 Section 7 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 7. Paralysis Diagnosis The clinical study of hysteric paralysis, the beginning of these paralysis, traumatic neuroses, the most frequent types of paralysis, the diagnosis of hysterical paralysis, the intrinsic characters, the localization and form of the paralysis, the examination of the reflexes, the value of the different signs, the extrinsic characters, the modification of sensibility, the description of hysteric anesthesia. Fashions prevail in medical studies as in costumes. At one time one problem raises general enthusiasm and everybody gives it his exclusive attention, forgetting all the others. Twenty years ago it was hysteric somnambulism that was in fashion. Nowadays one seems very much behind the age when one speaks of somnambulism. The latest fashion is to apply oneself only to the study of hysteric paralysis. Let us follow the fashion and reflect for a time on this curious problem of physiology and psychology. This lecture will be devoted to the study of hysterical paralysis from the clinical point of view. The next lecture will analyze the psychological features of paralysis and anesthesias. The hysteric are capable of completely paralyzing a part of their body. You know what I mean by such an expression. I need only state that patients who have had the accidents we spoke of before, fits of all kinds, simple or complicated somnambulism, careers of a special kind, mysterious contractures like those we have seen, may besides have paralytic accidents. It does not mean that a paralysis that presents itself in a woman who has had fits and somnambulism is necessarily a hysteric paralysis obeying the psychological laws of this kind of disease. It even seems to be the clearest result of the present studies which have spread everywhere nowadays to show us that it is not always so. That often, very often even, the paralysis that appears is a commonplace paralysis corresponding to a cerebral or medullary lesion. The diagnosis to be made is exceedingly difficult and important, but it is nevertheless true that in a certain number of cases, these subjects have paralysis analogous to their other accidents, whose evolution is the same and whose diagnosis and nature we must study. One. These paralysis appear in about the same circumstances as the other phenomena. They are always brought about by an accident which, while very slight in itself, is accompanied by a violent moral emotion and by disturbances of the imagination. One of the oldest cases and a very interesting one from a historical point of view is quite typical. I allude to the observation of Estelle, which originated the remarkable book of an old magnetiser, Monsieur de Spindex, in 1840. A girl, twelve years old, had fallen into a passion and against her mother's will had quarrelled and fought with one of her little friends. In the heat of the fight she had been knocked to the ground and had fallen rather violently on her posterior. This fall had been complicated by an aggravating circumstance. Namely, her frock had been much dirtied in a particularly significant part. The pain was slight and did not prevent the girl from getting up again and returning home, but what is essential is that she experienced a feeling of shame, of fright and tried to hide her fault. The next day began a complete paralysis of both legs, a serious paraplegia which lasted eight years. Bear this in mind, eight years paralysis of the lower limbs for having fallen lightly on her backside. Such facts were hardly known at that time to any but to those strange magnetisers. The same authors of whom we spoke lately, Brody, Todd, Duchenne, de Boulogne, Russell Reynolds, Charcot, Oppenheim and all the modern authors were the ones who began to study what was first called traumatic neuroses. Indeed traumatic accidents are among the most frequent causes. Railway catastrophes give rise to many of these accidents and some physicians had even adopted the expression of railway spine. Falls from carriages, from horseback and shocks received in battles are their most common origin. For instance, a drunken carter falls from his box on his right arm and presents a paralysis of this arm. A man of 18 falls in a staircase on his back. The consequence is a paralysis of the legs and a contracture of the lumbar muscles. Often the shock is only imaginary. The celebrated patient who appears in the first lessons of Charcot thinks he has been wounded by a carriage which did not run over him. One of the last observations I have noted is very strange. A man travelling by rail had done an imprudent thing. While the train was running he had got down on the step in order to pass from one door to the other when he became aware that the train was about to enter a tunnel. It occurred to him that his left side which projected was going to be knocked slant wise and crushed against the arch of the tunnel. This thought caused him to swoon away but happily for him he did not fall on the track but was taken back inside the carriage and his left side was not even grazed. In spite of this he had a left hemiplegia. Other circumstances may act similarly as for instance fatigues especially when located in a limb. A house painter felt his hand very tired while painting a ceiling and presented a severe paralysis of his right hand. I found it likewise in a girl who was learning the violin in those who had tired their hands on the piano. But here again to the fatigue must be added an emotional state as in this classical observation of ferret. A girl who tires herself in learning a piece on the piano is seized with the paralysis of her right hand at the moment when she is to play this piece at a ceremony. The part of emotion is so great that it may be sufficient when added to a purely imaginary fatigue as in this other observation of ferret. A girl dreams at night that she is pursued by a man and that she runs very fast in the streets of Paris. She dreams that she is exhausted with fatigue though she has not moved. The next day she is nonetheless paraplegic. Lastly there are some paralysis that follow some nambulisms and crises without our knowing very well for what reason. But as we shall see later on they affect limbs formally paralysed or having in them causes of decay, rachitic deformation, old scars, varices, etc. The paralysis thus brought about may be very various. For the present I only point out to you those most common and most anciently studied. I reserve others for the end of this study because they are particularly interesting as regards the interpretation. The most common hysteric paralysis seem to be analogous to the great organic paralysis. The most frequent, the most carefully studied nowadays is great hemiplegie in which one half of the body is completely paralysed. Usually it is true hysteric paralysis strikes the limbs rather than the face but the rule is not absolute. When the paralysis is in the right side for instance the face and speech may be paralysed as well as the arm and leg. Here is a girl of nineteen already neuropathic and daughter of an epileptic mother who lost her father a fortnight ago. The poor girl supported him with her right arm during his agony. On the very evening of the day on which he died she felt exhausted with fatigue especially in her right side and her right leg trembled when she tried to support herself on it. She could not sleep thinking every moment she saw and hurt her father. The next morning she had a pain in her abdomen. The menstrual discharge reappeared out of its period. The weakness in the right side had increased. On the third day the right arm and leg could still move but trembled continually. On the following day the right hemiplegia was complete and speech was entirely lost. After a fortnight the movements were little by little completely restored. I will observe to you here that this hemiplegia may appear in a more dramatic manner after a convulsive fit or a profound sleep which then absolutely simulates the apoplectic stroke. In such cases the diagnosis is very delicate. Though the hypothesis of a hemiplegia and a hysteric sleep is difficult and rare you must however think of it. Not long ago I recognized an accident of this kind in a man sixty years old who at first sight looked quite as if he had had an apoplexy. The second severe and frequent form is paraplegia in which both legs are completely paralyzed. This accident often appears when an individual is seized with an emotion while walking. It is about what English physicians call the giving way of the legs. A young woman of twenty-five, what is strange is that she was a nurse who as such ought to have known better, was one evening crossing a dormitory. She saw a patient in a crisis of somnambulism getting up and going about wrapped up in a sheet. She took her for a phantom, was terribly frightened felt her legs shake under her and fell down without being able to get up again. She remained paraplegic for several months. You must also be aware of these paraplegies after childbirths and after somewhat long diseases in which the subjects have remained long in bed. The third form will be monoplegy which strikes a limb or a segment of a limb for these paralysis may be very limited. With the painter I spoke of it affected only the right wrist. In other cases it affects the articulation of the elbow or the shoulder, the foot or the whole of the leg. A long discussion which is not yet quite settled bears upon the existence of hysteric facial paralysis. Charcot denied them and maintained that what was called a paralysis of the right side of the face was nothing but a contracture of the left side. He only admitted in the face the existence of the glossolabial spasm. This opinion has been much contradicted and many cases of facial paralysis have been brought forward which seem to be typical. For my part I do not see why paralysis of the eyelids, mouth and cheek should not exist and I have recognized some cases of this disease which seem to be convincing. Lastly there may be paralysis of the trunk and I refer you to the most interesting in my opinion of the studies I have had the opportunity of making on this matter. The subject is a girl who had fallen into a well and who after this accident presented a remarkable facidity of all the muscles of the trunk. She was quite unable to stand or sit, her head and body fell indifferently on every side. At the same time she had a remarkable paralysis of the diaphragm on which we cannot insist for the present. Such are the chief forms presented by hysteric paralysis. I must now somewhat insist on their diagnosis which is of capital importance for you. Two, the diagnosis of hysteric paralysis can be made in two manners. First in an extrinsic manner which was formally considered as the more important. In this case you examine the symptoms that are foreign to the paralysis itself, the disturbances of the sensibility, the disturbances of the intelligence, the simultaneous phenomena, the circumstances of the appearance, etc. Secondly you can make this diagnosis by an intrinsic examination which chiefly takes into account the paralysis itself and its clinical characteristics. This second method appears nowadays to be more accurate and scientific and is often preferred. As I told you, the fashion nowadays requires that you should discover the curious little modifications of the reflexes which may characterize a paralysis without having to make any inquiry of the patient or those around him. Let us then first give our attention to those intrinsic characters since at the present time they are considered as more serious. You may first in certain cases take into account the localization and form of the paralysis. An Austrian author, Professor Freud, has insisted a great deal on this point. Hysteric paralysis never affects only one muscle. It is always a paralysis in a mass which strikes a group of muscles. Do not suppose that every group of muscles may be thus affected. The group that is affected is always one that is necessary to a function of a part of the body. Yet the paralysis does not extend beyond the limit of the muscles necessary for the functioning of this part of the body. It does not easily encroach upon other regions. It is otherwise in all organic paralysis. A lesion of a nerve may affect only certain muscles. A lesion of a nervous plexus affects several muscular groups. For instance in the paralysis of the leg brought about by hysteria the thigh and buttock are affected but the sacral region and the genital region are intact which is not the case in spinal paralysis. The same author remarks further that hysteric paralysis is often seated in the extremities of the limbs only which does not happen in organic paralysis. The latter more often affecting segments that are near the centre. Notice also that hysteric paralysis is exaggerated always carried to an extreme which is very rare in organic paralysis. A man whose hemiplegia is consequent on a cerebral hemorrhagy can still move a little and make some efforts to conceal his paralysis. One in whom hemiplegia is due to hysteria has no longer a shadow of a movement in his diseased side. Hence comes this difference in the gait which Todd and Charcot formally pointed out and for which they invented rather barbarous Greek words. The subject affected with organic hemiplegia they said has a helicopode walk. He walks helically throwing his paralysed leg sideways by a movement of his loins. The subject affected with hysteric hemiplegia has a helicopode walk. He drags his paralysed leg in walking as if he did not trouble himself about it in the least as if it no longer existed at all. To these positive characteristics are added negative characteristics. Hysteric hemiplegia is not accompanied by any other serious disturbances in the diseased limb. In particular there is no atrophy or at least a very long time is required for it to appear after the period of immobility. So you must always carefully measure the two limbs of the patient. The existence of a notable atrophy will help you to recognize certain lesions of the medulla or brain. Nor are there any disturbances or electric reactions. The reaction called reaction of degeneration which is so rapid in certain forms of medulla lesions does not exist in hysteric paralysis. We come at last to the question of the reflexes. Now considered as very important chiefly it must be said on account of the studies of a French physician Monsieur Babinski who has devoted himself to this subject. In a general way all the reflexes of a limb must remain normal in a hysteric paralysis. This may easily be understood since these reflexes depend for the most part on lower medulla or cerebral centers which are supposed not to be affected with any disturbance. On the contrary, in an organic lesion a certain number of reflexes must always be injured because the lesion always bears more or less upon one of these centers. You have first to consider the tenderness reflexes in the elbow, wrist, knee, tendon of achilles. They must not be suppressed as in tabes, nor exaggerated as in cerebral hemorrhage or in the lesions of the pyramidal tract. You will seek especially in the foot for the epileptoid trepidation. The clonus determined by the sudden raising of the foot which appetines exclusively to the lesions of this pyramidal tract does not exist in hysterical paralysis. You will also examine the cutaneous reflexes. For instance, Babinski has shown the very important sign given by the toes when the ball of the foot is slightly rubbed by the pin. In normal adults, for there are some irregularities in children, the toes bend together towards the sole of the foot. In the lesions of the medulla on the contrary, you observe a raising and extension of the toes but nothing like this can be observed in hysteria. Excitation of the skin in different regions of the body on the internal face of the thighs on the abdomen, on the neck determined in a normal man contractions of the poissier muscles that is to say the muscles of the skin which disappear in organic accidents and not at all in neuropathic phenomena. Don't forget to examine carefully the reflexes of the pupils to light to accommodation. The slightest disturbances of these reflexes must put you on your guard. You know that the least alteration of these reflexes strongly inclines you to admit organic lesions, either those of tabis or those of syphilitic meningitis. Lastly, Babinski has shown the importance of the preservation of the muscular tonus in hysterical paralysis. He insisted too with great accuracy on the preservation of certain unconscious movements produced by association in these apparently paralysed limbs. This fact is analogous to the observation of the preservation of certain subconscious sensations in spite of hysterical anesthesia that we have to study in the following lecture. According to these authors this ensemble of signs is absolutely characteristic and it is possible to recognize a hysteric hemiplegia solely through this objective examination which requires nothing of the patient's psychological observation. The thing is perfect theoretically but practically it is much more difficult than is supposed. Most of the signs we have spoken of when treating of the localization of paralysis either are indecisive or apply but to quite particular cases. The signs of the reflexes are much more important but can we absolutely trust them? First of all we must eliminate the signs derived from the mere exaggeration of the tenderness reflexes. You cannot eliminate hysteria merely because a patient throws his leg upward too strongly after the shock of the rotulate tendon. For this exaggeration of the reflex is exceedingly difficult to appreciate and very irregular. A very great number of subjects when a little moved or nervous throw their legs too strongly upward when their knee is struck. It may be said that one should distinguish the real reflex which is quick and simple from the semi-voluntary, semi-emotional movement which is added to it and which is too tardy, too long, too much generalized. All this is true enough but in practice I defy you to make the distinction and moreover I am inclined to believe that in hysteric and neurasthenic patients there is often a real exaggeration of the reflexes which is perhaps due to a diminution of cerebral inhibition. The sign of the clonus of the foot has more importance. The significance is much discussed at the present time and several authors point out cases of unquestionably hysteric paralysis in which it has been met with. Some authors maintain that if they take the graphic of the shake with the registering apparatus they recognize the regularity of the organic clonus in contra-distinction to the irregularity of the hysteric clonus but this is not quite certain. Babinski's sign of the toes is exceedingly interesting. In reality, you need not hesitate when it manifests itself clearly. I don't think it has yet been distinctly observed in a hysteric paralysis but it is an irregular sign which often fails totally. Many subjects do not react at all or react by a retraction in a mass of the leg. The pupillary reflexes are likewise of capital importance. Be always on your guard when you meet with the sign of Argyle Robertson. But this sign is not absolutely characteristic either. First of all, many neuropathic patients have pupillary dilatation. Then, in some hystericals there are contractures of the iris with dilatation or meiosis which prevent the reflexes from taking place easily and may again be causes of error. In a word, it is certain that the intrinsic examination gives us exceedingly valuable indications. The invasion of the face the disturbances of speech the clonus, the signs of the toes the pupillary disturbances are strongly in favor of an organic lesion. Unfortunately, they are not absolutely certain signs and I think one is quite wrong in making things more difficult than they are in refusing the unquestionable services rendered to diagnosis by much more characteristic extrinsic signs. The most important extrinsic sign of all is derived from the examination of sensibility the modifications of which are of the greatest importance in hysteria. We already met with them when studying careers and contractures We observed that the hysteric patient often appears not to know what is going on in her arm or leg that she does not feel the fatigue of her protracted shakes or contractions and that what is more she may not feel the movement of which her arm is the seat. This anesthesia is still more characteristic in paralysis we must therefore insist now on its study. For a long time physicians had had some vague notions about the odd insensibilities of these patients You know that in the Middle Ages people recognized witches and possessed persons by seeking on their bodies for what was called the claw of the devil It was a more or less extensive part of the skin in which the subject was insensible to any touch or prick The expert entrusted with this work would close the eyes of the subject and armed with a sharp needle prick here and there the different parts of the body The sufferer was to answer with a cry to each prick and the claw of the devil on a certain spot was recognized from the fact that he did not cry when this spot was examined Later on, Sydenham in 1681 then Louis-Yves-Hermé in 1816 Georges in 1824 Landoussie in 1846 Later still, Briquet, Charcot and all the modern authors have strongly insisted on all the varieties of this phenomenon For the present we shall attend to the indications that anesthesia can give us as regards the diagnosis of hysteric paralysis and especially to its seat and depth This insensibility must be sought for this purpose in three organs on the skin, on the mucous membranes and in the muscles It may indeed extend either over the cutaneous coat of the limb or over the accessible mucous membranes of the natural orifices or it may bear upon the sensations of motion and upon the notion of the position of the limbs In the first case we have to examine the skin and mucous membranes as regards contact by passing our finger or a blunt instrument over them We may hope to obtain more accurate results by the use of the anesthesiometer which shows us how the subject recognizes the differences of sensation depending on the different spots of the skin You will examine on these same regions the temperature sensations by alternately applying on the skin unknown to the subject a cold and a warm object Lastly you will examine the sense of pain by pinching, by sticking in a needle or by using one of the various algizimeters You will thus find that these various sensibilities may completely disappear either simultaneously or separately It is not rare to find absolute insensibility of the skin accompanying hysteric paralysis You will then examine the so called muscular sensibility by displacing the limb in different ways and asking the subject to describe these positions and movements without looking at them or better still to reproduce them with his uninjured arm Here again you will often find hysteric paralysis complete insensibility to position the subject no longer possessing any information about his diseased limb The existence of such anesthesia already gives you an important piece of information No doubt anesthesia exists in organic lesions but it is much rarer and in general not nearly so deep as in hysteric affections Further it is easy to acknowledge that the anesthesia when it is connected with hysteria presents certain characters that are not found when the insensibility depends on organic affections of the nervous system One of the characteristics of this anesthesia and one that plays a most important part in the diagnosis has been well illustrated by Charcot and nowadays still appears to us to be very significant the localization or the place of this insensibility Charcot used to say that in hysteric paralysis anesthesia takes the form of geometric segments meaning that it is terminated by distinct regular lines assuming definite forms which can be foreseen Of course when the hemiplegia is complete and the hemianesthesia is also complete the form is very clear but has no great significance It stops just at the median line of the body dividing into two equal parts the forehead, nose, mouth, breast and abdomen This section is curiously regular On the one side the skin is absolutely insensible as well as the mucous membranes and as we shall see later on the organs of the senses On the other side the sensibility is intact You may barely observe some transition some degradation on the median line of the body On one side the subject feels nothing on the other she feels quite normally It is true even of the mouth and tongue the separating line is found on the palate and tongue This hemianesthesia exists also in certain forms of organic lesions in certain lesions of the internal capsule One may at most say that it is rare and that in general the separation is not so clear that there is a broader line of demarcation with confused sensibility One may say too that usually the troubles of sensibility are more severe in the extremities than at the root of the limbs instead of being regularly the same in all parts as in hysteria But of course in this case the form of the anesthesia will not give you much information In the other paralysis it seems to terminate precisely enough above the paralysed organ by a nearly circular line traced by the plane perpendicular to the axis of the limb Thus a paralysis of the hand brings about an anesthesia of the hand extending up to the wrist and terminated by a line in the form of a bracelet figure nine An anesthesia of the whole of the arm is limited by a line including the shoulder passing a little under the armpit in the form of a jacket sleeve A paralysis of the foot brings about a sock or a stocking of anesthesia A paralysis of the leg gives birth to an anesthesia in the form of a leg of mutton which generally spares the anus and the genitals figure nine Now these forms of anesthesia which look so simple are particularly extraordinary from a physiological point of view They by no means correspond to the distribution of the nerves or even of the nervous plexuses You know that the hand is innovated by three principal nerves the radial, the median and the cubital A section of one of these nerves brings about a well known anesthesia of anatomic form corresponding to the distribution of the nerve You know for instance the old anesthesia of the lesions of the cubital which only affects the little finger and the longitudinal half of the force figure ten It is not at all like our geometric segments in the case of a paralysis of the hand A lesion of the brachial plexus anesthetizes only a part of the arm and the limit of the anesthesia affects a special form because it reserves the sensibility of a portion of the shoulder above the deltoid which is innovated by the cervical plexus figure eleven A lesion of the sacral plexus brings about, it is true the anesthesia of the thighs on their internal face but affects the anus and the genitals On this distribution of the insensibilities and on the places of the reserved regions is founded the anatomic diagnosis of the lesions of the nerves and of the tumours of the medulla But it is not possible to connect the forms of anesthesias we just observed in the hysteric paralysis with these forms given by the organic lesions This difficulty of localization was so great that Bleke tried to make other hypotheses and asked himself whether the distribution of hysteric anesthesias did not depend on the vascular circumscriptions on the circulation of the blood more than on the nervous circumscriptions Now we see that such is not the case There is no arterial irrigation in the form of a wristband a jacket sleeve or a leg of mutton This form of anesthesia is something quite peculiar I have tried formally to sum up these localizations of hysteric anesthesia by a word that has had success The hysteric patient, I said seems to attend to the popular conception of the organ rather than to its anatomic conception For the common people, what is an eye? It is the ensemble of the organs that feel the orbit eyelids included and in fact, the hysteric person who has anesthesia of the eyes has on her face, as it were a pair of spectacles of anesthesia figure 9 affecting the two eyelids in their central part For the common people, the hand terminates of the wrist They don't care if all the principal muscles that animate the hand and fingers are lodged beyond in the forearm The hysteric person who paralyzes her hand seems not to know if her fingers is due in reality to a muscular disturbance in her forearm She stops her anesthesia at the wrist as would the vulgar who, in their ignorance, say that if the hand does not move, it is because the hand is diseased Now, this popular conception of the limbs is formed by old ideas we have about our limbs which we all keep in spite of our anatomic notions So these hysteric anesthesias seem again to have something mental, intellectual in them This characteristic, though really very important might still, however, give rise to some caveling There are in intoxications, in alcoholism for instance, in sensibilities in the form of a sock or a boot In the medulla, segmental localizations have been studied that may lead one to conceive anesthesias of the same kind Practically, you will be right 9 times out of 10 in basing a diagnosis of hysteric paralysis on this geometric form of anesthesia But in order to avoid the least chances of error, we must insist on the last characteristic to which we have just come, namely the mental character of this anesthesia It is, moreover, this character which will enable us to arrive at a more intelligible conception of the paralysis itself Such will be the object of our next lesson End of section 7 Section 8 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 8 The psychological conception of paralysis and anesthesias The problem of hysterical anesthesias Absence of any modification of the reflexes of any physiological disturbance Indifference of the patient Mobility of the anesthesia under various influences attack, sleep, intoxication, somnambulism suggestion, emotion and above all attention Contradictory character of this anesthesia The part played by absent-mindedness The dissociation of certain groups of sensations in the anesthesia The indifference, the lack of representation and memory in the paralysis The astasia abasia The systematic paralysis The dissociation of a system of movements The system of movements and sensations in a function Hemiplegia and paraplegious dissociations of functions The time has now come to give our attention to some psychological studies on hysteria that had a great development in France about 20 years ago and have contributed much to the development of pathological psychology They are perhaps rather special having perhaps a less general importance than we then thought But without them we could not understand the particular nature of hysterical anesthesia nor even perhaps form with sufficient clearness, a general idea of the hysterical disease itself and especially of the paralysis that exist in this disease We shall insist on the mental characters of anesthesia and try to derive from them a general conception and then we shall see that it finds its application in the study of paralysis which we shall take up again from a new point of view One We have already seen that hysterical anesthesia presents certain oddities which ought to attract the physician's attention It is accompanied by a very deep and even exaggerated paralysis and yet does not determine any serious objective disturbance Is it not odd to see a limb remaining quite insensible quite paralyzed for months and sometimes years together without any serious atrophy without any modification of the electric reactions and above all without any change in the reflexes Certain reflexes in particular astonish us very much The reflexes of the erectile organs those of pain remain intact You know for instance that if you determine a strong pain by pinching the skin at any point whatever of the body, the pupils contract suddenly This fact persists with our hystericals who declare they feel nothing The vascular reflexes in relation to the sensations of cold and heat are very delicate Monsieur Allion recently contrived great accuracy by means of a delicate little apparatus which he invented The application of a little ice on the forearm immediately brings about the contraction of all the vessels of the hand At my request he was so kind as to study the fact with my patients and found that the most anesthetic hystericals reacted quite correctly in this respect Besides, we know quite well what the disappearance of the cutaneous sensations produces in practice Physiologists have shown that when the limb of an animal is made insensible by the section of the sensitive root this limb, quite intact at first cannot nevertheless be preserved It is not long in becoming unclean and covered with sores and it disappears little by little for the animal itself bites it off Sensibility is a safeguard for our limbs We may observe the fact in a well known disease You know those patients who come to the consultation to complain that their hands are constantly burnt or wounded They have scars of burns on their fingers and are not able to avoid this accident They are syringomyelic patients and the lesion of their spines makes them insensible to cold and heat Why is there nothing of the kind to be found in our anesthetic hystericals? This absence of objective disturbances is mostly accompanied by a very curious subjective symptom, namely the indifference of the patient When you watch a hysterical patient for the first time many patients coming from the country who have not yet been examined by specialists you will find, like ourselves that without suffering from it and without suspecting it they have the deepest and most extensive anesthesia Laseg, who analysed very carefully many of the subjective characteristics of hysteria, has often pointed out this ignorance among the patients Charcot has often insisted on this point and shown that many patients are much surprised when you reveal to them their insensibility Recent authors are also agreed on this point It is far from being the case with anesthesias of organic origin that particular symptom of tabes which Charcot was one of the first to describe and which he has called the tibetic mask, is well known The patients lose the sensibility of a part of the face, more or less extensive but they account for it subjectively and declare that they experience a horrible feeling in regard to it Ask hystericals who have facial anesthesia and they are legion whether they experience a horrible feeling about it and they will all tell you that they do not care To explain precisely this important difference between hysterical anesthesia and anesthesia of organic origin it will not be out of place we think to relate a little anecdote We did not obtain it ourselves but it was given to us by our brother Dr. Jules Jeunet When he was house surgeon at the pitié with Dr. Paul Lyon he wanted to observe the following case A young girl of about 20 had met with a rather serious accident She fell through a glass door and a piece of glass cut into her right wrist just below the thena eminence The hemorrhage was stopped and the wound had united fairly well when, a few days after the accident the young woman presented herself for treatment She experienced a certain numbness in her right hand but no paralysis was present She complained particularly of a persistent ability, most inconvenient in the palm of the hand This slight anesthesia about the fingers was in fact complete at the level of the thena eminence The case was evidently one of a more or less complete severing of the median nerve and especially of its superficial branches But while accepting the observation of the patient we made a singular discovery She was a hysterical and on her entire left side she was completely anesthetic of which she had not said a word The physician joked her about it How is it, miss, that you come here complaining about an insensibility that affects but a small portion of the palm of your right hand while you do not even notice the much larger insensibility of the whole of your left side The poor girl looked surprised and ashamed To our mind she might have replied to her doctor with much more assurance and said, be that as you think, sir I came here to tell you what ails me It is the insensibility of the palm of my right hand that troubled me But my left side has never given me any trouble You are the doctor, explain it as you like To these general remarks must be added all that we have said already on the form of these anesthesias a form which has nothing anatomic or even scientific in it and seems to correspond to false popular notions These remarks compel us to enter more deeply into the scrutiny of the mental state corresponding to these strange insensibilities This study leads us now to point out a new characteristic in the same order of ideas namely the remarkable mobility of these anesthesias Unquestionably some patients retain their stigmata all their lives Aurel is still hemianesthetic at 75 Ler has kept a hemianesthesia and a contraction of the visual field for 40 years We shall have to keep an account of these cases but generally and perhaps even among these very patients without its having been observed Anesthesia becomes modified and disappears all at once for longer or shorter periods It varies from one moment to another says Monsieur Ferrer and under the influence of causes so slight that they may pass unnoticed However rapid in their mobility some of these changes may nevertheless be studied and one can note at least some of the circumstances in which they are often as defected The attacks modify considerably the localization of sensibility Many authors have noted that anesthesias often increase at the time preceding the attacks For example Margarite X who ordinarily has right sided hemianesthesia becomes during the hours that precede the attack totally anesthetic We point out a case much rarer still It is an opposite phenomenon Cell, usually totally anesthetic recovers complete sensibility sometimes during a form of excitement which lasts half an hour before the attack During the attack itself when we can obtain some intelligent sign we have seen that it is generally possible the sensibility becomes modified Often as happens with Belt it is recovered entirely After the attack many patients, like Margar return to their usual condition Others have for some time anesthesias more extended than usual Belt, generally hemianesthetic on the left side remains after the attack totally anesthetic and at the same time completely blind for some hours It often happens during natural sleep at night that tactile anesthesias disappear It is very difficult to verify the fact We have to take the patients by surprise at night using all sorts of precautions not to wake them We pinch them on the anesthetic side They groan, turn over complain in their dream or wake suddenly exactly as a normal person would Monsieur Jules Jeunet when he was an assistant of Dumont Palier has repeatedly verified this fact on two patients the observation of which he communicated to us We had the fact established on various persons, particularly on Belt and Ys Our friend Monsieur Dutille was kind enough to verify the fact for us on a hysterical G hemianesthetic on the left side Pinched on that side during her natural sleep she winced and spoke in her dream You are pinching me How stupid! During certain intoxications that bring with them states analogous to sleep insensibility vanishes more or less completely Many patients totally anesthetic become entirely sensitive when drunk Chloriform anesthesia in the period of excitation does away with all stigmata with the anesthesia as well as the contractures Among the most paradoxical consequences of the hypodermic use of morphine says Mr Ball You must cite the restoration of cutaneous sensibility with subjects who have lost it A hysterical drugged with morphine a dose of 8 centigrams a day felt all her pain disappear and her normal sensitiveness restored Abstinence brought back her hysterical symptoms The same fact has been described by Monsieur Jules-Voison In the same manner we see often a diminution of the anesthesia and a widening of the visual field in hystericals who are under the influence of morphine and we could verify too the reappearance of the anesthesia after the cessation of the influence of the drug Many other excitations must have analogous effects The object of our first work was, above all, the numerous modifications of sensitiveness during states of induced somnambulism Certain subjects under rare conditions recover suddenly and completely all their sensitiveness as soon as they are in the second state This fact has been sometimes pointed out in old descriptions of the magnetisers We have very often established these same facts at the outset of our researchers before we had read the very interesting observations of these authors Sometimes the subjects have, during their somnambulism, an anesthesia apparently general but the slightest excitation that directs their attention somewhat upon tactile sensitiveness causes this anesthesia to disappear even on parts that remained anesthetic when awake despite suggestions This restoration to sensitiveness of some subjects proceeds somewhat slowly and becomes evident only when the hypnotic state has been considerably prolonged Others, again, have a more complicated somnambulism They pass through several states in which sensibility and, above all, memory undergo many modifications It is only in one of these states often a state that develops after all the others that the subjects recover all their sensibilities Sensibility may be modified even in waking time Bréquet has insisted on the action of electricity Bourque and many others after him have shown that magnets metal plates and many other agents which all vary according to the patients have analogous effects The sensibility increased by these agents persists for a longer or shorter time and disappears with oscillations The influence of suggestion in general very powerful with hystericals requires momentarily to reestablish the sensibility but it should be borne in mind that this phenomenon is far from being general that, with a number of patients sensibility changes very little when it is suggested and, on the contrary, undergoes great modifications under the influence of certain excitations such as drunkenness or certain changes of psychological state as somnambulism Many other psychological phenomena come in to produce, modify or destroy anesthesia For example, strong emotion preoccupation, reveries, increase it The association of ideas may in some cases modify it We say to one patient that she has a caterpillar on her left hand and she cries out and pretends that she feels the tickling of it At this moment the whole of her left arm has become quite sensitive But there is a psychological phenomenon which plays a far more important part than any other and its study throws a great deal of light on the problem We mean attention To verify this fact we must remember as we shall demonstrate later that with hystericals attention is altogether the most difficult thing to fix and that only a few can succeed in directing it As a general thing we may for a moment attract their attention upon their anesthetic hand by whatever means we please A patient does not feel the electric current when he has his eyes shut He acknowledges a tickling on seeing the manipulation We fasten a red wafer on Bert's left hand She looks astonished and stares at her hand Let us leave her for a moment Then when her head is turned let us lightly pinch that hand so insensible but a moment ago Bert now cries out when we pinch her and feels it quite perfectly It is true that this fine sensibility will not last long We take that wafer off and a few minutes later she can no longer feel anything All these phenomena, the last particularly are the origin of many difficulties for they very easily upset the sensibility that is the object of the study They increase the anesthesia They fix it or suppress it They give it an extremely changeable aspect which discourages the observer Now, it will be asked Does the anesthesia, at least as long as it exists present itself to the observer definitely? Is it always very certain in whatever way you examine the subject? By no means There is a second series of observations which complicate the problem of anesthesia still more, for they present it to us not only as changeable, but as contradictory Laseg said in 1864 that hysterical anesthesia looked strange and that it seemed to be a psychological perturbation, a sort of alienation The studies which subsequently confirmed this theoretical conception were at first observations on an altogether special point namely on unilateral amorosis That is, on certain very interesting disturbance of the vision about which we shall speak in our next lesson If the unilateral amorosis presents embarrassing problems it is the same with all anesthesias Several years ago we made the following observation of a patient in Mr. Poilovich's service at the Avra Hospital She was attacked with hysterical paraplegia and presented a state of total anesthesia We used to treat her legs with electricity and noticed the strong muscular contractions she experienced at each contact of the negative electrode when all at once we saw that the two wires which fastened the plugs to the apparatus had dropped For a long time we had thus been applying electricity with mere pieces of wood We continued without fastening the wires to the ends and the contractions were all the greater by the simple contact of the plug This, it will be said, is nothing very wonderful There is a sort of habit in that a suggestion is taking place We think so too But how could this patient whose skin all over her body was wholly insensible and with her head well turned away feel the moment when the plug touched her legs and make a movement just then and only just then We may every day experience a similar embarrassment We propose to ease a little contrivance to verify her anesthesia quickly She is to answer yes when she feels and no when she does not feel anything As she is very simple minded she accepts without demurring and we discover then a curious contradiction Although she has her eyes carefully concealed behind a screen although we avoid any kind of rhythm and pinch her several times irregularly on the same side before we pass over to the other she is never mistaken and always says yes when we pinch her on the left and no when we pinch her on the right The same experiment repeated on a man Pask gives exactly the same results until he perceives the queerness of his answers and tries to answer attentively He then ceases but only then to say no when we pinch his anesthetic side Here now is another observation which bears no longer on the tactile but on the muscular sense A young woman, 22 years old whom we have often described by the name of Lucy took during her attacks certain cataleptic poses For an hour she would keep her eyes fixed on the window and her arms raised in an attitude of terror For the present we must insist on only one detail of this attack We observed that during the most normal of her waking states it was enough to raise both of her arms and place them in the posture of terror of which they took during her crisis to induce at once an attack Of course you will say the thing is quite simple and well known By the position of the arms you call forth the principal idea of attack and the rest follows True, but there is a little detail yet Lucy was anesthetic over her entire body and presented nowhere any trace of muscular sense As often happens in this case she would fall down at once as soon as you closed her eyes Now we have often taken the precaution to close her eyes before displacing her arms and the crisis occurred all the same as soon as the members had the required position How would you explain the notion of that position being appreciated by so insensible a subject All these facts and a great number of others which have been accumulated are very likely to puzzle the observer They show us that hysteric anesthesia not only changes from one moment to another but indeed varies in the same instant and manifests itself by contradictory phenomena according to the questions put to the subject Two We must rapidly lay aside a first interpretation of these facts The anesthesia of hystericals is extremely changeable and contradictory These patients pretend not to feel and by very simple artifices we can prove to them that they feel perfectly well Their insensibility is therefore simulated and our processes are only means to deceive a deceiver and unmask a fraud This resume of facts is to our mind altogether crude and insufficient Do hystericals take any particular interest of pleasure in having their arms pierced through with needles Do these young girls pass through the Council of Revision to simulate unilateral amorosis How is it that in all civilized countries hystericals should have agreed to simulate the same thing that we have in this case should have agreed to simulate the same thing ever since the Middle Ages to the present day We must not be content with this crude explanation and since anesthesia presents itself to us as a psychological fact we must seek among the few notions psychology furnishes us that which best summarizes facts of this kind We are happy to have Laseg confirm an opinion which we have maintained for several years Hysterical anesthesia is a certain species of absent mindedness A person said Laseg in 1864 absent minded through a great preoccupation does not perceive sensations which in another frame of mind he would scarcely have tolerated It is probable that hystericals whose moral state offers so many other singularities acquire likewise through their very malady a sort of laziness that renders them less apt to perceive certain psychic modalities This explanation based on absent mindedness is in reality but a first approximation anesthesia is surely not ordinary absent mindedness It has much more clearness and duration It is far from disappearing so easily as soon as the subject chooses and above all it appears without there being any fixed idea of any object which attracts the patient's attention to another point There is in it a pathological incapacity to collect the elementary sensations and a general perception In reality what has disappeared is not the elementary sensation the preservation of which we have just seen It is the faculty that enables the subject to realize this sensation to connect it with his personality to be able to say clearly it is I who feel, it is I who hear We shall often have the opportunity to reconsider this problem but let us remark by the way that this singular character of anesthesia is not unknown to us After all we have already seen something similar while studying the amnesias that follow somnambulisms I have already told you that the subjects were unable to remember what had happened during the fit of somnambulism and even to remember the principal idea which played a part in this state Iren whom I have repeatedly spoken of had forgotten after the crisis not only the comedy she played but also her mother's death and illness which were its starting point We accepted at that moment without discussing it the description of this amnesia for we did not want to complicate the matter but in reality that oblivion was very strange Was it real oblivion the obliteration of the recollections the destruction of the images by no means since the patient could be cured and is now able to relate clearly all those events Was it then the inability to reproduce them Was it that the brain while keeping their traces was nevertheless not able consciously to cause them to reappear by no means since the patient had dreadful fits every day during which she recited all the details of the events In a word she had forgotten nothing and she had the power to recite everything Then where was the oblivion The oblivion consisted only in this that she could not recite in a waking state with full consciousness of the other events and of herself She could relate it is true but in a dream, in a delirium without having at the same time the notion of herself As soon as she had the personal consciousness of her name, of her situation she could no longer associate the remembrance in question We tried to sum this up by saying that somnambulism is not the destruction of an idea but the dissociation of an idea that has emancipated itself from the ensemble of consciousness and that the ensemble of consciousness can neither recover nor control Well, our anesthesias which looked so strange have just presented to us the very same characters with more clearness still There are groups of sensations forming a kind of system full of sensations coming from the hand or the leg which can no longer be connected with the totality of consciousness although they still exist on their own account and even determine reflexes and usual movements Let us apply the same notion to our paralysis We shall see that the facts are absolutely of the same kind Besides anesthesia on which we dwelt for some time there are other mental phenomena which accompany hysterical paralysis The most curious are connected with a kind of indifference analogous to the one we remarked in anesthesia If we had a paralysed arm it would inconvenience us exceedingly We should fret very much about this disease We should perpetually regret our former state and be forever making desperate efforts to recover the motion we had lost We cannot help therefore being somewhat surprised and ill-humoured when we attend a paralysed hysterical This kind of patience vexes us with their calm indifference and inertia One of their limbs being out of use they dare to incommode them They think it quite natural to walk with but one leg and do not make the least effort to use the other leg It was just this that determined the famous distinction Sharko made between the Helicopode and Helicopode gates While the person affected with organic hemiplegia labours hard to move his restive limb forward the hysterical drags hers after her like a cannonball She almost despises it and she wants to beat it calling it an old stump as described This conduct corresponds to a very special mental trouble If you question such persons you find that they seem not to have kept the remembrance of their limb They do not know any longer what this paralysed limb used to do and they can no longer make the efforts of imagination necessary to conceive it Pire was one of the first who insisted on this point After having shut the patient's eyes he says I ask her to try to represent to herself the acuity movements of extension and flexion She is not able to do it She can represent to herself her right hand making very complicated movements on the piano But on her left she has the sensation that her hand is lost in empty space She cannot even represent to herself its form I have verified this remark more than 20 times This lack of representation and memory of the paralysed limb is one of the most typical things Many authors have remarked it Here is the statement of an English author Dr. Bastion who by the way has quite another conception of hysteria than we When I ask her if she can imagine that she touches the tip of her nose with her left finger she immediately answers Yes If I ask her to imagine the same movements with the paralysed hand she remains hesitating and at last answers No She can imagine herself playing on the piano with her left hand but not with her right hand The same remark applies to the old observations made at the outset on the will of these patients The English author Brody had already said In hysterical paralysis it is not the muscles which do not obey the will it is the will itself which does not enter into the action W. Page added When the patient says I cannot it means I cannot will and Monsieur Luchard said they cannot, they will not will What did these remarks applied to paralytics mean They meant that the patient did not seem to make the initial effort to apply his consciousness to a certain act He did not even seem to have the representation of this act All these remarks are of about the same kind and refined again in paralysis dissociations of psychological phenomena identical with those we have observed in somnambulic amnesias There is but one difficulty left What is the psychological phenomenon that dissociates itself? In somnambulism it was the idea of an event and was relatively clear but have we in our mind the idea of the motion of our two legs? Is it this idea that disappears in its entirety and makes us lose the motion of our legs? It seems very odd and we are not accustomed to apply the word idea to the ensemble of the movements of our two legs To make the thing clear we must now recall certain forms of paralysis of which I have not yet spoken and which will I think form the transition between the preceding phenomena of dissociation and the great paralysis which we do not understand 3 Several authors, one of the first of whom was Jacques and among whom we find Charcot, Bloch and Siglas had pointed out a form of hysterical paralysis still more extravagant and unintelligible than the others The subjects are as a rule young people They seem not to have the least paralysis of the legs when you examine them in their bed Not only are the reflexes intact but, and the fact is more surprising the movements are intact If you tell them to raise their legs to bend to turn them they do exactly all that is required of them What is more, they have kept a very great strength, quite the normal strength They push back your hand with their feet They lift you up if you bear down with all your strength on their knees Then you will no doubt say there is nothing at all the matter with them It is true, but they are absolutely incapable of walking To stand on the floor they will bend twist their legs throw them to one side and the other and fall down without having made one step and this will last for weeks and months They realise the paradox of having no paralysis of the legs and of being unable to walk In a few described by Charcot the comedy is still more complete They are able to make with their legs certain movements which seem very complicated as jumping, dancing, hopping on one leg running, but they fall as soon as they try to walk Can you conceive such an absurdity? For some time this disease which was called astasia abasia seems to be almost alone of its kind but soon physicians were obliged to recognise that there were many other paralysis belonging to the same type and that they were even frequent Some subjects are still able to walk but cannot stand Others have lost some functions of the hands They almost always forget their trade A needle woman can no longer sew An ironer can no longer handle an iron though they have no paralysis of the hand Frequently girls can no longer write at all or play on the piano Monsieur Babinski has shown such cases for the functions of the mouth The patient can no more blow or whistle while he can make all the other movements of the lips These examples are sufficient to prove to you that there are very often systematic paralysis in which a certain system of movements grouped by education separates from consciousness and takes the presence of its own These phenomena come much nearer to our somnambulic amnesia The oblivion of her mother's death which came upon one of our patients and of all the care she had taken of her during her illness was the loss of a system of images and movements which comes very near the oblivion of sewing or writing You understand that in these two cases the group and the more or less complex system are of the same kind Well if it is not too bold I will propose to you not to consider to play Bezier as an exceptional hysterical paralysis but on the contrary to make it the type of all the other hysterical paralysis The ensemble of the movements of the right hand is a system of images and movements exactly as the ensemble of the movements necessary to play on the piano Only it is a much more extended and above all a much older system It is the reason why it contains in itself and involves all the sensations of the hand whereas playing on the piano involved only the sensations And what about the paralysis of the two legs you will ask me It is in my opinion exactly the same The two legs form a unity not only anatomically but especially psychologically speaking Our ancestors, the animals constructed in their mind the association of the limbs of the same level, of the same segment These limbs have a common role to play such a segment enables us to stand such another to seize objects This system of images relative to the two legs is very vast It contains subdivisions as the system that concerns walking or jumping but it can be dissociated in its entirety Lastly, since we are making hypotheses we must not stop halfway Hysterical hemiplegia is a phenomenon of the same kind as Aesthesia or Abesia The movements of one side of the body also form a system We have a very clear idea of the ensemble of the actions of the right side as opposed to the ensemble of the actions of the left side No doubt you will tell me these great systems of sensations and images are at the same time anatomical systems which have a unity in the brain and in the spine I do not deny it by any means The fact that a system is psychological should not cause us to conclude that it is not at the same time anatomical On the contrary, the one involves the other When I begin to learn to ride a bicycle I voluntarily group together images depending on several centres which have never been grouped Consequently, I am very awkward After some time, I can maintain my equilibrium on a bicycle It means that these different images have associated together and regularly call forth one another It is very likely that this functional association corresponds to an anatomical association which has been effected among the different centres and that a new little centre has been formed in my brain the centre concerning bicycle riding It is even because this centre persists and develops that next year I shall be able to ride without learning again With regard to new functions we understand easily that the system is at once mental and physical But you should impress your mind with the belief that your ancestors, the monkeys, learnt to walk on two legs as you have learnt to ride a bicycle and that before the monkeys, there were other beings who learnt to systematise the movements of one side of their body and invented the right side and the left side This very old function has well organised centres but it is nonetheless a function that is to say a complete system of sensations and images Well, as the hysterical may lose while they have fits of somnambulism a little system of thoughts that emancipates itself which loss brings on two symptoms somnambulic agitation and amnesia So the same patient may in the same way lose through dissociation a great and old system of thoughts and sensations that of the right side or that of the two legs And this new dissociation will again manifest itself by two great symptoms First, by involuntary motor agitations which we studied in our last lecture in the form of careers and of more or less extended tics And secondly, by hysterical paralysis I don't insist on the details of these phenomena on the different degrees of these paralysis It is enough to have presented to you this general conception End of section 8 Section 9 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 Jeunet Lecture 9, The Troubles of Vision The Troubles of Different Perceptions Touch, Smell, Taste, Hearing The Total Dissociation of the Function of Vision Hysterical Blindness The Partial Dissociation of Vision Unilateral Amorosis The Contradictory Characters of this Amorosis The Dissociation of the Monocular and the Binocular Vision The Narrowing of the Visual Field The Dissociation of the Peripheric and Central Vision The Problem of Hysterical Hemianopsia Compared with Hysterical Hemiplegia Dischromatopsia The Troubles of the Movements of the Eyes You have just seen from our remarks on Hysterical Anesthesia that this neurosis may disturb the sensorial as well as the motor functions This remark is extremely important and the sensorial disturbances due to hysteria constitute a very considerable chapter of pathology In this summary review of the great symptoms we cannot follow this disease into the domain of each perception Moreover, what will be said about a particular sense can easily enough be applied to all the others On what sense must we particularly insist? What are the perceptions on which hysteria determines quite typical disturbances? We have already spoken of the tactile sense Besides, we may remark that disturbances of the tactile sense are not quite separate, that they are nearly always connected with disturbances of motion Remember this old remark of a French doctor to whom, in my opinion, justice has not been fully done Dr. Burk Anesthesia, he said, never exists without a myosthenia that is to say without muscular weakness No doubt, in certain cases the tactile perception may be disturbed only as perception in subjects who need their tactile sense to recognize objects, but this occurs seldom You may also observe disturbances of tactile localization particularly the singular phenomenon called alokiria, in which the patient always localizes on his left side what is done to him on his right side and vice versa Lastly, you may connect with disturbances of the tactile sense certain abnormal pains and sensations but deliriums always enter into these phenomena or at least associations of fixed ideas No more do I insist on the senses of smell and taste They are very often disturbed in hysteria but scarcely ever so in an independent way Their disturbances are nearly always associated with those of the functions of alimentation and breathing We shall find them again when we study the disturbances of the hysterical functions It would be more proper to devote a lecture to hysterical deafness to disturbances of hearing in these patients which are often associated with disturbances of speech but may also exist separately Beware of hysterical deafness It is frequent and, if I am a staked knot occasions very numerous errors of diagnosis To recognize it with reference to these troubles of hearing I am glad to indicate to you Dr. Walton, deafness in hysterical anesthesia published in The Brain 1883 To recognize this affection remember that it is a central and not a periferic deafness Rini's well known experiment will give you information concerning this first point When the deafness is periferic when it is due for instance to obstruction of the canal to a disease of the ossicles or to a disturbance in the aeration of the drum the patient keeps the central audition You may verify it by making him hear a watch or a diapason applied to his teeth or to the bones of his skull The vibrations propagated through the bones are still heard whereas they can no longer be transmitted by the air In central deafness it is just the reverse and the hysterical disease is connected with this last group This being once established you will be able to make the diagnosis by studying the motile and contradictory character of this anesthesia and by examining the evolution I regret not being able to insist any further on this curious symptom the study of which is now beginning to be in fashion But there is a sense so interesting from the point of view of hysteria and the alterations of which are so characteristic for the comprehension of this neurosis that I want to devote to it as much time as possible and it is the reason why our study on the hysterical disturbances of the perceptions must be, above all a study on the diseases of vision One You know now the general idea that directs us in the examination of the innumerable phenomena of hysteria It is the idea of dissociation This disease seems to have an analytic power It decomposes the enormous psychophysiological system, it separates its functions Nowhere is this dissociation more precise and curious than in the case of vision The reason is that vision is a very complicated function which is subdivided in numerous operations and which plays a great part in the mind Hysteria can affect on it every possible dissociation First it may separate at once the whole of the visual function from the ensemble of the mind This is the most radical and the rarest dissociation Then it may cause the visual function to crumble so to speak, dividing and subdividing it into its elementary functions doing away with one and sparing another with a cleverness that the greatest physiologist might envy You even see here an example of the services that hysteria may render to the physiologist by teaching him in what way composite functions are decomposed which he would be unable to analyse himself The first great disturbance we have just said is the dissociation of the ensemble of vision In other terms it is hysterical blindness This phenomenon is rare for it seems that the subject always keeps as much as possible the essential functions and loses only a part of the vision However the fact has been very often established as long ago as 1618 Le Poit pointed out this blindness Since then it has been studied by many authors and in this respect I especially draw your attention to the works of the French occulists such as Lundolt Borel and Parinot This total blindness comes unusually in consequence of accidents and it belongs to the phenomena of traumatic hysteria The following of the two latest cases I have observed A man 38 years old was busy cleaning a machine a rag full of grease and petroleum caught in a gear and lashed him on the face The face was only dirtied and he did not trouble about the accident He washed himself but he had much difficulty in clearing his skin and eyelids of these fatty substances Remark that nothing penetrated into his eyes and that he felt no pain in them However after an hour he seemed to see where a mist before him This mist grew thicker and two hours later he could no longer see at all His vision fluctuated a little on the morrow and the following days From time to time he could see a little chiefly with his right eye These fluctuations lasted for a month then they disappeared absolutely and for four years he remained quite blind Here is a woman 31 years old whose story is similar In a laundry where she worked she received in the face some water mixed in time in consequence of the explosion of a boiler Her skin was lightly burnt and her eyelids swelled she was in her menstrual period when the accident happened she felt very much agitated and very giddy During the first days she hardly dared open her eyes It was soon noticed that she could see no more the amorosis was complete for two years When I examined this patient there was already a slight restoration of the vision which was easily and rapidly completed In other cases the blindness is less serious It lasts a few days and disappears suddenly A woman of 27 has the following singular habit while reading she sees as it were a red flash of lightning which illuminates the room She shuts her eyes and when she opens them again she sees no more Once this accident lasted 12 days another time 7 another 8 Her sight comes back suddenly just as it disappears It is needless to tell you that when the blindness is thus complete the diagnosis is very difficult and that you cannot take too many precautions Of course you must first ask for a thorough examination of the vision made by a competent occulist You should beware of lesions of the fundus of the eye and of the optic nerve of hemorrhages of the vitreous body etc Inquire into the state of the pupillary reflexes Theoretically they must be quite normal in hysterical blindness It is a rule we have already seen It was so in the three cases of which I just spoke to you It is true you may have complications connected with the contractures of the iris but then do not be in too great a hurry to make a diagnosis Of course you will find a great help in the study of the mobility of the phenomenon if you can provoke it Sometimes this kind of blindness disappears absolutely in abnormal states in crises or in somnambulisms Then it is all right Lastly you will sometimes succeed with a contradictory character evident and in showing that in reality the hysterical can see though she maintains the contrary Professor Jolly of Berlin said in this respect Those children who seem not to perceive any light nevertheless avoid obstacles unexpectedly put before them They do not behave like people really blind They must have a kind of perception You recognise in this our subconscious perception the establishment of which assumes great importance here It is however true that complete hysterical blindness which happily is rare is always very perplexing to physicians Happily it is no longer so when we consider the incomplete and more frequent forms into which hysteria decomposes the visual function doing away with only one part of it The simplest and if I may say so the most amusing of these decompositions is unilateral amorosis which is simply grounded on the fact that man has two eyes and man is a system composed of two visions Very often you hear young people complaining that they see only with one eye They do not trouble very much however about this accident Usually they do not know its origin and have noticed it by chance Being one day obliged for some reason to keep their right eye shut they are quite surprised to find themselves in darkness You repeat the experiment and you recognise that they see quite well when they have both their eyes open but see absolutely nothing when one of their eyes is shut These observations are innumerable and they have given rise to many studies and discussions about hysteria It is perhaps one of the facts which served as introduction to the studies of experimental psychology The reason is that this amorosis presented itself in rather odd conditions and was for Oculus an irritating problem Why? There is nothing extraordinary in the fact that an eye is affected separately It is because we find here carried to the highest degree of hysterical anesthesia First this blindness occurs without any appreciable organic disturbance and without any impairment of the elementary function of the organ The eye is absolutely uninjured outwardly and inwardly Its important reflexes are quite unimpaired However you may not infrequently recognise a suppression of the reflexes of periferic origin I mean the corneal and conjunctival reflexes The touching of the conjunctiva or of the cornea with a bit of paper for instance will not bring on the spasmodic shutting of the eyelids We have there a reflex of superficial sensibility which may be disturbed But the pupillary reflexes to light and to accommodation are mostly perfect with a reservation of contractures of the iris of which I told you to beware In these conditions physicians are astonished that the subject cannot see In certain particular cases their distrust is still more justifiable as when for instance examination for recruits young men wishing to avoid military service maintain that they are blind of the right eye and that they are unable to take aim The army surgeon charged with the inspection has certainly a right to express some doubt when he does not recognise any objective disturbance in this eye and sees the pupil react to light as if the retina perceived quite well He invents subtle processes to find out what he thinks is a fraud The two prettiest of those processes are letters of Snellen and the box of Fless On an absolutely dark ground are pasted letters cut out of paper some blue others red To the eyes of the subject is applied a pair of eyeglasses, one of the glasses of which is quite of the same blue tint as the letters and the other of the same red tint Through the red glass which lets only the red rays pass through the red letters on the black ground can be seen But the blue ones become as black as the ground and cannot be distinguished from it The reverse is true for the blue glass The result is that in these conditions the right eye can read only one half of the letters and the left eye the other half A person who sees with both eyes instinctively completes one eye with the other and reads the whole word without difficulty In these conditions a one-eyed person can only read a part of the letters Now what does our recruit do? With the eyeglasses on his eyes he quietly reads all the letters on the black board The box of Fless is still more ingenious Here figure 12 is its schema The subject looks into a little box through two holes corresponding to his two eyes, D and G At each end of the box are two coloured spots, two wafers one red, R and the other white B for instance But the subject cannot see them directly He only sees their images in two little mirrors MM hidden in the bottom of the box in black paper and making an angle of 45 degrees with the bottom These mirrors cast the images of the wafers sideways in a strange way The object which in reality is seen by the right eye D appears on the left side in B and the object which in reality is seen by the left eye G appears on the right side in R Neither, however, of those wafers can be seen simultaneously by the two eyes How would a one-eyed man who has really lost his left eye conduct himself when asked to look into this box he would say It's the only one wafer, the white one B for instance but what astonishes me is that it appears on my left side Now usually I am not able to see on this side What will a malingerer do who sees with his left eye but pretends to be blind of this eye In reality he will see the two wafers but as he will think it necessary to suppress one he will of course suppress the one which appears on the left side the supposed blind side He suppresses the white wafer B and he declares that he sees only one wafer the red one on his right side Now as this wafer R can only be seen by the left eye which he pretends is blind the fraud is discovered How do our hysterical patients conduct themselves in presence of this box We must admit that they look very absurd Oftenest they naively say that they see both wafers You will understand that formally in these conditions they were generally accused of fraud It is strange to remark that our hystericals are not lucky Their accidents are such that they are nearly always mistaken for crimes or tricks Some were burnt on account of their fits or devil's claws Others were sent to prison in order to be cured of their amorosis However it may be these singular facts discovered by army surgeons had excited curiosity There was a time especially in France when the apparently insignificant little phenomenon of unilateral amorosis was intensely studied With the researchers of that period the names of Reignard, Parinot, Bernheim and perhaps also mine if you will allow me to recall it To the preceding experiments many others of much the same kind have been added You know the old experiment of the physicist Prusta If the subject looks at an object with both eyes open and if you press slightly on one of his eyes he sees two objects instead of one simply because the object is no longer painted on the concording points of the two retinas If in the same conditions without touching the eyes you put a prism before one eye the same phenomenon takes place the object is doubled Of course this doubling implies the existence of two eyes and two visions Nothing of the kind takes place if the experiment is repeated with a one-eyed person You can verify it yourself by shutting one eye and slightly pressing on the other The object moves but is not doubled Well in the unilateral amorosis of hystericals all these experiments and many others of the same kind give the same results as with normal subjects who see with both eyes The explanation based on fraud is very simple perhaps too simple in the case of persons who are not recruits and have not the least interest in giving themselves out to be one-eyed and must even pay the oculus when they take advice With a more attentive observation this first interpretation of things was given up We have all recorded our word on this question Of course Mr. Bernheim spoke of suggestion I have myself insisted on the subconscious sensations which continue to exist in certain cases though the subject has no personal perception of them But now I acknowledge that Mr. Parino has given the best formula of this special fact In a pretty disquisition on vision he showed that the existence of the two eyes and their position gave birth to two different visions First there is the monocular vision either separate or alternating which is the only one with many animals with horses whose eyes are on either side of the head They can look to the right or to the left they can alternate but that is all With animals such as man monkeys and some dogs whose two eyes are nearly on the same plane things are more complicated These beings may have not only the preceding monocular and alternating vision but also another vision called the binocular vision This vision consists in the synthesis of the two preceding ones which enables us to see only one object with two eyes This vision is an improvement on the preceding one in that it allows us to see the same object more clearly permits fixity and gives the appearance of relief It is the starting point of the experiment with the stereoscope Generally we make use of this vision but we retain the possibility of using the inferior vision which we utilize in many cases sometimes involuntarily to see sideways or when one eye is tired sometimes voluntarily by shutting one eye with a pistol or looking in a microscope Now it is very curious to see that hystericals are able to affect the dissociation of these two visions, the existence of which we scarcely suspected They mostly lose, and this is an accident that was not known They lose the binocular vision, that is to say the higher, truly human vision Only they do not complain of it It is the medical examination that will reveal to you this unexpected thing that an hysterical cannot look with a stereoscope and is unable to perceive the relief in Ducour d'Oran's anaglyphs But sometimes also they lose the monocular vision of one eye while keeping the binocular vision The preceding experiments by appealing to the binocular vision by making it necessary placed hystericals in conditions in which their disturbances did not appear You see that this singular amorosis has already dissociated the visual function in an amusing manner Setting apart now the binocular monocular function 2 Let us continue the examination of the hysterical disturbances of vision and we shall see that dissociation will still gain ground and enter into more delicate functions The most important symptom to be known now is the famous narrowing of the visual field on which we ought to be able to dwell for a long time You know that human sight owing to the dimensions of the retina extends over a certain surface The extent of the surface an eye can see simultaneously without moving is called the visual field No doubt all the points of this definition should be discussed It is not quite certain in particular that all the points of the visual field are seen simultaneously in a single act of attention But this definition is practically sufficient If you measure the visual field of a normal subject with those instruments which are called compimeters and perimeters the description of which would be too long You obtain the following figure which I have presented to you in this picture of the visual field of the right eye R in figure 13 The field has the form of an irregular circle more extended on the external and on the inferior sides where it measures almost 90 degrees which means that the angles formed by the fixation point, the hypha vertex and the limit of the visual field is of 90 degrees The circle is narrowed on the internal and superior sides where it is barely 60 degrees This very natural diminution is due less to the obstacle formed by the nose and the eyebrows Well, if you examine the visual field of hystericals you will recognize a very remarkable fact which very likely exists only in this neurosis The visual field is narrowed concentrically The extent of the simultaneous vision becomes smaller The field is almost circular at 30 degrees or 20 degrees as you see in the left eye of the figure 13 Sometimes the field has only 10 degrees or 5 degrees Nothing is left but the fixation point It is true that a disease of the retina pigmentary retinitis and perhaps also certain forms of chronic glaucoma give rise to an analogous phenomenon but then in the first place the visual field has an irregular form and in the second place there are visible lesions of the fundus of the eye As regards the diseases of the nervous system it has been said that this concentric contraction of the visual field is found in epilepsy and in disseminated sclerosis This has been recognized to be false so this symptom becomes one of the most important of hysteria not for the patient of course but for the physician who makes use of it as a characteristic sign This contraction of the visual field has interesting psychological properties It is quite a matter of indifference to the subject and this is a curious fact on which I have elsewhere insisted As a matter of fact nothing is so inconvenient as a real contraction of the visual field I know how the unfortunate people who are affected with chronic glaucoma complain of being no longer able to glance over the newspaper because they see only one word or one syllable at a time These patients who however see very well in the centre can no longer find their way in the street Hystericals who have an exceedingly small visual field run without in the least troubling themselves about it This is a curious fact to which I remember having attracted the attention of Charcot who had not remarked it and was very much surprised at it I showed him two of our young patients playing very cleverly at ball in the courtyard of La Salle Petrière Then having brought them before him I remarked to him that their visual field was reduced to a point and I asked him whether he would be capable of playing at ball if he had before each eye a card merely pierced with a small hole It is one of the finest examples that can be shown of the persistence of subconscious sensations in Hysteria Besides I had shortly afterwards making a still more precise experiment on the same point A young boy had violent crises of terror caused by a fire and it was enough to show him a small flame for the fit to begin again Now his visual field was reduced to 5 degrees and he seemed to see absolutely nothing outside of it I showed that I could provoke his fit by merely making him fix his eyes on the central point of the perimeter and then approaching a lighted match to the 80th degree by using suggestions of which we shall speak later A subject has received the order which he obeys unconsciously to raise his arm as soon as he sees a paper before his eyes The suggestion is executed even if the paper is put at the 80th degree far out of the limits of his conscious visual field You see that this hysterical disturbance has not quite done away with the ocular perception in the lateral parts of the retina It is again a dissociation like the preceding ones We have two visions, the central vision which is accurate and attentive and the periferic vision which is vacant and of secondary importance You see that the hysterical keeps only the first consciously the second persisting quite subconsciously I cannot end this examination of the visual field without saying a few words on a very curious problem in which I took a particular interest Can the visual field be modified only in this way? In other words, is the contraction always concentric? We have not the time to examine the different faces of this problem I shall only insist on one Can we meet in hysteria with the hemiopical visual field or with the phenomenon of hemionopsia? The question is more important than it looks Hemionopsia, that is to say the vision of only one half of the visual field is a frequent phenomenon often succeeding cerebral lesions The section of the optical nerves glaceolase radiations the lesions of the occipital lobes of the cuneus do away with the vision in one of the vertical halves of the retina and you know that the lesion is distinguished by the place and form of this hemionopsia After some fluctuations physicians had come especially after Gilles de la Tourette's work to deny absolutely the existence of hysterical hemionopsia and to reserve this symptom for organic lesions This decision is not tenable a priori I do not see any reason why the functional disturbance of hysteria should not realize the same symptoms as the organic destruction of the center of the function Every function as we said when treating of paralysis finally has when it is old its organic center and in certain cases the functional and organic disturbances may be alike Besides, did we not unquestionably establish this fact when we studied hemiplegia? There is no disturbance more symptomatic of a great lesion than motor hemiplegia and nobody denies that it takes place in hysteria It is the same with hemionopsia and in despite of theories we must recognize a fact if it exists After the preceding period of negation Monsieur Desjardins in 1894 and I myself in 1895 presented the first authentic observations of functional hemionopsia I think I gave the demonstration of the hysterical character of this syndrome by showing the existence of subconscious sensations in the apparently suppressed part of the visual field, figure 14 Since then I have had the opportunity to show other equally distinct cases a schema of which you see here figure 15 In a paper which appeared in the brain in 1897, W. Harris presented analogous cases He pointed out in particular as I had done myself some cases in which hysterical hemionopsia begins with amorosis It is at the time of the recovery from an hysterical amorosis that the visual field takes in many cases a hemionopsic form for some time I refer you with respect to this to my paper on transitory hemionopsia En cas d'hémyanopsie hysterique transitoire La presse médical October 25, 1899 page 241 These phenomena of hemionopsia should not, I think, astonish us beyond all measure and induce us to transform our general conception of the neurosis The study of the anatomical localization of the vision leads us to conceive a particular distribution of vision on the retina Suppose a man having only one eye in the middle of his forehead, like the cyclops or, if you prefer it, two eyes placed one under the other in the middle of his head Each of these eyes will have a right half and a left half, like the rest of the body and a distinct function of the vision to the right and of the vision to the left will form, comprising the two right halves and the two left halves of the two eyes Later the two eyes separated and disposed themselves otherwise But the function has remained the same and there is still now a function of the vision to the right and another of the vision to the left These functions may become dissociated in hysteria just as all the others Only as these functions are very old the dissociation seldom goes so far It exists sometimes, however and hysterical hemionopsia is a profound accident which can be compared to motor hemiplegia 3 You can now apply the same method yourselves to the interpretation of all the other visions which are still very numerous I will only point out to you discromatopsia, that is to say the loss of the vision of colours It frequently happens that hystericals while still having a good visual acuity cease to perceive colours or at least certain colours violet, blue and green seem to vanish first Red appears to be the most persistent colour This fact was formally considered as accounting for the fondness of hystericals for red They are fond of dressing in red They are fond of dressing in showy colours of putting red ribbons in their hair The reason is, it was said that these colours are the only ones they continue to see There is some exaggeration in this and it is more likely that moral reasons such as the very curious need they feel to be noticed play a more considerable part in this phenomenon I think also that this loss of colours has been examined with exaggerated accuracy A visual field of colours has been drawn and the efforts have been made to prove that in hysteria this visual field is modified in a regular manner the visual field of blue for instance becoming in this disease smaller than that of red It may be so but I advise you to be cautious in this study First of all the perception of colours at the periphery of the visual field changes very much even in a normal person according to all kinds of conditions and in particular according to the lighting Besides, in hystericals the influence of the association of ideas plays an enormous part in the perception of colours A young woman saw red flowers put on her father's coffin It made her very angry because these flowers constituted a political emblem She now holds red in abhorrence and has on that account a very fine perception of red and a visual field for red more extended than for white Special account should be taken of the part played by perceptions and ideas in the dissociation of the small details of vision particularly in the accidents of painful vision of fears of certain colours of photophobia which I merely point out to you I wish to insist before ending this lesson on some other accidents the types of which I must at least indicate to you These accidents are the disturbances in the motion of the eyes about which you will notice as many complications as about vision itself Let us not speak of the movements of the eyelids You will again find here the phenomena of paralysis, ticks, contractures which we have already studied But let us dwell a little on ophthalmoplegy such as was pointed out by Le Breton, Ballet, Bristo and especially by Koenig in 1891 because it is again an interesting phenomenon as regards interpretation Certain subjects seem to become unable to move their eyes They have an absolutely fixed look which seems strange Such fixity of the look is often connected with an automatic fixation of certain objects or with certain hallucinations This is the most frequent case and when one can divert the subject from his fixed idea he looks in every direction But in certain cases which have as yet been rather seldom described, it is not so The subject looks at nothing fixedly He can look at different objects but only by turning his head It is his eyes that do not move Earlier authors, among them Morax and Parinot showed that this immobility is purely in connection with the will If the subject wants to look sideways if he is asked to do so if he thinks of it, he cannot manage it But do not think it is an absolute immobility It is sufficient to let an object fall noisily near him without warning him and his eyes will immediately and rapidly turn in this direction In a word, here as always the subconscious and automatic motion is retained, whereas the voluntary motion is lost These disturbances of the movements of the ocular muscles may be less simple than the symptoms in irregular contractures Then, of course, the eyes will deviate in one direction or the other and you will have all possible forms of strabismus, the diagnosis of which is also important Lastly, the disturbance of the ocular motion may affect the internal muscles and particularly the muscles of the crystalline lens Here again we have a function that becomes dissociated, that of accommodation Instead of being able to accommodate their eyes to very various distances 50 cm to the horizon, these patients have only a very limited accommodation Their eyes are an optical instrument in crystal, adjusted to a given and immutable distance When you find the exact distance to which they are accommodated 50 cm, for instance, or 1 m an object placed at this distance is seen quite clearly but it is no longer seen at all if you put it nearer or farther This spasm of accommodation is connected with a great many hysterical disturbances on which I am very sorry not to be able to dwell Monocular Diplopie Polyopie Micropsia, Micropsia, etc Now objects are seen double or triple and that by a single eye which from the point of view of optics seems quite paradoxical Now they are seen too large or too small or deformed in a thousand ways I have described in this connection some very odd phenomena Objects appearing to the subject too big or too small in one of their halves only and quite normal in the other a kind of hemimacropsia I shall only point out to you if not two theses at least two tendencies in the interpretation of these odd phenomena Monsieur Parinot in his school sought a physical interpretation of the accidents in the contracture of the crystalline lens Others attribute a more important part to psychological phenomena You have here a fine field open to your personal researchers You see what would be the richness that spares upon the hysterical disturbances of visual perceptions Let us only retain the two following general notions First, the disturbance is never very profound and always bears solely on attentive and voluntary perceptions It always spares the elementary sensations, reflexes, anatomical movements Second, the disturbance seems to consist in a very curious separation of the different functions united in the vision which all at the same time separate from personal consciousness and seem to proceed henceforward on their own account End of section 9