A 63-year-old man presented six days after the sudden onset of horizontal double vision. His left eye became divergent two days later. On initial examination he had bilateral internuclear ophthalmoplegia with weakness of adduction and abducting nystagmus. Convergence was weak but there were no other neuro-ophthalmic signs. Constitutional signs included confusion and unsteadiness on his feet. A provisional diagnosis of arteritis was made. His ESR was 92 mmlh and a superficial temporal artery biopsy confirmed the diagnosis of giant cell arteritis. After two weeks or oral prednisolone his eye movements returned to normal. There have been no further relapses. This would appear to be a unique presentation of giant cell arteritis. The causes of internuclear ophthalmoplegia are discussed along with a review of the ocular and neuro-ophthalmic signs of giant cell arteritis.

In this paper I deal with the impact of the exchange marriage system in Pakistan. The system does not only guide in spouse selection, but it is also provide welfare, alliance formation and give strength to kinship. No part of the study, however, dealt with the impact of the system on children anywhere in the world. Based on the qualitative investigation, this article highlights 24 case histories. The Grounded Theory Method guidelines are followed for the data collection and analysis. There are different dimensions of the exchange marriage. However, t h is study reveals child engagement/marriage (even before the birth), forced marriages, mismatch marriage, violence and emergence of domestic conflict in the system of the exchange. This study found drug addiction among children, off and on the street children, children with broken homes, neglected children, and delinquency is due to the system of the marriage. Exchange marriage does not only provide social security and alliance formation but also insecurity and obscured socialization of the children. It is important to have looked on the system of the exchange in development perspective of the future generation. This study highlights the impact of the exchange marriage system among illiterate or low educated people only who strictly follow the system of the exchange.

An unusual case of dysphagia Sir, Regarding the paper of Treasure and Hall,' we wish to report a clinical story of similar symptoms but with a different aetiology.A 68 year old woman had progressive dysphagia that developed over a period of several months. She had the feeling of food remaining stuck in the upper third of her chest. There were no symptoms of heartburn or other chest distress and no weight loss.Clinical examination and routine chest X-rays were normal. Barium swallow revealed an oesophageal stenosis and endoscopy demonstrated a pulsatory mass at the 25 cm level. There were no mucosal abnormalities. A computed tomographic scan with the application of an intravenous contrast medium showed an aberrant right subclavian artery (ARSA) or arteria lusoria, running vertically and behind the oesophagus and causing the stenosis. In order to demonstrate that the dysphagia in the patient was caused by the presence of the ARSA, an evaluation of deglutition with solid food was performed. The food was labelled with technetium-99 in a colloidal suspension and revealed a stagnation for solids at the level of the ARSA, confirming the diagnosis of dysphagia lusoria. The patient was treated by simple division of the ARSA with decompression of the oesophagus. A reanastomosis was not performed since at operation the blood flow to the right arm through collateral circulation was noted to be satisfactory. After the operation the woman was free of any difficulties in swallowing.Dysphagia lusoria, the symptomatic compression of the oesophagus by the ARSA, is a rare syndrome.23 The anomalous vessel represents the persisting portion of the right fourth aortic arch, the cranial portion of this arch being obliterated.4 Symptoms can appear in childhood and in adults.2.5'6 A universally accepted explanation for the absence of clinical signs in children and young adults does not exist. Loss of mobility of the anatomical structures and a subsequent oesophageal motility disorder have been suggested. Furthermore, the dilatation, the tortuosity and rigidity of the great vessels, the increase in the dorsal kyphosis, the sclerosis and calcification of trachea, aorta and the abnormal vessels could be an explanation for the occurrence of dysphagia.2'6

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