On Eversion of the Eye, after the Operation for Strabismus

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On Eversion of the Eye, after the Operation for StrabismusAuthor(s): James J. AdamsSource: Provincial Medical and Surgical Journal (1840-1842), Vol. 1, No. 24 (Mar. 13, 1841), pp.387-389Published by: BMJStable URL: http://www.jstor.org/stable/25490182 .Accessed: 18/06/2014 08:02

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MR. ADAMS ON StRABISMUS. ' a

387

puzzled. The fact is, there is a fissure of the rectum, anid you may be led to suspect as much from the excruciating pain comsplained of, which is much greater than is com mnonly met with in mere cases of piles. You will also find considerable, difficuilty in passing the finger; it is tightly grasped by the sphincter, and the mall complains of its causing intolerable pain, so that you will always do well to put him in a corner where he caninot recede from you, be-' fore attempting to examine hiim. The finger being passed, you discover that there are no piles, but on turning it backwards and upwards towards the os coccygis, which is the mo3t usual seat of tbe fissure, you feel a deep sulcu, excessively tender to the touch; and on pressing which, all the synmptams are imtnediately aggravated. On withdraw ing the finger you find that its tip is stained with blood.

Now. you cail not only at once relieve all the symptoms, but cure. the disease to a moral certaiity by a straight bis toury. You pasthis instrument and cut straiglht throuighl te fissure, merely dividing the membrane, submucous cellu lar tissue, and a few of the muscular fibres, when all the symptons are gone; for even if a motion be passed soon after, there is merely a little smarting from the raw surface. Variouis other means have been recommended,.-zinc, cate chu, alum, and nitrate of silver. The three former are pf Very little use. The nitrate of silver destroys the sentient ,extremities of thes nerves, and relieves for a time; buit the sloughi is soon thrown off, the new granulations are as sensitive as the old' fissure, and all the suffeiing recurs,

while the' disease i5 certainly and rapidly cured- by simple iqcision. All you have afterwards to do is to attend to the state of the bowels and general health.

With regard to external piles, Sir Everard Home is of opinion that they do not take their origin in congested and dilated veins, as the internal ones do, but they arise from inflammation of the subcutaneous cellular tissue, and its thic'kening with deposit of adventitious matter. 'This is true with respect to one species, but there is another kind

which has been internal, but has become cuticular from constant protrulsion. Sometimes you will have both inter

al and external piles in the same patient, and sometimes what you may call the interno-external, from their hlaving origin ated internally. In the external you have more pain in the course of the sciatic nerve, and greater tenderness of the .oerirsaum, with very often some prolapsus ani; and

while the ligature is the remedy for the internal, so is ex cision for the externai. You mnust shave the'm clean off, so as to leave the verge of the anus perfectly smoothi, and then all you have to do to complete the cure is to OCCd sionally pass a bougie in the antis, to prevent contraction of the opening, resulting from cicatrization of the wouinds.

Where there are both internal arnd external piles, you must cure the latter first, otherwise they will act as an irritating cause preventing the cure of the former. About six weeks ago I was consulted by a patient in the Edgeware Road, who was in this situation, and his surgeon had tied several of the internal piles without securing permanent good; so I told him to remove the external ones, and this was followed by the most rapid amendment. I was consulted

by a lady, a governess in the family of a nobleman,. part of whose duty it was to walk oult witi the young ladies; but this caused her suIchI intolerable suffering, that she made d confidante of the eldest daughiter, and as she con cealed her infirmity from the rest of the family from a

motive of delicacy, whenever, they went out to walk, she used to go atid lie down at a friend's house close by; the young ladies walked alone and called for her as they returned. At last thils could go on no longer, and she told sue a moyt pitiable tale of her sufferings. The piles wcre external: I excised them, and she was perfectly cured. I - often meet her now, and she always gives me a look of the liveliest gratitude. I remember another case of a gentle

man who vas exceedingly fond of lhuiting, but he suffered extremely from piles, so much so that his saddle has ofteil been covered with blood, and he has had to stop in some field to return the protrided tumors., At last tievy

got so bad that he was obliged to give up his favourite amusement. I removed the external piles, and treated him with enemata and laxatives, but principally insisted on his having his motions at night. This is now eight years ago, and he has never had a return of the piles; but it is also eight years since he had a morning motion, or at least if the bowels from irregular action have acted more than onice a day or in the morning on that day, he never mounted his horse, as he said it gave hiim some faint idea, or siggested the recollection of what he had formerly suf fered. It is to this habit that he attributes his cure, and the case was a most obstinate one.

I have said that prolapsus ani frequently accompanies piles, and therefore it may be as well to say a few words as to its treatment. Under ordinary circumstances, you will cure the prolapsus by palliative means and by curing the piles which have caused it, but if the mucous membrane and the muscles have been so much relaxed as to render a large prolapsus permanent, yoiu must take up two or three folds of the mucous membrane which covers it and surround each fold with a ligature, then return the prolapsed gut into the pelvis. The patient will be disappointed at first as he is not relieved; it is the case that -there will be no great relief till the ligatutres come away, but after that the cure is permnanent, at least so it has proved in either three or four cases in which I have employed this method. You

may meet with a prolapsus t-ou are unable to return, and I remember an extraordinary case of this kind which oc curred to me, whiclh I believe is almost unique, at least I do not remember haring read a parallel one. I was called into the country, just beyond Riegate, some years ago, to see a person 'who was the proprietor of a notorious hell, and who was since shot in a duel at Boulognie. His case had puzzled lhis attendants and they called me in, or he wvislhed it, I forget which, and on going into his rooin I was struck by his cadaverouts appearance, which was heiglhtened as he was naturally a very darkl man. I was just about to ask him some question when he vomited some matter having a peculiar odour, and I instantly ptit my bauid to his groins to discover if he had a hernia, as there was every symptom of strangulated intestine preset.L However I could find none, and was hesitating wlhat to do, when my attention wa4 called to the state of the rectum, and I found a pro lapsus ani larger than my fist. It was turgid and purple, and the man was in fact dying of stranjgulated herniia, for here was the protrusion of a viscus from its naturaL cav ity, and this was not only prevented from returning, not only irreducible, but strangulated. I tried to return it, but found it impossible, so I tnade free incisions over the sur face of the tumour, let off thereby a large quiantitv of dark coloured blood, and tlheni by a little manipulation returned the gnt, and the patR!nt recovered without a bad symptom.

Had -this been inieffectual I should have divided the spliine ter, as I lhave no douibt this was the seat of stricture.

ON EVERSION OF THE EYE, AFTER TI-IE OPERATION FOR STRABISMIUS.

TO TIF. EDITORS OF TIIE PROVINCIAL MIEDICAL AND SURGICAL JOURNAL.

GENTLEME,r;,-T beg to return you my very sincere tlhainks for the readiness and liberality with fvhich you have devoted so large a portion of your valuable Journal to mv last communication, and to fbrward to you, according- to promise, a paper relative to an important practical pointiin the treatment of certain cases of strabismus.

In my last communiication I stated, that in order com pletely to remove the obliqtuity in some particular cases of strabismtus, it yas occasionally necessary to subbmit the

patient to two operations,-one on the distorted eve, thme other on the undistorted, and apparentlx unaffected, eve. I lhave nowv to observe, that two operationis are niot a(ivays. sifflcienjt to maintain an eye which has been affected witlh strabismxs in its central and natural position, but that it is

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388 M4R,.ADAMS

ON STRABISMUS.

occasionally niecessary to perform a thirdl, or even a fourthr, operation, before so fortuniate a result can be obtained; that is to say, either one or both of the external recti

muscles require to be divided after both the internal recti have beeni operated on.

The object of this paper is, not to poilnt out those cases in which a third or fourth operation may be advisable, but simply to state, that there are cases whichl require the third and fourth to make them perfect, and to suggest

means by which surgeons may detect such cases previous to the first and second operation.

A frequent result arising from the division of one or botlh of the internal recti muscles, is the eversion of onie or both eyes to a greater or less extent; the effects of which are sometimess to render the appearance of the patient wvorse, and his sensations far more uncomfortable than they were previous to operation, even to the rendering of fuirther surgical assistance absolutely necessary, in order that he may earn his living, or walk about without the fear of falling or hurting himself. Therefore, that the sur geon about to divide the innier recti muscles may not in future be accused of ignorance, that his skill in operating

may not be doubted, or the patient be grievously disap pointed by so apparently unsuccessful a termination to the operation for convergent strabismus, as the divergence of one or both eyes, it becomes of the utmost importance to the surgeon to be able to fortel such an event previous to undertaking the cure of his patient.

Having felt much surprise that the frequent occurrence of the above-mentioned results of dividing the internal recti muscles has not long since led to the adoption of some

means whereby the disposition to it may be detected, I carefully recorded the minute details of every case wlicih has come uinder my care, in the hope of finding, if possible, some symptoms on whilch e might rely for ani indication of this dispositioni to eversion; and in offering to the pro fession the following simple mnode of detecting stfh like lihood, I now feel thmat confidence which alone can result from extensive practice and repeated observation.

That the mode of examination for detecting the dispo sition to eversion may be rendered most intelligible, it will be well to examine a case of extreme convergent squint in the left eye, the right being straight. Place suich a patient before you iln a moderate light, which should be made to fall equally on both eyes; then let the examiner hold the extremity of a pen, pencil, or any other small- object, directly in front of the patient's nose, on a plane with the transverse axis of the eye-ball, and at a distance of a few inches, say six; the patient should next be directed to look steadfastly, with both eye-lids open, at the object, and the examiner begin to advance the extremity of the pencil graduallv to the root of the nose; having done so, it will be observed that the eyes have beconMe fixed in one of two positions, namely, either both eyes remain equally coIn verged, or one eye will be found more converged than its fellow.

It is in this latter state that the surgeon must look for tlie everting, sign; therefore, that it may be made evideuit in

w%hat nmauner this latter position exhibits the sign, I will beg the reader to suppose the subject under examination to baive, besides the extremne convergent squint of the left eye, a str-ongly marked tendency in the left external rectus to contract after the division of the left internal muscle; or. in otlher words, to lhave two muscles of the left eye affected 'with a disposition to an unequtal and u nnatural contraction at one and the same time, but which, from the cotitractile power being in excess in one of them, is not proved to exist in the wveaker, till the stronger of the two be divided. If the examination be again commenced,-as above recom

mended, and the object be slowly advanced towards the root of the nose, the following curious facts will be observed, accordingly as the object is held at particular distances from the nose :*-the effect of remnoving the object from

rFor the sake of making the different changes in position of the eyes at once distinct and plain, let it be sUpposed that the object is in the frat

the distance of six inches to four, will be a simple conver gence of the right or straight eye, the left remaining fixed in its- inner canthus; as the object is then slowly inoved from four inches tolthe distance of three, it will be ob served that the right eye has become more converged towards its internal canthus, and that the left, inistead of remaining buried in its inner canthus, has gradtully ad Vanced from its concealment towards its natuiral central position, as far as that point which would render its position correspondent to the right eye; thus, the object being held at' three inches, both eyes will be equally convergent; the right having turned from its central position towards its internal cantbus, the left having, at the same time, come from its inner canthus towards its natural central positioni, so that both eyes appear to have been attracted towards the object, and an equal convergence produced. If now the pencil be again moved towards the nose, the equal con vergence begins to be destroyed by the right eye continuing to approach the inner canthus, and the left eye gradually

movinig towards the centre of the palpebral aperture; and wben thie pencil shall have reached to a point distant one and a half inch from the toot of the nose, the probable position of both eyes will be thus,-inner margin of the right cornea near to the internal canthus, and the kft cornea full in the centre of its palpebral aperture; so that as the object has been approximated from the distance of three inches to that of one and a half, the right eye bas appeared to be attracted by it, while the lefthas appeared to recede fromn it: lastly, let the pencil be slowly advanced through the re

maining distance to the root of the nose, and observe what further change will take place. The right eye will become

more and more completely inverted, even to the concealment of a part of its cornea within the inner canthus, whilst the left will have gradually or suddenly turned outwards beyond its natural centre, to some point near the left ex ternal canthus; so that during the approach of the pencil witliin the last inch and a half, the right eye will appear to have been more and more attraCted towards the object, as if not to lose siglht of it, while the left will appear to have been repelled or driven away from it as far as pos sible; for the more earnestly the object be regarded by the right eye, the more extreme will be tlhe divergence of the left.

The instance above given is 'a very rare cgse, beidg Ithe most simple and eltretne form of this tendency to eversion. Something of the same kind may be seen ins the, straight and apparently healthy eyes' of some. person.; for while pursuing a statistical inquiry into the actions of straight and apparehtly bealthy eyes of nunmerou'fltidividuals, I observed that the following -turious irregular association was, by no

means unfrbquent :-if the poinit of a pesoil be held at tlhe distance of a few inches from the nose of a person witd both eyesopen, and directed towards the oabjeet, e slight equal con vergence will take place, arid as the object is' advaneed, the equal convergence will increase up to a certain pint, at a greater ae le4.s distance fom tle inner canthi,; if the

object be nmade to'approacl still nearer to the root of the nose, the convergence will b6eome no longer equal, -one eye will turn more deeply towaids the intenal canthus, and?sppear to keep a steady 'vew of lie object, while the other wilt -have turned, at the sante time, either suddenly or slo*iyo towards the centre of the palpebral aperture, sperhps slightly beyond it, or even to the e?fental'canthus. hi bst lnAewne, though not sa simple as the fitat, shows

how strong tlhe disposition of the external rect.s of one eye is to contract, while the internal rectus of the opposite eye is in a similar conditioti, andho* frequently the convergent power of the inner recti are uniequal.

The simple actions above deacribed T distingui;sh bv the following' terms:-attraction and replion. The term attraction hdre signifying, that movenient of the cornea which tatkes place from tie centre of the palpebral aper

inatanebeld at the distance of el inches from the eyes, ind tbat the pripcpal. changes take, pi" at, the following distanos,-r.fosr inches, t?iree inches, ons ixch and a half, and at the root of the nose.



OPERATIONS FOR THE CURE OF STUTTERING.' 389

ture towards the inner cantlhus, and so applied, because the pupil appears to approach the object, and to keep it constantly iII viCw. The term repulaion is applied to that movement of the cornea wrhich tak-es place in an opposite direction; that is, from the inner canthus towards the centre of the palpebral aperture; here the ptupil will, during a part of its course, turn from the object, and thus we acquire the term repulsion.

In conclusion, if an internal rectus muscle, of an eye affected with strabismus convergens, or of a straight eye, is about to be divided, let the surgeon ascertain if either eye be repelled beyond its centre; for as certainly as the

muscle is divided, so will be the unnatural divergence of the eye which was repelled previous to operation. In

many cases of conveT&ent strabismus, it is frequently found that no sign of repulsion can be detected previously to the first operation; but that on the division of one muscle there will be a distinct evidence of its existence, even, perhaps, to extreme repulsion; thouglh more frequently the repulsion is not central, and theretore need not prevqit the performance of the second operation, after whicli the repulsion is sure to be increased.

I hope that after what has been stated, no surgeon will in future hazard his reputation with his patient by neg lecting carefully 'to examine and search for this signi of eversion, or that he will fail to wmrn his patient of the probable result of dividing an inner rectus, either for the commencement or perecting of a case of convergent stra bismus.-I am, Gentlemen, your obedient servant,

JAMEs J. ADAMS. 27, New Broad Street, City,

March Ist, 1841.

ON DIVISION OF THE GENIO-GLOSSI MUSCLES, FOR THE CURE OF STAMMERING.

BY P. BENNIE:TT LUCAS, ESQ. Surgeon to the Metropolitan Pree Hospital, Lecturer on Surgery at the

Hunterian School of Medlicine, &e.

CASE OF PATRICK HERON.

(Continued from page 367.)

26. SAYS his tongue is steadier in speaking, that there is not tlhe "qiddiaees" ii it there was. He cait turn the tip (if his tongue steadily;and more freely upwards towards

his palate and superior alveolar arches, and ean pronounce without difficulty -words requiring such movemtents. The

'divided edges of tihe inucous membrane are separated from each -other to the extent of fo.ur or five litnes, and the apaco lefl by the division of the muscles is being. filled up with lymphi. The patulous orifice.s of the Whartoniani ducts lhold their natural position to each other, and move with the tongue. 'T'he patient says he did not suffer any pain to speak o? from tlhe operation, and is happy that lie sub nIitteLto it. . March 2. The wound made by the operation is nearly

healed. There is no trace of the fraenunis liuguae. The ability to elevate steadily the' tip of the tongue remains perfect, and he pronouaces, doctor, To, dea4, &c. without itapediment. When he pronounces the word trap, he Say8s he experienoes difficulty in doing so, on account of the t and the r following each other so closely. On watching the movements oft the tongue in pronounmicig troA the organ twists to the left side, which is more tur*d-upwards tha the right.

*Mqri 3,1840. William Clarkson, atat. 18, has stam mered since he was eleven years old. He cannot pro nounce words commencing with t,. -d, ti, &c. withiout experiencing much difficulty. When he makes a deep inspiration before.pronouncing a word commencing with any of the above letters, he overcomeb the diffictity he otherwrise experiences in doing so; but in comnmon con versation his hesitation and sttuttering are very painful.

'T'his patient's palate is very deep and narrow; his tongue is xell lornied; but in order to bring its apcx to tile'

superior alveolar arches, he is obliged to close his moutlh much more than is uisually done, and lhe says he cannot apply it with force against the alveolar arches or palate.

When desired to thrust his tongue out of the Ioutth, and to make its apex pointed, he caninot do so; the apex lhaving a truncated appearance. He complains of pain in con versation, which he refers to the lower part of the sternum.

Having divided the mucous menmbrane of the tongue, which covers the genio-hyo-glossi muscles, to the extent of an inch, anid having carefully and freely divided the sub mucous fcellular tissue in their vicinity, I exposed their antero-inferior edges. By two incisions I divided both muscles, and removed a trianguilar portion of eaclh, the base of*which corresponded to the divided mucous meni brane, and also removed any other musctilar fibres that appeared to confine the free movements of the apex and anterior portion of the tongue upwards. After the mucous menmbrane and subjacent cellular tissue were divided, sonec large veins and a branch of the linigual nerve were plainly discernable, running on the onter edges of each muscle; and although no arterial ramifications were seen, yet the proximity of the ranine arteries to thes9 parts nmade it of conseqiuence to observe caution. The patient for some time after the operation complained of a tingling pain shooting from the incision of the tongue to behind the lobe of the ear, which doubtless arose from a branch of the ninth nerve being divided; but this feeling in a short time subsided.

6. Is improved in a marked manner. His employers perceived t'he diference in his speaking, and asked him to pronounce Nippopotamus, a word which they used before to jest him on for " stumbling," at, but which now he says unhesitatingly. The wound is closing rapidly, a thin layer of lymph only separating its edges, and partly pro truding between them.

Alarrl. 6. Charles William Clarke, vetat. 16. This patient has stammered since he first began to learn to speak. The apex of his tongue is very limited in its move

ments, and its frenum is short. His tongule is unusually small, and very unsteady; he cannot touch with it the superior alveolar arches without his jawvs being more than half closed; and when he attempts this movement

witlh the moutlh open, the frenum lingum becomes very tense. His palate is highly arched, and anteriorly it is very niarrow. The words he finds most difficulty in pro nouncing are thosc commencing with t, n, d, &c., parti cularly if of only one syllable, as to, no, die, &c. Wlen a successioln of syllables, each commencing with any of these letters, comliposes a word, he finds difficulty in pronouncing the first syllable; but this being accomplished, the others follow easily; thus, in the word teetotaler, he says, -t-t-t-lotaler, and can even continue a sentence composed

of words commencinig witlh the letter i without aniy difli culty, except at starting. Having with difficulty accomn plislhed the first i in the following sentence, he pronounces the others freely :-thus, " t-t-t-two teetotalers taking tea together." There are other letters also which this boy cannot pronounioe, and in forming which the lips are engaged, as v, f, b, &c. With the assistance of Messrs.

Hugh Davies, Cameron, and Sharpe, I removed, as in the former case, a considerable portion of both genio-hvo glossi muscles. During the operation the patient coin plained of slight in shooting from the tongue to botl mastoid processes, which, however, almost immediately subsided. The haemorrhage was inconsiderable, and during the steps of the. operation the sub-lingual veins distendedi,

anjd a large branch of the lingual nerve on either sitte

was distinctly visible. A.fter the operation the improvement in the patient's

pronunciation became at once apparent; but not wishlin)g to form a liasty opinion, lest his state of mind at the timiie, his confidence in measures resorted to for his relief, or some otlher such attendant circumstanices might have exer cised its influence in facilitating his methlod of delivery, be was miot inteirogated beyuond a ftw sltxi1ncVs.



Article Contentsp. 387p. 388p. 389

Issue Table of ContentsProvincial Medical & Surgical Journal (1840-1842), Vol. 1, No. 24 (Mar. 13, 1841), pp. 385-400Clinical Lectures, in Course of Delivery during the Present Session at Guy's Hospital, Lect. XII. On Piles, Fissure of the Rectum, and Prolapsus Ani [pp. 385-387]On Eversion of the Eye, after the Operation for Strabismus [pp. 387-389]On Division of the Genio-Glossi Muscles, for the Cure of Stammering (Continued) [pp. 389-390]Remittent Fever Apparently Excited by Gas [p. 391-391]Fracture of the Patella, with Bony Union [pp. 391-392]Improved Apparatus for the Treatment of Fractured Thighs by Extension [pp. 392-393]Provincial Medical & Surgical Journal [pp. 393-395]The Medical Conference [pp. 395-396]Outline of a Plan for Reorganizing the Medical Profession. Given in by Dr. Forbes at the Conference Held at Exeter Hall in Feb. 1841 [pp. 396-397]Poor-Law Medical Relief [pp. 397-399]The Medical Conference [p. 399-399]The Medical Conference [p. 399-399]Newcastle Spring Assizes [pp. 399-400]Sir Astley Cooper, Bart. F.R.S. [p. 400-400]House of Commons, March 8 [p. 400-400]

On Eversion of the Eye, after the Operation for Strabismus

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