A Clinical Study in the Diagnosis and 
Treatment of Hyperphoria, 
With a Report of Four Cases. 
BY 
HOWARD F. HANSELL, M.D., 
CHIEF OPHTHALMIC CLINIC, JEFFERSON MEDICAL COLLEGE HOSPITAL, PHILA. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
April, 1891. Extracted from 
The American Journal of the Medical Sciences for April, 1891. 
A CLINICAL STUDY IN THE DIAGNOSIS AND TREATMENT 
OF HYPERPHORIA, 
WITH A REPORT OF FOUR CASES. 
By Howard F. Hansell, M.D., 
CHIEF OPHTHALMIC CLINIC, JEFFERSON MEDICAL COLLEGE HOSPITAL, PHILA. 
In this paper I shall discuss one of the propositions enunciated by 
Dr. G. T. Stevens, of New York-namely, that hyperphoria is respon- 
sible for ocular and muscular anomalies, together with other abnormal 
conditions of the nervous system less particularly defined, and shall 
attempt to show practically, in the history of a few cases, the value of 
this proposition. 
Hyperphoria is properly defined as " that condition of the ocular 
muscles in which, with a minimum of tension, a deviation of one visual 
line above the other would result." In other words, it is a tendency to 
upward deviation of the visual axis of one eye when both are supposed 
to be fixed in a small luminous object, such as a candle-flame, at 20' 
distance. The eyes are said to be at rest, or in equilibrium, when, 
without accommodation, the visual axes meet in a small object at 
the distance of 20'. They are not, it will be remembered, mathematically 
parallel, but the small angle at their point of fusion may be disre- 
garded. 
In hyperphoria there is a derangement of this parallelism by a clonic 
deviation upward of one of the axes (hypertropia), or by a tonic ten- 
dency to destroy vertical equilibrium (hyperphoria). This involves 
necessarily a lateral deviation-esophoria or exophoria, either or both 
(Eso., far ; Exo., near). Since vertical fixation is unattainable, no in- 
centive exists for equilibrium of the lateral muscles, and in fact it is not 
found, except as an accidental and transient manifestation. 
To determine the presence of hyperphoria, a special apparatus is 
necessary. Lateral insufficiency may be detected by the Von Graefe 
test-inducing diplopia by means of a prism of 6° base down or up. 
On account of the weakness of the prism, a slight malposition or an ap- 
proximation to the vertical position would not seriously affect the result. 
In dealing with the vertical muscles, however, it is necessary to use a 
prism of 10° or over, when a slight malposition of the prisms from 
carelessness of the physician or want of symmetry of the patient's head 2 
HANSELL, TREATMENT OF HYPERPHORIA. 
will vitiate the result. Such an apparatus is Stevens's Phorometer (for 
description see Arch. Ophth., June, 1887). A recent improvement, the 
substitution for the double horizontal prism of a pair of rotating prisms, 
greatly facilitates the examination. It is independent of, and its read- 
ings are not vitiated by, moderate movements of the patient's head ; 
it reveals the diagnosis instantly, and records the degree of deviation 
(under 6°). 
In testing for hyperphoria, several examinations are demanded. The 
diagnosis cannot be made, in kind or degree, at one sitting, as the strength 
of the muscles varies from day to day, owing to temporary and modify- 
ing conditions, which may be general or local. Again, if spectacles are 
worn by the patient they must be accurately centred, or the results will 
be modified and the true diagnosis remain undiscovered. It has been 
my practice in cases of ametropia to make the distant tests without cor- 
recting lenses, unless the defect of vision is too great to allow of accurate 
observation, believing that hyperphoria is practically uninfluenced by 
the condition of refraction, and that greater danger of incorrect diag- 
nosis lies in lenses which are not accurately centred than in ametropia. 
Presbyopic correction, when worn, should be made for all near tests. 
The symptoms of hyperphoria cannot be distinguished from the 
symptoms which belong to other muscular or accommodative strain, 
and while it is both interesting and instructive to note the presence oi* 
absence of the nervous phenomena which are attributed to this affection, 
no reliable or logical conclusions can be deduced from their enumeration 
which shall aid in the determination of the cause. They are partly 
local, largely reflex; the former including diplopia, pain, smarting, 
burning, etc.; the latter neuralgia, headache, chorea, insanity, epilepsy, 
palpitation, constipation, etc. My own experience in the treatment of 
the grave functional disorders of the nervous system, by means of the 
measures advocated by Stevens and seconded by others, does not permit 
me to form an intelligent opinion as to their efficacy. Such patients do 
not ordinarily consult the ophthalmic surgeon, but the neurologist; and 
although I have frequently examined epileptics and choreics for some 
evidence of ocular disturbance, it has thus far been my fortune never to 
have met with a case in which I could conscientiously advise prisms, or 
tenotomies, as the sole means of relief. On the other hand, the cases of 
hyperphoria which have been under my treatment have presented no 
symptoms of insanity, epilepsy, or chorea. They have complained, for 
the most part, of confusing the letters in reading, pain in the eyes, head- 
ache, photophobia, exhaustion following an evening at the theatre or a 
day's shopping, and of the other well-known complications of accom- 
modative strain. They have been, with singular unanimity, free from 
mental or intestinal symptoms. From their own unaided description of 
their sufferings an accurate diagnosis could not be made, and this is true HANSELL, TREATMENT OF HYPERPHORIA. 
3 
whether an error of refraction were associated with hyperphoria or 
whether it were hyperphoria in emmetropia. 
Diplopia may or may not be present. It should be sought for by every 
known test, since its discovery is an important item in the diagnosis and 
treatment.1 When diplopia exists, the diagnosis may be made by the 
relation of the two images to each other; when absent, the diagnosis 
cannot be made without a phorometer. 
Do errors of refraction bear a causative relation to hyperphoria? 
That they do has not as yet been proved, and the assumption of such 
relation is therefore only speculative. The third nerve supplies the 
superior, inferior, and internal recti, inferior oblique, ciliary muscle, and 
iris. There can be no accommodation without convergence. How can 
there be convergence without simultaneous stimulation of all other 
muscles innervated by the same nerve ? The relation of accommodation 
to convergence is not disputed; the same relation must hold with the 
superior and inferior muscles. It must be remembered that these mus- 
cles average only one-fifteenth part of the strength of the internal, and 
yet, however slight, comparatively, their contraction may be, it must be 
considered. Convergence and divergence are the result of the action of 
two different nerves; upward and downward deviation, of one only: 
hence hyperphoria, which is a want of coordination between two sets of 
muscles receiving their nerve force from a common source, must owe its 
origin to others than those that operate in the development of eso- or 
exophoria. Speaking generally, internal squint is associated with and 
dependent upon hypermetropia; external squint, with and upon myopia. 
To neither of these errors of refraction can hyperphoria be attributed. 
That it is present in individuals who have H., M., and As., is no evidence 
that it arises from those conditions. Stevens's table (loc. cit.) quotes 100 
cases of hyperphoria (200 eyes) among 45 Em., 42 M., 73 H., and 40 
As., but proves nothing. The same figures may be equally well or badly 
used to demonstrate any other ocular or bodily ailment. Tables adduced 
in evidence that heterophoria and errors of refraction are the causes of 
functional nervous diseases-insanity, epilepsy, chorea-because ma- 
niacs, epileptics, and choreics have some refractive or muscular anomaly, 
are equally misleading. Perfect muscular equilibrium is as rare as Em.,2 
and to assert that the absence of it is the cause of nervous disturbances 
" more than any other," is quite as unreasonable as to say it is the cause 
of consumption or of smallpox. 
Again, hyperphoria is found in every variety of misshapen eye, not 
1 Foran elaboration of this part of the subject, see Stevens's article on Hyperphoria, 
in Arch. Ophth., June, 1887. 
2 " The Relation of Errors of Refraction and Insufficiency of the Ocular Muscles to 
Functional Diseases of the Nervous System," by D. B. St. John Roosa, N. Y. Med. Rec., 
April IV, 1890. 4 
HANSELL, TREATMENT OF HYPERPHORIA. 
exclusively in one. Finally, it is relatively as frequent in einmetropia 
as in ametropia. 
On the other hand it is evident, whatever may be the cause of hyper- 
phoria, that it is a factor in the causation of functional nervous affec- 
tions in some individuals,1 and that its importance in certain cases has 
not been overestimated. It is admitted that headache, dizziness, and 
vertigo in neurotic patients are induced by strain of the accommoda- 
tion, and it is no argument to the contrary to say that because all 
patients with refractive errors are not subject to these affections that 
none are. But it is equally unjust to attribute the symptoms entirely 
to the ocular condition. There must be a constitutional dyscrasia, an 
exhaustion of the nervous system, a " nervous prostration," a neurotic 
tendency-a subnormal nervous power and force, whatever name be 
given to it. This is the underlying, predisposing cause. Accommoda- 
tive asthenopia and neurotic tendency are responsible for the nervous 
manifestation. This is no theory. It is daily proved in practice. Many 
published and unpublished cases are in evidence to prove that refrac- 
tive errors have been the disturbing cause in certain abnormal mani- 
festations of the nervous system which resisted all treatment until 
ametropia was suspected and relieved. And if reflex symptoms are 
caused by prolonged, irregular, or excessive contraction of the ciliary 
muscle, and of the internal and external recti, may they not also be 
caused by the superior and inferior recti under similar conditions- 
assuming, in the latter case as in the former, the existence, either in- 
herited or acquired, of a neurotic tendency or disposition upon which 
the superstructure of a specific or definite nervous disease may arise ? 
Muscular asthenopia is as familiar as accommodative. Thirty years 
ago, Von Graefe formulated laws for its diagnosis and treatment which 
guide us to-day, and while the terms employed by him-" insufficiency of 
the interni," " insufficiency of the externi "-have been replaced by 
shorter and more accurate designations, nothing really new has been 
added to our knowledge. This cannot be truly said of the relation of 
the vertical muscles with each other and with the lateral muscles. 
Stevens has contributed to the science of ophthalmology the valuable 
results of his studies and investigations; and if their importance and 
application have a narrower range than he claims for them, experienced 
and fair-minded men will not be slow, on that account, to accord him 
due credit for his contributions to this branch of scientific medicine. 
The first two cases recorded below are not illustrations of hyperpho- 
ria, and perhaps should be excluded from the paper, but as their his- 
tories and symptoms are identical with typical cases of hyperphoria as 
1 " May Ocular Insufficiency Produce Nervous Manifestations ?" By Allen M. Starr, 
N. Y. Med. Rec., January 4, 1890. HANSELL, TREATMENT OF HYPERPHORIA. 
5 
described by Stevens, and yet showed vertical muscular equilibrium, 
their recital is, I think, consistent and profitable. 
Case I.-Miss N., aged twenty-five, complained of constant headache, 
which was aggravated by the near use of the eyes. She was obliged to 
give up her work, the making of artificial teeth, on account of her great 
distress. She had no constitutional ailment, and but for her headache, 
which she believed to be ocular, would have been entirely well. Under 
a mydriatic (dubosia) her refraction was: R. 4- 0.75c. ax. 90° = ~. 
L. + 0.75c. ax. 90°. 20 
This correction was ordered for constant use. After several weeks 
there was no relief from headache, nor increase of ability to work. In 
examination for muscular anomalies, " insuf. of int. rect." = 6° far, 12° 
near, was found. Prism 3° base in O. U. gave temporary relief. Later, 
partial tenotomy of ext. recti. Immediately afterward: Esoph. far = 
4°; Exoph. near = 4°. In a few days: Exoph. far = 1°, near = 10°. 
No relief followed the tenotomy. The muscles varied in strength almost 
daily. Add. = 10-20°, abd. = 10-12° ; circum. 3-8°. 
After the tenotomy failed, I tested Miss N. anew with Stevens's im- 
proved phorometer, confidently expecting to find hyperphoria. In this 
expectation I was disappointed, for though the examinations were made 
for several consecutive days, each test showed equilibrium of the vertical 
muscles. 
My treatment by cylinders, prisms, and tenotomy was a marked 
failure. 
Case II.-Mr. C., aged forty-six, complained for many years of pain 
in the eyes, and of headache, which ensued in a very few minutes after 
every attempt to read or write. During these years he had consulted a 
number of the most distinguished ophthalmic surgeons in America and 
Europe, and had used lenses of various kinds, and kept his accommo- 
dation paralyzed by dubosia for three months without obtaining relief. 
I ordered an accurate correction of his refraction (R.-25 Q + 0.75c. 
ax. 45° ; L.-25Q + 0.50c. ax. 135°), and combined these cylinders with 
a presbyopic glass. 
Both pairs improved his vision, but did not lengthen the time he 
could read without suffering. Subsequent examinations with phorome- 
ter showed : Orthophoria far; Exoph. near = 10° ; abd. = 5°, add. -8°. 
Prism 3° base in O. U. were of no service. 
Mr. C.'s headache and ocular pain were not benefited. 
Case III.-Mrs. L., aged twenty-five, a strong, healthy, phlegmatic 
woman, with no nervous tendencies, complained of twitching of right 
lid and pain over right eye, after long-continued reading. She had no 
diplopia, headache, blurring, or photophobia, and finally, no insanity, 
20 
chorea, or epilepsy. (Dubosia) R. -f- 0.5 Q + 0.1c. ax. 90° = L. 
99 
0.75Q 0.5c. ax. 90° =-. R. Hyperphoria = 1-3°. Exoph. 
far = 12°, near = 27° ; abd. = 12°, add. = 20°. 
Unless diplopia was developed by alternately covering and uncover- 
ing one eye, Mrs. L. never noticed it; whether it was constant or not 
would be difficult to determine. 6 
HANSELL, TREATMENT OF HYPERPHORIA. 
The above lenses removed the slight asthenopia, and completely cured 
all symptoms. No other treatment. 
Case IV.-Miss J., of Bloomsbury, Pa., aged nineteen, delicate in 
appearance, nervous and quick in action ; complained of severe asthe- 
nopia, neuralgic headache, blepharospasm, and inability to read more 
than five minutes without either causing these symptoms, or greatly 
exaggerating them. No diplopia. (Dubosia) R. -j- 0.25c. ax. 90° = 
-. L. + 0.25 O 0.25c. ax. 90° = -. 
XX XX 
Double images were induced and maintained by the above described 
simple method after a few trials. B. Hyperphoria - 3s ° ; exoph., far 
and near, in great and varying degree. After a confirmation of this 
diagnosis, tenotomy of R. sup. rectus was performed. The entire 
tendon was divided, as no appreciable modification of the hyperphoria fol- 
lowed partial division. None of the neighboring attachments was 
severed. The immediate result was: L. Hyperphoria - 4°. Result in 
nine weeks-orthophoria far, exophoria near = 12°; in six months- 
orthophoria far, esophoria near = 8 ; add. = 30, abd. = 10. Complete 
relief of all asthenopic symptoms, and a decided subsidence of the 
severe nervous conditions, followed within a few days after operation. 
She enjoyed absolute freedom from pain, and the power of prolonged 
use of her eyes in near vision was reestablished. The hyperphoria 
was removed, and the exophoria, which before the tenotomy was very 
high, became esophoria. I advised no further treatment, believing that 
with the lapse of a longer period of time lateral muscular equilibrium 
would be established. The slight refractive error was not corrected. 
In this case the hyperphoria was the dominant element of disturbance, 
and complete success followed its removal. 
Case V.-Miss H., aged eighteen, Wilmington, Del., a stout, fully 
developed, and fine-looking girl, but with evidences of a lack of mus- 
cular tonicity and of anaemia; ears and lips pale, localized anaesthesia of 
the skin. She complained of constant headache, increased by the slight- 
est use of the eyes at the near point, occasional double vision, and 
general nervous exhaustion. The diplopia was a prominent but not 
constant symptom, and included both near and distant objects. It was 
easily induced without prisms and persisted sufficiently long to permit a 
thorough examination. 
This case is typical. First: on account of the absence almost of 
converging power without divergence. This was shown by the varying 
position of the false image and the changing relation of the false and 
true images. After having induced diplopia, without prisms, in testing 
with candle at 20', the image seen by the L. eye was lower (L. hyper- 
phoria) and to L. side (homonymous); at 18' it began to wander to the 
right, was lower, but did not fuse with, or at any time remain stationary 
under the other ; inside of 18' it was crossed and lower. The degree of 
deviation increased inversely as the distance. Throughout all the tests 
the image seen by the L. eye was always lower than that seen by the 
R.; i. e., L. hyperphoria = 2-3° persisted as a constant condition ; 
Esoph. far = 2° ; Exoph. near = 15°. 
Second : Stevens calls attention to the amblyopia which is frequently 
present in one or both eyes in hyperphoria. In Miss H.'s case V. on 
^0 
first examination was - ; no lesion of media or fundus. (Dubosia) R. 
XL HANSELL, TREATMENT OF HYPERPHORIA. 
7 
+ 0.75c. ax. 90° =_?L. L. + 0.75c. ax. 90° = 1°. With this cor- 
XXX XL 
rection, and during paralysis of accommodation, vision equalled only 
two-thirds of the normal in the R., which was considered by me as the 
better or fixing eye. 
After consultation with Dr. William Thomson, Miss H. was taken 
from school, ordered tonic remedies, nourishing diet, and exercise in the 
open air. After one month's treatment, the only improvement was in 
20 20 
V., R. , L. , probably brought about by wearing the astig- 
XXX XXX 
matic correction. The faulty action of the muscles was unchanged. 
With Dr. Thomson's approval, and with his assistance, I divided the 
tendon of the L. sup. rect. in the middle, leaving the edges intact, being 
guided in the extent of the cutting by the phorometer. After several 
interruptions for testing the effect, orthophoria for distance was obtained. 
The vertical displacement was entirely corrected. The lateral disap- 
peared, and Exoph. near = 3°. 29^/t (three days later), she " has had no 
double vision ; I cannot induce diplopia ivithout a prism." Exoph. far = 
. • 20 
2, near = 4; no vertical deviation. 3d: V. = Orthophoria far ; 
XX 
Exoph. near = 3°; add. = 20°, abd. = 8°; circum. =3°. 12th : Oc- 
casional double V. L. Hyperphoria = 1°. In induced vertical diplopia 
L. light (eye) wanders to R. and L., as before, according to distance; 
abd. = 7°, add. = 32°. Ordered prism 1° base up L. 24fA; Double 
V. on lying down. Complained of malaise ; fainted a few days ago, 
no headache unless she reads, and then it comes on in a very few min- 
utes. Esoph. far = 3°; Exoph. near = 4°. L. Hyperphoria = 1°. 
2d: R. inf. rect. divided partially. Immediately afterward : R. Hyper- 
phoria = 1°. 3d: Orthophoria. 12th: Double V. when recumbent. 
R. Hyperphoria = |° ; no lateral deviation; add. = 20°, abd. = 10°; 
circum.= 3°. Asthenopia has disappeared. " Read one hour by artifi- 
cial light without discomfort." This satisfactory condition has remained 
unchanged, but it was found at the last examination, made three months 
after the tenotomy, that Miss H. had diplopia in every direction, at the 
extreme limits of the common field of V. This cannot be ascribed to a 
want of equilibrium of any one set of muscles, but rather to deficiency 
of power of all the muscles. 
The final result is doubtful. The benefit from the operative 
procedures was relief from annoying double V., and ability to read a 
desirable length of time with comfort. 
Case VI.-Mrs. H., aged forty-seven, sent to me by Dr. R. R. Bunt- 
ing, Roxborough, Philadelphia. For many years she had suffered head- 
ache severe enough to require a day's rest in bed, after using the eyes 
for reading or sewing only a short time, and after physical exertion. 
It always followed a day's shopping, an evening at theatre, a long walk, 
or any unusual excitement. Her nervous system was exhausted. She 
had so-called nervous prostration, and had almost resigned herself to 
invalidism. I examined her in December, 1884, for reiractive error. 
She was wearing R. 1.25c. ax. 180°, L. -■ Is, for near use, 
which helped but did not relieve her asthenopia. 1 found, under 
dubosia: R. + 2c. ax. 175°=-°. L. + 0.25 Q 0.25c. ax. 180° = 
XX XX 8 
HANSELL, TREATMENT OF HYPERPHORIA. 
and ordered it for constant use. Eighteen months later -J- 0.5s. was 
added for presbyopia. With these two pairs of glasses Mrs. H. was 
enabled to use her eyes better than with the first pair, yet they were 
unsatisfactory. Her V. was improved, hut she could not wear the glasses 
constantly. The dizziness and headache were no better. Mrs. H. con- 
tinued to suffer until March, 1890, when she consulted me again, at my 
request, to determine the presence or absence of any muscular anomaly 
by means of the phorometer, which I had not used in previous exam- 
inations. I found the above refraction slightly modified: R. -|- 2c. ax. 
90 90 
175°=-- L. 4-5c. ax. 180° - -. With, and without, this cor- 
XX XX 
rection, in repeated tests, R. hyperphoria = 2° was determined. Esoph. 
far = 2° ; Exoph. near = 1° ; abd. = 6°, add. = 2°. Sup. rect. R. (and 
inf. rect. L.) overcomes 3°. Sup. rect. L. (and inf. rect. R.) overcomes 
only 1°. April 1st: Total division tendon sup. rect. R. Immediate 
result was: L. Hyperphoria = 1|°. 5th: L. Hyperphoria = 3°. 13fA; 
No hyperphoria. Exoph. far = 5° ; orthophoria near. Mrs. H. reports 
that she is certainly relieved of headache, can sew, read, shop, or exer- 
cise with no bad result. There was, six months later, no return of 
asthenopia, and general health decidedly improved. She wears distant 
glass constantly. 
This case illustrates a point which has not received sufficient atten- 
tion. Mrs. H. found it impossible to wear her astigmatic correction 
before operation ; afterward she found it equally impossible to go without 
it. The explanation is not far to seek. Before the tenotomy, with her 
refractive error corrected, images were distinctly formed on each retina, 
and it required constant contraction on the part of the R. inf. rect. to 
prevent distressing, because distinct, double V. Without the correction, 
the indistinct blurred image of the R. was suppressed, or at least was 
not disturbing. After tenotomy the visual axes were parallel, and the 
eyes required lenses that made the images of equal size and clearness, 
since they fell on corresponding points on the retina. 
The result of the tenotomy was an unqualified success, both in respect 
of its effect on the power to use the eyes without pain and upon the 
reflex symptoms. 
Method of Operating.-Stevens has suggested special instruments, 
differing principally in size from those in use in strabismus operations. 
He advises a division of the tendon, either partial or complete, according 
to the degree of hyperphoria, and to stop the section where the axes of 
V. are on one horizontal plane. My own experience, limited as it is, 
does not confirm this teaching. How can orthophoria obtained imme- 
diately after a tenotomy be retained ? Is it practicable or in accordance 
with the laws of pathology to suppose that no union of the divided 
structures will take place, and that the orthophoria will remain as a 
permanent condition ? 
The operator must determine in each case how much effect he should 
obtain, and no general law can be formulated which shall cover all HANSELL, TREATMENT OF HYPERPHORIA. 
9 
cases. In my own operations I have aimed to produce an opposite 
hyperphoria equal in degree to the original, and have succeeded fairly 
well, with one exception, which I afterward regretted, since a second 
operation became necessary. 
Is there a latent hyperphoria ? It seems impossible to determine its 
existence before operating, and our only safeguard is repeated and 
thorough examinations, allowing the muscles ample time to fall into 
that pathological position which is one of rest for them. That the total 
deviation is not ascertained before tenotomy, is proved by the subsequent 
history of a case operated on by Dr. Wm. Thomson. 
Should, then, the tenotomy be partial, or complete ? And, Can hyper- 
phoria, with its array of reflex symptoms, be cured by a tenotomy 
limited to the centre of the tendon? I confess the results secured by 
others have not been attainable in my own experience. I have divided, 
in a number of instances, other than those here recorded, the centre of 
the tendon, leaving its edges and attachments to the capsule intact, but 
without effect. A measurable displacement of the image followed only 
when I had made a complete section. 
It is important to determine which eye shall be chosen for operation. 
It must not be forgotten that functional hyper-, as well as eso- and 
exophoria, is an affection of two eyes and two or more muscles, and not 
of one eye or one muscle only. Other than muscular conditions may 
decide which is the weaker or stronger eye, and which muscle may with 
the greater benefit be cut-such as relative position and instability of 
one image, error of refraction, and inclination of the head. If there be 
no reason to suppose one eye more at fault than its fellow, the tenotomy 
may be divided between the sup. rect. of one and the inf. rect. of the 
other eye. 
Conclusions : 
That hyperphoria is a real affection, and that, while it may exist 
without causing symptoms, it is in some cases of the highest importance. 
That it may produce reflex disturbances in an over-sensitive or ex- 
hausted system. 
That reflex functional disorders are found in patients with hyper- 
phoria, which are not caused by hyperphoria. 
That it is not dependent upon errors of refraction. 
That it should be sought for in every case of asthenopia. 
That the degree can be determined only after repeated examinations. 
That tenotomy, and not prisms, is the treatment for hyperphoria. 
That in most cases the tendon should be completely divided. 
Of the six cases reported above, two presented symptoms of hyper- 
phoria when no want of equilibrium of the vertical muscles could be 
detected; one had hyperphoria with asthenopia, which was entirely 10 
HANSELL, TREATMENT OF HYPERPHORIA. 
relieved by the correction of the refractive error. Three had local and 
reflex symptoms due to hyperphoria, and were cured by tenotomies. 
It may be objected that the cases are too few to enable one to deduce 
therefrom laws for general acceptance. No such deductions are made. 
Nothing more has been attempted than a truthful recital of the histories 
and a careful observation of the points presented to my own mind. 
They furnish so much data from which the reader may form his own 
opinion and draw his own deductions. The subject is new, attractive, 
and important, and deserves more impartial investigation and study 
than it has hitherto received. 
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Ylye JVEedical jTeWs Visiting List for 18Q1 
Will be published in four styles: Weekly, dated, for 30 patients; Monthly, undated, for 120 
patients per month; Perpetual, undated, for 30 patients weekly per year; Perpetual, for 60 patients 
weekly per year. The first three styles contain 32 pages of important data and 176 pages of 
assorted blanks; the 60-patient perpetual consists of 256 pages of blanks. Price, each, $1.25. In 
combination with either or both above periodicals, 75 cents. Or, Journal, News, Visiting List 
and Year-Book, $8.50. Thumb-letter index for Visiting List, 25 cents extra. 
LEA BROTHERS & CO., PUBLISHERS, PHILADELPHIA, 706 & 708 SANSOM STREET.