NEUROLOGICAL FRAGMENTS.

128

DR. HUGHLINGS JACKSON ON NEUROLOGICAL FRAGMENTS.

contribution to neurology. The following is Dr. Turner’s concluding paragraph : " The view that the oculo-facial group of muscles is innervated from the oculo-motor nucleus, originally advanced by Mendel from experimental facts alone, therefore’ receives corroboration both from clinical and anatomical ’data." Both the papers I have quoted from were the subject of a leading article in THE LANCET of April 1st.5 In the patient under the care of Dr. Ferrier there is wider paralysis-to be mentioned in a subsequent note-than I have indicated, but there is no such complication as invalidates the bearing of the case on Mendel’s hypothesis. I am now dealing with but one point-the state of the orbicularis palpebrarum. I am very much indebted to Dr. Wood for aid in this investigation. To auperSoial observa. tion the patient can shut both eyes efficiently ; but he told the firmest closure he saw light between us that on the lids and volunteered the remark that soap got into, his eyes whilst he was washing his face. Moreover, when he shuts his eyes as strongly as he can we have not theslightest difficulty in opening them against all the resistance he cm make. Clearly in this case of ophthalmoplegia. externa there is some degree of paralysis of the orbiculares.

NEUROLOGICAL FRAGMENTS. BY J. HUGHLINGS JACKSON, M.D. ST. AND.,

F.R S.,

PHYSICIAN TO THE HOSPITAL FOR THE PARALYSED AND EPILEPTIC.

No. 1.

I

TWO CASES OF OPHTHALMOPLEGIA EXTERNA WITH PARESIS OF THE ORBICULARIS PALPEBRARUM (ILLUSTRATION OF MENDEL’S HYPOTHESIS).

HAVING regard to certain researches of Mendel brought into prominence in this country by Dr. Tooth and Dr. Aldren Turner (videinfra) I thought it likely that in cases of ophthalmoplegia externa there would be some degree of paralysis of the orbicularis palpebrarum, as indeed these physicians predicted. I looked for and found weakness of this muscle on both sides in two cases of paralysis of the external muscles of the eyeballs. One of the two cases was that of a patient under the care of Dr. Ferrier, to whom I am indebted for permission to record the observation I made. Mendel’s suggestion is that fibres to the orbicularis palpebrarum, although they come out by palpebrarum. the seventh (portio dura) nerve, do not arise from the There was recently under my care in the London Hospital seventh nucleus, but from the nucleus of the third nerve. a patient, J. C-,aged thirty-four, who had ophthalmoplegia, The two cases mentioned give, from the clinical side, great externa, kindly transferred to me by my colleague, Dr. support to Mendel’s hypothesis. I here refer to an article Frederick J. Smith. It is thecase mentioned by this physician by Dr. Howard Tooth and Dr. Aldren Turner, and also to in a letter published in THE LANCET of April 8the.6The. oneby Dr. Aldren Turner. To both these contributions I am patient is now under my care in the Hospital for the Paralysed very greatly indebted. I quote two paragraphs from the and Epileptic, Queen-square. (I am greatly indebted to Dr. paper in Brain, which is a report by Dr. Tooth and Dr. Hawkes, house physician at the London Hospital, and to Turner of a case of bulbar paralysis, with post-mortem exami- Dr. Wood, house physician at the Hospital for the Paralysed nation, and with an elaborate microscopical examination of and Epileptic, Queen-square, for help in the investigation the nervous centres. of this case.) Here the paralysis of the orbiculares palpe. "Belation nf f rccial7eerve to seventh nllclp.us.-We are enabled brarum is not so great as in Dr. Ferrier’s patient. The’ by the microscopical examination of this case to produce patient can see nothing between his lids when he shuts anatomical evidence of the possible innervation of the orbicu- his eyes and soap does not get in when he washes his face;,9, laris palpebrarum by the oculo-motor nuclei. As above but that the orbicular muscles are weak is clear from the described, the oculo-motor nuclei (third and sixth, fourth not ease with which we can separate his eyelids with our examined) are quite healthy, whilst the seventh nucleus fingers against his greatest efforts to keep his eyes and the ascending loop of the nerve lying dorsally shut. Mr. Waren Tay corroborated this observation. Conto the posterior longitudinal bundles are deeply de- trasts with healthy persons were of course made. The generated. Now it is probable that this ascending limb patient can shut one eye at a time. Mr. Marcus Gunn includes all the fibres from the nucleus proper ; but examined his eyes on June 6th. There was then marked’ the nerve root, on the other hand, passing through the of both upper eyelids, leaving narrowed and equal’ drooping medulla to issue from the side as the seventh nerve, though palpebral apertures. On being told to open his eyes there was not presenting the size and compactness of the normal root, a slightly increased action of the occipito-frontalis, a muscle yet contains many perfectly normal fibres. We must suppose constantly in action in this patient. Both eyeballs moved to, that these have come from some other source than the highly a very slight extent and equally on his attempting to lookto’ degenerated nucleus, and we believe that they come from the the sides and downwards ; there seemed to be no moveoculo-motor nuclei by way of the posterior longitudinal ment upward beyond the horizontal. The right pupil’ bundles, and are passing in the trunk of the facial nerve to was 6 ’5 mm., the leftabout 5 ’75 mm. ; the pupils acted tosupply the unaffected muscles of the upper face, or, as we light and with attempts at accommodation. There was may call them, the oculo-facial group (frontalis, corrugator entire absence of power of convergence. The pupils became supercilii and orbicularis palpebrarum)."3 smaller on attempts to look upwards and dilated on "In support of this view we refer to a suggestive paper by looking downwards. This was confirmed at a subsequent Mendel,4 who performed experiments after Gudden’s method observation by Mr. Gunn, Dr. Wood and myself. On being on rabbits and guinea pigs. The upper and lower eyelids told to shut his eyes tightly both were quite closed and were stitched together and the frontalis extirpated in newthe skin of the lids was thrown into wrinkles, the left being. born animals. After six to ten months they were killed. apparently less firmly closed than the right. On endeavouring Careful examination of the abducens and of the seventh nuclei to overcome the resistance of the orbiculares palpebrarum failed to show any change in them. The facial trunk on with the finger both were found to be rather feeble, the left the side operated on appeared thinner than on the other being the more so. At my suggestion cocaine was dropped side. Marked changes were found in the hinder parts of, into one eye. Its action on the pupil was marked, but the third nucleus-namely, greater diminution in the number Mr. Gunn observed no widening of the ocular aperture after of the ganglion cells, so as to cause the nucleus as a forty-five minutes nor did Dr. Wood several hours later. whole to be much smaller on the same than on the opposite Dr. Wood made two other examinations with like results.i side. The cells were atrophied and their protoplasm stained defer making any remarks on the action of cocaine in the case less vigorously than normal. He suggests that the path of- of this patient. One reason for doing so is that about six connexion between the oculo-motor nuclei and the facial nerve weeks before the observations made by Dr. Wood cocaine is the posterior longitudinal bundle. did, as Dr. Hawkes and I witnessed, produce widening of the In the paper in the Royal London Ophthalmic HospitalI aperture of the eye into which it was dropped. It is to be Reports, vol. xiii. p. 328, entitled "The Diagnostic Value ofE observed that, in one examination made by Dr. Hawkes, there the Loss of the Pupillary Light Reaction, with a Note on the3 was dilatation of the pupil of the cocainised eye without Oculo-facial Muscular Group," Dr. Aldren Turner deals with1 widening of the ocular aperture until after the lapse of some the matter again. He considers the clinical and experimental1 time ; the widening was noticed an hour and a half after evidence, and adduces anatomical data from the case he and1 the instillation. I am indebted to Dr. Wood for the Dr. Tooth recorded in Brain. This paper is a very valuablee following electrical examination of the patient. " On faradaising the orbicularis palpebrarum there was found 1 Brain, to be less response in this muscle than there is in that of a part lvi., Winter Number, 1891. 2 Royal London Ophthalmic Hospital Reports, vol. xiii, part 3. normal Several healthy persons, including myseli 3 Study of a case of Bulbar Paralysis, with Notes on the Origin ofifand Dr.person. were Willis, tested, and a very distinct difference Certain Cranial Nerves. Brain, vol. xiv., p. 437. 4 Ueber den Kernursprung des Augen-Facialis : Neurologisches Oculo-motor Symptoms in Organic Nerve Disease. Centralblatt, 1887. p. 537. Mendel refers to a discussion on the subject 6 Oculo-motor Symptoms in Organic Nerve Disease. in the Berliner Klinische Wochenschrift, 1887, No. 48. ,

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5

MR. F. T. PAUL ON GASTRO-ENTEROSTOMY.

could be demonstrated. It was possible to obtain, by using a weak faradaic current, no reaction in the patient’s orbicularis palpebrarum, whilst the same current caused a distinct contraction in that of a healthy person ; the patient’s orbicularis oris reacted to a current which would not contract his orbicularis palpebrarum. On using the galvanic current it was found that there was no changed polar reaction and that kathode closing contraction was in each case greater than anode closing contraction, but the contraction with the same current was not so good or so sharp as in that of a although the same strength of current was healthy person, used in both." A slight degree of paralysis of the orbicularis palpebrarum may easily be overlooked. To refer to a very different kind of case from the two instanced, one may note differences in the degree of closure of the two eyes in one patient. In some cases of ordinary hemiplegia the patient can shut the eye on the paralysed side efficiently, although not so firmly as on the sound side. This is to be proved by the much greater ease with which one can open the eye on the side paralysed than one can the eye on the non-paralysed side against his resistance. I will now merely allude to a few things having a general bearing on the application of Mendel’s hypothesis. I suppose that it is the inner circle of the orbicularis palpebrarum which is, or is most, affected in the cases of ophthalmoplegia externa mentioned. We have, Fuchs tells us with regard to closure of the lids, to distinguish between moderate closure, such as takes place in winking and in sleep, and the process of screwing the lids tightly together. Duchenne says that the orbicularis palpebrarum is really composed of four muscles. Everybody knows of Darwin’s researches on the action of the orbicularis palpebrarum during crying &c. No doubt this muscle is represented in several places in the central nervous system (lowest level), according as it takes a share in different movements (actions). I have often

129

published records from other districtd appear in to be of a more hopeful nature ; but prolonged relief is certainly the exception and not the rule, whilst the symptoms have in several cases pointed to a repetition of the Liverpool experience, though the result has In not often been verified by post-mortem examination. Senn’s record of his original experiments there are only four examples of gastro-enterostomy. Of these one dog died from causes indirectly connected with the operation on the following day and another was killed on the Hence the first two have little or no seventh day. bearing upon the question of the permanency of the opening. The third was killed on the thirty-fourth day and the fistulous opening was found to be large enough to admit the index finger. The fourth was killed on the fourteenth day and the opening was entirely closed. Mr. Bowreman Jessett records two experiments in which he repeated Senn’s operation, killing one dog three weeks and the other a month afterwards, with the result that water passed freely through the opening in each case, but the size of the opening is not stated. Senn’s explanation of the cause of closure is that either the opening in the bone-plates was too small or the lateral sutures had been passed too near the edge of the cut, thus allowing its margins to approximate. But whether this simple explanation is correct or not, and it is at least doubtful, the fact remains that both in the original experiments and in the practice of several surgeons subsequently the opening has closed. At the same time it may be said to have been clearly shown that a fistuloug communication The cancer. some instances

between the stomach and bowel may be established, even in very debilitated subjects, without great risk to life, and this is an important point. Having once learnt the secret of a safe operation, it is surely only a matter of detail to secure an opening which will prove to be more permanent. Cases in the human subject seem to show that the inosculation is at first quite satisfactory, that for some six or eight suggested that nervous centres represent movements, not weeks it remains fairly free, and that then it slowly contracts, muscles. It is suggested that one place for the representa- with the recurrence of symptoms of obstruction. This points tion of the orbicularis palpebrarum is that where the external to the character of the opening being in fault rather than It is a clean incision ocular movements for directing the eyes for the estimation of the bone-plates or the suturing. distance are represented. Presumably the peering move- involving no loss of tissue, and clean incisions in the ments of a short-sighted person-movements helping him to stomach tend to heal remarkably well. Probably the more see better-will be represented with certain movements of the food that passes through the new opening the better it is eyeballs. Since writing the foregoing I have seen, with Mr. maintained, and that in cases of combined pylorectomy and Couper, a patient the subject of ophthalmoplegia externa. The gastri-enterostomy, like Mr. Rawdon’s and Mr. Jessett’s, it lateral movements of both eyes were nearly abolished and the would always be permanent; but the obstruction offered by upward and downward movements were much narrowed in a pyloric cancer is diminished by the temporary relief which range; there was ptosis on the left side. The pupils acted to the operation affords, just as rectal stricture yields for a time light and during accommodation. In this case the orbiculares after colotomy. No doubt at first food again passes by the palpebrarum were weak ; the one of the left side was the pylorus, as we know that fasces pas again by the rectum weaker. Mr. Couper examined these orbicular muscles care- when no "spur" has been made, and in either case the new fully and agreed with me that they were decidedly weakened. opening is liable to shrink. It was in the belief that the Subsequently he examined J. C-. and agreed in the obser- cause of failure is to be found in the character of the vations as to the weakness of the orbiculares palpebrarum. opening that some further experiments, presently to be Another drawback to the Manchester-square, W. described, were undertaken. present method of operating is the necessity of bringing the jejunum across the transverse colon to attach it to the front of the stomach. In my case this produced a GASTRO-ENTEROSTOMY: condition of partial obstruction, which was very troubleBEING A MODIFICATION OF SENN’S METHOD.1 some to the patient owing to the constant distension of the csecum with gas. The difficulty has been met in two ways. BY F. T. PAUL, F.R.C.S. ENG. &c., is at all satisfactory. neither of which One is to tear SURGEON TO THE LIVERPOOL ROYAL INFIRMARY. through the transverse meso-colon and gastro-colic omentum and to bring thejejunum through this opening to the front of SENN’S bone-plate method of performing the operation of the stomach. The other is to turn the whole stomach up gastro-enterostomy has been practised in the neighbourhood and to attach the intestine to the back instead of the front of Liverpool about six times, and three patients are known to surface of it. The former plan has resulted in obstruction of have lived long enough after the operation to test its results. the bowels through kinking, and the latter is a very difficult in Mr. Stansfield’s patient lived for four months, symptoms and sometimes impossible operation to perform the presence of malignant disease. of pyloric obstruction recurring about eight weeks after The operation about to be described strangulates the conthe operation. A post-mortem examination was made and nected surfaces of the stomach and intestine, effecting by the new opening was found to be perfectly closed with the sloughing a clean circular opening between the bowel and the silk ligatures ira situ. Mr. Larkin’s case, so far as the opening back of the stomach, which in experiments on dogs has is concerned, proved to be an exact counterpart of Mr. shown no tendency to diminish up to a period of 107 days, the longest experiment made. The special apparatus required Stansfield’s, and there was my case, in which the patient involves more than a hard ring, preferably of bone, died about two months after the operation with the opening about nothing of an inch in diameter for human inthree-quarters contracted to at least one-third of its original size. These testine and with four small equidistant holes. perforated being the only "successful"cases in this district, it is perhaps The ring may be rounded on all sides or only on one, as in not to be wondered at that physicians are a little shy of the diagram (Fig. 1). This surface should always be round in encouraging the operation of gastro-enterostomy for pyloric order that it may not cut the piece out too sharply and lessen the breadth of surrounding adhesions. The four holes are 1 Abstract of a paper read at the Liverpool Medical Institution. charged each with a needle carrying a strong double silk