“I don’t know why you can’t see…”
Medically unexplained visual loss (MUVL) and Joseph Babinski
It’s been over a century since William James wrote:
“Poor hysterics… first they were treated as victims of sexual trouble …then of moral perversity and mediocrity …then of imagination”
The philosopher was referring to people who had symptoms of disease, but for whom no medical cause could be found. The term hysteric, a word with gynophobic connotations relating to the womb, implied an emotional and exaggerated cause of symptoms. His pithy summary of the theories behind these conditions reflected the lack of consensus about what causes them.
Sadly, even to this day progress in understanding and treating these conditions remains very limited.
Hysterical?
Various different phrases have been used over the years to describe this spectrum of illnesses. Others include “Functional” or “Non-Organic”. The key is to differentiate this from other conditions where there are non-medical causes of visual loss. These are:
Munchausen’s — Where a patient repeatedly and purpusefully acts as if they have a physical/mental illness even when not sick, considered to be a mental illness and associated with emotional difficulties.
Munchausen syndrome by proxy (MSBP) — Where a caregiver makes up or causes an illness to a person under their care.
Malingering — Pretending to have disease for external benefit, usually money.
Treatments throughout the ages
All manner of remedies have been used to treat so-called functional disorders, including MUVL, over the centuries. The use of electricity appears to have been very popular , cleric John Wesley referring to it as the “ethereal fire”— this image shows an electrotherapy machine:
Blood-letting was another technique used to treat functional disorders including MUVL. This was a vestige of Ancient Greek medicine from the time of Hippocrates — where bodily fluids were regarded as “humours” that had to remain in balance to maintain health.
With the growth of psychiatry in the 19th and early 20th century, new drug treatments with sedative or hypnotic properties, such as amobarbital were used. The growth of asylums meant that sadly many patients with medically unexplained disorders ended up not getting any proper treatment and becoming institutionalised.
Charcot at the Salpêtrière — Hypnosis
A desire to change this underlined the resolve of legendary French neurologist Jean-Martin Charcot. He was the first to differentiate organic eye disease and functional visual disturbance. This beautiful painting shows him performing hypnosis at his Tuesday morning clinics in the Salpêtrière Hospital. Charcot had the theory that MUVL is a classic form of hysteria, and was a degenerative nervous system disease with dissociated mental functions, producing effects which our conscious selves couldn’t control. He suggested hypnosis as a possible therapy.
Charcot’s morning clinics are now the stuff of legend, and this painting shows why. Holding the hypnotised patient is Joseph Babinski who would himself become a great Neurologist, albeit not Charcot’s most famous prodigy. Sitting at the front, clad in an apron, is Georges Gilles de la Tourette. Many other future luminaries are sitting in the audience, all enraptured by Charcot’s lecture: Gilbert Ballet, Édouard Brissaud, Victor André Cornil, Alix Joffroy, Albert Gombault, Désiré-Magloire Bourneville, Henri Parinaud, Romain Vigouroux. Many of these shaped medicine in the turn of the century.
Finding the Cause: A teacher and his three students
Charcot had three students who shaped our understanding of functinoal visual disturbance, indeed functional disorders in general, and suggested ways of treating them. First and foremost was Pierre Janet, a Neurologist and founding father of Psychology who was a tireless observer and described “hysteria” as a dissociative disease. He ascribed the root of this condition as a bad response to trauma, he called it an “illness of the personal synthesis”. Actually, he called it a “form of mental depression characterized by the retraction of the field of consciousness and a tendency to the dissociation and emancipation of the systems of ideas and functions that constitute personality”.
Second on the list is a young Sigmund Freud, who attended Charcot’s clinic for over a year and found that this his approach to medicine changed completely at the Salpêtrière. Freud was influenced by Charcot so much that he named his son Jean-Martin, and sought to progress Janet’s dissociation theory. His theories, which dominated the 20th century, were based on the theory that oedipal-genital conflicts lead to unconscious conversion of psychic energy to physical symptoms, and his theories dominated the 20th century
The Third Student John Babinski — The Power of Persuasion
“Pithiatism is produced by suggestion…
… and cured by persuasion”
But it was Babinski himself who first suggested that the patient’s suggestibility is the key attribute of their personality which can be modified, and that there is an immense power of persuasion in these disorders, which he called pithiatism ((a word which didn’t really catch on). And even though his message was the least accepted at the time, in retrospect it is probably the best one.
Much non-organic vision loss likely results from too much weight being put on the expectation rather than the sensory input by the brain. Models of the brain used by neurologists and neuro-psychiatrists explain functional motor and sensory symptoms in terms of perception and action arising from inference based on prior beliefs and sensory information.
Perhaps evaluating new potential modes of treatment may require us to re-frame how we think of functional visual loss….
