 Section 10 of the Major Symptoms of Hysteria, this is a LibriVox recording. All LibriVox recordings are in the public domain. For more information or to volunteer, please contact LibriVox.org. The Major Symptoms of Hysteria by Pierre Jeanet. Lecture 10, The Troubles of Speech. Importance of the psychological study of the disturbances of speech. Description of some cases of hysterical mutism. The part played by emotion by shocks on the right side. The characters of hysterical dumbness. The forgetfulness of speech. The absence of paralytic phenomena. The alleged differences between hysterical mutisms and organic aphasias. The different forms of hysterical dumbness. Aphonia. Stammering. Aphemia. Agraphia. A case of hysterical word deafness. Automatic speech during hysterical mutism or alternating with periods of dumbness. Ticks or agitations of speech. The emancipation of the function of speech. As we now know the disturbances of motion and those of perceptions, we can enter upon the study of a complex phenomenon which in reality is nothing but a mixture of the preceding symptoms. I mean the disturbances of speech. The function of speech plays a considerable part in every impairment of thought. It is always more or less modified in all intellectual disturbances. However, most mental derangements bear upon a somewhat higher level upon the formation of ideas properly so called. On the contrary, hysteria which bears essentially upon the voluntary functions of motion, upon the conscious perceptions, reaches precisely this mental level to which speech corresponds and must determine very frequent disturbances in the expression of thoughts. These disturbances have long been known but physicians have generally been inclined to consider them as being of quite a particular nature. They thought that hysterical phenomena could not be like others and it seems to me that they separated far too much the disturbances of speech in hystericals from the pathology of speech in general. I should like to show you that all the disturbances of speech, whatever they may be, are to be found in these patients and that you can study the pathology of aphasia in them as well as inorganic patients and even better. Now when in the papers of Dr Pierre Marie of Paris the troubles of aphasia are brought nearer the disturbances of thought, it is interesting to study the hysterical troubles of speech in which the alteration of the whole consciousness is more evident. 1. In antiquity certain impairments of speech had already been noticed, the rapid evolution and the surprising cure of which seemed unaccountable. The following observation made by Hippocrates appears to relate to a hysterical accident. The wife of Polymarcus, having an arthritical affection, felt a sudden pain in her hip as her menses had not come. Having drunk some beetroot water she remained voiceless for the whole night until midday. She could hear and understand. She showed with her hand that the pain was in her hip. This description seems to contain everything, the stopping of the menses, the arthritic disturbances which are probably disturbances of motion, the preservation of the perceptions of speech and the dumbness. It is not necessary to remind you of the story of Cresus's son, the dumb young man who suddenly recovers his speech to cry, soldier do not kill Cresus. We may pass on to modern times and remind you of all the stories of dumbness in possessed people and ecstatics. I have already alluded to Carré de Mangeron's work on the miracles of Deacon Paris in which she can read the case of Marguerite Françoise Duchenne. After a fit of lethargy which lasted seven or eight days, there appeared a nearly total loss of voice. She was deprived of everything, even of the power of complaining. A month afterwards, she recovered her hearing and sight, but it was not the same with her voice, which was never restored to her. In the 19th century, such cases became more numerous. The English surgeon Watson boasted of having, through an electric treatment, restored the power of speech to a young lady who had been voiceless and dumb for twelve years. Brighay, Guzmar, Revilleux, Charcot and Cartas insisted very strongly on these phenomena, which are now well known in their ensemble. This accident may happen to confirmed hysterics who have already had many accidents of the neurosis after a somnambulism or a fit, but they may also happen to people who have hitherto seemed nearly normal. It is almost always brought on by a great and somewhat sudden emotion. It was so, for instance, in the classical case studied by Charcot. A man of about forty, living in a little town, had saved some money. His wife persuaded him to come and spend it in Paris. He settled with her in a hotel in the Metropolis. One day, after a short absence, he came back to the hotel and found that his wife had disappeared, taking the little hoard with her. The poor man was so upset that he was deprived of utterance and remained speechless for eighteen months. Now, though seemingly cured, he is still liable to the same accident. At the least emotional fatigue, he loses again the use of speech for a fortnight or for two months. Notice, by the way, this character of hysteria. When an accident has once happened in a particular and serious form, it is always the same accident that reappears on every occasion. The same remark applies to the following observation which I have noted down. A man who is now forty-six has been ill since he was twenty. One day at that period he was in a garden near a glass veranda. A heavy object thrown from one of the upper floors fell on the veranda and broke some of the glass with a noise like the report of a gun. Our man was very much frightened and remained dumb for two months. Though twenty-six years have elapsed since the accident, he never recovered from it. The slightest noise he hears suddenly near him, a word spoken somewhat too loud, is enough to make him dumb again for thirty or fifty days. In other observations the dumbness begins in young women of twenty on occasion of a fire, of the break-off of a betrothal, or of a quarrel with their parents. In one case it is caused by the sudden appearance of a man disguised as a spectre. The accident happened when she was eighteen and is not yet cured at forty-one. Sometimes the emotion bears particularly on the organs of speech or respiration. It comes on after a sore throat or a disease of the chest. In certain cases one must not forget that the accidents bore on the right side of the body. A young man of eighteen fell from horseback on his right knee. The consequence was a really hysterical hemiplegia of his right side and a dumbness. A young woman working in a tavern hurt her right hand with a broken bottle. She was first paralysed in her right side and this paralysis seemed to extend to the throat for she lost the use of speech. These last cases are important in regard to the association of paralysis of the right side with aphasias. In another curious case I will remind you of the story of a woman, a great spiritualistic medium, who after having too often made use of automatic writing was affected with hysterical dumbness. This again is interesting as regards the interpretation. However it may be when this dumbness is constituted it appears nearly always in the same manner of which Schalkor gave a very famous and vivid picture. The patient, save in exceptional cases, looks healthy and is not paralysed. He has not that weak and sickly appearance of persons struck with an organic hemiplegia consequent on a cerebral hemorrhage. Nor does he offer a very visible intellectual weakness, the dazed look of the latter patients. On the contrary he seems intelligent and lively. He comes forward with an expressive face, understands all you tell him, but takes a singular attitude when he has to answer. The characteristic fact is that he does not try to answer. He does not make those efforts of speech that an aphasic person makes or that a foreigner makes when trying to express himself in a language he knows imperfectly. He does not look as if he thought it possible to answer with words. He does not open his mouth, he makes no sound. He answers with signs or else takes up a pencil and answers in writing. In a word there is no imperfect speech, there is no speech at all and there does not even seem to be any idea or remembrance or wish of speech. The subject seems to have forgotten that use which men right or wrong have made of their mouths. I insist on this character because all the authors with much exaggeration in my opinion make it a sign of distinction between organic aphasia and hysterical dumbness. When you try to realize the reason of this silence which has often lasted for months together you examine the different peripheric organs and then notice the second character of our affection. Namely the total absence of paralytic phenomena. The lips, cheeks, tongue and soft palate move easily in the most correct way. The patient who understands everything does all he is asked, moves his lips, bears his teeth, smiles, draws his lips one way or the other, makes all the movements of his tongue and that without difficulty. No doubt I think in certain cases some reservation should be made about this somewhat too theoretical description of charcoals. You will very often find in these mutes certain small localized disturbances of such or such an organ for instance slight contractures of some muscle of the tongue. You must seek for them carefully for it is important to do away with them before trying to bring back speech. You will also remark that the movements of the lips are not so perfect as Charcro said. There is no paralysis properly so called but there is often awkwardness, clumsiness and ugliness. Yes ugliness. These subjects whose mind retrogrades in my opinion lose the delicacy, the perfection of certain functions and you can very well notice their return to animality from the vulgarity of certain delicate movements. However I readily recognize that these motor impairments are slight and quite inadequate to account for the enormous paralysis of speech which are to be observed. If we go farther we try to study the condition of the vocal cords. This study begun in Charcro's time is summarized in the thesis of Cartas. He recognizes that in reality there is no great disturbance in the vocal cords. Certain authors have tried to establish a certain degree of paresis in the adduction but I fear they have deluded themselves. The only means we know to establish the drawing nearer of the vocal cords is to ask the subject to speak or utter a sound. Now as he cannot speak or cry he does not produce this movement before us. There is nothing to prove that the vocal cords are not able to accomplish it if it were asked of them. So we are again obliged to appeal to moral phenomena in order to explain the hysterical syndrome and all the authors are obliged to acknowledge that the disturbance is purely mental. Two, one of the things that in my opinion obscured this study at the outset and brought on many difficulties is the difference that physicians at once wished to establish between these hysterical mutisms and the aphasias accompanied with right-sided paralysis which were observed to succeed hemorrhages and softenings of the brain and whose cerebral localizations were so eagerly studied in imitation of broker. Aphasias with destruction of the third frontal convolution were, it was said, the true impairments of the psychophysiological function of speech and these aphasias do not present the same symptoms as hysterical dumbness. In aphasias the subject feels that he has lost the use of speech and he makes desperate efforts to express himself. These efforts have some success for he has never lost all power to utter a sound. He can give cries, make varied noises with his larynx, oftenest he has even retained a few words which have more or less meaning as papa, come, come, makasi, makasa, which he repeats at random, sometimes oddly varying the intonation. On the other hand the disturbance spreads farther. A patient who cannot speak at all very seldom keeps all the other functions of speech intact. He has nearly always considerable disturbances of writing. He can no more read or he reads with difficulty without understanding the meaning of what he spells. Lastly he does not thoroughly understand the words spoken before him. These different disturbances which nearly always exist in germ in aphasia properly so-called may develop separately. You know the classification of the disturbances of speech made in this connection according to the predominance of such or such a symptom. Motor aphasias, agraphias, sensorial aphasias with word blindness and word deafness have been described. Nothing of the kind it has been said is to be found in hysterical dumbness which seems to be at once more extended and more restricted. It is more extended for in this case motor speech is more distinctly done away with and the subject does not seem even to make efforts to speak as aphasia patients do. It is more restricted for the disease seems to be limited to the expression of words and not to impair kindred phenomena such as writing, reading and the understanding of words perceived by the ear. So the two things are different and as aphasia was considered as the impairment of the function and of the centre of speech hysterical dumbness was necessarily quite another thing. To these remarks which I think quite wrong we must first answer clinically. Hysterical dumbness which I have described to you after Charcot is a type this word being taken in the sense given to it by this author. It is a particular and striking case which is very remarkable from many points of view but was somewhat arbitrarily chosen. You must not fancy that all the disturbances of speech brought on by hysteria are always conformable to this theoretical model. We have first to put beside it many attenuated imperfect or rather incomplete forms in which the function of language is analysed as the visual function was before. One of the most frequent forms distinguishes the two degrees of vocal power we have at our disposal. We have the loud voice with intense sounds which enables us to be heard in public and we have the whispering voice in which the movement of the lips and tongue is complete but in which there is very little emission of air. Very often in hysteria the first voice is lost and the second is kept. It is what is called a phonia. In certain cases the dissociation is still nicer. Certain subjects can sing aloud and cannot speak except in whispers. These distinctions will remind you of Aestasia Abasia. In still other cases there are only slight disturbances of speech. The subject can speak but stammers or stutters or has a special voice more or less different from his normal voice. I do not insist on these varieties because it is more important to study the varieties approaching the table of Aephasia properly so-called. In my opinion many hystericals have disturbances of speech quite identical with those described as succeeding an apopleptic ictus. Here is an observation I borrow from the second volume of my Nevorseide Fix page 452. A young woman of twenty in consequence of various emotions shows for a few hours or days a very singular disturbance of speech that little resembles typical hysterical dumbness. First of all she is not voiceless and can make a noise with her larynx. She even utters cries either spontaneously or when she is asked. Nor is she quite dumb for she tries to speak which the preceding patients did not do. She makes with her tongue and lips movements that produce articulate sounds but these sounds have no meaning and they nearly always consist in the repetition of a few incomprehensible syllables. If I say to her Miss X you walk much better today she answers smiling petit-bedable, petit-bedable, chat chat petit-bedable. To the question what happened to you today she replies very quickly petit-bedable, chat petit, petit-bedable. We can draw nothing more from her. She will go on with this jargonage as she says for a few hours. Notice that we have here a real oblivion of the movements necessary for the pronunciation of words. She is impatient at not being understood and seeks to answer by giving different intonations to her word petit-bedable. It seemed to us that the intonations were often right as well as the expressions of the face but the words never changed. Are other functions of speech disturbed? The audition of words is not disturbed in the least. She can understand very correctly all that is said to her. She reads very well. I mean that she does all you ask her in writing but she is unable to read aloud. As for writing it is not totally lost but there is a phenomenon that appears to us worthy of a remark. The writing has quite changed. It has become very bad. It is curious to compare her writing during this state with her normal writing. You see that the faculty of writing is markedly diminished if not entirely lost. How can we designate these symptoms if not by the usual words of motor aphasia or aphemia with a certain degree of agrafia? It is needless to demonstrate here that these symptoms are hysterical. With such a patient the demonstration would be superfluous. Besides these phenomena will disappear in a few hours. We could if we chose cause them to disappear immediately. During the hypnotic sleep which is easily induced the patient will at once assume a normal manner of speaking. What is more as we shall see presently the subject presents even during her periods of disturbance automatic words which she utters during a state of delirium. And which are quite normal. It is then an altogether hysterical phenomenon and yet as you see it differs in no way from an organic aphasia. Such cases might easily be multiplied. Besides these cases you can observe as many phenomena of agrafia as you please. I have already indicated to you the loss of writing as one of the possible forms of systematic paralysis. Charcot already pointed out some such cases in his leçon du martyre. Le pin, ballet, solier, published some, I observed several. You may even observe some curious forms in which the writing becomes again childish and is quite like old writing books of the patient. Can we go further? Do there exist in hysteria word blindness and word deafness? For my part I am convinced of it and I do not see why this dissociation should not take place when all the others do. It must be acknowledged however that cases of this kind have seldom been published. I therefore recommend to you to study an observation that in my opinion is important. The one which concerns a young girl called Rachel and which I published in the second volume of my book on neuroses and fixed ideas. The observation and the discussion are too long to reproduce here. I only point out the principle points. A girl of nineteen has a strange bearing. As soon as we speak to her she looks embarrassed. She does not answer, moves on her chair, moans and at last says, I do not understand, I cannot understand. At first sight it looks as if she were deaf. That is moreover the dominant opinion entertained about her in her surroundings. Yet this opinion is not right. If you make a noise behind her she almost always turns around. Curiously enough if you put a watch near her ear she declares that she hears. You may thus recognise that she hears the ticking of the watch at sixty centimetres on the right and at forty on the left. The hearing of this girl was very carefully examined by Monsieur Gilles two different times. His conclusions were always the same and quite definite. This patient is not deaf by any means. All we can say is that there is a slight diminution of the auditory acuity especially on the left. There is no appreciable lesion of the external auditory apparatus. But then why does not this patient answer us? Because as she says herself she does not understand. Though she hears our words they have no meaning for her. It is the same with musical ears. She hears them very well but she does not recognise, does not understand them. In a word it is the syndrome well known under the name of word deafness. In the present case this word deafness is quite complete. The patient has also completely lost the functions that appear to depend on word audition. She is quite incapable of writing from dictation and of repeating even without understanding them the words spoken before her. They are noises she says and she does not know how she could manage to repeat them. The disappearance of that connection between sounds and movements has often been noticed in word deafness. If the word deafness is complete it is nonetheless very isolated. That is to say all the functions of speech saved the audition of words seem to have remained quite intact. Now what are the diagnosis and origin of this clinically incontestable word deafness? They are most strange. A few years ago this already impressionable and nervous girl was being educated in a convent. At the age of 12 she had a typhoid fever and remained weak and nervous though still intelligent and free from any disturbance of speech we are hearing. A short time afterwards she began to present odd symptoms about which unfortunately we have quite insufficient information for they were only observed by the nuns of the convent. The child had a disposition to fall asleep in the middle of the day especially between 1 and 4 in the afternoon. These sleeps were sometimes complete and very deep nor could anything awaken the sleeper who did not even feel prickings made in her arm. On other days the sleep seemed less profound since the child kept her eyes open and went on with her sewing. But she did not answer, could not be disturbed and unawaking would say that she had done nothing and was surprised to see her work getting on. This is all we know about those sleeps which lasted for nearly two years with the same characteristics. One day the nuns became incensed at these continual sleeps and punished the child but it was of no use. The chaplain was sent for and it was demonstrated to her in a fine exhortation that if she slept again she should first be shut up in a dark room and later on go to hell. The little girl was frightened and swore that she would sleep no more. When the hour of her usual sleep came she contrived through desperate efforts to remain awake. It is impossible for us to know exactly what happened. Rachel asserts she had no convulsions, went on with her sewing but felt her mind confused and her head as it were clogged. Moreover her recollection in this respect is very vague. However it may be after a few hours discomfort she realized that she was no longer sleepy at all. When she was spoken to she did not answer and her features assumed a dazed expression. Every endeavour was used to rouse her but it was soon noticed that she understood nothing and answered very badly. What was exactly the extent of the disturbance at the outset? Our information is insufficient. It seems certain that there was no paralysis but it seems that speech was disturbed as well as hearing. However it may be the disturbance of speech did not persist. After a few weeks she spoke correctly as now. She had only a somewhat odd accent but the hearing of words made no progress. She remained as at the outset incapable of understanding anything. No doubt all this is not very definite and we may wish to find later on more distinct observations of hysterical word blindness and word deafness. However these sleeps, these somnambulisms, the neuropathic disturbances which still persist, the total absence of any symptom of cerebral lesion or lesion of the ear seem to prove that the disease approaches the great neurosis. These observations which could easily be multiplied show you distinctly enough I think that besides the classical and typical hysterical dumbness there are all kinds of forms of this affection and that some of these forms are quite identical with what is understood under the name of aphasia. So there is no opposition between those two groups of symptoms. The hysterical dumbness of Chalcro is nothing but a more sharply differentiated, more isolated form of the disturbances of speech. The subject loses absolutely the power of speaking and loses only that. He loses the power so entirely that he forgets it and does not regret it so that he has no longer even the idea of the efforts to be made. This we already saw when studying hysterical paralysis and anesthesias. It is therefore very likely that the function of speech is also disturbed in the same manner in all those organic and neuropathic accidents. 3. To understand the impairment of this function of speech we must rapidly make some remarks which you already know. Let us take up again the observation of the hysterical who to all the questions put to her could only reply with the words, often in the midst of this state of aphasia the patient had kinds of reveries or deliriums in which she experienced a loud either fixed ideas which preoccupied her or conversations she had just had in which she put the questions and made the answers herself. In all those slight deliriums she spoke very correctly either in French or in English and there was no trace of aphasia left. Observe that in all those chatterings she said things she regretted later on expressing her secrets aloud. They were quite involuntary words. If you interrupted her, if you attracted her attention to ask her to reply to a question you put her, she listened, tried to speak and no longer said anything but, In a word there was aphasia in conscious and voluntary speech and the normal expression of ideas reappeared only in the deliriums and automatic speech. This fact is more general than is commonly believed. In patients affected with dumbness you may often recognize in the period of dumbness itself that normal speech reappears during the crises, the somnambulisms, the dreams. Oppenheim indicated some facts of this kind. Gilde Latourette describes a dumb patient who speaks during her dreams. More often still those automatic and irrepressible words do not coincide exactly with the period of dumbness, but present themselves in the same patients before or after this period. We then find in these subjects crises of irresistible chattering to which we already alluded in connection with somnambulisms. Sometimes these crises come on during a sleep or an abnormal state but often they take place while the patient is awake and then he listens in astonishment to the words he speaks. Read again in the history of the Kamizals in the 17th century, the anecdotes relating to the lesser prophets of the Seven and to the most celebrated among them all, Elie Marion. He felt himself as it were seized by the Lord, he could no longer dispose of his voice or speak voluntarily, he did not know what his mouth was about to utter and was quite surprised at hearing the fine discourses with which the Holy Ghost inspired him. This verbal automatism should be placed beside the automatism of writing in the spiritualistic medium. He also feels that his hand escapes his control and is no longer ruled by his will, he is quite surprised at seeing what his hand has written. It is a phenomenon of the same kind. With the same group are also to be connected the tics of speech which are numberless in the form of coprolalia, echolalia, etc. You will find a very good description of them in the little book of Monsieur Segla on the disturbances of speech. I should be inclined to go even further and to say that many verbal hallucinations of inner words are phenomena of the same kind, though somewhat less marked. In all these facts the function of speech which is by no means destroyed seems to escape the conscious will of the subject. Inwardly or outwardly he speaks in spite of himself and without any participation of his self. It is a mechanism which has emancipated itself. Well I believe that for this fact as for the preceding ones this symptom of agitation of automatic functioning of the function should be placed beside the paralysis bearing on the same function. They are two parallel and concomitant phenomena. One more example occurs to me. Bez had very varied crises in the hospital. After her ordinary crises in which she had cried to exhaustion she retained perfectly the power of speaking. But she had special crises in which her speech seemed as it were to be thrown out of gear in which she chatted in a low voice with extreme volubility. After these crises she always awoke dumb. The emancipation of speech brought on dumbness. This we have already seen in the somnambulism that brings about amnesia in Korea and in the tic that brings about paralysis. Here again everything happens as if the system of the movements and images that constitute speech separated from the personality and functioned apart in an automatic and at the same time inferior and as it were degraded manner. End of section 10. Section 11 of the major symptoms of hysteria. This is a LibriVox recording. All LibriVox recordings are in the public domain. For more information or to volunteer please visit LibriVox.org. The major symptoms of hysteria by Pierre Jeanet. Lecture 11. The disturbances of alimentation. Visceral troubles. Hysterical anorexia. The description of its three periods. The gastric period. The moral period. The period of inination. The frequent termination by death. The theory of the fixed idea. The diagnosis with the psychosthenic refusal of food. The theory of anorexia through the anesthesia of the stomach. The part played by anesthesia in the modifications of the feeling of hunger. The motor agitation of the patient. The different explanations of this fondness for physical exercises. The suppression of the feeling of fatigue and the motor excitation. The psychological function of alimentation. The hysterical dissociation of this function. The dissociation of the elements of this function. The paralysis of the lips, tongue, pharynx, esophagus, abdomen. The troubles of the function of the bladder. After passing in review the mental disturbances of hystericals. Their sensory and motor disturbances. We shall now enter upon a rapid survey of their visceral disturbances. These patients in fact seem to present great impairments of the visceral functions. Especially of the functions of digestion and respiration. These visceral phenomena have always greatly puzzled physicians. And nowadays they're still often opposed to those who want to give a mental explanation of this disease. We must therefore insist on their interpretation. To penetrate into the study of the mental disturbances of hysteria. We shall begin by studying a very important phenomenon. That of anorexia. Which by its character at once physiological and mental. Will furnish a transition between these new studies and the preceding ones. One. The words hysterical anorexia. Designate a disease both mental and physiological. Very long and very complicated. Which consists chiefly in the systematic refusal of food. In certain digestive disturbances and in a consequent inination. This odd phenomenon was for a long time very ill known. It was confusedly ranged among the other manias of those patients. And their strange way of living without eating. Was often ascribed to the action of the demon or to that of God. Its accurate description is recent. It was made almost simultaneously by W. Gull in 1868. And by Lasseg in 1873. The article of Lasseg was the only one that had success. And contributed to spread this new medical notion. It led Gull to observe in 1873. That he had already indicated these facts in 1868. The English physician called this disease. Apepsia hysterica. Lasseg named it hysterical anorexia. Neither of these two appellations is perfect. The absence of pepsin. Which moreover is doubtful. Has nothing interesting in it here. The loss of appetite is more important. But it is not certain that it is the essential characteristic. Therefore some subsequent authors wishing to emphasize the capital fact. Which is systematic refusal of food. Made use of the word city of phobia. That is to say aversion to food. And city aegia. Food repelling. That is to say rejection of food. Or even of the words hysterical inination. Lasseg had also proposed. The last words are evidently better. But usage which is a great master. Has not accepted them. And has even employed them differently. It has retained the term hysterical anorexia. It is enough if we understand one another. This accident may happen in the course of hysteria. After many characteristic phenomena. Which will serve for its recognition. Oftenest it forms the outset of hysteria. And its real nature is only recognized late. Many cases have been cited in adult and young men. But it cannot be denied that it is infinitely more frequent in women. A case has been cited at the age of 11. Kisel. I have observed one in a little girl of 9. It has also been recognized in a woman of 38. Lately I studied a very distinct case in a woman of 40. But it was an old accident which reappeared. It must be acknowledged that these ages are quite exceptional. The greatest number of cases by far. The greatest number of cases by far. The greatest number of cases by far. The greatest number of cases by far. The greatest number of cases by far. 9 out of 10. Are to be met with in girls of 16 to 23 or 25 at most. It is one of the facts of the special pathology of the girl of 18. You should never forget it when in presence of a patient of this age. That affection which seizes the girl of 18 is a chronic one. It is a disease that never lasts less than 18 months to two years. And often continues for 10 years. The result is that it goes through different periods which Lasseg reduced right away. It is a disease that never lasts less than 18 months to two years. And often continues for 10 years. The result is that it goes through different periods which Lasseg reduced right away. It is a disease that never lasts less than 18 months to two years. The result is that it goes through different periods which Lasseg reduced right away. To three principal ones. The first period might be called the gastric period. For everybody fancies that the disease consists simply in an affection of the stomach and behaves accordingly. The beginning which is not always easy to know often coincides with a slight more or less real affection of the stomach. More often it is again the consequence of an emotion. Mu for instance a girl of 19 of whom I often think when speaking to you of anorexia. speaking to you of anorexia, presented her first gastric disturbances after the death of her brother, who succumbed rapidly to pulmonary thysis. The patients complain of various and vague sufferings, which they connect with their digestion. Then come consultations on consultations, and of course a lot of absurd diagnoses and ridiculous medicines. It is thought quite natural that the girl, whose stomach is diseased, should be careful of what she eats. Her medical attendance would even be inclined to prescribe to her a still stricter diet. She resigns herself to everything and shows herself a patient of exemplary docility. Moreover, safe for vaguer and vaguer pains in her stomach, she seems to enjoy perfect health. Her tongue is clean, her stomach and abdomen normal. The only thing she may suffer from is obstinate constipation. Usually, after a long time begins the second period, the moral period, or period of struggling. The family at length become disquieted at the indefinite prolongation of these treatments and ultra-stricter diets, which do not seem very well justified. They suspect hyperchondriac ideas and obstinacy, and their attitude becomes quite modified. Now they try to allure the patient by all possible delicacies of the table. They scold her severely. They alternatively spoil, beseech, threaten her. The excess of the insistence causes an exaggeration of the resistance. The girl seems to understand that the least concession on her part would cause her to pass from the condition of a patient to that of a capricious child, and to this she will never consent. All the relatives and friends interfere by turns to try what their authority and influence may do. Naseg has well described to those distressed families who, all day and to the first comer, speak mournfully of the girl's food. It's all of no use. The disease develops more and more under the influence of these surroundings. Now the girl scarcely ever speaks of her pains in the stomach, but she repeats that she will eat when she is hungry, and that she is never hungry, that she does not need more food, that she can very well live indefinitely in that way, that moreover she has never felt better. In fact, she seems to be in very good health and shows much strength and activity. She has even a greatly exaggerated physical and moral activity to which we shall have to revert, for the fact is very important. Supported by this conviction, our strange patient struggles with all those around her, by every possible means. She seeks a support in one of her parents against the other. She promises to do wonders if her family is not too exacting. She has recourse to every artifice and to every untruth. It is the period when such patients hide victuals in their pockets, fill their cheeks and throat with them, to go and spit them out in the lavatory, when they learn to vomit immediately what they have just swallowed, et cetera. Lastly comes on sooner or later, but sometimes only after years, the third period, called period of inination. Organic disturbances begin to appear. The breath is foul. The stomach and abdomen are retracted. There is an insuperable constipation. The urine is scarce and contains little urea, only three grams instead of 30 grams with one of my patients. The skin becomes dry, pulverulent, and in certain places, as on the wrists and forehead, cracked and covered with pimples. The pulse becomes very quick, between 100 and 120. The breathing is short and hurried. You hear cardiac and arterial breaths. Lastly, the extenuation, which the parents best observe, makes surprising progress. It is a clinical fact which one must well remember that weight is not a reliable sign of the progress of the disease. For after a rather great decrease at the outset, it is only at the end, and often too late, that it falls suddenly. Matters have changed then. The patients who no longer leave their beds remain in a semi-delirious, semi-comatose condition. At this stage, they behave in two different ways. Some continue to be delirious and, as Chalcro said, have but one idea left, namely to refuse to eat. Others, fortunately, begin to be frightened. This was what Laseg expected. Because of a singular therapeutic dignity, he judged that the physician was not justified in doing anything before. At that moment, he resumed his authority, and according as the patient yielded completely or partially, which latter case was the more frequent, he cured her more or less completely. In fact, the hysterical is privileged in this respect. You know that the dog cannot be called back to life when it has lost 40% of its weight. The hysterical can still be saved at 50 and above. There is a limit, however. Out of his eight cases, Laseg had not one death. The number of deaths since then cannot be numbered. I know three for my part. It is the melancholy period when those poor girls ask to eat and it is too late. It is true that things generally take another turn and an intercurrent disease comes on. Bronchoniumonia are almost thysis, which simplifies the situation. Such is the general history of this strange mental disease. Its gravity, its frequency, the regularity of its evolution, whatever may be the intelligence of the subject, show that it is due to a deep psychological disturbance of which the refusal of food is but the outer expression. Two, this disturbance of thought is fairly well known in its details and evolution, but it is certainly very difficult to interpret and various theories of anorexiae give the preeminence to one or the other of the essential phenomena. Laseg, and later on Charcot, gave the preeminence to a delirious disturbance to a fixed idea. The disease consists essentially in an idea of which the patient is perfectly conscious, though she often conceals it, and which has for consequence the voluntary and calculated refusal of food. Some are over-anxious about their stomach, apprehend the pains provoked by digestion, or simply fear the sensation of a ball in their esophagus. Others have scruples, regret to eat the flesh of living animals, are ashamed to eat when too many poor people have not sufficient food. I knew a girl of 18 who died in consequence of her abhorrence of turnips, which she had contracted when at school. To the end she refused to eat anything, saying that everything smelt of turnips. Very often they simply have the commonplace idea of suicide. For some reason or other, these girls make up their minds to die because of a thwarted marriage, a reproach for having quarreled with a friend, et cetera. And in their innocence they adopt starvation for their mode of death, judging it to be a simple, clean, not very painful process which will arouse nobody's suspicion. The following observation of Charcot is famous. While undressing a patient of this kind, he found that she wore on her skin, fastened very tight around her waist, a rose-colored ribbon. He obtained the following confidence. The ribbon was a measure of which the waist was not to exceed. I prefer dying of hunger to becoming big as mama. Cocotries of this kind are very frequent. One of my patients refused to eat for fear that during her digestion, her face should grow red and appear less pleasant in the eyes of a professor whose lectures she attended after her meals. The authors who have observed such ideas seem to me to be inclined to exaggerate their importance. This is what certainly happened to Charcot, who used to seek everywhere for his rose-colored ribbon and the idea of obesity. I believe there is on this point a diagnosis to be made on which I have much insisted in the first volume of my work on obsessions. Refusals of food are not always a phenomenon of the hysterical neurosis. They belong at least as often to the psychosthenic neurosis. It is in the Latin neurosis that fixed ideas remain alone and play a predominant role to the end. These patients will be recognized by the absence of other psychological disturbances associated with the fixed idea. In particular, they have no real anorexia. They have retained the feeling of hunger and they often submit to veritable torches in order not to yield to their need of food. These patients make it a point of honor not to yield, at least before others, and this accounts for an odd fact often indicated in their history. After having all day refused the food offered to them, they get up at night secretly and steal dirty victuals so that one must always be careful to leave food within their reach. As they have no real loss of the feeling of hunger, so they have no real anesthesia, either in their mouth or in their epigastrium. Lastly, they do not present that excessive need of movement, the importance of which I have already indicated in real hysterical anorexies. In the latter, in fact, the fixed idea of which existed at the outset, it is true, and played a certain role for a while, becomes complicated with very serious phenomena as the loss of appetite, the anesthesia of various organs, certain phenomena of systematic paralysis of the acts relating to alimentation and the great motor agitation. I believe therefore that one should distinguish real hysterical anorexia from those refusals to eat brought on by various obsessions and in particular by obsessions of scruples in various psychosthenics. Therefore, other theories tried to take these new phenomena into account, and this is done in particular by a theory which is nowadays pretty widespread, the theory of anorexia through the anesthesia of the stomach. Besides the anorexies due to delirious ideas relating to illness, to periodicity, to obesity, it has been asked whether there do not exist anorexies brought about by disturbances of the organic sensibility. They would then justify their name and to be above all losses of the sensation of hunger. This already old thesis which was indicated by magnetizers such as De Peen in 1840 has been chiefly developed through studies on metallotherapy carried on especially by Birk 1875 to 1882, since then it has been systematized and exaggerated by Stollier. Anesthesia, Birk once said, exercises a preponderant influence on all the other symptoms in particular on the disturbances of alimentation and on the secretions. His great argument was that he could cause these anesthesias to vanish through the use of the metallic plates and armatures he had contrived and that he then saw the hysterical phenomena, anorexia in particular, disappear. There is much truth in these remarks. First of all, we must recognize an anorexia when already well settled and have decidedly hysterical nature, the existence of numerous anesthesias. They are observed in the mouth, on the tongue, on the internal face of the cheeks, in the esophagus. At the same time may be noted the absolute anesthesia of the special senses of taste and smell. You know that the patients, especially at the outset of their disease, want to have raw elements and ask for salt and vinegar in order to give some taste to their food and that later on they complain that they're given sand or earth to eat. You also know that some of them do not feel the food in their mouths. It is not rare to observe at the same time the anesthesia of the lower part of the digestive tube of the anus and of the rectum. The anesthesia of the stomach itself and of the small intestine is the more difficult to establish as the sensibility of these organs is commonly very obtuse, but it is highly probable. Many subjects do not feel too hot or too cold food descend into their stomachs. Moreover, you have already seen a very curious law indicated by Monsieur Gilles de la Tourette, namely that often in hysteria, superficial anesthesia of the skin accompanies the anesthesia of the organs placed under it. Now in hysterical anesthesia, a patch of cutaneous insensibility is often recognized, seated just in the epigastric region. It is probable, therefore, that the mucous membrane of the stomach is as anesthetic as that of the mouth. Do these various anesthesias seated in all the parts of the digestive tube play a role in the disturbances of the functions of alimentation? The thing seems to me very likely. The fine studies of physiologists, in particular those of Monsieur Pavlov, have shown that the saliva secreted by a dog varies with the object presented to him, with the taste and smell of that object. They have shown that the secretions of the stomach and of the intestine were in connection with the sensation of the food in the various parts of the digestive tube. Since these patients feel neither taste nor smell nor any excitation of the mucous membrane of their stomachs, it is very likely that their digestion will be disturbed. A physician even tried to go still further. You know that the anesthesias of hystericals are mobile, that it is possible through various processes to cause them to disappear and to reappear. This physician thought he recognized, at least in one case, that the secretion of the gastric juice was very different according as the subject felt or did not feel in his esophagus and in his stomach. From these remarks results a new conception of the disease. It is the gastric anesthesia which is here the great culprit. While the sensation of the movements and of the secretions of the stomach is the starting point of the feeling of appetite, the immobility and insensibility of the stomach bring on complete anorexia and all the delirious ideas which are considered here as secondary. There is some truth in this conception but it does not seem to me to be complete. First of all, the anesthesia of hystericals is never complete and does not do away with the reflexes. We have already studied this point. If food is introduced by force with the sound into the stomach of the most anorexic hysterical, if you prevent immediate vomiting, you will recognize that the digestion, perhaps somewhat slow at the beginning, comes to be completely effected and in the most normal way. This Monsieur Henry Français has just shown again in his thesis on apepsy which he maintained this year. So psychic insensibility does not play here a considerable material part. Supposing the anesthesia of the stomach should do away with the appetite, it would not make the patients incapable either of eating or of digesting. In my opinion an exaggerated importance is ascribed to the role played by these local phenomena of the mouth and stomach in the general feeling of hunger and in the function of alimentation. Animals that have been deprived of their stomachs still try to feed. We do not always need a perfectly marked appetite to eat. We often accept food out of politeness in mere imitation of others or because we think it reasonable when we do not really wish for it. In a word, these authors are right in adding more elementary and more general disturbances of the fixed ideas of hystericals. They are wrong in stopping in this matter at the sensibilities of the mouth and stomach. I wish a more thorough investigation might be made in this connection of a phenomenon that is as yet very imperfectly elucidated. Namely the excessive fondness for physical exercise that characterizes a whole group of anorexic patients. This character was already noted by Laseg. It is well indicated in a short and unfortunately very incomplete article of Dr. Wallet. The patient, he says, is exceedingly fond of long walks. As she is growing thinner with enormous rapidity, they are forbidden to her. She then begins to walk from morning to night up and down the little garden of the house, which was likewise forbidden to her. Then she plays all day at shuttle clock. It is prescribed that she stay in her room. There she gives herself up to violent gymnastic exercises. Even in bed she goes on with her gambles and somersaults. For my part, I was much struck with this odd phenomenon, which most authors merely indicate without dwelling upon it. One of my patients, Mu, has had for years a mania of walking of at least as great gravity as her mania of refusing to eat. She must needs go every day on foot as far as the Torcadero and the Bois de Boulogne. The carriage has only the right to follow her. She tires the person to accompany her. If a limit is fixed of two hours fast walking a day, she makes scenes about the calculation of the minutes. No supplications or menaces can stop her walking any more than they can stop her in an issue. With a very singular woman who has periodical anorexies consequent on the least emotion, the need of walking begins immediately with the refusal to eat. It happens suddenly. After the emotion, she refuses to return home as well as to dine. This character is at least as strange as the first. The first explanation of this fact was presented by Laseg and by Charcot, and since then it has always been repeated without hesitation. These patients walk too much and take too much exercise by virtue of a piece of reasoning. They want to make those around them believe that they are still strong and robust in order not to be compelled to eat more. I confess, this explanation does not satisfy me. Many patients who spoke to me sincerely during or after their disease have assured me that they thought nothing of the kind. Moreover, this exaggerated emotion is to be found in aged patients who are left at liberty and whose alimentation nobody watches over. Another curious explanation is that which was given by Monsieur Rallet in 1892. The patient walks in order to grow thin. In order to compensate with the exercise he takes, the alimentation that is imposed upon him. With this explanation, we return to the initial idea of Charcot, namely that all these patients want to grow thin. You know that it is not true, that if in some particular cases this exaggeration of motion can be explained by such reasoning, it would be absurd to generalize the explanation. I believe that the phenomenon in question is much more important and serious than these authors thought. It is not the result of a little particular imposition. It is connected with a very general disturbance. This disturbance first comprises the suppression of the feeling of fatigue which is here much more important in my opinion than the anesthesia of the stomach. It comprises besides something that is very little known, namely a general excitation to physical and moral activity, a strange feeling of happiness and euphoria according to the medical term which are certain but very little studied facts. The need of food goes with the feeling of weakness and depression. Persons depressed by neurasthenia are great eaters. The exaltation of the strength, the feeling of euphoria as it is known in the ecstatic saints for instance, does away with the need of eating. Our hysterical anorexia is to be traced to much deeper sources than was supposed. This is how I propose to you to represent it to ourselves without however pretending to explain it. The function of alimentation if we consider it on its psychological side is one of the most considerable systems of thoughts that exist in the brain of an animal. It comprises fundamental phenomena such as the feeling of weakness, of depression and the fear of death. Besides, it comprises numberless secondary phenomena such as the sensations and emotions connected with all the parts of the organism that play a role in alimentation from the hands, lips and tongue to the rectum and anus. Lastly, it also comprises phenomena of improvement as the images of pleasant elements, the habits of eating cleanly and the mixture of certain social phenomena that usually complicate our alimentation. There is in the hysterical a dissociation of this system which may totally or partially withdraw from consciousness. In complete anorexia, you will find the loss of all the elements I have just described, the loss of the sensation of weakness replaced by a pathological euphoria, the loss of the sensations of the organs but also more than is generally believed, the loss of the movements. These patients can no longer cleanly convey their food to their mouths, they can no longer masticate and above all they can no longer swallow nor can they go to stool. There is besides a phenomenon which has not been much noticed and which consists in losses of the social ideas of alimentation. Marceline was very amusing when she explained to me how ridiculous she thought the act of eating and how much she wondered to see people gather for this dirty operation. Hysterical anorexia is at bottom a great amnesia and a great paralysis. Alimentation has become as it were the somnambulistic phenomenon which can only be affected in the second or somnambulistic state as happened with the last patient. This phenomenon is lost to the normal and waking consciousness. Three. Before concluding this lecture I should like rapidly to add a few details which it is necessary that you should know but to dwell on which would take too long. The dissociation of which I have just spoken to you may bear on all the elements of which the function is composed and suppress them separately. You have then kinds of paralysis or amnesias as you choose which may be connected with all sorts of organs. It is needless to enumerate them. You have only to follow the organs themselves. The hysterical patient may lose the functions of the lips in alimentation as she lost them in speech. She may lose the functions of the tongue or those of the teeth. Grant a little more attention to the functions of deglutition of the pharynx. Many of these patients can no longer swallow and they should not be confounded with psychosthenics who have the phobia of deglutition. Some of these subjects cannot make their food pass from their esophagus into their stomach. I'm attending an old hysterical lady and do you know what my first care must be when I see her after her lunch? It is to make her swallow her lunch which she still has in her esophagus. I'm sure that the amnesia of defecation plays a role in many obstinate constipations. What happens for the intestine is still more important and frequent for the bladder. You know that hystericals may lose all the functions of the bladder or only some part or other of them. Nothing is more important for a physician to know thoroughly the neuropathic disturbances of micturition. He can render many services to unfortunate people and avoid many guilty mistakes. How many operations are performed on young women under pretence that their urethra is either too big or too narrow when their urethra has nothing to do with their urinary awkwardness. They can no longer either begin the micturition or stop it or control it and you have varieties of incontinence or retention that may become exceedingly complicated. This rapid review of the dissociation of the functions of alimentation confirms my general studies on hysterical paralysis and amnesias and gives us the plan of our next lecture on respiratory disturbances. End of section 11. Section 12 of the Major Symptoms of Hysteria. This is a LibriVox recording. All LibriVox recordings are in the public domain. For more information or to volunteer, please visit LibriVox.org. The Major Symptoms of Hysteria by Pierre Jaunet. Lecture 12, The Ticks of Respiration and Alimentation. Respiratory paralysis, the problem of hysterical asphyxia, respiratory anesthesia, respiratory disorders, the rhythm of chain stokes, the paralysis of the diaphragm with alternating seesaw respiration, respiratory agitations, polypnea, inspiration ticks, the sigh, yawn, hiccup, aerophagia, expiratory ticks, hysterical cough, laughter, hysterical bark, complex ticks, the meteorism of the abdomen, the ticks of alimentation, bulimia, polydipsia and polyuria, the spasms of the jaws, cheeks, pharynx, the tick of erectation, the tick of regurgitation, the ticks of aspiration, hysterical vomiting, the vomiting of blood. We have to repeat in regard to respiration a study analogous to that which we devoted to the functions of alimentation. The phenomena are about of the same kind, though they are of less gravity. On the other hand, they are of infinite variety and we might dwell indefinitely on the apneas, dyspneas, suffocations, respiratory disturbances, on the varied respiratory paralysis, on the innumerable ticks, polypnea, yawn, sigh, sob, hiccup, cough, sneeze, bark, shakes of the abdomen, meteorism, without counting the ticks of the organs of alimentation, which I should like to place by the side of the latter, namely, erectation, regurgitation, borboregums, vomiting, et cetera. Do not be too frightened. We shall be brief on all this, for the general rules once known, these various phenomena are always similar to one another. One, let us first speak of the respiratory paralysis and to illustrate our teaching, let us at once place a very curious example before your eyes. The case was published a few years ago by Monsieur Leroye, a distinguished specialist in diseases of the nose and larynx. Being very interesting as regards the theory of hysteria and being described simply without any preconceived idea by a physician who has not made a specialty of the diseases of the nervous system and who is not engaged in the quarrels of our schools, this case should have attracted the attention of scientists much more than it did. The girl of about 20 was taken to Monsieur Leroye because her nose was obstructed by adenoid vegetations, which disturbed her respiration and attention. The vegetations were not very big and the operation was effected without any difficulty. But it was noticed that the girl did not breathe better than before, that in particular she was obliged to keep her mouth open, which dried her tongue and lips. Monsieur Leroye thought the nose was still obstructed, so he examined it minutely, but he discovered nothing for the respiratory channels were wide open. Wishing to prove to the girl that she breathed very well through her nose, that she kept her mouth open needlessly and out of habit, he applied his hand on her mouth with the idea that she would simply breathe through her nose. To his great surprise it was not so. There was no breath through the nostrils, the patient writhed as if she were choking and as he insisted on her trying again while she was being held fast, her face and ears turned blue. In a word, this girl suffocated when you shut her mouth while leaving her nose open. There was, however, no obstacle at any point. There was only a singular disturbance of the nervous system, an incapacity of effecting the respiratory motion of moving her chest in the least as soon as the mouth was shut. As Monsieur Leroye very rightly said, this girl had forgotten how one manages to breathe through one's nose. Can a finer confirmation be found of our teaching on functional paralysis and amnesias? Have we not there a pretty dissociation of the respiratory function or at least of one of the parts of the respiratory function? This example at once shows you that we shall find the same problems in the study of respiration. Yet it is incontestable that we cannot begin with so important and so definite a disturbance as anorexiae. The latter was, as we saw, the suppression, the dissociation of the whole of alimentation going as far as inination and death. It was the great functional paralysis. Is there a corresponding absence of respiration, a corresponding asphyxia, suppressing all respiration and going as far as death? The point is moot. You may see the opinions foreign against it in the book of Monsieur Gilles de la Tourette. For my point, I hesitate to admit that it can be true. I have seen several persons die of hunger. I have not yet seen anyone die of suffocation. Hysterical asphyxia, resulting from various disturbances in the respiratory mechanism, does not seem to us to be capable in general of bringing about death. A moment comes when asphyxia brings on fainting, that is the arrest of the higher functions of the brain and the respiration being no longer impeded by these higher functions is restored owing to the automatism of the bulb. Therein lies, in fact, the difference I indicate to you between the elementary and respiratory disturbances. Alimentation, or at least the mechanical part of it, consisting in the prehension of elements, is entirely a conscious voluntary function. Even if we die of hunger, if we are in a swoon brought on by an omniscient, no bulbor mechanism will cause us to eat. Whereas respiration is not entirely a conscious and voluntary function. Consciousness may disturb it greatly, no doubt. We shall see how many foolish things it may do. But happily for us, there is outside our consciousness a fundamental mechanism which is the safeguard of our hystericals. This difference between hysterical anorexia and hysterical asphyxia, as regards danger, is still another fact to be pointed out in order to justify our mental interpretation of the disease. However it may be, there exist hysterical disturbances of respiration, which, in fact, we understand very well now we know the influence of the brain on this function. Fluorance, in 1842, connected respiration entirely with the bulb. But since the works of Kost in 1861, of Danielowski in 1875, of Lepine, of Richet, of Franck, of Pachon, and especially of Mosso, we know very well that there is a cerebral respiration. When the brain is benumbed, the respiration decreases and is reduced. It seems that in total respiration, there is a part of superfluous respiration or respiration of luxury, as Mosso called it, which depends on cerebral activity. It is this respiration of luxury that hystericals can modify in a thousand ways. We first find disturbances of the respiratory sensibility, which, of course, play a fairly important part in the evolution of the accidents, for you know that every loss of a function or every paralysis is accompanied by an unconsciousness relative to the special sensations that play a part in the function. That is to say with a systematic anesthesia. You will often find more or less diffuse anesthesia as distributed over the organs of respiration. The nose is very often insensible and the absence of the perception of odors and nosmia accompanies the respiratory disturbances as well as the disturbances of alimentation. The pharynx is very often insensible. You know that formerly Sharon wanted to make this insensibility and the loss of the pharyngeal reflex to tickling a symptom characteristic of every hysteria. This is very exaggerated, though the fact is frequent since it accompanies the disturbances of alimentation and those of respiration. You will find disturbances of sensibility distributed over the thorax and abdomen. What is more interesting, you will be able in certain cases to recognize a very special anesthesia relative to respiration itself. We feel our respiration and above all we feel the need of breathing. Monsieur Bloch in 1897 invented a curious apparatus for measuring this respiratory sensibility. The subject is obliged to breathe through a tube, the end of which is closed by a window of calculated dimensions. A screw allows you to gradually reduce the dimensions of the window and the subject whose eyes are shut must indicate at what moment he feels a difficulty in breathing. The figures obtained vary pretty much with the subject, the hour of the day and the movements the subject has just made. But I have been able to observe that in hystericals the figures are often very different and infinitely smaller. The patient indicates only very late the need to breathe much later than a normal individual would do when she is already half suffocated. This phenomenon shows a special unconsciousness of the respiratory need which is to a certain extent comparable to anorexia that is to say to the unconsciousness of hunger. These disturbances of the sensibility are accompanied with motor disturbances of which the subjects are more or less conscious. They can no longer breathe voluntarily though they do not arrive at total asphyxia for the physiological reasons I have pointed out. They can no longer add to their respiration that luxury to which we are accustomed. The subject complains of feeling oppressed, of feeling contracted in her neck, in her chest, of suffocating, of not being able to make air into her chest. Sometimes these phenomena are consequent on accidents bearing on the respiratory organs. We have just seen this in the case of L'Ermoye and the least cold in the head may cause similar phenomena in the patient in question. Sometimes they are consequent on any emotion whatever, disturbing the respiration which the subject cannot restore. In many cases the respiration abnormal during the waking state very quickly becomes normal again during the somnambulistic state or the periods of absent mindedness. The accident is quite conformable to the rules that apply to paralysis. You should not believe however that these facts are connected with real paralysis of such or such an organ of respiration. The paralysis is less definite here than in elementary disturbances again for the same reason. A most interesting phenomenon which I have very often recognized in this connection is the respiratory disorder an absence of regularity and harmony. Respiration depends on complex organs the nose, the pharynx, the glottis, the thoracic cavity, the diaphragm. It cannot be effected correctly if everything does not work at the same time and in the same direction. It is useless to dilate your thorax if you shut your glottis or swell your diaphragm. This is what our patients do. The efforts they make in their various organs are contradictory and that is the reason why they make only very little air into their chest in spite of apparently considerable efforts. Bear this detail in mind. You must not think that people breathe very much when they agitate their chest very much. Spirometric measures show us that hystericals breathe very little in reality in spite of great apparent heavings of their thorax and abdomen. Their respiratory disturbance is less a paralysis proper than a want of synergy. This is also interesting for the comprehension of their paralysis which are, as I have told you, paralysis of a system. One may no longer be able to ride a bicycle without having any apparent paralysis of the legs. In certain cases, however, the respiratory disturbance may assume more determinate forms which have greater resemblance with known paralysis but these facts are rare and still discussed. I merely indicate to you the problem. I myself communicated to the Congress of Psychology held in Paris in 1900, a fact which is very important in my opinion, namely the appearance of the rhythm of chain stokes in hysteria. You know that about 1816, chain of Dublin and stokes described a certain quite special irregularity of respiration which, to their mind, was characteristic of the most serious states. As you see on this table, figure 16, this rhythm is characterized by respiratory pauses. There is a series of 10 to 15 quick breaths, then an arrest of the respiration which may last long, half a minute in some cases. Then the active respiratory series begins again. At the outset, this phenomenon was only established in cerebral apoplexy in most forms of agony, in certain varieties of cerebral tumors. Later on it was also found in typhoid fever, in uremia and various intoxications. Monsieur Mosul was the first to generalize this respiratory rhythm singularly. He showed that it existed in simple natural sleep and profound, and in general, in all states of general numbness. At a time when I used to take systematically and with some exaggeration, the graphic of the respiration of all the hystericals I attended, I was very much astonished to find with one of them a graphic which exactly presented the rhythm of chain stokes. I refer you to my article if you wish to see studies which are not without interest in the modifications of this rhythm. This patient was always in a state of absent-mindedness and reverie. When her attention was attracted through any process, her respiration changed and it became again nearly normal. It is the same in the other cases of chain stokes that I found in hystericals. This respiration exists in subjects who are in a condition of half-sleep and who are incapable of any attention. It vanishes when the subject is more awake and more active. These observations are interesting in that they show the role of respiration and attention. They are also important for the theory of hysteria, for they show us here the disturbance of a function that of attentive respiration, which is not a function known to the subject and which consequently cannot be disturbed through preconceived ideas. In the same order of ideas, I wish to indicate to you rather as a curiosity, for this time I have seen only one case of the phenomenon, a paralysis of the diaphragm with alternating seesaw respiration. You know that in normal respiration, the diaphragm falls when the thorax rises, actively forces down the intestines and consequently swells the abdomen during each inspiration. If the diaphragm is paralyzed, it cannot perform this active movement. It floats like an inert veil and allows itself to be drawn up during each thoracic inspiration. The abdomen hollows inwards instead of swelling when the thorax dilates. That is what is called seesaw respiration. It was formerly considered as very dangerous and incompatible with life. Bricket already vaguely indicated an instance of it in a case of hysteria. I have very accurately described an observation of this phenomenon relating to the girl whose whole trunk was paralyzed in consequence of a fall into a well. You see in this graphic figures 17 and 18 that the respiration is very quick, 80 respirations in a minute and that the graphic of the thoracic respiration, T, and of the abdominal respiration, A, are not parallel but discordant. The abdomen hollows inward instead of swelling when the thorax dilates, which I have pointed out as the sign of the paralysis of the diaphragm. The young patient of this case had undoubtedly a number of hysterical accidents and this phenomenon was, I think, of the same kind. But it is, I own, a phenomenon whose presence in hysterics is still open to discussion. If this presence is confirmed, we shall be obliged to admit more profound, older functions relative to the movement of the diaphragm, which may be troubled in certain serious forms of hysteria as old functions are disturbed in hemiplegia and hemianopsia. Two, to those paralysis of the respiratory function are added as is always the case and according to the rule we know, automatic agitations. The functions are never entirely lost in hysteria. They are emancipated. In this state, they are performed in a more or less absurd manner without the will of the subject. As there are in the respiratory function a quantity of small distinct functions, each of them may emancipate itself separately and give rise to very varied attics. Let us put in the first rank the exaggeration of total respiration, polypnea. Here is a fine case. A is a man of 30, a foreman in a seaport. One day he was commanding some workmen who were working a capstan in order to raise a tall mast. He saw a rope break and the mast incline and fancied that it was falling on his workmen which caused him to utter loud cries. No accident occurred but he was so fatigued with this emotion that he was obliged to return home. The next day it was noticed that he breathed in an odd way. The respiratory disturbance grew little by little and turned to a great polypnea which lasted several months. He kept on breathing with unheard of quickness and force. His chest heaved very strongly and very quickly without any interruption. He had 88 then 97 respirations a minute instead of the normal 18, bigger 19. This formidable respiration exhausted him, threw him into a perspiration and above all did not leave him the least freedom of mind. He sat motionless on his chair thinking of nothing, doing nothing but breathe. Notice also that continual parallel of the disturbances of respiration and those of attention. As soon as he was hypnotized the respiration became calm and he was very quickly cured through this process. But note in passing a fact to which we shall revert later on. Our patient remained cured for two years then he lost a little daughter and you know what disturbance he was affected with in consequence of this grief? Was it a some nambulism or a crisis as was the case in so many of the patients we passed in review? No, it was the same polypnea which began again and had to be cured through the same process. By the side of this case might be put that of a girl who breathed 70 times a minute after suffering an attempt at rape and many of the same kind. After those exaggerations of the total respiration let us rapidly enumerate the exaggerations of details the ticks bearing on such or such a particular function. Let us first consider inspiration ticks exaggerated inspiration which is connected with a certain degree of dyspnea and will assume the form of continual size when a little stronger it will be a sob than a yawn. You know what importance was formally attributed to the hysterical yawn which was thought very amusing. Nothing in fact is more singular than those poor girls who all day long and two or three times a minute yawn till they almost disjoint their jaws. It is one of the phenomena in which the imitative contagion is best exhibited. It is also a phenomenon in relation with the disturbances of alimentation. It is the same with the last inspiratory tick the hiccup which is also very frequent. The hiccup is nothing but a very rapid inspiration with a certain degree of spasm of the glottis. The air cannot re-enter quickly enough because the inspiration is too rapid and also because the glottis is a little closed. This results first in a certain characteristic noise and also in a certain thoracic vacuum which causes an aspiration in all the organs. You can see this fact in the graphic of hiccup figure 20 when the hiccup appears at the beginning of each inspiration. The abdomen is aspirated and the graphics of both respirations, thoracic T and abdominal A are momentarily discordant. This will presently play a great part in the phenomenon of air of phagia with patients who swallow air and in vomition. Let us only remark that the hiccup is one of the most frequent phenomena. When looking over my notes to prepare this course of lectures, I counted 29 great observations of hysterical hiccup that had lasted for months together. Among the expiratory ticks, we shall first range the hysterical cough that little phenomenon so frequent at the outset of the disease. There are in this connection clinical observations on the evolution which are facts of experience and cannot very well be accounted for. Thus the hysterical hiccup is to my mind a rather serious phenomenon of bad prognosis. It points to a great hysteria. The hysterical cough which is almost like it is a more commonplace and less serious phenomenon. Almost every girl has had an irrepressible cough in consequence of a certain cough of efforts in singing or of fits of bashfulness. When the phenomenon is isolated, it is very difficult in my opinion to say whether we have to deal with incipient hysteria or with a mere psychosthenic tick. As always pay attention to the state of the sensibility, to the degree of the unconsciousness and to the effects of distraction. One degree further, you have hysterical laughter, those interminable crises of laughter which develop for hours together like real fits of hysterics. You know the psychological problem of laughter and are aware that this phenomenon apparently so amusing is a torturing problem for the unfortunate scientists. You should not fancy that laughter is always the expression of joy. Certain hysterical laughter are of this kind. Thus a girl of bad morals had undergone a little surgical operation for which she had been half chloroformed but during this trifling operation young students of the hospital who surrounded her had kept joking her and making her laugh. Probably under the influence of the chloroform this laughter was transformed into an independent automatic phenomenon and persisted as a tick. But in other cases laughter accompanies pain. It accompanies nervous exhaustion and is to be observed in great delirious attacks. It is probably a phenomenon of derivation of the nervous strength very difficult to account for. One degree further and the expiration more violent and accompanied with spasms of the glottis will bring about the most varied cries, the famous hysterical barks. You know that they occurred epidemically in the Middle Ages and that in the Convince nuns began by hundreds to howl, bark or mew. It was necessary to threaten them with a hot iron to silence them. It is by far less widespread nowadays and is not so epidemic but nevertheless it exists very often under various forms. In many cases this tick is mixed with some phenomena of disturbances of speech of which we have already spoken. Little by little the bark becomes a particular word, the name of a person or some obscenity or other. You understand in fact that all these various ticks we have analyzed may be mixed with one another and give rise to complex phenomena. One of the most interesting is that to which I alluded just now when speaking of the hiccup. The hiccup through the vacuum it determines in the thorax produces a draft in the esophagus and causes the subjects to swallow air. After three or four hiccups the stomach is full of air which brings about another fact. Namely the expulsion of those gases from the stomach through an erectation. Therefore as you may easily notice great hiccups are always interrupted now and then by erectations of different tones. I used to note down in the following manner the noises that one of my patients regularly made. Nupe, nupe, nupe, za. And thus indefinitely. This same patient complicated her respiratory disturbances a little by adding to them disturbances of speech. Thus the noises of her hiccup were often transformed into veritable words. Now and then she would repeat all right and all rock which sounded about like the name of a medical attendant. It even appears that the noise nupe, nupe had been consequent on the reading of a novel in which some savages sang you, you. With those same complex ticks of respiration I should like to connect an exceedingly curious phenomenon the swelling of the abdomen or materialism. It is necessary that you should know this phenomenon well because it is the one which gives rise to the most common and grotesque medical errors. You know of those newly married young women who long to have a child. The men's seas are suppressed. The abdomen becomes big and hard. The breasts hard and colored. There are nauseous and vomiting. A midwife is called in. She feels the arm of the child and fixes the date of the delivery. This date comes and nothing ceases. The expectation continues. On fine day everything disappears without it's being possible to know what has become of the child. It is the famous nervous pregnancy of which I have noted down about 10 cases and of which one should be aware. The error is less serious here than when these swellings of the body are attributed to various tumors and operations are counseled. However that may be, this abdominal swelling is not very easy to account for. The old theories of the time of Chalcourt connected it with a paralysis of the intestinal walls admitting of the dilatation of the gases. I am much more inclined at the present day to believe that it is due to respiratory phenomena. One of those phenomena is a spasm of the diaphragm which remains lowered and compresses the viscera forward but it only brings about the smaller swellings. The other is in relation with that same aerophagia which I have just mentioned. Certain patients eject the air they have inhaled by means of erectations. Others do not succeed in emptying their stomach through the upper end. They force their pylorus open and send this air into their intestine which determines varied disturbances of the digestion and in particular diarrhea but at the same time are sometimes enormous swelling of the whole abdomen. You may imagine many other combinations of these respiratory disturbances. Three, but before leaving the subject of visceral disturbances I should like to tell you briefly of some other very important ticks which depend on the function of alimentation of which we have spoken. Most of these ticks of alimentation besides are at the same time complicated with a respiratory phenomenon. In the first place the function of alimentation emancipated from the personal consciousness may become exaggerated and give rise to various forms of bulimia. Patients affected with bulimia cannot stop eating they constantly ask for food. The fact of bulimia it is true exists in hysteria but be on your guard. It mostly belongs to psychosthenic impulsions. It is to be met with among those patients who feel weakened, depressed and have taken the mania to revive themselves by some stimulant or other adopted more or less at haphazard. Some have the mania of always eating. Others, and they are the most numerous have the mania of drinking alcohol. Yet there is one form of those manias which is in relation with a hysterical phenomenon and which it is right that you should know. It is polydipsia which is not to be confounded with dipsomania. The dipsomaniac seeks after exciting drinks and it is alcohol he wants to swallow. The polydipsicle is not so hard to please. He is content with pure water but he swallows 20 liters of it a day. This excess of drink has an inevitable consequence namely an excess of urine, polyuria. Some of these patients discharge 18 liters a day. Curiously enough, more stress has generally been laid on this consequence of the phenomenon than on the phenomenon itself. Polyuria was studied among the disturbances of the renal secretion to be met with in neuropathic patients. I think it should rather be connected with deliriums or with the disturbances of the functions of alimentation which bring about the impulsion to drink indefinitely. But after those great automatisms of the function of alimentation, we have to point out a host of partial disturbances, spasms of the jaws and cheeks, spasms of the pharynx, ticks of perpetual spitting and salivation. Tileism, which is frequent in certain melancholy deliriums, exists also in hysteria. I do not insist on the spasms of the esophagus to which we alluded in our last lecture. You also know that ticks of erectation and the belches of which I have just spoken to you in connection with the hiccup. But I must point out to you a complication of the phenomenon which is called regurgitation, mericism. Some of these patients learn to ruminate like cows. They know how to bring back into their mouths the food they have swallowed. It has been said that this constituted an odd physiological phenomenon in which the movement of the esophagus was reversed. I think rather that it is one of those curious phenomena of aspiration induced by abnormal respirations. By making a movement of aspiration very quickly while shutting the glottison, preventing the air from entering into the lungs, one induces a vacuum in the thorax which can react on all sides. A certain individual who was formally celebrated in Paris thus drew up air through his anus and knew how to eject it in a melodious way. We know that many thus draw air into their esophagus. But the aspiration into the esophagus may be effected in the opposite direction and throw up the contents of the stomach. We shall see this mechanism assume a greater importance still in the following phenomenon, the only one that is really important, namely hysterical vomiting. Hysterical vomiting is almost as serious as anorexia itself. It is certainly responsible for several deaths. It almost always complicates all the preceding disturbances. This vomiting is rarely pure. That is to say, it rarely depends on hysteria alone. Nowadays, as I told you at the outset, the attention of physicians is much more directed to associated hysteria, to the organic affections that are at the starting point of hysteria or its localizations. Lately, Messier, Mathieu and Roux in a paper in the Gazette des Hôpitaux again insisted on this point in connection with hysterical vomitings. Almost always, they said, there is at the starting point some organic affection which induces the beginning of the phenomenon. This premium mobile may be either the vomitings in pregnancy or alcoholic gastritis or gastritis of any kind or above all ulcers of the stomach of which we shall have to speak again. But however it may be, what characterizes the phenomenon is the exaggeration and regular and indefinite reproduction of the vomiting long after the action of its cause. This vomiting, in fact, is exceedingly rapid and easy. It immediately follows the meal. It is accompanied with very little nausea and no effort. It is repeated with any kind of food and produces the most dangerous indignation. It is also in cases of this kind that the tuberculous complications supervene which almost always terminate hysterical indignations A rather characteristic phenomenon is that the patients cannot seem to endure the arrest of the vomiting. When through any process they are prevented from vomiting, they exhibit anguish, are agitated, writhe in every way, complain of a thousand sufferings and finally become unconscious in a great hysterical attack. Many patients have thus to choose between delirious attacks and perpetual vomiting. This is quite the character of an automatic agitation which they can no longer control. Formerly, an apparently very serious accident was always brought close to hysterical vomiting, namely the vomiting of blood and these hematemesies were unhesitatingly connected with hysteria. It had been noticed, and that very rightly too, that these hematemesies almost always coincided with the beginning of the menses and it was usually said that these women have their menses through their stomachs. At the present time this notion of these neuropathic gastric hemorrhages tends to become obliterated and physicians are inclined to say that they are due to an unrecognized ulcer of the stomach. The symptoms that were formally indicated as conducing to the diagnosis seem to have lost something of their value. The pain occurring long after the meal, the irregular paroxysic crises, the relation with the menses, even the relation with moral emotions, all that was found again in the ulcer. Kutner in 1895 pointed out a patient whose first vomiting of blood came on after the death of a relative. He was led to cut open her stomach and found a real ulcer. Another woman after a scene in which her daughter left home forever had a vomiting of blood which formerly would have been unhesitatingly connected with emotional neuropathic disturbances. Her stomach was also cut open and an ulcer was found. It is in the work of Messier, Mathieu and Roux that you will find a very well conducted discussion of this fact. The authors, however, hesitate to make a complete denial of purely hysterical hematemesies. They admit it in hemorrhagic patuities, in pituitous vomitings tinted with blood, in hematemesies coinciding with multiple hemorrhages of the skin, of the ear. Then why should it not be admitted that in certain cases, this disposition to hemorrhage may be localized in the stomach? Be very prudent, however, in this diagnosis, which at the present time must be less readily accepted than formally. The same prudence, even still greater prudence, is of course necessary when you have to deal with fecaloid or still stranger vomitings which some of those subjects may exhibit. They are almost always due to simulations or deliriums which you must know how to recognize. The real ticks of alimentation and respiration we have just described are numerous enough for us not to complicate their list with doubtful phenomena. One of the characteristics of the present study of hysteria is that efforts are made to limit the disease more clearly than formally and to leave out mysterious phenomena or phenomena depending on another malady. Our enumeration of the symptoms of hysteria is already complete enough and we can now enter upon more general studies on the common characteristics of these diseases. End of section 12.