In a case in which the fusion faculty is normally developed, this tendency to undue convergence induced by abnormal accommodation is kept in check, but if the fusion faculty be deficient or, as in some cases, absent, the relative directions of the eyes are to a lesser or greater extent dependent merely on their motor co-ordinating. The result is that we find in these cases, first of all, a squint manifesting itself when the child accommodates. In many of these cases, provided there is some fusion faculty present, it is found that correction of their refractive error will, by ridding the patient of the associated tendency to over-convergence, entirely correct the deviation.

The deformity, which is at first present only when the child is looking at near objects, gradually is more often seen-(a child, as a matter of fact, spends most of his waking hours playing with objects at near range)—and if the case remains untreated it will be found that after a time it persists even in distant vision.

Now, this abnormal condition existing, the two eyes looking in different directions, it naturally occurs to one that the child must be seeing double, and if we could obtain an intelligent report from him we would probably discover that such was the case, but he will not long accept the discomfort and annoyance of this state of things, and what occurs is that he in time unconsciously refuses to perceive the image of the deviating eye-what is technically known. as "suppression of the vision" of this eye occurs.

It is easy to appreciate what will now happen. If the arm of a child during this early period of development were to be strapped to his side it would not be many months before wasting of the member would be very apparent. So in the case in question, the deviating eye can do only one thing-gradually lose its power of vision. And this is what occurs. We find in all cases a greatly diminished acuity in these cases.

These more or less blind eyes are, however, if their training is taken in hand sufficiently early, capable of restoration, and this brings us to a consideration of the method of treatment.

In all cases the first thing to do is to thoroughly atropinize both eyes and measure their refraction. It will usually be found that hypermetropia, with or without astigmatism, is present, and this refractive error should be fully corrected with glasses. No child is too young to wear glasses, and, contrary to popular belief, injuries to the eyes from their breaking are extremely rare. In a certain proportion of cases, as already stated (about 30 per cent.) the deviation is corrected thereby; in any case the fusion sense is probably defective and the child will be benefitted by fusion training by

means of the amblyoscope. In the majority of the cases, however, it will be found that even with these refractive errors corrected the child still squints. It will also be found that the squinting eye possesses very defective vision. Now, before anything can be done. directly to correct the deviation, we must first restore the squinting eye to an equality of vision with the fixing one. There are a couple of methods commonly employed to accomplish this. One of these consists in daily bandaging the good eye for several hours, thus forcing the poorer one to exercise what function it possesses. With continued treatment over a period of several weeks or months, depending on the degree of blindness present, we will find that normal vision in this eye is regained. A child does not like a bandage, however, and most mothers do not like the responsibility of seeing that it is kept on, so that a better method to employ is the daily instillation of a drop of atropine solution into the good eye only. The child is now unable to see near objects with this eye, and the deviating eye, therefore, takes on the work of near vision, and by reason of the enforced exercise of its functions gradually returns to a normal degree of acuity. The atropinized eye is, moreover, not so subject to loss of function as though it were entirely occluded by a bandage.

We now reach a point where we have normal vision in each eye, but the deviation still exists. It is now time to undertake fusion training. Although the vision in the deviating eye may be perfect, there is usually "suppression" by it. It is, therefore, necessary in using the amblyoscope to have a separate lighting arrangement for each half of the instrument. By increasing the illumination behind the unperceived image, therefore, the squinting eye can be forced to see it.

The images used are pictures drawn on thin paper and pasted on a piece of glass which slips into the object-slides. The images used on each side are different; they are commonly two different portions of a complete picture, such as a man with a hat on his head and a stick in his hand. One slide will contain the man minus perhaps one arm, one leg and the hat and stick. The other slide will have the complementary portions. Another favorite device used is a bird on one slide and a cage on the other. Suppose the bird and the cage be put in position, the child is seated on the surgeon's knee and the instrument placed before the child's eyes. He will probably say that he sees either the bird or cage, depending on which is in front of his fixing eye. The illumination is, therefore, suppressed behind this image and increased behind the other, until he sees both the bird and the cage. The two halves of the

instrument are now approximated until the child sees the bird in the cage. By alternately separating and approximating the tubes it will be found that the bird is now in, now out of the cage. The child is striving to keep the bird in, and after a time one finds that the two halves can be moved out and in several degrees and the bird still remain in. These treatments are given at intervals of several days for several weeks, and each time it is found that one can commence with the two halves of the instrument further apart, until finally the eyes assume their normal axes.

Sometimes, probably because the treatment has been undertaken too late, we find after improving the deformity considerably it remains stationary. In these cases a shortening of the external rectus of this eye, with or without a tenotomy of the internal rectus, will overcome the still existing deviation, and the patient will then take on binocular visions.

Of course, we see cases every day, in older children and in adults, for which nothing remains but operation, and the operation suitable will depend on the judgment of the surgeon. Either tenotomy or advancement of the muscles of the deviating eye or of both eyes are indicated, according to the degree of deformity. Advancement of the external rectus is undoubtedly preferable to tenotomy of the internal, and is suitable in cases of as high as 25 degrees. In cases of greater deviation than this, a tenotomy will be required in order to obviate retraction of the globe. In any case one expects nothing but a cosmetic effect from either procedure.

But what I want to suggest to you particularly this evening is the comparative innecessity of these operative measures if the case is appreciated early. Children from three to five years of age are the best subjects for fusion training; in the sixth year they are amenable to it, but with more difficulty, and after that it is very difficult often to accomplish much.

It may, perhaps, as I have described it, appear a long and tedious method of treatment, but surely the saving of an eye and the avoidance of such an ugly deformity is worth a much more difficult regime.

But remember, to get ideal results, one must have these cases young in life. The laity have no conception of the meaning of squint, therefore let every physician be a preacher when the occasion arises, and let him preach

1st. That squint is curable, if treatment be undertaken young. 2nd. That it is the exception for children to "grow out of" squints, and

3rd. Whether they "grow out of" it or not, there will always remain to the patient the heritage of a blind eye.

INCOMPLETE MYXEDEMA-HYPOTHYROIDEA.*

BY J. MCWILLIAMS, M.D., LONDON, ONT.

The object of this short paper is to bring before this Society what I think may fairly be termed one of the more recent steps in the differentiation of disease.

Fully-developed cases of myxedema are now fairly well understood and would be recognized by most of us, though many men will have had a large experience and not meet with a case, or fail to recognize it if they should see it.

Myxedema is admitted to be due to a lack of proper secretion of the thyroid gland, and this lack of secretion may be complete or partial. If complete, we have a completely-developed case of myxedema, with all its subjective and objective signs and symptoms. If, on the other hand, the failure in secretion is only partial, we have an incomplete set of symptoms and signs, and I believe we have many cases of this kind which have been variously diagnosed in the past, most of the cases having been relegated to that haven of rest so often taken advantage of by all of us when we do not know, viz., hysteria-and the unfortunate patient lived a miserable life, accused of having an affection which they could avoid by the exercise of will power, and in other cases the long-continued existence of the peculiar symptoms have produced a state of mind diagnosed as insanity, and I believe that many cases now confined in our asylums are cases of incomplete myxedema.

Signs and Symptoms.-As in the complete form, the skin and mucus membranes, and their appendages, the hair and the teeth, are the organs that show the ill-effects of the disease first, or at least most prominently.

Premature old age is the first thing that ought to lead one in the right direction in examining a case. The hair is thin on the temples, and on the occiput, and baldness may exist in patches. This thinning of the hair on the temples, in women especially, has been the beacon light that led me in the right way on several occasions recently. The hair is dry and fluffy and untidy. Dandruff is always present. The eyebrows and eyelashes are thin, and a scruffy condition exists at the external angle of the eyebrows. The teeth are decayed, especially the molars. Tartar of a green or black color is always present; a general condition of nasal and pharangyeal catarrh is always present; the tongue is swollen and

* Read before the London, Ont., Medical Association.

has the marks of the teeth on its edges, and this marking of the tongue ought to lead the physician to consider the possibility of hypothyroidea. How often we have been consulted about a case of catarrh and the expression added that the patient had a poor memory and was unable to think. Such complaint on the part of a patient or his friends ought to lead us to look for this disease. Morning headache is a prominent symptom. I believe it has its origin in disease changes in the mucus membrane of the sinusus. The skin is not thickened, but there is puffing under the eyes. The expression of the face is one of sorrowful fatigue, and the whole complaint is that, "though I eat plenty I am so tired and weak." Morning pain between the shoulders is also a common symptom and comes on in the night and prevents sleep. Constipation is a predominating symptom, with all the evils that it brings. The skin has a lemon tint or dirty copper color.

There are many other signs and symptoms not so constant, such as buzzing in the ears and sound of bells, hallucinations of sight, seeing rats and mice running through the room; in females, dysmenorrhea or amenorrhea, displacement of uterus; loss of sexual appetite in both sexes; improvement in the health of the female during gestation, owing to increased activity of the thyroid gland during that period; feebleness of the heart's action, a tendency to bleed easily owing to increased tension of the arteries and reduced coagulability of the blood, and many other symptoms. But the object of this paper is not so much a full and minute description of every detail of the symptoms and signs, but rather to bring before you some of the more prominent and constant signs, so that with these in our minds we may be able to recognize the disease.

When a patient complains of constant constipation, continuous nasal and pharyngeal catarrh, constant desire to rest, loss of interest in life, being often accused of laziness by the friends, has a muddy complexion, morning headache, morning and night pain in the back between the shoulders, marks of the teeth on the sides of the tongue, lost or much-diminished sexual power, the hair on the head being very thin and unhealthy, then treatment for hypothyroidea will help to cure, no difference what else may be neces

sary.

A word as to treatment. Thyroid extract is, of course, the main medicament, and if dementia has not arrived it will do much for the patient, but it often fails because it is not absorbed, and it is not absorbed because the stomach and intestines are too acid, as the result of putrefactive changes, the result of the long-continued constipation. Soda bicarbonate and soda sulphate, in small doses