seale (1936) oral sepsis as a cause of paralysis of the ocular nerve
TRANSCRIPT
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8/10/2019 Seale (1936) Oral sepsis as a cause of paralysis of the ocular nerve
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[KOYE1>IBER 28
1936.
779
section of their motor upply, and noted
that
the
extreme
fineness
of
fibre
of
these muscles.
and
there
fore po sibly
greater permeabil ity,
might ., throw
light on the extremely difficult problem of the
morphology of their nen'e supply.
I may perhaps be
pardoned
for a more lengthy
excerpt from
Duke-Elder in consideration of
causal relationships of t\\'o ca es I purpo e to descnbe
presently.
His
whole paper,
h O \ ~ e v e r ,
is
.\\ 01:th
careful
study. Perhaps those
puzzhng
t\\'ltchl11gs
and
spasmodic contractions
of
the orbicular is and muscles
upplied by the facial nerve may
be .
a ~ c ~ U n t , e d
for
now. Duke-Elder suggest two posslblttles for
the
muscle peculiarities,
.
the anomalous physiolo.gica
behaviour of these muscles seems to correlate Itselt
with
an
anomalous nerve supply.
It
has long been
known that in addition to the motor nerye endings
derived from the third, fourth and sixth nerves. an
extraordinary
number
0 f
nerves
of
the sensory type
are
met
with in these muscles
...
'
It
has been
suggested . . .
that
these fibres
b e l O 1 ~ g
to the sym
pathet ic, but , to
nlY
mind. the suggestIon
S
based on
no adequate evidence.
Where
the fibres come from
is not known. It might be suggested that they come
from the fifth. and in con idering thi nerve one at
once thinks
of
its enigmatic mesencephalic root. , ' .
In the second place. if the peculiarity is not
neuro
logical in orig-in, it
is
possible that it may he due to
ome peculiarity
of
the muscle-fibres them eh'es.
The
fibre
of
these muscles are extremely fine and delicate.
and it '
is
concei,'able that they possess a greater
permeability than the fibres
of o ther
keletal mu. c1e.,
It
is thus po ible that choline act
upon ordmary
keletal mu
c1e
onlv after denervation. becau e by
thi mean their
p e n ~ l e a b i l i t y
ha been increa ed,
that
it act upon the
extrin
ic muscle
of
the eye m
normal c ircumstance and
without
any
trauma
becau e
the permeability
of
their thin and delicate fibre is
sufficiently great.
~ l o r e
recent work on ocular disorders associated
with the wisdom tooth i to be found in an article in
the
British J mwl Ophthalmology
for
July,
1935.
by C.
Bowdler Henry,3 Hunterian
Profe or
Lecturer in Oral Surgery, Royal Dental
Ho
pltal.
London. Here the very definite st atement
is
made
that in
certain case a per fec tly healthy but unerupted
wisdom tooth
may
produce g r ~ v di tur.bances in the
eyes which mu t be a cribed eIther to d l r ~ c t .
p r ~ s
u.:e
on neighbouring nerve or to ome reflex IrrItatIOn:
He had
collected 700 cases
of
disorder
of
eruption
of
the
third
molar . and
among
these \\'ere
eighteen
contributed and thiry-two
literature
ca e in
~ ~ i c h
was
ome ocular ymptom.
Iriti and
Uyeltls were
mentioned as
the
commonest eye troubles caused by
thi condition,
but
neuralg-ia, twitching-- and
ev.en
g laucoma might be due to .it. One ca e quoted by hlJ11
proved that
the
eye affectIOn was. caused
by pre ure
of
the root
of
an
unerupted
\\ dom tooth on the
infradental nerve.
That oral sepsis a a cau e of ocular paralys is was
not
of
much account
in
the
mind of
neurolog-i
ts
until
ORAL SEPSIS.
S,A.
TYDSKlIIP vm]
G N S ] [ ~
r l
~ t p s i s
as a < taus. of aral sis of
xttrnal
Brular
.lRu.ults.
By E.
A. SL\LE, :'ILD. (DuBL.).
GR.\HA:\fSTOWX.
Before
19
2
3 little
attention
had been paid to
the
condition of the
mouth
in the presence of eye trouble.
In
that
year,
at
the
annual meeting
at Oxford of
the
Oxford
Ophthalmolog-ieal Congre s. the chief
J}lace
was given to a discussion on the relationship
of
dental
sepsis to disease
of the
eye.
1
The
first
paper
wa
read
by ~ 1 r . W.
:\ckland,
of
Bristol. followed
by
the veteran
London ophthalmologist. :'Ilr. Wm.
Lan
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8/10/2019 Seale (1936) Oral sepsis as a cause of paralysis of the ocular nerve
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Examination howed a marked downward deviati
of the left eye. with light outward direction.
Vi ion of each eye equd and above s tanda
Fundi normal: in fact. no thing wrong but the squi
The Maddox tangent _cale howed the fal e ima
2t feet above and a couple of inche to the r ight .
From the hi tor)' and aeneral good health I w
inclined to exclude
lue,
but a ked for a blo
examination
hould
impro ement
not follow attent
to hi unsatisfactory oral condition.
an
irm
[
S A
MEDIC
JOURN L
teeth were
he
I a ked Dr . Kaplan for a repor t and he wa
goo
enough to give one which is unusually full.
Th
report
reads: On May 27 pre ented himself f
relief
of
pain radiating along right mandible wi
hi tory of an aching first lowe. molar ( righ t) of thr
days' duration. The following teeth were timdin
843
21
12
3 - - 67
7
6
53
21
12
3457
8
'
exhibited
marked
attrition. Considerable recession
gums;
deep pockets interdentally, which harbour
food .particles: accumulation
of
tartar
and
chron
general periodontitis present.
,
In
the
mandipl
right side-the first molar had
an
exposed pulp sole
caused by attrition
of
the occlusal surface.
The
seco
molar was non-vital. having been devitalized
arsenic in 1934
these two teeth were sensitive
percussion, the
pain
radiating along the mandib
The ornl mucosa in this area was inflamed, partic
larly in the
retromolar
triangle distal to
the
seco
lower molar, where a probe could be admitted betwe
the flap of gum and the distal root of this tooth whi
communicated with
an
unerupted
third
molar. Dire
smears were
taken
from
various oral
areas.
Examination
of
these smears
showed a
Vincen
infection; Bac fllsiformis; Bac necrosis and taphyl
cocci and streptococci.
Dr. Kaplan observations are enlightening.
H
says: The case is one
of
general oral sepsis w
incent 's infect ion. In addition, a condensi
osteitis existed in the mandible in the area of
devitali.zed econd molar and an impacted wisdo
tooth.
It
is possible that the oral sepsi eau
inflammation of
the
periodontal membrane of t
unerupted
molar and thi again reflex irritation in t
inferior
dental
nen e-a
the distal root wa in dire
contact with the main nerve.
The
fai lure to
g et
f
an:esthesia
wa
probably due to non-absorption
of
t
solution throug-h the myelin sheath of that nerve, t
result of degenerative change. With the removal
the _econd molar and the resisting- bone anter io r
the wisdom tooth opportunity for migration \\
allowed. thereb,' relieving the main nerve fro
pre sure.
The
clearing up
of
the oral ep i togeth
with the removal of the teetl-i anterior to the
\Vi
do
tooth has amel iora ted the general condi tion.
The second ca e wa al 0 a man in the fiftie. e
to
me
by Dr. Ca_tIe on Augu t 6 la t.
He
complain
of
double vi ion
for
even day, but aid it disappear
for one day oon after it on
et;
it then gradually g
worse.
ORAL
SEPSI
.
xecently I should like to show by quoting from
an
addre by Dr . James Collier delivered
at
the jubilee
Congress
of
the Ophthalmological Society
of
the
United Kingdom in 1930. The title
of
his paper was
Oculomotor Palsies
resulting from Infective and
Toxic
Proces es.
4
Diphtheria, polyneuritis, botulism
and nronal
intoxication, etc.,
and
the paralysis
of
myasthenia gravis were discussed, but no case of
ocular
paralysis mentioned
as
due to oral sepsis.
::\1r
A. F. Mc =allan, in
the
ensuing debate,
described a case
of
paresis
of
the inferior rectus
muscle cured by removal of
an
impacted wisdom tooth.
He
said
research work
by dental surgeons
and
bacteriologists has shown that practically all un
erupted
and
impacted teeth lead to infection
of
the
surrounding tissues by streptococci of various kinds.
As my search has not yielded any case
of
paralysis
of
the external rectus
or
superior rectus muscles due
to oral
sepsi,
I now record one of each recently
occurring in
my
practice.
In
both was
marked sepsi ;
ir:
one
an
unerupted wisdom tooth.
On
::\lay 26
last
I was consulted by a man in the
middle fifties for a squint in the right eye of ten days'
duration, It
was
first noticed when read ing on a long
raih ay journey, and after some pain in the right side
of
the face and head.
There was a very marked in fe rior t rabismus of the
.eye-fully
40 -wi th
inability
of
movement beyond the
mid-line.
He
felt quite well and was going to office
as u ual. -
0
abnormali ty in the
fundus o r
elsewhere
wa. detected and vision up to standard in each eye.
I
ordered
a
KI mixture
and referred him to his
physician fo r a general overhaul and blood examina
tion. I also advi ed him to see his dentist as his mouth
did not appear 1).ealthy. Dr.
Drury
report \\'a very
sati
fac tory: the
\i\'a
sermann
negative. Between this
consultation and the next on June I he saw hi dentist.
Dr. . Lewi Kaplan. on
May
27. and after ome pre
liminary
treatment teeth were extracted. Block
amesthe ia
of
the infer io r dental canal gave the usual
en ation-Ios to the mid-line and to the ide of
the
tonglle
and
lip, but evere pain wa felt deep in the
ja\\' \ \'hen the forrep was applied, The fir t molar
was removed. bu t the crown
of
the second broken;
operation tnpped on account of pain. Daily treat
ment
of
the gllm was continued. and on June 9
an
X-ray taken
of
the region. An impacted and un
erupted wi 'dom tooth wa revealed with root
infringing on the mandibular canal and nene. The
root were ub equently remo\'ed
and
free drainage
allowed.
I next
saw
him on June 8, when a definite improve
ment in eye-movement wa percept ible, On June 17
further
marked improvement was recorded. the move
ment ranging
1-
to 20
beyond nud-l ine. but,
of
cour e. double vision still t roubl ing. On July I still
better
movement howed, though at 12 feet the double
images
of
a candle
were separated
by
about
15 inche .
When next
examined, July 18, double vision wa com
pletely gone
and
no abnormality detected,
7
80
NOVEMBER
28, 1936.]