Journal of Neuro-Ophthalmology, December 2013, Volume 33, Issue 4

The Blind Photographer, Observations on the Bewildering Nature of Feigned Vision Loss

The diagnosis of feigned vision loss in adults taxes the doctor-patient relationship because the relationship should be based on trust, honesty, and the mutual desire to improve the medical condition. Even under ideal circumstances, physicians rarely have a complete understanding of the factors that lead patients to simulate disease they do not have. We describe the historical figure of John Howard Griffin (1920-1980) who likely perpetuated feigned vision loss for a decade. His writings provide a unique perspective on motivation (or inspiration) behind factitious disease.

The Blind Photographer. Observations on the Bewildering Nature of Feigned Vision Loss Curtis E. Margo, MD, MPH, Lynn E. Harman, MD, Mitchell Drucker, MD Abstract: The diagnosis of feigned vision loss in adults taxes the doctor-patient relationship because the relation-ship should be based on trust, honesty, and the mutual desire to improve the medical condition. Even under ideal circumstances, physicians rarely have a complete under-standing of the factors that lead patients to simulate dis-ease they do not have. We describe the historical figure of John Howard Griffin (1920-1980) who likely perpetuated feigned vision loss for a decade. His writings provide a unique perspective on motivation (or inspiration) behind factitious disease. Journal of Neuro-Ophthalmology 2013;33:367-369 doi: 10.1097/WNO.0b013e3182994f57 © 2013 by North American Neuro-Ophthalmology Society Nonorganic vision loss in adults is one of the most common isolated manifestations of simulated disease and a condition that most ophthalmologists and neurologists are trained to recognize (1-5). As a broad diagnostic cate-gory, this form of visual loss provides no information as to etiology, but for practical purposes necessitates a decision as to causation: is the visual loss intentionally feigned or an unconscious somatoform disorder? (1,5). The importance of making this distinction is in the divergent strategies for managing culpable malingering and involuntary hysteria. In terms of deliberately faking disability, the question of motivation naturally arises. J. M. Charcot, the famous 19th century neurologist, saw the purposeful simulation of neurological illness as a diagnostic challenge (6). He fully appreciated the difficulty of separating nonorganic from organic disease, yet when confronted by feigned illness he preferred not to speculate on motivation. There is a facet of feigned vision loss in adults that has gone largely unrecognized because perpetrators have limited interest in medically legitimizing their visual impairment through physicians, preferring instead to live as sightless individuals in the public domain. We describe the case of John Howard Griffin (1920-1980), author and historical figure associated with the civil rights movement, as an exam-ple of the wide-ranging motives behind factitious vision loss. CASE REPORT This history is extracted from John Howard Griffin's autobi-ography Scattered Shadows. A Memoir of Blindness and Vision, which details his 10-year experience of total blindness and recovery (7). Griffin grew up in Texas and traveled to France before World War II where he was a premedical student. He interrupted his studies in 1941, at the age of 21 years, to join the United States Navy, serving in the Pacific theater until the end of the war. When stationed on the island of Morotai in 1944, he sustained a concussive injury that left him uncon-scious for 2 days (7) (p. 32). After awaking in a rudimentary medical facility, he remembered overhearing his doctors say "damage to the sub-arachnoid area of the brain" (7) (p. 37). No focal neurological deficit was ever described. At discharge from the Navy that December, his vision was 20/200. Hav-ing never worn glasses, this screening test was the first indi-cation that his vision might not be normal. Griffin returned home to Fort Worth, telling his family about his concussion and discharge examination. He was seen by an eye specialist who offered no explanation for his impairment but sent him to a neurosurgeon for another opinion. After tests and an examination, the neurosurgeon advised Griffin to abandon the idea of studying medicine (7) (p. 39). Given the normal appearance of his eyes, the neurosurgeon explained "there's still a great deal about the brain that we don't yet know" (7) (p. 39). Griffin returned to France in the summer of 1946, describing his solitary journey back to Europe in this context: "I felt that losing my sight was a thing I had to do Departments of Ophthalmology (CEM, LEH, MD) and Pathology and Cell Biology (CEM), Morsani College of Medicine, University of South Florida, Tampa, Florida. The authors report no conflicts of interest. Address correspondence to Curtis E. Margo, MD, MPH, Morsani College of Medicine, MDC Box 21, 12901 Bruce B. Downs Boule-vard, Tampa, FL 33612; E-mail: [e-mail] Margo et al: J Neuro-Ophthalmol 2013; 33: 367-369 367 Clinical Observation Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. alone" (7) (p. 40). In Tours, he met a blind man, who demonstrated by example how to cope with blindness on a daily basis. By the spring of 1947, Griffin was totally blind. On his voyage back to America, he reported not being able to see sunlight, appreciating only its warmth on his face (7) (p. 109). After rejoining his family in Texas, he learned Braille, took up farming, became a rancher, and tried writing. He married, became involved in community affairs, and appeared to enjoy the challenge of blindness. Griffin wrote: "I was so immersed in discovery that I never stopped to dwell on my condition as tragic. I felt that I was simply living in a new and different way that fascinated me" (7) (p. 117). Although he associated the concussive injury during the war with his blindness, Griffin never applied for any disability benefits he was entitled to, claiming it was a matter of principle (7) (p. 123). His success as a blind writer attracted considerable attention. In 1952, LOOK Magazine devoted an article to his accomplishments (Fig. 1) (8). Almost 10 years to the day after losing vision, his sight returned over a span of days. On January 13, 1957, Griffin was walking to the barn when he suddenly saw the "door, cut in portions, dancing at crazy angles" (7) (p. 213). His eyes were filled with "triangles of color [that] faded and swirled." By January 15, he could appreciate the serene beauty of Vermeer's paintings while thumbing through an art book. When Senate majority whip Lyndon B. Johnson heard of the news, he sent a telegram to his fellow Texan congratulating him on the miracle (7) (p. 216). Twelve days later, Griffin was playing ping-pong and billiards and began to read again. He was driving his car months later. Having fully regained his vision, Griffin was able to reassume the many activities that interested him before the war, particularly photography, which he described in a collection of essays published under the title Available Light (9). In that publication, Griffin attributes his appre-ciation of visual detail to his decade of blindness. DISCUSSION Despite the lack of objective medical documentation about John Howard Griffin's ophthalmic condition, it is improbable that any disease adequately explains the full recovery of vision after a decade of absolute blindness. Griffin was propelled onto the national stage several years later when he altered his skin color to simulate that of an African American. In 1959, during the turbulent civil rights movement, he traveled throughout the South dis-guised as a Black man so he could better understand the personal injustice of racial segregation. This curious exper-iment, and unflattering portrait of the South, was recounted in his book Black Like Me (10). It made Griffin a celebrity and an unwelcomed member of his local community. It is difficult to ignore the parallels between faking racial identity to better understand the challenges of being Black in the segregated South and feigning vision loss to better understand the challenges of living in a world designed for the sighted. Having the will and determination to actually implement such experi-ments in public for any length of time is indeed quite remarkable. Griffin would not be the first public figure to voluntarily deny himself sight for the sake of curiosity. Charles Fletcher Lummis, an Indian rights advocate, author, editor, and friend of Theodore Roosevelt, made a highly public display of his blindness in 1911, from which he totally recovered a year later (11). Like Griffin, Lummis was energized by the daily test of blindness but was unable to adequately simulate total vision loss without the use of a bandana to cover his eyes, a maneuver that smacked of theatrics. John Muir, a close friend, doubted whether Lummis was truly blind and suggested in a personal letter that too much work might have been a contributing factor (11). There are other noteworthy similarities between the behaviors of Griffin and Lummis. In the 1890s, Lummis suffered a devastating paralytic stroke that left him without function of his left arm. Although details of the anatomical and physiological inconsistencies of his stroke-mimicking condition are described elsewhere (11), for 3 years and 7 months, he delighted in learning to shoot a rifle with 1 arm, role cigarettes with 1 hand, and break wild broncos with 1 arm tied to his side. Several years after his paralysis suddenly (literally instantaneously) disappeared, Lummis wrote a book titled My Friend Will, in the same inspira-tional genre as Scattered Shadows (12). Both Lummis and Griffin minimized their contact with doctors, despite the devastating nature of their disabilities. FIG. 1. John Howard Griffin was the subject of a LOOK Magazine personal portrait in 1952. The article recounted his achievements and included a series of photographs showing him in daily activities (Courtesy of LOOK Magazine Photograph Collection, Library of Congress). 368 Margo et al: J Neuro-Ophthalmol 2013; 33: 367-369 Clinical Observation Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Historically, the medical profession has had a limited role as gatekeeper in judging disability. For instance, requiring a medically validated diagnosis for visual impairment is a 20th century prerequisite for disability compensation, income tax benefits, and workers' compen-sation. Unfortunately, the administrative process is vul-nerable to abuse and often entangles physicians to function as a safeguard against misuse (13) (p. 54). Before social safety nets existed, feigned blindness for monetary gain was a public affair. A typical example is depicted by Harry Bernstein in his autobiographic account of immi-grating to America during the Great Depression (14). After coming to the United States as a young teenager, Bernstein accidentally discovered his grandfather posing as a blind man selling pencils on the streets of New York City (14). Having injured his back in a fall as a roofer, Bernstein's grandfather had no means of support. He was compelled by his circumstances to simulate another dis-ability in order to beg successfully in public. The psychosocial factors that contribute to factitious vision loss are complex and associated with unflattering connotations that almost reflexively discourage inquiry into the murky territory of motivation. The memoir of John Howard Griffin provides some insight into the machina-tions of an abstruse man whose inspiration to feign blindness remains difficult to comprehend. REFERENCES 1. Bruce BB, Newman NJ. Functional visual loss. Neurol Clin. 2010;28:789-802. 2. Incesu AI, Sobaci G. Malingering or simulation in ophthalmology visual acuity. Int J Ophthalmol. 2011;4:558- 566. 3. Mavrakanas NA, Schutz JS. Feigned vision loss misdiagnosed as occult traumatic optic neuropathy: diagnostic guidelines and medical-legal issues. Surv Ophthalmol. 2009;54:412- 416. 4. Kathol KG, Cox TA, Corbett JJ, Thompson HS. Functional visual loss. Follow-up of 42 cases. Arch Ophthalmol. 1983;101:729-735. 5. Griffiths PG, Eddyshaw D. Medically unexplained visual loss in adult patients. 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Margo et al: J Neuro-Ophthalmol 2013; 33: 367-369 369 Clinical Observation Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.