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Localisation of Visual Hallucinations

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Localisation of Visual Hallucinations BRITISH MEDICAL JOURNAL 16 JULY 1977 147 of hypothermia; the duration of cardiac arrest; and the disturbances of sleep or consciousness.4 Hallucinations may be promptness and correctness of treatment. Peterson's pessi- evoked by sensory deprivation, but other factors are usually mistic report from California,8 in which all 15 near-drowned present; thus the "black-patch" delirium that may follow children who had fits, fixed dilated pupils, flaccidity, and loss cataract extraction in the elderly probably results from sensory Br Med J: first published as 10.1136/bmj.2.6080.147 on 16 July 1977. Downloaded from of pain sensation suffered severe anoxic encephalopathy, deprivation and mild senile brain changes and is more frequent may be explained by the high water temperatures there. In when hearing is also impaired.5 warm water the protective effect of hypothermia against brain Hallucinations may be due to focal lesions. Past experiences, damage would be missing. In contrast was the case described the quality of eidetic imagery, and psychodynamic "actors in Trondheim, Norway,9 in which a 5-year-old fell through influence the content of organic hallucinosis,6 and it would be ice in fresh water with an outside temperature of 10° below unwise to lean too heavily on the occurrence and nature of zero centigrade. He was in the water for 22 minutes and was hallucinosis in localising intracranial lesions. Visual hallucina- brought out apparently dead, with widely dilated pupils and tions are a relatively infrequent accompaniment oflesions ofthe bluish white skin. He was warmed up (the method was not calcarine cortex (Brodmann's area 17), which has few thalamo- described) and-despite the risks noted above-was given cortical connections; yet they may occur as a false-localising external cardiac massage without suffering ventricular symptom of frontal or subtentorial lesions. Ritchie Russell and fibrillation, the heart beat returning in 2A hours. Subsequently Whitty,7 tabulating the degree of complexity of visual hallu- the child had an exchange transfusion to cope with haemolysis cinations found with wounds of the calcarine cortex, optic and haemoglobinuria. He was unconscious for six weeks but radiation, and higher centres, have shown considerable overlap recovered, becoming a normal active boy with only trivial in the type of recorded hallucination. clumsiness of the hands and an almost normal mental age. Formed and unformed hallucinations have been reported The moral is that persistence with intensive measures is with subcortical and neural lesions. Lesions of the optic usually justified. tracts, chiasm, optic radiation, and lateral geniculate bodies can evoke simple hallucinations, usually in the form IGolden, F St C, and Rivers, J F, Anaesthesia, 1975, 30, 364. of brief 2 Imburg, J, and Hartney, T C, Pediatrics, 1966, 37, 684. flashes of light. Although more complex hallucinations have 3Keatinge, W R, Survival in Cold Water. Oxford, Blackwell, 1969. been described, the circumscribed localisation of the lesions 4Golden, F St C, Proceedings of the Royal Society of Medicine, 1973, 66, 1058. cannot be accepted uncritically.8 Of historic interest is 5Craig, A, American3Journal of Diseases of Children, 1973, 125, 643. Lhermitte's peduncular hallucinosis,9 where a lesion of the 6 Lloyd, E L, British Journal of Anaesthesia, 1973, 45, 41. cerebral peduncles results in mild confusion with hallucinations I Lloyd, E L, and Mitchell, B, Lancet, 1974, 2, 1294. 8 Peterson, B, Pediatrics, 1977, 59, 364. of brightly coloured, kaleidoscopic, Lilliputian people. 9 Kvittingen, T D, and Naess, A, British Medical3Journal, 1963, 1, 1315. Reports of tumour localisation cannot match the physio- The Reviva, made by Peter Bell Engineering, the Slack, Ambleside, logical exactitude of the stimulation experiments of Penfield6 Cumbria. or the studies of traumatic epilepsy of Ritchie Russell and Whitty7 and of cerebral infarction recently presented by Lance.8 Such data provide a basis for a hypothetical scheme of cerebral localisation, but its value is theoretical rather than clinical. http://www.bmj.com/ Localisation of visual Hallucinations from the occipital cortex and association areas usually project on the contralateral visual field, which hallucinations more often than not is a blind one. Lesions of the occipital pole of the calcarine cortex produce static lights and stars. Hallucinations are perceptions in the absence of external With more anterior lesions the lights appear at the periphery stimuli; illusions are misinterpretations of external stimuli. and move towards the centre. From the parastriate area 18 As it is impossible to establish how much insight an individual luminous sensations may be obtained of coloured flashes and on 27 September 2021 by guest. Protected copyright. has into phenomena of this kind it is better to work with rings; alternatively, stimulation of these areas may produce broad definitions.1 Imagery forms part of everyone's mental negative phenomena as a grey or black fog-phenomena similar process, providing thought-vehicles for reasoning, for memory, to the scotomata of migraine. and for taking in sensory data, as in rapid reading. The quality Hallucinations from the parieto-occipital cortex, including ofvisual (or eidetic) imagerv varies from person to person, with parastriate area 19, are stereotyped, with an emphasis on every inflexion from achromatic silhouettes to the vivid objects, people, and animals. These bizarre apparitions are recollection of colours and hues. Hallucinations and illusions one degree more complex than the flashes, zigzags, and impinge on the consciousness of normal people in dreams; in whorls of colour obtained from the primary receptive cortex, hypnagogic states; in wish-fulfilment hallucinations of the but they fall short of an integrated visual memory.8 From the bereaved; under stress or sensory deprivation; or as organic visual association areas other phenomena may occur along with symptoms such as tinnitus, thalamic pain, and sensations from visual hallucinations.'0 11 These include perseveration of a a phantom limb. visual image in time (palinopsia) or in space (visual illusory Most observers have been unhappy to attribute all halluci- spread)'2; impaired visual recognition (visual agnosia or nations to disturbances in the psychological mechanisms of prosopagnosia); defective visual localisation'3; errors in thought: thus Hughlings Jackson2 claimed that hallucinations naming colours (anomia)"4; and defective perception of colours originated in instability of cortical cells. Duke-Elder3 argued (achromatopsia).15 that these phenomena had a physical basis, for a non-physio- Hallucinations from the temporal cortex are more complex. logical (inadequate) stimulus applied to any part of the neural Scenes may be recalled from experience after stimulation of pathway may produce visual hallucinations. Many hallucina- the posterior part of the temporal lobe. Visual hallucinations tions result from impaired cerebration in dementias, arterio- alone may result from stimulating a large area of the lateral sclerosis, toxic states, or hallucinogenic drugs-or from surface of the non-dominant temporal lobe. Elsewhere they dissociation of the reticular activating system, as in may be combined with auditory hallucinations-and there may 148 BRITISH MEDICAL JOURNAL 16 JULY 1977 be distortion of the size of objects (macropsia or micropsia)- seems no reason why the coroner's pathologist should not or they may be associated with sensations of familiarity or with make himself available to the relatives ifthey want clarification personalisation of the image (autoscopy). The Doppelganger of the cause of death and further explanation about the phenomena; thus "phosphenes"-sparks of light produced by circumstances. In some cases this is already done, notably in Br Med J: first published as 10.1136/bmj.2.6080.147 on 16 July 1977. Downloaded from himself, is most commonly attributed to lesions of the parietal connection with the "cot death" syndrome. The British Guild lobe.16 for Sudden Infant Death Study was founded as a counselling Finally, hallucinations occur with disorders of the eye. As service by a full-time forensic pathologist, and for many years there is often a coexistent central disturbance, many fanciful Professor John Emery has been carrying out a similar function explanations have ascribed ocular hallucinations to illusory among bereaved parents in Sheffield. phenomena; thus "phosphenes"-sparks of light produced by Many deaths requiring medicolegal investigation leave the mechanical distortion of the globe-vitreous opacities in relatives in a state of profound emotional unrest. By the very myopia, and the movements of a detached retina may all excite definition of coroners' cases, they are usually sudden, un- hallucinations.3 In these circumstances it has been argued that expected, or traumatic. The survivors are more shocked than entoptic images from the retinal ganglionic network and from if death follows some illness, where previous explanations by "luminous dust," which are normally filtered out from clinicians should at least have prepared the ground for the conscious perception, impinge upon the deranged mind and fatal outcome and have given some understandable reasons for are misconstrued.17 it. In forensic cases the reverse is frequently true, and the emotions aroused vary from stunned grief to outright anger. ' Hare, E H, British Jouirnal of Psychiatry, 1973, 122, 469. The sudden loss of a middle-aged husband and father from a 2 Jackson, J H, and Beevor, C, Brain, 1889-90, 12, 346. 3 Duke-Elder, S, and Scott, G I, System of Ophthalmology, vol XII, p 560. myocardial infarction may engender shocked disbelief. The London, Kimpton, 1971. surviving spouse of a suicide may show anger at what is seen 4 Brain, W R, Brain, 1958, 81, 426. as 5 Flynn, W R, PsychiatryQuarterly, 1962, 36, 55. selfish inconsideration. Self-recrimination is common 'Penfield, W, and Perot, P, Brain, 1963, 86, 595. among mothers of cot-death babies, while murder and rape Russell, W R, and Whitty, C W M, Jou4rnal of Neuirology, Neuirosuirgery may lead to intense hatred against the perpetrator as the pre- and Psychiatry, 1955, 18, 79.
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