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A Study of Tubular and Spiral Central Fields in Hysteria*
610
NOTES, CASES, INSTRUMENTS
A STUDY O F TUBULAR AND SPIRAL CENTRAL FIELDS IN HYSTERIA* T H O M A S H . F A M E S , M.D. Behnont, Massachusetts
Concentrically contracted ( o r tubular) visual fields are variously regarded as symptomatic of hysteria. Ford,^ May," and T a s s m a n ' have listed such fields as at least suggestive of hysteria. Yasuna* pre sented 15 cases of hysterical amblyopia, 14 of which exhibited tubular fields, and H a l p e r n ' reported 15 cases of hysterical amblyopia in which the field tracings were usually tubular. M a y suggested that the spiral field might be included here. In such cases, progressive contraction is noted during examination. Berens and Zuckerman* listed spiral fields as being due to fatigue or functional causes, while Peter' and T r a q u a i r ' were of the opinion that spiral fields occur in neurasthenia rather than in hysteria. Discussion with medical and psychologic colleagues mir rored this Λ'ariation in opinion. T h e pres ent study was undertaken to contribute further data to the subject. The normal central field" as tested on a tangent screen at 750 mm. with a 1-mm., white test object extends nasally 26 de grees ; temporally, 33 degrees; superiorly, 26 degrees; and inferiorly, 28 degrees. Tubular fields are concentrically con tracted with the same isopter distance in all meridians. Their extent is variously estimated up to about 25 degrees. T h e cri terion used in this study was concentric contraction to 15 degrees or less from the fixation point as determined with the tangent screen under the conditions de scribed in the opening sentence of this paragraph. Of the 193 unselected school children
examined, 9 percent exhibited tubular central fields. T h e median age of these pupils was 9 years, 11 months. T h e me dian extent of their tubular fields was 9 degrees, with Qi, 7 degrees, and O 3 , 10 degrees. T h e tubular field chartings ex hibited no marked variation with changes in the test distance as normal fields tend to do. O n e child presented a spiral field but displayed no other evidence of hys teria or neurasthenia. Forty-four percent of the cases with tubular central fields exhibited amblyopia suflScient to reduce visual acuity to 20/30 or less; while 11 percent showed ambly opia with visual acuity of 20/150 or less. Eighty-three percent of the tubular, cen tral-field cases were failing in their school work in one or more subjects. Hysteria was suspected in 77 percent of the cases, and a positive diagnosis of hysteria was made in 33 percent; a provisional diag nosis, in 44 percent. Twenty-three per cent of the cases exhibited no other symp tom or sign of hysteria. O n e of the cases presented a confused picture. This patient was failing in school, exhibited signs of hysteria, including a moderate amblyopia and tubular central fields, but he also had a concurrent illness which might have caused either or both visual impairment and central-field re striction. Unlike the others this patient's field returned to normal very slowly over a period of 14 months, during which time h e received remedial teaching as well as therapy for his concurrent illness. It is impossible to determine which condition was responsible for the tubular central fields in this particular case. Forty-four percent of the tubular cen tral-field cases were rechecked at various intervals averaging 12 months in length. All exhibited central fields of normal size and shape when rechecked except for the single case with concurrent disease. This study supports the contentions
• From the Schoo! of Education, Boston Uni versity, Boston, Massachusetts.
NOTES, CASES.
t h a t : ( 1 ) tubular central fields occur fre quently but not necessarily always in cases of hysteria; and (2) tubular cen tral fields and amblyopia together are fre quent but not invariable manifestations of that condition. It is my opinion that both these manifestations when taken to gether are a more reliable indication of possible hysteria than either one taken alone, since there are diseases which can influence either central fields or visual
INSTRUMENTS
611
acuity in such a way as to confuse the picture beyond reliable interpretation. Therefore, when visual acuity measure ments and central-field chartings are used in examinations for hysteria, a diagnosis should not be made on the mere presence of either or both of these conditions, al though the demonstration of either or both should suggest the possibility of the presence of hysteria. 560 Pleasant Street.
REFERENCES
' Ford, Frank R. Diseases of tlie Nervous System in Infancy, Childhood, and Adolescence. Springfield, 111., Charles C Thomas, 1944. ' M a y , Charles H . Manual of the Diseases of the Eye. Baltimore, William Wood & Co., 1941. " Tassman, I. S. The Eye Manifestations of Internal Diseases. St. Louis, C. V. Mosby Co., 1946. •Yasuna, Elton R. Hysterical amblyopia. Amer. Jour. Ophth., 1946, v. 29, May, p. 570. ' H a l p e m , H. J. Hysterical amblyopia: Report of cases. Bull. U. S. Army Med. Dept., 1944, No. 72, January. 'Berens, Conrad, and Zuckerman, Joshua. Diagnostic Examination of the Eye. Philadelphia, J. B. Lippincott Co., 1946. ' Peter, L. C. Principles and Practice of Perimetry. Philadelphia, Lea & Febiger, 1931. ' T r a q u a i r , H. M. An Introduction to Clinical Perimetry. St. Louis, C. V. Mosby Co., 1940. ' See reference No. 6.
A FIXATION LIGHT FOR THE CARDINAL DIRECTIONS O F GAZE* W I L L I A M COUNCILMAN O W E N S ,
Baltimore,
M.D.
Maryland
T h e deviations of the eyes in the six cardinal directions of gaze should always be measured in the routine study of ocular motor anomalies. T o make these measure ments quickly and accurately, certain im portant factors should be controlled and standardized. T h e measurements should be made with the head erect to eliminate changes in the tone of the ocular muscles induced by turning and tilting the head on the neck.^ I n addition, the measure ments should be made with the eyes at * From the Wilmer Ophthalmological Insti tute of the Johns Hopkins Hospital and Uni versity.
constant, standard angles of rotation from the primary position. Only by such stand ardization are the measurements repro ducible, or comparable with measurements made on diflFerent patients or on the same patient at different times. T h e best method of making these measurements is by the use of the prism cover test while the patient fixates a light, for this method reveals most about the ocular muscles. In measuring the deviation by this meth od, the observer is constantly watching the action of the muscles as the eye moves to take u p fixation. White* stated that the prism cover test "makes for much keener power of observation, and for an intimacy with the functions of the ocular muscles which cannot be acquired by any other test." Although many instruments^ have been devised to facilitate measuring the devia tion in the six cardinal directions, the use
NOTES, CASES, INSTRUMENTS
A STUDY O F TUBULAR AND SPIRAL CENTRAL FIELDS IN HYSTERIA* T H O M A S H . F A M E S , M.D. Behnont, Massachusetts
Concentrically contracted ( o r tubular) visual fields are variously regarded as symptomatic of hysteria. Ford,^ May," and T a s s m a n ' have listed such fields as at least suggestive of hysteria. Yasuna* pre sented 15 cases of hysterical amblyopia, 14 of which exhibited tubular fields, and H a l p e r n ' reported 15 cases of hysterical amblyopia in which the field tracings were usually tubular. M a y suggested that the spiral field might be included here. In such cases, progressive contraction is noted during examination. Berens and Zuckerman* listed spiral fields as being due to fatigue or functional causes, while Peter' and T r a q u a i r ' were of the opinion that spiral fields occur in neurasthenia rather than in hysteria. Discussion with medical and psychologic colleagues mir rored this Λ'ariation in opinion. T h e pres ent study was undertaken to contribute further data to the subject. The normal central field" as tested on a tangent screen at 750 mm. with a 1-mm., white test object extends nasally 26 de grees ; temporally, 33 degrees; superiorly, 26 degrees; and inferiorly, 28 degrees. Tubular fields are concentrically con tracted with the same isopter distance in all meridians. Their extent is variously estimated up to about 25 degrees. T h e cri terion used in this study was concentric contraction to 15 degrees or less from the fixation point as determined with the tangent screen under the conditions de scribed in the opening sentence of this paragraph. Of the 193 unselected school children
examined, 9 percent exhibited tubular central fields. T h e median age of these pupils was 9 years, 11 months. T h e me dian extent of their tubular fields was 9 degrees, with Qi, 7 degrees, and O 3 , 10 degrees. T h e tubular field chartings ex hibited no marked variation with changes in the test distance as normal fields tend to do. O n e child presented a spiral field but displayed no other evidence of hys teria or neurasthenia. Forty-four percent of the cases with tubular central fields exhibited amblyopia suflScient to reduce visual acuity to 20/30 or less; while 11 percent showed ambly opia with visual acuity of 20/150 or less. Eighty-three percent of the tubular, cen tral-field cases were failing in their school work in one or more subjects. Hysteria was suspected in 77 percent of the cases, and a positive diagnosis of hysteria was made in 33 percent; a provisional diag nosis, in 44 percent. Twenty-three per cent of the cases exhibited no other symp tom or sign of hysteria. O n e of the cases presented a confused picture. This patient was failing in school, exhibited signs of hysteria, including a moderate amblyopia and tubular central fields, but he also had a concurrent illness which might have caused either or both visual impairment and central-field re striction. Unlike the others this patient's field returned to normal very slowly over a period of 14 months, during which time h e received remedial teaching as well as therapy for his concurrent illness. It is impossible to determine which condition was responsible for the tubular central fields in this particular case. Forty-four percent of the tubular cen tral-field cases were rechecked at various intervals averaging 12 months in length. All exhibited central fields of normal size and shape when rechecked except for the single case with concurrent disease. This study supports the contentions
• From the Schoo! of Education, Boston Uni versity, Boston, Massachusetts.
NOTES, CASES.
t h a t : ( 1 ) tubular central fields occur fre quently but not necessarily always in cases of hysteria; and (2) tubular cen tral fields and amblyopia together are fre quent but not invariable manifestations of that condition. It is my opinion that both these manifestations when taken to gether are a more reliable indication of possible hysteria than either one taken alone, since there are diseases which can influence either central fields or visual
INSTRUMENTS
611
acuity in such a way as to confuse the picture beyond reliable interpretation. Therefore, when visual acuity measure ments and central-field chartings are used in examinations for hysteria, a diagnosis should not be made on the mere presence of either or both of these conditions, al though the demonstration of either or both should suggest the possibility of the presence of hysteria. 560 Pleasant Street.
REFERENCES
' Ford, Frank R. Diseases of tlie Nervous System in Infancy, Childhood, and Adolescence. Springfield, 111., Charles C Thomas, 1944. ' M a y , Charles H . Manual of the Diseases of the Eye. Baltimore, William Wood & Co., 1941. " Tassman, I. S. The Eye Manifestations of Internal Diseases. St. Louis, C. V. Mosby Co., 1946. •Yasuna, Elton R. Hysterical amblyopia. Amer. Jour. Ophth., 1946, v. 29, May, p. 570. ' H a l p e m , H. J. Hysterical amblyopia: Report of cases. Bull. U. S. Army Med. Dept., 1944, No. 72, January. 'Berens, Conrad, and Zuckerman, Joshua. Diagnostic Examination of the Eye. Philadelphia, J. B. Lippincott Co., 1946. ' Peter, L. C. Principles and Practice of Perimetry. Philadelphia, Lea & Febiger, 1931. ' T r a q u a i r , H. M. An Introduction to Clinical Perimetry. St. Louis, C. V. Mosby Co., 1940. ' See reference No. 6.
A FIXATION LIGHT FOR THE CARDINAL DIRECTIONS O F GAZE* W I L L I A M COUNCILMAN O W E N S ,
Baltimore,
M.D.
Maryland
T h e deviations of the eyes in the six cardinal directions of gaze should always be measured in the routine study of ocular motor anomalies. T o make these measure ments quickly and accurately, certain im portant factors should be controlled and standardized. T h e measurements should be made with the head erect to eliminate changes in the tone of the ocular muscles induced by turning and tilting the head on the neck.^ I n addition, the measure ments should be made with the eyes at * From the Wilmer Ophthalmological Insti tute of the Johns Hopkins Hospital and Uni versity.
constant, standard angles of rotation from the primary position. Only by such stand ardization are the measurements repro ducible, or comparable with measurements made on diflFerent patients or on the same patient at different times. T h e best method of making these measurements is by the use of the prism cover test while the patient fixates a light, for this method reveals most about the ocular muscles. In measuring the deviation by this meth od, the observer is constantly watching the action of the muscles as the eye moves to take u p fixation. White* stated that the prism cover test "makes for much keener power of observation, and for an intimacy with the functions of the ocular muscles which cannot be acquired by any other test." Although many instruments^ have been devised to facilitate measuring the devia tion in the six cardinal directions, the use