Mar.

1942] MCGILLIVRAY: STRABISMUS 265

and we have made a working rule to discontinue
chemotherapy if the count falls below 6,000,
giving the patient a short rest and then com-
mencing the drug again if the general indication
is still present. Frequent blood transfusions
seem to be of value in this group of cases, and
we are employing this more in recent months
with the hope that it will permit pushing the
appropriate drug to a fuller extent. It would
appear that we have not yet found the solution
to the treatment of the pneumococcus type III
infections, although we had in the hospital
during July, 1940, a patient under the care of
Dr.. D. H. Ballon who made a successful re-
covery from a type III pneumococcal infection
of the meninges, but as a radical mastoidectomy
was done and the middle ear suggested a chronic
suppurative otitis media the case was not in-
cluded in this series. Bacteriological reports in
this case persistently reported very light growth
of the organisms while in the cases where very
heavy growths are reported apparently the
thickening of the spinal fluids leads to obstruc-
tion and the development of internal hydro-
cephalus which proves fatal.
SUMMARY
1. The report deals with a series of 29 cases
with 8 recoveries from proved streptococcus
hwemolyticus beta meningitis.
2. The value of the soluble dagenan is
stressed, because in this form more efficient
administration and control of the drug can be
carried out.
3. Administration by mouth in the earlier
cases produced vomiting which tended to pro-
duce uncertainty as to the dosage and how much
the patient had retained. The addition of
nicotinic acid to this compound seems to have
reduced the vomiting and some of the toxic
manifestations.
4. Careful attention to the white blood cell
count and the condition of the kidneys must be
given to all cases under active treatment.
5. Forcing fluids with frequent lumbar punc-
tures is an important step in the treatment.
6. Maintenance of satisfactory chemical level
in the blood and cerebrospinal fluid (46 to 8 mg.
per cent).
7. Early and accurate bacteriological diag-
nosis must be established.
I am indebted to Dr. D. H. Ballon, Director of the
Department of Otolaryngology of the Royal Victoria
Hospital, and my colleagues, for their co-operation and
permission to use certain of their cases. I am also in-
debted to Dr. Wilder Penfield, Director of the Montreal
Neurological Institute, and his colleagues, for their sub-
stantial contribution to the material that appears in
this paper.

ORTHOPTIC TREATMENT OF STRABISMUS*

BY JAMES MCGILLIVRAY, M.D.
Chief of Department of Ophthalmology and Orthoptics, Children's Hospital, Winnipeg
ALTHOUGH the treatment of strabismus nurse, who takes the vision. This is preferably
should begin when a definite deviation is done with a revolving illiterate E chart.
noted, orthoptic measures can only be instituted Refraction under atropin follows. The rule
when the age of the patient makes co-operation is to give esotropes with hypermetropia, a full
possible. In clinics this is usually at five years, correction, thus holding in abeyance the accom-
but in private practice one can often begin a modation-convergence reflex. Exotropes would
little earlier. be under-corrected, also esotropes with myopia,
At the Outdoor Clinic of the Children's Hos-
while myopic exotropes would receive a full
pital our procedure does not vary much. First, correction.
The child is then seated before a synoptophore,
the age and date of onset are recorded, then, any where the following data are obtained.
history of infectious diseases or hereditary fac- (a) Objective angle.
tors. The approximate angle, plus or minus, is (b) Subjective angle.
noted, also, whether the condition is monocular (c) Presence or absence of:
Simultaneous perception.
or alternating. Finally, the motility of the eyes Simultaneous macular perception.
a Hyperphoria.
is tested. The patient is then turned over to Cyclophoria.
False associated fixation.
*
Round Table Conference at the Seventy-second Suppression.
Annual Meeting of the Canadian Medical Association, Fusion.
Winnipeg, June, 1941. Stereopsis.
 266 THE CANADIAN MEDICAL ASSOCIATION JOURNAL
If single binocular vision is to be attained, it
is essential that the child should have approxi-
mately normal vision in each eye. To this end
we use some form of occlusion on the good eye.
If the vision in the deviating eye is one-third or
less we use the adhesive patch. Incidentally,
for patients of this class the various occluders
offered on the market are a waste of time, and
the same can be said of atropin. Occlusion
should be maintained until the deviation is re-
versed. But in children under seven years care
must be taken lest the good eye becomes amblyo-
pic. Usually a cover should not remain on
without inspection for more than a month. The
longer the deviation has persisted, the longer the
total occlusion required. If, however, a reversal,
and with it an improvement in vision, is not
possible in six months the best that can be ex-
pected is a cosmetic result. When reversal does
come, the lens before the good eye is either
stripped, covered with a cellophane patch, or,
shellacked. The patient is then ready for
orthoptic training, and is instructed to return
two or three times a week.
Again, seated before the synoptophore, and
wearing his correction, the patient is asked if he
sees the soldier in the hut, the car in the garage,
or, any other Grade I slides-the instrument
being adjusted to his angle. If he does, he has
simultaneous macular perception. The arms of
the instrument are then locked, and lateral
swings attempted. Later, duction exercises are
introduced by converging and diverging the
tubes, the point at which the "break" occurs
being noted, i.e., the point where the soldier
leaves the hut.
The next step is fusion.
Perhaps the best completed target is a rabbit
holding a bunch of carrots, but in one of the
complementary pictures he is minus a tail, and
in the other the carrots are lacking. The same
exercises as in simultaneous macular perception
are repeated. The results, however, are dif-
ferent, for, whereas the car will move out of
the garage on any slight lateral movement, the
fused rabbit will not break so easily. On each
successive day the amplitude of fusion is ex-
tended, until finally the visual axes reach
parallelism.
Not every case, in fact very few, present such
a happy and uneventful ending. Anisometropia
may prove very difficult; for example, a plus
0.5 sph. in one eye and a plus 3.5 cyl. on the
other. Where the differential is even greater, as
[Mar. 1942
in a recent clinic case where the patient accepted
-3.50 sph. with a -3.00 cyl. in one eye and a
+0.75 sph. with a +1.25 cyl. in the other,
single binocular vision was obviously out of the
question.
When a child turns his eye in he must ex-
perience diplopia, project at a false angle, or
suppress. Suppression is very common. It may
be partial or complete. For its treatment dis-
sociated objects are used, such as the car in the
garage. The angle of the synoptophore is ad-
justed to somewhere near the patient's angle,
and he is prepared mentally by telling him to
look for the car in the garage. Frequently he
will say that he sees the car but that it is to the
right of the garage. On converging the tubes
so as to bring the car closer to the garage, sud-
denly he will state that the car has faded out
to reappear on the other side. This "black out"
is the suppression area. The usual procedures,
after telling the child to fix steadily at the
garage, are:
1. Increase the illumination on the car as it passes
over the suppression area.
2. Flick the slide up and down.
3. Execute short lateral movements, on the theory
that a moving object excites more interest than a still
one. This is sometimes spoken of as massaging the
suppression area.
Usually this fading out, or, crossing over,
becomes progressively shorter until finally the
car is seen in the garage. All movements of the
instrument are stopped, and the child is allowed
to look for a while at the completed picture.
About twenty treatments suffice to overcome
suppression. A return of diplopia is a good sign.
Another problem is false associated fixation.
This condition is said to exist when the patient,
for example, in a convergent strabismus, puts
the soldier in the hut, not at his own angle but
at zero or a few degrees' plus. As to incidence:
In a group of 400 cases we had 34, or 81/4 per
cent. This is considerably lower than that re-
corded by Pugh with 186 out of 400, or 42 per
cent.
The treatment of false associated fixation
leaves much to be desired. In our experience
only about 50 per cent develop true projection.
The synoptophore is of value in stimulating the
macular areas, and in breaking up suppression.
Patching is important. By this means the child
is prevented from using his false, which may
slowly be abolished from disuse. Frequently
operation is required, and so, when the eyes have
been put straight and the patient is passing
Mar. 19421 McGiLuvRAY: STRABISMUS
McGILUvRAY:
through a period of visual reorientation, the
orthoptist should make her final bid for fusion.
But even if fusion is not attained, the cosmetic
result is always worth while. As. a matter of
fact, to the child or the parent single binocular
vision usually means nothing.
After operation, a rare but annoying symptom
is persistent diplopia. But what is more dis-
concerting to the surgeon is that if pre-operative
training has not been sufficient his patient may
slip back to his old angle.
Another hurdle is "loss of central". In these
cases the eye has become so amblyopic that it
will nlot follow the finger or a small flashlight.
We had 25 of these. Twenty-three regained
fixation, and the average period of treatment
was seven months. In this connection it is of
interest to note that many writers claim that
loss of central cannot be cured.
A condition not to be confused with the above
is eccentric fixation. Here, there is a large and
obstinate suppression area. When the dominant
eye is covered the other still deviates at about
the same angle. Vision is low, usually less than
1/10th, and abnormal retinal correspondence be-
comes absolute. My experience with these cases
is that they are hopeless from an orthoptic
standpoint.
Finally, there is the problem of vertical and
torsional deviations. In the former, the soldier
(using Grade I slides) is too high or too low
for the hut. In the latter, he is seen to be
leaning. Out of a group of 169 cases we had
11 with marked hyperphoria. The treatment
consists of:
1. Refraction.
2. Get rid of suppression and false associated fixation.
3. Fusion exercises.
THE GAME OF GOLF.-Golf is a form of work made
expensive enough for business men and doctors to enjoy.
It is what letter-carrying, ditch-digging and carpet-
beating would be if they all had to be performed on
the same hot afternoon. The game is played on care-
fully manicured grass with little white balls and as many
clubs as the players can afford. A golf-course is 18
holes, 17 of which are unnecessary and are put in to
make the game harder. A hole is a tin cup in the centre
of the green. A green is a small parcel of grass costing
about $1.65 a blade and usually located between a brook
STRABISMUS
267
267
4. Correct lateral deviation, either by orthoptics or
operation, or, both.
5. From the observation that a covered eye turns
upward, one should patch the hypophoric eye.
In conclusion, a few observations may be in
order on the more important devices used in
orthopties. The key instrument is, of course,
the synoptophore. It is not only accurate, but
it is also a great time saver. Angles, grades of
vision, or, suppression can be quickly deter-
mined, but frequently a patient will not show
the same progress off the instrument that he does
on it. For the further development of single
binocular vision I still like the old style stereo-
scope with Wellsworth charts. Besides, if one
is dealing with a residual angle, it is not diffi-
cult to slip in a compensating prism.
Bar reading is also excellent training if one
is sure the child is not alternating or moving
his head. This exercise can be done at home.
No expensive instrument is needed. A pen or
a pencil will do, held midway between the eyes
and the printed page.
Another very useful instrument is the cheiro-
scope. It is designed so that the child looking
through a pair of plus 8 spheres, secured in a
head rest, draws with his right hand a picture
thrown on a slanting mirror which acts as a
diaphragm visible only to the left eye.
There are many other devices, and they all
have a place, if properly controlled, in a well
appointed clinic. Slides should be used of those
things in which children are most interested.
The more colour the better, and exercises should
never be continued to the point of boredom or
fatigue. This is particularly true of younger
children. To them orthoptics should combine
all the entertaining features of a picture show
and a game.
and a couple of apple trees or a lot of unfinished ex-'
cavation. The game is to get the ball from a given
point into each of the tin cups with the fewest number
of strokes and the greatest number of words. The ball
must not be thrown, pushed or carried. It must be
propelled by about $200 worth of curious looking imple-
ments, especially designed to provoke the owner. After
the final or 18th hole the golfer adds up the score and
stops when he reaches 87. He then has a shower, a
pint of rye, sings Sweet Adeline with. six or eight other
liars and calls it a perfect day.-Bull. of Vancouver Med.
Ass., Nov., 1941.