THE DIAGNOSIS OF OCULAR PARALYSIS.

1612 Germinal transmission of a micro-organism, whether spermatic or ovular, is altogether unknown in human pathology. With all due deference to Pasteur’s great authority I am inclined to think that his results with regard to the hereditary transmission of pébrine are in need of careful revision. But even if corroborated by further investigation these researches would have no bearing on the pathology of the human germ cell, which is totally different in structure from that of the silkworm. Placental transmission, although undoubtedly occurring in most infectious diseases, is far too rare in tuberculosis to explain the clinical fact of the frequent existence of the disease in both parent and offspring. The almost general opinion of the medical profession of all countries at the present day is, I think, expressed in the words of M. Bouchard : " Que les parents ne transmettent pas à leurs enfants la tuberculose en nature, mais en expectative, enpossibilite, c’est l’hérédité de terrain." It is on this " territorial " heredity that I desire to make a few remarks. The hereditary disposition to tuberculosis is still denied by some thoroughgoing contagionists. Such an eminent pathologist as Cohnheim considered that the use of the word ’’ disposition " or "predisposition " is unscientific and "rather deters from than invites to further investigation."" Certainly if the word is to receive a tangible, definite, and truly scientific meaning the diversities of disposition must be reduced to diversities of morphological or chemical nature. Since Cohnheim’s days much has been done in this direction. The experimental work of Landouzy, Charrin, and others stands out pre-eminently. Of course, the question of a specific disposition to tuberculosis in the human species could only finally be decided in a strictly scientific manner by inoculating a large number of human beings in the same way, with the same quantity, and the same culture of the bacillus. Such an experiment is, however, not likely to be performed. Meanwhile, we have certain clinical facts which, as far as clinical evidence goes, seem to prove conclusively a hereditary disposition. It is well known to all pathologists, and particularly in those cases of tuberculosis which die about the time of puberty, that the heart is usually found to be small and the aorta narrow. Whether, and how far, this anatomical peculiarity may be considered as predisposing to the development of tuberculosis, and whether it is of a hereditary character, as has been alleged, I will not attempt to decide. On the last point the post-mortem evidence in dealing with two subsequent generations is up to the present too scanty. But another fact seems to prove beyond doubt that at least a local hereditary disposition exists-viz., that tuberculosis in the offspring almost invariably starts in the same lung which was first attacked in the parent. Similar observations have been made by others. I have not been able to prepare an exact table of my cases, but their number is between 25 and 30, and the result is almost constant, where the history of the development of the disease in both generations was capable of being ascertained with sufficient accuracy. I only mention one case as an example. Here the father and three children became affected, all at the age of about 25 years, the disease in every case beginning in the right lung. Such facts certainly prove the hereditary transmission of a locus minoris resistentiæ. With regard to a general hereditary predisposition it has been said that a difference must be made between a specific disposition and a general constitutional weakness, and also between a truly hereditary disposition existing in both parent and offspring, and a congenital disposition not existing in the parent but produced in the infant by the parent’s diseaseun phenontene para-tuberculeux. These distinctions, which are certainly of much scientific interest, are hardly of great practical bearing. That certain constitutional habits, inherited from the parents, play an important part in the causation of pulmonary tuberculosis seems to constitute a clinical The following is an almost fact beyond all possible doubt. classical example in illustration of this fact. It is the case of a family consisting of a father, a mother, and of two and three daughters. The father has a well-built chest and is healthy. The mother is always ailing and suffers from chronic lung disease. She comes of a family in which cases of consumption have been frequent. The three daughters take after the build of the healthy father. They are healthy women. Both sons take after the mother. They are tall and slender and have small flat chests, and have in addition the mother’s reddish complexion, which M. Landouzy has described as "terrain vénitien." From their earliest youth they were away from home at public schools and only sons

The eldest son died from of the other, now 20 years at the 24 years; age consumption of age, is in a health resort on account of lung disease. The daughters remain healthy, although constantly exposed to a at home

during the holiday terms.

greater infection through daily association with the mother.

Cases of this kind have no doubt occurred in the experiof every practitioner. Whether in this case the disposition inherited is specific or not is a difficult question. It is certain, however, that the sons inherited from their mother a constitutional habit which made them specially liable to infection by the tubercle bacillus, but there is no evidence that this particular inheritance renders them more liable to infection by other parasites. The French Hospital in London has lately opened a sanatorium for consumptives at Brighton which I have no doubt will afford relief and cure to many sufferers. At the same time it will give ample opportunity of studying further the important and difficult subject which I have ventured briefly to discuss. The results obtained by further observation I hope to publish at a future ence

date.

Welbeck-street,

W.

THE DIAGNOSIS OF OCULAR PARALYSIS. BY ARCHIBALD S. PERCIVAL, M.B., B.C. CANTAB., SENIOR

SURGEON

TO

THE

EYE

INFIRMARY, NEWCASTLE-UPON-TYNE.

I WAS much interested in Dr. D. M. Mackay’s paper on this subject illustrated by Professor Elschnig’s diagram in THE LANCET of Nov. 18th, p. 1495. Personally I prefer Mr. E. E. Maddox’s diagram (see illustration) as a mnemonic

for the actions of the ocular muscles. It is easily seen from this figure that a superior or inferior rectus elevates or depresses the eye most when the eye is directed (27°) outwards, and an inferior or superior oblique elevates or depresses the eye most when the eye is turned (510) inwards. The 12 muscles of the eyes may be divided into three groups of four each, four moving the eyes laterally, four upwards, and four downwards. ’Aa, Right-turners... Right external rectus’and left A. Lateral.

Ab,

Ba, Ca,

internal rectus.

Left-turners to

to

C Depressors. C. Depressors. Cb, to

(.

Left external rectus and internal rectus.

right

right

Right superior

right

rectus and left inferior oblique. Left superior rectus and right inferior oblique. Right inferior rectus and left

left

...... Left inferior rectus and

ElevatorsBb, to left

B. Elevators. B.

...

......

......

superior oblique. superior oblique.

right

It will be seen, as Mr. Maddox says, that the six pairs in the right hand column are Graefe’s "true associates." ’’ The true associates can always be borne in mind by remembering that their names are the most contrary possiblee.g., the left inferior oblique is in every term opposite to right superior rectus." Now consider the patient’s field of vision : upwards to the right, or right superior area ; to the right, or right external area ; downwards to the right, or inferior area ; and name similarly the three fields to the left. Then in looking towards any superior or inferior area the muscles employed are the same-named rectus and the

right

1613 Thus in looking downwards and to the left-i.e., to the left inferior area-the patient uses his A NOTE ON THE CONDITION OF PATIENTS left inferior rectus and his right superior oblique. AFTER THE REMOVAL OF THE We are now in a position to consider the diplopia which VERMIFORM APPENDIX. will arise from an ocular paralysis. The chief symptoms of under-action of an ocular muscle are: 1. Limitation BY LAWRENCE JONES, M.S. LOND., F.R.C.S. ENG., of movement of the affected eye in some one direction. As SURGICAL REGISTRAR TO ST. GEORGE’S HOSPITAL. they move together in that direction one of the two lags more and more behind the other, producing a continually increasIN the early part of this year I took the trouble to write to ing deviation. This gives rise to (2) diplopia, which is most marked of course in that position of the eyes towards whichall those patients upon whom operations had been performed the affected muscle, when normal, moves the eye. The false for appendicitis at St. George’s Hospital in the years 1900, image is always in the direction of the action of the paralysed 1901, and 1902, with a view to ascertain how many of them were muscle. 3. Altered position of the head. In order to avoid satisfied with their condition and how many suffered. diplopia as far as possible the face assumes a position entirely similar to that which the eye would take were the paralysed from ailments, trivial or severe, which they referred to themuscle to act upon it. In fact, the face looks in the direc- region of the operation. It was impossible to see all thetion of greatest diplopia. Thus the face looks towards the patients personally and the majority of them only 80mright with a right external or a left internal paralysis. municated with me by letter, but, notwithstanding this, It is now an easy matter to determine the particular their answers are, for the most part, sufficiently full and of muscle affected in a given case by noting the diplopia interest. Information was especially asked for on the which occurs on moving a candle to the right, to the left, following points : (1) the existence of pain, constipation, upwards and downwards in front of the patient. If the flatulence, &c., as being possibly caused by adhesions;. diplopia is increased-i.e., if the separation of the image is (2) tenderness of the scar ; and (3) ventral hernia. The increased-in more than one of these directions an affec- number of letters despatched was 184 and from these tion of. more than one muscle is indicated. It is important resulted 87 These 87 may be separated according to replies. to avoid forming one’s diagnosis upon the observed inclina- the condition of the patient at the time of operation into threetion of the false image, for a previous heterophoria may groups : (1) those in whom the peritoneum had become render one’s conclusions erroneous. The procedure which I infected, with a resulting abscess or generalised peritonitis ; adopt is really an epitome of the methods described by Mr. (2) those with a definite acute attack at the time of operation Maddox in his book on the Ocular Muscles and is indicated but with no suppuration outside the appendix ; and (3) those I have found it simple, free from pitfalls, below. upon whom operation was performed in a quiescent period or and logical. Just as " a botanist with a flower inquires a subacute To deal with these groups. attack. during successively into its natural order, its genus and its species," separately. so the ophthalmologist reaches his diagnosis by stages, 1. In some of the cases in which there was definite supdetermining first whether the muscle at fault belongs to the puration around the appendix the viscus was removed during order A, B, or C, then the genus a or b, by noting if the the patients’ stay in the hospital, while in others the abscess separation of the images is increased by moving the candle cavity was merely drained, the appendix being left unto the right or to the left. By placing a red glass before touched. Considering these two classes apart, the first the right eye we can at once determine which eye, and included 22 patients, and of these 12 could mention no therefore which muscle, is at fault. All that one has to do defect in their present health, three suffered with slight in a case of vertical diplopia is to determine in which area occasional local pain, three had noticed some bulging of the of the patient’s field of view the greatest vertical separation scar, one was more constipated than formerly, and one was occurs and the paralysed muscle is either the same-named Two ascribed definite lesions to the operamore flatulent. rectus or the cross-named oblique." Thus if the greatest tion : the first had become ruptured in both groins, an effect, vertical separation occurs in the right inferior area the he considered, of his abdominal scar ; the second, whoseparalysed muscle must be either the right inferior rectus or scar had reopened" " after leaving the hospital, wrote pagesthe left superior oblique. This is Mr. Maddox’s mnemonic describing various vague complaints and has probably deand I have found that it is readily grasped by students and veloped a ventral hernia. Of these two the former has nois never forgotten. The use of a red glass before the right proper ground of complaint. eye distinguishes the two quite simply by means of the Among the patients whose appendices had not been removed two developed an acute attack later and underwent removal appended table. of the offending organ and are now quite well. Nine are in, image to right, right external perfect health, although the appendix is still, presumably, in the right iliac fossa ; six could mention the usual milder increases to right Act left, left internal troubles which, however, failed to inconvenience them rectus. 4 lateralA. Lateral Red image to right, left externa seriously, and included pricking pain with bulging of the rectus. le ft Ab increases to left scar, femoral thrombosis which has since cleared up, slight to left, right internal bulging of the scar, abscess of the scar, and, in two cases, rectus. on exertion. image higher, right superior pain Red 2. The patients, upon whom operations had been perrectus. to right lower, left inferior formed during an acute attack but before obvious peritoneal had occurred, numbered 16, and in no case did Increases up{ B. Increases Red image higher, right inferior infection of these instance trouble sufficiently severe to inany oblique. to left Bb 12 were in perfect health ; Red image lower, left superior capacitate them in any way. in one case the scar was slightly tender on pressure, in two Red image higher, left superior others there was slight pain with some fulness in the scar, oblique. and in the fourth there was a definite hernia at the site of and to right lower, right inferior operation as large as a hen’s egg. C Increases down 3. Those patients operated upon during a subacute attack higher, left inferior or in a quiescent period were 32 in number and furnished the and to left following replies. 20 expressed themselves as being better oblique. in every way and much benefited by the operation, nine Newcastle-on-Tyne. could find some symptoms which they thought possibly due example, four had noticed slight occasional THE QUEEN’S JUBILEE HOSPITAL.—We have to theonscar-for exertion or on coughing, one suffered from conpain received information from the matron of the Queen’s Jubilee stipation, one from "flatulent dyspepsia," another from Hospital that she, a sister, and the staff-nurse have resigned tenderness in the scar, and three thought that the scar their situations at the institution. showed more prominently than before. SMALL-POX HOSPITAL AT DEVONPORT.-A smallThree patients wrote letters which seemed to show signs pox hospital has been erected by the isolation hospital sub- of their dissatisfaction with their present lot ; the first, a committee of the Devonport town council, at a cost of about woman whose appendix had been removed for recurrent £500. The building is of wood and iron and will accom- attacks of appendicular colic and whose wound had supmodate 12 patients-six males and six females. parated, has since developed a large ventral hernia and has z 3

cross-named oblique.

TableofDiplopias. to left internal lRed toleft,

{r

{RedRed image Ab{ Red image

.

.

and

Ba Red image

andand

rectus. Red image Carectus. Cb{{Redrectus. image

.

oblique.

.

.