HYSTERICAL, OR FUNCTIONAL, BLINDNESS. BY ALVIN A. HUBBELL, M. D., BUFFALO, Professor of Ophthalmology and Otology in the Medical Department of Niagara University. REPRINTED FROM THE Ncto Yorft Iftetucal Journal fort July 17, 1897. Ref rinted from the New YorTc Medical Journal for July 17, 1897. HYSTERICAL, OR FUNCTIONAL, BLINDNESS * BUFFALO, PROFESSOR OF OPHTHALMOLOGY AND OTOLOGY IN THE MEDICAL DEPARTMENT OF NIAGARA UNIVERSITY. ALVIN A. HUBBELL, M. D., Cases are rare in which complete loss of vision takes place in one or both eyes without there being pres- ent fundus changes or lesions of the optic nerve or brain to account for it, and in which, after several days or weeks, the vision begins to return and is finally restored. I am therefore led to report the following cases which have recently come under my observation. Case I.—Miss J. H., daughter of a physician, is a young woman eighteen years of age, who usually has good health, and is quiet in her manner and not emo- tional. Two years ago she had “ malarial fever,” hut fully recovered, from it. The menstrual functions are normal and regular, and there is no evidence of uterine derangement. She has never had convulsions or any nervous disturbances suggesting hysteria. On March 9, 1897, she was seized with pain in the left eye, which extended over the left side of the head and into the left ear. This was so severe as to require anodynes for its relief. In three days it had nearly dis- * Read before the American Ophthalmological Society, Washington, D. C., May 6, 1897. Copyright, 1897, by D. Appleton and Company. 2 HYSTERICAL BLINDNESS. appeared. The vision of this eye began to he affected soon after the onset of the pain, and was very “ foggy ” the next day, March 10th. On the morning of the third day, March 11th, when she awoke she found that the vision of this eye was lost, not being able to distin- guish even light with certainty. Her father took her to an ophthalmic practitioner in a neighboring town for consultation, and was given the opinion that it was a case of retinal thrombosis. A line of treatment was marked out and followed for a few days without im- provement. The father’s anxiety became so great that he determined to seek further advice, and on March 16th brought his daughter to me. Examination of the eyes externally showed them to be alike in appearance and their movements nor- mal. The pupils were of normal and equal size, hut the reaction to light was a little slower and less complete in the left eye than in the right, there being a slight dilatation when exposed alone. There was manifest hy- permetropia of 0.50 D. of the right eye and vision was f Snellen’s test-types. The vision of the left eye seemed entirely lost. There was perhaps a slight per- ception of strong light at the extreme temporal part of the visual field, but of this the patient was not quite certain. Ophthalmoscopic examination through the un- dilated pupils did not show anything abnormal in either eye. To insure a more thorough inspection of the left eye the pupil was dilated with homatropine solution. A most careful search was then made for some pathological change in the fundus, hut not the slightest could he found. There was no obstruction in the retinal circula- tion or change in the vessels, no oedema, discoloration, or hsemorrhage of the retina, and no changes of the optic disc. The retinal vein at the disc could even he seen to pulsate. Tension was normal. The patient complained of a “ weakness ” of the eye and some headache, and gen- eral weakness. I ventured the opinion that the ease was one of so-called functional blindness. The father then informed me of the diagnosis of the colleague who HYSTERICAL BLINDNESS. 3 had preceded me in the case. There being so much dif- ference between us in regard to the diagnosis, I suggested that still another opinion he obtained. On the next day, March 17th, my friend, Dr. F. W. Abbott, kindly examined the case most carefully, and he, too, was un- able to find anything, objectively, to account for the loss of vision. To him the fundus was entirely normal in every respect, except, perhaps, a slight engorgement of the retinal veins. Dr. Abbott suggested that a leech be applied to the left temple and the patient kept quiet in a darkened room for a few days. His suggestion was followed, and the patient was also given five grains of iodide of potas- sium three times a day, and later there was added one six- tieth of a grain of strychnine three times a day. On March 19th there was distinct perception of light, and she could see the movements of my hand. 20th.—She counted fingers held in the peripheral part of the visual field with difficulty. 22d.—She counted fingers readily when held periph- erally in the visual field. Left the darkened room and simply kept the eye covered. 23d.-—I began to apply to the eye the interrupted gal- vanic current of electricity for three to five minutes once a day. 28th.—She read No. 60 Snellen at one metre but only by looking to one side of it. April 3d.—She was able to read No. 60 Snellen at five metres viewing the letters eccentrically. 1 examined the eye again with the ophthalmoscope, hut the fundus was normal, as before. She returned to her home in the country, where essentially the same treat- ment was to he continued. 15th.—Came to my office again, and I found that vision had increased to Snellen No. 9 at five metres (f,) and Jaeger No. 6 slowly at ten inches. From that time the vision has gradually improved, until she is now able to read No. 1 Jaeger, hut with some effort. The large type seems more or less confused, 4 HYSTERICAL BLINDNESS. and she says the “vision is very weak.” Still further improvement will undoubtedly take place. Although the vision for objects has become so nearly restored, the color sense is very much impaired. I have not been able to test this, but her father writes me that “ she can not distinguish colors. Red is black to her.” Another interesting accompaniment of the visual symptoms is the loss of function of the corresponding lacrymal gland. On one or two occasions, when feeling badly, she has cried. The tears would trickle down the right cheek freely, hut there was no lacrymation of the left eye. This, to me, is additional evidence of the func- tional character of the blindness. Case ll.—Mrs. S. has been a patient of mine for years. She is fifty years old, is the mother of several children, and has usually been in good health. She has passed the menopause without special disturbances, and has lately increased considerably in weight. She has hypermetropia 1.75 D. in each eye, the correction of which has given her normal vision—Snellen No. 5 at five metres (|)—and the correction of the presbyopia with -|- 4.50 I), has enabled her to read Jaeger No. 1 at four- teen inches. On March 16th, after suffering for a few days from a “ cold,” the vision of the left eye began to fail, and in three days she was unable to see objects. Not getting better, after using some domestic treatment, she con- sulted me on April 3d. I found the vision of this eye was a little more than perception of light, but not suffi- cient to distinguish fingers or large objects distinctly. The external appearances of the eye were normal, and the pupil was of the same size as that of the other, and reacted as well to light. After dilating the pupil with a solution of homatropine, I was unable to find any patho- logical changes whatever in the fundus of the eye. No lesions elsewhere were apparent, and there was no hemi- ansesthesia. I made the diagnosis here also of functional blind- ness and ordered small doses (five grains) of iodide of potassium to be taken three times a clay. HYSTERICAL BLINDNESS. 5 On April 15th vision had risen to Snellen No. 15 at five metres and at the present time (May 24th) it is | nearly. Case lll.—Mrs. C., thirty years old, is rather slight in stature, is not strong and robust, and is of an active, “ nervous ” temperament. Eight years ago she gave birth to a son, and has since had some slight uterine displacement. She came in February last to Dansville, N. Y., from New York city, to visit her husband, who was at the sanatorium for treatment. Before leaving home she had been working unusually hard by reason of some extra household duties that had come upon her, and was therefore much fatigued. A few days after her arrival, on February 19th, at about 5 p. m., while pre- paring her toilet for supper, she suddenly became dizzy. She started for the bed, but had taken hut a step or two when she fell, striking the hack of her head against the iron-bound edge of a large trunk. Shortly before six o’clock she was discovered. She says she remembers fall- ing, hut does not know how long she lay on the floor. It is estimated that it was twenty to forty minutes before she became conscious and assistance reached her. She was put to bed, simple restoratives were administered, and she was soon quite comfortable. She noticed a hook lying on the foot of the bed and, feeling so well, she thought she would read a little. As she rose up and leaned forward to reach it, she was seized with a “ sudden and severe rush of blood to the head,” as she described it. Dr. Gregory, of the sanatorium staff, was called, and she was soon made comfortable and remained so until about nine o’clock, when she was taken with severe pain in the head, this being worse in the occipital region, and accom- panied by a sense of great pressure. To her it was like “ a cataract flowing copiously down the hack of the head and brain.” The pain was so intense that it was con- trolled only by the hypodermic use of morphine. Dur- ing the night she became delirious at times, and she be- gan to have “ cramps,” which affected, more or less, the whole body. Dr. Gregory characterized them as “ cata- 6 HYSTERICAL BLINDNESS. leptic ”in nature. These seizures were frequent, and lasted from “ two to ten minutes.” The pain, delirium, and convulsions began to diminish after two or three days, and had quite disappeared at the end of ten days. Nausea and vomiting were also frequent during this period. There were no emotional symptoms, no glohus hystericus, no hemianesthesia. At no time previous to the fall had she had convulsions, dizziness, or “ falling sickness.” On February 20th, the next day after the fall, Mrs. C. began to complain of dimness of vision in both eyes, and within twenty-four hours afterward she was unable to distinguish even light with either eye. At first she said there was a sense of “ glare,” and this gradually changed to total darkness or blackness. The expression of her face was the vacant stare of any blind person. At times her eyes pained her considerably, but were never reddened or watery. During the first two weeks she was thoroughly exam- ined for fracture of the skull and lesions of the brain, but none could he found. The vision not returning, while in other respects the patient had nearly recovered, I was called to see her on March sth, just two weeks after the fall. She was then quite free from pain, and there had been no convulsions, delirium, or vomiting for several days. She was some- what weak and still kept her bed. There were no symp- toms of anaesthesia or paralysis of any part, and the hearing and other senses, except vision, were very acute. Careful search made negative any lesion of the brain whatsoever—contusion, haemorrhage, or compression. The injury at the hack of the head had been so slight as scarcely to produce an abrasion. The only abnormal conditions apparent at this time were the general physical weakness and the loss of vision, which was complete. I could not elicit any evidence of the slightest perception of the strongest light. The ex- ternal appearances of the eyes were normal, and the move- ments of the halls and lids were unrestricted. The hysterical blindness. 7 pupils were of equal and ordinary size and reacted quick- ly and fully to light. To facilitate the ophthalmoscopic examination I used a mydriatic, and after dilatation of the pupils made a most careful examination of both fundi. No abnormal appearance of any kind could he found in either the optic discs, retinal vessels, retinae, or other structures. The picture of the parts was one of perfect health and function. The case appeared to me to be one of functional or hysterical blindness, and in this light I was able to give a favorable prognosis. The treatment was directed toward the general im- provement of the patient and the use of electricity. She gradually gained in strength, but her vision did not change till the fifth week after the injury. On March 34th she thought there was more light in her room. On March 36th she could distinguish large objects, and on March 37th she could recognize faces. It was on this date that I visited her the second time, and I have not seen her since. But on April 33d she wrote me that the vision quite fully returned in both eyes shortly after my last visit, and that she was now able to see as well as ever, except that her eyes were “ weak.” I submit these cases as belonging to that extraordinary class known as functional, or hysterical. When the pa- thologist will give us an acceptable explanation of hys- terical ansesthesia of areas of the skin or of hysterical pal- sies of certain muscles, then we, by analogy perhaps, may offer some rationale of the blindness in such cases as I have related. At present we are entirely in the realm of unsubstantiated theory, and I refrain from specula- tion. The Hew York Medical Journal. A WEEKLY REVIEW OF MEDICINE, EDITED BY FRANK P. 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