Slight wound of occiput: Ophthalmoplegia externa, influencible, however, by tests and replaced by spasmodic convergence of globes with myosis; hysterical stigmata and convulsions.
Case 435. (Westphal, September, 1915.)
A German volunteer, 20, was slightly wounded in the occiput by revolver-shot at Ypres. Then followed headaches, vertigo, and complaints of pains in the eyes such that he could not open them or see sidewise. May 5, 1915, he showed a picture of an ophthalmoplegia externa: complete immobility of the two bulbi, lively blepharoclonus, rapidly passing into blepharospasm, photophobia. The visual field for white was practically limited to the fixation point. Central scotoma for all colors. Otherwise normal.
On further examination, the apparently immobile bulbi were found to pass into convergence upon request to look to the right or left. Thereafter, this position of convergence was assumed if any test made by a strong light, such as that of a pocket flash, was used. The pupils contracted to the maximum during this assumption of the convergent position of the globes, and no further light reaction could be observed. The convergence gradually passed off when the light was removed. The appearance of bilateral external ophthalmoplegia had disappeared.
If the patient was requested to follow a finger moved to one side, the globe of that side to which the finger was being moved, stood unmoved in its central position, but the other globe followed the eye and placed itself in the convergent position. The patient complained of diplopia. Even after the closure of one eye a double vision appeared (monocular diplopia). There was achromatopsia. The cornea failed to react to stimulation.
There was an analgesia of the skin of the whole body, with a hypesthesia for tactile stimuli on the left side. Smell and taste absent. The convergent position of the globes with myosis was preserved in the midst of convulsive seizures, which could be produced by exciting the patient. When it was attempted to dissolve the eye troubles by hypnosis, convulsive attacks occurred. The patient was pronouncedly hysterical.
The case is beyond question hysterical,—the phenomena consisting of an ophthalmoplegia externa, alternating with spasmodic contracture of the internal recti, associated with myosis and loss of light reaction. The influencibility of this situation during the process of tests, to say nothing of the other stigmata, clinches the diagnosis—an important one, since the development of an external ophthalmoplegia after occipital trauma might possibly be regarded as an organic disease due to hemorrhage in the region of the eye-muscle nuclei.