this anomaly, if weak or in ill health, often experience a dread of walking in crowded streets unattended, fearing that they may fall or suffer from mental confusion in the crowd.

The attitudes and facial expressions of hyperphoria, while not universal, are quite characteristic. The head is, in a very considerable proportion of cases, carried habitually toward one shoulder. If the right eye tends higher than the left, the head is carried to the left shoulder; if the left eye tends above, the head is at the right.

The efforts made by the eyelids to aid in forcing the eyes in position give certain peculiarities to the facial expression. One eye may appear partly closed, or both eyes are opened very widely with a kind of stare which has been described as "the hyperphoric stare."

The eyes in hyperphoria have, in many instances, an unsteady gaze. One eye may appear to float away from the other and then back again.

Vision is, in a considerable proportion of cases, affected. It has been found that, in more than fifty per cent of cases, vision is less than two thirds the normal standard.

Many cases of abnornal secretion of tears have their origin in this condition. They do not yield to the ordinary methods of treatment for such complaint, and are liable, by means of the excessive flow of tears, to result in distention of the lachrymal sac and in inflammation of the lining membrane of the nasal canal, leading to its contraction.

In its reflex results hyperphoria is an extremely im

portant element in neuroses. Especially in epilepsy and vertigo should it be looked for with great care.

TREATMENT OF HYPERPHORIA.

The best treatment for hyperphoria is tenotomy of the muscle which forces the eye out of its proper direction. It is not always easy or even possible to determine to which muscle we are to attribute the vicious tendency. The superior rectus of one eye may be short, causing too great tension upward, or the inferior rectus of the opposite eye may be at fault, tending to draw the eye downward, or one of the four oblique muscles may cause the loss of equilibrium. With all these elements of uncertainty, the highest skill of the surgeon may be demanded in forming a correct conclusion. A complete knowledge of what is known of the physiological action of the various eye-muscles is essential in this examination. In the majority of cases, however, in which the hyperphoria does not exceed three degrees, it is proper to relax either the superior rectus of the eye of which the deviating tendency is upward or the inferior rectus of the other. general, it will be found best to select the superior rectus. If more than three or four degrees of deviating tendency is found, it is better to correct a part upon the superior rectus of one eye and what remains of the defect upon the inferior rectus of the other eye some days later.

In

The method of performing tenotomy in these cases of deviating tendencies less than strabismus has been

* See page 135.

already described.* Since submitting this method to the Royal Academy, however, I have found it advisable to modify the procedure somewhat, rendering the operation more simple and the results more satisfactory. As now performed, the eyelids being retracted, a fold of the conjunctiva is seized by a fine but rather rigid pair of mouse-tooth forceps, parallel with the course of the muscle and exactly over its insertion. With a pair of small, narrow-bladed scissors, having blunt but very perfectly-cutting points, a transverse incision is then made through the membrane exactly corresponding to the line of insertion of the tendon. The conjunctival opening thus made should not exceed in extent one fourth of an inch. With the forceps now pressing the outer cut edge of the conjunctiva slightly backward toward the course of the tendon, the latter is seized behind, but very near its insertion. The distance may depend upon the freedom with which the intended section of the tendon is to be made. But in hyperphoria, or in slight relaxations of the lateral muscles, a distance barely sufficient to allow a small part of the tendon to be raised from the sclera is all that should be allowed. Making some tension now with the forceps, the points of the scissors are directed against the central portion of the tendinous insertion and toward the sclera, when a small opening is made dividing the center of the tendinous expansion exactly on the sclera. The small opening is now to be enlarged by careful snips of the scissors toward each border, keeping more carefully on the sclera as the border of the tendon is approached. As the section of

the tendon is carried toward the borders, the outer blade of the scissors passes beneath the conjunctiva. If the relaxation of the tendon is to be slight, the extreme outer fibers of the tendon are to be preserved untouched, but if a considerable effect is desired these fibers can be entirely severed, provided that the reflection of the capsule of Tenon upon the tendon is not disturbed. By means of the capsule acting as an auxiliary attachment, the tendon is held in position but is allowed to fall back slightly while maintaining its relation to the eyeball. In this respect, and in preserving the outer tendinous fibers, this operation differs radically from the ordinary operation for strabismus, and from any operation which has been proposed for so-called "partial tenotomy" of the recti muscles.

The judgment of the operator must determine the extent to which the division should be carried; but, should it be found that too little has been accomplished, the section can be extended. In doing this, the use of a very fine hook may be advisable. For this purpose a hook very much smaller and more delicate than the ordinary tenotomy-hook should be employed. Its rounded point is carried under the remaining border of the tendon with great care to prevent hæmorrhage or unnecessary disturbance of the connective tissues, the extension being made toward one and then toward the other border, as the demand for further relaxation may require. When the remaining band of fibers is made tense by the hook, it is slightly elevated from the sclera, when the fine-pointed scissors are introduced beneath the conjunctiva, and

the necessary extension of the wound is made with an extreme caution not to divide the capsular attachment. The conjunctival suture should in no case be employed. All bandaging of the eye or covers of any description are not only needless but mischievous. Bandages are promoters of heat, filth, and septicism.

ESOPHORIA.

Esophoria, or "insufficiency of the externi," is an exceedingly common and a very troublesome anomaly of the ocular muscles. In esophoria the relative tension of the eye-muscles is such that, if the force of the will were to be removed, the visual lines would approach each other and cross at a point less distant than that for which the eyes are accommodated. In strabismus convergens this tendency is carried to the extent that one visual line constantly deviates from the direction of the other. In esophoria there is habitually an ability to bring the lines simultaneously to the same point. The effort required to continue this adjustment may be, and in the great majority of instances is, made without the direct consciousness of the individual, and there is not of necessity any appearance of deviation, although it is not uncommon to observe an appearance of insufficient distance between. the eyes-giving, in this respect, a narrow facial expression disproportionate to the general features.

Graefe, in his extensive writings upon the ocular muscles, devoted only a passing notice to this condition, his treatise on muscular asthenopia containing but a single paragraph relating to it. In this, how