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.