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of the wound, from which a small quantity of pus was escaping. By the twenty-third day the skin had given way and underneath was an extensive cellular inflammation, caused from the catgut used to stitch the muscle fascia. This infected the catgut in parietal peritoneum, and also that which was used in the broad ligament. After this for some days I could remove small pieces of catgut, and as soon as I could get all away wound healed and patient recovered nicely, being in bed five or six weeks, with a temperature of from 100 to 103 from the eleventh day until about the first of April.

Why do I say it was the suture that caused the infection? First, because of the time it came on; second, because as soon as it was removed source of infection was stopped, fever subsided and wound healed rapidly; third, because I know my instruments, assistants and everything pertaining to operation was absolutely clean and sterile, patient being prepared by one of the best and most conscientious nurses I ever saw; fourth, because, having eliminated all other sources, I could not account for it in any other way.

The catgut I used was prepared by B. K. Hollister & Co., of Chicago. I have been using it prepared by the above firm for five years, and only this one instance could I trace any trouble directly to it. With this treacherous nature considered, I can not help liking catgut. It is, after all, the most used and appreciated suture material.






The subject which I have chosen for my address to you is: "The Study of the Muscle Balance for the Detection of Latent Insufficiencies During the Routine Examination of the Eyes of Those Who Come to Consult Us."

For many years it has been a recognized fact that careful correction of errors of refraction and accurate adjustment of the lenses would not only improve vision, but would cause headaches to cease and relieve many reflex phenomena of a disagreeable nature. The wearing of glasses, however, in many instances failed to relieve the suffering and then came the awakening to the fact that for one to enjoy binocular single vision something more than the exact focusing of light upon the fovea of each eye was necessary, and it was that the power of the extrinsic muscles which move the globe should be so nicely balanced that at all times and under all circumstances the rays of light should fall on parts of the retina of each eye whose positions bore a constant definite relation to each other. In the past decade and a half much work has been done in the investigation of muscle imbalance and a great deal has been written about it. Indeed, there has been so much confusion in the nomenclature and so many instruments devised for testing the muscle balance and treating disturbed conditions of its equilibrium that the subject has become appalling in its intricacies. My object in addressing you is to advocate thoroughness and at the same time

simplicity in the routine examination of eye muscles. It is my belief that the state of the muscle balance should be known in every patient who comes to the office. Of course I exclude traumatic and acute inflammatory conditions. That which I wish to emphasize is that the mere knowledge of the muscle balance for distance is of no value. Habit parallelism of the visual lines may exist in persons in whom there is little or no convergence power and whose eyes are therefore of no use for close application. It is no uncommon thing to find orthophoria for distance, with 6° to 10° of exophoria in accommodation with a marked disproportion between adduction and abduction and little or no convergence. Esophoria of from 1/2° to 6°, or 7° for distance, may be found while there is an exophoria of 5° or 6°, or even higher in accommodation. Very high degrees of esophoria (12° or 13°) may exist with orthophoria in accommodation. It is in these latter cases that damage is often done by attempts made to correct the esophoria through tenotomy of the interni. The esophoria is corrected for the time, but at the price of convergence and an ultimate outward deviation of the visual lines. Again, there may be apparently normal balance both for near and distance, that is, orthophoria for distance and in accommodation according to the usual tests. With the correcting glass, the patient having normal vision, it would be expected there would be no asthenopia, but after some days, or weeks, the patient returns, complaining that he is unable to use his eyes for close work at any length of time without producing fatigue, headache and other unpleasant symptoms. The cause for this is that there is a disproportion between adduction and abduction and little power of convergence. In these cases a few days exercise with prisms placed bases out will raise the adduction and power of convergence and give relief without necessarily altering the state of orthophoria. The explanation for this state of affairs, I believe, is that many persons have habit parallelism without ever having awakened sufficient innervation to control convergence, and it is demonstrated that the power lies dormant by the rapidity with which strong convergence is acquired under instruction.

One of the chief reasons for neglecting to take the few steps which it is necessary to acquire a knowledge of the state of the muscle balance is the time that is occupied in the routine examination of the patient, but it is sufficient recompense for the ten minutes spent, if we can discover the one case out of possible many in whom the wearing of glasses will not re-establish the disturbed muscle equilibrium. Unquestionably in many instances all that is necessary is to wear correcting lenses. For in a proportion of these cases the muscle imbalance is dependent upon the disturbed relation between accommodation and convergence, the result of errors of refraction. The question presents itself: What is the best method to pursue in making these examinations? There are on the market numerous phormeters, clinoscopes, clinometers, prism batteries and rotary prisms, all of which have their advocates. My own experience has convinced me that expensive and complicated apparatus is unnecessary. In giving you a brief detail of the manner in which I proceed in these examinations, which is nothing new, I may be pardoned for the personality and for the simplicity of my method when I assure you that it has proved satisfactory in many hundreds of cases and has been consistenly carried out in every instance in my private practice and most of my hospital work.

After the patient's history is taken and the usual superficial looking over is done the vision is measured for five meters distance and the near point of accommodation for each eye. I proceed then to test the lateral and vertical balance for distance; for this purpose I use the ordinary Maddox rod test, having the patient look at a small point of light in the center of a dark screen five meters away. For the near test vertical diplopia is produced by placing a prism base down before one eye and having the patient look at a small black dot drawn on a white card, which is held at 30 c. m. from the eyes. The prisms which are found in any trial case may be used to measure the amount of deflection of the streak of light, or of the dot. These will accomplish the purpose as well as any of the rotary prisms, or phorometers, provided one uses

care to see that the base apex line of the prism is held horizontally or vertically, depending, of course, upon whether one is testing the horizontal or vertical balance. Prism abduction is next measured by finding the strongest prism placed base in with which the patient can see a single light whilst looking at the test light before mentioned. Prism adduction is measured in the same manner but the base of the prism is placed out. The near point of convergence is then obtained in the usual manner by having the patient look at a fine point which is approached to the eyes in the median line. The order in which these tests are made is of importance. The test for abduction and adduction and convergence should remain for the last, for the voluntary effect which is evoked in these latter awakens a latent innervation which would vitiate the other tests were they made primarily. I do not make a special test for cyclophoria, for my experience has not taught me to believe that these disturbances of the vertical axes exist as frequently as one would suppose, nor are they of the clinical importance that the writings of certain men would lead us to believe. The routine which I have described is all sufficient to detect most errors and if persistently adhered to will, I believe, prevent the passing through our hands, unsuspected, any cases of latent muscular insufficiency. If, however, after our examination one is at all in doubt we have still recourse to the parallax, the cover and diplopia and colored glass tests. There are, also, useful adjuncts in studying a case after the muscular defects have been detected; as is also a careful measurement of the field of binocular fixation. Should the person under examination be wearing correcting glasses they should be worn while the tests are made. The objection which is commonly made to the Maddox rod is that results obtained with it are not always exact. That occasionally 1/2° to 1° of esophoria may be shown when other tests show orthophoria. Even if this be true, which I have not found it to be, of what importance is it? As I have stated, esophoria, exophoria, or low degrees of hyperphoria are of themselves of no matter. That which is necessary is that convergence should be in harmony with accommodation, and

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