CASE OF HYSTERICAL BLINDNESS.
BY D. B. SMITH, M. D.
Professor of Diseases of the Eye and Ear in the Medical Department of Western
Reserve University.
On the fourth day of June I was called to see Miss C. R., aged nineteen years, a clerk, who told me that she had gone to bed the night before perfectly well, and that when she awoke in the morning she found herself totally blind, and had remained so up to the time of my visit, about eleven o’clock. This blindness she said had come on without the least pain or bad feeling, and the eyes were not in the least degree uncomfortable, nor had they been during the morning. No cause on the part of the patient could be assigned for the attack, and nothing of the kind had ever happened to any member of the family before. The external examination gave not the slightest evidence of any disease of the eyeballs or lids. The conjunctiva was perfectly normal, as were also the cornea iris and pupil. The ophthalmoscope revealed a perfectly healthy retina and optic nerve and clear media. The tension of the eyeball was normal. There was not the least constitutional disturbance, if we except a marked nervousness caused by the fear that she would be permanently blind. The patient declared most positively that she could not see the lamp even when held close to the eyes. From the fact that the pupils were perfectly normal and moveable under the influence of light, and that the patient put out her hand to shake hands with me in a way that I felt she could not do if she did not see, I diagnosed a case of hysterical blindness. It was more than a simulated blindness, for all the anxiety and mental distress of actual blindness were present; and I am satisfied the patient was honest in her belief that she could not see. The ordinary remedies for hysteria were given and were taken faithfully and regularly, and although for several days she took large doses of the bromide, valerianate of ammonia, hyoscyamus, assafœtida, and kindred drugs, there was not the slightest improvement in her vision. These remedies were continued from the fourth to the fourteenth without any perceptible effect. After ten days I began to give her tonics instead, and although she took the elixir cinchona with dilute hydrochloric acid, tincture of nux vomica, quinine, iron oxid of zinc, and finally stimulants, there was no improvement and the patient said she remained in total darkness. This tonic course was continued up to the twenty-ninth, and had been followed out thoroughly for two full weeks without effect.
During the nearly four weeks treatment the patient said that when the eyes were shut she could discern the position of the lighted lamp, but when the eyes were open she could not see the lamp or the slightest object, or even tell daylight from darkness. At various intervals during this time her pastor visited her and offered her his most heartfelt sympathy. Her friends were becoming exceedingly anxious least the sight would never return, although I could assure them that there was not the least danger of permanent blindness. I became satisfied at this time that medication was not going to dispel this peculiar attack of hysteria and that it would need something besides medicine to produce such an impression upon her mind that she could overcome it, so I told her that I was going to do something the next day that would surely make her see before night, and that she should be of good cheer for her sight would return very soon. The next morning I went down about nine o’clock armed with my ophthalmoscope, my case of trial glasses and my Hearteloup’s artificial leech. The patient seemed to be quite confident that she would soon see, and was very hopeful as to the result of what was to be done. I looked into the eyes with my ophthalmoscope, and then applied the cylinder of the artificial leech to the temples without scarifying and used considerable traction, first on one side and then on the other, having previously told her not to open the eyes until I told her to do so. In about half an hour I told her to open the eyes gradually so as not to let the light in too suddenly and then tell me what she could see. The instant she opened them she said I can see the light and the position of the window. I then told her to close the eyes again and I reapplied the cylinder and commenced the suction as before. By this time the temples had become red and so sensitive that she now complained of some pain when the cylinder was reapplied. After twenty minutes she was told to open the eyes again and she said she could see objects about the room distinctly. She was then tried with large letters but she said she could not see to read them, but could see the black objects. Told her glasses would help her and placed a No. 72 convex spherical glass before the eyes when she could see Jaeger No. 20, then told her she needed other glasses and replaced the No. 72. She now saw to read No. 16. I continued taking off and putting on this same No. 72, with good effect and whenever she came to a standstill in reading reapplied the cylinder with uniform benefit until finally after two hours constant work she could read Jaeger No. 1. During all this day she was able to see distinctly. The next day she was again unable to read but a short repetition of the same course brought her vision back again. There was no return of the blindness after that except occasionally for a short time at intervals of two or three days.
In the course of ten days all trace of the difficulty had passed by and since has never returned. This case was diagnosed as one of genuine hysteria and not one of simulating blindness or malingering, and is reported as the most marked case I have ever had illustrating the effect of hokus pokusing (to call it by a mild name) which produced such a strong mental impression that the patient lost sight of her own peculiar mental condition, and by which a perfect cure was effected.
To her the blindness was real, and her friends feel that a remarkable cure has been performed. Such a blindness can occur in any nervous hysterical patient, while simulated blindness usually occurs in those who wish to avoid service in the army or navy, or in the case of lazy young people who do not wish to study at school or college, and in those who have received a slight injury and wish to make it appear more serious for the sake of obtaining large damages, either from private individuals or corporations.
For its detection there are several methods which are usually sufficient to give us positive proof that the blindness is not real. Von Graefe placed a number eight or ten prism in front of the eye, with the base upwards, downwards or sidewise, and if strabismus is present before the removal of the prism there is binocular vision.
Juler places spectacles with an opaque glass in front of the good eye, when, if the patient can read, he must see with both eyes; or he places concave 20 before the good eye, when if the patient can read fine print he must see it with the other eye.
Juval places a ruler before the eye so as to cover part of the page to be read, when, if one eye is blind, not all the page can be read.
Mittendorf puts atropine in the good eye, when if the patient can read fine print he is not blind with the other eye.
Wells places a prism in front of the supposed blind eye, and notices whether the apis of vision of that eye changes when the prism is removed.
Bull bandages the good eye and places a prism in front of the other eye, and holds a lighted candle before the eye, and if the eye turns as the prism is turned, the eye is not blind.
The test with Snellens or other colored letters is also a good one. A word with alternate red and bluish green letters is painted on glass and placed in the window, and the patient is asked to read the letters. If a bluish green glass is held in front of the good eye, he will see only the green letters unless he can see with the other eye, for all but the red rays in the red letters are cut off in the transparency in the window, and the green glass cuts the red off, leaving those letters a perfect blank to the well eye.
Kugel places various colored glasses before each eye and then places an opaque glass in front of the sound eye, and a transparent glass of the same color before the other one, and if the patient sees the object, he is simulating blindness.
Herring has the patient look through a tube large enough to cover both eyes, and then suspends a small ball in front of the tube and drops small objects near this ball, and if the patient can tell whether the balls are dropped in front of or behind the suspended ball, he must see with both eyes.
Lawrence recommends the stereoscope for detecting binocular vision, and places in a covered stereoscope a picture each side of which is different, and yet such as to make a single picture when both sides are seen. A clock dial, for example, with figures in one side only or figures with complemental colors, such that with both eyes the object would appear differently colored from what it would when seen with either eye separately. The distance apart of two objects held up in front of both eyes can be readily told by the patient if he sees with both eyes, no matter how the objects are held with relation to each other. But if there is vision with one eye only, the patient can tell the distant apart with accuracy only when the objects are both held at the same distance from the eye, but not when one is held considerably in front of the other.
One who sees with one eye only always thinks he is nearer to the object than he really is when reaching out for that object. It is always more difficult for him to pour from a pitcher into a cup or glass if held a little distance below it, hence the blind in one eye usually place the nose of the pitcher in contact with the glass before pouring. The old parlor trick of placing two pins in the wall and putting a cent on them and directing the patient to stand across the room and then walk over to the cent and knock it off with the outstretched finger without hitting the pins, may be made use of as a test in simulated blindness, for with one eye the patient always falls short of the mark the first time the experiment is tried. The most simple method of detecting simulated blindness in one eye is by noticing the movement of the pupil under the influence of light. If an eye is blind, the light has little or no effect upon it when the other eye is closed. The pupil is usually dilated. It may be well to mention here that atropine dilatation is generally wider than that due to amaurosis, and also that a cone of light from a strong convex glass thrown upon the sound eye will contract the pupil of the blind eye if the dilatation is not due to atropine. Simulated blindness in both eyes is not likely to be seen, and then the condition of the pupil is of great value in detecting it, and is one of the best guides in connection with the ophthalmoscopic observation.