- Email: [email protected]
Peduncular hallucinosis according to Jean Lhermitte
revue neurologique 175 (2019) 377–379
Available online at
ScienceDirect www.sciencedirect.com
History of neurology
Peduncular hallucinosis according to Jean Lhermitte E. Drouin a,*, Y. Pe´re´on b a
Centre d’e´tudes de la renaissance, 59, rue Ne´ricault-Destouches, 37013 Tours, France FILNEMUS, laboratoire d’explorations fonctionnelles, centre de re´fe´rence maladies neuromusculaires rares Atlantique-Occitanie-Caraı¨bes, European Reference Network Neuromuscular Diseases EURO-NMD, Hoˆtel-Dieu, 1, place Alexis-Ricordeau, 44000 Nantes, France
b
info article
abstract
Article history:
Peduncular hallucinosis (PH) is a rare clinical syndrome with dream-like visual hallucina-
Received 5 September 2018
tions intruding normal consciousness. It was initially reported in a 72-year-old woman by
Received in revised form
Jean Lhermitte in 1992. We uncovered the medical file of this patient with handwritten notes
11 November 2018
by Lhermitte and commented on it in the light of neurological knowledge that was common
Accepted 13 November 2018
at that time. All along his career, Lhermitte has always been fascinated by consciousness
Available online 2 May 2019
disturbances, dreams and hallucinations. He had here the brilliant intuition of linking PH to awareness mechanisms located in the mesencephalic area. This PH case represented a good
Keywords:
opportunity to him to emphasize the close relationships between neurology and psychiatry.
Jean Lhermitte
# 2019 Published by Elsevier Masson SAS.
Peduncular hallucinosis History of neurology
Jean Lhermitte (1877–1959) worked with Pierre Marie and Henri Claude. Head of the laboratory at La Salpeˆtrie`re in 1911, he was the director of L’hygie`ne mentale (1928) and co-director of L’Ence´phale (1931). He was also a major figure in catholic neuropsychiatry during the 1930s and was one of the pillars of the Saint-Luc Catholic Medical Society. Lhermitte contributed to the ‘‘E´tudes Carme´litaines’’, in which he notably published, in 1933, a paper named ‘‘Origine et me´canismes des hallucinations’’. He explained having focused on this topic because he was a catholic physician accustomed to meet theologians, e.g. at the ‘‘Journe´es Carme´litaines’’ in 1953. The journal’s point was to confront mysticism to modern data from psychology and psychiatry. There was a renewal of catholic beliefs about mysticism occurring * Corresponding author. E-mail address : [email protected] (E. Drouin). https://doi.org/10.1016/j.neurol.2018.11.005 0035-3787/# 2019 Published by Elsevier Masson SAS.
in the 30s while psychiatrists were debating about hallucinations. Links between psychiatry and mysticism were the top ranking subjects of catholic scientific journals at that time. Mental imagery always occupied a central place for Lhermitte. It was therefore logical that he would be interested in hallucinations and, in particular, those of mystics. He thus contributed to E´tudes carme´litaines, within which he published a work in 1933 entitled ‘‘Origin and mechanisms of hallucinations’’. Likewise, in 1935, his friend Henri Ey (1900–1977), neuropsychiatrist, chose to discuss hallucinations in relation to the mystic problem in a Dominican journal, La Vie spirituelle. For him, as for Lhermitte, it was a matter of participating to the lively debate, that was at the centre of the Catholic networks,
378
revue neurologique 175 (2019) 377–379
concerning the relationships between hallucination and mysticism, from a medical point of view. Indeed, it was in 1922 that Lhermitte reported the first case of peduncular hallucinosis (PH) to the French Society of Neurology in a 72-year-old patient (Mrs. B.L.A.) admitted at the General Infirmary of the Paul-Brousse hospice in 1920 for senility [1]. We found in the archives of Lhermitte the medical record (8 handwritten pages) of this patient he examined several times at Paul-Brousse hospital. The clinical and neurological descriptions exactly correspond with what he reported in his publication in 1922 [1]. Lhermitte observed the integrity of her major neurological functions, including cognitive ones. He observed, amongst other things, esotropia secondary to external ocular motor nerve palsy. He described the hallucinatory disturbances that the patient presented and gave them the label of hallucinosis. Mrs. B.L.A saw animals that she could touch ‘‘but the sensation was strange’’. Lhermitte noted that she ‘‘saw a succession of settings that reminded her of old memories, the animals fled because they were afraid of her. She just had to close her eyes and when she re-opened them, the setting had been refreshed.’’ Furthermore, ‘‘the singing of birds that she heard was not natural’’. Mrs. B.L.A reported her feelings to be more like a dream than delirium; she called reality into question. It should be noted that no autopsy had been performed at the time to establish the damage to the cerebral peduncle. Hallucinosis must be distinguished from hallucination. According to the simple definition of hallucination, it is ‘‘an individual who has the intimate conviction of a perceived sensation where no specific external object has stimulated or bought the sensation and in a state of hallucination’’. Esquirol (1772–1840) was the first to make a distinction between illusion (a real object is perceived but the interpretation of the perception is abnormal) and hallucination (perception without an object) [2]. PH, such as that described by Lhermitte, is more a wide-awake or insufficiently asleep dreamer, a critical hallucinate in a hypnagogic state. Henri Ey and Henri Claude were also interested in the distinction [3,4]. A review of the literature of PH cases has recently been performed [5]. The patients, generally aged in their fifties, frequently saw animals (zoopsia) and strange people, as Mrs. B.L.A. had seen. The symptoms were, in most cases, transitional and lasted several weeks [5]. The lesions responsible for PH affect the upper part of the brain stem to varying degrees but are always associated with some disruption of the functional pathways toward the visual cortical areas implicated in the release of the hallucinations [6]. Some encephalitis, depending on the damaged topography, can also trigger hallucinatory experiences into visual hallucinosis. It has recently been suggested that there is a thalamocortical network between the areas of the brain causing PH and those involved in the disorders of functions during paradoxical sleep [7]. Lhermitte was interested in these phenomena throughout his career. He described them as a real ‘‘hallucinatory tide’’ unleashed by lesions of the protuberantial calotte bulb or of surrounding areas, such as the meso-diencephalic or the median hypothalamus [8]. During the hallucinoses, the impairment of consciousness is not as pure and simple as some observations that he described. It contains, as in more or less impaired sleep, a more or less well organised dream. In his
work Le sommeil [9], Lhermitte deducted from anatomicalclinical confrontations that there is a site for the regulatory mechanism for waking and sleeping in the meso-diencephalon that could be involved in hallucinoses. He thus suggested that the dream state has a ‘‘double face’’: a negative one with the suspension of conscience and a positive one in the form of a dream. According to him, the peduncular lesion did not directly determine the blossoming of these false visual perceptions, it intervened by modifying sleep. Indeed, images of hallucinosis resemble dream-like visions. The ‘‘awake’’ patient is impassive before these phastasmagnia, he remains inert before the bewildering spectacle he witnesses. However, the ‘‘dream-like’’ images of these hallucinoses are more colourful, mobile and often silent. In normal dreams, the subject aids in the sequence of images where the inconsistency is not met with a response. At the same time in the 20s, Van Bogaert concurred that hallucinosis was characterised by a relaxation of the ‘‘me’’ with a weakening of reality and spatial and temporal disorientation. It provides the anatomical proof of the site of the legion in the peduncular hallucination. It also demonstrates in an indisputable manner the validity of the pathogenic relationship established by Lhermitte. Van Bogaert reported the case of a patient having the impression of touching snakes but perceived an odd texture that did not stir any emotional reaction [10]. This woman appeared to confuse sensations, image and memories. This is also the case during sleep and normal dreams. However, in the latter the visual image is projected to the sleeping consciousness and the sleeping subject seems to ‘‘accept’’ these images that are imposed on him, exclusive of willingness. He will secondarily perform a ‘‘critical analysis’’ after awakening. Additionally, Lhermitte showed that during a physiological dream a parade of visual images occurs, (sensory and cenesthesia), were more or less faded, without logical connection or emotion [9]. Lhermitte was always passionate about dreams, sleep, consciousness, body image and hallucinations. It was therefore logical that he would linger on the examination of such PH patients. The PH syndrome contained, according to Lhermitte, a double interest: neurological (necrosis by vascular obliteration of the pedoculo-protuberantial calotte, confirmed by the damage to the 3rd, 4th and 6th pairs of cranial nerves), and psychiatric (visual hallucinations). As often with him, the case was at boundaries of both neurology and psychiatry, 2 fields that he had mastered in and never wanted to separate.
Disclosure of interest The authors declare that they have no competing interest.
references
[1] Lhermitte J, Syndrome de la calotte du pe´doncule ce´re´bral. Les troubles psycho-sensoriels dans les le´sions du me´sence´phale. Revue Neurol (Paris) 1922;2:1359–65. [2] Esquirol JE, Baillie`res. Des maladies mentales conside´re´es sous les rapports me´dical hygie´nique et me´dico-le´gal. Paris (Bruxelles): Bailler; 1838 [3 volumes].
revue neurologique 175 (2019) 377–379
[3] Ey H, Claude H. E´volution des ide´es sur l’hallucination, position actuelle du proble`me. L’Ence´phale 1932;5:361–7. [4] Ey H, Claude H. Hallucinose et hallucination. Les the´ories neurologiques des phe´nome`nes psychosensoriels. L’Ence´phale 1932;7:376–621. [5] Galetta KM, Prasad S. Historical trends in the diagnosis of peduncular hallucinosis. J Neuroophtalmol 2017. http:// dx.doi.org/10.1097/WNO.0000000000000599. [6] Boes AD, Prasad S, Liu H, Liu Q, Pascual-Leoe A, Caviness S, et al. Network localization of neurological symptoms from focal brain lesions. Brain 2015;138:3061–75.
379
[7] Geddes MR, Tie Y, Gabrieli JD, McGinnis SM, Golby AJ, Whitfield-Gabrieli S. Altered functional connectivity in lesional peduncular hallucinosis with REM sleep behavior disorder. Cortex 2016;74:96–106. [8] Lhermitte J. In: Doin G, editor. Les hallucinations cliniques et physiopathologiques.. Paris: G.Doin & Cie; 1951. p. 230p. [9] Lhermitte J. In: Colin A, editor. Le sommeil. Paris: Armand Colin; 1931. p. 211p. [10] Van Bogaert L. Syndrome infe´rieur du noyau rouge ? Troubles psycho-sensoriels d’origine me´sencaphalique. Revue Neurol (Paris) 1924;40:417–23.
Available online at
ScienceDirect www.sciencedirect.com
History of neurology
Peduncular hallucinosis according to Jean Lhermitte E. Drouin a,*, Y. Pe´re´on b a
Centre d’e´tudes de la renaissance, 59, rue Ne´ricault-Destouches, 37013 Tours, France FILNEMUS, laboratoire d’explorations fonctionnelles, centre de re´fe´rence maladies neuromusculaires rares Atlantique-Occitanie-Caraı¨bes, European Reference Network Neuromuscular Diseases EURO-NMD, Hoˆtel-Dieu, 1, place Alexis-Ricordeau, 44000 Nantes, France
b
info article
abstract
Article history:
Peduncular hallucinosis (PH) is a rare clinical syndrome with dream-like visual hallucina-
Received 5 September 2018
tions intruding normal consciousness. It was initially reported in a 72-year-old woman by
Received in revised form
Jean Lhermitte in 1992. We uncovered the medical file of this patient with handwritten notes
11 November 2018
by Lhermitte and commented on it in the light of neurological knowledge that was common
Accepted 13 November 2018
at that time. All along his career, Lhermitte has always been fascinated by consciousness
Available online 2 May 2019
disturbances, dreams and hallucinations. He had here the brilliant intuition of linking PH to awareness mechanisms located in the mesencephalic area. This PH case represented a good
Keywords:
opportunity to him to emphasize the close relationships between neurology and psychiatry.
Jean Lhermitte
# 2019 Published by Elsevier Masson SAS.
Peduncular hallucinosis History of neurology
Jean Lhermitte (1877–1959) worked with Pierre Marie and Henri Claude. Head of the laboratory at La Salpeˆtrie`re in 1911, he was the director of L’hygie`ne mentale (1928) and co-director of L’Ence´phale (1931). He was also a major figure in catholic neuropsychiatry during the 1930s and was one of the pillars of the Saint-Luc Catholic Medical Society. Lhermitte contributed to the ‘‘E´tudes Carme´litaines’’, in which he notably published, in 1933, a paper named ‘‘Origine et me´canismes des hallucinations’’. He explained having focused on this topic because he was a catholic physician accustomed to meet theologians, e.g. at the ‘‘Journe´es Carme´litaines’’ in 1953. The journal’s point was to confront mysticism to modern data from psychology and psychiatry. There was a renewal of catholic beliefs about mysticism occurring * Corresponding author. E-mail address : [email protected] (E. Drouin). https://doi.org/10.1016/j.neurol.2018.11.005 0035-3787/# 2019 Published by Elsevier Masson SAS.
in the 30s while psychiatrists were debating about hallucinations. Links between psychiatry and mysticism were the top ranking subjects of catholic scientific journals at that time. Mental imagery always occupied a central place for Lhermitte. It was therefore logical that he would be interested in hallucinations and, in particular, those of mystics. He thus contributed to E´tudes carme´litaines, within which he published a work in 1933 entitled ‘‘Origin and mechanisms of hallucinations’’. Likewise, in 1935, his friend Henri Ey (1900–1977), neuropsychiatrist, chose to discuss hallucinations in relation to the mystic problem in a Dominican journal, La Vie spirituelle. For him, as for Lhermitte, it was a matter of participating to the lively debate, that was at the centre of the Catholic networks,
378
revue neurologique 175 (2019) 377–379
concerning the relationships between hallucination and mysticism, from a medical point of view. Indeed, it was in 1922 that Lhermitte reported the first case of peduncular hallucinosis (PH) to the French Society of Neurology in a 72-year-old patient (Mrs. B.L.A.) admitted at the General Infirmary of the Paul-Brousse hospice in 1920 for senility [1]. We found in the archives of Lhermitte the medical record (8 handwritten pages) of this patient he examined several times at Paul-Brousse hospital. The clinical and neurological descriptions exactly correspond with what he reported in his publication in 1922 [1]. Lhermitte observed the integrity of her major neurological functions, including cognitive ones. He observed, amongst other things, esotropia secondary to external ocular motor nerve palsy. He described the hallucinatory disturbances that the patient presented and gave them the label of hallucinosis. Mrs. B.L.A saw animals that she could touch ‘‘but the sensation was strange’’. Lhermitte noted that she ‘‘saw a succession of settings that reminded her of old memories, the animals fled because they were afraid of her. She just had to close her eyes and when she re-opened them, the setting had been refreshed.’’ Furthermore, ‘‘the singing of birds that she heard was not natural’’. Mrs. B.L.A reported her feelings to be more like a dream than delirium; she called reality into question. It should be noted that no autopsy had been performed at the time to establish the damage to the cerebral peduncle. Hallucinosis must be distinguished from hallucination. According to the simple definition of hallucination, it is ‘‘an individual who has the intimate conviction of a perceived sensation where no specific external object has stimulated or bought the sensation and in a state of hallucination’’. Esquirol (1772–1840) was the first to make a distinction between illusion (a real object is perceived but the interpretation of the perception is abnormal) and hallucination (perception without an object) [2]. PH, such as that described by Lhermitte, is more a wide-awake or insufficiently asleep dreamer, a critical hallucinate in a hypnagogic state. Henri Ey and Henri Claude were also interested in the distinction [3,4]. A review of the literature of PH cases has recently been performed [5]. The patients, generally aged in their fifties, frequently saw animals (zoopsia) and strange people, as Mrs. B.L.A. had seen. The symptoms were, in most cases, transitional and lasted several weeks [5]. The lesions responsible for PH affect the upper part of the brain stem to varying degrees but are always associated with some disruption of the functional pathways toward the visual cortical areas implicated in the release of the hallucinations [6]. Some encephalitis, depending on the damaged topography, can also trigger hallucinatory experiences into visual hallucinosis. It has recently been suggested that there is a thalamocortical network between the areas of the brain causing PH and those involved in the disorders of functions during paradoxical sleep [7]. Lhermitte was interested in these phenomena throughout his career. He described them as a real ‘‘hallucinatory tide’’ unleashed by lesions of the protuberantial calotte bulb or of surrounding areas, such as the meso-diencephalic or the median hypothalamus [8]. During the hallucinoses, the impairment of consciousness is not as pure and simple as some observations that he described. It contains, as in more or less impaired sleep, a more or less well organised dream. In his
work Le sommeil [9], Lhermitte deducted from anatomicalclinical confrontations that there is a site for the regulatory mechanism for waking and sleeping in the meso-diencephalon that could be involved in hallucinoses. He thus suggested that the dream state has a ‘‘double face’’: a negative one with the suspension of conscience and a positive one in the form of a dream. According to him, the peduncular lesion did not directly determine the blossoming of these false visual perceptions, it intervened by modifying sleep. Indeed, images of hallucinosis resemble dream-like visions. The ‘‘awake’’ patient is impassive before these phastasmagnia, he remains inert before the bewildering spectacle he witnesses. However, the ‘‘dream-like’’ images of these hallucinoses are more colourful, mobile and often silent. In normal dreams, the subject aids in the sequence of images where the inconsistency is not met with a response. At the same time in the 20s, Van Bogaert concurred that hallucinosis was characterised by a relaxation of the ‘‘me’’ with a weakening of reality and spatial and temporal disorientation. It provides the anatomical proof of the site of the legion in the peduncular hallucination. It also demonstrates in an indisputable manner the validity of the pathogenic relationship established by Lhermitte. Van Bogaert reported the case of a patient having the impression of touching snakes but perceived an odd texture that did not stir any emotional reaction [10]. This woman appeared to confuse sensations, image and memories. This is also the case during sleep and normal dreams. However, in the latter the visual image is projected to the sleeping consciousness and the sleeping subject seems to ‘‘accept’’ these images that are imposed on him, exclusive of willingness. He will secondarily perform a ‘‘critical analysis’’ after awakening. Additionally, Lhermitte showed that during a physiological dream a parade of visual images occurs, (sensory and cenesthesia), were more or less faded, without logical connection or emotion [9]. Lhermitte was always passionate about dreams, sleep, consciousness, body image and hallucinations. It was therefore logical that he would linger on the examination of such PH patients. The PH syndrome contained, according to Lhermitte, a double interest: neurological (necrosis by vascular obliteration of the pedoculo-protuberantial calotte, confirmed by the damage to the 3rd, 4th and 6th pairs of cranial nerves), and psychiatric (visual hallucinations). As often with him, the case was at boundaries of both neurology and psychiatry, 2 fields that he had mastered in and never wanted to separate.
Disclosure of interest The authors declare that they have no competing interest.
references
[1] Lhermitte J, Syndrome de la calotte du pe´doncule ce´re´bral. Les troubles psycho-sensoriels dans les le´sions du me´sence´phale. Revue Neurol (Paris) 1922;2:1359–65. [2] Esquirol JE, Baillie`res. Des maladies mentales conside´re´es sous les rapports me´dical hygie´nique et me´dico-le´gal. Paris (Bruxelles): Bailler; 1838 [3 volumes].
revue neurologique 175 (2019) 377–379
[3] Ey H, Claude H. E´volution des ide´es sur l’hallucination, position actuelle du proble`me. L’Ence´phale 1932;5:361–7. [4] Ey H, Claude H. Hallucinose et hallucination. Les the´ories neurologiques des phe´nome`nes psychosensoriels. L’Ence´phale 1932;7:376–621. [5] Galetta KM, Prasad S. Historical trends in the diagnosis of peduncular hallucinosis. J Neuroophtalmol 2017. http:// dx.doi.org/10.1097/WNO.0000000000000599. [6] Boes AD, Prasad S, Liu H, Liu Q, Pascual-Leoe A, Caviness S, et al. Network localization of neurological symptoms from focal brain lesions. Brain 2015;138:3061–75.
379
[7] Geddes MR, Tie Y, Gabrieli JD, McGinnis SM, Golby AJ, Whitfield-Gabrieli S. Altered functional connectivity in lesional peduncular hallucinosis with REM sleep behavior disorder. Cortex 2016;74:96–106. [8] Lhermitte J. In: Doin G, editor. Les hallucinations cliniques et physiopathologiques.. Paris: G.Doin & Cie; 1951. p. 230p. [9] Lhermitte J. In: Colin A, editor. Le sommeil. Paris: Armand Colin; 1931. p. 211p. [10] Van Bogaert L. Syndrome infe´rieur du noyau rouge ? Troubles psycho-sensoriels d’origine me´sencaphalique. Revue Neurol (Paris) 1924;40:417–23.