CHAPTER II Tue Lips (Part 2)

in this disease may be mistaken for the congenital form unless we note the presence of contractures in some of the muscles. Occasionally ptosis occurs in connection with such intracranial lesions as hemorrhages, tumors, abscesses, and embolic or throm- botic softenings of the brain, and then may serve as a localizing symptom, as it shows an involvement of some part of the oculomotor tract, either along the base of the brain, in the peduncles, in the tegmentum, in the thalamus, or in the nuclear region; in which of these places the lesion is situated must be determined from other symptoms. Associated with bitemporal hemianopsia ptosis is @ symptom of hypophyseal disease. A tumor of the cerebellum can produce ptosis only when it presses on the corpora quadrigemina. Ptosis of one eye associated with paresis of the facial and hypo- glossal nerves on the other side indicates a lesion to be situated in the peduncle. A bilateral ptosis without hemianopsia, but with other cerebral symptoms, points to the region of the nucleus as the situation. Sometimes the development of a ptosis is useful in the differen- tiation of the various forms of meningitis; it is rarely met with in the epidemic cerebrospinal variety, occurs in the purulent only when the inflammation is situated at the base of the brain, and when it develops slowly we may be pretty certain that the patient is suffering from the tubercular form. Other diseases in which ptosis is met with are Graves’s disease or exophthalmic goiter, acute poliomyelitis, multiple neuritis, Lan- dry’s disease, Gerlier’s disease, herpes zoster, ophthalmic migraine, and polymyositis. A moderate ptosis of one eye, associated with a reduced tension of the eyeball, a slight enophthalmos, and myosis, suggests that some lesion involves or presses upon the ganglia of the cervical sympathetic nerve on the same side; the lesion may be a swollen cervical gland, a goiter, a neoplasm of the oesophagus, an intrathoracic growth, an aneurysm of the aorta, an abscess of the mediastinum, or an operative removal of the superior cervical ganglion. At first we find also a hyperemia of the conjunctiva, a flushing of that side of the face with anesthesia, a local elevation of temperature and increased secretion, but later the skin of that side of the face atrophies and becomes pale, the local temperature is lowered, and the secretions are diminished. This form of ptosis is unilateral almost invariably, and is due to a paralysis of Mueller’s THE LIDS 23 ‘muscle. <A ptosis of this nature is met with occasionally in syringo- -myelia. Finally, ptosis may be caused by hysteria, and we suspect this to be the cause when the lid falls more quickly after it has been raised by the finger than is usual in the paralytic form. In many cases hysterical pressure spots can be found, where pressure with the finger will cause the eyes to open instantly. These spots are likely to be found in the same places as in hysterical blepharospasm. WINKING The act of winking is partly voluntary, partly reflex. Ordinary winking is an involuntary reflex excited by stimulation of the filaments of the trigeminus through a slight dryness of the surface of the cornea. The levator is relaxed while the palpebral fibers of the orbicularis contract so as to move the upper lid downward, and both lids slightly toward the nose, a movement which spreads a film of moisture over the surface of the eyeball, removes any dust that may have fallen upon it, and propels the tears into the lacrimal lake. The frequency of the act is given by some authors as from two to four winks per minute, by others as from five to ten, but it varies a great deal within normal limits, and is affected by various conditions, such as local or general fatigue, so it must be increased or decreased considerably in order to become a notice- able symptom. Abnormally infrequent winking is one of the symptoms of ex- ophthalmic goiter, or Graves’s disease, but commonly it indicates that the surface of the cornea is. insensitive, whether made so by the instillation of an anesthetic like cocaine, or by a lesion of the trigeminus. When the corneal anesthesia of both eyes is profound the act of winking is nearly or quite abolished, the epithelium of the cornea tends to become dry, and a keratitis may be started which will develop into a keratitis e lagophthalmo if the anesthesia persists long and the eyes are not protected from desiccation. Very slow winking, in the absence of a local anesthetic, should lead us to search for a lesion that inhibits the function of the ophthalmic branch of the trigeminus. The lids respond by the same act to protect the eye when it seems to be threatened by an approaching body, and this reflex may be utilized sometimes to determine whether a suspected hemi- anopsia is present or not; if we move an object rapidly toward the 24 DIAGNOSIS FROM OCULAR SYMPTOMS eye in the field that is supposed to be blind and the lids close, we know that the eye perceived the movement, but if they do not move the object was not seen. Voluntary winking is used mainly as a test for paresis of the orbicularis; if the patient cannot close the eye perfectly this muscle has lost more or less of its function. Many healthy people exhibit a peculiar vibratory tremor of the lids when they keep their eyes gently closed, but such a tremor is more distinct in neurasthenia. Some have fibrillary twitchings of individual bundles of fibers of the orbicularis which not only can be seen by others, but are felt by the patient; when these are transient they are apt to be the result of either sexual excesses, great fatigue, or hard, near work of the eyes in persons who are anemic or neurasthenic, but when they are constant they form what is known as muscular tremor, which is met with in cases of facial paresis and of migraine. BLEPHAROSPASM Blepharospasm is an abnormal closure of the lids produced by ‘a spasmodic action of the orbicularis. It appears in two forms, clonic and tonic. In the clonic form the spasm is of short duration and soon recurs, in the tonic the lids remain closed for some time. A clonic spasm may be described as an accentuated form of winking, the act being more forceful, more frequent, and more prolonged than normal. We see it frequently in children who have some slight irritation of the eyes, such as may be produced by an error of refraction, or a follicular conjunctivitis. When such a nictitation persists after the local irritation has been removed the child usually is anemic and nervous, and in need of a general tonic treatment. Clonie spasms are met with also in chorea, and in what is called habit chorea, when they are associated with twitchings of the mouth and shakings of the head. Sometimes a single clonic spasm is pro- duced when a person goes suddenly from the dark into a bright light, and then it is apt to be preceded by a sneeze. A tonic blepharospasm commonly indicates trouble on the surface of the eye, the presence of a small foreign body, the scraping of eye- lashes, a phlyctenular keratitis, an interstitial keratitis, or an ero- sion of the corneal epithelium by some other cause. It is met with occasionally in nearly all the inflammations of the conjunctiva, cornea, and iris. Sometimes it occurs in trigeminal neuralgia, in herpes zoster, and in diseases of the nose, mouth, pharynx, and THE LIDS 25 teeth that irritate other branches of the trigeminal nerve. Usually the cause is easy to detect in all of these cases, except the last class, in which it may be recognized only after its removal, as when 2 persistent blepharospasm disappears immediately after the extrac- tion of a carious tooth. Blepharospasm may be caused also by anything that irritates the facial nerve at any point in its course from its nucleus to its periph- eral filaments. It forms a part of the facial spasms that are excited by an irritative lesion at the nucleus of the nerve; it appears together with spasms and pareses of muscles on one side of the body when the cortical center is irritated, and therefore is met with among the symptoms of Jacksonian epilepsy; it may be excited by tumors and aneurysms at the base of the brain, by meningitis, by troubles in the ear and temporal bone, and by scars on the forehead or cheek. In all of these cases the cause is to be learned through the accompanying symptoms. A strong light is rather apt to excite a blepharospasm in nervous or hysterical persons, and sometimes does so in others when a dazzling is produced by opacities in the refractive media, such as occasionally happens in incipient cataract. An occupational ble- pharospasm is met with in watchmakers who have long been in the habit of holding a magnifying glass in the grip of the orbicularis. In many cases we have difficulty in explaining the occurrence of a blepharospasm when it is a symptom of a traumatic neurosis that follows a slight injury to the head, or appears during an attack of migraine, or in hysteria, as in these cases it does not seem to be dependent on any observable lesion. When such an unex- plainable blepharospasm is associated with a contraction of the visual field, an inversion of the color fields, monocular diplopia, photophobia, contractures of the muscles, or anesthesia of the skin of the lids, all unexplainable by any determinable lesion, it may be pronounced hysterical. Such a blepharospasm usually is bilat- eral, but it may affect only one eye, and then if the palpebral fibers of the muscle alone are involved, it may simulate ptosis by pro- ducing the condition known as pseudoptosis. In some cases it may be arrested by pressure on certain tender points, which usually are situated along the course of the trigeminus, as at the infraorbital and supraorbital foramina, but often are found elsewhere. Roemer tells of a patient whose blepharospasm was stopped by pressure on the tip of the nose, while other observers have found such points 26 DIAGNOSIS FROM OCULAR SYMPTOMS in the nose, in the mouth, on the cartilages of the ribs, and on the vertebre, Conversely, pressure on various parts of the body has been known to excite a blepharospasm in hysterical people. Tonic spasm of the palpebral fibers of the orbicularis is able to keep an eye closed for a long period of time and to simulate a unilateral ptosis. This is pseudoptosis, and is hysterical in most cases. The differentiation from true ptosis is made from the facts that the forehead is not corrugated, the brows are low and straight, and the skin of the lid is not smooth and lax. Sometimes the eye can be observed to open in a moment of excitement. Some old people suffer from a senile blepharospasm that recurs at rather short intervals, comes on suddenly and keeps the eyes closed for quite a length of time. At the moment of attack the margin of the lower lid may be seen to rise, that of the upper one to sink, and both to move toward the median line of the face, while curved transverse folds form in the skin of the lid and about the eyes, and the patient distorts his face and opens his mouth in an effort to overcome the spasm. Attacks of this nature have placed old persons in great danger while walking on the street, as they were suddenly rendered practically blind. The cause of this trouble is unknown. C:DEMA OF THE LIDS The skin of the eyelids is very thin, and is attached so loosely to the subjacent muscles that collections of serous fluid frequently form beneath it and distend the subcutaneous tissue. This cedema can be recognized easily from the fact that the swollen lid pits on pressure, while the finger feels no crepitation, and the swelling often can be reduced considerably when the pressure is maintained. It may or may not be inflammatory, may affect the upper or the lower lid, or both, and may be unilateral or bilateral. The skin is reddened in the inflammatory variety, paler than normal in the other. Cidema is symptomatic of so many local and general lesions that all cannot be enumerated, but a few will be mentioned to try to impress the fact that its presence is an urgent indication for a thorough and exhaustive inquiry into the condition of the organism until its cause shall have been ascertained. A chronic, noninflammatory, bilateral cedema, usually of the lower lids, may be due to heart disease, nephritis, a hydramic con- THE LIDS 27 dition of the blood, chronic arsenical poisoning, or trichinosis. A similar cedema of shorter standing in the lids of either one eye or both may indicate an earlier stage of any of the above conditions, or an inflammation in one of the accessory sinuses. An oedema that lasts a few days, with no inflammation or itching, and then disap- pears to recur in a few weeks, may indicate the onset of blepharo- chalasis, but is also suggestive of Quincke’s disease, in which it may appear alone or in association with a similar cedema of the skin elsewhere, or of the mucous membranes. This disease is not yet fully understood, but it is thought to be an angioneurosis of central origin. Another disease in which cedema is a symptom is myxoedema, in which the swollen lids protrude and the skin is pale and cool. An inflammatory oedema may be due to traumatism, as in a black eye; to a focus of inflammation in the lid itself, as in a hordeolum, or the sting of an insect; to inflammation of neighboring tissues, as in dacryocystitis or periostitis of the margin of the orbit; to acute in- flammation of the eye, such as conjunctivitis, iritis, glaucoma, and panophthalmitis; to an inflammation in the orbit; or to an inflamma- tion in one or more of the accessory sinuses. Hence, a careful ex- amination must be made of the eye itself and of its appendages in every case of cedema of the lids. When the lower lid is more swollen than the upper, perhaps feeling brawny while the upper one is soft, and the swelling extends down along the side of the nose, we have reason to suspect an acute dacryocystitis, while if the region along the nose is approximately normal and the middle of the swelling is directly beneath the eye, the focus of inflammation is more likely to be in the lower part of the orbit when it cannot be found in the lid itself. A sudden inflammatory oedema of the upper lid that is not associated with an inflammation of the eye, and is not explained by traumatism, or a local focus of inflammation, leads us to suspect in- flammation in one of the accessory sinuses, and we feel particularly confident of this diagnosis if the swelling is mainly in the inner third. When the outer part of the upper lid is chiefly affected we think rather of a possible abscess, an orbital cellulitis, or an acute dacryo- adenitis. When no cause can be detected we must remember that an oedema of the lids may be a forerunner of a trouble that has not yet made itself manifest. Beard states that an alveolar abscess has caused a palpebral oedema before it was known that there was any dental trouble. A recurrent or fugitive oedema associated with 28 DIAGNOSIS FROM OCULAR SYMPTOMS pain, replaced at times by a blackening suggestive of ecchymosis, sometimes is indicative of sinus disease. The so-called solid cedema is a condition in which the lids are enlarged enormously with no signs of inflammation or of involve- ment of other parts. Ball describes the swelling as soft, elastic, pitting on pressure, and of a dusky reddish brown color, and states that in the majority of cases it has followed attacks of erysipelas, as well as that some cases have terminated in tuberculosis of the conjunctiva. The affection seems to be due to an obstruction of the lymphatic circulation, but its nature is not clear. Malignant cedema may appear as a sequel to, or as a precursor of an attack of anthrax. The color of the skin is pale at first, while the lid has a doughy consistence, but later it becomes cyanotic, bulle appear, and patches of necrosis are formed. The diagnosis is estab- lished by the other symptoms and the demonstration of anthrax bacilli. EMPHYSEMA OF THE LIDS When we press our fingers upon what appears to be a noninflam- matory oedema of the lids and feel crepitation, we know that the subcutaneous tissue is filled with air instead of fluid, a condition called emphysema. The air has entered through a fracture or other opening in one of the bones of the orbit which is so situated as to open communication between the subcutaneous tissue and the cavity of the nose, or one of the accessory sinuses. ECCHYMOSES OF THE LIDS Hemorrhages into and beneath the skin of the lid are produced very commonly by contusions, penetrating wounds, and operations in which the free escape of the blood is impeded, when the history and the associated oedema or wound clears up the diagnosis. A trivial injury may cause a large ecchymosis in hemophilia. Similar hemorrhages occur in children during paroxysms of whooping cough, and in elderly people, whose blood vessels are brittle, as the result of violent efforts, vomiting, or straining at stool. They may be pro- duced also by severe compressions of the thorax and abdomen, and often are symptomatic of fracture of the bones of the orbit, or of the base of the skull. In these cases there may be little or no oedema, though this