Functional hemianopsia: A historical perspective

SURVEY OF OPHTHALMOLOGY

HISTORY DANIEL

JOHN

EDITOR

Hemianopsia:

W. GITTINGER,

DiGion

NUMBER 6 * MAY JUNE 1988

OF OPHTHALMOLOGY

ALBERT

Functional

VOLUME 32.

A Historical

Perspective

JR., M.D.

of’ Ophthalmology.

Department

of Surgey, 1 ‘nir)ersi
oj’.lln.aachusetts

Medical

School.

Il~wrrttrr.

Abstract. The controversial

monograph

history of functional hemianopsia is rr\iewed from Briqurt’s 18.59 WI 430 cases of hysteria, through the 19th century works of Charcot. Freud. and

Janet, and the observations of Fox and Wilbrand and Saenger m the early 20th centur)-. hlorr recently, concepts of this entity have been clarified by modern binocular testing of visual liclds. [Surv Ophthalmol 32:427-132, 1988)

Key words.

functional

hemianopsia

l

hysteria

“He who knows hysteria knows medicine. ” Osler*

Conclusions based on clinical observation of individual patients are necessarily tentative. This inherent uncertainty is nowhere more evident than in functional disease, which includes the disorders classically known as hysteria. While preparing a report of four patients with functional monocular temporal hemianopsias, ” I encountered a considerable literature in the latter nineteenth and early twentieth century that debates the existence of functional hemianopsias. As an interesting example of how medical science functions, I summarize it here.

Pierre Briquet

published in 1859.’ This monograph on his study of 430 cases of hysteria is considered the first modern description of this ancient entity,“’ and twentieth century students have suggested that the polysymptomatic form of hysteria be referred to as “Briquet’s syndrome.““’ In what appears to be the first mention of functional hemianopsia, Briquet stated that some hysterics had blindness that affected only half of the retina, usually either the internal or external half, but provided no specifics.” The first case reports were to appear later in the nineteenth century, in an era dominated by the man his contemporaries nicknamed the “Napoleon of Neuroses,” %Jran-Martin Charcot .”

(1796-1881)

The controversy involved some notable nineteenth century physicians, beginning with Pierre Briquet. Briquet’s place in medical history is based on his Traiti Clinique et ThPrapeutique de L’ffvstPrie,

Jean-Martin *Cited by Duke-Elder (Ref. 5, p. 580). I could not locatr this epigram in O&r’s writings, although he did make a similar statcment about syphilis-“Know syphlbs in all its manifestation, and all things clinical will be added unto you” (Aeguanimitas).

Charcot (1825-1893)

In 1848 at the age of twenty-three, Charcot was appointed an interne des h6pitaux at L’Hospice de la SalpCtri&e, one of the two workhouse infirmaries of 427

428

Surv Ophthalmol

32(6) May-June

1988

Paris. The Salpitriere, which contained beds for 5000 and took its name from a history of gunpowder storage on its site, admitted female patients, and its companion institution, the Bicitre, males. In 1862 at the age of 36, Charcot was appointed meiiecin des h$itaux for one of the larger sections of the Saip~triere, a title that Briquet had held a generation earlier. Rather than follow the accepted path of French senior physicians of that time, moving from hospital to hospital according to which had patients that suited their current interests, and ending their careers at the HGtel-Dieu, Charcot vowed to remain at this “grand asylum of human misery.“” He proceeded to set up a pathological laboratory at his own expense and, with the students he soon attracted, to establish neurology as a separate discipline within medicine. Using the clinical material at his disposal, he described amyotrophic lateral sclerosis and the pathology of the plaques of multiple sclerosis, among many other contributions.“” His fame grew, and in 1881 a chair of neurology, the first in the world, was established at the Salpetriere for him. In 1870 Charcot had taken charge of a ward where women with seizure disorders were mixed with others who had pseudoseizures. Charcot’s studies of these women led to a classification both of epilepsy and hysteria. By 1878 he had added hypnotism to his armamentarium, a bold move in view of the controversy that surrounded this technique after the misadventures of Franz Anton Mesmer a century earlier. (F or a sympathetic account of Mesmer’s life and works see Zweig.“’ Other historians of science are more critical of Mesmer’s moa paper on his tives.24) In 1882 Ch arcot presented use of hypnosis at a meeting of the Academy of Sciences in Paris that led to acceptance of the technique by the French medical community. In addition to his skill as a clinician and researcher, Charcot was a gifted teacher, and his lectures were extremely popular, attracting not only physicians, but also an audience that included “authors, journalists, leading actors and actresses, fashionable demimondaines.“36 He developed departments of medical illustration and photography and used their pictures in his presentations. He was noted for his ability to imitate neurological signs and had a flare for dramatic demonstrations. One of his most famous maneuvers was to introduce several women with tremors, each wearing large hats with feathers whose oscillations emphasized to observers the difference among their movements.30 A common manifestation of hysteria in Charcot’s time was hemianesthesia. Charcot observed that amblyopia was common in hysterical hemianesthesia, but hemianopsia was rare. Charcot lectured more than he wrote, often leaving the publication of

GITTINGER

his ideas to his numerous students. One of them, Gilles de la Tourette, compiled Charcot’s teachings, added his own observations, and published a twopart monograph in 1891 and 1895 that had almost the same title as Briquet’s work and superceded it in the minds of most French physicians.” He noted that, while hemianopsias (and central scotomas) were rare in hysterics, generalized constriction of the visual field was common. In 1865, Galezowski” included in his medical thesis at the University of Paris a description of the case of a young woman admitted to the Hotel-Dieu with a hysterical illness who had diminished vision in her left eye and a complete nasal hemianopsia. This lasted two weeks and then recovered. In his Traite’ des Maladies des Yeux published in 1872, he also described a 25-year-old woman who developed symptoms of hysteria after having observed her sister during an attack ofcholera.” Initially, she was blind and unable to walk, but during her recovery she manifested a right homonymous hemianopsia, which then resolved. Galezowski, thus, probably deserves credit for the first case reports of functional hemianopsia. In England, Sir William Gowers, a prominent neurologist at the National Hospital, Queen Square, stated in his textbook first published in 1886 that it was “doubtful whether hemiopia is ever of hysterical origin.“‘+ He had, in his large experience, encountered only a single case in which this diagnosis was tenable. Only two years later, however, LeeszR reported in the Lancet the case of an 1 l-yearold boy with unilateral cataract and amblyopia who manifested a transient binasal hemianopsia along with a hysterical hemianesthesia. The first discussion of functional hemianopsia in the American literature appears to be in Mitchell and de Schweinitz’s paper in the 1889 American Journal of the Medical Sciences. Two of the eight patients they described with hysterical anesthesia had hemianopic defects.‘” These same authors returned to this question in 1894, describing a patient with binasal hemianopsia and visual field constriction.34 Some years later, in one of the first books published in the United States devoted to the discipline now known as neuro-ophthalmology, de Schweinitz took the opportunity to emphasize the constriction rather than the binasal quality of the fields in this patient, concluding that “hemianopsia as an enduring ocular symptom of hysteria, in the same sense as concentric contraction of the visual fields, does not exist. “39 The intellectual center of medicine during the latter part of the 19th century was France. The controversy over the existence of functional hemianopsias next involved two of Charcot’s most brilliant

FUNCTIONAL

HEMIANOPSIA

Fig I. This Famous painting of’ A. Brouillet shows Charcot presenting a case of hysteria to his students. Babinski supports the patient, possibly Blanche Wittmann, the ‘Queen of Hysterics,” who eventually recovered from her illness and became one of the first radiology technicians, only to die from complications of exposure to Xrays.” Ellenherger~i points out that Brouillet had inadvertently included in the painting Charcot’s “fatal error” in regards to hysteria: his simultaneous verbal explanation of the “crisis” and the illustration in the background, both suggesting the expected response to the patient.

students,

Sigmund

Freud

and

Pierre *Janet.

Sigmund Freud (1856-1939) Because of his central rote in the origins of the psychoanalytic movement. Sigmund Freud of Vienna requires no introduction. In 1885 when Freud was granted a travelling hursary to Paris, he was in the midst ofwhat his biographer ErnestJones refers to as “The Cocaine Episode” (Ref. 25, Vol. 1. pp. 78-97). Freud was twenty-nine years old and had yet to establish a name for himself; Charcot at sixt) was at the peak of his fame. In Paris between October of’1885 and February of 1886, Freud had intended to pursue neuroanatomic work, but gravitated LO Charcot’s clinic. .\ccording to his formal report of his time in Paris (Ref. 40, Vol. 1, p. 9), “On Mondays Charcot delivered his public lecture, which delighted his hearers by the perfection of its form, while its subject-matter was familiar from the work of the preceding week. LYhat these lectures ofrered was not so much elementary instruction in neuropathology as information. rather, on the Professor’s latest researches: and they produced their effect primaril!- by their constant references to the patients who \vere being demonstrated. On Tuesdays Charcot held his “consultation exteme,” at which his assistants brought befijre him fbr examination the typicat or puzzling cases among the very large number attending the out-patient department. . . \Yednesdays

were

part]>,

devoted

to ophthalmological

CX-

out in Charcot‘s presence, On the remaining days of the week Charcot made his rounds ofthe wards, or continued whatever researches he was engaged in at the time, examining patients h)r this purpose in his consulta&nation,

which

Dr. Parinaud

carried

Freud

was not noticed

ing-room.” .\I

lirst

hv Charcot,

but

transcripts of Charcot’s clinics had been published in French as the Leqons du .Ilardi 0 la .SnlpP*tGre, and Freud offered to translate this work into German. He was then admitted into Charcot’s inllcr circle. Freud described an interaction with Charcot in a footnote from his translation (Ref: 10, \*ot. I. p. 139): Charcot denied that hemianopsia was present in cases oforganic hemianesthesia, and Freud questioned him. arguing that this contradicted the theory of hemianopsia. Charcot replied, “1~ thiorit c’est bon: mais ca n’empiche pas d’existcr” (Theor) is good. but this doesn’t prevent something li-om existing.) This epigram tvas one ofFreud's iiivorites. (Strachey’” notes that Freud relates a somewhat different version of this incident in later writings.) One ofFreud's souvenirs ofhis time at the Salp& tri&r \vas a copy ofa lithograph that shows C:harcot esamining a hysterical woman (Fig. 1). \vhich he bun,? in a prominent place in his home. \+‘hen his eldest daughter asked her father \vhat \vas wrong with the g;irl, he would reply that she was “too tightly laced” and gaze affectionateI>, at the scene (Ref: 25, Vol. 1. p. 210). Freud’s brief \.isit to Paris had forever changed the fhcus of his interests. Before Freud left to return to L’ienna, (:harcot suggested that he report upon some of the clinical material from the Salpt%riPre. Se\sen !ears later Freud finally submitted a manuscript in French to the .-lrchizv.sde Xeurologie comparing organic and hysterical motor paralyses. This was published inJuly of 1893, only a few weeks before C:harcol’s death at thr age of sixty-eight.s Freud’s cryptic explanation for the delay in the preparation of this paper offered in its opening paragraph is “causes accidentelles et vcars had personetles.” Of course, the intervening been busy ones in his personal life: he had married and his wife had borne four oftheir sis children. The

430

Surv Ophthalmol

32(6) May-June

1988

Freuds named their first-born son Jean-Martin after Charcot. In this paper Freud states, “Hemianopsia has not yet been observed in hysteria, and, I believe, never will be.“* He did, however, qualify this statement, “I am conscious that it is almost risking a wager to assert that such and such a symptom is not found in hysteria, when the researches of M. Charcot and his pupils find in it - one might say every day - fresh symptoms which had not been suspected previously. But I must take things as they are at the moment.” Freud was apparently unaware of the publications of Galezowski and Lee. Incidentally, Freud had a prior interest in hemianopsia; in 188% he had published on hemianopsia in childhood.’ Negative evidence is always weak, as Charcot had pointed out to him, and Freud had been away from the Salpftriire for seven years. In fact Dejerine, who was destined to be one of Charcot’s successors to the chair of neurology, and his student Vialet were about to publish two more cases with homonymous hemianopsia attributed to hysteria.” Their evidence that these were functional was the presence of associated hysterical findings and the variation of the hemianopsias with time. Janet, however, soon presented even clearer proof that hemianopsias could be functional.

Pierre Janet (1859-1947) The fame of Pierre Janet does not match that of Charcot or Freud, but Janet was an estimable figure. In 1881, already a philosophy professor at the Lyceum in Le Havre at the age of twenty-two, Janet intended to prepare a medical thesis on hallucinations, but instead studied a woman (Lionie) who had been hypnotized and “had been observed to perform some curious things with clairvoyances, mental suggestion, and hypnotism from a distance, etc.“37 A paper on this work was ready by Janet’s uncle at a meeting in Paris where Charcot was presiding on November 30, 1885, a date that falls during Freud’s visit. Subsequently in 1889, Janet came to Paris from Le Havre to pursue medical studies at the Salpetriere. Even before these were completed, Charcot made him head of a section on experimental psychology. Janet published an estimated 15,000 pages, producing his first paper at age 27 (on Leonie) and his last at age 86. He delivered a series of lectures at Harvard Medical School on the occasion of the opening of the Longwood quadrangle, which was published in 1907 as The Major SymFtoms of Hysteria,20 and was a featured speaker at the Harvard Tercentenary Conference. His most noted work was Psychological HeaLing,22 which Karl Menninger describes as

GITTINGER having “influenced the medical profession all over the world, especially psychiatrists” after its publication in French in 1919 and in English in 1925.” Janet presented his observations on a patient, “Justine,” at a conference at the Salpetriere on January 25, 1895, and they were published in May of that year.ls Justine was one ofJanet’s first patients in Paris, and he had described her irrational fear of cholera (Janet’s paradigm of an idlejxe, a term he coined) and his successful treatment of her elsewhere.” She had a number of hysterical manifestations, including hallucinations and right hemianesthesia. When she complained of blurring of objects to her right, examination of her visual field, to Janet’s surprise, revealed a bilateral nasal hemianopsia, with some sparing of the central field and constriction of the field in the right eye. Visual acuity in the right eye was reduced. Janet had already used hypnotism in the diagnosis of functional visual loss. He refers to the use of posthypnotic suggestion for this purpose, describing a patient told to fall asleep when given a certain signal, whose visual fields were constricted to 5 degrees, but who responded to the signal presented at 75 degrees (Ref. 20, p. 197). In Justine, he used a similar technique to plot “Subcorucient” visual fields that were full. (Janet was also the first to use the word subconscious in this context.) Janet further demonstrated, in another subject, that a right homonymous hemianopsia could be produced by suggestion. Janet quotes Freud’s assertion that homonymous hemianopsias do not occur in hysteria, and concludes the paper with the statement that it had become more and more difficult to state that a particular symptom is not found in hysteria. Janet’s interest in functional hemianopsias continued, and in 1899 he described a transient homonymous hemianopsia that evolved during recovery from monocular functional blindness treated by Janet was aware that hehypnotic suggestion.” mianopic visual field defects could be elicited from many suggestible subjects by an examiner who expected or wanted them, but denied that this was the mechanism in his case, since he had not anticipated this finding. Between the publication of these two papers, Harris” published an extensive review of hemianopsias in Brain, including a section on “Hemianopia in with eight citations. He contributed a hysteria,” case of “general analgesia of the whole body” and contracted visual fields with a left hemianopic pattern. This changed to total blindness, and vision was restored by a course of galvanic stimulation to the eyes and temples through a wire brush. Lannois and Tournier” had also reported on a case of hysterical homonymous hemianopia, presenting the pa-

FUNCTIONAL tient

to Janet,

HEMIANOPSIA who confirmed

The Twentieth

431

their

diagnosis

Century

Despite the contributions of nineteenth centur) physicians. the question of whether a persistent hemianopsia could be a manifestation of a functional disorder remained unresol\.ed.
The Current

Understanding

Se\.eral fkctors contributed to the persistence of the controversy. The diagnosis of functional illness or hysteria is often difficult, and a precise definition of hysteria has ne\‘er been achieved. One charactrristic of f‘unctional illness is that its manifestations change with the social environment: which includes the expectations of physicians. Charcot’s la grade hq’Jt& was e\.entually considered, exren by his students. to have been at least partially an artifact of the circumstances in which it was studied. The hysterical manifestations of the women of the Salpitrike so dramatically demonstrated by Charcot in his clinics diminished after his death. In the case of functional hemianopsias, there was the additional problem that most cases offunctional visual loss were indeed accompanied by visual field constriction, a finding that was rarely encountered with organic pathology, and most cases of hemianopsia ha1.e an organic etiology. Transient disorders could be either functional or organic, and the distinction remains difficult. The only type of functional hemianopsia that Gilles de la Tourette would

admit was that associated with miaraine.” a phcnomenon now considered organic in origin. X final difficulty was the nature of‘ the evidence for a functional etiology. Most physicians are confident in this diagnosis when the symptoms can be eliminated by suggestion - e.g., the patient whose acuity is 20/400 initially, but \vho impro\.cs to 20/Z) when small lenses are shufTled in and out da trial frame - or Lvhen the results of the examination arc physiologically impossible - P.,c.. the patic,nt ~.ho claims no light perception in one eye hut has normal stereopsis. In the instance of’ \,isual ficlld constriction. the simple maneuver of testing at two distances on a tangent screen ofien demonstrates so-called tubular fields. the failure of‘ the \-isual litsld to YSpand ph\,siologically. ,Janet’s obser\.ation that his patient’s bilateral nasal hemianopsia event a\va)- in the h!zpnotic state was an adequate proof that her \.isual field defect Leas f’unctional. but hypnosis after (:harcot was again to undergo an ecl;pse as a medical technique, with (as ,Janet prophesized) a rcavi\,al in the midtwentieth century.” In the 1890’s hvpnosis \vas used to treat fiinctional Visual loss,’ but it 5oon fialt out of f‘avor. (:urictusly, Duke Elder’ credits.Janet xcith the ust of a comparison of the results of’ monocular visual field testing with that of binocular toasting. althou,qh I can find no mention of this technique in
explosion.

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In 1975 Pillcy and Thompson”’ used binocular testing of visual fields to demonstrate physiological impossibility in patients with bilateral nasal hemianopsias. Such patients should ha\rc “preiisation blindness” when tested binocularly. and its absence established the functional nature of‘ their deficit. Deane”, applied this maneuver to patients with monocular temporal hemianopsias. iAt least one example of monocular temporal hcmianopsias had been recognized in the 19th century, btlt its functional basis was not, engendering speculation on the anatomy of the visual pathways involved and the suggestion that an associated phosphaturia was significant.‘) Mills and Glaser ‘($ also used binocular fields to demonstrate that even the usually organic bitemporal hemianopsia could occasiona& be functional.

432

Surv Ophthalmol

32(6) May-June

Freud and Janet -

Epilogue

Both Freud and Janet’s interests moved away from the analysis of neurological symptoms such as hemianopsias into an attempt at understanding of the entire psychology of the individual.” The question of who had priority in the evolving understanding of the human unconscious brought these men into conflict again. Janet suggested that some of Freud’s ideas were derivatives of his own concepts which had been acquired during Freud’s visit to the SalpetriZre,‘3 an implication Freud denied vigorously. In fact, Janet had not yet come to the Salpetrikre when Freud visited, although his first paper had been read in Paris during Freud’s visit. Arguments over scientific priority often become acrimonious, and in 1937, when Freud was eighty and Janet seventy-six and both were internationally recognized scholars with secure reputations, Freud refused to meet with Janet, who was visiting Vienna, because he resented Janet’s failure to give him what he considered appropriate credit (Ref. 25, Vol. 3, pp. 213-2 14). As the intellectual progeny of Charcot, these great men were not above a sort of sibling rivalry.

References Booth JA: Hysterical amblyopia and amaurosis. Report of live cases treated by hypnotism. .Medicaf Record #:25&260, 1895 Briquet P: Trait@’ Clinique et Thirapeutlque de L’~vst&e. Paris. ,JB Bailliere et Fils, 1859, p 294 Coursserant H: Htmiopie temporale unilateralc. - Phosphaturie. La Lancette Francaise; Gazette des Hipitaux, March 23, 1878, p 276277 4. Dejerine JJ, Vialet N: Sur une forme sp&iale d’hCmianopsie fonctionelle dans la neurasthenic et al n&rose traumatique. Comptes Rendus Hebdomadaires des SPance et .Weinories de la So&X de Biologic, July 28, 1894, p 626-629 Duke-Elder S, Scott GI: System ofOphthalmologv, Chl. XII: Neuroophthalmologv. St Louis, CV Mosby, 1971, p 585 Fox CD: The P;vchopatholou offlvsteria. Boston, Gorham Press,

9. 10. 11. 12.

13. 14. 15.

GITTINGER

1988

1913, p 124 Freud S: Uber Hemianopsie im friihester Kindesalter. M’ienMed Wxhr 38: No 32, 1081 and No 33, 1116,1888 Freud S: Quelques ConsidCrations pour une Ptude comparative des paralysies matrices organique et hystPriques. .4rchioes de Neurologie 26:29-43, 1893 Ellenberger HF: The Discoverv of the Unconscious: the Historv and Evolution of Dynamic Psvchiatv. New York. Basic Books, 1970 Galezowski X: De I’amblyopie hystCrique. Lancette Francaise; Gazette des H+itaux. 1877, p 75-76 Galezowski X: Traite’des Maladies des Yeux. Paris, JB Bailliere et Fils, 1872 Gilles de la Tourette AEB: Traiti Clinique et ThPrapeutique de L’Hvsthie D’apres L’Enseignement de la SalpAriire. Paris, E Plan, Nourrit et Cie, Vol 1, 1891. Vol. 2, 1895 Gittinger JW Jr: Functional monocular temporal hemianopsia. Am J Ophthalmol 101:22&23 1, 1986 Gowers WR: A Manual of Diseases of the Nervous System. Vol 2. Philadelphia, P Blakiston, Son & Co, (ed 2) 1893, p 158 Guillain G: J-M Charcot: 1825-1893: His I,$ - His Work. New York, Paul B Hoeber. 1959. p 49

16. Guze SB: Studies in hysteria. Can J Pvchiatrv 28:434-437, 1983 17. Harris W: Hemianopia, with especial reference to its transient varieties. Brain 20:308-364, 1897 18. Janet P: Un cas d’htmianopsie hystirique. Archives de Neurologie 29:337-358, 1895 19. .Janet P: Un cas d’hemianopsie hystPrique transitoire. La Presse .Wedicale 2:241-243. 1899 20. Janet P: The Major Symptoms ofHysteria. F$een Lectures Given in the Medical School of Harvard Universitv. New York, Macmillan, 1907 21. Janet P: Neuroses et Zde’es Fixes, Vol 1. Paris, Alcan, 1898, pp 156-172 22. Janet P: Psychological Healing: ‘4 Historical and Clinical Study. New York, Macmillan, 1925 23. Janet P: PrinciplesofP
eve

GE: Neuroses and psychoses. in Posey WC. 39. de Schweinitz Spiller WG (eds): The Eve and Nerrrous S&em: Their Diagnostic Relation by Various Authors. Philadelphia. JB Lippincott, 1906, pp 6 14-696 40. Strachey J: The Standard Edition ofthe Complete P
Wiesbaden,

JF Bergmann,

Neroen- und Augeniirzte Vol3, No 2.

1906, p 1034

Reprint requests should be addressed to John W. Gittinger, Jr., M.D., University of Massachusetts AMedical Center, 55 Lake Avenue North, Worcester, M.4 01655.