Extracted from the TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, THIRD SERIES, VOLUME II. HYSTERICAL AFFECTIONS OF THE EYE. By GEORGE C. HARLAN^ M.P., SURGEON TO WILLS HOSPITAL, OPHTHALMIC AND AURAL SURGEON TO THE CHILDREN'S HOSPITAL. [Read June 7, 1876.] Though the term " hysterical" is a vague and in- definite one, which most of us would rather not be called upon to accurately define, still it has a con- ventional meaning, and, by common consent, is made to include a large class of cases in which there may be decided or even alarming symptoms without real disease. The expression is used here in its broadest sense, as it is not my intention to undertake a dis- cussion of psychological pathology, but merely to call attention to a class of eye symptoms which I believe are not sufficiently dwelt upon in the text books, and which I feel sure are very often misin- terpreted in practice. I have more than once met with interesting, but rather mysterious, cases which had been reported in good faith by experienced sur- geons, but which seemed to me to be clearly of this character; and, without doubt, a large proportion, if not all, of the magical cures of blindness by gal- vanism, that we occasionally hear of, may be referred to this class of cases. The hysterical affections of the eye that have come 140 HARLAN, under my notice'have appeared to me to include three kinds of patients. I. Those who are the subjects of a kind of moral insanity, or, at any rate, of an insane perversity; who deliberately simulate a disease for months or years; who, in short, may be called hysterical malingerers; and who to be cured need only to be exposed. II. Those who really believe themselves to be affected as they profess to be, and are honestly anxious to be cured; who are subjects of hysterical paralysis; and whom it would, perhaps, be unjust to accuse of acting a part. III. Those who are subject to irregular nervous action, to paralysis or spasm without assignable cause, but in whom there is no question of mental or moral complication. I reported several instances of the first class, and gave the various means that have been resorted to for their detection, in an article on " Simulated Amauro- sis" in the American Journal of the Medical Sciences for October, 1873. One case, as a good illustration, may be reproduced here. Two years ago a girl eleven years of age, apparently in excellent health, was brought to me by her parents with the statement that they had recently discovered her left eye to be quite blind. She had been sent to the family physician, a homoeopathic practitioner, on account of a slight conjunc- tivitis, and, as the result of the consultation, had returned with this startling announcement. She denied even per- ception of light in that eye. Never having met with a similar case, I failed to detect, or even suspect, the deception, but as a careful ophthalmo- scopic examination revealed no lesion or imperfection of the organ, I assured the girl's parents that there was no present HYSTERICAL AFFECTIONS OF THE EYE. 141 disease there, and no indication for treatment. The other eye was found to be perfect in all respects, and I advised them to return her to school and pay no attention to the blind eye while the sight of the other remained unimpaired. A few weeks since she was again brought to my office, complaining that the other eye was failing, the left still continuing stone blind. She said that the print looked blurred when she attempted to read, and her parents had noticed that she held the book nearer to the eye than usual. 20 She admitted a vision of - and with a -T'5 glass acknow- 20 . ledged to - • central limitation of the field of vision was very well counterfeited. The result of a careful oph- thalmoscopic examination was entirely negative. While I was engaged in recording her case, she amused herself by looking over the trial glasses, and announced that the plain blue glass made a great improvement in her sight. This being the only discernible indication for treatment, I ordered blue glasses ; but not finding the large blue coquilles, with which the optician furnished her, becoming, she, at the next visit, denied that they were of any use. When directed to look at a distant gas flame through a prism with its base up- wards, held before the right eye, she at once acknowledged the double images, but when the attempt was made to sepa- rate the images by means of a colored glass, her suspicions seemed to be aroused, and her answers were negative. When required to read the test letters at varying distances there were evident discrepancies in her answers. The pretended amblyopia of the right eye precluded the use of a,ny of the tests for monocular blindness based upon the reading of ordinary type, and confined me to the large letters which she had acknowledged being able to recognize. I, therefore, placed the trial frames before her eyes with a plain glass in the left side, and a convex one of ten inch focal distance in the right. The latter, without exciting her suspicion, excluded the right eye from any distinct 142 HARLAN, vision beyond the focus of the glass. She still read. No. L at twenty feet. Then, having first substituted for the test card another with a different series of letters, I placed an opaque disk in front of the plain glass, and she could not make out a letter. This proved, at least, that she had been reading No. L, at twenty feet, with the eye that she pretended was not conscious even of the bright glare from the oph- thalmoscopic mirror, and was quite enough to justify a com- plete distrust of all her statements. She did not appear again, but her father called on me some days afterwards and reported that she had come home in a very bad humor, indignantly accusing me of having treated her with great injustice, but, the next day, had made admissions which, though partial and constrained, were sufficient to convince him of the correctness of my view of her case. ' This form of hysteria is the only one usually re- ferred to in works on ophthalmic surgery. The following case of simulated monocular diplopia is, I believe, unique :- An unusually bright little girl, ten years of age, was brought to me by her father, who said that she had been troubled with double vision for two weeks. The symptom first appeared in a very crooked copy in her writing lesson, had since been constant, and had disturbed her sight so much that she sometimes stumbled as she walked, or ran against people in the street. There was no evident disturbance of her health, but she complained of occasional frontal headache and sleeplessness, stating that she heard the clock strike nearly every hour during the night. She said she was never free from the double vision except when the right eye was closed ; that closing the left eye made no difference. Examination of the eyes gave the following result: Left, 20 V = , and in all other respects quite normal. Right, V XXX 20 , p i * i ™ = - ; no improvement by glasses of any kind. When CO HYSTERICAL AFFECTIONS OF THE EYE. 143 tested with the candle, two distinct images of the flame side by side, separated by a narrow but well-defined space. Field normal, and double images the same in all directions. Neither the use of a stenopaic hole, nor complete atropiniza- tion, produced any effect on this symptom. The media were perfectly clear, and the ophthalmoscope showed an emme- tropic refraction and a typically normal fundus. The patient's manners were so perfectly childlike and ingenuous that I was completely puzzled, and merely assured her father that I had been unable to detect any disease, and asked him to bring her again in a few days. In thinking over the case after she had gone, the symptoms seemed in such entire defiance to the laws of physiology and optics that they could not be real. I mentioned my suspicions to the family physician, Dr. Ellwood Wilson, and he at once acted upon the hint. The little patient was carefully watched during the night, and found to sleep calmly and quietly without interruption. Directions were then given that she should not be allowed to use her eyes for an instant either in work or play, and that whenever there was the slightest warning of headache, she should at once be sent to a darkened room to remain until the pain disappeared. This regimen was too much for her active mind, and she soon announced that the two objects were coming closer together, and that she should not be surprised if they were to go into one. In a few days her father called at my office to say that all trouble had disappeared. Almost any derangement of vision may be counter- feited. A little girl of eight years complained that every object that she looked at seemed covered with diagonal white lines, the direction of which she indi- cated with her finger. As the ophthalmoscope revealed a normal fundus, a favorable prognosis was given. This was made more positive the next day, when the white lines changed to blue, and was justified by the early disappearance of the difficulty. 144 HARLAN, In the second class of cases we have more or less retinal.anaesthesia with anomalons and variable symp- toms changing, perhaps, at each examination. The following case may afford an illustration:- Miss A., aged about twenty, lived some distance from town, and was seen only at comparatively long intervals. The diagnosis was made easy by a very well-marked hysterical history. The first record is : Right eve, V = - ,Left - XL XXX Both eyes emmetropic, and ophthalmoscopic appearances perfectly normal. Accommodation deficient and irregular. She was ordered 4- for reading, which seemed to give great 15 assistance. At the next visit, vision had diminished to -. c Soon afterwards there was a partial limitation of the field of 15 • 15 vision with V .- at the periphery and less than - at the LX C centre. A high degree of photophobia was now added to the symptoms. In a few days more the amblyopia had still further increased, to an extent that gave the greatest alarm to her friends, whom it was difficult to convince that she was not drifting into hopeless blindness. After this time she did not appear for three months, when she reported that her sight had improved so much that she had been able to read and sew with the aid of the glasses, but that it had again grown much worse. She could now make out No. C not further than six feet, and that for a few seconds only, when the sensibility of the retina seemed to be exhausted. When the eyes were fixed upon an object a foot distant, it was soon lost to view entirely. There was also a high degree of insufficiency of the internal recti. Having now pretty nearly exhausted the list of available symptoms, the patient stopped short of complete blindness, and, without special treatment, gradually but entirely re- covered. HYSTERICAL AFFECTIONS OF THE EYE. 145 In the third class of cases the parts affected have been the retina, the muscle of accommodation, the external muscles of the eyeball, and the elevator of the upper lid. It is not very uncommon to meet with patients who have apparently perfect eyes and full acuity of vision, but who say that the test letters become blurred and unrecognizable after they have looked at them for a few seconds. That this is due to an exhaustion of the sensibility of the retina which disables it from the sustained performance of its function, and not to an irregular action of the accommodation, is shown by the fact that it persists when the eye is fully under the effects of atropia. A partial failure of the accommodation may occur in nervous persons, either alone or in connection with other symptoms. Very satisfactory results may some- times be obtained from the use of weak convex glasses, in the case of ladies who are quite young and entirely emmetropic. Exception may be taken to including the opposite condition of accommodative spasm among hysterical affections, because it usually occurs in con- nection with some error of refraction. In a very large proportion of cases, however, the subjects are delicate women, and the error of refraction is a very slight departure from the normal standard, such as would not be felt by a person of fair average strength and nervous equilibrium. In other words, it is only the exciting cause, a strong predisposition existing in the temperament of the individual. These cases are of quite frequent occurrence in ophthalmic practice. The following is a good illustra- tion :- io 146 HARLAN, Ail intelligent but delicate school-girl, fourteen years of age, just before the first appearance of the menses, complained that she was growing more and more near-sighted, could not recognize people in the street, and was obliged to hold the book very close when reading. Vision without glasses was 20 found to be only - Concave glasses of eight inches focus c 20 brought it up at once to -, but, in a few seconds the par- xx tial closing of the eyelids and corrugation of the brows showed that this acuteness of vision was gained at the expense of considerable accommodative strain. The ophthal- moscope revealed a perfectly normal fundus and a refraction nearly emmetropic. Under atropia it was evident that there was not only no myopia, but a slight degree of hypermetro- pia, and + ?'2 brought vision up to the normal standard. This might fairly be called a case of hysterical myopia. Irregularity in the action of the external, muscles of the eyeball, particularly insufficiency of the inter- nal recti in convergence, is not uncommon in patients of this class, and frequently complicates their other ailments. A young married lady, a painfully7 hysteri- cal subject, could scarcely use her eyes at all, though they were perfectly healthy and emmetropic, and the acuteness of vision was normal. The external muscles seemed, as it were, to have dissolved partnership and each to act on its own account when she attempted to converge. Their irregular and variable action made anything like an accurate measurement of their force impossible. The following is one of several cases in which there was occasional double vision from spasmodic action of one of the external muscles. HYSTERICAL AFFECTIONS OF THE EYE. 147 Miss M., a little below par in general health and of ex- tremely nervous temperament, complained that frequently, without warning and without special exciting cause, as at the dinner table or at the opera, everything suddenly appeared double* and at the same time it was evident to her that she had lost control of the movements of one eye, which felt as if forcibly turned to one side. On closing the lids and pressing the ball for an instant, the symptoms would dis- appear. The acuteness of vision was normal, the balance of the external muscles for distant sight correct, and refraction nearly emmetropic. The correction of a hypermetropia of 4'5 did not prevent the recurrence of the annoyance. There is one more affection to which I wish to call attention; it is of especial interest because, though in this class of cases of little moment, it may be, in others, a symptom of very grave lesions. I refer to a temporary paresis of the elevator of the upper lid. There is a great difficulty, sometimes an impossi- bility, of opening the eyes when rousing from sleep. Some patients are able to raise the lid naturally after several vigorous efforts of the will, while others are obliged to raise it with the fingers, and to rub or bathe it before acquiring control over its action. This occurs always on awakening, whether in the morning, during the night, or after a nap in the day- time, and is naturally the occasion of much uneasiness. I have notes of four such cases occurring in delicate ladies and evidently of an hysterical character. Two recovered entirely, though not very quickly, under the use of tonics; a third lived at a distance, and I saw her only once; and the fourth is still under treatment. In the last, the affection is of long stand- ing, and is peculiar in the fact that for many months it was confined to one eye. 148 HARLAN, The patient, about eighteen months ago, had difficulty in opening the left eye on awakening, the trouble lasting, at that time, for a few weeks only. About a year ago it com- menced again in the same eye, has persisted since, and dur- ing the last few months has involved the right eye also, though to a less degree. Always when tired or weaker than usual she has the annoyance to a much greater extent; at times she is almost free from it. Iler health is very feeble, she has had attacks of ague, etc., and is subject to functional palpitation of the heart and nervous prostration. There have never been any brain symptoms. The only example of this affection that I have seen in the case of a man, rather confirms the view of its hysterical character. A gentleman, forty-two years of age, was sent to me on account of a violent attack of gouty irido-sclerotitis in the right eye. For eight or nine months he had been the victim of the most excruciating sciatica, and slighter neuralgia of other parts of the body, with gouty inflammation of some of the smaller joints; and had been almost constantly under the effects of morphia by hypodermic injection. There had never been any pain in the head or face until the commence- ment of the iritis a week before I saw him, since when it had been unusually violent in the eyeball, and in the branches of the fifth pair on the affected side. Coincidently with the other eye symptoms occurred this partial loss of control of the levator palpebrse. Always on awakening he was unable to raise either eyelid without the assistance of his hand, and had to bathe and rub the lids before regaining the power to raise them naturally. This sometimes occurred when he closed his eyes without falling asleep. At the time of examination, he could easily wink rapidly, but if the eyes were closed tightly, or even gently for more than a few seconds, they could not be opened without assist- ance. The orbicularis seemed completely relaxed, and a HYSTERICAL AFFECTIONS OF THE EYE. 149 very slight touch only of the finger was necessary to enable the levator to act. His sensation was, as has been the case with all the other patients, as if the lid were unnaturally weighted, and too heavy to be raised in the usual way. This symptom gradually disappeared as the inflammation of the eye subsided, and in a little more than two weeks from its commencement there was full control over the lids. The attending physician, Dr. JohnM. Adler, tells me that, in the progress of the case, the patient's manner and some of his symptoms have frequently been very suggestive of hysteria. There has even been, after some of the more violent parox- ysms of pain, a very copious flow of colorless urine. I have not seen any reference to this affection in print, but on speaking of it to some of my friends in general practice, I find that they have met with cases. Of course, no careful practitioner would lightly set aside so suspicious a symptom, or pronounce it merely " nervous," without due investigation. The danger of doing so has been sufficiently impressed on my own mind by the fact that the first case that came under my observation, a good many years ago, ended fatally some months afterwards from an intracranial tumor of which this symptom had been the earliest indication.