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1888 The Lancet  
a case of considerable interest, both from a clinical and physiological point of view. It is an instance of an affection occasionally met with, but still comparatively rare, being an uncomplicated case of paralysis of the fifth nerve, practically equivalent to a precise physiological experiment. And it has this advantage over an experiment on any of the lower animals in that, so far as subjective functions are concerned, we are able to obtain direct testimony as to the existence or absence of
more » ... nce or absence of states of feeling, whereas in the lower animals we are obliged to infer these from external manifestations more or less intelligible. And it is astonishing to find, in respect to questions of this nature-e.g., the sense of taste,-how, apparently with the same facts before them, different observers have come to diametrically opposite conclusions. Let me first give you briefly the chief facts as to the previous history and present condition of the case which I have chosen as the subject of my remarks. Abel S-, aged forty-eight, railway guard, was admitted into the Craven ward on November 25th, 1887. He stated that three years ago he was thrown out of a truck on which he was standing on to the ground, and rendered unconscious for about a quarter of an hour. By his fall he had received several cuts about the head and body, and was obliged in consequence of his injuries to remain off duty for about three months. He states that ever since the accident he has suffered from severe paroxysms of pain over the right side of the head and face. About nine months ago he began to attend the Middlesex Hospital as an out-patient, when he had some teeth drawn from the right upper jaw. No ansesthetic was administered, and yet he felt no pain during the operation. This was the first knowledge he had that he had loss of sensation of that side of his face. Six months ago he began to suffer from inflammation and impaired vision in the right eye, for which affection he has been undergoing treatment up to the present time. His general health has been otherwise good. He admits occasional intemperance and a slight attack of gonorrhoea when eighteen years old, but denies ever having bad syphilis. The patient is a healthy-looking man, of a ruddy complexion. The right temporal region and the right cheek appear somewhat thinner than the left, and there is a slight drooping of the right upper eyelid. The ocular movements are normal, as also are the movements of the muscles of expression. He is unable to open his mouth widely, and when it is open the chin deviates very decidedly to the right side. He cannot move the lower jaw from side to side alternately, nor can he protrude the lower beyond the upper incisors. When he closes the jaws, the right temporal and masseter muscles do not become hard like those on the left, and a similar difference is observed in respect to the depressors of the lower jaw when he opens the mouth to its fullest extent. Faradic stimulation of the left temporal and masseter muscles causes instantaneous closure of the open mouth, whereas no effect is produced by faradisation of the same muscles on the right side with as strong a current as can be conveniently borne by the patient. The tongue is protruded straight, and both sides react equally to the faradic current. On examination of the palate it was found that there is a perforation to the left of the uvula which causes a slight deformity and deflection of the uvula to the left side, but the arches of the 1 From notes [revised and amended] by Sir Hugh Beevor, M.B., palate rise normauy ana equally during inspiration ana phonation. There is complete anaesthesia and analgesia on the right side of the forehead and temporal region, the right eyelids and eyeball, the right side of the nose and right cheek, and anaesthesia, with perhaps slight sensibility to severe pinching, along the course of the lower jaw up to the middle line. There is also complete insensibility of the right nostril and the mucous membrane on the right side of the mouth as far back as the tonsil, and a similar condition over the whole of the right side of the tongue. There is also slight superficial ulceration of the mucous membrane of the inside of the cheek, and he says that he cannot feel his food when he chews it on the right side. Smell is slightly diminished in the right nostril; but he is able to recognise the smell of menthol, though less distinctly than with the left nostril. On examination of the right eye Professor MacHardy reported as follows :-The right cornea somewhat hazy; the right tension distinctly, though only slightly, greater than the left. Ophthalmoscopic examination reveals no change in either fundus. There is absolute anaesthesia, of the right cornea and conjunctiva. The right pupil is almost universally adherent to a ring of inflammatory effusion, some two millimetres in diameter, in front of the lens. The action of atropine has failed to break down any of these adhesions. The patient is subject to severe paroxyms of pain in the right eye of a burning character, referred to the back of the eyeball. After examination of the ears, Professor Pritchard reported :-The hearing distance for a watch on the right is -N-5u, on the left -836. After syringing and inflation with Politzer's bag, the condition as to hearing was: left :to, right. Tuning fork, medium C, on right mastoid 0, left 1 + ; 0 equalling normal length of time. The high notes of Galton's whistle not heard; lower ones heard equally by both ears. Conclusion: Nerves of hearing fairly normal for age. Middle ears very slightly affected by old catarrh, and probably partly specific; right meatus partially blocked with wax. On removal, right equals left ear. On examination of the sense of taste on Nov. 29th, it was found that neither sugar, nor salt, nor citric acid, nor quinine was appreciated on the right anterior two-thirds of the tongue; whereas on the posterior third on the right side, as well as over the whole of the left side of the tongue, the taste of these substances was easily perceived. Perhaps the power of taste on the posterior third of the right side of the tongue was not so acute, relatively, as that of the left. On Dec. 1st the sensibility of the lower facial region, both externally and internally, had undergone some improvement; and the same was true as to the common sensibility and sense of taste on the right side of the tongue. The positive pole of the galvanic current was distinctly felt on the right side of the tongue, especially at the tip; less so further back. Quinine was not tasted on the anterior part of the right side of the tongue at all; other substance?, such as citric acid, sugar, and salt, were now capable of being perceived on the right side, but less distinctly than on tha left. A few days later tactile sensibility had almost completely returned in the lower facial region as well as on the right side of the tongue; and at this time sapid substances seemed to be tasted equally well on both sides. The area of anaesthesia in the other parts of the face was also receding, but still very marked in the region of distribution of the first and second divisions of the fifth, and absolute in the right side of the palate and upper jaw and mucous membrane adjoining. Sensation has continued to improve from day to day on the right side, but the eye still remains absolutely anaesthetic, and continues to be the seat of severe pain. The muscles of mastication remain in the same state of paralysis as at first. The symptoms in the case which I have just read are mch as can be only caused by some lesion which has Lmpaired the continuity of the trunk of the fifth nerve, both sensory and motor divisions-at first absolutely, and now in process of being recovered from. Recovery has irst taken place in the third division of the nerve. In favour of the peripheral nature of the lesion is the atrophy with loss of faradic contractility of the muscles of mastication. For though, theoretically, a similar condition might je caused by destruction of the motor and senory nuclei of ;his nerve, such a lesion could not exist without causing )ther and far-reaching disturbances, which are here entirely absent. What has been the exact cause of the lesion is not altogether free from doubt. The fifth nerve is not unfreluently implicated in tumours, inflammations, syphilitic
doi:10.1016/s0140-6736(02)26520-4 fatcat:sy2kc76vffhwvd4cyrdxvktg5e