70 Mr. Gabriel Stokes on the Closure of the Eye in Sleep.

~ . The presence of chronic rheumatic arthritis may not only lead us to suppose that a fracture exists when the bone is entire, but also when there is no doubt as to the existence of fracture, may render diagnosis difficult as to the seat of the in- jury with respect to the capsule.

24. Severe contusion of the hip-joint, previously the seat of chronic rheumatic arthritis, and the impacted fracture of the neck of the femur, are the two cases most liable to be con- founded with each other.

25. Each particular symptom of fracture of the neck of the femur, separately considered, must be looked upon as equivo- cal : the union of all can alone lead to correct diagnosis.

I cannot terminate this memoir, without expressing myself grateful to the surgeons of the Richmond Hospital, for the kind- heSS and liberality with which, upon this and many former oc- casions, they have permitted me to make use of the prepara- tions contained in their valuable museum; and if, availing my- self of this permission, I have been enabled to dispel any of the doubts and uncertainties which envelope the important subject of whlch I have treated ; if the preceding pages contain a single observation calculated to elucidate the diagnosis of injuries of the hip-joint, the object of this memoir is fully accomplished.

Arrr. H.--Observatio~ on the Closure of the Eye in Sleep. By GABRIEL STOKES, M.D., M.R.C.S.I.

THE closure of the eye in sleep is an action, which appears to me to be erroneously described and explained by some physiolo- gists, who are still looked up to and quoted as high authority, and by others who have written at a later period, and who have adopted what I conceive to be the true explanation of the phenomenon, this explanation has not been by them suffi- cleatly proved.

Now it is in the study of the effects produced by paralysis of

Mr. Gabriel Stokes on the Closure of the Eye in Sleep. 71

the orbicularis palpebrarum that we can discover data on which to found a true explanation of the closure of the eye in sleep. Let us inthe first place examine what the received opinion on this subject has been : most of the authorities in anatomy are silent upon it: Wlnslow, Meckel, Boyer, and Cloquet, make no al- lusion whatever to i t ; Bichilt, however, observes, " that the closing of the eye is performed in a different manner in wake- falness and in sleep. In the first instance the dosing of the eye is active, and is produced by the voluntary contractions of the middle portions of the orbieularis, the curved fibres ofwhlch become straight. While in the second case (in sleep) the ap- proximation of the eyelids is purely passive, produced by the fall of the superior eyelid, owing to the relaxation of its eleva- tion ; a phenomenon quite analogous to what is observed in cases of paralysis of this muscle."

Adelon goes still further, and thinks that, under ordinary circumstances, the closure of the eye, both in sleeping and waking, is produced by the alternate contractions and relaxa- tions of the levator alone.

Bichat's opinion is still, however, very generally taught, although more correct views have been published by some late writers, which shall be noticed presently.

Let us now turn our attention to the disease termed la- gophthalmia, or paralysis of the orbicularis palpebrarum, and we shall find evidence to disprove the doctrine of Bichat, and his followers.

Sir Charles Bell, in his work on the nervous system, speak- ing of paralysis of the face produced by division or injury of the portio dura of the seventh pair, says at page 86, "The eyelids from thenceforth stand apart, the eye would be per- manently uncovered, the cornea become opaque, and the vision

of the eye lost." Further, in file appendix to the same work, where a number

of cases of the paralytic affection of the face are given, in Case

72 Mr. Gabriel Stokes on the Closure of the Eye in Sleep.

II. page 6, it is stated that,--" the eye is open in sleep, the

eyeball turned up." Again, in Case III. page 7, in a case where the disease

was of several years' standing, and where there was considerable disease of the eye; it is observed, that, "his (the patient's) wife states that he never closes the eye, not even when he is

asleep." In Case VII. page 21, "in sleep the right eyelids are closed

as usual, but the left eye (theone affected) remains uncovered." In Case X. page 35, " During sleep the eyelids remain

wide open." In Case XXVII. p. 68, "When the child sleeps, the aper-

ture formed by the want of approximation of the eyelids drops about the middle of the cornea.

Many other cases proving that when the orbicularis is para- lyzed the eye does not close in sleep, could be quoted from authors of nearly equal celebrity as Sir Charles Bell ; but we shall be content with recording one case that came under our own observation in the medical wards of the Meath Hospital, in the person of a young man admitted under file care of Doctor Stokes : the following are some of the particulars of his case.

Patrick Boyle, aged 22, a sawyer, states that he always enjoyed good health until about two months ago, when from ex- posure to cold while overheated, he was seized with violent pain in the right side of the head and face, which was almost imme- dlately followed by paralysis of the muscles of the right side of the face, which has continued ever since. The face has a twisted appearance, particularly when he speaks or laughs ; he has lost the power of whistling; and in eating, the lips on the right side frequently fall between the teeth ; the eyebrow is de- pressed, and cannot be elevated, as on the opposite side ; the right eye remains constantly open ; there is occasionally very slight motion in the orbicularis, but he cannot at all effect the closure of the eye; the eyeball is turned up, and there is a patch of superficial ulceration commencing at the lower part of

Mr. Gabriel Stokes on the Clo.~ure of the Eye in Sleep. 73

the cornea ; complains of great pain in this eye when exposed to the light. During sleep file right eye remains open, and the eyeball is turned up as in the cases described by Sir Charles Bell. Besides this affection of the nerves, this individual labours under extensive organic disease of the abdomen, and is reduced to a state of extreme marasmus.

After lingering for several weeks in hospital, this patient gradually sunk, worn out by a constant diarrhoea, and profuse perspirations. These symptoms were accompanied by a vora- cious appetite, which continued to the last ; the paralysis of the face also continuing unchanged. As in this form of paralysis opportunities of making a post mortem examination are exceed- ingly rare, I seized the opportunity now offered to determine s as far as one case can go, whether this form of paralysis depended on orgaaic lesion of the nerve, or was merely functional. Thirty- six hours after death the body was examined; an incision was made through the parotid gland, and the trunk of the posterior nerve of the seventh was exposed, as were also the plexus which it forms in this gland, and the branches proceeding fi'om it to the muscles of the face. No morbid appearance whatever could be detected, the nerves presented their natural appear- ance in every respect, there was no atrophy or softening. The fibres of the orbieularis were exceedingly pale and indistinct, as were also those of the other muscles of the face ; the levator palpebr~e recti, and oblique muscles, were of their natural size, colour, and consistence. The eyeball was examined, but the only morbid change that could be detected was a slight degree of opacity in the lower part of the cornea. The brain was then abstracted, and the origin of the portio dura carefully examined, but without being able to detect the slightest trace of morbid action, either in the nerve itself, or in the portion of the brain from which it takes its origin ; neither could any disease of the brain itself be discovered. So that as far as one case can esta- blish a fact in medicine, it would appear that this particular form of paralysis is a functional and not an organic disease.

VOL. XVIII. NO. 5~.

74 Mr. Gabriel Stokes on the Closure of the Eye in Sleep.

I have introduced here the details of this dissection, because, few dissections in cases of this disease are on record, and those few for the most part are cases in which the disease was pro- duced by tumours or abscess pressing upon the nerve.

But to return lo the mechanism of the closure of the eye in sleep. It is quite clear that if the eye remains open during sleep where the orbieularis is paralyzed, that the doc- trine taught by Bichat, namely, that the eye closes passively from relaxation of the levator, is erroneous: there can be no doubt whatever ofthe fact, that the eye, under such circum- stances, does remain open ; and yet in such cases, the levator becoming relaxed in sleep, the eye does not close, which it should do if it was merely a passive action, or the fall of the eyelid from its own weight. What then is the power by which the eye is closed in sleep ? The answer to this question will be found by examining into the nature of the orbicularis muscle. This muscle presents all the anatomical and physiolo- gical characters of a sphincter muscle, and as such is not only possessed of a contractile power which is directed by the will, but also of an involuntary power of contraction independent of the will; by its voluntary powers during wakefulness the func- tion of winking is performed, which is produced by the alter- nate contractions and relaxations of the orbicu!aris and the le- vator. But when sleep comes on, both these muscles lose the voluntary power of contraction simultaneously, and the eyes would remain open, but that the involuntary power of contrac- tion still remaining in the orbicularis, in virtue of its being a mixed muscle, the eye by it becomes gently closed.

Mr. Partridge in the article "Face," in the Cyclopvedia of Anatomy and Physiology, is the only author that I am aware of that gives this explanation of the closed eye in sleep, but he brings forward nothing to disprove that this action is not passive, but the observation, that resistance is met with in endeavouring to open the eyes of a sleeping person, and does not appear to

Dr. Edward W. Murphy, on the Second Stage of Labour. 75

be aware of the decisive evidence against the theory of passive closure derived from a study of the phenomena attending para- lysis of the orbicularis palpebrarum.

Mr. Partridge, in the same excellent article, adopts the di- vision of the orbicularis proposed by Riolan, namely, into the orbicular and palpebral portions, and supposes, that the orbi- cular portion is a purely voluntary muscle, while the palpebral possesses both a voluntary and involuntary power of contraction. This I think, is at least doubtful.

First. Because there is no analogy for this in any of tim other sphincters.

Second. An injury of the facial nerve affects both portions of the muscle in a similar manner.

Third. Their acting sometimes independentl~ of each other does not prove that they are physiologically distinct, for we have abundant examples in the muscles of animal life, where different portions of the same muscles act independently of each other.

From these considerations, I am inclined to consider the entire of the orbleularis as a mixed muscle, and not merely the

palpebral portion.

ART. III.--ztnlnquiry into the Management of the SecondStage of Labour, (Mechanism of Parturition.) By EDWARD WIL- LIAM MURPHY, A.B.M.D.,late Assistant Physician to the Dublin Lying-in Hospital ; Lecturer on Midwifery, &e.

HAVING at a former opportunity entered upon an inquiry into the management of the first stage of labour, tbr the pur- pose of determining, if possible, the validity of opposite rules of practice, I propose, at present, to examine in a similar manner the second stage, in order to derive from its consi- deration some definite conclusions upon disputed points.

By the second stage, I mean that period of tile labour which