brings the focus still farther in front of the retina. This lack of stimulation of accommodation does away with the stimulus given the internus in hyperopia, and if the externus has the advantage over the internus, as to size or point of attachment, the eye will turn out. The degree of the squint, of course, depending on the difference in the muscles as to size, attachments, etc.

We find squint in all classes of patients and at all ages. Usually internal squint begins at about the age of 2 or 3 years, sometimes sooner, sometimes later; while, as a rule, we do not see external squint until later in life. Internal squint begins to manifest itself at about the time a child is old enough to notice objects closely. However, the parent usually dates the squint from the time of a fall, fright and things of like nature. These may be the means of bringing the notice of the parent to the condition, but it plays very little part in the actual cause. When we see this condition in middle-aged persons, we may safely conclude that it is because of inability to have anything done when first noticed or from fear, or from the advice they frequently follow, to let it alone and outgrow it. Of course this does not apply to squint caused by paresis or paralysis; squint from either of these two causes is not included in this paper.

The advice to give parents bringing you a child whose eyes are crossed, is for them to have the condition corrected and at as early a time as possible. There are two good reasons for this: one is for the cosmetic effect, and secondly and most important, the other is for the preservation of good vision in the crossed eye. There is no one who wants to go through life with crossed eyes, and if the patient be a girl, it is more essential, so far as appearances go, to have the eyes straightened. However, the most important reason why the eyes should be straightened is on account of the vision. In squint, while at first the vision of the two eyes may be practically the same, and the patient may use either one with as good results, the annoyance caused by the diplopia causes the mind to select one of the two eyes for doing all the work and suppresses the image in the other eye, and turns the eye in so as to be as much out of the way as possible. We all know that lack of exercise of

the arm or leg or, for that matter, any part of the body, tends to weakness of that part, and if, for instance, an arm should be bound to the body in such a manner that it would never be brought into use, as a matter of fact it would finally become useless. The same thing takes place in a squinting eye. The mind pays less and less attention to the images formed on the retina of the squinting eye, and, from lack of use, the vision in that eye becomes less and less until, finally, it amounts to nothing. The cause of this is no pathological condition in the fundus, but is simply one of mind blindness. When the squint is due to some error of refraction, alone or combined with imbalance of the muscles, the prognosis should always be favorable.

In the treatment of strabismus, there are two methods employed, viz., surgical and non-surgical, and in the majority of cases we are required to resort to both methods to get the desired results.

The non-operative method consists in the fitting of the proper glasses to relieve the error of refraction found. In internal squint, the error of refraction found is almost always hyperopia. After thoroughly putting the eyes under the influence of a mydriatic, either atropin or homatropin, we give the strongest convex glass in internal squint that gives best vision; a simple convex sphere if it is hyperopia only, a sphero-cylinder if the hyperopia is complicated by astigmatism. Frequently this is all that will be required to relieve the condition, showing clearly that the squint was caused by the strain, due to the refractive error. In external squint, associated with myopia, we give the concave lens, either sphere or sphero-cylinder, that gives best vision for distance. This, when the object is brought close, will call for normal action of the ciliary muscle with its accompanying stimulation of the interni. The glasses in both cases are to be worn constantly. In hypermetropia, at first, the vision for distance will not be perfectly clear and distinct on account of the ciliary muscle not relaxing entirely its accustomed strain, but the lens will relieve the strain, and in a short time the ciliary muscle will relax, and the distant vision become clear. It is best in children to resort to the non-operative treat

ment first. The sooner the child is brought for treatment, the better are the prospects for relief without operating. Children of 2 to 3 years of age, instead of objecting to wearing glasses, as one would naturally suppose, find so much relief from their use that they do not have to be compelled to wear them; on the contrary, if they are left off, the child will call the parents' attention to it.

The surgical treatment consists of tenotomies of the stronger muscles, advancement and shortening of the weaker muscles. It may require only one of these to get the desired result, or we may have to do them all, that depending on the amount of squint, length of time the eye has been crossed, etc.

We all know the property a muscle has of contracting when severed completely, but none of us know just how much contraction will take place in any given muscle, and in operating for squint we should stop a little short of rather than run the risk of overdoing it. Could we know or had some means of judging just how much a muscle would contract, then we, possibly, would be justified in doing complete tenotomies in some cases, but since we do not know this, we should confine ourselves to partial tenotomies in every case, and what we fail to correct we can finish by tenotomies, advancements or shortenings of other muscles. There is only one operation of complete tenotomy that should be considered and that is one devised by Panas. In this operation the muscle, before being severed, is first put on as great a stretch as possible by means of tenotomy hooks. This stretching of the muscle causes a paresis of its fibres, and when the muscle is divided it does. not retract as much as it otherwise would, and by the time it recovers from the paresis, the inflammatory reaction has formed the new attachment. The danger from complete tenotomies is that the muscle may retract so far before becoming re-attached, that we will eventually have a condition opposite that for which we operated. Supposing the operation has been done to relieve an internal squint, the patient may show up later with an external squint. A squint caused by too freedivision of a muscle is always harder to relieve than the former condition. Then again the patient does not submit so readily to other operations as in the first instance.

To prevent this too-far retraction of the muscle and subsequent condition opposite that we wish to relieve, we should confine ourselves strictly to partial tenotomies, dividing, as a rule, the central fibres of the muscle and leaving a few fibres at both edges to act as stay-cords. The degree of squint, size, strength and attachment of the muscle will, of course, be a guide to us as to whether to divide all the central fibres or only a few. In the case of a large, broad muscle, attached close to the cornea-scleral margin, we would divide all the central fibres, leaving only a few at both edges to prevent too far retraction.

In advancements and shortenings, it is a hard matter to know just which one we will do until the muscle has been exposed and its strength and point of attachment have been approximated. Of course, we have to bear in mind the amount of turning we wish to accomplish. In some cases, a shortening will give the desired results, in others, advancement of the tendon will promise us more. Should we find the muscle attached normally, but long and rather lax and narrow, a shortening is indicated, giving the muscle more power by decreasing its length. However, on exposing the muscle, should we find the muscle attached rather far back, then best results would be gotten from an advancement. Should we not accomplish all that we desire from the operations on the squinting eye, then we can turn our attention to the other eye and follow out the same plan. A great deal depends on the judgment of the operator, and he soon learns, by experience, just about how much to do to get the desired results.

Before doing any operation at all, we should first see if the images can be fused. If they can be, then it is a clear case for operation. When we find a case, however, where the vision of the two eyes is about the same, we should suspect antipathy to binocular single vision and test for it thoroughly. In this condition we cannot fuse the images; they may be made to come very close to each other but will not fuse; and when we find a case like this, we should do nothing at all. Should we operate with a view to lessening the squint, this would bring the images of the two eyes closer together and make it more annoying and confusing for the patient. In

conclusion, let me advise you to get the patient under treatment as soon as possible. Correct the error of refraction by the proper glasses, and finish the work by advancements or shortenings and partial tenotomies, but never do a complete tenotomy.

Randolph Building.

LESIONS OF THE BRAIN AFFECTING THE
FUNCTIONS OF SPEECH.*

B. F. TURNER, M.D.

MEMPHIS.

THE disturbances of the function of speech which are associated with certain lesions of the brain-always a complex though interesting field of research-have now become so far elucidated as to render considerable assistance in locating obscure difficulties, in differentiating between them, and in rendering a prognosis. Upon this occasion I propose to exhibit two cases which illustrate different phases of this sort of disorder. But before doing so, allow me to sketch briefly, for the purpose of clearness, the main points involved in the normal function of speech.

The motor nerves which supply the organs of articulation, the lips, cheeks, tongue, palate, etc., are in communication with certain circumscribed areas of the cerebral cortex by means of fibres descending thence through the internal capsule. The power to originate motor speech impulses resides in the third frontal convolution-on the left side in righthanded persons, and on the right in the lefthanded. Lesions of this area are attended by loss of power of articulate speech-motor aphasia―a loss of function analogous to paralysis which follows the disturbance of other motor centres.

It will be remembered that articulate speech is eminently a function which is the result of education. A child must hear words often repeated and for a long time before he acquires the use of them. Moreover, it is to be remembered that in educated persons the power of expressing thought through language is not confined to articulate speech, but by invoking *Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Nov. 15, 1904