reexaminations at stated periods, be- 
cause the refraction must necessarily change in 
eyes the lenses of which are swelling under the 
influence of cataract formation. With such cor- 
rection, however, aided by alteratives and tonics, 
much of the distress, either in the eyes them- 
selves, or in the head, in the form of headache, 
which not infrequently is associated with the 
1 University Medical Magazine, March, 1889. 38 
early stages of cataract, may be alleviated. In 
this particular it is necessary only to refer again 
to Dr. Risley’s paper. I would call attention to 
the good central vision which was obtained in 
the incipient cataract cases when the opacities 
were still in the periphery, and had not encroach- 
ed upon the pupil space. The ages of these pa- 
tients varied between 50 and 70. 
V. Cases characterized by various types of head- 
ache and associated nervous phenomena bordering 
on the type oj the so-called “ reflex neuroses." 
Case 1. Subjective Vertigo.—K. E., a woman 
aged 57; general health moderate; constipated 
and has haemorrhoids; much eye pain, lachry- 
mation and distress when at close work; for the 
last six months vertigo, sudden and subjective, 
when looking to the right. Discs gray and gen- 
eral absorption of the pigment epithelium of the 
choroid. Discs on a lower level than the macu- 
las. 
O. D. + .25s Q + 1.25c axis 15 j-f. O. S. + 
•75s O + 1.c axis 165 yf. The use of laxatives 
and regulation of the general condition did not 
relieve the vertigo; the glasses did. 
Case 2. Occipital Headache; Melancholia.—D. 
S., a woman aged 48; general health good at 
present; occasional attacks of depression; has had 
two periods of melancholia once requiring seques- 
tration; severe occipital headache; muscse. Oval 
discs, rather gray, with a patch of choroiditis at 
the outer side of each. 
O. D. + .50s 0 + .50c axis 15 yf. O. S. + 39 
•5os O + .50c axis 165 yf. These glasses 
afforded entire relief to the occipital head- 
ache. Owing to a high grade of insufficiency 
of the internal recti (exophoria), the cor- 
responding reading glass was combined with 
prisms. There have been no attacks of melan- 
cholia since, and the woman’s spirits are better, 
but the previous attacks of melancholia were so 
directly connected with grave disasters in the pa- 
tient’s immediate family that it would require a 
stretch of imagination to think that the eye-strain 
had had aught to do with their production. 
Case j. Marked Asthenopia; Typical Neuras- 
thenia.—T. W., a woman aged 67; reasonable 
general health; marked asthenopia; cannot read 
for five minutes; easily depressed; has attacks of 
“night ptosis.” Discs gray, with visible scleral 
rings, and fibre layers of the retinas somewhat 
opaque. 
O. D. 4- 2.s Q + .90c axis H yf. O. S. + 
2.s Q + .75c axis H yf. Great improvement 
followed the use of these glasses, and while the 
asthenopia has not disappeared entirely, the eye 
endurance has markedly improved. With this 
improvement in eye-tire the previous depression 
of spirits has disappeared correspondingly. I11 
this case there was also a high insufficiency of 
the internal recti, and prisms were combined with 
the reading glasses. The “night ptosis,” or in 
other words, a contracture or dropping of the up- 
per lid which came on during the night, especi- 
ally if the eyes had been used during the earlier 40 
evening, making the patient desire to “prop up 
her lids,” which she declared she could not vol- 
untarily raise, is a curious symptom that I have 
twice noted in patients suffering from asthenopia 
and allied ocular conditions, and who were as 
well the subjects of general hysterical manifesta- 
tions. 
Case 4. Frontal and Occipital Headache; Gen- 
eral Nervousness.—P. G. J., a woman aged 53; 
chronic acid dyspepsia; eyes pain; cannot get 
glasses to suit; severe frontal and occipital head- 
ache follows eye use at close ranges, which re- 
sults in attacks of general nervousness unfitting 
her for her ordinary duties. Fundus healthy, but 
the discs rather pallid. 
O. D. + i.s 3 + -25c axis H yf. O. S. -f- 
r.s 3 plus .50c axis H The result in this 
case was very satisfactory. 
Case 5. Fugitive Headache; Taciturn, Morbid 
a?id Moping.—J. H. L., a girl aged 13; beginning 
to menstruate; much headache unrelieved by gen- 
eral medication; photophobia; moping; unnatur- 
ally quiet, indisposition to any exertion. Discs 
with blurred edges, many lymph reflexes and 
hazy retinas. 
O. D. + 1.50s 3 + .75c axis H O. S. 4- 
1 5os C + -25c axis H f$. Great relief fol- 
lowed, but the ocular treatment was associated 
with the use of iodides, bromides, iron and ergot. 
For a number of months she remained free from 
trouble, became more cheerful and pursued her 
ordinary duties; then a relapse took place, char- 41 
acterized especially by photophobia, following an 
attack of fever somewhat remittent in type. The 
case has again improved without recorrection by 
the aid of bromide and ergot. The glasses were 
certainly one of the factors in relieving the gen- 
eral nervous symptoms in this case. 
Case 6. Occipital Headache; Vertigo.—B. N., 
a man aged 46; general health good; recurring 
attacks of congestion of the bulbar conjunctiva; 
occipital headache; aggravated vertigo. Hori- 
zontally oval, gray discs with absorption of the 
pigment epithelium. 
O. D. + i.sQ + .50c axis 165 f-£. O. S. + 
i.s C + .25c axis J5 In this case the cor- 
rection did not relieve the vertigo, or had not 
done so at the patient’s last report some time 
since. The headache was relieved and the read- 
ing power increased, but otherwise the ocular 
therapeutics were not sufficient to subdue the 
chief symptom for which he presented himself— 
vertigo. 
Case y. General Headache; Insomnia.—G. M., 
a man aged 64; has chronic gout; severe headache 
increased by eye use ; reading well nigh impossi- 
ble; aggravated insomnia. Horizontally oval 
discs, gray; many yellow dots in the macula; 
urine normal. 
O. D. .+ 2.25s Q + .50c axis i5f$. O. S. + 
2.50s 3 + .60c axis 165 f$. Great relief, as 
far as the headaches were concerned, followed 
the use of this correction. The insomnia also 
was markedly relieved, but this has fluctuated 42 
very much according to the man’s general condi- 
tion and the absence or presence of gouty symp- 
toms. 
Case 8. Right-sided Headache; Excessively 
Nervous.—E. F., a woman aged 34; has casts and 
albumin in the urine; severe right-sided head- 
ache with pain in the eyes, the use of which 
caused great nervousness; weeps readily; is de- 
pressed; globus not present. 
O. D. + 3-s 3 + -25c axis 165 f$. O. S 
+ 3.25s 0 plus .50c axis 15 f-jj-. There was 
entire relief of the headache, and with its relief 
the nervousness was materially calmed. The 
patient was under treatment, also, for the 
coexisting Bright’s disease, and it was difficult, 
owing to its presence, to determine which head- 
aches belonged to eye-strain and which to the 
kidney disease, and also which one of these two 
factors was to blame for the excessive nervousness 
which amounted in its 'sum to manifestations 
closely resembling hysteria. 
Case 9. Constant Morning Headache; Hypo- 
chondriasis.—W. E. H , a man aged 42; organs 
sound, but very nervous and despondent; thinks 
he has brain tumor and various other organic le- 
sions; has had much mental worry; troublesome 
morning headache. Horizontally oval discs, 
rather gray. No change in the fields *of vision. 
O. D. + .75s 0 + .50c axis 30 f£. O. S. + 
.50s 0 + .60c axis 165 f$. There was grad- 
ual but decided relief of all symptoms ; this, 
however, became complete only when a tonic reg- 43 
imen, systematic exercise, and massage were add- 
ed. The improved ability in reading and the dis- 
appearance of the morning headache were decided 
factors in relieving the mental depression. 
Case io. Occipital Headache; Vertigo.—D. M. 
J., a woman aged 44 ; general health poor ; has 
chronic cystitis ; has general vertex and occipital 
headache with a bruised feeling in the eyeballs; 
very distressing vertigo, especially when walking 
on the street. Slightly pallid discs with mellow 
edges, and fine, dust-like opacities in the anterior 
cortices. 
O.'D. + .90c axis 15 O.S. 4- .60c axis 
165 f$. These glasses afforded almost entire re- 
lief to the head symptoms with the exception of 
the vertex pain which persisted. The vertigo 
also disappeared. This is a good example of the 
fact that patients often suffer with two kinds of 
headache, the vertex headache being in this case 
almost certainly associated with pelvic disorders. 
Case 11. Headache; Nervous Prostration ; 
Vertigo with Nausea.—J. P., a woman aged 45; 
has had several attacks of nervous prostration ; 
eye work causes nausea; general nervousness ; 
this is apparent, especially when the eyes are 
used at distances midway between those which 
come into play in reading or close work, and at 
twenty feet or beyond. The fundus is normal. 
O. D. + .50s Q + 1.50c axis 15 O. S. + 
1.50s O + .50c axis H f$. The glasses in this 
case, which was seen in consultation, have af- 
forded partial relief; certainly since their use the 44 
patient is said to be in a more satisfactory condi- 
tion, and thus has reported herself, but is not 
entirely free from the symptoms above detailed. 
There appears to be no organic disease. 
Case 12. Vertigo.—C. E., a woman aged 45; 
general health good; menopause not yet begun ; 
recent severe and constant vertigo. Oval discs 
with broad scleral rings. 
O.D. + .37c axis H f-$. O.S. + .50s 3 + 
.25c axis 60 |$. The relief of the vertigo began 
with the use of the mydriatic, but the patient is 
also under general treatment. 
Case ij. General Headache; Nausea; •Mus- 
cular Twitchings.—S. C., a woman aged 29 ; 
complete nervous breakdown ; muscular twitch- 
ings ; insomnia ; constant severe headache be- 
ginning as frontal and becoming general; eye- 
work causes nausea, increased headache, ex- 
cessive nervousness and insomnia; organs sound. 
The fundus is normal except for some retinal 
haze. 
O. D. + i.s 3 + .75c axis 15 O. S. + 
.50s C + i.c axis 165 f$. Relief began with 
the mydriatic, and up to the present time the pa- 
tient is better. She, however, at the same time 
is having massage. The case is still under ob- 
servation, and the date too soon to state posi- 
tively the ultimate result. 
Case 14.. Sensation of Falling Forward when 
Walking in a Crowd; Confusion of Ideas.—M. 
P. F., a man aged 35 ; up to two years ago in 
good health; then an attack resembling epi- 45 
lepsy, but probably not epileptic ; since then has 
had frequent attacks of mental confusion with a 
sense of falling forward, especially if walking on 
a crowded street; no general disease discovered. 
The fundus is perfectly normal, except a few 
yellow dots near maculas. 
O. D. + i.s 3 + .50c axis H O. S. + i.s 
3 + 50c axis H There has been only one 
attack since the patient was glassed. He is still 
under observation, which has extended over 
many weeks. He has taken no general medi- 
cation. 
Case 15. Severe Headache; Neurasthenia; 
Globus Hystericus.—S. J3., a woman aged 35 ; 
very gouty ancestry ; vertex and occipital head- 
ache marked neurasthenia ; globus hystericus- 
at times; keeps eyes closed. Fundus normal 
except for slight retinal haze. 
O. D. + .50c axis 15 O. S. + .50c axis 
165 f$. All symptoms better, but also under 
general treatment. 
Case 16. Frontal and Occipital Headache; Nerv- 
ous Prostration.—C. S., a man aged 60 ; in poor 
general health ; recent complete nervous break- 
down forbidding, in large measure, any mental 
labor ; unable to read satisfactorily ; dull oc- 
cipital and sharp frontal headache ; recently had 
an injury followed by typhoid symptoms (sep- 
ticaemia?); media clear. Horizontally oval discs 
with mellow edges and deeper layers gray. 
O. D. + .50s 3 + .25c axis 15 O. S. + 
.75s 3 + -6oc axis 165 Distinct improve- 46 
rnent in reading power and mental effort followed 
the use of this correction. It is quite evident in 
this case, however, that the nervous prostration 
was the result of the shock occasioned by the 
injury, and the patient is now undergoing a rest 
treatment. 
Case iy. General Headache ; Excessive Nerv- 
ousness and Parcesthesia of the Face and Threat. 
—M. H., a woman aged 57 ; general health good 
and organs sound ; for some years pricking sen- 
sations in the face and throat; occasional right- 
sided neuralgia ; headache, and general nervous- 
ness, excessive after eye use. Oval, rather gray 
disc ; a few spicules in left lens. 
O. D. + 3,s 3 + i.c axis H f-j}. O. S. + 
3.50s 3 T -5oc axis 3° T7T- Relief has followed 
the treatment in this case which, however, did 
not consist alone in the prescription of glasses. 
Case 18. Trigeminal Neitralgia ; Vertigo or 
Faintness after Reading.—A. G. W., a woman 
aged 56, fourteen years ago had ptosis of the 
right side, the remains of which are still appar- 
ent ; general health now good, but complains of 
dim vision, easily tired eyes, sometimes a sub- 
jective vertigo, or perhaps more accurately, feel- 
ing of faintness, and very constant attacks of 
trigeminal neuralgia. There is much eye trouble 
in the family. The father is blind from glaucoma 
and the brothers and sisters are all hyperme- 
tropic and astigmatic to a considerable degree. 
The ophthalmoscope revealed oval optic discs 
with unduly broadened scleral rings; no cupping; 47 
the media clear ; and the retinas fairly healthy. 
O. D. + .50s 3 + .60c axis 150!$. O. S. + 
i.s O + .60c axis H. f$. These glasses re- 
lieved the faintness or vertigo, but had no influ- 
ence upon the trigeminal neuralgia, which is 
probably connected with a gouty taint that runs 
through the family. 
Case 19. Occipital Headache ; Insomnia.—L,. 
D., a man aged 49, complains of burning in his eyes 
after reading for a short time, also of brow and oc- 
cipital headache ; he has stubborn insomnia. 
He uses simple convex sphericals for reading. 
The patient for many years has had chronic diar- 
rhoea and leads a very sedentary life. The oph- 
thalmoscope reveals in each eye a pallid, oval 
optic disc, with clear edges and reasonably 
healthy retinas. 
O. D. + .50s 3 -5oc axis 165 O. S. 
-f .50s 3 + -5oc axis H f$. These glasses 
combined with a suitable presbyopic correction, 
were efficient in relieving the local inconvenience 
to his eyes and the headache, but had no influ- 
ence upon the insomnia. This was in all proba- 
bility connected with his anaemic condition which 
in its turn was secondary to the chronic diarrhoea. 
So, also, the headache was not entirely relieved, 
depending also probably largely upon constitu- 
tional causes. 
Case 20. Ocular Pain; Neurasthenia.—J. M., 
a man aged 61, has broken down from business 
strain and complains of unequal vision, sore 
eyeballs and pain in the head. In the right eye 48 
the disc is a large oval, pallid, the edges slight- 
ly mellow; in the macula are a few spots of 
choroidal degeneration; in the left eye a similar 
disc but no macular changes. Neither syphilis, 
albumin, sugar, nor demonstrable atheroma of 
the vessels was present. 
O. D. + i.s 3 4- .50c axis H f-$. O. S. 
+ i.s 3 + *50C axis H yf. These glasses 
appeared to prove satisfactory; the patient, how- 
ever, was upon a very carefully regulated course 
of treatment including a modified type of the 
rest-cure with massage, electricity, etc., and con- 
sequently the effect of the glasses, except as aids 
to vision, cannot be estimated. 
Case 21. Persistent Subjective Vertigo.—D. V. 
R., a man aged 56, who leads an active life, of 
full habit, a martyr to rheumatism, having had 
both endo- and pericarditis, and once au attack 
of peritonitis, for three months has had persist- 
ent vertigo. His present glasses, convex spher- 
icals both for distance and reading, serve him a 
good purpose, but do not control the vertigo. In 
each eye au oval, gray-red optic disc, with mel- 
lowed and veiled nasal edges, exhibiting, in short, 
the appearances of a low grade neuritis. 
O. D. + .50s Q + .75c axis 30 O. S. 
+ .50s 3 + -5oc axis H f-&. The fields are 
distintcly contracted. There is right hyperphoria 
which fluctuates between one and four degrees. 
Diplopia is denied. These glasses afforded relief 
especially* when combined with a prism base 
down before the right eye, but they did not cure 49 
the vertigo, which in this case was so evidently 
connected with circulatory disturbances. It is 
interesting, however, that they were distinctly a 
factor in such relief as the patient obtained. 
Case 22. Vertigo and Pain in the Back.—F. 
P. C., a man aged 47, is compelled to use his 
eyes a great deal and complains of dizziness and 
pain in the back; his personal history is good; 
his digestion rather poor; he has had two severe 
illnesses in his previous life, once typhoid fever 
and once varioloid. Each optic disc was a ver- 
tical oval and contained a large physiological 
cup. There was some broadening of the scleral 
ring and slight retinal haze; in each macula fine 
yellowish dots; the urine, however, was normal. 
O. D. + .60c axis 165 O. S. + .60c 
axis H Glasses may fairly be credited with 
having relieved the dizziness. 
Case 23. Headache; General Neurasthenia.— 
D. W. M., a woman aged 60, of great activity, 
after prolonged mental strain broke down and 
presented a series of neurasthenic symptoms, as- 
sociated with severe pain in the back of the head, 
rather of the character of soreness than anything 
else, and a feeling described as a “sinking away of 
the nerves. ’ ’ Both optic discs decided ly gray; oth- 
erwise no changes. 
O. D. + 1.75s O + .75c axis 15 f$. O. S. 
+ 1.75s O + .50c axis 165 f$. This and a 
suitable presbyopic correction, a month after its 
use caused the patient to report herself as doing 
well. It should be stated, however, that she was 50 
under careful general treatment and had under- 
gone a prolonged rest-cure, and that any mental 
work was forbidden, for, if it was undertaken, it 
was likely to produce a relapse. 
Case 2j_. Fronto- occipital Headache; a Tenden- 
cy to Fall Forward in Walking—A. J. Q., a woman 
aged 44, is in good health with the excep- 
tion of an acid dyspepsia and a great deal of 
general nervousness, probably induced by much 
sorrow in her family ; cannot read or thread the 
needle, and has a good deal of fronto-occipital 
headache; the most aggravated feeling is that of 
falling forward when walking, probably a species 
of vertigo. In each eye an irregularly oval disc 
with a partially absorbed choroid ring. In the 
right eye some slight macular changes. 
O. D. + O 3-s + -25c axis H f$. O. S. + 
3.50s + .50c axis H f$. Her symptoms began 
to improve from the time the mydriatic was em- 
ployed. 
Of the twenty-four cases just detailed vertigo 
was a prominent symptom in eight of them, which 
either was relieved or cured in six by the use of 
the glasses, but unaffected in two Ocular ver- 
tigo, usually subjective, is a common and con- 
stant symptom in errors of refraction, so much 
so that the investigation of a case is quite incom- 
plete without a study of the eyes. It does not 
seem likely that it is any more common in cases 
of astigmatism against the rule than in those 
where the refraction error is according to the rule. 
In an analysis of one hundred cases of ordinary 51 
far-sighted astigmatism, I think it is not very 
unlikely that eight of them, at the very least, 
would complain among other symptoms, of at- 
tacks of vertigo. Cases 14 and 24, in which there 
was a confusion of ideas and the sensation of fall- 
ing forward, especially when walking in a crowd, 
might also be classed among the vertigos. In these 
cases the refraction error appears really to have 
been the exciting cause of the symptoms. I have 
seen two precisely analogous cases alleviated by 
the correction of a refraction error, the one of an 
ordinary myopic astigmatism of low grade, the 
other of a simple hypermetropic astigmatism. 
The mere feeling of falling forward as a symp- 
tom of errors of refraction, in common with all 
of my colleagues, I have seen many times, but 
in the cases detailed it was associated with 
a confusion of ideas and pallor of the cheeks of 
such a grade that at the original examination 
petit mat was suspected. Three of the cases 
were associated with hypochondriasis or melan- 
cholia. In one of the melancholic cases there could 
be no possible connection traced between the error 
of focus and the mental state. In the other two 
cases the glasses appeared to be one of the factors 
which brought about relief, although both patients 
were under systematic general medication. All 
the cases of neurasthenia and general nervousness 
— it is difficult to secure another expression 
to describe their sensations — were relieved 
by the use of glasses, just as the relief of eye 
strain, the result of the more ordinary types of 52 
refraction error, will produce a like result; but 
general treatment was not lacking when indica- 
ted. In one of the cases of insomnia it was not 
possible to determine whether this was the result 
of the headache, of eye-strain or of the pain of 
gout; more probably, however, the latter. In- 
somnia, either simple in character, or the result 
of night headache, which in its turn is caused by 
eye-strain, is often indirectly relieved by the 
proper correcting lenses. In the woman who 
suffered from paraesthesia the effect of the glasses 
cannot be determined definitely because, in addi- 
tion to their use, other measures of treatment 
were employed. 
It seems from an examination of these cases 
that the associated symptoms, with perhaps sev- 
eral exceptions, were not more severe than would 
be present in a like number of cases of astigma- 
tism according to the rule. It is very far from 
the purpose of this paper to belittle in any way 
the correction of all types of errors of refraction, 
for the purpose of improving ocular health, for 
relieving headache, and for removing a possible 
factor that may depress general nutrition and be the 
starting point of a reflex neurosis. But it certainly 
seems to the writer that in the present day there 
is a tendency to ascribe too much effect to the 
correction of refraction errors, and that because 
these ‘exist the search for other causes of the as- 
sociated symptoms at times becomes defective. 
When astigmatism against the rule exists, as Dr. 
Theobald has said, “We are warranted in correct- 53 
ing fully every particle of the defect which we 
can render manifest,” and which should thus be 
rendered by the judicious use of an active my- 
driatic. Perhaps in no other instance do we find 
the strikingly good effects of adding very weak 
cylinders to the combination of lenses; in a num- 
ber of the instances detailed in this analysis the 
question of comfort or discomfort having been 
obtained by the finding or failing to find so low 
a degree as plus .25 D. The balance of the ocu- 
lar muscles has not been recorded in the present 
series of cases, althugh it was studied carefully 
as a matter of routine practice. The presence or 
absence of insufficiency introduces an entirely 
different element, and its exact relation to reflex 
troubles of various types at present is being 
weighed in the balance. It is almost hackneyed 
to repeat what, however, sometimes is forgotten, 
that apparent insufficiencies, especially, of low 
degree, disappear entirely after full and proper 
corrections, and with their disappearance the 
associated symptoms subside. This, as Professor 
Knapp has said, is one of the most thankful tasks 
which the practicing ophthalmologist performs. 
No where is it more necessary that this full and 
careful correction should be obtained than in ex- 
amples of astigmatism contrary to the rule asso- 
ciated with low grades of insufficiency. 
In conclusion, from these one hundred cases 
of astigmatism contrary to the rule certain facts 
may be ascertained. 54 
Age. The following table represents the num- 
ber of cases according to the age: 
First decade 2 cases. 
Second “ 9 “ 
Third “ 5 “ 
Fourth “ 14 “ 
Fifth “ 25 “ 
Sixth “ 26 “ 
Seventh" 17 “ 
Eighth “ 2 “ 
It will be seen, then, that more than half the 
cases occurred between the ages of forty and 
sixt}'. 
Sex.—The majority of the patients were wom- 
en, thirty one males, and sixty-nine females. 
The Degree of Astigmatism.—This varied from 
a 0.12 of a dioptre to 2. dioptres; the vast major- 
ity of the cases representing low grades of astig- 
matism, .50 to .90 dioptres. 
It may be concluded: 
1. That the associated symptoms in these cases 
of astigmatism were not more severe than those 
which probably would have been found in a sim- 
ilar number of examples in which the refraction 
error was according to the rule. 
2. That useful results follow the correction of 
the least degrees of measurable astigmatism—re- 
sults which are not obtained when this correc- 
tion is neglected, and that the mere presence of 
so-called normal central vision according to the 
ordinary best standards, does not preclude the 
possibility of low degrees of astigmatism being 55 
present, which should be sought out and correct- 
ed. 
3. That ocular health is conserved by such 
careful and thorough measurements of astigma- 
tism, and hence indirectly general or so-called re- 
flex disturbances are alleviated, but that these 
latter should never be ascribed solely to the astig- 
matism simply because this is present, when they 
may be the evident pointings of Nature for relief 
to be obtained by measures directed towards a 
constitutional vice,or an insufficient nervous tone. 
4. That the importance of low degrees of in- 
sufficiencies of the ocular muscles should not be 
estimated until the effect upon them of complete 
correction of the astigmatism has been obtained. 
5. That while no doubt in careful hands ex- 
cellent results may be obtained by ophthalmome- 
try and skiaskopy without mydriasis, the pa- 
tient does not obtain the very benefit which is 
often most essential by the use of the mydriatic, 
namely, its local sedative influence and the com- 
plete rest which a thorough paralysis of the cil- 
iary muscle entails. The most perfect correction 
placed upon an eye the subject of symptomatic 
retino-choroidal disturbance,fails to fulfil its func- 
tion until the former has been subdued, and in 
its subjection prolonged mydriasis plays an essen- 
tial part. 
DISCUSSION. 
Dr. S. M. Burnett, Washington, thought 
that astigmatism contrary to the rule was more 
productive of painful eye symptoms than when it 56 
was according to the rule. He had never been 
able to find a satisfactory explanation of this, 
but he has found that 0.5 D of astigmatism con- 
trary to the rule will generally cause more trou- 
ble than i.D of astigmatism according to the rule. 
Dr. Savage explained his theories of asthen- 
opia in astigmatism in which the meridians devi- 
ate from the vertical or horizontal position. This 
is especially the case if there is asymmetry be- 
tween the meridians of the two eyes. He illus- 
trated how this asthenopia is produced by the 
oblique muscles rotating the eye on their antero- 
posterior axis in their endeavor to make an ob- 
lique meridian correspond to a vertical or hori 
zontal one. 
Dr. Jackson said he had observed no further 
trouble from astigmatism against the rule than 
with the rule.