Hysterical pseudoptosis.
Laignel-Lavastine and Ballet present a case of what they term hysterical pseudoptosis in a patient who showed no signs of organic disease of the nervous system, and moreover no special mental disorder. This soldier, 30 years of age, working in the auxiliary service, suffered from a troublesome lowering of his left upper eyelid. He went to the front in February, 1915. Aside from suffering a few mild and temporary blindnesses (éblouissements), he was entirely well up to the time of being wounded, March 18, 1915, by a bullet in the arm, and a bullet occasioning a superficial and slight wound 2½ centimeters above the middle of the left eyebrow. About three years later, a shell burst near him and made a large contusion about the right eye, without hurting the globus. He was then evacuated to Châlons-sur-Marne, and there remained for 48 hours, totally blind, probably on account of spasmodic closure of his eyelids. He then began to be able to use the left eye, which remained, however, very photophobic. A fortnight later, the wounds were healed, but the patient found himself unable to open his right eye. Three months later he returned to his dépôt, and left for the front October 24.
He was reëvacuated November 4, as unsuitable for service. He was then examined by an ophthalmologist at Chartres, who found a very mobile right pupil and a slightly atrophic right papilla; vision ½; left eye normal; vision ⅔; total paralysis of right levator palpebrae superioris without contracture of orbicularis. There was also paresis of the left upper lid, which ceased when the right eye was closed. The right half of the face was anesthetic, but there was no corneal anesthesia.
November 15: Right eyebrow lower than left; if the head was moved backward, the right eyelid followed the movements, and in this position there was no ptosis.
November 16: Analgesia in the super- and sub-orbicular region. November 17: frontalis and orbicularis functions normal.
At time of examination, patient complained of not being able to open his right eye, and that he could only partly open the left eye. To catch a view of his examiner, he had to throw his head back and to the right. He could not open his eyelids, and in the effort to do so, the forehead muscles contracted; and whereas the left eyebrow was properly elevated, the right eyebrow was only partially elevated. Associated movements could be noted in the musculature of the lower part of the face. In looking to the right, the eyelids, especially the left, were elevated slightly. The patient complained of photophobia. From time to time, he felt completely blind, and at the end of these spells of blindness, he had a severe headache. His head felt heavy. Sometimes on looking to the left, he saw objects double, although this diplopia had grown less marked of late. All the muscles of both eyes appeared to work normally. Upon pressure on the right globus, especially pressure directed from above and behind on the internal part, the patient would raise his left eyelid, but the paresis reappeared the moment the pressure was released; a fact which the patient himself noted while a tampon was being placed upon his eye.
It seems there had been a wound at the external angle of the eye, some nine or ten years before, as a consequence of which the eyelid of this side could never be parted as well as before. The accident in question had happened in 1905, and there had been a slight suppuration of a wound 2½ centimeters from the external angle of the palpable fissure.
The patient then went through a period of reëducation. It seemed that when he was trying to raise his eyelids, there was a mental inhibition which could be overcome only by effort. An attempt may be made to resolve the phenomena into three groups:
First, enophthalmia of the right side (post-traumatic, antebellum, a predisposing cause).
Secondly, a situation corresponding to so-called hysterical pseudoptosis of Charcot and Parinaud (eyelid falling without wrinkles, head thrown back, frontalis contraction on effort to open eyes, eyelid lowered). The diagnosis of hysteria was supported by the transient opening of both eyelids when a sudden sharp order was given to move the eye-balls, and further supported by synergic automatic lid-movements when the patient voluntarily raised his eyes. He could not raise his eyelids to order.
Thirdly, functional ocular palpable synergy (left eye opening upon compressing the right eye).