Gordon Holmes

Cerebral Integration of Ocular Movements

It is customary among us to commemorate great men from time to time by a lecture or discourse relating to their work or to some subject in which they were interested. To-day we meet to pay a tribute to the memory of Victor Horsley, almost on the twenty-second anniversary of his death in the service of his country, while striving for those ideals which characterized his life-the relief of suffering and the defence of liberty. Horsleys name is indelibly inscribed on the records of human achievement. His workas a physiologist is incorporated in the heritageof our knowledge, and he will ever be remembered as a pioneer in the surgery of the net-vops system, which since his day has grown as only his faith could ha, -foreseen. But great though his achievements were in the realm of science, it is his personality which keeps his memory most vividly alive to those of us who had the privilege and good fortune to work with him. We recall his amazing energy, his enthLusiasm for knowledge, the help he gave so liberally to younger colleagues, his kindness and generosity, and his unswerving devotion to the welfare of his fellows. I accept gratefully this opportunity to add my contribution to his memory. The subiect of this lecture is one to which Horsleys investigations contributed materially ; some of his earliest work defined accurately an area of the cortex by stimulation of which ocular movements could be obtained; later he described the anatomical paths connecting the visual cortex with the oculomotor apparatus in the midbrain; and his latest experiments on the cerebellum, which unfortLinately have never been published in full, dealt with the movements and postures of the eyes which can be elicited on electrical stimulation of this organ or result from lesions of it. There are several categories of ocular movements. In the first place we can move our eyes by an act of volition, bit few of their ordinary movements are in this sense voluntary or the result of a consciotus effort. Any peripheral stimulus, as movement, a flash of light, or a sound, may deviate our eyes involuntarily towards its source, while accurate vision demands accommodation and fusion, ,which is effected by so arranging the visual axes that the images of the object at which we look fall on corresponding parts of the two retinae. Finally, there are the compensatory or adjusting movements by which the eyes are kept directed on an object when either it or our heads move. The upper part of the brain stem contains

INJURIES OF THE SUPERIOR LONGITUDINAL SINUS.

During the si4 months following D Day, 1944, a considerable number of cases of head injury were received at an E.M.S. neurosurgical unit. These presented every type of injury, with varied signs and symptoms, but among them were a number of injuries which had involved the superior longitudinal sinus (S.L.S5 to a varying degree. These were an interesting group, and I1 of the 26 cases seen were selected for study as presenting fairly clear-cut examples of the S.L.S. syndrome without the complicating factors of other injuries. As a group these cases did very well, and this study is directed with special reference to their follow-up over the last four years.

ACUTE FEBRILE POLYNEURITIS.

ACUTE FEBRILE POLYNEURITIS. Thu B SWm 3 I was asked to see a man in the dysentery ward on account of an effusion into the kiiee-joint. I found the patient bright and cheerfuil but exceedingly emaciated. The right kiiee was flexed and contained a good deal of fluid. It was neither painful inor tender, there was no temperature and no haemorrhagic staining. I-could not discover the cause, and thought that it might be an example of so-called dysenteric arthritis. The joint very soon improved and the man began to get about again, but two weeks later he suddenly developed a large subcutaneous haemorrhage down the inner side of the leg and extending into the instep and sole of the foot. Another man recovering from a bad attack of enteric fever and who had been on milk diet for several weeks rapidly developed a large haematoma on the buttock, the tissues all round were also infiltrated with blood, and there were petechial spots on the legs. I drew off 30 c.cm. of broken-down blood clot, and a few days later a similar amount of haemorrhagic pus was evacuated by incision.

The Montgomery Lectures IN OPHTHALMOLOGY: Delivered in Trinity College, Dublin, June, 1919

LECTURE I.-THE CORTICkL LOCALIZATION OF VISION. IN my first lecture I will attempt to place before you tlle evidence we now possess as to the regions of the surface of the brain where the images of objects that fall on the retinae excite visual sensations. Owing to the decussation of a portion of tlhe fibres of the optic nerves in the clhiasma, each1 optic tract conveys impressions from the same sides of bothl eyes-that is, impressions excited by the.retinal images of objects in the opposite halves of the visual fields. And since each tract terminates in the primary optic centres of the same side, and tlle optic radiations that spring froin here pass to the same side of tle brain, a total lesion of any part of the one optic systemi above the clliasma produces lhemianopia, or blindness in the opposite lhalves of the visual fields. It lhas only been within recent years tlhat, as a result of many anatomical, physiological, clinical, and pathological investigations, we have acquired any accurate information as to tlle region of thie cortex where retinal impressions excite visual sensations. These investigations indicate that the visual centres lie within and along the lips of the posterior parts of tIme calcarine fissures, and that they probably correspond to that portion of the cortex characterized by the presence of Gennaris line, whicl Professor Elliot Smitlh has called the area striata. In most brains this striate araa extends around the occipital pole on to the lateral surface of the hemisphere. Until lately, too, we possessed very little evidence of the mAnner in whichl the different segments of thle retinae are rppresented in the visual cortex, but, owing to the large number of cerebral injuries that have been produced by gunslhot wounds, tlle late war lhas given us an unequalled opportunity to investigate this problem. Numerousobservations by myself and otlhers lhave provided fuller data on whiclh to discuss it. In March, 1916, 1 publislhed, in coll.boration witlh mey colleague, Sir W. T. Lister, a commounication on this subject; last year I was able to aimplify tlhe views whicll we th6en put forward, and to-day F wisl to place before you suclh final conclusions as 1 c%n .d;raw from v-ery large number of observations. Two. facts tend. to. malic theseo conclusions less con-

The Montgomery Lectures IN OPHTHALMOLOGY

as it was then called. In the first place, the patients general healtlh must, if necessary, be improved, for lhysteria is liable to occur in those in whom it is below normal. Secondly, the treatment must be begun as early as possible, for, quite apart from its being always wise to get a patient well quickly, the longer hlysteria Iasts the more difficult it is to cure. Thirdly, as just mentioned, the doctor must nmost carefully avoid, by his mode of examination and by his wording of questions, suiggesting symptoms. Visitols and nturses must also avoid suggestion. Notliing is more lheartrending for the doctor than the well meaning visitor, who says: ;Poor man I what a terrible time you must have had I The wonder is you have any power left in your legs. A sentence suchi as this will undo hours of hard work on the doctors part, and it is because of tllis constant liability to the suggestion of new symptoms tllat it has been found advisable to treat hysterical soldiers in special hospitals where it is understood how to manage them, and -where they are encouraged by seeing othier patients getting well. This is an extremely influential part of the cure. Fourtlhly, and most essential, is the reawakening of the supraliminal consciousness and tlle mnaking of suggestions powerful enough to overcome the hysterical symptoms. Sometimes this is not performed by the doctor. A soldier was invalided from tlle front for mutism; he had not spoken for weeks. He was playing draughts with another soldier, who clleated. The nmute broke out in a torrent of abuse, and spoke ever after. A woImDan had lain in bed for years owing to hysterical paraplegia. The house caught fire; she ran downstairs fast enough to save her life. Hypnotism was employed for this part of the treatment, but is not at present much used as it is unnecessary. Persuasion and re-education are now largely practised, witli excellent results. Men who have not been able to use one or other of their limbs or straighten their backs lose their disability in quite a short time. The nmedical journals, books on war neuroses, and the studies from the SealeHayne lhospital give details of many cases. It is necessary that the doctor should convince tlhe patient tllat a cure can and will be effected. Many employ electricity as a means of sugg,estion. We use at Guys an effervescina mixture containing asafoetida and valerian; it is successful in imany cases of mild hysteria; it acts by suggestion that it will cure, especially as the patient eructates into her moutl asafoetida and valerian during a great part of the day, and is tlherefore constantly reminded that she is going to be cured. The Weir Mlitchell treatment, which often works wonders in tlle wasted hysteries, illuistrates these principles. The general healtlh is improved by the overfeeding and nassage, the isolation removes the patient from the suggestions of her friends and lher old surroundings, and a skilful doctor and nurse avoid suggesting new symptoms and devote their energy to suggesting to thle patient that she will recover. I trust the war has shown that we ouilit to give our best attention to hysteria, for the study of it is a pleasure in itself. It is very common; if you doubt this go to Lourdes. It is capable of cure; it is not, as some people seem to think, mlalingering. Remember Sir James Pagets famouis saying: Tlle patient says she cannot, the frienids say slhe will not, the cloctor says shle cannot will, and it is a curse to the patienit, her friends, and lher relations. Do you recollect what Fielding says in Amelia.: These fatigues added to the uneasiness of her mind, overpowered her weak spirits, anid threw her into one of the worst disorders that can possibly attend a woman-a disorder very commonI among the ladies, and our physicians have not agreed uponi its name. Some call it a fever oni the spirits, some a nervous fever, some the vapours, atid some hysterics. Oh I say no more, cries Miss Matthews,1L pity you, I pity you from my soul. A man lhad better be plagued with all the curses of Egypt than with a vapourish wife.

A CASE OF BILATERAL MOTOR APRAXIA WITH DISTURBANCE OF VISUAL ORIENTATION

IThas beea only within the last feW years that the umotor disturbance known as apraxia h&s claimed much attention, o1 been fully ivestigated, and even yet very few well-markel instat669 of cendition have been described in English literature. In fact; it is mainly tlhrough the careful summary oftheworkof Continental authors, published seven years ago by Dr.S&A. K. Wilson, that apraxia is known to English readers. Apraxia is a comnplicated condition, but in its simplest terms it consists in inability tocoxbbine simple movements into complete purposive acts; in other words, it is a condition in which a patient in whom the power of voluntary movement is intact, or atleast not seriously affected by palsy, ataxia, or sensory loss, is yet unable to perform certainpaons,qr is Ancapable of employing objects-as a knife or a key-correctly, even though hie is aware what

Preliminary Notes ON THE TREATMENT OF THE CRANIAL INJURIES OF WARFARE

DURING tlle past five mnonths we hiave lhad tlle opportunity of seeing and dealing with a large number of cases of lhead injury at the base hospitals in France, and we now feel that our experience is sufficient to juistify a preliminary communication. Any such experience is the nmore important as, owing to modern metliods of warfare, and especially to trench figlhting, the proportion of head injulries to the total number of w-ounded is surprisinglcy large. -The excellence of the Britislh transport arrangemtients allows a large number of these eases to be dealt with at the base hospitals at an early date after the infliction of the wound, and many even of the severest cases now reaclh the base wlich would not survive the journey if the means of tranisport were less efficient. Further, the patients are rarely seriously affected by tlle journey, and the mlost imiportant and in mnany cases the determining factor in the prognosis is proper early treatment before the woun(ds lhave becomne seriously septic.

Observations on OCULAR PALSIES

We are accustomed in dealing with loss of the power of movement of any part of the body to distinguish those varieties due to structural lesions of, or functional dis turbances in, the upper motor neurones which carry im pulses from higher centres to the motor nuclei and their nerves, and those the result of lesions of the nuclei and nerves which innervate the muscles directly. The latter are the lower motor neurones or the final common paths, for by them only can nervous impulses reach the muscles.

Evolution of Clinical Medicine Illustrated by the History of Epilepsy.

To all who have been for some years eng,ged in the practice of clinical medicine it is obvious that important developments in the diagnosis of many diseases have taken place during the period of their professional life, but many are apt to forget how recent is the acquisition of much knowledge. Hughlings Jackson, to whom I was house-physician, was accustomed to say he had been a neurologist many years before the knee-jerk was first described, and I had almost passed out of studentship when Babinski drew attention to that type of pathological plantar reflex which has become such a valuable sign in the diagnosis of nervous disorders. Advances in treatment are perhaps more striking, but as rational therapeutics depend on recognition of the nature of the disease, diagnosis is evidently the first essential step in progress. In many instances recognition of the nature and origin of a morbid condition has developed suddenly as a result of careful clinical observation, as the distinction of typhus from enteric fever; by the demonstration of constant and characteristic anatomical changes associated with it; and, more critically, by the discovery of a specific causal factor, as the infecting organism of an infectious illness. Sometimes, however, it has been due to introduction of new methods of investigation, as the use of the electrocardiograph in that branch of medicine in which the founder of this lecture is a recognized authority. More frequently the differentiation of separate diseases as

A British Medical Association Lecture ON SOME CLINICAL MANIFESTATIONS OF TABES DORSALIS: Delivered to the Harrogate Branch, October 7th, 1922

THERE can be little doubt that no nervous disease presents itself under so many and varied manifestations as tabes dorsalis; perhaps no other affection of the body assumes so multifarious forms, and the experience of my own practice is that in no otlher condition is my help in diagnosis more frequently asked by general practitioners atnd by otlher specialists. I have consequently selected as my subject some of the clinical manifestations of this disease, and will deal chiefly with those which offer difficulties in diagnosis. These are usually early or isolated symptoms. Time will, unfortunately, prevent any but a cursory reference to the pathology 6f the disease or to the pathiogenesis of its symptoms, and even the q.uestion of treatment must be largely neglected, conscious tlhough I am that to tlhose engaged in the daily care of patients treatment must denmand the foremost place in the discussion of any disease. My excuse is that in tabes diagnosis must precede efficient treatment.