The myopia, in these cases, is not the cause of the squint, but only a favouring circumstance. If the same preponderance of the interni is developed at the same age in emmetropia, squint is not so easily caused, as the distinct retinal images present in the whole field of vision render it easy to retain binocular single vision. Therefore we see the same form of squint arise less often in emmetropia (see Case 45) when childhood is past, than in myopia. As a rule preponderance of the interni in hypermetropia leads eventually to convergent squint even in childhood.
In emmetropia and hypermetropia convergent strabismus seldom arises after the tenth year (paresis of the abducens of course excepted), therefore in my investigations as to the time of commencement of typical squint I have only considered those patients who came under my treatment before their tenth year. We must rely for the most part on the vague statements of the parents, which lose in exactness in proportion as the origin of the squint is of distant date; moreover, I have myself seen a great many of the children before they were four years old. In this way I have collected reliable information respecting the origin of the squint in 193 cases, and of these (a) 88 cases occurred in children one to three years old, (b) 53 in children three to four years old, (c) 35 cases in children of over four years of age. It is thus at once seen that in the great majority of cases, convergent strabismus commences in children under four years of age, who have not yet begun to read and write, and have no inducement to use their accommodation severely, and still less continuously.
SQUINT FROM PARALYSIS OF THE ABDUCENS.
Convergent squint as a result of paralysis of the abducens is not very often seen. It is first to be observed that a convergent squint, including the whole field of vision, occurs by no means in all cases; in about half the cases binocular fusion is retained towards the healthy side, diplopia then only occurs when the weak abducens is exerted beyond its strength. In those cases in which convergent squint is present in the whole field of vision paralysis of the abducens cannot be the sole cause, but some other cause than the most apparent one must co-operate. An insufficiency of the externi of previous existence, or an elastic preponderence of the interni may be considered. I have not been able to persuade myself of the fact that hypermetropia can play any part therein.
In by far the greater number of cases paralytic convergent squint recovers together with the paralysis of the abducens, the field of single vision transfers itself gradually from the healthy side to the side of the weak abducens, and at length governs the whole field of vision. In proportion as the muscle again fulfils its normal functions, the habit of binocular fixation regains its power, and it seldom happens that the elastic tension of the muscles has so changed during paralysis that the desire for binocular single vision does not suffice to overcome it. Case 48 furnishes an example of the fact that although the squint occurred as a consequence of paralysis of the abducens, it certainly remained in existence after healing of the paralysis on account of previously existing insufficiency of the externi.
Congenital paralysis of the abducens seems more frequently to have convergent squint as a result. If, for example, convergent squint is observed in the first year of life, and we find a complete defect of motion on the part of one abducens when the children become old enough to be examined, we may certainly assume that the case is one of congenital paralysis of this muscle, or at least that the paralysis originated soon after birth. Doubtless, however, cases appear, of congenital paralysis of the abducens without squint, and as these cases are so rare I will describe two which I observed in adults.
Case 8. Miss H—, æt. 17, has nominally since her birth a considerable defect in the outward movement of the left eye. On looking to the left homonymous diplopia is present, on looking to the front and the right binocular single vision and no squint; on both sides emmetropia and full acuity of vision.
Case 9. Mr. V. W—, æt. 24, has likewise congenital paralysis of the left abducens. No squint, but as soon as the left eye is used for fixation in the left direction there occurs in the right one a strong secondary movement inwards.