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1386 AMBLYOPIA OR FATIGUE ? P AFFECTIONS OF THE GALL-BLADDER AND CARDIAC PAIN To the Editor of THE LANCET SiR,-The communication by Dr. Charles H. Miller on this subject to THE LANCET of April 9th leaves little room for discussion, because of its informatory value, but I should much like to suggest that the term " cardiac pain " is a positive assertion relating to a particular organ. For the last 25 years I have in my notes used the words " cardiac area pain," a term which expresses a symptom, and that a diagnosis has to be made. In general practice, where scientific niceties some- times have to go by default, it is more necessary to have a definite clinical basis to work upon. A cardio- graph is not easily read. Blood pressure is a will-o’-the- wisp, and only of value after many records have been taken and with full consideration of the circumstances occurring before making them. The size and position of the heart, in spite of a definite departure from anatomical correctness, may be the normal condition of the individual. To assist in drawing the right lessons from " heart area pain " and accompanying skin tenderness (if any), I make a surface plan, showing six places or points in the cardiac area, the inner end of the right costal cartilages and the outer end of the left costal cartilages forming the lateral boundaries. To each point I attach a mental signpost, on which are recorded various common diseases. The e diagram is a quadrilateral with four ana- tomical corners (points) and one triangular space in the middle third of the base line, the apex being above the line. The points are : (1) the junction of the right second costal cartilage and the sternum ; (2) at the junction of the left second costal cartilage -with the rib ; (3) at the centre of the left fifth intercostal space in the line of juncture of the costal cartilages and ribs ; I (4) at the junction of the right sixth costal cartilage and the sternum. These four points are joined up with a skin pencil. (5) The middle third of the line 3-4 corresponds to the base of an equilateral triangle ; (6) represents all the costal cartilages in the area. Against these figures I visualise the following diseases, and proceed to verify a distal heart hint into possibly a local truth : (1) and (2) Aortic, heart, and thymus disease. (3) Mobile kidney, liver, spleen, diseases of rectum and anus with occasional shooting pain along line 2 to 3. Diseases of the gall- bladder also show hyperaesthesia of the right fifth or sixth intercostal nerve. (5) Stomach and duodenum affections. (6) Hyperaesthesia and pain over the costal cartilages suggest pleuritic adhesions and neurosis, such as follows an old herpes zoster. Late manifestation of diseases mentioned under above headings show one or more tender cartilages. In advanced diseases all six points may participate as reflex phenomena. I will add three illustrative cases :- (1) In the late spring of 1922 Sir Fredk. Treves asked me to see him during a visit he was paying to Weymouth ; I was then in practice in Dorchester. He was complaining of cardiac distress, and was very nervous about his condition. He referred his pain to the area I have described as No. 3 in the diagram : also there was a tender right sixth inter- costal nerve. I assured him he had gall-bladder trouble ; he did not agree, and was confident his heart was wrong. In December, 1923, he died from a perforated gall-bladder. (2) Dr. K., aged 65, complained of cardiac area discomfort and shortness of breath-he had a sensitive No. 3 area-and tender right sixth intercostal nerve. He would not agree that his gall-bladder was the cause. Nine months later, at 3 A.M., I was sent for. He was suffering from acute abdominal pain and retching, which he persisted in calling appendicitis. His general collapse was so serious that no surgical measure could be contemplated. Ten days later, in consultation with the late Dr. Hyla Greves and with his approval, I removed a gall-bladder containing about 100 stones, ranging in size from a split pea to a small walnut. He made a good recovery. (3) Dr. C., aged 56, was cranking up his car and was seized with acute upper segment abdominal pain ; one hour later he motored home five miles. I saw him in consultation with his partner, and found a very sensitive fifth area and board-like abdominal muscles ; he declared he had " no pain." His contracted pupils led me to ask him how much morphia he had taken; he owned up to half a grain. Within three hours I opened his abdomen, and found a rupture of his duodenum. He recovered. My diagram I have found more useful in early cases when the reflex phenomenon of heart area pain is always greater from remote disease than when the heart is the primary cause. I am, Sir, yours faithfully, Tunbridge Wells, June 14th, 1932. W. B. COSENS. AMBLYOPIA OR FATIGUE ? To the Editor of THE LANCET SiR,-The annotation with this heading in your issue of April 9th (p. 789) misrepresents the point of view taken in my paper on Amblyopia in the same issue (p. 774), where I am said to claim " to have cured many cases of amblyopia associated with weak converging power by treatment by means of prisms calculated to increase the power of the con- verging muscles." Herein lies the misconception of my hypothesis, because astheno-vergence is not due to weakness of the converging muscles but to the weakness of response to its natural stimulus of a reflex controlled by a centre situated in the brain. In the paper reviewed and in my previous publications there is not a single indication that I have ever given treatment calculated to increase the power of the converging muscles. I have never met with a case of astheno-vergence (weakness of involuntary convergence) due to weakness of the ocular muscles. On the contrary I have often drawn attention to the fact that weakness of the eye musculature is out of the question in the diagnosis of astheno-vergence. Your annotation says : " We would suggest to Dr. Stutterheim that the term amblyopia is hardly a suitable one for a psychical condition that affects both eyes, and that any measures that produce an amelioration of this condition are effective not so much through the muscles as the mind." But I have taken great care to point out that con- vergence (the visual reflex) is not a muscular function of " low level " in the hierarchies of the brain or mind, as for instance adduction, which can be produced probably even by the lowest mammals, but a function of the highest mammalian minds-a kinetic function of very high rank-one of the three chief factors, to use the words of Sherrington, of man’s outstripping other competitors in progress towards that aim which seems the universal goal of animal behaviour,

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Page 1: AMBLYOPIA OR FATIGUE ?

1386 AMBLYOPIA OR FATIGUE ? P

AFFECTIONS OF THE GALL-BLADDER AND

CARDIAC PAIN

To the Editor of THE LANCET

SiR,-The communication by Dr. Charles H.Miller on this subject to THE LANCET of April 9thleaves little room for discussion, because of its

informatory value, but I should much like to suggestthat the term " cardiac pain " is a positive assertionrelating to a particular organ. For the last 25 yearsI have in my notes used the words " cardiac areapain," a term which expresses a symptom, and thata diagnosis has to be made.

In general practice, where scientific niceties some-times have to go by default, it is more necessary tohave a definite clinical basis to work upon. A cardio-

graph is not easily read. Blood pressure is a will-o’-the-wisp, and only of value after many records have beentaken and with full consideration of the circumstances

occurring before making them. The size and positionof the heart, in spite of a definite departure fromanatomical correctness, may be the normal conditionof the individual.To assist in drawing the right lessons from " heart

area pain " and accompanying skin tenderness (if any),I make a surface plan, showing six places or points inthe cardiac area, the inner end of the right costalcartilages and the outer end of the left costal

cartilages forming the lateral boundaries. To each

point I attach a

mental signpost,on which arerecorded variouscommon diseases.The e diagram

is a quadrilateralwith four ana-

tomical corners

(points) and one

triangular space inthe middle third ofthe base line, theapex being abovethe line. The

points are : (1) thejunction of the

right second costal cartilage and the sternum ; (2) at thejunction of the left second costal cartilage -with the rib ;(3) at the centre of the left fifth intercostal space inthe line of juncture of the costal cartilages and ribs ; I(4) at the junction of the right sixth costal cartilageand the sternum. These four points are joined upwith a skin pencil. (5) The middle third of theline 3-4 corresponds to the base of an equilateraltriangle ; (6) represents all the costal cartilages inthe area.

Against these figures I visualise the followingdiseases, and proceed to verify a distal heart hintinto possibly a local truth : (1) and (2) Aortic, heart,and thymus disease. (3) Mobile kidney, liver,spleen, diseases of rectum and anus with occasionalshooting pain along line 2 to 3. Diseases of the gall-bladder also show hyperaesthesia of the right fifthor sixth intercostal nerve. (5) Stomach andduodenum affections. (6) Hyperaesthesia and painover the costal cartilages suggest pleuritic adhesionsand neurosis, such as follows an old herpes zoster.Late manifestation of diseases mentioned under above

headings show one or more tender cartilages. Inadvanced diseases all six points may participate asreflex phenomena.

I will add three illustrative cases :-

(1) In the late spring of 1922 Sir Fredk. Treves asked meto see him during a visit he was paying to Weymouth ;I was then in practice in Dorchester. He was complainingof cardiac distress, and was very nervous about his condition.He referred his pain to the area I have described as No. 3in the diagram : also there was a tender right sixth inter-costal nerve. I assured him he had gall-bladder trouble ;he did not agree, and was confident his heart was wrong.In December, 1923, he died from a perforated gall-bladder.

(2) Dr. K., aged 65, complained of cardiac area discomfortand shortness of breath-he had a sensitive No. 3 area-andtender right sixth intercostal nerve. He would not agreethat his gall-bladder was the cause. Nine months later,at 3 A.M., I was sent for. He was suffering from acuteabdominal pain and retching, which he persisted in callingappendicitis. His general collapse was so serious that nosurgical measure could be contemplated. Ten days later,in consultation with the late Dr. Hyla Greves and with hisapproval, I removed a gall-bladder containing about 100stones, ranging in size from a split pea to a small walnut.He made a good recovery.

(3) Dr. C., aged 56, was cranking up his car and wasseized with acute upper segment abdominal pain ; one hourlater he motored home five miles. I saw him in consultationwith his partner, and found a very sensitive fifth area andboard-like abdominal muscles ; he declared he had " nopain." His contracted pupils led me to ask him how muchmorphia he had taken; he owned up to half a grain.Within three hours I opened his abdomen, and found arupture of his duodenum. He recovered.

My diagram I have found more useful in early caseswhen the reflex phenomenon of heart area pain isalways greater from remote disease than when theheart is the primary cause.

I am, Sir, yours faithfully,Tunbridge Wells, June 14th, 1932. W. B. COSENS.

AMBLYOPIA OR FATIGUE ?

To the Editor of THE LANCETSiR,-The annotation with this heading in your

issue of April 9th (p. 789) misrepresents the point ofview taken in my paper on Amblyopia in the sameissue (p. 774), where I am said to claim " to havecured many cases of amblyopia associated withweak converging power by treatment by means ofprisms calculated to increase the power of the con-verging muscles." Herein lies the misconceptionof my hypothesis, because astheno-vergence is notdue to weakness of the converging muscles but to theweakness of response to its natural stimulus of areflex controlled by a centre situated in the brain.In the paper reviewed and in my previous publicationsthere is not a single indication that I have ever

given treatment calculated to increase the powerof the converging muscles. I have never met with acase of astheno-vergence (weakness of involuntaryconvergence) due to weakness of the ocular muscles.On the contrary I have often drawn attention to thefact that weakness of the eye musculature is outof the question in the diagnosis of astheno-vergence.Your annotation says :

" We would suggest to Dr. Stutterheim that the termamblyopia is hardly a suitable one for a psychical conditionthat affects both eyes, and that any measures that producean amelioration of this condition are effective not so muchthrough the muscles as the mind."But I have taken great care to point out that con-vergence (the visual reflex) is not a muscular functionof " low level " in the hierarchies of the brain or mind,as for instance adduction, which can be producedprobably even by the lowest mammals, but a functionof the highest mammalian minds-a kinetic function ofvery high rank-one of the three chief factors, touse the words of Sherrington, of man’s outstrippingother competitors in progress towards that aimwhich seems the universal goal of animal behaviour,

Page 2: AMBLYOPIA OR FATIGUE ?

1387TRAINING IN MASSAGE AND MEDICAL GYMNASTICS

namely, to dominate more completely the environ-ment. The other two factors are the promotionof the fore limb to a delicate explorer of space inmanifold directions, and the organisation of mimeticmovements to express thoughts by sounds.A baby announces its presence in a way that

leaves no doubt as to the power of its laryngealmusculature. Yet later on it has to learn how bestto express thoughts by sounds. Is that done bymeans calculated to increase the power of his speakingmuscles ? Later on the child arrives at the school

age and is going to learn how to use his fore limbas a delicate explorer of space in a very special way-viz., to form letters and words in writing. Is thisbecause its writing muscles are lacking in power ’?Do we not have to curb in our babies the utterancesof laryngeal power, and must we not protect livingand other valuables against the manifestations ofmanual and digital muscle-power of our youngilliterates ? Likewise my astheno-vergence patientscan at will squint internally to 60°-75°, while they ’,can only produce involuntary convergence to, say,8° of deviation. Education enables the centres forhand movements and for speech in the neo-palliumto gain better control over the motor-coordinationspresiding over the powerful musculature of the

peripheral organs concerned. Likewise, kinetic treat-ment enables the centres for convergence in the neo-pallium to gain a surer control over the midbraincentres for ocular movements in the interest ofbi-foveal single vision.

I have chosen " amblyopia " and not " fatigue " asthe term for the partial loss of sight under considera-tion, because in all my patients treated for eyestrain onaccount of astheno-vergence I never saw an instance ofchronic fatigue (mental or other), except in the onlythree neurotics I tried to treat kinetically. If Ihad, I would not have given them a strenuous kinetictreatment, but would rather have prescribed themmental and visual rest. My astheno-vergencepatients were without muscular eye defects andcertainly not "run down in health." The partialloss of sight was not attributable to any other causethan to chronic inability of long standing to bringthe two foveal images to cover one another com-pletely, accurately, and at any moment required.The adults treated by me for astheno-vergencewere almost without exception vigorous, healthy,keen, hard-working men and women ; the childrentreated were, apart from astheno-vergence, normal.I made the mistake-unavoidable at the time-of

treating also three patients of neurotic disposition,and these treatments were notable failures. These

patients may have suffered from mental fatigue but,granting that they did, I cannot see why the term"

amblyopia " should not be applied to such cases.To use the word fatigue in this connexion would beunduly stretching its usual meaning. I could,perhaps, admit that fatigue is a link in the chainof causality of the partial loss of sight in this sense ;that the chronic inability to bring the two visualaxes to meet accurately on the object of vision laysa strain on the visual centres, a strain which leads to acertain amount of exhaustion or fatigue of the motorpart of these centres, and that in the long run a givingway, a kind of neutralisation of vision of on or botheyes manifests itself in amblyopia. But the amblyopiais an observed fact, the mental fatigue only a hypothesis Ito explain the fact.-I am, Sir, yours faithfully,

Johannesburg, S. Africa, May 4th. N. A. STUTTERHEIM.

* * We spoke of the claim to cure amblyopia"by means of prisms calculated to increase the

power of the converging muscles," whereas in the casesreferred to it is not the muscles that are defectivebut the nervous mechanism which governs theiraction in converging the two eyes on any givenpoint, and we accept Dr. Stutterheim’s correctionwithout reserve. It is not hard to understand that

by his exercises he succeeds in so toning up the reflexnervous mechanism that the range through which"

involuntary convergence " is effective in overcoming

prisms base out, with the eyes fixed on a distantobject, can be greatly increased in most healthysubjects. It is far more difficult to accept his claimthat visual acuity, both binocular and monocular,can be definitely increased by these methods. Whenthis happens the explanation may, as we suggested,be the overcoming of fatigue affecting, on the onehand, the nervous mechanism through which con-vergence of the two eyes to any given point is effected,and, on the other hand, the nervous mechanism bywhich the retinal images of one or both eyes areinterpreted. This explanation may not be correct,but the claim to cure " amblyopia " by Dr. Stutter-heim’s procedure is so startling that one seeks forsome explanation to make it seem possible.-ED. L.

TRAINING IN MASSAGE AND MEDICAL

GYMNASTICS

To the Editor of THE LANCET

SiR,-It has come to the knowledge of the CharteredSociety of Massage and Medical Gymnastics that thereare a number of organisations in London and in provin-cial towns which profess to give a training in massageand medical gymnastics by correspondence, and whichissue certificates and diplomas. These subjectsnecessitate a considerable knowledge of anatomy,physiology, pathology, medicine, and surgery as wellas technical ability and clinical experience. This

knowledge and experience can only be obtained bypersonal teaching and by the actual treatmentof patients. It is to be hoped that membersof the medical profession will inquire criticallyinto the qualification and experience of masseurs

and masseuses who offer to assist them in treat-

ing their patients, and that they will not bedeceived by diplomas granted after a correspondencecourse or some other totally inadequate systemof training.

I am, Sir, yours faithfully,

Portland-place, W., June 9th, 1932.R. C. ELMSLIE.

BORACIC POWDER AND VACCINATION

To the Editor of THE LANCET

SiR,—In your issue of June llth (p. 1288) a questionwas asked in the House of Commons regarding the useof boracic lint in vaccination in the Army. Theanswer was given that it was to be abandoned on thescore of economy, but that boracic powder and ordin-ary lint would be issued instead. If this is correct itis a pity that the mistaken use of boracic in dressinga vaccinated arm should be continued. It is directlyresponsible for the irritation so frequently seen.

Since substituting plain sterile gauze I have not seenone single case of irritation, whereas previously it wasthe rule rather than the exception.

I am, Sir, yours faithfully,June 10th, 1932. Late R.A.M.C., T.