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inflammation involved the tissues of the orbit or gave rise to any anxiety as to the safety of the eye. In reviewing this case there are causes sufficient to account for the severe inflammation which followed the operation, and although the writer is aware that advancement of a rectus muscle with tenotomy of the opponent is considered a hazardous operation, his own personal experience does not lead him to regard it as such when it has been properly done and the necessary precautions have been taken for such an important surgical procedure. THE PRESIDENT.-Before there is any discussion, it would be well to have the next paper read.

TREATMENT OF STRABISMUS INTERNUS. BY W. W. SEELY, M.D., CINCINNATI, 0.

FOR the greater part of my professional life it has been a questioh in my mind whether the dicta in regard to operative interference in strabismus should be obeyed. Each year, with its added experience, has strengthened the conviction that early operations (up to the I2th or I 5th year) are questionable and possibly should be entirely abandoned. The general profession and laity have always held that children "out-grow their squint." But we have all been taught as specialists to combat, in the most vigorous manner, such heterodox ideas. One of the most recent Text Books on the eye in English, says, in regard to strabismus operations: "These operations ought to be done comparatively early in life. The old story, that the child will out-grow its squint as it gets older, ought to be struck from the list of answers which a physician will give to the inquiring parents in a case of strabismus. The percentage of cases in which a once permanent squint disappears without surgical interference is extremely small, and

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I do not think it is ever observed after early childhood." This is truly amazing! Certainly nothing is better established than the relation between ametropia and strabismus, and all recognize the necessity, or possible necessity, of glasses for preventing the recurrence of the squint after tenotomy. It must be strange if any man has been in practice even a decade of years, and has not seen divergence in cases said to have been perfect corrections of the internal squint for even long periods subsequent to the tenotomy. But if cases of divergence have not been met with, certainly those of " insufficiency," due to the tenotomy, must have been. Furthermore, every one knows the possibility of correcting cases of squint by setting aside the ametropia by means of glasses. The exact or even an approximate explanation of the righting of a deviating eye as the individual grows older, may perhaps not be given, but it will undoubtedly come when we cease closing our eyes to the fact. I do not know how it is with others, but I can safely say, I do not make more than one tenotomy in young persons for internal strabismus, where I would formerly have made ten. I cannot believe that many children of from one to four or even six years of age are operated upon, in spite of all the

teaching. Who has the assurance to say to parents, in private practice especially, " your child's squint will be perfectly corrected by an operation"? Who has reduced the results of tenotomy down to such mnathematical certainty? When we look over our statistics, what per cent. of immediate results are more than cosmetic? My early conviction that somethzinzg should be left for time and glasses, long since grew into an absolute law of action, for I became thoroughly persuaded that imnmediate eerfection meant, later in life, inzszufficiency or even diverge;ice. I think we have advanced so far now, that instead of making operative interference thefirst consideration, it shiould be regarded in the light of an adjuviant, to be resorted to later onzf neccssa;y. In conclusion, I would submit, Ist. That with our present light, routine operative interference is wrong.

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2d. That to thoroughly correct the deviation in young children by operative interference is extremely liable to subject tham in after life to insufficience, or external squint. 3. That a large percentage of squints can be corrected with glasses alone. 4th. That a later period of life, if anything, favors better results from operative interference. DISCUSSION.

DR. KNAPP.-I only want to point out the dangers of advancement, and would like to take issue with Dr. Holt in the group of cases of excessive convergence. I have mostly been able to correct the highest degrees of strabismus internus by two operations and stitching the eye to the commissure. In some cases, I have been obliged to make a third tenotomy. I should rather make three tenotomies than make one advancement. Personally I have had no bad luck with it, but I remember that, when a student, I had a conversation with the assistant of one of the most renowned ophthalmic surgeons of Europe. This operation, said I, strikes me as being somewhat dangerous, yet the professor has never said anything about failures. "No," replied the assistant, "he has not, but I have put the artificial eyes in." DR. THEOBALD.-I can indorse what Dr. Knapp has said. I have never found advancement necessary in convergent squint. I am astoniished to hear Dr. Seely's expression of opinion in his conclusions. There are few operations that I have found more satisfactory than tenotomy for convergent squint. The cases which are likely to be unsatisfactory are those in which the operation is postponed until the squinting eye becomes extremely amblyopic, and central fixation is lost. If we have good vision in both eyes, so that the images are brought on the yellow spot of each eye, I think that a good result can be obtained almost invariably. Out of a considerable number of cases,-I do not recollect a single instance in which divergTent squint has occurred after tenotomy of the internal rectus. Professor N. R. Smith, who for many years did most of the eye surgery in Baltimore, had a large experience with this operation, and his results were extremely satisfactory. I have seen many of his cases years after the operation, and found the eyes straight. I think there must be something xvrong with the operative procedure if it is fre0

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quently followed by insufficiency of the internal recti muscles. I seldom cut both muscles at once. After tenotarmy, the most satisfactory evidence to me that the eyes are in proper relation is elicited in this way. I cover one eye, usually the squinting one, and allow the patient to fix some object with the other, and very commonly, after a satisfactory tenotomy, the excluded eye will turn somewhat inwards. When the cover is removed, an outward movement of this eye is observed, which proves the existence of binocular fixation. In my experience, after a successful operation for convergent squint there is, as a rule, a preponderance of power in the internal recti muscles, which manifests itself in the way I have described. I have always performed the subconjunctival (or Moorfields) operation, making the section of the.tendon very close to the sclerotic. DR. WADSWORTH.-I wish to say a word in reference to the theory that the eye becomes amblyopic because the squint remains. After spending a great deal of time in the clinical study of this point, I am convinced that amblyopia ex anopsia is a myth. The ability to use the amount of vision which the patient has, certainly does seem to be lost by a continuance of the strabismus, but it may be again recovered by practice. I have been unable to convince myself, however, that the actual acuteness of vision was increased by the operation. Great care needs to be taken to determine the vision in the first place, for it is often difficult to determine the full amount of vision of a squinting eye. I think that in general, though not always, one may discover some reason why the eye should be amblyopic. If there is no opacity of the cornea, or great error of refraction, or high degree of astigmatism, one may often find irregular astigmatism, which may have been due to some corneal affection, other signs of which have passed away. I must confess that my experience has not been satisfactory so far as binocular vision after squint operations is concerned. I have seen few cases in which vision was really good in both eyes, and very few cases in which true binocular vision was present after the operation. Even where the vision is nearly equal in both eyes, there sometimes seems to be really a dread of binocular vision. I do not know how to express it better. A striking example of this was observed some twelve or fourteen years ago, in a boy on whom I performed three tenotomies, with the result of bringing the eyes nearly straight. Double images were readily seen, and held, and by the use of prisms it was possible to bring the two images together, but

OLIVER: Test Letters.

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the instant they came together, there was a jerk and they separated in a vertical direction. I spent hours over that boy, at various times, and the result was always the same, the instant the two images of a candle flame were made to overlap by prisms, they separated again with a jerk. I have seen one or two other cases in which similar dread of binocular vision existed, but none so marked. DR. BULL.-I differ with Dr. Seely in regard to the frequency of divergence following these operations, but I agree with him in believing that in very many cases of squint operative interference is a matter of secondary consideration, and not to be undertaken until all other means have proved useless. I am glad to hear Dr. Wadsworth speak so positively in regard to his doubts of the existence of amblyopia ex anopsia, which doubts I have shared for a long time. DR. PROUT.-I wish to express a general concurrence with what Dr. Seely has said, and also my sense of the value of Schweigger's views as to the inferior seeing-power of the squinting eye.

A NEW SERIES OF METRIC TEST-LETTERS FOR DETERMINING THE ACUITY OF DIRECT VISION FOR FORM. (BASED UPON SNELLEN AND DEWECKER.) BY

CHIARLES

A. OLIVER, M.D.,

PHIILADELPHIA.

THE accompanying sheet of test-letters has several advantages not possessed by any other single form of test-card. These are as follows: First,-T/ie Letter. In order to accurately fulfil the condition of Snellen's basis of letter formation, it was found that the nineteen letters,

AB G

VWXYZ I J KM N PQRSUY

had to be expunged, leaving the letters

C D E F LO T for employment. Each letter used embraces a square area included in a five minute angle for both height and breadth,

Treatment of Strabismus Internus.

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