"Prisma-therapy" tested on 160 patients suffering from a syndrome of Ménière
by G.P. UTERMÖHLEN
[Translated from the Netherlander]
FIG.1 Photocopy of the title of the article in Review N.T.V.G. on Saturday January 11, 1947
The title is in the same font, the same size, same alignment as all the texts of the review, only appears in the margin the mention: "Utermöhlen,De prismatherapie"
The review was found in the basements of the Faculty of Medicine of Maastricht, thanks to Doctor R. PIGASSOU-ALBOUY and the co-operation of Maria sister.
[UTERMÖHLEN G.P. De prismatherapie getoest aan 160 lijders aan het syndroom van Ménière. Nerder. Tijdscher. v. Geneesk., 91, 124-126, 1947.]
Since the first publication in the N.T.V.G. in 1941, the number of patients suffering from Ménière disease to which this therapy, practised by the author, was proposed increased by 23, in more of the 160, currently are we to 196. The patients are originating from various areas of the country and, for a great part, entrusted to this treatment on the councils of interested fellow-members.
It is desirable to speak about "prisma-dioptres" according to its relationship to the off-centring, thus one does not need to worry about the kind of glasses.
We will try to answer the question: how will one arrive, without wasting time and with the simplest means, to a result? Those which do not have the means, the assistance and the division of work that a private clinic can offer, can arrive there? Where one cannot arrive at a sure diagnosis, it is essential to refer to a private clinic that has the experiment. It happens that one confuses causes and effects. One regards the patient with symptoms of Ménière sickness as a nervous, but while looking closely one realizes that it is a Ménière disease which, by fear to have again an attack, and by its continual or intermittent feeling of insecurity, in the street and at the house, became nervous. One often regards him as a simulator or a sursimulator, because he is "finally" in good health. But he does not support the radio or strong noises, the cries of children; then he fears to lose his work. He lost his confidence in the future. It is desirable to maintain the name of Ménière, with the requirement by adding to it, like an explanation, "labyrinthian neurovegetative dystony". The prism effect has results only when it acts on horizontal nystagmus, or that this one is to be waked up, sometimes combined with rotatory nystagmuses. When nystagmus observed in a usual way is not seen any more, it seems, since the patient is able to see the back and forth pass of a fixed point, that there exists despite everything a minimal nystagmus.
The anamnesis must be examined in a wide way. One learns thus from the special complaints more than the stereotyped complaints, like visual hallucinations, to see flames, difficulties of opening the eyes which occur in night attacks during which the patient must raise the higher eyelid (Oblongata centrum; cilio-spinal; nape of the neck sympaticus, musculus tarsalis [NoT:????]), allergic symptoms, attacks of asthma occur after having sneezed, blowing ones nose strongly (too strongly), to have used a hot or cold shower on the head, not to support the sunlight or of the solar rays falling directly on the head. All these symptoms accompany the factor nystagmic.
The examination starts with the examination of the eyes: vision, refraction, fundus oculi, eventually heterophoria for determination of the power of the prism (more in case of esophoria, less in case of exophoria). If there is or not a heterophoria does not have any importance for the determination of the position of the prism: the base of the prism must always be nasal; when this position is reversed, i.e. when one puts the prism in temporal base, then the symptoms worsen instead of disappearing or to be improved.
The auditive examination is done in the ordinary way. The bad ear seems to have a tonic effect on the eye on the same side.
One needs researching the Rombergs sign, possibly with a plumbline. It is necessary to seek reflexes to eliminate the possibility of a multiple sclerosis; one must also think of an acoustic neurinoma. After this clinical examination one will practise vestibular tests. One can do it in a very simple way. To awake nystagmus and other signs of Ménière, it is enough to ask the patient to turn on himself, around his vertical axis, initially on the right as the needles of a clock, then on the left. A rotation lasts from three to four seconds. One lets the subject turn from one to four times. At the end of a series of rotation, one starts a stop watch that one stops when the patient beforehand educated says: "Everything stops outside, does not move any more.". When the nystagmus induced by rotations disappears, i.e. by the sudden stop, the patient can sometimes nevertheless perceive la teral movements of his surrounding. One can have the patient turn open or closed eyes. Sometimes one is obliged to let it turn up to five times, exceptionally the reaction is even slower to be established and one obtains nystagmus and eye troubles only after the sixth turn.
And now arrives the exciting moment. On the trying-test spectacles, one places prisms of a half-dioptre, in nasal base on the two sides. After having turned on himself two, four or five times, the patient put the trying-test spectacles and note that his surrounding "does not move any more", it almost immediately stops turning. The patient can bend down without difficulties, he can also look upwards, behind, turn his eyes abruptly on the right and on the left, very astonished being able to do it, he cannot think that "that can arrive to him". If it seems that the patient is still better subjectively with prisms of one dioptre and half on the two sides, then one chooses this power. Or if he says feeling better with prisms of one dioptre on the two sides. It can happen that one places two dioptres on an eye, one dioptre on the other. If, for any reason, still occur attacks of dizzinesses, one can increase the power of the prism of a half-dioptre, to stop the attack. It is necessary to try to discover the cause by the data communicated under the heading: factors nystagmophores [NoT. Sorry for this passage, which we do not understand].
It is completely astonishing to note that when the patient carries these prismatic glasses, its over-sensitiveness with the noises disappears, to reappear when it removes his glasses.
When one asks the patient to walk for and from, open eyes and with these glasses, he returns exactly to the starting point, while it deviates definitely on the right or on the left, when he does not have these glasses.
After measuring the interpupillary distance, one prescribes glasses. For emmetrop subjects, one prescribes only prismatic glasses. For hypermetrop, short-sighted or astigmates ones, one obtains the prismatic effect by an off-centring, outside or inside according to the formula, which each optician knows. With trying-test spectacles carrying glasses adapted to the vision of the subject, the optician decentres immediately, as much as it must, according to the known formula, to obtain for example an effect of half or one prismatic dioptre. For hypermetrop patients, the corrective lenses must be eccentric by bringing them closer, for the short-sighted ones by drawing them aside. One can, in this way of off-centring, arrive empirically to one third of dioptre for the two eyes, but this has only a theoretical interest.
The number of men and women who were treated is about similar. The age of beginning of the disease is generally between 40 et50 years. Among some patients the complaints had existed for several years: one to two years for the majority, four or five years is not rare, twelve, fourteen, eighteen and even twenty and one years, it arrived once. There was a few years ago an investigation into the follow-up of the treatment for almost the first 50 patients treated by the prisms, it showed that the results remained good. For the patient treated later on (during the last years of the war and especially after the liberation, because improving of transport) the result remained good. Some, especially women, had still some attacks, but they did not like to put away their glasses. They probably went to work too quickly. They are exceptions.
It is rational to prefer an optical treatment instead of an operation.
Convergence is relieved by the continual port of the prisms in base nasal, which is an important factor anti-nystagmique, able to fight against the symptoms of Ménière disease. But nystagmus must be horizontal, or at least to have a horizontal component in the rotatory cases of nystagmus.
If the vision of an eye is practically null whereas the other eye is completely or relatively functional the prismatic effect is always still of a great value, on the basis of simultaneity and of similar intensity semblable stimulating convergence [NoT : Sorry ! but we dont understand this sentence].
The power of the prisms varies between a half and one and half dioptre. They are glasses that one does not find in the trying boxes of glasses, because one thought being able to neglect these powers, not very significant. It was by chance that I have under the hand a half-dioptre prism for my first patient, this prism placed in a special manner had this marvellous effect. It was to solve her problems of convergence that I tested the prism in nasal base. When I put the prism in temporal base, to see, then the symptoms of the patient worsened. And since I always observed the same thing in the other cases. I have no other explanation than that I have given in the N.T.V.G. of 1941.
Mr. KOSTELYK requires: "Can a faulty position of the corrective lenses, inducing a prismatic effect, cause a vertigo at a person in good health? One of my colleagues had twice vertigo that he thought due to prismatic effect due to a faulty position of his corrective lenses.