Just as in myopia even in the lesser degrees, insufficiency of the interni or preponderance of the externi is not rare, so in hypermetropia insufficiency of the externi or preponderance of the interni appears to be frequent; and if this disturbance of the muscular balance be followed even in myopia or emmetropia by convergent strabismus, this will of course happen still more easily if at the same time hypermetropia, or even without hypermetropia, the remaining favouring conditions mentioned by Donders are present. Of course I do not deny the effect of the hypermetropia and of those other favouring conditions, but only wish to draw attention to the fact with reference to them, that as a rule they do not of themselves suffice to produce convergent strabismus.
Nebulæ have always been regarded as one of the causes of squint; here I quite agree with Donders that they may operate, firstly, as general causes of weak sight; secondly, through this, that the irritated condition, combined with the keratitis, may produce a spasmodic, afterwards a trophic shortening of the muscles; but this seldom happens.
Whether nebulæ are found rarely or often in squint, depends in great measure on the statistic materials which are worked out. In my statistics they do not occur in any quantity worth mentioning, because in private practice purulent ophthalmia keratitis, and in short, the whole army of external inflammations of the eye is much rarer, than in that portion of the populace which fills public clinics. Further, it is to be observed that the mere occurrence of nebulæ in squint proves nothing—even squinting eyes may develop keratitis. We must at least require to be assured that the squint began after the keratitis.
Among the causes which promote the occurrence of squint, Donders mentions also conditions which diminish convergence. We have ascribed a very important rôle to the muscles, and have only to occupy ourselves here with the relation between the visual line and the axis of the cornea, which we have already mentioned on page 2. Donders has measured the angle a in ten cases of hypermetropia with convergent strabismus, and from the comparison with hypermetropic non-squinting eyes draws the conclusion, that in similar degrees of hypermetropia a higher amount of a specially disposes to strabismus. I will not repeat here the witty deduction by which Donders seeks to point out that a higher value of a must be followed by insufficiency of the externi and preponderance of the interni; the concession is enough that these circumstances exist and are the cause of the squint.
PERIODIC CONVERGENT SQUINT.
The opinion is prevalent that convergent strabismus usually begins in the form of periodic squint, and that a permanent deviation is developed in this way only. In many cases it may be so; on the other hand I have sometimes seen convergent strabismus arise suddenly, without a preliminary stage of periodic squint. This question, however, is of no special interest. It is more important to note that periodic squint frequently continues to exist unchanged, without ever becoming permanent.
Like the whole doctrine of strabismus, opinions on periodic squint have been governed by Donders' theory, regardless of facts, but as the accommodation frequently exercises a perceptible influence, it is judicious to consider first of all the cases in which this does not happen.
Convergent squint in myopia begins as a rule with periodic squint, and may continue to exist in this form: some patients who would not be operated upon have been under my observation for years; sometimes a correct position was retained for a long time, and sometimes strong convergent squint was present, proving that accommodation had nothing whatever to do with it. In myopia of higher degree the accommodation is scarcely used—unless concave glasses are worn; still periodic squint occurs under these circumstances. For example: