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On the Amaurosis and Painful Affections Which Attend StrabismusAuthor(s): James J. AdamsSource: Provincial Medical and Surgical Journal (1840-1842), Vol. 2, No. 30 (Apr. 24, 1841), pp.66-68Published by: BMJStable URL: http://www.jstor.org/stable/25490319 .

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MR. ADAMS ON AMAUROSIS.

most dangerous liquids in the economy, and produces the most frightful ravages, when it is effused into the serous cavities, or infiltered within the cellular tissue. It is not therefore astonishing that one or more of its component parts, forced,

we know not how, to enter the torrent of the cir culation in consequence of the operation of cathe terism, should become the cause of the phenomena. I will not, gentlemen, insist too much on this point, for it is too easy to lose oneself in the field of hypothesis. The most important point to be ascertained is the treatment. Unfortunately I am unable to inform you on this point; it is im possible to determine a preservative treatment, for accidents occur under circumstances the most opposed. I am as much at a loss in the way of curative treatment. I have employed, without suc cess, venesection, leeches, emollients and anti spasmodics. The disease has advanced in spite of

*ese remedies, and in other circumstances it has cured itself without anything having been done.

Ought we to open the articulations when they are distended with pus ? I have mentioned a case of cure to you, in which I opened both tibio-tarsal articulations, which operation was followed by re covery; but this is probably only an exception, as death is most commonly the result of such open ings. You know that purulent arthritis in the knee is almost always mortal. The amputation of the limb is the best remedy in such a case; but 'when several articulations are attacked at one time, what can you do? Wil you open all the articulations, or practise amputation of several limbs on the same subject? If the case be com plicated, as I believe it is, with the presence of a deleterious agent in the animal economy, how are we to combat it when we are ignorant of its nature? In trusting that new researches will dis cover to us the remedy for these terrible accidents, 1 have thought proper to describe them to you, and recommend you to study them well, for their etiology is extremely obscure, and above all to be on your guard against them, for you see, from what I have told you, how ineffectual our present resources are.

ON THE

AMAUROSIS AND PAINFUL AFFECTIONS WHICH ATTEND STRABISMUS.

TO THE EDITORS OF THE PROVINCIAL MEDI CAL AND SURGICAL JOURNAL.

GENTLEMEN,-In mylast communication to you I stated that there existed numerous cases of amau rosis, more or less complete, and totaUy uncon nected with strabismus, which were capable, by the division and free separation of certain recti

muscles, of being cured or relieved. On the same occasion I described a most interesting case of par tial amaurosis, where no obliquity of the eye was present, with the particulars of its cure by opera tion; and expressed a hope that I should speedily be able to offer to the profession a simple means of detecting the like cases of amaurosis, to which, for their cure, the division of the recti muscles is applicable.

Preniously to fulfilling the above intention, it has appeared to me that a report of the following new and important observations, which I have

made on amnaurosis, as connected with strabismus, might not only prove highly acceptable to the pro fession, but lead to the future better understand ing of that peculiar form of amaurosis, which, un accompanied by strabismus, admits of cure by operation.

Amaurosis, when complicated by strabismus, is frequently attended by very peculiar symptoms,

which so vary in particular cases, that the sur geon, previously to any operation, may predict, often with certainty, the degree of sight that will be restored to the patient after the strabismus has been removed.

The symptoms are of two kinds, objective and subjective.

The objective are few and simple ; being a slightly-dilated state of the pupil, with a greater or less obliquity of the eye.

The subjective symptoms, on the other hand, are remarkable for their variety and severity. They admit of being classed under two heads; namely, those which concern the sight, and those which affect the parts either in the neighbourhood of the eye, or at a distance from it.

Firstly, of those which affect the sight, the fol lowing are the principal:-NWhen both eyelids are open, objects may appear double, either on all sides, or in a particular direction. The patient

may be unable to read, or to view minute objects, without bringing them to within two or three in ches of the eyes, and even then may not be able to read a moderately-sized print, nay, even a large one, for longer than the space of two or three mi nutes, without the letters becoming so misty and confused, that a black mass alone seems presented to the view.

The above imperfection of vision is an extreme case, and of not very frequent occurrence; the

more frequent symptoms are less severe, and are as follow:-If small objects are to be viewed, or a book is to be read, they are brought closer to the eyes than is usually natural, in order that the pa tient may see them distinctly or read clearly, and this he may do, without inconvenience, for the space of ten or twenty minutes, when the sight

will become gradually dim, the object indistinct, and the letters confused, and (as it were) running one into the other; if the patient continue to look at an object or print, for the space of a few se conds, it will become distinct, then misty, again distinct, and again misty, till at last the mist will increase and remain to such an extent that the form of the largest letter cannot be seen, and he

will become, for a few minutes, more or less blind. However, if the eyes be closed for a few seconds, the sight will be again restored, and the patient once more enabled to see to read distinctly; though, instead of being able to read for twenty

minutes before the symptoms of confusion and dimness of vision commence, he will find that he cannot read during more than ten or fifteen before another rest will be required, and that of a longer duration than the first, even, perhaps, to three or four minutes; at the end of which time the sight

will again become fit for reading, but for a still shorter period: perhaps not more than five mi nutes will elapse before the confusion of the letters will require another period of rest, of a still longer duration than the preceding; thuis the increasing inability to maintain a clear view of an object ,ill continue, until at last the patient will find it

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MR. ADAMS ON AMAUROSIS. 67

impossible, even after a long rest, to see any near object for more than a few seconds together; he is therefore compelled to give up, for many hours, or for the remainder of the day, the em ployment of his eyes on the subject which causes the dimness. Thus are numerous individuals ren dered perfectly incapable of earning their living by any employment which requires exertion on the part of the eyes.

If each eye be examined separately, its fellow being closed, it will, most commonly, be found that one eye has excellent sight, and can view the

minutest objects for a long time without fatigue; while the other is more or less imperfect, seldom, indeed, to such complete amaurosis as not to be able to distinguish between light and dark, thouigh frequently to a degree of blindness which will not permit the patient to guide himself about, if the best eye be closed. The most frequent degree of impaired vision is somewhat less than the above, the patient being able to distinguish the forms of large letters, without being able to read a full size print.

The impairment of vision is sometimes likened unto a dark or light fog, a mist or cloud.

Its degree may be permanent, or liable to con siderable variation; the most frequent variation is a rapid increase of density in the mist, on the slightest application of the eye to a minute object or print. The extent or situation of the mist is subject to much variety; in some cases it is con siderably more dense in the direction of the outer canthus; in others, towards the inner canthus; and in certain instances the object is most obscured when situated directly in front of the central axis of the eye. Of all these peculiarities, the one of the most importance to the surgeon is, the rapid increase of dimness in the affected eye when it is called into use by itself; for in no instance where the patient has permitted me to perform the ne cessary operations for its removal have I failed to restore the eye to perfect and permanent good sight.

Secondly, of those symptoms which affect the parts in the neighbourhood, or at a distance from the eye: they present so remarkable a character, and are of such frequent occurrence, that I cannot but express my surprise that they should so long have escaped observation and mention.

The most frequent symptoms of which a stra bismus patient will complain, are occasional pains and aching over the brow of the affected eye; they are produced or aggravated by exerting the eyes on bright objects, or' by attempting to read for longer than a few minutes; in some cases, if the patient will persist in endeavouring to read or

work, the pains will extend to the opposite brow, across the forehead, and through both temples, till they become so severe that he is compelled to rest his eyes; in others, lachrymation will be pro fuse, and increase in proportion to the degree of pain, so that the sight, by the presence of the tears, will become obscured, and form an addi tional reason for the patient's desisting from read ing or working; in a few cases, simple dimness,

without lachrymation, will accompany the pain, and increase according to its severity, so as to requare a temporal but perfect rest of the eyes.

'rhese painful symptoms resemble, in one re spect, the dimness and confusion of vision; that is, in their mode of approach: for if the patient

be anxious to pursue his occupation, and will only rest his eyes when the pain is 'intolerable, and attended by dimness of sight, he will find that the periods of occupation will become shorter and shorter, while the intervals of rest will require to be gradually increased in length, even to the abso lute rest for many hours: such are the frequent symptoms produced by attempting to read small prints, or to view objects which are fine and bright. However, particular employment of the eyes is not the sole exciting cause of these pains, for they are frequently produced by light and heat; indeed, the majority of persons who are afflicted by strabismus complain of more or less pain over the brow of the affected eye, if exposed to a strong fire, or to the heat and light of the sun during the summer; in some cases, the rays of the sun will produce a most severe pain in the eye-balls, brows, forehead, and temples, with an aching of the whle head, particularly at the occiput; the samptoms being frequently worse on the side in which the affected eye is situated.

In some cases, the cause of these peculiar symp toms is not so apparent, for they come on periodi cally; in many of these instances, the pains have not only been of the most severe kind, but the patients have suffered from violent attacks of gid diness and sickness, which have obliged them to keep their beds during one or two days on each occasion. In two remarkable cases of this de scription the patients declared that they had never remembered to have been quite free from pain about the eye and brow.

The frequency of the attacks is liable to much variety, even from three times in a week to once during a fortnight or three weeks; or, what may appear still more curious, to only the summer

months. The duration of an attack may be from one

hour to twenty-four, or longer. The length of time to which a patient may be

liable to these attacks is from childhood to nearly fifty years, or indeed till relief by operation; in

many instances the attacks last but few years, then cease to trouble the patient; but in a few cases they have lasted so long as seriously to affect the health of the patient.

I have been thus particular in describing the above painful affection, both because I believe it to have been here described for the first time, and because its severity, however extreme, forms no kind of hindrance to the performance of the opera tion for strabismus, but, on the contrary, renders the division of the recti muscles more than ever to be desired; for in no instance has the division and extensive separation of one or more of the recti muscles failed to permanently relieve or cure it.

The following curious and novel fact is one of the most remarkable that I have found to occur in the treatment of amaurosis or impaired vision,

when connected with strabismus, namely, that it is occasionally necessary to produce a temporary amaurosis in the straight and well-seeing eye, for the complete removal of a long-standing amaurosis*

in the distorted eye. In ord'er that the above in teresting result of my investigations may be ren

v For what is here meant by the teru amnaurosis, I beg to refer the reader to the detinition which has been giveni in my last communuiication to the Provincial Medical and Surgical Joturnal. See No. 27, vol. ii.

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68 DR. FOVILLE ON THE BRAIN.

dered the mori intelligible, I subjoin, as an example, the following case, which is one of several of the like kind.

M. A. B., afflicted by convergent strabismus of the right eye, the sight of which is so imperfect that she cannot see to guide herself about by it unassisted by the left. Sight in the left eye per fectly good.

1840, Oct. 19. I divrided the right internal rectus; position of the right eye became nearly central, and its sight very much improved.

November 19. Divided the left internal rectus. Both eyes became abducted, the right more than the left; and the sight still more improved in the right: but in the left the sight was made bad.

December 14. Divergence of both eyes equal; sight very imnperfect, but equal.

1841, February 8. Divided the right external rectus. Position of the right eye, central and na tural; its sight perfectly restored: while in the left it was rendered still worse than before the last operation.

March 12. Divided the left external rectus, which caused the left eye to become central and correspondent with the right. Previous to the last operation the patient could not see to read, by the left eye, a large print, but in a few minutes after the division of the muscle she was able to read newspaper print, and in a short time the sight became as perfect as ever, and equal in strength with the right.

-To these, and to the mention of many other deeply-interesting facts which I have repeatedly observed during the treatment of impaired vision, I will take a future occasion to return; here only observring in conclusion at present, that the neces sity for these operations on the apparently unaf fected eye is not confined to cases of impaired vision complicated by strabismus, but is applicable to cases of impaired vision which are not attended by any obliquity of the eye.

In order that many of your readers may not be deterred from pursuing this practice, permit me to say, that I have divided upwar ds of four hundred recti muscles, without ever having produced the slightest permanent impairment of the sight.

I am, Gentlemen, Your obedient servant,

JAMES J. ADAMS. 27, New Broad Street, April 12, 1841.

NEW VIEWS OF THE

ANATOMY OF THE BRAIN. By Dr. FOVILLE.

(Continuedfrom page 50.) THE convolutions connected with the prolonga

tions in the brain of the fibrous parts which pro ceed from the basilary quadrangle, or the common

meeting point of the sensorial nerves and the pos terior parts of the medulla, constitute all the plane internal part of the hemisphere, the surface of the basilary cerebello-temporal zone, and the lobule of the insula; those developed in the terminations of the pyramidal fasciculus of the crus, constitute all the external part of the hemisphere and the con cave surface of the orbital region of its base. Trhe

respective limits of these two classes of convolu tions are indicated, on the one hand, by a grand line of convolutions, which courses along the

whole extent of the large circumference of the he misphere, commencing in front at the anterior margin of the perforated quadrangle, and termi nating behind at the posterior margin of the same quadrangle; and, on the other hand, by another line of convolutions, which forms the enclosure of the fissure of Sylvius, arising before and ending behind, like the preceding grand line, at the op posite margins of the perforated quadrangle.

Those parts of the brain connected with the fibrous expansions of the lower part of the crura, appear to have no intercommunication between the opposite sides, whilst those parts which pro ceed from the posterior columns enter into the formation of all the commissures. In this fact

will be found the explanation of a very singular phenomenon. In paralytic persons, from cere bral diseases, the faculty of sensation is almost never so completely destroyed as that of motion. This -will be the necessary result of the power which the sensorial parts on the unaffected side have by means of the commissures of communi cating with the affected limb.

From the foregoing anatomical details, Dr. Fo. ville deduces certain physiological conclusions, which he expresses in the form of corollaries, thus:

1. " I consider that the fibrous parts of the brain are conductors, some from without to within, others from within to without. I believe that these conducting parts may be distinguished into affe rentes and efferentes, and that the distinct course of both the one and the other may be demon strated. The first are inserted especially into the circumference of the gray substance, and the se cond into its internal surface."

The "afferent" conductors are those fibres which are intermediate between the posterior parts of the spinal marrow, the optic and olfactory nerves, and the circumference of the convolutions; the " efferent " are those parts connecting the in ternal surface of the convolutions with the anterior pyramids.

2. " 'T'he gray substance of the convolutions in termediate between the two preceding orders of fibrous parts seems to me to be the material sub stratum through the instrumentality of which the

will directs the movements of the body." 'This opinion is greatly strengthened by the fre

quent occurrence of diseased conditions of the gray substance in lunatics; and great stress has been laid on this fact by those physicians who have at tempted to account for insanity on physico-patho logical grounds. Dr. Foville considers that the frequent atrophy of the convolutions in demented persons has its origin also in the disuse of the functions of the gray substance, and that the fibrous portions become atrophied secondarily, as the optic nerve wastes from disuse in the blind.

The latter part of this interesting memoir is occupied with some novel observations on the mo difications received by the cranium from its con tents. It has been generally considered that the solid portions of the brain, and the frontal sinuses,

were the only agents in the production of those prominences and depressions which mark the ex terior of the skull. Wherever a prominence or a bump, as phrenologists call it, was observable,

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