CASE OF PERIPHERAL PARALYSIS OP THE THIRD NERVE. By
Surgeon-Major F. Odevaine, F.R.C.S., dith
Regiment
N. I.
The patient, a rather plethoric man, aged about 34, has for the last month had severe pain of a lancinating nature referred to the left temple, eyebrow, forehead, &c., the pain being more or less constant and not observing Some days subany regular periodicity as to recurrence. sequent to the advent of the neuralgic symptoms, he observed the upper eyelid of the left side droop, so that the vision on this side was consequently obstructed.
Arcust i,
1878.]
A MIRROR OF HOSPITAL PRACTICE.
On examination of the left eye, I found ptosis, dilated and external strabismus with slight exophthalmos, all indicative of lesion of the_ oculo-motorius of the same side, and beautifully illustrating its anatomical distribution to the sphincter pupillas and muscles implicated. If the patient is directed to look upwards, downwards, or inwards, he is unable to turn the cornea in the direction required : on closing the right eye, and asking the patient to look inwards with the left, we find, when the former is again opened, that the secondary angle of squinting is in excess, as is always the case when strabismus is due
pupil
to
paralysis.
The fundus
of either eye appears perfectly normal, there is some difficulty in getting the left optic disc into view with the ophthalmoscope, owing to the inability of the patient to turn his eye in the requisite direction.
though
The question to solve in this case is, whether the parais central or peripheral. As to the former, we may dismiss it as a cause of the paralysis in the present instance, as there are no other indications of brain lesion ; no want of power of other parts ; no impairment of mind, aphasia or other symptoms of cerebral implication, and no intra-ocular indications of optic neuritis or choked disc. The patient had syphilis seven years ago ; he is not rheumatic, and has no positive signs of malarial poisoning, unless indeed we attribute the hemicrania he suffers from to miasma, notwithstanding its want of periodicity : be this as it may, I think we can, by exclusion, very reasonably attribute the paralysis of this man's third nerve to peripheral causes, and in all probability to the neuralgia of the ophthalmic division of the fifth. These two nerves are intimately connected in that small ganglion situated between the optic nerve and external rectus, which plays such an important part in affections of the eye ; I of course allude to the lenticular ganglion, which is formed by a twig from the nasal branch of the ophthalmic division of the fifth and a small branch from the third, a filament being contributed by the sympathetic. It is quite probable, that the state of irritation, or whatever it may be, that originated the neuralgia of the ophthalmic division of the fifth, was, through the lenticular ganglion, propagated to the third, and thus the paralysis may be anatomically traced to the connection existing between the two nerves. One peculiarity is the absence of diplopia in this case, which, had it been present, would of course have been crossed. Why no double vision exists, I am at a loss to say ; it may be that the pupil of the affected eye being so dilated, the image from an object impinges on the same part of the retina as on the right side ; I endeavoured to negative this by placing a diaphragm before the left eye, but yet there was no diplopia. Vision for distance is good when the lid is raised, but for near objects, his accommodation is evidently less than normal. The above case may well come under the mixed variety of ophthalmoplegia recently alluded to by Mr. Jonathan Hutchinson, that is 0. externa, plus implication of the lenticular ganglion, as evidenced by the state of paralysis of the sphincter pupill? and ciliary muscle, in addition to the muscles moving the globe which receive their nerve force through the third. The treatment consisted in the administration of an aperient, and afterwards he was put on solution of Perch] oride of Mercury in combination with twenty grain doses of Ammonium chloride, given in decoction of Cinchona three times a day ; electro-magnetism being also employed locally. Under this treatment the patient improved, so that.he was able to raise the lid by an effort, and thus allow of the pupil being brought into view ; the other muscles also regained somewhat their power, but the patient, though much better, could not be pronounced cured" when he ceased attending.
lysis
Sehorc, May,
1878,
213
Surgeon-Major F. Odevaine, F.R.C.S., dith
Regiment
N. I.
The patient, a rather plethoric man, aged about 34, has for the last month had severe pain of a lancinating nature referred to the left temple, eyebrow, forehead, &c., the pain being more or less constant and not observing Some days subany regular periodicity as to recurrence. sequent to the advent of the neuralgic symptoms, he observed the upper eyelid of the left side droop, so that the vision on this side was consequently obstructed.
Arcust i,
1878.]
A MIRROR OF HOSPITAL PRACTICE.
On examination of the left eye, I found ptosis, dilated and external strabismus with slight exophthalmos, all indicative of lesion of the_ oculo-motorius of the same side, and beautifully illustrating its anatomical distribution to the sphincter pupillas and muscles implicated. If the patient is directed to look upwards, downwards, or inwards, he is unable to turn the cornea in the direction required : on closing the right eye, and asking the patient to look inwards with the left, we find, when the former is again opened, that the secondary angle of squinting is in excess, as is always the case when strabismus is due
pupil
to
paralysis.
The fundus
of either eye appears perfectly normal, there is some difficulty in getting the left optic disc into view with the ophthalmoscope, owing to the inability of the patient to turn his eye in the requisite direction.
though
The question to solve in this case is, whether the parais central or peripheral. As to the former, we may dismiss it as a cause of the paralysis in the present instance, as there are no other indications of brain lesion ; no want of power of other parts ; no impairment of mind, aphasia or other symptoms of cerebral implication, and no intra-ocular indications of optic neuritis or choked disc. The patient had syphilis seven years ago ; he is not rheumatic, and has no positive signs of malarial poisoning, unless indeed we attribute the hemicrania he suffers from to miasma, notwithstanding its want of periodicity : be this as it may, I think we can, by exclusion, very reasonably attribute the paralysis of this man's third nerve to peripheral causes, and in all probability to the neuralgia of the ophthalmic division of the fifth. These two nerves are intimately connected in that small ganglion situated between the optic nerve and external rectus, which plays such an important part in affections of the eye ; I of course allude to the lenticular ganglion, which is formed by a twig from the nasal branch of the ophthalmic division of the fifth and a small branch from the third, a filament being contributed by the sympathetic. It is quite probable, that the state of irritation, or whatever it may be, that originated the neuralgia of the ophthalmic division of the fifth, was, through the lenticular ganglion, propagated to the third, and thus the paralysis may be anatomically traced to the connection existing between the two nerves. One peculiarity is the absence of diplopia in this case, which, had it been present, would of course have been crossed. Why no double vision exists, I am at a loss to say ; it may be that the pupil of the affected eye being so dilated, the image from an object impinges on the same part of the retina as on the right side ; I endeavoured to negative this by placing a diaphragm before the left eye, but yet there was no diplopia. Vision for distance is good when the lid is raised, but for near objects, his accommodation is evidently less than normal. The above case may well come under the mixed variety of ophthalmoplegia recently alluded to by Mr. Jonathan Hutchinson, that is 0. externa, plus implication of the lenticular ganglion, as evidenced by the state of paralysis of the sphincter pupill? and ciliary muscle, in addition to the muscles moving the globe which receive their nerve force through the third. The treatment consisted in the administration of an aperient, and afterwards he was put on solution of Perch] oride of Mercury in combination with twenty grain doses of Ammonium chloride, given in decoction of Cinchona three times a day ; electro-magnetism being also employed locally. Under this treatment the patient improved, so that.he was able to raise the lid by an effort, and thus allow of the pupil being brought into view ; the other muscles also regained somewhat their power, but the patient, though much better, could not be pronounced cured" when he ceased attending.
lysis
Sehorc, May,
1878,
213
