[Reprinted from The Medical News, March 3, 1894.] 
TWO CASES OF FUNCTIONAL NERVOUS DISEASE 
TREATED BY TENOTOMY OF THE 
SUPERIOR AND INFERIOR 
RECTUS MUSCLES. 
By HOWARD F. HANSELL, M.D., 
OF PHILADELPHIA, PA. 
The following cases demonstrate, individually, the 
role played by a want of equilibrium in the ocular mus- 
cles, demanding constant and unconscious effort to main- 
tain single and clear vision, in producing disturbances 
of the nervous system, simulating organic disease, and 
the marked amelioration of the symptoms following 
restoration of the equilibrium. 
The conservative physician demands proof, or at least 
undisputed evidence of the trustworthiness of new thera- 
peutic agents, before adopting the suggested line of 
treatment and risking his patient's health and his own 
reputation by displacing older,well grounded, and authen- 
ticated methods, although perhaps unsatisfactory. 
Current ophthalmic literature seems to indicate a more 
general belief in the theory, advanced by Stevens, of the 
causative relation of anomalies of the ocular muscles 
to functional disease of the nervous system, than pre- 
vailed for some years after the publication of his Belgian 
Prize Essay and his series of articles in the Archives of 
Ophthalmology, at least in so far that opportunities for 
personal investigation are availed of after therapeutic 
efforts in other directions have proven unsuccessful. 
The subject is attractive to both ophthalmologist and 
neurologist-to the former, in widening his limited field of 2 
practice, and to the latter in suggesting for his considera- 
tion a means of cure, in properly selected cases which 
have not yielded to his other therapeutic resources. 
I am indebted to my friend Dr. K. C. McWilliams, ot 
Philadelphia, for the opportunity to see in consultation 
and to present to the attention and judgment of the pro- 
fession the two cases described herewith. I have endeav- 
ored to limit the clinical histories to a bare statement ot 
facts and have purposely omitted comments. 
Case I.-Miss R., aged sixteen, a school-girl, of good 
family history, with no inherited neurotic tendencies, 
consulted Dr. McWilliams in May, 1893, on account of 
epilepsy. Her mother related that the first seizure 
was excited by the horror of seeing a brother drown 
Fig. i. 
Miss R., one week before operation. 
two years before. The attacks have very gradually in- 
creased in frequency until the present, when they recur 
three and four times in the week. Without warning, 
she becomes unconscious, falls if standing, has a slight 
general muscular spasm or convulsion, recovers after 
a few seconds, and eructates large quantities of gas. 3 
She complains also of severe headache and vertigo after 
an hour's close application to her books. She makes no 
mention of the facial spasm conspicuously shown in the 
photograph. In spite of treatment directed to both the 
nervous system and the eyes, by various specialists, dur- 
ing the past two years her symptoms have increased in 
severity. Refraction under atropin = + 0.755.= 6/6, o.u. 
Left hyperphoria 2C - 30. Lateral muscular action incon- 
stant ; at times esophoria, more frequently exophoria. 
Occasional diplopia. No lesion of media or fundus. 
Prisms to correct the hyperphoria were worn for one 
week with great benefit. On June 20th, tenotomy of the 
left superior rectus was practised and the muscular equi- 
librium established. 
Fig. 2. 
The relief to the epilepsy, headache, and vertigo was 
immediate and absolute, and to this date (February 6, 
1894) has continued. 
Case II.-Miss O., aged nineteen, a weaver, without 
inherited diathesis, consulted Dr. McWilliams, October 
13,1893, complaining of severe asthenopia of six months' 
Miss R., a few days after operation. 4 
duration. Attempts to use the eyes for close work 
were attended with pain in the head and eyes and fre- 
quently with nausea, vertigo, and loss of conciousness, 
without general muscular spasms. In the absence of 
known organic disease and from the close connection of 
the periods of unconsciousness with use of the eyes at 
the near-point, the girl properly concluded that the source 
of her trouble must be in a derangement of the ocular 
apparatus. She had not placed herself under medical 
treatment during the preceding six months, but had con- 
sulted two ophthalmic surgeons and had worn various 
spherical lenses without benefit. The diplopia has re- 
cently become a nearly constant symptom. Left hyper- 
phoria - 4°. Exophoria alternating with esophoria at 
6 m. Exophoria in accommodation. Refraction under 
atropin = iD = 6/6, o.u. No lesion of media or fundus 
was present. Prisms correcting the hyperphoria were 
worn with comfort for seven days. October 29th, tenot- 
omy of the left superior and right inferior rectus gave 
perfect binocular fixation. 
Miss O. has been relieved of headache, vertigo, and 
fainting attacks and has been able to resume her occu- 
pation. She still has some asthenopia in reading. 
These cases demonstrate the necessity for including an 
examination of the ocular apparatus in determining the 
cause of functional disease of the nervous system.