Part 11 (1/2)
_Of Squinting._
Though this is a subject which well deserves our particular attention, yet having spoken of such a variety of subjects in the preceding part of this lecture, I have not time for many observations on this. I shall just mention the princ.i.p.al opinions, concerning the cause of this deformity, and point out that which seems to me most probable. This subject is certainly very worthy the attention of the physician, as it is a case concerning which he may often be consulted, and which it may be sometimes in his power to cure.
A person is said to squint, when the axes of both his eyes are not directed to the same object.
This defect consists in the wrong direction of one of the eyes only.
I have never met with an instance in which both eyes had a wrong direction, neither have I seen one accurately described by any author.
The generality of writers on this subject have supposed this defect to proceed from a disease of, or want of proper correspondence in, the muscles of the eyes, which not acting in proper concert with one another, as in persons free from this blemish, are not able to point both eyes to the same object. But this, I think, is very seldom the cause, for when the other eye is shut, the distorted eye can be moved by the action of its muscles, in all possible directions, as freely as that of any other person, which shows that it is not owing to a defect in the muscles, neither is it owing to a want of correspondence in the muscles of both eyes; for when both eyes are open, and the undistorted eye is moved in any direction whatever, the other always accompanies it, and is turned the same way at the same instant of time.
I shall next take notice of the hypothesis of M. de la Hire, who supposes, that in the generality of mankind, that part of the retina which is seated in and about the axis of the eye, is of a more delicate sense and perception than what the rest of the coat is endowed with; and therefore we direct both axes to the same object, chiefly in order to receive the picture on that part of the retina which can best perceive it; but in persons who squint, he conceives the most sensible part of the retina of one eye, not to be placed in the axis, but at some distance from it: and that, therefore, this more sensible part of the retina is turned towards the object, to which the other eye is directed, and thus causes squinting. This ingenious hypothesis has been followed by Dr. Boerhaave, and many other eminent physicians. If it be true, then if the sound eye be shut, and the distorted eye alone be used to look at an object, it must still be as much distorted as before, for the same reason: but the contrary is true in fact; for if you desire such a person to close his other eye and look at you with that which is usually distorted, he will immediately turn the axis of it directly towards you. If you bid him open the undistorted eye, and look at you with both eyes, you will find the axis of this last pointed at you and the other turned away, and drawn close to the nose, or perhaps to the upper eye lid. From these facts, and some others mentioned by Dr.
Jurin, I think we may conclude that this defect is seldom, if ever, occasioned by such a preternatural make of the eye, as M. de la Hire supposed.
From the most accurate observations it will appear, that by far the most common cause of squinting, is a defect in the distorted eye. Dr.
Reid examined above twenty people that squinted, and found in all of them a defect in the sight of one eye; M. Buffon likewise, from a great number of observations, has found that the true and original cause of this blemish, is an inequality in the goodness, or in the limits of distinct vision, in the two eyes. Dr. Porterfield says this is generally the case with people who squint; and I have found it so in all that I have had an opportunity of examining.
With regard to the nature of this defect, the distorted eye is sometimes more convex, and sometimes more flat, than the sound one; sometimes it does not depend upon the convexity, but upon a weakness, or some other affection, of the retina, of the nature of which we are ignorant.
It will be easy to conceive how this inequality of goodness in the two eyes, when in a certain degree, must necessarily occasion squinting, and that this blemish is not a bad habit, but a necessary one, which the person is obliged to learn, in order to see with advantage. When the eyes are equally good, an object will appear more distinct and clear when viewed with both eyes than with only one; but the difference is very little. The ingenious Dr. Jurin, who has made some beautiful experiments to ascertain this point, has shown, that when the eyes are equal in goodness, we see more distinctly with both than with one, by about one thirteenth part only. But M. Buffon has found that when the eyes are unequal, the case will be quite different. A small degree of inequality will make the object, when seen with the better eye alone, appear equally bright or clear, as when seen with both eyes; a little greater inequality will make the object appear less distinct when seen with both eyes, than when it is seen with the stronger eye alone; and a still greater inequality will render the object, when seen with both eyes, so confused, that in order to see it distinctly, one will be obliged to turn aside the weak eye, and put it into a situation where it cannot disturb the sight of the other. The truth of this may be easily proved by experiment. Let a person take a convex lens, and hold it about half an inch before one of his eyes; he will, by these means, render them very unequal. and if he attempt to read with both eyes, he will perceive a confusion in the letters, caused by this inequality; which confusion will disappear as soon as he shuts the eye which is covered with the lens, and looks only with the other.
Squinting is a necessary consequence of this inequality in the goodness of the two eyes; for a person whose eyes are to a certain degree unequal, finds that, when he looks at an object, he sees it very indistinctly; every conformation, or change of direction of his eyes which lessens the evil, will be agreeable; and he will acquire a habit of turning his eye towards the nose, not for the sake of seeing better with it, but in order to avoid, as much as possible, seeing at all with the distorted eye; for which purpose it will be drawn either under the upper eye lid, so that the pupil may be entirely or partially covered; or directly towards the nose, in which case the image of the object will fall at a distance from the axis of the eye: and it is a fact well known to philosophers, that we never naturally attend to an image which is at a distance from the axis; so that in this situation it will give little disturbance to the sight of the other.
It is easy to show that a squinting person very seldom, if ever, sees an object with the distorted eye. Indeed in above forty cases that I have examined, I found that when I placed an opaque body between the undistorted eye and the object, it immediately disappeared, nor were they able to see it at all, till they directed the axis of the distorted eye to the object. I find the same observation made by Dr.
Reid and M. Buffon.
M. Buffon takes notice of a fact which I have often observed; viz.
that many persons have their eyes very unequal without squinting.
When the difference is very considerable, the weak eye does not turn aside, because it can see almost nothing, and therefore cannot disturb the vision of the good eye. Also, when the inequality is but small, the weak eye will not turn aside, as it affords very little disturbance to the sight of the other: when the inequality consists in the difference of convexity, or difference of the limits of distinct vision, having the limits of distinct vision in each eye given, it may be calculated with some degree of accuracy what degree of inequality is necessary to produce squinting. It seems then that there are certain limits with regard to the inequality of the eyes, necessary to produce this deformity; and that if the inequality be either greater or less than these limits, the person will not squint.
Having now endeavoured to show what is the most common cause of squinting, I shall briefly attempt to point out those cases in which we may expect to effect a cure, and afterwards give a very short account of the most likely methods of doing it.
We cannot have great hopes of success, when there is a very great defect in the distorted eye. When the eyes are of different convexities, there is no other way of removing the deformity, than by bringing them to an equality by means of gla.s.ses, and then the person would only look straight when he used spectacles. When this defect is owing to a weakness in the distorted eye, it may sometimes be cured: M. Buffon observes that a weak eye acquires strength by exercise, and that many persons, whose squinting he had thought to be incurable, on account of the inequality of their eyes, having covered their good eye for a few minutes only, and consequently being obliged to exercise their bad one for that short time, were themselves surprised at the strength it had acquired, and on measuring their view afterwards, he found it to be more extended, and judged the squinting to be curable. In order therefore to judge with any certainty of the possibility of a cure, it ought always to be tried whether the distorted eye will grow better by exercise; if it does not, we can have little hopes of success; but when the eyes do not differ much in goodness, and it is found that the distorted eye acquires strength by exercise, a cure may then be attempted: and the best way of doing it, (according to M. Buffon) is to cover the good eye for some time, for, in this condition, the distorted eye will be obliged to act, and turn itself towards objects, which by degrees will become natural to it.
When the eyes are nearly brought to an equality by exercise, but cannot both be directed to the same point, Dr. Jurin's method may be practised, which is as follows.
If the person is of such an age, as to be capable of observing directions, place him directly before you, and let him close the undistorted eye, and look at you with the other; when you find the axis of this fixed directly upon you, bid him endeavour to keep it in that situation, and open the other eye; you will now see the distorted eye turn away from you towards his nose, and the axis of the other will be pointed towards you, but with patience and repeated trials he will, by degrees, be able to keep the distorted eye fixed upon you, at least for some time after the other is opened, and when you have brought him to keep the axis of both eyes fixed upon you, as you stand directly before him, it will be time to change his posture, and set him, first a little to one side of you, and then to the other, and so practise the same thing. And when, in all these situations, he can perfectly and readily turn the axes of both eyes towards you, the cure is effected. An adult person may practice all this before a mirror, without a director, though not so easily as with one: but the older he is, the more patience will be necessary.
With regard to the success of this method, M. Buffon says, that having communicated his scheme to several persons, and, among others, to M. Bernard de Jussieu, he had the satisfaction to find his opinion confirmed by an experiment of that gentleman, which is related by Mr.
Allen, in his Synopsis Universae Medicinae. Dr. Jurin tells us that he had attempted a cure in this manner with flattering hopes of success, but was interrupted by the young gentleman's falling ill of the small pox, of which he died. Dr. Reid likewise tried it with success on three young gentlemen, and had brought them to look straight when they were upon their guard. Upon the whole this seems by much the most rational method of attempting to cure the deformity.
The only remaining morbid affections of the eye which I shall take notice of in this lecture, are two, which produce the indistinct vision of an object, by directly opposite means. The first is caused by the cornea, and crystalline, or either of them, being too convex, or the distance between the retina and crystalline being too great.
It is evident, that from any of these causes, or all combined, the distinct picture of an object, at an ordinary distance, will fall before the retina, and therefore the picture on the retina itself must be confused, which will render the vision confused and indistinct; whence, in order to see things distinctly, people whose eyes are so formed are obliged to bring the object very near their eyes; by which means the rays fall upon the eye in a more diverging state, so that a distinct picture will be formed on the retina, by which the object will be distinctly seen: from the circ.u.mstance of such persons being obliged to hold objects near their eyes, in order to see them distinctly, they are called short sighted.
If a short sighted person look at an object through a small hole made in a card, he will be able to see even remote objects, with tolerable distinctness, for this lessens the circles of dissipation on the retina, and thus lessens the confusion in the picture. For the same purpose, we commonly observe short sighted people, when they wish to see distant objects more distinctly, almost shut their eye lids: and it is from this, says Dr. Porterfield, that short sighted persons were anciently called myopes.
The sight of myopes is remedied by a concave lens of proper concavity, which, by increasing the divergency of the rays, causes them to be united into a focus on the retina: and they do not require different gla.s.ses for different distances, for, if they have a lens which will make them see distinctly at the distance most commonly used by other persons, for example, at the distance at which persons whose eyes are good generally read, they will, by the help of the same gla.s.s, be able to see distinctly at all the distances at which good sighted people can see distinctly: for the cause of shortsightedness, is not a want of power to vary the conformation of the eye, but is owing to the whole quant.i.ty of refraction being too great for the distance of the retina from the cornea.