COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 29772 RC532 .F83 1913 Psychopathology of l ^^ tm f^ ilMLTH »0IimtKS MRumy Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/psychopathologyoOOfoxc Psychopathology of Hysteria CHARLES D. FOX, M. D. fj& y^fi^^fr^ RICHARD G. BADGER THE GORHAM PRESS BOSTON COPYRIGHT I913 BY RICHARD G. BADGER All Rights Reserved c^ THE GORHAM PRESS, BOSTON, U. S. A. PREFACE Than hysteria, probably there is not any dis- ease which is more interesting, which has been more misunderstood, which is capable of caus- ing a greater diversity of manifestations, and about which more has been written. Its absorb- ing interest is due mainly to the peculiar char- acter and unlimited possibilities of its expres- sion. Surely, a disease is worthy of the con- sideration which has been bestowed upon hysteria when it is capable of causing such diverse s^nnptoms as paralysis, con^Tilsions, blindness, multiple personality, and which can occur in epidemics that, in the past, have caused greater disturbance to whole nations than a war would have occasioned. Its history and literature, which would fill a spacious library, show that from the days of the Grecian oracles, or of the sibyls of even more distant ages, to the present trance mediums, the unfortunate Adctims of the disease have been subjected alter- nately to persecution as witches and demons, or to devotion as the inspired source of wisdom and of supernatural knowledge. It is only recently, and through psychologic means, that hysteria is beginning to be under- stood. The credit for elucidation of problems of the disease is due principally to the French. In fact, the psychology characteristic of their 4 PsycJiopathology of Hysteria nation truly may be said to have been based npon studies of the abnormal psychology of hysteria. The present era of enlightenment con- cerning the disease may be considered to have been initiated by Bernheim. It is his interpre- tation — which to a great extent has stood the test of time — of the phenomena of hypnotism that enabled this earnest investigator to grasp the mysteries of hysteria in a manner which never before had been possible. In spite of the greatest opposition and acrimonious contro- versy, his views of the causation and nature of many of the symptoms of hysteria are obtaining at last the recognition and acceptance which they deserve. Babinski, for instance, the most ardent of the revisionists, eagerly contends now, as Bernheim insisted many years ago, that suggestion is of the utmost importance in the genesis of symptoms of the disease. It is to Janet that credit is due for the theory that dis- sociation of the personality is the underlying mechanism of hysteria, and also for innum- erable and valuable experimental researches concerning the psychic nature of the dis- turbances of sensory perception. Of great im- portance, too, was his exposition of the somnam- bulistic qualities of many of the manifestations. In this country, the most fruitful investiga- tions haA'-e related to dissociation of the person- ality; a subject which has received considerable attention. Probably the most extensive and the Preface 5 most valuable contributions on the clinical study of this condition have been made by Mor- ton Prince and by Boris Sidis. Finally, the studies of Sigmund Freud, sub- jected at "first to neglect and later to opposi- tion, now are exerting an enormous influence in revising our conceptions of hysteria. The ex- haustive manner in which this Austrian studied his cases is remarkable. Not only have his ob- servations been a revelation of the importance of psychic insults in the etiology of the disease, and of the remarkable manner in which disso- ciated or submerged memory complexes dom- inate the hysteric, but they have been of the greatest consequence in showing how normally one's actions and mode of thinking are largely determined by motives of which one is uncon- scious. In spite of the multitudinous volumes in Avhich the disease, or certain of its symptoms and mental states are described, but few English books have appeared in which the dis- ease as a whole has been treated on the basis of the results of modern psychopathologic re- searches. In the belief that such a volume may not overburden the already great ranks of those dealing with the disease, the author. has modestly attempted to meet this deficiency. In conclusion, this work is based upon, in fact is an exposition of, the modern conception of hysteria as enter- tained by the foremost contemporary students 6 Psychopathology of Hysteria of abnormal psychology. A not inconsiderable amount of personal experimentation and clinical investigation has been drawn upon, and, not desiring the responsibility to rest upon the' shoulders of others, it is necessaTy to ac- knowledge, also, that some personal views con- cerning the disease and its symptoms have been incorporated. Philadelphia, Pa. CONTENTS CHAPTER PAGE Preface 3 I Preliminary Considerations 11 II Etiology 31 III Disturbances of Sensory Perception.. 56 IV Disturbances of Sensory Perception : The Special Senses 89 V Visceral and Circulatory Derange- ments 136 VI Psycho-Motor Disorders 173 VII Psycholepsy 212 VIII Alterations of Consciousness 268 IX Multiple Personality and Amnesia. . 312 X Hysteric T empei^ament , Suggestibil- ity, Delusions, Insanity, Theories . . 354 XI Diagnosis, Prognosis, Treatment ... . 394 PSYCHOPATHOLOGY OF HYSTEEIA PSYCHOPATHOLOGY OF HYSTERIA CHAPTER I Preliminary Considerations THE normal personality may be regarded as a highly mutable synthetic product of memories of past instruction and experiences as modified by present per- ceptions, either of external stimuli — exogenous — or of the countless number of various sen- sory impressions arising as a result of the activ- ity of the different structures of the body — endogenous or coenesthetic. By reason of the modifying influence of present external stimuli one's personality seems to undergo the greatest variation in accordance with the difference in his reactions to diverse environments; the mode of reaction suitable for one kind of environment being of pathologic import if displayed in an- other. As the memories of all experiences are fused with the personality, and as memories are never destroyed except by gross organic disease of the brain, every event in a person's life inevi- tably exerts an influence upon his individuality — upon his manner of reacting to his environ- ment. 11 o 12 Psychopathology of Hysteria In connection with the laws that "all nervous function is conditioned upon sensation," and that all sensory impressions invariably become transformed into immediate or delayed move- ment, or action, W. K. Walker states : ' ' That which is present in the mind at any given in- stant is therefore due to its past experiences; to previously experienced sensations, impulses, ideas, and emotions. These 'stored up' 'sensa- tions tend to final transformation into action' — that is, either action or restraint of action, — not only according to the laws governing all neural and mental manifestations in general, but, in particular, with the gradually acquired habit of reaction of the individual organism." (Med. News, Jan. 28, 1905.) By saying that we have forgotten something, we mean only that we are unable at the time to reproduce the memory — to raise the memory above the threshold of consciousness. In spite of our efforts to recall them, such memories re- main dormant only because we have been unable to obtain the proper association of ideas, and at any subsequent time reproduction can be effected, providing that the proper stimulus is called into play. Now, even though events have been "forgotten," still their dormant memories continue subconsciously to influence the actions, feelings, and mode of thinking of the individual. We act more or less in accordance with our feel- ings and our general conceptions, and though Preliminary Considerations 13 we may forget in what manner these have been originated, vet the influence of the underlying forgotten occurrences persists. One may not re- member just how the knowledge w^as first acquired that heat may cause pain, but the deficiency in our ability to reproduce these memories does not impair the value of a con- ception which has largely been the product of painful experience. The acquisition of knowledge, through personal experience, requires at first the conscious memory of particular causes and effects, but later, these details subside below the level of consciousness, unless the occurrence has been noteworthy, and only general conceptions remain. Consequently, my knowledge that fire may cause pain does not necessitate recollection of the many times when fire has caused me to experience pain. In this respect, then, a certain amount of submergence of memories is a normal concomitant of psychic development, and its value lies in the freedom which it insures from being mentally en- cumbered mth countless and useless facts. Ac- cepting as true these well known characteristics of the human mind we may conclude that, excepting possible hereditary factors and the effects of education, an individual's personality is of a certain nature, mainly because of the character of memories of countless experiences in which he has taken part; these memories, whether conscious or submerged, becoming 14 Psychopathology of Hysteria integrals in the continual growth of the person- ality. It is for this reason that one evil act paves the way for another, and that no one can do wrong once with the intention afterwards to forget about the unpleasant act, and thus be free from harmful consequences. Each act or thought of an individual tends towards the recurrence of similar acts or thoughts — the production of a habit. In terms of materialism, this fact is explained as being the result of* lowered synapsal resistance. Otherwise, a cer- tain kind of reaction having occurred in re- sponse to a given stimulus, we assume that, whether conscious or dormant, the memory of the experience largely determines repetition of the same reaction when a similar stimulus occurs. The economics of this tendency are easily grasped, for all forms of normally auto- matic activity are but examples of acquired re- flexes due to habitual modes of volition, an i if it were not for such automaticity one's atten- tion would constantly be employed by the performance of the ordinary acts of life, at the expense of higher forms of activity and of acquisition of knowledge. To the normal process of forgetting, let us apply the term dissociation with the under- standing that this designation implies merely that though certain memories have subsided below^the level of consciousness their influence Preliminary Considerations 15 still persists in that they exert a continual ef- fect upon modes of thinking and of acting. In discussing this question Ernest Jones has writ- ten : ' ' We are beginning to see man not as the smooth self-acting agent he pretends to be, but as he really is, a creature only dimly conscious of the various influences that mould his thought and action, ... " (Rationalization In E very-Day Life, Jour, of Abnormal Psych., Vol. 3, p. 168.) No matter if one does think that he knows the mechanism and all the motives of any given act or thought, these have been originated or modified by memory complexes which are more or less completelj^ dormant. Upon becoming acquainted with an estimable person, and without knowing the cause, one may experience towards him an '' instinctive" dislike. Later, the true reason flashes into mind: it was because the object of aversion resembles another individual who had wronged him in some manner. If we should stop a moment to consider one of our most cherished ideas, perhaps we would not be able to recall the reasons which had led us to the adoption of that particular belief ; yet we know that there were a number of factors which determined its growth, and which con- tinue subconsciously to control us. Often we hear some one honestly make a positive asser- tion with all the assurance that would be war- ranted by thorough knowledge of the subject. 16 Psychopathology of Hysteria Let a question arise concerning the grounds for his convictions and at once he is at a loss for data with which he can justify his assertion, even though he knows that formerly he was cognizant of these. Our supposed knowledge of the motives for our thoughts and actions is exceedingly super- ficial and illusory, and constantly we are the unconscious slaves of our past. In this sense, at least, we have not any freewill, and we are but the automata with superadded consciousness about which so much has been written ; reacting as we do to our present environment, according to the influence, more or less unconscious to us, of the past surroundings in which we have been placed merely as a matter of accident, as far as our own inclinations were concerned. In the last few years even more acceptably might have been written Spinoza's celebrated remark to the effect that '^ men think themselves free, inasmuch as they are conscious of their volitions and desires, and never even dream in their igno- rance, of the causes which have disposed them to wish and desire." (Ethica, Elmes trans.) To illustrate the agency of subconscious mem- ory complexes there is no better example than the "Frost King" episode in the case of Helen Keller. "When twelve years of age Miss Keller wrote a story, which she called the "Frost King," and it was published in one of the Perkins's Institution Reports. Afterwards it Preliminary Considerations 17 was discovered that this story was a duplicate in ideas — and in places even words — of another story which had been read to her three years before, or a little over one year after she had acquired the faculty of language — the sign lan- guage. 3Iiss Keller was totally unable to re- member the original, and, until convinced by the facts of the case, she was equally positive that hers was entirely the product of her o^vn mind. (The Story of My Life, 1903.) It must be remembered that this excellent instance of unconscious plagiarism is an unusually exag- gerated one, because of the limited amount of knowledge possessed at that time by Miss Keller, and because of the fact that by reason of cer- tain mental characteristics and of the difficulties under which she labored what she had once learned subsequently tended to almost complete reproduction, without, however, being coupled ^vith the associated ideas of source. For this reason a thought might be considered by her to be original, when, in reality, it arose from her subconscious store-house of what had been read to her. The Hindoo cycle, in the case of Helene Smith, almost parallels the above occurrence both in the accuracy and in the unconsciousness of the plagiarism. (Flournoy: From India to the Planet Mars, 1901.) The tendency to unconscious plagiarism is not abnormal; nor is it unusual. Let one who is open to conviction read an authoritative book. 18 Psychopathology of Hysteria If he reads much, a year later he may be unable to recall the facts and theories which it con- tained, but, nevertheless, these continue to exert an influence in determining his own conceptions, though he may be unaware of the fact. A year or so later let him read the book again, and he will be surprised to find that beliefs which he thought not only were original but were of re- cent origin, were reallj^ derived from his first reading of the work. The following quotation from Hammond is a fine example of the activity of normally forgot- ten memories: ''A friend has related to me some circumstances in his own case similar to the above, and illustrating the same points. In the course of his practice as a lawyer, it became necessary for him to ascertain the exact age of a client, who was also his cousin. Their grand- father had been a rather eccentric personage, who had taken a great deal of notice of both his grandsons — his only direct descendants. He died when they were boys. My friend often told his cousin that if his grandfather were alive there would be no difficulty at getting at the desired information, and that he had a dim recollection of having seen a record kept by the old gen- tleman, and of there being some peculiarity about it which he could not recall. Several months elapsed, and he had given up the idea of attempting to discover the facts of which he had been in search, when, one night, he Preliminary Considerations 19 dreaiTied that his grandfather came to him and said: 'You have been trying to find out when J was born; don't you recollect that one afternoon when we were fishing I read you some lines from an Elzevir Horace, and showed you how I made a family record out of the work by inserting a number of blank leaves at the end? Now, as you know, I devised my library to the Eev. . I was a d — d fool for giv- ing him books which he will never read! Get the Horace, and you will discover the exact hour at which J was born. ' In the morn- ing ail the particulars of this dream were fresh in my friend's memory. The reverend gentle- man lived in a neighboring city ; my friend took the first train, found the copy of Horace, and at the end the pages constituting the family record, exactly as had been described to him in the dream. By no effort of his memory, how- ever, could he recollect the incidents of the fish- ing excursion. '^ (Sleep and Its Derangements, 1869.) What is of particular interest in this case, is the fact that the dissociation was so complete that conscious recollection was impos- sible, yet complete synthesis was obtained dur- ing the dream. Furthermore, in the waking state, the lawyer was totally unable to recognize the personal nature of the memories which had been recovered. Now, let us suppose that independently of consciousness dissociated, or submerged, mem- 20 Psychopatkology of Hysteria ories become integrated with one-anotlier, or that a massive dissociation of complexes from consciousness should occur, in consequence of some psychic insult, and that the dissociated fragment of what constituted the more or less normal personality took on activity irrespective of the present states of consciousness of the Individual. Such processes naturally constitute pathologic disaggregation of personality, and if the offshoot were massive enough, a secon- dary personality would be produced. As a working hypothesis let us postulate that all the functional neuroses, or more prop- erly psychoses, are dependent upon disintegra- tion of personality, and that as such they are merely the result of pathologic exaggeration of what is a normal component of psychic devel- opment. Then neurasthenia, psychasthenia, hys- teria, and multiple personality would be clinical syndromes having a common origin; the under- lying disintegration being rudimentary in the first instance, more decided and often suspected even by the patient in the second one, still more developed and not surmised by patients suffer- ing with the ordinary types of hysteria, and massive enough to be complete in the condition known as multiple personality. By means of this prevalent and well founded hypothesis, almost every symptom of hysteria can be explained as satisfactorily as the mani- festations and pathologic changes of any organic Preliminary Considerations 21 disease. Accordingly, amnesia results from ab- normally complete or massive dissociation from consciousness of certain memories, and the proof of its functional character can readily be adduced by means of reproduction of the lost memories through the agency of certain well known procedures. Anaesthesia, analgesia, amau- rosis, deafness, etc., would imply, on the other hand, that sensory perceptions had not become integrated with consciousness — that they had been appropriated, so to speak, by the dissociated components of the former personality. Experi- mentally, this explanation has been amply verified. After adducing experimental observations of Pierre Janet, Paul Janet, Binet, Pitres, and Bernheim, concerning phenomena of hysteria, no less authority than William James states: "It must be admitted, therefore, that in certain persons, at least, the total possible consciousness may he split into parts luhich coexist hut mutu- ally ignore each other, and share the objects of knowledge between them. More remarkable jstill, they are complementary. Give an object to one of the consciousnesses, and by that fact you remove it from the other or others. Bar- ring a certain common fund of information, like the command of language, etc., what the upper self knows the under self is ignorant of, and vice versa.' ^ (The Principles of Psychology, Vol. 1, p. 206, 1905.) 22 Psych opathology of Hysteria At best, our knowledge of mental processes is superficial. Moreover, the difficulty of describ- ing normal and abnormal psychic phenomena is great. Any language necessarily must be a faulty vehicle for conveying the thoughts of one individual to another. A group of words is in- capable of reproducing in one person the exact conceptions of another. To this difficulty is added one's inability to describe briefly and accurately any process. Suppose we subject a remark to the same kind of criticism that would be attracted by the description of a mental pro- cess. By reason of poverty of words and in- exactness of verbal representation we say briefly that a cigarette is smoking, and that a man is smoking, or that the paper burns, and that he is burning the paper. In reality, the man neither smokes nor burns the paper, and, to say nothing of his own part in these acts, these phrases are most superficial and condensed representations of a variety of most complex chemical processes. In the same manner causation always must be obscure. Wliat was the cause of destruction of the paper? The immediate one was oxidation. This was superinduced by heat which the man had applied. But then the endless chain arises concerning the causes of the man wishing to destroy the paper that was not destroyed, but whose chemical components were merely disso- ciated, to be recombined in a different manner and with the addition of oxygen. Preliminary Considerations 23 In describing tlie psychic mechanism of hys- teria we say that the disease is caused by disso- ciation of consciousness, and that this process causes increased suggestibility, then, in the next breath, that further dissociation may result as the effect of this symptom. These statements only imply, however, that a vicious circle is formed. The same process is apparent in the use of hypnotism. By means of suggestion a subject is hypnotized. The increased suggesti- bility produced by this state of dissociation then enables us to induce more readily further disso- ciation. Two individuals being exposed to the same psychic stress, one may develop hysteria, and the other psychasthenia ; the difference in the two syndromes being equivalent to difference in the modes of feeling, thinking, and acting of the two persons. The condition of the one who developed psychasthenia is said to be due to dissociation of the personality and that as a Consequence, fear and expectant attention appear as symptoms. Then, like the vicious circle of hysteria, these symptoms, by causing further dissociation, induce various other phenomena. In a gross materialistic way the pathologist is satisfied when, with the assistance of stains, microscope, and other laboratory apparatus, he finds that certain lesions occur more or less con- stantly in some disease. He seems to be con- tented with this knowledge — ^he has discovered 24 Psychopathology of Hysteria the cause of a disease — yet the discovery of these lesions does not explain the cause for the same reason that dissociation of personality does not account for the production of the psy- choneuroses. There is an inherent tendency for one to believe that he knows much about a dis- ease merely because he possesses some knowledge of the anatomical changes which are really con- comitants or secondary causes. To say that lesions of the islands of Langerhans are the cause of diabetes does not explain the disease. Not only is there a cause, or causes, for this sclerosis, but there may be a whole succession of pathological processes that precedes its develop- ment. The greater part of pathology consists only in a superficial knowledge of terminal pro- cesses, and the only advantage it has over psy- chopathology is that scales, test tubes, and a microscope lend an aspect of scientific precision which cloaks in a satisfactory manner our real ignorance of causality. In spite of what the materialistic pathologist would have one believe, psychopathology is not entirely a matter of groundless theories based upon the morbid in- trospection of deviates. With the assistance of association reaction time experiments, the psy- chogalvanic reflex, pulse reactions, etc., the psy- chologist can '' measure" the emotions and de- tect and reveal subconscious ideation. In the early studies of hysteria, and, in fact, even to the present, it was customary to describe Preliminary Considerations 25 a number of sjrmptoms as characteristic, or stig- matic, of the disease. Among the most import- ant were anaesthesia and concentric contraction of the visual fields. We are beginning to under- stand, now, that these '"stigmata" are only ac- cidental phenomena, which, except when created by reason of faulty methods of examination, are rather unusual if not rare. It was only by rea- son of the suggestive technique of the ordinary examination that, until recently, the occurrence of ''stigmata" was so common. The recent discussion of hysteria before the Paris Neurological Society brought out the quite general recognition of the fact that the symptoms of the disease, as many have intimated for years, are caused by suggestion, and that what have been called the stigmata usually owed their origin to examinations by physicians who dis- regarded, or were unaware of, the effects of sug- gestion in causing the conditions which they sought. Certain members averred that by at- tempting to avoid the pathogenic effects of sug- gestion during their examinations of hysteric patients, they no longer find anaesthesia and the like, provided that the patients had not been examined previously by others. In fact, the tendency of some of the members seems to have been to ascribe to suggestion all the symptoms of the disease. According to BabinsM, for in- stance, a patient is not hysteric whose symptoms are incapable of being reproduced by suggestion 26 PsychopatJiology of Hysteria and removed by persuasion. Yet Babinski was one of those who formerly opposed the conten- tions of Bernheim, to the effect that the stigmata of hysteria are merely the product of suggestion. Consequently, his present views possess greater significance than if he had upheld the theory from the beginning. If it is desirable to establish stigmata of hysteria let us confine ourselves to the only symptom which is characteristic of the disease. The only one whose presence is at all constant, and whose pathogenic importance cannot be overestimated, is pathologic increase in sug- gestibility. This veritable stigma has been a prolific cause of blunders in the past studies of the disease. It is by reason of its agency that any enthusiastic investigator ordinarily and un- intentionally can cause whatever he may wish to find in support of his views ; no matter what these may be. Thus, one can appear to demon- strate that the symptoms of hysteria are due only to intentional simulation, or that any symptom is essential to the existence of the disease. At la Salpetriere, for instance, there was created a typical epidemic of hysteric con- vulsions which influenced for years the study of hysteria, and which was the effect solely of an elaborate suggestive training and of psychic contagion. Since Bernheim 's recognition of the danger of misinterpretation of the occurrence of symp- Preliminary Considerations 27 toms of hysteria through the raore or less un- conscious use, or rather abuse, of suggestion by the observer, the understanding of the disease has advanced considerably at the expense of numerous theories and classic experiments which owed their very existence to suggestion. Many years elapsed, though, before the full sig- nificance of the well known cautionary "be- ware of suggestion" of this pioneer became ap- preciated. The delay was due to the power- ful antagonism exerted by Charcot in conse- quence of his total disbelief in the effects of suggestion. In fact, the experiments of Char- cot and his followers upon hysteric patients were rendered valueless by reason of their dis- regard of suggestion. To no other factor than ignorance of the possibilities of suggestion can be ascribed the ludicrous experiments and theories of Luys.* and others of the Salpetriere school, concerning the wonderful effects of magnets, of metals, and of medicine in sealed glass tubes. It has been demonstrated conclusively, that because of this increased susceptibility to sug- gestion, so invaluable for therapeutic purposes, prolonged, unnecessary, and repeated neuro- logic examinations of hysterics, their associa- tion with other victims of the disease, and their demonstration before clinics, where they hear (♦Reported and exposed by Ernest Hart in Hypno- tism, Mesmerism and the New Witchcraft, 1896.) 28 Psychopathology of Hysteria descriptions of their symptoms and of the dis- ease, both create symptoms and prolong those already in existence. Therefore, one can read- ily appreciate that the earnest and faultily con- ducted studies and the clinical exploitation of these cases formerly was responsible for an incalculable and irreparable amount of injury. Recognizing the importance of increased suggestibility in producing symptoms, we can commonly interpret the classic stigmata as arti- ficial creations. As such, they have almost as much diagnostic value as formerly; providing that their production, which usually cannot be considered justifiable, is thought necessary. Then, too, the acceptance of these views leads to a better understanding of the symptoma- tology of hysteria, and, furthermore, we will have advanced one step in the pursuit of the first cause. With the justification afforded by the con- ceptions of the modern French neurologists, as briefly indicated in these few prefatory notes, the symptomatology of hysteria will be largely considered upon a basis of suggestion, and the effects of the abnormally great suggestibility in creating or in modifying symptoms intention- ally will be reiterated with the purpose of call- ing attention to the possibilities of unconscious abuse of this characteristic of the disease. A fact which must be borne in mind, one which a priori must be true, is that each per- Preliminary Considerations 29 son's hysteria must differ just as the mental characteristics of all individuals vary. More- over, the kind of symptoms possessed by a patient depends entirely upon the nature of the incidental exciting causes, upon the per- sonal equation, upon psychic contagion from others, and upon the effects of accidental sug- gestion. Bernheim believes that it is impossible to de- &ie hysteria because it is not a morbid entity. According to Lasegue hysteria never has been defined and it never will be. In a more hope- ful spirit Grasset does not despair of any progress, but he believes that the definition is still impossible. In spite of the restrictions of these, and other neurologists, the definitions of hysteria, like those of insanity, are almost as numerous as the writers who have described the disease. Having the sanction, then, con- ferred by numerous precedents, and recognizing the impossibility to define satisfactorily such a protean malady, the following may be regarded merely as a provisional definition: Hysteria may be designated a psychoneurosis, ■or so-called functional nervous disease, which, tending to develop particularly in those predis- posed by neuropathic heredity and by \T.cious en- ^ronment, is dependent upon disintegration of personality and is characterized by symptoms originating from the morbid control of the body by subconscious states ; whose s;\^mptoms 30 PsychopatJiology of Hysteria can be shown to be but exaggerations or per- versions of normal modes of feeling, of think- ing, and of acting; a disease which is distin- guished by a peculiar type of temperament, faulty adaptability to environment, pathologic increase in suggestibility resulting in the liability to develop many kinds of phenomena, and the possibility of the appearance of any one or more of a vast number of "accidents" arising, from morbid ideation. CHAPTER II Etiology HEREDITY. In common wiih the other psyehoneuroses, hysteria is thought usually to occur in those whose nervous system is rendered, as a consequence of neuropathic heredity, more susceptible than usual to functional derangement. Undoubtedly this is true, but the occurrence of hysteria does not necessarily always imply the instrumental- ity of heredity, or the existence of a state of organic nervous degeneracy. In fact, the family history is above reproach in about 10% to 20% of cases of hysteria. If one accepts the extreme ^dews upon degeneration promulgated by Nordau* and others, then but few families could be con- sidered entirely free from some variety of hereditary psychopathic taint. It is best, therefore, to entertain conserva- tive views about this matter and to limit our conception of the influence of neuropathic he- redity to those cases in which a history of epilepsy, insanity, dipsomania, or distinct crim- inal tendencies can be found in the immediate ancestry. Direct inheritance of hysteria may be possi- ble, but the more apparent deleterious effects ♦Deg-eneration, 1897. 31 32 Psychopathology of Hysteria of constant association of the offspring with a hysteric parent is sufficient to account for those instances in which the disease is encountered in two consecutive generations of a family. A broad minded view of the part played by heredity in the production of hysteria is to hold the opinion that the disease is potential in every one, and that the potentiality becomes more decided when neuropathic heredity exists. Then the relationship between hysteria and direct heredity is practically the same as that in tuberculosis; direct inheritance of either disease being rare, and the usual character of transmission being that of increased suscepti- bility. The aptness of this comparison becomes more evident if one stops to consider the many families in which, despite the existence of psy- choneuroses in the parents, the children present merely a nervous type of temperament, which is not decided enough to be regarded patho- logic. The potentiality of the disease in every one may be likened, also, to the general suscepti- bility to its analogue, hypnotism. With the exception of the insane and of the psychas- thenics, whose peculiar mental state renders hypnosigenesis difficult, but not impossible, as Janet asserts, about 90% of people are capable of being hypnotized ; our failure to succeed with the remainder probably being due to lack of patience, and, when the attempt is not made Etiology 33 for therapeutic purposes, to the absence of a good reason for its induction. Environment. Those who have to deal with the psychoneuroses hear the complaint constantly that nervousness has been engen- dered, as well as aggravated, by that of those with whom the individual has been in constant association. It is usually the continual irrita- tion, and the state of expectant attention, or auto-suggestion, which is induced by the pro- pinquity of hj^steric parents that increases the liability of the progeny to develop the disease. Then, having developed, heredity receives the blame. Under the caption psychic contagion the influence of environment will receive fur- ther attention. Faulty Education. As hysteria is com- monly disposed to attack those who have not acquired sufficient emotional stability, self- control, and the proper appreciation of the rela- tion between self and the outside world, any system of education which is deficient in devel- oping these qualities may lead to the produc- tion of the disease. The pernicious effect of over indulgent par- ents is great. Faulty conceptions of external relations and faulty modes of reacting to other environments are produced, and these, together with the effects of the parent's habitual disre- gard of emotional outbursts, constitute a kind of temperament which cannot be other than 34 Psychopathology of Hysteria conducive to hysteria — if not already a feature of the disease. Few, indeed, are the ' ' spoiled ' ' children who are unselfish, whose tempers are reasonably controlled, and who are capable of developing into self-reliant men and women! Fortunate are the children of the poor in that they are less apt to be the recipients of such undesirable attentions ! Let not the impression be gained from these sentences that hysteria is most frequent in children. The child is father of the man, and as the adult's temperament and mode of reac- tion is the outcome of that of the child, early educational methods are of the greatest impor- tance either in the causation or in the pro- phylaxis of psychoneuroses. Age. The emotional disturbances charac- teristic of pubescence, and the unstable psychic equilibrium of maturity, the period of great- est exposure to the stresses of life, naturally favor the onset of hysteria. This is shown by the following table constructed from a dispen- sary service from which patients younger than 15 years were excluded; these cases being treated in another department : Age. 15-20 25 30 35 40 45 50 55 60 65 % 23 13 11 17 10 5 8 6 5 2 Sex. Because of their inherent emotional- ism and relative inferiority in logical reasoning and philosophical acceptance of the various inevitable stresses of life, females are more sus- Etiology 35 ceptible to hysteria than are males. The dif- ference in the incidence of the disease in the two sexes is explained by Ziehen as being due to the fact that the psychic reactions which nor- mally characterize the female sex closely re- semble those essential to hysteria. (Modern Clinical Medicine, Diseases of the Nervous Sys- tem, p. 1048, 1908.) It is the absence, too, of the hardening effects of the greater responsi- bilities, which are shouldered by men, that is a great factor in producing this inequality. Even more unreliable than usual are the sta- tistics concerning hysteria. As all the psy- choneuroses are only clinical syndromes de- pendent upon the same psychic abnormality — disaggregation of personality — it is impossi- ble for neurologists to come to an agreement over the disposition of the borderland cases. However, most stimulating to progress in the study of this great and important group of dis- eases is the difference of opinion concerning their classification. The personal element enters so largely into the collection of these statistics that, according to the difference in their concep- tions of hysteria, various statisticians have col- lected figures which vary as much as 50%. With this qualification, then, which applies also to the other figures in these pages, the ratio of hysteria in males and females lies between 1 to 3 and 1 to 6. Careful examination of the rec- ords of 100 consecutive cases of hysteria, to- 36 Psychopathology of Hysteria gether with revision of the diagnosis when this was considered necessary, showed that 25% of the cases were males. Among males, by no means is it the effemin- ate man who is most apt to develop hysteria. Experience shows that the disease attacks more frequently the hard working and often prosaic man; the reason being that in males the mani- festations almost invariably follow traumatism, and, consequently, those men who are most ex- posed to physical injury are the ones most liable to develop hysteria. Both for this reason, and on account of the less dangerous occupa- tions followed by women, traumatic hysteria occurs more frequently in men. A noticeable feature of the disease in men is its severity, and its tendency towards what appears to be monosymptomatic expression; such manifesta- tions as paralysis, mutism, and psycholeptic at- tacks being the ones most commonly observed. Social Factors. Though the relatively de- ficient amount of education possessed by the rural population and the hard working poor of the cities renders them more susceptible to the acute epidemic form of the disease they are less inclined to be subject to essential hysteria than those of the upper urban classes. The com- parative freedom of the former is due to the fact that they escape the over refining influ- ences of a life of idleness, emotionalism, and luxury, and that their psychic equilibrium is Etiology 37 rendered more stable by what usually is not an abnormal amount of responsibility. Other im- portant reasons for this difference are afforded by the more self-reliant manner in which their children are brought up, and by the fact that the greater freedom of these children causes them to be less exposed to psychic contagion in case one or both parents are neurotic. Then, too, the fact that the poor marry early pos- sesses significance in that it lessens materially the exposure to a certain kind of emotional stresses whose importance in the etiology of hysteria has been shown to be too great to be ignored. As the dregs of the city community is com- posed of individuals who follow lives of in- ordinate excitement and whose passions are un- accustomed to self-restraint, and as this social element contains an undue proportion of the truly degenerate, hysteria is not only frequent but it is encountered in its most highly elabor- ated forms. The disease is most common, there- fore, in the extremes of society. Occupation. Certain occupations are attend- ed with an increased liability to the develop- ment of hysteria because of the emotionalism and unsettled mode of living that they ne- cessitate. Particularly is this the case when an imaginative or artistic, one might almost say hysteric, temperament is one of the requis- ites. Thus, artists, musicians, authors, and 38 Psychopathology of Hysteria members of the dramatic profession, are fre- quently attacked by the disease. The excessive anxiety and alternation of intense emotions en- tailed by the character of their occupation in- creases the predisposition of stock traders and others whose fortunes are largely dependent upon chance. Race. As the French were the first to study extensively and to write about hysteria, it was formerly thought that this disease was en- countered but rarely outside of France. Since physicians of other countries have become better acquainted with hysteria, and thus are able to differentiate its major manifestations from those of other diseases, this erroneous idea has dis- appeared. Because of their emotional tem- perament, however, the condition probably is more prevalent and more highly developed in people of the Latin races. Although infrequent as a distinct endemic dis- ease, epidemics of hysteria, usually of a religious nature, are not uncommon among the uncivilized. Indeed, symptoms of hysteria are frequently ob- served in connection with the religious ceremo- nies of savages, and these manifestations may be the true source of certain religious beliefs. Climate. — Hysteria is more frequent in tropical countries because these are inhabited mainly by the Latin races. The mental effects of a new environment and of the physical dis- comfort caused by an unaccustomed amount of Etiology 39 heat, together with the stimulating effects upon emotional activity of this relatively excessive heat, results in tlie production of an unusual number of cases of psychoneuroses among North- erners wlio liave emigrated to the tropics. Americans residing in the Philippines seem to he particularly prone to develop neurasthenia. According to Louis H. Fales "nearly all Amer- ican women and a large proportion of men who have been in the Islands one year or more suffer, at least to some extent, with nerve exhaustion. It is conservative to state that 50% of the women and 30% of the men suffer with neurasthenia to such an extent that they are in a state of semi- invalidism. " (Amer. Jour, of the Med. Sciences, 1907, vol. 1, p. 583.) Exciting Causes. The exciting causes may conveniently be divided into acute psychic insults and chronic mental stresses. Acute Psychic Insults. — Traumatic hysteria should be considered the result of the acute mental shock of an accident and not the physical effect of traumatism. For instance, even though hysteric paralysis should appear in a limb immediately after it has been injured, ex- perimentally it can be proven that the paralysis is entirely psychic in nature, and, therefore, un- der certain conditions the affected part can be used in a manner that does not differ from the normal. Indeed, if such were not the case the paralysis would not be symptomatic of hysteria. 40 Psychopathology of Hysteria Consequently, the direct physical effects of the injury are not instrumental either in producing or in maintaining the condition. Even though not any symptoms of the disease had ever before been apparent theoretically any- one may develop a simple physical manifes- tation of hysteria, or even a more elaborate form of the disease, as the immediate or de- layed consequence of a severe or trivial acci- dent. In quite a few cases symptoms first appear after a surgical operation. Like the ones following traumatism these do not result from the physical effects of the operation but rather from the anxiety, actual pain, and other distressing features of what is a novel ex- perience. Often the manifestations of these post-operative cases are elaborated from the or- ganic symptoms for which the patients were op- erated, or from the transient ones occasioned by the operation, or the surgical anesthesia. In this manner various pains, anorexia, vomiting, tympanites, urinary retention, and other symp- toms may be prolonged through the agency of a complicating hysteria. Other than those resulting from physical traumatism probably the majority of cases of acute development are due to psychic insults whose nature is more obvious. To this large class belong the ones following sudden disappoint- ment, deaths, and illness in others, or in self. The emotional perturbations arising from Etiology 41 tumultuous affaires du coeur, or from ones which have resulted in disappointment, are pro- lific exciting causes of hysteria. Any relatively severe emotional shock, however, is capable of acting as an exciting cause. Though the onset of hysteria may appear to be gradual, yet, upon investigation, it will often be found that the underlying disintegration took place suddenly, and perhaps even that it ante- dated by weeks or months the appearance of symptoms; this '^ period of incubation" having been appropriately designated the period of meditation, or of auto-suggestion. Usually, the more acute the onset the more typical and severe are the manifestations and the less complicated by neurasthenic symptoms is the resulting symp- tom complex. Such cases, too, are more amen- able to treatment, and, after recovery has taken place, there is less tendency towards recurrence. Chronic Mental Stresses. The many possible chronic exciting causes are inseparable from predisposing factors. They include such diverse conditions as prolonged illness, chronic organic diseases, and any kind of long continued emo- tional strain such as induced, for instance, by familial and marital difficulties. The development of hysteria in those afflicted with organic disease often is most misleading to the diagnostician. It is easy to comprehend how the knowledge that one is afflicted with a severe, incurable, organic malady, together with the 42 Psychopathology of Hysteria mental effects of what may be distressing physi- cal symptoms, is most conducive to the gen- eration of a superimposed hysteria. In epilepsy, for instance, how frequent is the interposition of typical epileptiform seizures of hysteric origin! Many, too, are the cases of multiple sclerosis which are complicated by hysteria. Toxemia. In harmony with the theory that brain cells secrete thought it has been con- tended that the psychoneuroses are directly caused by the deleterious effects upon the nerve cells of autogenic toxins. Also that ingestion of toxic substances is capable, in the same man- ner, of producing these conditions. Experience shows, however, that while auto-intoxication is quite common in neurasthenia and psychasthe- nia, it is not frequent in cases of hysteria. In view of the fact that in but few cases of the pure forms of hysteria can any evidence of toxaemia be found, another view of the mechanism of pro- duction not only is possible but is a necessity. Granted that toxins may exert a direct effect upon nerve cells, does not this act only as a pre- disposing factor in the majority of cases appar- ently due to toxagmia ? It is easy to conceive of a heightened susceptibility to hysteria as a re- sult of the state of mental depression caused by a chronic auto-intoxication. It is too much to expect any one to feel well whose head aches and who experiences vertigo and other unpleasant symptoms as consequences of toxaemia from Etiology 43 gastro-intestinal disturbance. The state of men- tal depression resulting from a condition of chronic intoxication only decreases cerebral in- hibition so that in the presence of an adequate exciting cause hysteria can develop more readily than otherwise. A common error is to ascribe to the etiology of hysteria the not uncommon autotoxis due to gastro-intestinal derangements which, in reality, are secondary effects of hysteria and not the cause of the disease. One has only to remember the effects of emotional states upon digestion, as shown by Pawlow, Cannon, and others, to under- stand how auto-intoxications can occur as com- plications of hysteria. As an exciting cause of hysteria the mechan- ism of toxaemia might be compared with the mode of production by drugs of hallucinations and delusions. No one knows just how or why a drug or a toxin acts upon the brain, but we do know of the extreme variations in the cere- bral effects of these substances. We have good reason to suspect that the delusions and halluci- nations that may occur during certain drug in- toxications are produced reflexly, and, therefore, that they are secondary to the effect of the drug upon cerebral inhibition. As such they are com- pletely the analogues of the delusions and hallu- cinations of dreams. Let us say that a drug does not directly cause a delusion but that it merely diminishes cerebral 44 Psychopathology of Hysteria inhibition, and thus permits lower forms of re- flex cerebration whose nature is largely depend- ent upon the character of the coenesthetic im- pressions and of the chance external stimuli which are perceived at the time. Furthermore, such mental activity necessarily must be based upon the character of previous environment and education. An intoxicated man reacts to his environment in a manner that is more or less completely de- void of the control of cerebral inliibition. Conse- quently, his actions are better standards of his true character than are those when he is sober — ^when he has assumed his mask. One cannot reasonably assert that alcohol so acts upon the brain cells that an intoxicated person is rendered pugnacious, or boisterous; it is more probable that these manifestations are revelations of the individual's real character undisguised by cere- bral inhibition. After taking opium a commonplace man might experience sleep, which, as far as he was after- wards aware, was dreamless, while a brilliant thinker like De Quincy or Coleridge would un- dergo, with or "without the production of sleep, the most exhilarating and lucid forms of intel- lectual activity. Or, quite commonly the admin- istration to a nervous patient of certain hypno- tics not only may be devoid of any tendency to produce either dreams or sleep, but it may lead to aggravation of the symptoms for which it was given and to the production of new ones. Etiology 45 The theory advanced by Obersteiner and Pryor that sleep results from the accumulation of toxic matter is analogous to the theory that hysteria is the outcome of a similar condition. As the result of his experimental study of sleep Sidis concludes tliat the state ''is not a disease, it is not, as the chemical speculators would have it, a kind of narcosis of the system by the poisons of fatigue products" but that it is "an actively induced passive state in relation to the external environment." (Jour, of Abnormal Psychology, vol. 3, p. 189.) Biologically interpreting sleep as an instinctive reaction of defense, Claparede avers that we sleep not because we are in- toxicated or tired, but in order not to be so. (ArchiA^es de Psychologic, Feb. and Mar., 1904.) The strongest argument against the hypothesis that in consequence of the direct effects of the toxins upon the structure of the nerve cells toxsemia is a cause of hysteria is the fact that many cases occur suddenly after accidents and in the absence of toxaemia, and also that practi- cally every symptom of the disease can be dupli- cated so veritably by hypnotic suggestion as to deceive an expert. Naturally the whole subject revolves around tlie ancient and ubiquitous prob- lem of the relation between brain and mind; the time honored question of monism and dualism. Psychic Contagion. Not only is psychic contagion important as a predisposing cause but its significance in the actual production 46 Psychopathology of Hysteria of hysteria cannot be emphasized too greatly. The influence of psychic contagion is par- ticularly noticeable in children on account of their normally great susceptibility to suggestion; the suggestibility which is the cause of their in- herent tendency to imitate, and which enables them to acquire knowledge easily by reason of the ready acceptance, to which it leads, of any statement made by one in whom they have con- fidence. Quite commonly, indeed, children are en- countered who present accidents of hysteria identical in character with those of their parents. I can recall a typically hysteric woman who had psych oleptic attacks simulating focal elipepsy whose child, after witnessing a number of these seizures and hearing his mother describe the symptoms of which she was conscious, developed similar crises. Even the aura and the march of the symptoms were duplicated. In fact, the crises of more than 25% of cases of psycholepsy can be traced directly to similar attacks which the patients have observed in others. In another instance all the children of a large family pos- sessed gastric symptoms like those of their father's "gastric neurosis" in addition to cardiac symptoms that they had acquired by psychic contagion from observing their mother's heart attacks. Among school-children, in hospital wards, and in dispensary clinics, the effects of psychic con- Etiology 47 tagion are frequently encountered. Particularly is this true of large clinics where many cases of psychoneurosis have the opportunity to com- pare symptoms, to observe the physical disabili- ties of those afflicted with organic nerv^ous dis- eases, and to hear lectures concerning neurologic subjects. One patient who had been treated for epilepsy heard a description of the procursive variety of epileptic attack during a clinic of which he was the subject. In less than a week procur- sive seizures developed like those whose descrip- tions he had heard. This led to question of the diagnosis, and, after close study, it was found that his seizures were hysteric in origin. Another patient who was supposed to be an epileptic, though there was good reason for re- garding his attacks as being symptomatic of hysteria, acquired a lot of new symptoms of which he made complaint during the first visit after ha^dng been examined by students in a clinic. All of these new conditions were ones whose presence had been sought, and their genesis was due to the suggestive manner in which inexperienced students had conducted their tests. Even the most carefully conducted ex- aminations, however, may be followed by psycho- genetic symptoms. Recognizing this fact Gowers stated that : ' ' Medical inquiries and examina- tions often suggest to patients the definite ideas of symptoms, and the physician's knowledge of the natural association of symptoms may thus 48 Psychopathology of Hysteria lead to their consistent grouping in a mimetic malady, even when there is not, and still more when there is deliberate simulation." (A Manual of Diseases of the Nervous System, p. 989, 1903.) In addition to abnormally great hetero-sugges- tibility psychic contagion resulting from patho- logic auto-suggestibility — expectant attention — naturally has interfered greatly with the proper interpretation of the incidence of certain symp- toms, and has been the sole cause of the appar- ent verification of many otherwise baseless theo- ries of the disease. The dabbling with spiritualism of the less in- telligent is an especially pernicious factor both in predisposing to hysteria and in producing the disease. For obvious reasons it is usually the credulous, emotional, imaginative, and highly suggestible person who attends seances and who believes in the supposed evidences of spirit con- trol which he witnesses, and as there are many manifestations of hysteria among these pheno- mena he is fortunate if he does not acquire some by psychic contagion. More harmful are attempts to become me- diumistic. When an individual deliberately seeks and encourages the development of self- induced, organized, mental dissociations, such as those required by trance states, automatic writ ing, etc., he is but creating and evolving a tendency that subsequently may escape his con- Etiology 49 trol and become the foundation of actual hysteria. Even the successful self-induction of these conditions might be considered with good reason proof of hysteria. Because spiritualistic enthusiasts have wit- nessed so many diverse manifestations of hys- teria, and because quite commonly they are well posted in a spurious form of psychology, or rather abnormal psychology, if hysteria develops there is at hand a wealth, of knowledge of pathologic symptoms upon which autosugges- tion can operate in the production of a most completely developed type of hysteria; one in which the disease is expressed less physically than as a psychosis. By reason, too, of their pseudo-knowledge of transcendental psychology, philosophy, and metaphysics, spiritualists and Christian Scientists are most resistant to psycho- therapy, and their very knowledge prevents the successfal application of other forms of treat- ment. Epidemic Hysteria. When widespread, psy- chic contagion may cause veritable epidem- ics of what is regarded by some as hysteria, and by others as hypnotism. Frequently this occurred in the Middle Ages, and even at pres- ent the tendency has not entirely disappeared. A wave of epidemic religious hysteria has been known to sweep over an entire race and to con- tinue until interest either died out naturally or until it was directed to some other object. 50 Psychopafhology of Hysteria The ghost-dance religion of onr own Indians is an excellent example of an epidemic of psychic contagion in a partially civilized peo- ple. This epidemic is particularly interesting in that it has been reported so carefully by James Mooney. (Fourteenth Annual Report of the Bureau of Ethnology, Smithsonian In- stitute, Part 2, 1892-93.) Incidentally, the manifestations of epidemic hysteria among sav- ages are often identical with those which have occurred during many similar epidemics among highly civilized people. Epidemics of hysteria have usually assumed a religious character because of belief in the supernatural entertained by those who were affected. Through lack of intelligent appre- hension certain accidental phenomena may be ascribed to supernatural agencies with the re- sult that abject fear, together with the in- creased suggestibility characteristic of mobs, leads to the birth of an epidemic. Those who are most liable to become subject to these in- fluences are the credulous, the superstitious, and the impressionable ; ones who are incapable of thinking for themselves and who are de- pendent upon others for guidance. In modern times epidemics of hysteria have usually assumed the form of revivals, and have oc- curred mainly among the impressionistic and highly superstitious negroes and Indians. The best example of a comparatively recent epi- Etiology 51 demic among intelligent people was the de- plorable New England witchcraft episode. When hysteria becomes epidemic it cannot be considered other than an acute transitory form that reveals the inherent potentiality of the disease in all people. Not infrequently epi- demics occurred in convents, and as in these instances the number of those exposed was limited, the ubiquity of the potentiality is re- vealed more fully. In such epidemics not a few, but the majority, if not all, of the inmates were affected. The effect of repression of the sexual instinct was a conspicuous feature of epidemics involving the occupants of convents ; the disease being expressed mainly by what was termed demoniac possession of which a frequent symptom was delusions of sexual in- tercourse with evil spirits. Since the exposi- tion of Freud's theories of hysteria the signi- ficance of this fact can be grasped more intelli- gently. Man tends to explain to the best of his ability phenomena of whose nature he is ignorant. If he believes in demons, and if he has no other more plausible explanation, he accounts for cer- tain unusual incidents by assuming that they result from diabolic agencies. If such views of an individual receive popular acceptance, or if they are prevalent ones of the age, an epi- demic of demonophobia may be the outcome. In the study of vampirism, demonophobia, 52 Psychopathology of Hysteria witchcraft, and the like, we have to deal actually with two interdependent epidemics ; one of abject fear of the possessed, and the other of suggested evidences of possession. For about 200 years the whole of Europe was a vast charnel house owing to the countless numbers of the supposedly possessed who were put to death by many almost inconceivable forms of torture. The discovery of an anaes- thetic spot was sufficient evidence to condemn an individual, and very lucrative became the profession of detecting these unfortunates. The examiners went around searching for anaes- thetic areas in those who were suspected, and just as physicians seek for a certain kind of angesthesia and by their examination alone create this product of suggestibility, so, too, did the witch hunters seek and create ''evi- dences" of possession. Consequently, unnum- bered thousands of men, women, and children owed the loss of their lives to the effects of suggestion and to the ignorance of the age in which they lived. The history of such epi- demics, including our own small one of witch- craft, besides being of scientific interest scarce- ly can be other than conducive to reflections upon the injustice and barbarities which hys- terics have received. Even though epidemic hysteria be regarded merely as an acute and transitory form of the disease its symptoms, nevertheless, are just as Etiology 53 severe as those observed in the most completely- developed cases of endemic hysteria occurring upon a decided foundation of psychopathic heredity. Epileptiform convulsions, various rhythmical movements, hallucinations, delu- sions, and trance phenomena, are the most common of the severe manifestations which are prone to occur during epidemics. For instance, in describing the revivals among Southern ne- groes, Davenport writes: ''At many of the 'big quarterlies' and the 'protracted meetin's' which are held in the South, there are scenes of frenzy, of human passion, of collapse, of cata- lepsy, of foaming at the mouth, of convulsion, of total loss of inliibition, compared with the scorching heat of which the Indian ghost-dance seems at times only a pale moon." (Primitive Traits in Religious Revivals, 1906.) During the revivals among the whites of Kentucky, in 1800, among other manifestations such as visions and trances the same author describes the "bark- ing exercise:" "The votaries of this dignified rite gathered in groups, on all fours. Like dogs, growling and snapping the teeth at the foot of a tree as the minister preached, — a practice which they designated as 'treeing the devil!' " Belief in the doctrines expounded during pathologic revivals is not essential to con- tagion; in spite of the greatest efforts to with- stand them the manifestations might appear. Thus the Rev. Myron Eells spoke of the Indian 54 Psychopathology of Hysteria Shaker religion: ''It seems to be as catching, to use the expression of the Indians, as the measles. Many who at first ridiculed it and fought against it, and invoked the aid of the agent to stop it, were drawn into it after a little, and then they became its strongest up- holders." (Fourteenth Annual Report of the Bureau of Ethnology, Smithsonian Inst., p. 748.) A typical instance is quoted by Sidis: ''A gentleman and a lady of some note in the fashionable world were attracted to the camp meeting at Cone Ridge. They indulged in many contemptuous remarks on their way about the poor infatuated creatures who rolled over screaming in the mud, and promised jestingly to stand by and assist each other in case that either should be seized with the convulsions. They had not been long looking upon the strange scene before them, when the young woman lost her consciousness and fell to the ground. Her companion, forgetting his promise of protection, instantly forsook her and ran off at the top of his speed. But flight afforded him no safety. Before he had gone 200 yards he, too, fell down in convulsions." (Psychol- ogy of Suggestion, p. 352, 1899.) Epidemic hysteria reflects the ignorance of a people. In fact, it is the direct outcome of their state of unenlightenment and its mani- festations are the expression of their convic- tions. Indeed, one would be safe in affirming Etiology 55 that among the intelligent of present, or of future ages, epidemics of demonophobia and the like could not be repeated. The history of recent times shows that the epidemics of de- moniac possession of the Middle Ages have been replaced by epidemics of religious revivals, of popular spiritualism, of financial bubbles, etc. CHAPTER III Disturhances of Sensory Perception IN the minds of the laity paralysis must be accompanied necessarily by numbness; paralysis implying that the affected mem- ber must ''feel numb and dead." In most individuals this prevalent idea probably results from the temporary paralysis and numbness that most of us have experienced after having slept ^vith the head pillowed on the arm. Hj^notic experiments conducted upon normal persons commonly demonstrate the existence of this erroneous conception; one that is based upon valid premises drawn from personal experience. If the suggestion is made to a hypnotized subject that one arm is paralyzed, then comparative tests of the sensibility of both arms will reveal almost invariably the presence of anesthesia in the paralyzed one. This re- sult is obtained even when the experimenter has been most careful to eliminate the possi- bility of creating the anaesthesia by uninten- tional suggestion in his method of making the tests. As a consequence, then, of the concep- tion that numbness is a symptom of paralysis, a hysteric person who develops paralysis, either organic or functional, is apt to have an asso- ciated numbness, or anaesthesia, of the affected member. 56 Disturbances of Sensory Perception 57 Among other similar cases Bernheim writes of a painter who, becoming the victim of saturnism, presented wrist-drop associated with analgesia of the dorsal aspect of the wrist and hand; the palmar surface and the fingers not being involved. The analgesia having been readily dispelled by means of suggestion, Bern- heim remarks that according to the patient's idea it was the dorsal surface of the hand and wrist which seemed to be the seat of trouble ; it was there that his imagination localized the motor paralysis; it was there, also, that logi- cally he created a sensory paralysis. Being able to flex and to extend the fingers, these, in the patient's mind, were not paralyzed, and, there- fore, not anesthetic. (Conception du Mot Hysteric, 1904, p. 11.) Independently of paralysis angesthesia may be evolved in a number of ways. Thus, the transitory numbness following minor trauma- tism to sensory nerv^es may become fixed as a psychic anesthesia through the instrumentality of autosuggestion. In the same manner the symptom may develop on the basis of a limb ''going to sleep," or from the numbness that is noticed after an extremity has been held in a constrained position for a considerable length of time. It is not unusual for hemiangesthesia to ap- pear in patients who have a fear of apoplexy, due, perhaps, to the occurrence of this condi- 58 Psycliopathology of Hysteria tion in some relative or friend. Constantly ex- pecting to become hemiplegic, and believing that hemianaesthesia is a symptom, or even a forerunner, of the condition, patients may de- velop hysteric hemianesthesia either with or without paralysis. Often it has been noticed, even in persons who were not considered to be subject to hys- teria, that a hand engaged in automatic writing became anaesthetic at the time. The explana- tion of this event is not difficult. In order that automatic writing can occur there must be coexistent dissociation of consciousness with elimination of the automatically functionating extremity from the field of consciousness. Not only are the motor functions dissociated but, commonly, the member as a whole is elided from consciousness mth the result that sensory impressions originating in the part are not consciously perceived. When produced by any of these means, or by similar ones, anesthesia may be said to be autogenous. Now, if a certain kind of anes- thesia be considered a typical symptom of hys- teria, and if it is diligently sought by examin- ing physicians, both because of its interesting features and on account of its supposed diag- nostic import, then the condition intentionally or unintentionally may be created in the patient through the agency of the abnormally increased suggestibility that is characteristic of the dis- Disturbances of Sensory Perception 59 ease. Thus, angesthesia, and other symptoms, may be heterogenous. Parenthetically, the distinction between auto- suggestion and hetorosuggestion is only one of convenience in that these two terms super- ficially indicate, or appear to indicate, the source of the suggestion ; the mechanism of production of symptoms by either form of sug- gestion being the same. When, by reason of a faultj^ technique, the examining physician unconsciously creates auEesthesia in a patient, or when the condition is deliberately suggested upon a hypnotized subject, it is produced only because the individual accepts and acts upon the implied or the evident suggestion that has been conveyed to him. The anesthesias which' have not originated from medical examinations usually follow some injury which has produced temporary numbness of the part, and the symp- tom thus suggested is fixed as a psychic anaes- thesia. In the ultimate analysis all effects of suggestion, whether apparently due to auto- suggestion or to heterosuggestion, are in reality examples of autosuggestion which has been provoked by an external stimulus, immediate or remote. That hysteric anesthesia is almost invaria- ably the product of a faulty technique of ex- amination can easily be demonstrated clinically. If, for example, in ten consecutive cases whose tactile sensibility is being tested for the first 60 Psych opathology of Hysteria time, the patient is told to close her eyes and immediately to say "now" luhen any part of her body is touched, anaesthesia probably will not be found in any, unless, perhaps, and this is unusual, autogenous anagsthesia had already existed. On the other hand, if, in a similar number of cases, the patient is told to close her eyes and say "now" if she is able to feel herself touched, anaesthesia will be discovered — created — somewhere in over a quarter of the cases, providing that the usual unnecessarily prolonged and careful examination be made. As commonly conducted the tests contain even a greater element of suggestion. Perhaps the physician states in advance that he intends to examine in order to ascertain if she has lost the feeling of any part of her body, or in some other way unintentionally conveys the impres- sion that anaesthesia is expected; that it is a symptom which she should possess. A state of expectant attention having been excited by these suggestive remarks the examiner pro- ceeds to stimulate various areas while asking if the patient feels "this," or if she can feel "that." Except direct hypnotic suggestion no better means could be employed intentionally to create ansesthesia. The more prolonged and thorough the exami- nation of sensibility the more frequently anaes- thesia will be found and, if the tests are re- peated during subsequent visits, it will be Disturbances of Sensory Perception 61 fortunate, indeed, if one out of ten cases escapes the production of this ''symptom." It is the avoidance, now, of such faulty methods of ex- amination that has caused hemiangesthesia to become so rare in the practice of many of the French neurologists when formerly it was a common symptom. These facts alone show that the experimental study of hysteria is largely the study of its symptomatic increased suggestibility, and that those who devote their time to the investigation of such manifestations as anaesthesia for the most part are really not dealing with essential symptoms of the disease but with the reactions of the patient to suggestion. As the confirmed hysteric is inclined to wan- der from one physician, or clinic, to another, the examinations of the first few physicians commonly are quite sufficient both to create and to render more or less permanent certain "stigmata.'' Those who have subsequently to deal with these old and repeatedly examined cases naturally do not cause by their own ex- aminations the production of these symptoms, and, no matter how careful their technique, anaesthesia and the like will probably be found for the reason that- they had already existed. In the case of Lizzie B., a patient who had been examined by anotlier physician without any sensory deficit ha^ang been noted, the conscious perception of tactile stimuli had become imper- 62 Psychopathology of Hysteria lect and much delayed. After having been asked to state which side had been touched, the stimuli were referred to the corresponding point on the contralateral member — allocheiria. On repeat- ing these tests, after a short rest, she was unable consciously to perceive any of the stimuli. Thus, hysteric angesthesia was created by the examina- tion. Now, by telling her that there really was nothing wrong with her sensibility, that she could feel, that she would signify her perception of each stimulus by saying ''now" just as soon as she felt it, and each time that she would state exactly where she had been touched, both anaes- thesia and allocheiria were caused to disappear. These conditions did not return so long as she was under observation — over a year. As typical of the modern reaction from the extreme views of anesthesia held by the older observers is Babinski's total disregard of the infrequent autogenous angesthesia by his sweep- ing assertion that angesthesia is always the result of suggestion during medical examinations con- ducted with a faulty technique. In support of his contention he states that during ten years he had not encountered hemiangesthesia among hy- steric patients who had not been previously ex- amined by others. In 1910 Bernheim, too, as- serted that since 1900 he has failed to discover hemianaisthesia in patients examined for the first time. In order to explain the absence of the condition in his service he states : ' ' To-day I Disturbances of Sensory Perception 63 explore with the idea that it does not exist; and this idea suffices to modify my technique of ex- amination, and to eliminate its suggestive char- acter." (Hypnotisme et Suggestion, Hysteric, Psychoneuroses, etc., 1910, p. 269.) Now there must be some way of reconciling such statements with the fact that other ob- servers found anaesthesia in from 75 to 95%, and hemianaesthesia in 30 to 50% of their hysteric patients. The only plausible explana- tion for such conflicting results is that while formerly physicians created anaesthesias by rea- son of their faulty methods of examination, now, on the contrary, Bernheim, Babinski, and others have perfected their technique of examination to such a degree that no longer do they suggest the conditions upon the patient. But liow account for the absence of autogen- ous anaesthesia and hemianesthesia in the prac- tice of these physicians ? If it suffices to produce ana3sthesia merely when the physician expects to find sensory deficits and examines his hysteric patients in accordance with his views, surely when one explores, as Bernheim does, with the idea that the condition does not exist, autogenous angesthesia, if present, will disappear in conse- quence of the fact that his method of testing ex- presses his convictions. In the first instance the suggestive character of the examination is patho- genic ; in the second one it is therapeutic. That such an explanation is not improbable is indi- 64 Psychopathology of Hysteria cated by the fact that through the agency of in- tentional suggestion it is just as easy to cause anaesthesia to disappear as it is to create the con- dition. If anaesthesia were not usually of medical origin certainly the statements of Bernheim and Babinski would be remarkable in view of the fact that, until recently, this condition was one of the most frequent of the supposed symptoms of hysteria ; so frequent, in fact, that it was con- sidered stigmatic of the disease. It is such facts as these that lead one to ques- tion all theories of the disease, for no matter how well supported by facts they may seem to be, and no matter how general their acceptance, the history of the malady renders only too evident the eifeets of suggestion and of psychic conta- gion in the elaboration of innumerable hypo- theses which afterwards were proven to be erron- eous. Less radical are Janet's views concerning the significance of anaesthesia. To express the dif- ficulty in interpreting the psychologic character of hysteric anaesthesia he writes: ''Now, your examination alone will suffice to cause a real anaesthesia to disappear; now — and this is more serious — your manner of interrogating will create outright an anaesthesia that did not exist. The study of the stigmata is made on no patients so well as on old ones; real pillars of the hospital, who have already been examined Disturbances of Sensory Perception 65 thousands of times. When you have to deal with new patients, who have not yet been touched, you recognize with astonishment that anaesthesia is rarer, less important than Charcot said. On this point I apologize myself, and acknowledge that, under the influence of la Salpetriere, I formerly attributed more importance to anaesthe- sia than I would do now." (Major Symptoms of Hysteria 1907, p. 274.) In an earlier work we find the following sig- nificant statement pertaining to hysteria in the young : ' ' The patients, in the beginning, have no anesthesia; this has been observed by all au- thors." (Mental State of Hystericals, 1892, Cor- son trans. 1901, p. 47.) Why do not young hysterics present anaesthesia? Being young these patients have not yet been examined by numerous physicians and thus heterogenous anaesthesia is less apt to have been created, and because of their age they are not apt to possess knowledge of such a condition as anesthesia so that it is not liable to develop as an autogenous symptom. In connection with anesthesia it was form- erly noticed with astonishment that what should be a distressing symptom almost never was made the subject of complaint. Or, that the majority of patients were not aware of their sensory deficit until this was revealed by an examination. The patient might exclaim: ''Why, I never knew that I couldn't feel in 66 PsycJiopathology of Hysteria that arm!" The majority, however, expressed neither surprise nor concern when the physi- cian spoke of anaesthesia which he had found and whose existence previously had been un- known. By means of the argument that hysteric anaesthesia is only subjective and that as such the patient really perceives tactile and other stimuli but that the perceptions are not syn- thetized with consciousness, exception might be taken to the view that this symptom is com- monly produced only by suggestive examina- tions. Though quite true as an explanation of the inocuous nature of existing angesthesia logically it does not seem legitimate to con- clude that all anaesthesias antedate the exami- nation during which they are discovered both by physician and by patient. Practically, the weight of evidence is overwhelmingly against such reasoning. In their conceptions of diseases of different parts of the body laymen think in popular terms of arms, legs, halves of the body, etc., and not in scientific ones of peripheral sensory distribution. Naturally, then, hysteric anass- thesia, being entirely psychic in origin, does not conform with the anatomical peculiarities of sensory distribution. The one conceivable exception to this rule is the possible occurrence of psychogenetic angesthesia limited to the dis- tribution of a sensory nerve as a result of the Disturbances of Sensory Perception 67 fixation of transitory numbness provoked by slight traumatism to that nerve. The atten- tion of the patient having been directed to the symptom and to that particular distribution unconscious autosuggestion amplifies and fixes the primarily organic sj^mptom. In view of its anatomical inconsistency any anaesthesia is suggestive of hysteria when it is limited precisely to one lateral half of the body, when it surrounds an arm or a leg like a glove, a coat sleeve, a stocking, etc., or when it occurs in irregular disseminated patches. Total hysteric anaesthesia is most exceptional. The borders of organic anaesthesia are fixed, or varying but gradually, and they are not well defined because of the overlapping that exists in the distribution of the various nerves. Those of hysteria, however, are sharply delineated and varying much from one examination to another, and even during the same examination. In fact, their borders can be determined at will according to the use of suggestion by the examiner. The following instance, mentioned by Prince, shows how readily the hysteric is influenced by the conceptions of her physician, and, therefore, how one is apt to discover, or unintentionally to create, whatever one expects to find: "In one instance the examining physician, thinking the limiting line should be two inches from the median line on the anaesthetic side, demonstrated 68 Psychopath ology of Hysteria this boundary, but when erroneously told it should be on the opposite side, corrected, as he thought, his faulty observ^ation and demon- strated the line in the new situation." (Amer. System of Pract. Med., p. 643.) Hysteric anassthesia does not occasion loss of the reflexes except, perhaps, those of the skin, and, during sleep, stimulation of an anassthetic limb not only may cause its withdrawal but even verbal remonstrances may be provoked. Also, it has been noticed that hysteric angesthesia may disappear during the exhilaration caused by drugs. Finally, there need not be any impair- ment in the use of the affected member ; with her eyes closed the patient being able to write, for in- stance, even though unable consciously to feel the pencil she grasps. Quantitatively, hysteric anaesthesia may be complete or incomplete; conscious perception either being absent or only impaired. Not only the skin but the mucous membranes, or both, may be involved. Qualitatively, any one or all of the various kinds of sensory perception are capable of being the subject of disturbances sim- ilar to those of tactual perception. In hysteria, as well as during hypnosis in a normal person, it has been noticed that small wounds in an an- aesthetic region are not apt to produce haem- orrhage or, in fact, even that haemorrhage may not appear at all, and that perspiration may be lessened in the same region. Disturbances of Sensory Perception 69 Let us examine some patients and, by means of suitable experiments, demonstrate the pecul- iarity of hysteric anaesthesia and attempt to de- termine its nature. The most easy and convinc- ing experiments are accomplished with the aid of h^'pnosis. Numerous ones have been devised and witli a little ingenuity anyone can contrive others suitable for the case at hand. Sometimes one ViWl fail while, in the same patient, the appli- cation of another is attended with success. If differentiation from organic ansesthesia depends upon such tests alone, one successful result indi- cates that this one symptom, at least, is hysteric in origin no matter how many other experiments were failures. Suppose we blindfold a patient who presents an old, well organized, and complete anesthesia and then lightly touch the anaesthetic region a certain number of times. Upon being ques- tioned the patient asserts positively that she has not felt anything. Now we hypnotize her and suggest that she tells us how many tactual impressions were perceived. Without hesita- tion she states the correct number. If, in a manner that is not too obvious, the experi- menter suggests to the patient that she will in- form him of the number of the impressions tchich she perceived in many cases a successful result wdll be secured without resorting to hypnosis. In a patient with long continued hemianges- thesia occurring in association with organic 70 Psychopathology of Hysteria hemiplegia all forms of sensibility were lost on the affected side of the body. In consideration of the history of the patient, together with the findings of a hurried first examination, it was thought that the sensory loss was one of the consequences of a cerebral haemorrhage. Im- mediately afterwards he was carefully ex- amined before a body of students. Even in this patient, one familiar with many clinics and with neurologic examinations, it was pos- sible, during this second examination, to carry out successfully the above procedures without resorting to hypnosis. Disregarding other facts and excluding a number of peculiarities which were inconsistent with organic hemianaesthesia, the results of these tests alone would have been sufficient to prove that the hemianesthesia, at least, was hysteric in nature. The sensory de- ficit was too general and too absolute ; he ap- peared to exhibit absolute loss of every form of sensibility that was tested. Thus he asserted that he could not feel tactual, painful and thermal impressions and that osseous sensibility to the tuning fork was absent. Even though several pounds of pressure was exerted, suffi- cient to push his leg along the floor, he said that he felt nothing. When the affected limbs were placed in various positions and he was told to retain these passively assumed attitudes he did so without other support than his own efforts. He was unable, however, to duplicate Disturbances of Sensory Perception 71 these postures with the members of the other side because as he asserted, he did not know where the paralyzed ones were located. Be- sides the experiments that demonstrated posi- tively his perception of various kinds of stimuli the anomalous character of his sensory losses was sufficient to reveal their psychic nature. During examination of tactile sensibility it is frequently noticed that the patient starts slightly whenever the anesthetic region is stimulated, yet consciously she does not per- ceive the impressions. By training the patient to carry out some simple act each time a normal area of the skin is stimulated it is often possible to obtain the same response when an anaesthetic region is stimulated in the same manner. Janet has suc- ceeded in causing the patient to say "yes" when a normal area of the skin was touched, the patient's eyes being shielded, and ''no" when an anaesthetic area likewise was stimu- lated. This curious result was obtained by tell- ing the patient in advance that she was to an- swer affirmatively when the tactile impression was perceiA'ed, and negatively when it was not felt. After these instructions the physician must proceed rapidly with his tests in order not to give the patient time to think about the inconsistency of the replies. Naturally, too, if she is intelligent enough to remark this incon- sistency not only will the procedure fail but 72 PsychopatJiology of Hysteria the physician exposes himself to censure for implying that she was malingering. The same author speaks of a patient with hysteric total anaesthesia upon whom elec- tricity was being employed for therapeutic- purposes. One day it was noticed that on each application of the electrode strong muscular contractions appeared as usual, although by accident the electrodes had been disconnected, and, furthermore, the patient could not see when the applications were made. Here, then, through unconscious autosuggestion, there oc- curred motor reaction to a supposed applica- tion of electricity even though by reason of her ana3sthesia the patient consciously could not perceive the application of the electrode^ (Janet: op. cit., p. 27.) In order to demonstrate the doubling of eon-^ sciousness in hysteria Alfred Binet adduced some interesting experiments upon patients with complete anaesthesia of an upper extrem- ity. He pricks the hand a certain number of times and then asks the patient what number comes into his mind. Often the patient gives the same number as that of the pricks he was unable to feel. To vary the experiment some object may be placed in the anaesthetic hand and then the patient asked to name the thing of which he is thinking. Having screened" the hand Binet passively flexes and extends- one of the fingers a number of times. Fre- Disturbances of Sensory Perception 73 quently he finds that the movements automati- cally continue a few times after he ceases im- parting the passive motion. In order to continue the actions of flexion and extension the patient must have perceived the sensory impressions — muscular and articular — produced by the pas- sive movements. Subconscious perception and recognition accounts, too, for the fingers grasp- ing in the correct manner such objects as scis- sors or a pen which are placed in the anaes- thetic hand. By means of guiding the screened movements of the pen the same author causes the hand to write a familiar name. In doing so the name intentionally is misspelled. Now, having started the hand to rewrite the name the writing is automatically completed, but often the mistake is corrected. This experi- ment shows that not only did there occur sub- conscious perception of the primarily passive movements but that some kind of intelligence which was apart from the consciousness of the patient recognized and corrected a mistake in orthography. Finally, becoming accustomed to automatic writing the patient writes a word which has been traced upon the back of his ansesthetic hand. (On Double Consciousness, 1905.) By proving that, in spite of what appears to be complete anaesthesia, patients do perceive im- pressions arising in the affected region the term anaesthesia — T\ithout feeling — ^is shown to be a 74 Psychopathology of Hysteria misnomer. Then, are all patients with hysteric anassthesia nothing but malingerers? Success- fully to simulate a condition with such peculiar qualities would necessitate that the individual be exceedingly clever and stoical enough to with- stand pain without a murmur. However, no person who is simulating with a definite object in view would expose his malingering by reacting to experiments in the manner which has just been de^scribed. Might not a woman simulate anaesthesia solely in order to provoke attention? If anyone should simulate the symptom with no other apparent object than to excite interest the condition could not be considered malingering in the sense that this term is commonly employed, but the rea- son for the simulation alone would be indicative of one of the mental peculiarities of hysteria. It is safe to look upon hysteria as the only condition — except insanity — in which an adult might simulate for the purpose of arousing sym- pathy. But, simulation of anaesthesia by a hysteric is rare, and enough has been written al- ready to show that hysteric disturbances of sensory perception are symptoms over which the patient has not any control, originating, as they do, in dissociation of consciousness. The curious qualities of hysteric anesthesia can be interpreted in only one way. It is only a psychologic explanation which is adequately capable of accounting for the fact that a patient Disturbances of Sensory Perception 75 is unaware of a perception whose existence can be demonstrated. Hysteric anesthesia, and other similar disturbances of perception, can be made intelligible by assuming that while sen- sory impressions really are perceived there is lack of synthesis of the percepts with conscious- ness. In other words, there is deficiency of per- sonal perception, or, less technically to express the condition, hysteric anaesthesia, as indicated by Lasegue in 1864, is but a result of patholo- gic exaggeration of normal absent-mindedness, personal examples of which each of us can readily recall. It is, then, only the exaggeration of the normal peculiarity of the human mind which permits one to search for the hat which is upon his head, or which is accountable for the fact that soldiers who have been wounded often continue to fight without feeling any pain, and, in fact, even ignorant of the wounds which they have sustained. Hysteric anaesthesia might be compared, also, with the field of attention in the act of vision. One whose attention is concentrated on an object in any portion of the visual field may not con- sciously perceive objects in any other portion of the field, yet experimentally it has been demon- strated that under these conditions there has actually occurred subconscious perception of visual impressions in the field peripheral to the fixation point of attention. 76 Psychopathology of Hysteria According to Janet, hysteria is characterized by retraction of the field of consciousness with the consequence that the patient is unable to at- tend to the many impressions which are con- stantly being conveyed to the brain from dif- ferent parts of the body. Certain perceptions, therefore, are ignored, and this primarily volun- tary suppression of perceptions, becoming ha- bitual, results in the production of ansesthesia, amaurosis, etc. Freud looks upon anaesthesia and other symp- toms as symbolic representations of former ex- periences which have been forgotten — suppressed — because of their unpleasant nature. This ex- planation of the absence of personal perception is not, however, universally applicable. It does not explain, for instance, why anaesthesia may appear after traumatism of which the patient has a most vivid recollection. It is eminently practi- cable in those cases in which the disease has de- veloped after more obvious psychic insults whose memories really have been suppressed from consciousness. Although hysteric angssthesia does not usually cause any disturbance of the motor functions of the affected part there may occur occasionally, in a profoundly anaesthetic member, an asso- ciated motor disability that is present only when the patient's eyes are closed, or when they are directed away from the part. This pseudo- paralysis, known as Lasegue's syndrome, is appar- Disturbances of Sensory Perception 11 -ent only during attempts to perform consciously some movement ; automatic and lower reflex acts not being impaired. When a part is the seat of total hysteric ana3sthesia it is non-existent to the patient unless she can see it, or feel it with some other member, and this alone is quite sufficient to account for the condition. Such an explana- tion is supported by the fact that these patients are able, with the assistance of visual imagina- tion or of tactile impressions, to carry out a movement, and, furthermore, subconscious move- ments are not affected. Unless originating as a psychologic artefact — a product of too careful study or of unconscious suggestion during medical examinations — it would seem that the development of Lasegue's syndrome is, to say the least, most improbable. The mental processes of sensory perception have been divided by Ernest Jones into two groups ; the first of which comprises those pro- cesses dependent upon esthesic impulses, and the second group, designated auto-somatognos- tic, embraces the memory feelings of different parts of the body. It is by reason of the normal activity of memories of feelings that have been experienced in the past that enables one to recognize not only that a sensory percept results from a stimulus applied to a certain part of the body, but also to know which side had been stimulated. And it is by association with these memories that a sensory percept is experienced 78 Psychopathology of Hysteria with the warmth that implies personal percep- tion. Now, according to the same author, if the esthesic sensibilities — tactile, pain, coenes- thetic, etc.— return first, during recovery from hysteric anaesthesia, there results impairment of personal perception so that the patient de- scribes a tactual perception as having been induced by a sensory impression in a part that does not belong to his body, or the perception is referred to a corresponding point on the con- tralateral member whose sensibility is normal. As an instance of the former Jones w^rites of a patient who said: ^'You are touching the back of some fore-finger with a blunt pin; it isn't my finger and I have no idea where it is, but it causes an intensely disagreeable shudder to run all up one side of me. ' ' Dyschiria, or difficulty in naming the side of the body from which a sensory impression has been perceived, is due to loss of the "chirognos- tic" sense — the feeling of sidedness. Sensory dyschiria is divided by the same author into achiria when the patient cannot recognize which side of the body has been stimulated, though the sensory impression was perceived, allochiria when the stimulus is referred to a corresponding point on the opposite side of the body, and synchiria when a stimulus simultaneously arouses the feeling of a sensation at corresponding points of each side of the body. (The Precise Diag- nostic Value of Allochiria, Brain, 1907, p^ Disturbances of Sensory Perception 79 490. The Significance of Phrictopathic Sen- sation, Jour, of Nerv. and Ment. Dis., 1908, p. 427. The Dyschiric Syndrome, Jour, of Abn. Psych., vol. 4, p. 311, etc.) Like Lasegue's syndrome, it is probable that most of the instances of dyschiria were the pro- duct of examinations during which this condi- tion was sought. When by reason of the sug- gestive technique of the examination patients are permitted to grasp the idea that it is pos- sible for a stimulus to be incorrectly localized allochiria and other defects in tactual orienta- tion not infrequently are discovered. Accord- ing to the usual technique the patient's hand, for instance, is stimulated and then she is asked first if she felt anything, then ivhich hand was touched. I venture to state that these defects will never be found if, instead of such a sug- gestive technique, the physician casually tells the patient that after closing her eyes she will perform a certain act when her right hand is touched, and a different one when the left hand is stimulated. In common with other manifestations anaes- thesia may be transferred from side to side, modified, and even caused to disappear by means of the local application of metals, mag- nets, or any kind of apparatus, provided only that the patient can be induced to anticipate any of these results. These phenomena, the consequence of expectant attention on the part 80 Psychopathology of Hysteria of the patient and of suggestion on that of the physician, besides being additional evidence of the psychic nature of symptoms of hysteria, are mentioned in order further to indicate how readily one can misinterpret these manifesta- tions, and how natural it is to ascribe curative virtues to drugs and to other therapeutic means whose beneficial action is due entirely to sug- gestion and to expectant attention. On account of ignoring the effects of sugges- tion many papers and books concerning the curious and remarkable therapeutic effects of local application of metals, magnets, etc., were written during the last century. In fact, metallo-therapy and magneto-therapy were practiced as late as 1880 by many famous physicians and at many hospitals; including la Salpetriere. Even some of the recent text- books contain descriptions of the peculiar effects of applications of metals or of magnets to anaesthetic or paralyzed members, without however, suggestion being recognized as the true cause of these modifications. It is the same principle that caused the vogue of Per- kin's metallic tractors, electric belts, valerian, asafoetida, and the like. It is curious that while many physicians are quite willing to grant that suggestion is capable of producing and of modifying symptoms of hysteria yet they do not recognize the pathogenic effects of their own suggestive examinations, and they Disturbances of Sensory Perception 81 accept with avidity new therapeutic ag^ents whose supposed virtues, in the treatment of the disease, are dependent entirely upon sug- gestion. In case hysteric anaesthesia has not existed for a long time, and provided that it has not been made the subject of much experimenta- tion, and that sensibility is not examined repeatedly, it is usually an easy matter to cause the condition to disappear. Otherwise, it may continue indefinitely as shovni by the old Salpetriere patients; ones that have served as clinical material for a succession of authors. Before proceeding, it is advisable perhaps to state that, excluding exceptional cases in which the diagnosis is obscure, the physician is not justified in creating the "stigmata;" condi- tions which may persist indefinitely unless removed promptly by suggestion. Enough has been written already to point out that the only diagnostic significance they possess is the in- creased suggestibility which they imply. As already mentioned, hysteric disturbances of sensibility are not confined to the tactile sense. Besides absence of conscious percep- tion of tactile impressions there may occur similar perceptual derangements involving the pain sense — analgesia- — , the temperature sense — thermo-ansesthesia — , the pressure, muscle, vibratory, and electrical senses. Being of great importance, "anaesthesia" of the special 82 Psychopathology of Hysteria senses will receive consideration in a separate chapter. Excepting loss of the muscle sense — a condi- tion whose existence is incapable of being con- ceived by most patients — a part which is the seat of hysteric anaesthesia is usually affected also with loss of the pain, temperature, and perhaps even other, senses. Necessarily this must be true, for patients do not possess knowl- edge of the anatomic and physiologic differen- tiation of sensibility, and, consequently, a part that is numb must be numb to all kinds of stimuli. Rarely, involvement of the muscle sense may occur independently in cases of profound anaesthesia, but it may be found more fre- quently if the condition is sought, for then the attention of the patient is directed to the pos- sibility of the occurrence of this manifestation. As compared with what should be observed in case of organic loss of muscle sense the hysteric variety presents some characteristics which, to say the least, are peculiar. Thus, the hysteric is able to maintain the position in which a limb has been passively placed while her eyes were closed, yet, as in two patients I have observed, she asserts that she does not even know where her limb is located. This would be utterly im- possible if the disturbance were organic and advanced to such a degree. Then, too, the hysteric may be able, without the assistance of Disturbances of Sensory Perception 83 vision, to move the affected extremity without any ataxia becoming apparent, even though she is unable to duplicate the position in which the contralateral and normal member has been placed. Other patients who, during an exami- nation, present decided hysteric incoordination of the lower extremities, afterwards walk around without exhibiting ataxia. While examining a hysteric there not infre- quently develops a kind of static ataxia, but even if this be sufficient to cause her to fall, it does not seem to occasion any inconvenience, and almost invariably it can be caused to dis- appear if the physician impresses the patient with positive assurances of her ability success- fully to stand with the eyes closed. It will be noticed, too. that the patients who present this inoeuous form of ataxia are often the ones who complain of vertigo. This is significant be- cause the vertigo serves as a basis from which, by autosuggestion, static ataxia is developed. The conclusion to be drawn from study of the various kinds of disturbances of sensory percep- tion that have been described is that one can not be too careful in testing for the purpose of eliminating possible organic disease, because, if the patient is a hysteric, the very conditions that are sought will be created solely by reason of unconscious suggestion, unless the technique of examination is almost perfect in its freedom from pathogenic suggestion. 84 Psychopathology of Hysteria Formerly, the discovery of hyperaesthetic areas in the inframammary and ovarian regions was supposed to possess considerable diagnostic significance. Clinical experience shows, how- ever, that if pressure is made in any part of the body while asking the patient if pain is pro- duced, areas of hypergesthesia can be cre- ated without further suggestion in almost all cases of hysteria, and wherever one desires. On the other hand, this symptom will almost never be found if the regions supposed to be the elective seat of hyper^esthesia be pressed upon while the patient's attention is directed else- where, or if the pressure be made without hav- ing caused the patient to believe that pain or any other unpleasant sensation is expected. Inasmuch as it was customary, and for obvious reasons, to regard the ovarian and the inframam- mary regions as the ones in which hypersesthesia commonly existed, these were the only ones which ordinarily were subjected to examination. Con- sequently, hypersesthesia in these regions was supposed to be valuable evidence in favor of the diagnosis hysteria. Now, we can interpret this "stigma" almost invariably to be the conse- quence of the suggestive manner in which it is sought. Wlieii occurring independently of examina- tions, quite commonly hyperassthesia results as the peripheral projection of hallucinatory pain arising from a fixed belief that has been en- Disturbances of Sensory Perception 85 gendered — suggested — by some former accident or unpleasant experience. In some of these cases the hj^peraesthesia or pain has been caused to continue long after the painful effects of the trauma, or of the disease process from which it originated, should have disappeared; the con- tinuation being due to fixation of the s\Tiiptom by expectant attention. Following an operation for appendicitis, for instance, the patient may continue to complain of pain or of hyperassthe- sia around j\IcBurney's point. If pressure be exerted in this region the perception, by asso- ciation of ideas mtli the memory complex con- cerning the former appendicitis and the op- eration, arouses a mental representation so vivid as to cause the hallucination of pain. That the symptom is not due to adhesions or to some other cause of actual pain can be demonstrated by causing, through psychotherapeutic means, com- plete and permanent removal of the pain. Syngesthesia is the name applied to that phe- nomenon characterized by mental representation of a perception of one kind of sensation in conse- quence of a stimulus to a totally different sen- sory system. In the subdivision of synsesthesia known as audition coloree the hearing of a cer- tain name, or sound, arouses a fixed color rep- resentation. The various kinds of syngesthesia are due to associations of ideas which were usually formed in infancy. Suppose, however, by reason of the same process — association of 86 Psychopatlwlogy of Hysteria ideas — the sight of a knife or the word ''op- eration" should provoke hallucinatory pain be- cause these stimuli "touch" the repressed com- plex of a surgical operation: then this analogue of an instance of normal synesthesia is patholo- gic because it is not compatible with the best in- terests of the individual. In the absence of an organic cause for the symptom, hysteric pain may be regarded as the hallucinatory expression of a subconscious mem- ory of pain. Prince compares hysteric pain with the power of mental representation possessed by good visual izers and auditives, who revive with the intensity of a hallucination the visual or au- ditory memories of past experiences. He consid- ers hysteric pain to be a quasi-hallucination due to revival of memory images of a former and actual pain. (Amer. Syst. of Pract. Med., p. 628.) Hypersesthesia and pain may occur also in any hysteric patient who has a variety of symp- toms which imply, to her, a disease that ordi- narily is accompanied with pain or tender- ness. If the pain is located in the breast and is associated with hysteric oedema it is pos- sible to mistake the condition for tumor of the breast. Ovarian disease, coxalgia, and other organic diseases may be mimicked in the same manner. Hysteric pseudo-migrane is very com- mon; perhaps more than half of the so-called eases of migrane in women really are hysteric Disturbances of Sensory Perception 87 in origin, and, therefore, the condition has no other relation to true migraine than its super- ficial resemblance to this disease. By reason of the psychic nature of hysteria there is not any structure in which organic pain can arise that is not capable also of being the seat of externalized pain of psychic origin. At all events there should not be any difficulty in distinguishing between organic pains and those due to hysteria. The hysteric often smiles pleasantly while describing the severe pain with which she is afflicted and though her suffering, judging from her description, is so intense that it should pros- trate her, yet it does not seem to cause any real distress. While conversing with the pa- tient one frequently gains the impression that the emotional and physical reactions are exag- gerated, and, upon resorting to a physical ex- amination, careful search fails to reveal any physical cause for pain, or one is found which is insignificant as compared mth the amount of pain of which the patient complains. Pressure upon the alleged painful region not only may provoke an exaggerated expression of distress but it may precipitate some one of the innumerable kinds of hysteric crisis. Dur- ing distraction of the patient ^s attention, how- ever, the same procedure may be repeated with- out causing any evidence of pain whatever. The so-called hysterogenic zones can be de- 88 Psychopathology of Hysteria scribed more appropriately in connection with the attacks of hysteria. Painful organic conditions of the chest and abdomen are productive of a characteristic type of disturbance of respiration; the rate usually being increased, and inspiration being superfi- cial and repressed. Hysteric pain referred to the same regions may be accompanied by in- creased frequency of respiration, but, instead of being shallow and interrupted in type, in- spiration is free and enormousl}^ increased in depth ; especially when pressure is applied over the seat of pain. In case of abdominal pain a valuable differential sign is afforded by the fact that if we press upon that part of the abdo- men which the hysteric asserts is painful, we notice the absence of the protective rigidity that is aroused by painful organic abdominal disease. CHAPTER IV The Disturbances of Sensory Perception — The Special Senses VISUAL Perception. Amaurosis, an unusual condition, though much less uncommon than was formerly supposed to be the case, may be unilateral or bilateral, paroxysmal or con- stant, complete or incomplete — amhlyopia — , and it may persist for many years or appear only as a transitory manifestation. Usually this special type of psychic anaesthesia develops in females, and the unilateral form of visual deficit is decidedly more common than bilateral amaurosis. Amblyopias are encountered much more frequentlj^ than amaurosis, and, like anaes- thesia, they may be either autogenous or the result of suggestion during examination of the patient's vision. Xot a few of the reported cases of monocular amaurosis and amblyopia have occurred in association with homolateral hemiansesthesia and similar unilateral sensory derangements. The reason for this is apparent when one stops to consider that, in the minds of the laity, hemi- ansesthesia should include all of the senses of one lateral half of the body. When amaurosis occurs independently of hemi- anesthesia the cornea and the skin immediately 89 90 Psychopathology of Hysteria surrounding the eye may be the seat of anaes- thesia. This may be explained in the same manner that we account for the anomalous bor- ders of ordinary anesthesia. Just as the layman thinks in popular terms of arms, forearms, and legs, so does he think of the eye as including vision, the eye ball, the eyelids, and adjacent structures ; the popular use of such expressions as "closing of the eyes" being somewhat indica- tive of this conception. Accordingly, in asso- ciation with psychic amaurosis what is more natural than the occurrence of subjective angesthesia of the cornea, and eye lids? The exciting cause, particularly of monocu- lar amaurosis, often is found to be some trauma, rarely other than trivial, which the patient believed capable of producing blind- ness. For instance, in one of Gradle's cases hysteric monocular amaurosis followed an in- jury adjacent to, but not involving, the af- fected eye. (Jour, of the A. M. A., April 24, 1909, p. 1308.) Like the production of other symptoms of hysteria it would appear that anything which merely concentrates the patient's attention upon the visual function is sufficiently sugges- tive to result in amaurosis or amblyopia. In two of my ovni cases amaurosis was evidentlj^ caused by procedures which had induced con- centration of the patient's attention upon vision. The Special Senses 91 Miss M., aet. 23, presented typical major symptoms of hysteria. October 12, 1908, a drop of tuberculin solution was instilled into her right eye, and, to control the test, a drop of saline solution was placed in the left one. The great importance, to her, of the results of the Wolff-Eissner test led Miss M. frequently to examine her eyes ; in fact, there was aroused a constant state of expectant attention cen- tered upon her eyes and upon vision. The next day, though both eyes appeared to be normal, the patient complained of a feeling of irritation in the left one, and of homolateral impairment of vision. She was told, then, that the tuberculin had been instilled only into the right eye. Complete monocular psychic amaurosis, affecting vision with the right eye, was present when she awakened the following morning. Having had explained to her the nature of the blindness, and after positive as- surances that her vision would become normal in the course of a few days, the symptom was caused to disappear promptly without necessi- tating recourse to other procedures. In the case of Mabel A., a major hysteric, aet. 12, attacks of complete bilateral psychic amaurosis developed 22 days after perimetric examination and without any other probable cause being ascertainable. The prolonged and repeated examination with the perimeter, a quite sufficient cause for the production of the 92 Psychopatkology of Hysteria symptom, so concentrated the attention of the patient upon her visual function that, follow- ing a not uncommonly extended period of meditation, or of autosuggestion, amaurosis ap- peared. The attacks of amaurosis, each of which lasted several hours, were caused to dis- appear without difficulty by means of sugges- tion during the hypnotic state. The shock of being told by another physi- cian that her fundi showed evidences either of iirt"emia or of tuberculosis ( !) was sufficient in one patient to provoke bilateral amblyopia of high degree. After the elimination of pos- sible organic causes for the reduction in visual acuity psychotherapy was effectual in causing speedy return of vision to normal, and, it is needless to say, ophthalmologic examination resulted in negative findings. Another instance of an emotional cause is worthy of mention. A young lady was much agitated in anticipation of singing a solo in church. When the time arrived her vision be- came indistinct and the congregation seemed to disappear from view. These symptoms might appear in anyone and without further difficulty being experienced. In the ease of actors with stage fright often the audience ap- pears to be blotted out, but this systematized amaurosis is only a temporary manifestation of a reaction of defense. As stage fright is primarily due to fear of the audience suppres- The Special Senses 93 sion of the visual image of this body must be a conservative process. At all events, the young lady was subject to hysteria, and, consequently, the temporary emotional blurring of vision be- came elaborated into complete bilateral amaurosis. It was necessary to lead her home, and the symptom persisted for three days, when spontaneous recovery of vision occurred. Following this experience any decided excite- ment was sufficient to provoke a similar at- tack. Recurrence of hysteric accidents is common. It seems that any emotional disturbance tends to cause repetition of former pathologic reac- tions providing that another kind of reaction is not casually suggested upon the patient. Moreover, transitory attacks of amaurosis are quite common ; it is only the more permanent ones which are unusual. As all the possible accidents of hysteria are potential in a given case and as each requires only an adequate exciting cause to render it actual, so in these four cases the diagnostic tests and the emotional disturbances were quite sufficient to determine the genesis of amaurosis. Naturally, a factor which is capable of acting as the exciting cause of a symptom in one hysteric individual is of negligible etiologic importance in others ; the harmlessness of the factor or the induction of pathologic conse- quences depending entirely upon the personal equation. 94 Psychopathology of Hysteria One of the symptoms of hysteria is the ten- dency, exaggerated above the normal, towards interference with the perfect accomplishment of volitional acts, and more particularly of more or less automatic acts, when the patient's attention is directed to their performance. For this reason, during examination of visual acu- ity, amblyopia may often be noticed in the same manner that dyamometric examination may ap- pear to indicate that the patient's gripping power is greatly diminished. In either case the condition is brought about by the tests and usually it disappears promptly with the con- clusion of the examination. These subjective and temporary amblyopias are well known, and, in testing the visual acuity of hysteric patients, every ophthalmologist employs sug- gestion, whether unconsciously or intention- ally, in the effort to reassure the patient and to induce her to read the letters of just one more line lower down on the test card. It is not im- possible, too, that tests of visual acuity may occasion more persistent amblyopia or amaurosis just as perimetric examination of Mabel A. eventuated in the production of this symptom. Prince has written of a patient whose peculiar kind of amblyopia may have been produced by an examination of vision. The patient had always believed that his vision was good until he was examined to determine his fitness for appointment to the Boston police force. As the The Special Senses 95 examination showed defective visual acuity, each eye being tested separately, he was reject- ed. Subsequently, he was examined by Dr. Putnam and Dr. Prince who found that while binocular vision was 20/15 monocular fixation reduced his vision to 17/100 with the left eye, and to 17/70 with the right one. (Plysterical Monocular Amblyopia Coexisting with Normal Binocular Vision, Amer. Jour, of the Med. Sciences, Feb. 1897). Even a distressing sight may cause amauro- sis. Great excitement normally may bring about a temporary and more or less complete inhibition of vision. In such cases the individ- ual asserts that everything became dark, or that he acted without being able to see what he was doing. When one witnesses a distress- ing or revolting scene, there is a tendency to shut out the view by closing the eyes, or by clapping the hands over them. Consequently, when hysteric amaurosis develops after such an exposure^ the condition seems to be but the psychic elaboration of this normal reaction of defense. And the dissociation of visual per- cepts from consciousness once having occurred, the symptom, in a hysteric, would tend to per- sist indefinitely. An excellent instance of this mode of genesis is afforded by a case which was reported by H. Gradle, who writes: *^The patient, hitherto in good health, had had a severe shock to her feelings, . . . , and, 96 Psychopathology of Hysteria clapping her hands to her eyes to shut out the sight, found herself absolutely blind/' The next day, suggestion, reinforced with mild faradism, caused the return of conscious perception of visual impressions. (Gradle: op. cit.). In the more pure forms of hysteria the pres- ence of amaurosis may not annoy the patient nor cause her to be alarmed. In fact, complete bilateral amaurosis may not cause any in- convenience in some cases, and, in spite of the visual loss, the patient may contrive to go about as usual ; though exhibiting, perhaps, the uncertain actions of organic blindness. Be- cause of its psychic nature, and in contradistinc- tion to most varieties of organic blindness, the reflexes of the iris are unimpaired, with but few exceptions, and ophthalmologic examina- tion fails to reveal any pathologic changes. It scarcely need be mentioned that the suddenly appearing ambloypias due to toxaemias and to exposure to intense light, may not be accom- panied with fundus changes, and, therefore, these possibilities must be excluded before making a diagnosis. Of some diagnostic impor- tance is the discovery of corneal anaesthesia and of a ring of anaesthesia surrounding the eyes. While reading a book the attention of a normal person may become concentrated upon some ex- traneous idea. Subconsciously he continues to The Special Senses 97 read; but when his attention returns to the book he finds that he is ignorant of all that he had read while his attention was diverted. Now, we know that experiments performed under sim- ilar circumstances have been successful in caus- ing the subject to reproduce the memories of events which occurred during distraction of at- tention, and we are justified, on these grounds, in asserting positively that in the above instance it would be possible to effect reproduction of the subject matter which was read while the indivi- dual was pursuing the extraneous line of thought. During distraction of his attention the person was not blind ; he continued to read auto- matically but the visual perceptions were not synthetized wdth consciousness. Hysteric amau- rosis is identical in character. The visual ap- paratus of the hysteric is normal, and subcon- sciously visual perception occurs, as can be demonstrated readily, only she is not attending to these perceptions. They remain subconscious ; they are not sjTithetized with consciousness. In her case the mental blindness is due to dominant belief in her inability to see, and just as soon as she can be induced sincerely to expect disap- pearance of her blindness it wdll disappear. Let us adduce another common example of the psychic blindness of absent-mindedness. While walking along the street a person whose attention is concentrated upon some problem passes his friends, perhaps looking directly at 98 Psychopathology of Hysteria them, yet fails to respond to their salutations. Subconsciously he sees them, but there is lack of that personal perception which is requisite for conscious recognition. In the same manner he fails consciously to perceive the many visual im- pressions which arise, and he may even walk past his destination. By means of post-hypnotic suggestion one is able to create a psychic blindness which will per- sist after the hypnotic state has been caused to disappear. When produced in this manner psy- chic amaurosis possesses all the characteristics of that due to hysteria, and in itself is indistin- guishable from hysteric blindness. With the as- sistance of hypnotic suggestion, or of post-hyp- notic suggestion, one can cure hysteric amauro- sis. These facts, together with the known influ- ence of extra hypnotic suggestion in causing, modifying, and in curing hysteric blindness, seem to be sufficient grounds for the proposi- tion that hysteric amaurosis, in common with other symptoms of the disease, is always the effect of expectant attention, suggestion, or whatever one wishes to call the process. As such, the condition is really the same as that produced with hypnosis, from which it differs only in its mode of production; the first being due to autosuggestion that has been induced by some external stimulus, or suggestion, that even may have proceeded accidentally from a second person, and the other being the direct The Special Senses 99 eiffect of intentional suggestion by another. Otherwise, the nature and mode of genesis of inorganic psychic blindness have never been explained in a manner that is compatible with what now is known of its qualities as revealed by experimentation. Hysteric monocular amaurosis might be com- pared with the habitual suppression of the secondary image of diplopia in cases of strabis- mus. A more accurate comparison is afforded by the voluntary suppression of visual impres- sions arising in one eye, when, with the other, the pathologist is intently studying some specimen with the microscope. Even more interesting is hysteric system- atized amaurosis, a condition in which lack of conscious perception of visual impressions is confined to one or more kinds of objects ; vision otherwise being normal. This symptom, too, is but the pathologic exaggeration of what is a normal peculiarity. The foUomng citation from Jastrow'of a normal instance of system- atized psychic amaurosis and anesthesia serves well to introduce the subject: "A business man living in the suburbs, as he entered the train upon his homeward journey, reflected upon the threatening aspect of the sky, and considered the chances of finding his carriage awaiting him at the station, in case the impending rain came on. His hopes were doomed to disappointment; and he resigned 100 Psych opathology of B.ysteria himself to a wet walk home. As the downpour became heavier, he more keenly regretted his wavering hesitation in the morning in regard to taking an -umbrella. When at length he pre- sented himself dripping at his door, he was greeted with shouts of derision at his plight; for tucked under his arm was the umbrella, unopened, unperceived. So convinced had he been that he had neglected to provide himself with this protection, that the repeated solicita- tions to his senses offered by the presence of that object passed unheeded. Doubtless, in the course of his walk, the umbrella had fallen within the range of his vision; and certainly his arm had sufficiently attended to the feelings resulting from the carrying of the article to prevent its being dropped. To these appeals to see and feel and recognize did his mental prepossession ren- der him blind and insensible. Had any passer- by broken through his "absent" spell and pointed out his neglected opportunities, he would at once, and with some surprise and amusement, have seen and felt and consciously used what in his reflections he repeatedly longed for: in this last consideration lies the normality of the ex- perience." (The Subconscious, 1906, p. 306.) Now, let us consider a pathologic instance ; one described by Morton Prince in his report of the Beauchamp case of multiple personality. One of the alternating personalities had lost one of ^liss Beauchamp 's rings. In order to insure the safety The Special . Senses 101 of the other two a second personality had strung them on a ribbon about her neck. Believing that all the rings had been lost Miss B, could neither see nor feel the remaining two. Even when the rings were struck together she was unable to hear the resulting click. In these two cases, the one normal and the other pathologic, we have to deal with lack of sjmthesis with consciousness of all kinds of sen- sory perceptions arising from certain objects — an umbrella in the first instance, and a ribbon and two rings in the second one. The deficit, therefore, is systematized and it involves each sense that is stimulated by these objects. In other words, owing to a firm conviction the umbrella, ribbon, and rings had ceased to exist as far as consciousness, only, of the various perceptions of each of these objects was concerned. Excluding consciousness each of these objects was perceived. Otherwise, as Jastrow remarks, how could the man have carried his umbrella? And in Miss B.'s case a second personality had actually sus- pended the rings from her neck. In the normal instance the business man was dominated by the con"\iction that he had left his umbrella at home with the consequence that all kinds of percep- tions arising from the umbrella failed to be synthetized wdth consciousness. In the same way Miss B. was dominated by the belief that her rings were lost. Suppose, now, that a hypnotic subject be given 102 Psychopathology of Hysteria the suggestion that a third person, C, has left the room, and that only he and the one who induced hypnosis remain. After dissipating the hypnotic condition it will be found that the sub- ject exhibits a systematized lack of conscious perception of all kinds of sensory impressions aroused by C, and the resulting condition re- sembles that of the business man and of Miss Beauchamp. Only in this case the conviction is deliberately suggested upon the subject by his hypnotizer while in the other instances it arose spontaneously. The various kinds of systematized deficiency of personal perception have been designated negative hallucinations. Though convenient, this term, originated by Bernheim, has been con- sidered inappropriate. More objectionable are descriptions in which the lack of conscious per- ception of various kinds of sensory impressions is said to be due to dissociation of these percepts from consciousness. In order that percepts can be dissociated antecedent synthesis must have occurred, and if dissociation took place after synthesis, then the resulting condition would be amnesia instead of a disturbance of perception. Diagnosis of Binocular Hysteric Amau- rosis. Without the use of psychic means it may be difficult, indeed, to exclude organic blindness. With the assistance of hypnotism one may be able to make a positive diag- nosis of hysteric amaurosis by means of demon- The Special Senses 103 strating the existence of unconscious vision. For the patient, while in the hypnotic state, per- haps can be caused consciously to see as well as before the onset of the symptom, and, in addi- tion, he may be induced to state the name of an object which had been held before his eyes pre- "sdous to hypnosigenesis. Excluding the application of hypnosis as a diagnostic means there are other tests which may not be so successful. A simple one is to have the patient look at an open book. Normally there is an irresistible tendency for the eyes to traverse the page, and if these ocular movements occur with the jjatient one is justified in pre- suming that some kind of vision exists. By means of having the amblyopic patient write automatically Binet succeeds in demon- strating subconscious perception of letters which are too small for the patient consciously to per- ceive; and the writing of these letters proceeds while the patient reiterates his inability to recog- nize them. (On Double Consciousness, 1905, p. 32.) With the assistance of the method of guessing it is possible, sometimes, to secure positive results in cases of hysteric amblyopia. Suppose we tell a patient whose visual acuity is 10/70 that we know she is unable to read the smaller letters two lines lower down on the test card, but that we desire her simply to make rough guesses of these letters as we point to them. Often tbe 104 Psychoxjathology of Hysteria guesses are correct, just as in case of anaesthesia the number that flashes into the patient's mind after we have touched the anassthetic region a certain number of times is the same as the num- ber of tactile stimuli. In either case the patient declares that she does not see the letters or that she has not perceived any sensations in the affected region. Naturally, it may be possible to improve visual acuity by employing suggestion — even without induction of the hypnotic state. "When resort is had to this kind of suggestion it is important that the patient should not become aware of its use, and, therefore, we must dis- guise the suggestions. For example, after noting the patient's visual acuity, we tell her that different test lenses are to be tried in order to determine which improves her vision the most. Now, by employing plain glasses while making free use of suggestion, it may be noticed that vision is materially improved. Diagnosis of Monocular Hysteric Amau- rosis. As a layman is ignorant of the physi- ology of the visual mechanism, unilateral psychic blindness, whose character is founded solely upon his conceptions of vision, necessarily must present some very curious physiological incon- sistencies when the condition is subjected to- various tests. In the study of patients with hysteric monocu- lar amaurosis even more apparent than with The Special Senses 105 other symptoms of the disease, is the fact that the results of experimentation are determined almost entirely by the patient's conception of the disturbance with which he is afflicted. He is blind in one eye only because he is firmly con- vinced that such is the case. Any test which is adopted for the purpose of demonstrating vision in the amaurotic eye and whose significance is not appreciated by the patient will succeed, then, for the reason that it does not conflict with his belief. We should be able, therefore, to differ- entiate readily this visual disturbance from organic blindness of one eye. The differentia- tion is rendered still more simple by reason of the number of excellent tests to which we can resort. In the presence of binocular single vision diplopia occurs when one eyeball is displaced by pressure. The same effect may be produced more accurately and less rudely if we take ad- vantage of the principles of refraction and place a prism before one eye. In case of or- ganic monocular amaurosis both displacement of one eyeball and the use of a prism before either eye must necessarily fail to produce reduplication of the image. Consequently, if a patient with unilateral blindness can be caused to experience diplopia by either of these means the existence of binocular vision is proven — the blindness is psychic. It is possible that the test may fail because of lack of synthesis -with 106 Psychopathology of Hysteria consciousness of the perception of the image which is on the same side as the amaurotic eye. Or, when the prism is used, the two images may become fused if the ocular muscles are strong enough to counteract the refractive effects of the prism. A test has been described by Prince that does not require any apparatus but which necessi- tates care in its application. While the patient is reading, a pencil is slipped before the normal eye. If the blindness is organic, one or more words, being obscured by the pencil, are not seen by the patient. If the condition is hysteric the patient may continue to read without skip- ping any words, thus demonstrating the per- ception of visual impressions which could have originated only in the blind eye. One must be careful to hold the pencil between the normal eye and the printed page and to hold it still. Likewise the patient's head must not have moved during the test. Like other tests this one will fail if the patient becomes aware of its full significance. To render its performance less obvious artifice may be employed. For instance, one may disguise the test by saying: **When I raise this pencil continue to read, but do so more rapidly." Then, apparently as an accident, the pencil is raised high enough to be in the visual axis of the normal eye. Another ^experiment whose application is easy, but which may not yield positive results, The Special Senses 107 is that of Pitres: Even though a screen — a blotter for instance — is held vertically between the patient's eyes and at right angles against his face he may be able to read from a book in spite of the fact that one lateral half of the page can be seen only with the amaurotic eye. If the screen is not held perpendicular to the center of the page the results are vitiated. Monocular amaurosis must be psychic if the patient, when looking through a stereoscope, acknowledges that the picture stands out in relief, because the successful use of this con- trivance requires binocular single vision. Be- sides these simple measures, tests dependent upon hypnosis, and similar to those employed in detection of hysteric binocular amaui'osis, can be applied with positive results in many cases. With the assistance of special apparatus suc- cessful results are more apt to be secured. Stoeber's ingenious device comprises a pair of spectacles containing one red and one green glass, and an object consisting of a printed word, of which the letters are alternately red and green upon a black background. When a patient with organic blindness fixes the object through these glasses he can read only those letters whose color is the same as that of the glass which covers the normal eye. If a pa- tient is able to read the whole word then his 108 PsychopatJiology of Hysteria visual defect either is due to hysteria or it is feigned. When the box of Flees is used what is seen with one eye appears to have been seen with the other, so that the hysteric reports having observed either both objects or only the one •which, in reality, was seen with the amaurotic eye. The malingerer asserts that he noticed but one object, and he indicates the one which we know could have been seen only with the eye which he affirms is blind. While the indi- vidual with organic monocular amaurosis re- ports having observed an object which, to his surprise, appeared to have been seen with his blind eye. Unfortunately, the results of these experi- ments, except those dependent upon hypnosis, may be the same as the results obtained with malingerers. As far as the tests themselves are concerned there may not be any way of differ- entiating the two conditions and the diagno- sis may depend entirely upon associated symp- toms and upon the experience of the examiner. In commenting upon this diagnostic difficulty H. Gradle writes: "The distinction between hysteric — or let us say psychic — blindness and wilful simulation can not be based upon objec- tive findings. They would be the same in both cases. We must base our judgment on a psychologic analysis of the patient's mind and object." The Special Senses 109 If the utmost care is not exercised in making the tests the answers of a clever malingerer, or of a simulating hysteric, may be the same as those of a patient with organic monocular amaurosis. In either case the subject may be enabled to do this if he has the opportunity furtively to close the supposedly blind eye and thus to acquire information concerning what should be seen were his feigned symptom real. Or. if intelligent, he may be able to grasp the significance of certain of the tests. As a hypnotized malingerer ordinarily would not acknowledge that previous to the induction of hypnosis he had seen an object with his "blind" eye such a test would be useful; unless we accept as true the fallacy that a hypnotized person always must tell the truth. The results, too, of the tests that have been described may appear positively to prove that hysteric unilateral blindness is only a feigned symptom ! But how can we account for those cases in which the condition persists for years in patients who do not have any motive for simulation, or who have excellent reasons for desiring that their A^sion should be normal? For instance. Prince's amblyopic patient had gone to much trouble in his attempt to qualify for appointment to the police force. As he de- sired this appointment it was not to his inter- est to simulate defective vision. Yet the tests seemed to indicate that he was deliberately 110 Psychopathology of Hysteria malingering; provided that one disregards the fact that the same results could be obtained in hysteria. This patient had perfect binocular vision but each eye separately was amblyopic. A prism having been slipped before either eye during binocular fixation amblyopia developed at once. Novir, the patient once having reacted in this manner the same results were obtained when two prisms were placed together so as to counteract each other and then held before his eye. One who failed to consider the patho- genic influence of belief would conclude at once that this patient was a malingerer. According to de Schweinitz hysteric amauro- sis may last even as long as ten years, though vision has ultimately returned in all recorded cases. Wlien the patient comes under treat- ment before the condition has had time to be- come fixed, removal of the symptom is com- paratively easy. In addition to its diagnostic value, hypnotic suggestion possesses great therapeutic efficiency. Even though the patient be not hypnotized syn- thesis of the visual function with consciousness possibly may be effected without difficulty by means of suggestion. In case suggestion is em- ployed the various suggestions should be made as positive as possible without, however, allowing the patient to become aware of its use. The necessity for this lies in the fact that the more apparent and more direct the suggestion the The Special Senses 111 more inclined is a hypnotized patient to accept and to act upon it, while in the application of suggestion to one who is not hypnotized, the chances of successful realization vary directly with the patient's ignorance of its employment. The effect of suggestive treatment is mate- rially increased when the suggestions are rein- forced and disguised by the use of such an im- pressive agent as electricity. The physician suggests, for instance, that the blindness will disappear when the electrode is applied. Or the patient may be placed in a dark room, and, after having received an electrical treatment, her eyes are bandaged while she is assured that her sight will be normal when the bandages are removed the next morning. As each therapeutic failure tends to convince the patient of the incurable nature of her mal- ady it is best not to incur this risk and to waste valuable time by holding hypnotism in reserve. Instead of waiting until other measures have failed we should use first, as J. Arthur Booth has recommended, the therapeutic resource which offers the greatest possible chance of success; and this is hypnotic suggestion — the most effective kind of suggestion. (Hysterical Amblyopia and Amaurosis — Report of Five Cases Treated wdth Hypnotism, Med. Rec, Aug.. 24, 1895.) Byschromatopsia. In the same manner that complete amaurosis occurs so also does 112 Psychopathology of Hysteria psychic blindness for colors — achromatopsia. To the achromatopic patient all colors appear grey. The oft quoted experiments of Parinaud show that hysteric achromatopsia is entirely a psychic disturbance. In case of monocular color blindness a green object appears to be grey when seen by the achromatopic eye. Now, if diplopia is produced by placing a prism be- fore the normal eye the patient may declare that both images are green, as they really are. But, the production of diplopia necessitates vision with both eyes. Therefore, perception of one of the images is dependent upon an eye which is color blind. If the patient states that both images are grey then the use of the prism has effected a temporary achromatopsia of the normal eye. When the prism is placed before the achromatopic eye the patient declares either that both images are grey or that they are green. Naturally, these results imply the same peculiarities of perception as did the results obtained when the prism was placed before the normal eye. Bernheim was the first to show that achroma- topsia could be caused by means of hypnotic suggestion, and that when thus produced the condition experimentally is identical with that of hysteria. Discarding, therefore, the involved explanation of Parinaud he contended that both hysteric and hypnotic achromatopsia were the product of suggestion. In this he is sustained by the modern French neurologists. The Special Senses 113 When there is total lack of synthesis with con- sciousness of perceptions of only one kind of color impressions the cause of the defect should be readily discovered. A hysteric who has had some terrifying or disagreeable experience may afterwards develop achromatopsia for one color which was prominently identified with the pain- ful experience. This partial achromatopsia con- stitutes part of a reaction of defense for the reason that the memory complex concerning the experience has been dissociated from conscious- ness and as conscious perception of the color would subsequently tend, by association of ideas, to recall the dissociated complex these percep- tions are also repressed. In these cases, too, the disturbance can be demonstrated to be psychic in nature. The neat experiments of Charcot and Regnard suffice. These depend upon the principles of fusion of colors. Wlien red and green are fused by me- chanical means — rotating disc — the patient mth monocular blindness for green declares that she sees a greyish tint. Now, such a tint, under these circumstances, requires the perception of its green constituent; otherwise, the patient, per- cei^dng green as white, should see light red as the result of fusion of red and green. The different kinds of psychic disturbance of color perception are very infrequent in this countrj^. May not the reason for this depend upon the fact that physicians of this country do 114 Psychopathology of Hysteria not usually include in their examinations tests of color perception? Therefore, dyschroma- topsias not being sought they are less apt to be accidently suggested upon the patient. Concentric Contraction of the Visual Fields. This '^ symptom," one of the classic *' stigmata" of hysteria, was considered to pos- sess considerable diagnostic importance. It is probable, however, that it is always caused by suggestion during perimetric examinations and, consequently, it is indicative only of the abnormal suggestibility which is essential to hysteria but which also occurs in other psycho- neuroses. In reference to 86 cases reported from Bernheim's clinic Amselle states that not even once were hemianesthesia and retraction of the visual fields discovered in patients who had not been examined previously. (Conception de I'Hysterie, p. 237, 1907.) That concentric contraction of the visual fields is not a spontaneous symptom of hysteria can be reasonably ascribed to the improbability that a layman could conceive such a condition. As the symptoms of hysteria are dependent either upon the conceptions of the patient or upon accidental suggestion — using this term in its most comprehensive sense — one might lay down the axiom that the hysteric is incapable of pre- senting any symptom of which previously she did not have some conception, or which was not suggested upon her. Neither can one experience The Special Semises 115 a dream whose content is independent of all previous knowledge, nor can one cause a hyp- notic subject to hallucinate an object which he had never perceived. It is not intended to convey the impression that concentric contraction of the visual fields is always created by reason of a faulty technique of examination, but that the examination per se is sufficiently suggestive to determine the pro- duction of this condition unless the physician employs suggestion in order to counteract the tendency. Except those patients whose fields previously have been examined, it is most un- usual to find contraction of the fields in hyst-erics who are examined with the rough finger test, provided that this is performed in a manner that is not too elaborate nor too prolonged. "With the perimeter, an imposing and suggestive apparatus and one which requires that the patient be subjected to an unduly prolonged examination, it is rare, indeed, not to find mod- erate or high grade contraction of the fields unless the physician, by his antagonistic sug- gestions, prevents the production of the condi- tion. During former investigations of the visual fields it was my custom to eliminate verbal sug- tion, at least, by explaining to the patient just what was required; stress being laid upon the injunction that she was to say "now" just as soon as she saw the peripheral white spot. Then the 116 Psychopathology of Hysteria examination was commenced and finished with- out further directions or remarks. In this man- ner suggestions, whether tending to cause or to prevent the production of concentric contrac- tion, are avoided and only the suggestive char- acter of the examination itself remains. Under such conditions reduction of the visual fields varying from a moderate amount to contractions so extreme as to indicate pin-point vision were invariably found; even though previous rough finger tests showed, in almost every case, that the fields were approximately normal. On the other hand, if the physician desires to avoid the production of concentric contraction it is easy to do so by means of suggestion and persuasion during the course of the examina- tion. By this means distraction of the patient's attention is avoided, she is induced to attend strictly to peripheral vision, and, in addition, if vision at any one radius does not correspond to the normal she is assured that she can do better than that and the test is repeated. "When this technique is adopted concentric contraction of the visual fields rarely will be found in cases whose fields are being examined for the first time. In order to prove that hysteric contraction of the fields was only subjective it was my custom to hold up several fingers in the arc of the peri- meter well beyond the limit of the field which had been previously determined. Upon asking The Special Senses 117 the patient if she saw the fingers the reply would be negative. Then, resorting to hypnosis, it was usually easy to induce her to state just how many fingers she had seen in the supposedly blind portion of her field. I soon found, how- ever, that hypnosis was unnecessary; for it was much easier simply to ask her in a positive man- ner how many fingers she saw. Since adopting this procedure not one of perhaps 25 consecu- tive cases of hysteria has failed to ansvv^er cor- rectly the majority or all of the times that the test was repeated. Such a test, which is but one of many similar ones which may be employed, experimentally proves at once that hysteric concentric contrac- tion of the visual fields is only a psychic dis- turbance. Clinically, this fact has been known for many years. How, otherwise, could we ex- plain the following case described by Janet: A boy who developed crises whenever he saw a flame, possessed visual fields which were con- tracted to 5°, yet a crisis could be precipitated by holding a lighted match at 80° while the patient was at the perimeter and fixing its cen- tral point. (Major Symptoms of Hysteria, p. 197.) How, too, could we account for the fact that there is not any embarrassment of the actions of those patients whose fields are con- tracted to a point, and in whom the condition has been fixed by repeated examinations and clinical demonstrations. In reference to this 118 Psychopathology of Hysteria anomaly Janet writes of a patient who was able to play at ball in spite of an extreme degree of contraction of the fields. It vv^ould be hardly necessary to state that this would be absolutely impossible in case of organic contraction to the same degree. Try to imagine anyone playing ball while looking through a pair of telescopes or a double barrelled gun! In spite of the laws of optics a contracted field of hysteric origin remains the same regardless of any increase of the distance at which it is taken ; instead of enlarging, as it should. Natu- rally, this inconsistency depends upon the con- ception of the visual defect that the patient formed during the first perimetric examination. Being ignorant of optics she believes that the area which she can see should remain the same whether she is fixing upon an object one foot away, or on one which is at a distance of 20 feet. It was remarked, also, that the size of the field could be made to vary according to the use of suggestion by the examiner, and accord- ing to the mental state of the patient while being examined. By causing the patient to con- centrate her attention upon some problem Janet secured variations amounting to as much as 60°. Finally, it is possible, with hypnotic suggestion in almost all cases and with suggestion during the usual state of consciousness of the patient in most cases, to enlarge, perhaps even to the normal, a contracted field. Likewise, one may The Special Senses 119 create a contraction in patients whose fields previously had been normal. From a diagnostic point of view there should not be the slightest difficulty in differentiating the concentric contraction of hysteria from the infrequently encountered similar visual defect of multiple sclerosis, or the quite common one of tabes dorsalis — 50% of 25 cases in which the disease had existed for an average of 51/2 years — and of other varieties of optic atrophy. The advisability of producing contraction in hysteric patients is decidedly questionable; though apparently they do not seem to incon- venience or to harm the patient in any way, considered as a means of diagnosis the field changes that have been described can be re- garded only as indicative of abnormal sug- gestibility and not as essential symptoms of the disease. Furthermore, the functional con- traction which is elicited by examination is by no means pathognomonic of hysteria ; in the other psychoneuroses it can be observed just as frequently, but usually not to such an ex- treme degree as we find in some cases of hysteria. Ordinarily, it is thought that spiral fields are characteristic of neurasthenia, and that the condition is due to progressive fatigue occa- sioned by the examination. In hysteria, never- theless, spiral fields are created more commonly than in neurasthenia when the perimetric ex- 120 Psychopathology of Hysteria animation is conducted according to the tech- nique which I have described. Moreover, fields which are concentrically contracted may be changed into spiral fields solely as the effect of the manner in which the patient is ques- tioned during repetition of the examination. Let me adduce a typical example: As examined by the rough finger test, the visual fields of Lizzie B. were approximately normal; perimetric examination, however, re- sulted in production of spiral fields of small amplitude. Being so marked, the contraction could not have escaped detection by the finger test; consequently, it must have been caused by the perimeter. During the same visit, re- examination resulted in diminution of the fields to a point. Seven days later the fields were found to have remained unchanged. After about six months had passed, she was subjected to a third perimetric examination. Commenc- ing at 0° and progressing rapidly from the nasal to the temporal fields, the tests were made 30° apart in order not unduly to prolong the examination. After one complete circuit of the left eye she was allowed to rest five minutes, and then the right field was taken. Although hysteria is characterized by the opposite of abnormal readiness to the induction of fatigue, periods of rest were allowed on returning to the left eye, at the termination of each complete circuit. Proceeding in this manner, the spiral The Special Semises 121 field which was produced could not have been due to transient fatigue. Being able, after- wards, correctly to count fingers which were held in the arc of the perimeter at the periphery of what should be the normal field, she was given a brief explanation of the fields of vision, and, furthermore, the inconsistency of the re- sults in her case was demonstrated to her. Now^ upon repeating the examination, her fields were found to be practically normal. Repeated single tests which were without defijiite radial sequence verified the boundaries of these fields. When produced by the technique already de- scribed both spiral fields and the fact that, in case of concentric contraction, the field of the second eye examined is usually smaller than that of the first, can be explained acceptably by assuming that the further one proceeds with the examination the better able is the patient to grasp the suggestion which it implies, and. conse- quently, the more forcible it becomes. This cumulative effect of the suggestive nature of perimetric examination is like the cumulative effect of suggestions during the hypnotic state. When a hypnotized subject refuses at first to accept a suggestion often it is necessary only that it should be repeated several times, and with each repetition one can plainly see that the resistance of the subject is decreased until, fin- ally, the suggestion is accepted and acted upon. 122 Psych opathology of Hysteria The Color Fields. As investigations of the color fields require extended perimetric ex- amination, and as it is extremely difficult to induce a hysteric to concentrate her attention upon one subject for any length of time, such investigations necessarily must be extremely variable in their results; even more so than we fiend in our examinations of the fields for white. It is well known that the size of the visual fields of a hysteric to a great degree is de- pendent upon suggestion and upon the amount of concentration of the patient's attention on the examination; distraction of her attention being accompanied by reduction in the size of the field which is being examined at the time. "Whenever the patient becomes preoccupied with some extraneous idea, or whenever her atten- tion is distracted by some noise, someone enter- ing the room, or what not, we notice correspond- ing modifications in the size of the visual field. "We may find, therefore, that the field for red is larger than that for blue simply because the patient's attention was concentrated upon the examination while she was being tested with the first color, whereas her attention was distracted during the tests with blue. Moreover, being pro- longed the examination is apt to arouse a state of indifference, or of active rebellion, with the consequence that each successive field may be- come smaller. The cumulative effects of the suggestive character of the examination tend to The Special Senses 123 produce the same sequential modification. A priori, then, one should not expect to find any typical or constant relative disturbance of the color fields. Clinically, this inference receives abundant verification. In their mode of production contractions in the color fields need not be considered as differ- ing in any way from contraction of the field for white; all such contractions being the effect of the increased suggestibility characteristic of hysteria. It has been considered that inversion of the color fields was a prerogative of hysteria. Of the greatest importance, therefore, are the findings of Bordley and Gushing relative to the color fields in cases of brain tumor. Their in- vestigations show that inversion is just as char- acteristic of brain tumor as it has been con- sidered to be of hysteria. (Archives of Ophthal., Sept., 1909.) In a later paper Gushing and Heuer (Jour, of the A. M. A. 1911, 2, p. 200) state that out of 123 patients with brain tumor in which perimetric examination could be made there were 53 who presented contraction and in- version of the color fields, and, what is more important, in ten of these the disturbances occurred in the absence of choked disc, or else only a very incipient process was found. On the other hand, one must not forget the fre- quency with which symptoms of hysteria, as Gowers has remarked, are painted upon a back- ground of organic disease, and thus to ascribe 124 Psychopathology of Hysteria to brain tumor symptoms which may have been the effect of increased suggestibility due to super- imposed hysteria. Hemianopsia. That hemianopsia ever occurs as a symptom of hysteria has been the subject of controversy. At all events, a few cases have been reported, and besides, there is no good reason for assuming that this type of de- fect in the visual field cannot develop. The infrequent occurrence of hysteric hemianopsia can be explained on the grounds that laymen do not possess knowledge of the difference in the cerebral distribution of fibres from different parts of the retina, and, therefore, they cannot have any conception of hemianopsia. Moreover, perimetric examination, as usually conducted, tends to cause general reduction of the fields and can hardly convey to the patient the sug- gestion of hemianopsia. In about 50% of those afflicted with migraine the attack is preceded by some visual disturb- ance. Quite commonly this assumes the form of a scintillating scotoma which may produce com- plete but transient hemianopsia. Now, is it not reasonable to assume that a hysteric who in this manner has acquired knowledge of homonymous hemianopsia subsequently may develop hysteric hemianopsia ? May not the symptom of migraine or of auto-intoxication become fixed as a result of the tendency of hysteria to appropriate and to elaborate the symptoms of other diseases ? At The Special Senses 125 any rate, one patient stated that shortly before psychic homonymous hemianopsia appeared she had experienced for the first time a scintillating scotoma which had obscured the same half of her visual field. If hysteria were more com- monly associated with true migraine probably hysteric hemianopsia would be less infrequent. A second patient declared that she had been ivell until her fifteenth year when suddenly she lost the ability to see anything to one side of "the point at which she was looking. Without being prompted she explained in detail the na- ture of this difficulty. Careful inquiry failed to disclose the cause of the symptom; she had never experienced a scintillating scotoma, and, before the onset of the symptom, her eyes had not been examined. Following the first attack of hemianopsia she had been subject, for a v7hole yeSiT, to other ones that lasted about twenty minutes and which occurred several times daily. Beginning with this visual dis- turbance a most severe type of major hysteria became evolved. Deafness. In hysteria, whatever is done or perceived in a more or less unconscious or automatic manner is apt to be accomplished or perceived better than when the act receives the conscious attention of the patient. On account of this, together, perhaps, with the effects of the suggestion implied by the test, hysteric pa- tients who present evidences of possessing an 126 Psychopathology of Hysteria ordinary amount of strength almost invariably are incapable of registering on the dynamome- ter a degree of strength greater than that of a child. Or, when testing vision, conscious per- ception of the test letters may be no better than 10/50, yet, at other times, visual acuity of the same patient is obviously normal. In the same manner hysteric patients whose hearing evidently is normal almost always show, when tested, decided reduction of acuity of audition ; unless this functional impairment is prevented by suggestion. Suppose we subject a number of hysterics to an examination in which the following tech- nique be employed: The patients are directed to declare when they hear the watch, and then no other remarks are made during the course of the test. Each ear is tested by gradually bring- ing a watch from an inaudible distance towards the ear. It will be found that with a watch that should be heard at about three feet, in the neighborhood of 90% of the patients do not detect the ticking at a distance greater than about five inches, and approximately 10% re- quire the watch to be placed in contact with the ear. Having examined a hysteric who asserts that she is unable to hear the watch until it is placed in contact with her ear, and having had her close her eyes, let us hold the watch sta- tionary at almost the extreme limit at which The Special Senses 127 it should be heard. Now, by asking at fre- quent intervals, ' ' Do you hear it yet ? ' ', the im- pression is conveyed that the watch is being gradually brought closer to her ear, as it was during the first test. After a few such ques- tions the patient announces that she perceives the ticking. In the absence of an organic cause for the impairment this experiment in my hands has failed to succeed in only two in- stances. In a few cases, however, before a positive response can be obtained it may be necessary to bring some metallic object into contact with the patient's ear, thus causing her to believe that it is the watch which she feels. Having demonstrated the subjective nature of the reduction in hearing, and while retaining the watch in the same position, the patient is told to open her eyes. Being aware of the deficiency brought about by the first test, she at once expresses surprise at the distance at which she heard the watch, and, what is impor- tant, she continues to hear it at the same dis- tance. In testing v^th the Galton whistle often we find that the highest notes are not consciously perceived by the patient, but this has the same significance as the defects brought about by testing acuity of audition, or of vision. Occa- sionally, it is possible to demonstrate very nicely with the Galton whistle the pathogenic effects of a suggestive technique of examina- 128 Fsyclwpathology of Hysteria tion. The patient is told to apprise us when she begins to hear the whistle, and then, progres- sively lowering the pitch from the extreme limit of normal audibility, we find that she fails to hear the whistle until a note of, for instance, 21,000 vibrations is obtained. Now, suppose we instruct her to notify us when she is not able any longer to hear the whistle. Continu- ing gradually to lower the pitch, infrequently we may find that she is unable to hear a note whose vibrations are less, for example, than 10,500. No other interpretation can be placed upon such curious results than that they were determined entirely by suggestion. In addition to these rudimentary and practi- cally inocuous kinds of temporary disturbance of auditory perception, complete unilateral or bilateral psychic deafness is uncommonly en- countered. When unilateral, psychic deafness, like hysteric monocular amaurosis, may occur in association with hemianesthesia and other dis- turbances of perception of sensory impressions arising from the same side of the body; the association of these symptoms being due solely to the patient's belief that hemianaesthesia must necessarily include homolateral loss of all forms of sensibility. "When occurring independently of hemi- anaesthesia, unilateral psychic deafness is often evolved from some unimportant local affection which concentrates the patient 's attention upon The Special Senses 129 her ear, and upon hearing, or it may be the consequence of the psychic effects of trauma- tism to the ear. The history of one patient showed that the condition had developed from what presum- ably was a furuncle of the external auditory canal. Two years after the onset, a compe- tent otologist, finding that the auditory ap- paratus was normal, advised her to consult a neurologist. When engaged in conversation, the patient did not appear to be inconvenienced except when her attention was directed to her hearing. Then, turning her sound ear towards the person with whom she was conversing, she seemed to experience difficulty in perceiving what was said, and occasionally she required that a sentence be repeated. When tested with the fork, she asserted that she was unable to hear either by osseous or aerial conduction. With the exception of the psychoneuroses such a finding indicates organic nerve deafness. But, when the auditory apparatus of only one side is the seat of organic nerve deafness, osseous conduction is not entirely lost because the vibrations are transmitted across. the skull to the opposite side. When examining patients with psychic deaf- ness, the results of tests necessarily must be in accordance with the patient's conception of deafness. Consequently, all kinds of auditory impressions, whether these be the product of 130 Psychopathology of Hysteria aerial or of osseous conduction, fail to be syn- tlietized with consciousness — they lack personal perception. If a hypnotized subject accepts the suggestion that he cannot hear with one ear, one will find that the same results are obtained with the fork. In addition to those patients who present loss of both forms of sensibility occasionally we find one in whom the tests show apparent loss of osseous conduction with pres- ervation of aerial conduction. This finding can occur only as, a result of suggestion in psycho- neurotic patients. Reverting to our patient, after inducing the hypnotic state, it was easy to effect partial return of bone conduction. After a few subse- quent treatments, air conduction at first was secured, and then caused progressively to im- prove until it became normal. During the fol- lowing eighteen months that she was under observation not any further auditory difficulty was experienced. The occasional association of deafness and mutism is probably due to the popular knowl- edge of the frequency with which mutism occurs as a complication of organic deafness. In the case of Mabel A., total psychic deafness, associated with mutism, suddenly developed without any ascertainable cause. After lasting four days, speech and hearing returned, but for over a month, attacks of deaf -mutism re- curred every afternoon at the same hour that The Special Senses 131 the first attack had appeared. Save the initial alarm at the sudden appearance of these major symptoms, she was not disturbed in any way, and, in fact, she was reluctant to consult a physician. During the first attack, aerial and bone conduction were absent, and she seemed totally unable to speak or to hear. In this case, too, the symptoms were readily infiuenced by hypnotic suggestion — adopted on the nine- teenth day — and, after two treatments, the at- tacks no longer recurred. The psychic nature of hysteric disturbances of sensory perception are well illustrated by Oettinger's interesting case. After a period of auto-hypnotic sleep, this patient exhibited deaf- mutism which persisted for over four months. In explanation of his comprehension of what was said to him, he asserted, in writing, that he could read the lips of those who talked to him, yet it was found that he was unable to read the lips during silent speech. Further- more, when the babies cried in the children's ward he volunteered his services, though he could obtain knowledge of the opportunity for his assistance only by hearing the crying. Several other inconsistencies were also apparent. The symptoms disappeared spontaneously in this case; faradism having been ineffectual and efforts to hypnotize him having proved fruitless. Afterwards, he spoke complacently of his suc- cessful resistance to suggestion. (Jour, of Nerv. and Ment. Dis., 1908, p. 129.) 132 Psychopathclogy of Hysteria The character of the disturbance has been ludicrous in some of the recorded cases of hys- teric deafness. Knapp's case, for example, was treated for a couple of Aveeks with suggestive applications of faradism with the result that her complete deafness was changed to word deaf- ness. The peculiarity consisted in her ability to hear her own voice, though unable to hear the voices of others. Further improvement hav- ing taken place, she became able to hear the voices of females, but psychic deafness for male voices continued to exist. (]\Ionatsschr. f. Psychiat. u. Neur., Dec, 1907.) The distinction between organic deafness and that due to hysteria should not be difficult. Sometimes one can startle the patient into dis- closing her consciousness of a noise. This pro- cedure, however, not only is crude but it should succeed only in cases of malingering, or of hys- teric malingering. A better method is to at- tempt to produce, by suggestion, subconscious reaction to auditory stimuli. One may succeed in demonstrating that a case of deafness is not organic by means of another device which is dependent upon suggestion. In the presence of the patient the physician, after having deter- mined that what he is about to suggest is not already present, incidentally remarks to who- ever happens to be present that the patient should present such and such a sign. If the case is one of hysteria, subsequent examination The Special Senses 133 may show that, in the interval, the patient has developed the sign which she has been induced to believe is essential to her disease. Finally, with suggestion it may be possible at once par- tially or eompleteh^ to restore normal hearing. Smell and Taste. Psychic anosmia and psy- chic ageusia are encountered less frequent- ly than similar disturbances of vision and of audition because the senses of smell and of taste are rarely examined by physicians, and, therefore, these conditions are not so liable to be produced as artefacts. Probably the major- ity of cases of unilateral anosmia and ageusia are only part of hemianiesthesia, and the asso- ciation of the symptoms is the consequence of the patient's conception of hemiangesthesia. By reason of his faulty technique of examination some physician creates hemiansesthesia. and then he. or some other one. discovers by fur- ther tests that the patient has homolateral deafness, amaurosis, anosmia, and ageusia. Wlien cases of anosmia and ageusia are sub- jected to critical examination the results, from a physiologic standpoint, are remarkable. Mary D., for example, never had been aware of any disturbance of sensory perception until a phy- sician had "discovered" hemiauEesthesia and hemianalgesia. Months afterwards she was unable, during my tests at least, consciously to perceive tactile, thermal, painful, or pressure stimuli applied to the right side. The other 134 Psychopathology of Hysteria physicians who had examined her had not tested her special senses, and, as far as she was aware, these had not been impaired. My ex- amination, conducted in the usual manner, i. e., without attempting to avoid the production of symptoms, showed unilateral deficiency of all the special senses of the right side. Therefore, either these troubles had existed unbeknownst to her, or my examination was their sole cause. At an}^ rate, though olfaction by means of the left nostril was not impaired she asserted that she was unable to perceive any odor when she smelled various test substances while the left nostril was occluded. Except as a manifesta- tion of hysteria this condition would be most remarkable, indeed, for even if the odors were received only through the nostril of the affected side unilateral anosmia could not cause total abolition of the sense of smell. Not only would the posterior naris of the sound side aid in detection of the odor, but, with some odors, the associated sense of taste alone would be suffi- cient. From a physiological point of view even more extraordinary is the fact that inhalation of ammonia through the right nostril was absolutely devoid of reaction. As a conse- quence, then, of her firm conviction that she was unable to smell with her right nostril, there results associated immunity from the usual effects of ammonia upon respiration. This in- The Special Senses 135 stance of the total inhibition of the effects of such a powerful respiratory stimulant is a re- markable, but not unique, example of the exalt- ed power, in hysteria, of the mind over the body. In the same patient the substances usually employed for testing the gustatory sense were readily perceived when applied to the left side of the tongue. On the other side, however, they were not detected until the tongue was with- drawn, and then only with difficulty, or not at all. In addition to unilateral anosmia and unilateral ageusia, this patient had almost com- plete monocular amaurosis — ^V. 0. D. 4/200 — miilateral deafness, and incomplete hemiplegia. CHAPTER V Visceral and Circulatory Derangements RESPIRATORY System. Except com- plete cessation of breathing hysteria can occasion all the possible vari- ations of respiration. The atten- tion of the patient may have been concen- trated upon the respiratory effects of great excitement with the consequence that these' normal reactions have become fixed as symp- toms of hysteria. Or, the respiratory symp- toms resulting from accidental and transient organic disease may be prolonged in the same manner. There is a tendency for a hysteric to develop the symptoms with which she is most familiar, so that long after having become acquainted with the symptoms which resulted from some organic disease, or from excitement, these may return as hysteric manifestations, consequent upon some psychic trauma which she has undergone. In this case the relation between the exciting cause and its effect is dif- ficult to understand unless the former incident is known. Naturally the frequency of respiration be- comes increased during convulsive and emo- tional attacks, but sometimes the symptom oc- curs independently, and it may persist for weeks. Often it is paroxysmal; recurrences 136 Visceral and Circulatory Derangements 137 being effected by mental stresses. The rate may be increased to an extent which can be scarcely credited. In a case recorded by Char- cot respiration attained a frequency of 180 per minute. During hysteric ''coma" brought about by a mental shock one patient who came under my observation exhibited a respiratory rate of 120 for several hours, over 100 for more than a day, and between 80 and 108 for several days. A few days later a second attack de- veloped, and during five consecutive days respi- ration was maintained between 50 and 80. It is remarkable, indeed, that such a rate could have been maintained for this length of time. One has only to attempt voluntarily to breathe this rapidly in order at once to discover how difficult and how exhausting it is. Spasmodic disturbances of respiration are usuall}^ due to true volitional tics of the respi- ratory muscles, and they occur in patients who do not present any of the signs of hysteria, but rather those of psychasthenia. These tics, like similar ones in other parts of the body, are produced by obsessions which the patient is impelled to gratify, and thej^ are accompanied by self-consciousness and shame. Generally speaking, spasmodic disturbances of breathing are not due to psychasthenia when they cannot be voluntarily duplicated. For instance, one never encounters attacks of sneezing or of true singultus in typical psychasthenics. The 138 Psychopathology of Hysteria mechanism of the spasmodic respiratory symp- toms of hysteria is entirely subconscious, and, therefore, these manifestations are not pro- duced by conscious efforts, nor are they de- pendent upon conscious impulsions. Instead of being ashamed the patient ignores her respi- ratory tics ; she may be even unaware of them. Abnormally frequent sighing and yawning is often seen in cases of hysteria, but these symptoms are comparatively unimportant. Several times a year the dispensaries of large hospitals receive patients who present contin- ued singultus vera. By means of the news- papers these cases may be traced from one dis- pensary to another until, after several days, weeks, or months, the symptom disappears. In spite of various kinds of treatments in different hospitals, hiccough had continued to occur about every thirty seconds in one of my cases. By means of hypnotic suggestion the symptom was immediately removed. Attacks of sneezing and of rhinorrhoea some- times appear during emotional excitement. In one instance I have known a young lady by psychic contagion alone to contract such at- tacks from her sister. When sufficiently elab- orated these attacks constitute what cannot be differentiated from the syndrome known as hay fever. Suppose an acute rhinitis with sneezing is acquired by an individual at a time of the year when ordinary colds are uncommon Visceral and Circulatory Derangements 139 — when hay fever is in season. More than one kind friend may express sympathy while in- forming the patient that the condition is hay fever, and that it will return at the same time every year. This suggestive explanation is apt to be accepted, especially by one who obviously is hysteric, with the consequence that the individual begins to anticipate his ''hay fever'* at about the same time the following year. Now, if this state of expectant attention is sufficiently developed to produce recurrence of the symp- toms of what originally was an ordinary cold, then a precedent is established, an association neurosis is formed, and each recurrence only strengthens the primarily weak associations just as any habit becomes more fixed as the result of repeated indulgence. Morton Prince has reported an instance of *'hay fever'' existing as a neurosis in five mem- bers of one family. One of these patients was told by a physician that fruit was capable of inducing attacks. Subsequently, she was unable to eat fruit without suffering from hay fever. The evident influence of autosuggestion in the production of hay fever caused Prince to propound the question: *'May not a very large number — one cannot generalize too ex- tensively and say all — of the cases of recurrent periodic hay fever develop in the same way? May not the attacks come on at a certain date because of apprehension or expectancy, by 140 PsycJiopatJiology of Hysteria which the patient suggests to himself or her- self that at that time he or she will be suscep- tible to external irritants of one kind or an- other, and then at the suggested time the irri- tant produces its habitual and expected ef- fect?" (Annals of Gynaecology and Paediatry, 1895). How often we encounter patients who declare that their hay fever will begin on a certain date, — that such always has been the case ! Be- cause change of environment is reputed to be effectual in warding off recurrences of hay fever, and because they know from experience that such often has been the case, these patients, if their position in life enables them to do so, will com- mence long in advance of the set date to arrange their affairs so that they can escape to their favorite retreat just before the attack is due. In a case of hysteria such a state of mind certainly is most favorable for the induction of what is expected so confidently; either the appearance of an attack about the time it is expected, or the avoidance of one resulting from the pa- tient's conviction relative to the prophylactic effects of a prospective vacation. Concerning the yearly recurrence of attacks on a fixed date. Prince questions the pathogenic influence, other than through the agency of expectancy, of the relative position of the moon to the earth. That many, at least, of the cases of what clinically is kno^^^l as hay fever are really symp- Visceral and Circulatory Derangements 141 toms of hysteria is sho\\Ti by the fact that we xiSLB. cure many of these cases by no other means than suggestion. On the other hand, Prince has been able to produce coryza by means of de- liberate post hypnotic suggestion. Having sug- gested during hypnosis to ''B. C. A." that the presence of a certain flower caused hay fever subsequently she developed coryza when exposed to this flower, even though she had never had liay fever, or thought about it, before the sug- gestion had been made. After having been awakened she did not remember the suggestion, ^nd when the coryza appeared the thought flashed into her mind that if it were summer she would think she had hay fever. ( The Mechanism of Recurrent Psychopathic States, with Special Reference to Anxiety States, Jour, of Abnormal Psychology, Yol. 6, p. 148.) It seems that hysteria is capable of causing what cannot be differentiated from asthma, as far as symptoms and clinical signs are concerned. As a matter of fact, many cases of psychogenic asthma have been reported, and the cure of such <;ases through the agency of hypnotic suggestion is ample proof of the validity of the diagnosis. For nine years, Mr. X., an indi^ddual whose manifestations were those of hysteria and who also presented psychasthenic fears, had been afflicted with frecjuently recurring attacks which were typical of asthma. The seizures first ap- peared during an attack of influenza, and they 142 Psychopathology of Hysteria recurred every morning at about three o'clock. Examination of his chest revealed the typical signs that one would expect to find in a case of asthma of nine years duration. Since the first treatment with hypnotic suggestion the patient has not had a single attack of asthma. (Report of a Case of Dissociated Personality, Jour, of Abnormal Psychology, Aug.-Sept., 1909.) Before the true nature of the condition was recognized another patient had been treated in a hospital a whole week for cardiac asthma. The attacks occurred several times daily and each lasted about a half hour. One appeared during his visit to the dispensary. Following a sudden deep inspiration, rapid stertorous respiration developed, the face became cyan- otic, and lachrjnuation occurred. After about a half minute the neck became extended and rigid, the hands tightly clenched, the limbs catatonic, and the pupils widely dilated. This phase of the seizure lasted about two minutes, and then he relaxed, and dyspnoea continued in association with a succession of brief attacks whose main features were general but moderate clonic movements and a state of consciousness resembling the somnambulistic states of hys- teria or of hypnosis. That the attacks were due to hysteria was indubitable. As the pa- tient did not return — he lived at some distance from the city — the outcome of the treatment is not known. Visceral and Circulatory Derangements 143 A third patient, aet. 23, had suffered from asthma since an attack of pertussis in his eighth year. Severe asthmatic seizures which lasted over 48 hours occurred about once monthly. These were so severe that he was totally incapacitated for three or four days, and, on account of losing so much time from his work, he was about to be discharged from his place of employment. Each of the major attacks was preceded for 24 hours by decided aggravation of his bronchial symptoms. In no way did his seizures differ from what is typical asthma, and not any of the physicians who had examined him had questioned the diagnosis. In addition to the severe attacks, he was sub- ject to lesser ones which occurred twice every night and which lasted about three-quarters of an hour. These mild ones were prone to arouse him at two and at five-thirty in the morning. The physical signs were those characteristic of well developed asthma ; namely, the physical signs of chronic bronchitis and emphysema. The treatment consisted entirely of hypnotic suggestion. The first treatment was given while the patient was having one of his severe attacks. Immediately upon the induction of hypnosis his respiration became decidedly less difficult. During the following 24 hours his symptoms, though very distressing, were much less severe than usual. Extending over a period of four months he was hypnotized seven 144 Psychopathology of Hysteria times with the following results: After the first treatment he did not have a single severe attack, and the milder ones progressively im- proved until they, too, entirely disappeared after the sixth treatment. Alimentary System. The experiments of Pawlow, Cannon, and others have shown the great importance of the effects of appetite and of emotions upon the secretion of gastric juice. The experiments of Pawlow, (The Work of the Digestive Glands, 1910,) for instance, showed that the mere exhibition of food to a dog re- sulted in the secretion of gastric juice in quan- tities which actually exceeded those provoked by allowing the dog to swallow the same food and to eject it through an oesophageal fistula. It was observed, also, that the quantity of juice secreted largely depended upon the in- tensity of the desire for food, so that the author says emphatically: "Appetite spells gastric juice.'' The truth of this dictum was unques- tionably demonstrated by the fact that though the sight of food induced almost immediate and copious secretion of gastric juice, yet, pro- viding only that the animal was unaware of the presence of food, the direct introduction of food through a gastric fistula was followed by the secretion of a greatly inferior quantity of the juice, and the appearance of this secretion was delayed for one-half to several hours. Visceral and Circulatory Derangements 145 Depressing emotions not only cause an un- pleasant dryness of the mouth but they are capable also of inhibiting gastric secretion. Moreover, the digestive juices are not secreted in sufficient quantities when one eats without experiencing desire for food, or when there is positive distaste for food. As a secondary pro- cess fermentation occurs, followed by auto-in- toxication and anorexia — a vicious circle is formed. In most of the cases of gastric neurosis the patient, possessing an elaborate system of erroneous ideas concerning digestion, believes that he has some organic gastric disease. Con- stantly being obsessed by the fear that through some dietary indiscretion he will aggravate his existing dyspepsia the flow of digestive juices is rendered insufficient as a result of his de- pressing mental states during meals. This type of gastric neurosis, or ''emotional dyspepsia," may be classified as a manifestation of psychas- thenia. Less frequently the condition occurs in hysteria. In this case the imperfect secre- tion of the digestive juices is due to absence of appetite — psychic anorexia — ; the patient eating in order to avoid the importunities of the family. Or, attacks of indigestion may follow ■undue emotional activity. The following instance, mentioned by W. B. Cannon, well illustrates the disturbing effects of emotional excitement upon digestion: "A 146 " Psychopathology of Hysteria refined and sensitive woman who had had digestive difficulties, came with her husband to Boston to be examined. The next morning the woman appeared at the consultant's office an hour after having eaten a test meal. An ex- amination of the gastric contents revealed no free acid, no digestion of the breakfast, and the presence of a considerable amount of the supper of the previous evening. The explana- tion of this stasis of the food in the stomach came from the family doctor, who reported that the husband had made the visit to the city an occasion for becoming uncontrollably drunk, and that he had by his escapades given his wife a night of turbulent anxiety. The second morning, after the woman had had a good rest, the gastric contents were again examined; the proper acidity was found, and the test break- fast had been normally digested and dis- charged." (Amer. Jour, of the Med. Sci. Apr. 1909.) Anorexia. The most grave of the symp- toms of hysteria is anorexia; a condition which only too frequently has eventuated in death. Since the introduction of rectal alimentation and the stomach tube death from hysteric anorexia would seem to be unpardonable. The anorexia has been ascribed to visceral anaesthesia, but it should be remembered that this anaesthesia, like the other varieties, must be only subjective ; the condition being the result of lack of synthesis Visceral and Cirmdatory Derangements 147 wdth consciousness of the perceptions of coenes- thetic impressions pertaining to the feeling of hunger — the feeling of need for food. The stomach is not the only factor concerned in the feeling of hunger, and, therefore, a hypothetical gastric anaesthesia does not explain hysteric anorexia. If an ecstatic is firmly convinced that she can live without eating, if she believes that she is the instrument of a miracle, complete dis- sociation can occur of all the perceptions con- cerned in the composition of the feeling of hun- ger, just as Miss Beauchamp developed systema- tized lack of perception of auditory, tactile, and visual impressions arising from the rings which she thought she had lost. The origin of this peculiar and dangerous symptom may have been some former event which was prominently associated with eating, or the idea of hunger, and which made a strong impression upon the patient's mind. Or it may have been the result of hysteric elaboration and fixation of a purely symptomatic and transient distaste for food. In some cases the symptom is the direct outcome of too careful dieting, by physicians, of patients mth hysteric disturbances of digestion; the patient gradually eliminating from her diet one kind of food after another, as the feeling of the need for food gradually is dissociated. Regardless of the cause, the patient refuses to eat because there is an absolute lack of desire for food, even though there is not any 148 Psychopathology of Hysteria real disturbance of the digestive system, and in spite of the fact that emaciation progresses rapidly. Janet describes a case whose anorexia was dependent upon hallucinatory commands from her dead mother, who, reproaching her for some faults she had committed, told her that she was not worthy to live, and that by refusing to eat she should rejoin her in heaven. (Mental State of Hystericals, p. 288.) In addition to true psychic anorexia hysteric individuals may simulate the condition in order to attract attention to themselves and to excite wonder. In such cases the patient affirms that she can live without eating, or that she cannot eat because she has no desire for food; yet emaciation does not ensue because privately she is consuming a sufficient amount of food. Notwithstanding the fact that the condition is simulated the patient cannot be called a malingerer with any greater justice than one can apply the same designation to an insane patient who simulates certain of his manifesta- tions in consequence of motives which, them- selves, are symptoms of insanity. As these cases of simulated anorexia or fast- ing usually occur in hysterics, the patient, if prevented from secretly obtaining nourishment, may starve herself to death rather than ac- knowledge the deception which she has prac- ticed. Hammond made a collection of cases of simulated fasting, and in one instance — Sarah Visceral and Circulatory Derangements 149 Jacob— to the disgrace of all those concerned, including a vicar, nurses, and physicians, the patient was forced to starve herself to death because the careful guarding by nurses that had been sent from Guy's Hospital finally pre- vented any further eating in private. In the interest of science and truth, then, a hysteric girl was forced to commit suicide. Those who were responsible for the fatal outcome escaped serious consequences, except the patient's father and mother, who were committed to jail for 12 and 6 months respectively. (Nervous Derangement 1883, p. 95.) The anorexias of hysteria should not be con- founded with those of psychasthenia. The psychasthenic refuses to eat not because he lacks desire for food, but principally through fear of the gastric distress, or other suffering, that he knows will surely follow. This emotional dyspepsia of expectancy and fear constitutes the very common gastric neurosis in whose production the physician is the main factor by reason of his paying too much atten- tion to the organs of digestion instead of to the patient. Vomiting. Hysteric vomiting, another serious manifestation which has been known to ter- minate in death, and which usually occurs in association with hysteric anorexia, is not at all uncommon. Generally its origin is found to be some former acute disease which occasioned 150 Fsychopathology of Hysteria vomiting, and, after the original cause sub- sided, the symptom continued as a manifes- tation of hysteria. By reason, too, of ex- pectant attention, or what really is unconscious autosuggestion, the physiological vomiting of pregnancy can be caused to persist. Just as the normal person may experience nausea, and even vomiting, as a concomitant of disgust, so the hysteric may suffer from hyper- emesis as a result of subconscious ideation. It is well known that association of ideas is ca- pable of producing vomiting. A typical instance is mentioned by Carpenter: "Thus Van Swieten relates of himself, that, having chanced to pass a spot where the bursting of the dead body of a dog produced such a stench as made him vomit, on passing the same spot some years afterwards he was so vividly affected by the recollection, that the sickness and even vomit- ing recurred." (Mental Physiology, p. 432, 1883.) If Van Swieten had forgotten the original disgusting experience with the conse- quence that each time he vomited he had been ignorant of its cause, then his case would be identical with the mechanism of production — subconscious association of ideas — of symp- toms of hysteria. As it was it resembled psy- chasthenia in that the symptoms were the effect of conscious association of ideas. The hysteric, then, may vomit whenever there is aroused into activity, by association of ideas, Visceral and Circulatory Berangeraents 151 a dissociated complex of memories of some for- mer experience which made a distinct impres- sion upon the patient, and in which vomiting was a prominent factor. As the provocative association of ideas usually occurs below the level of consciousness, it is only by some psy- choanalytic method that the origin of the con- dition can be discovered. Motor activity of this sort, whether it is a convulsion, a contracture, a tremor, vomiting or what not, constitutes what is termed motor automotism; a condition characterized by motor activity independently of consciousness; a dissociation of motor ac- tivity. In treating a case of alcoholism with hypnotic suggestion we may artificially create a motor automatism whose psychic mechanism is identi- cal wdth that of hysteria. While the patient is in the hypnotic state suggestions are made that tend to strengthen his moral character; which are directed against the fundamental neurosis; ones which are calculated to abolish the crav- ing. Then we may suggest that the idea of drink- ing liquor ^dll always be associated ^vith a feel- ing of disgust, that the odor alone will nauseate him. and that if he should ever take any alco- holic drink he would vomit immediately. If the patient is a good hypnotic subject he will not remember any of these suggestions after the hypnotic state is dispelled. In this manner we have produced a dissociated memory com- 152 Psychopathology of Hysteria plex which, when aroused into activity by the proper stimuhis, should produce vomiting. Now, if at any time the patient should take some whiskey he would probably vomit, and, like the hysteric, he would not know the real cause of his vomiting — the association of ideas would be subconscious. Often the vomitus contains blood, and then the diagnosis becomes difficult indeed. If we accept the possibility of vasomotor disturb- ances due to the disease, then true hysteric hsematemesis can occur just as other hsemor- rhagic conditions have been known to be pro- duced both by hysteria and by hypnotic sug- gestion. Excepting this possibility, one which is the subject of much controversy and which must be extremely infrequent, all cases of hysteric hsematemesis are merely instances of deception: as far at least, as the presence of blood in the vomitus is concerned. At all events, in each of the few cases which have come under my observation the patient had swallowed blood procured by picking at the nostrils until epistaxis was produced. Even though a patient with hysteric vomit- ing deliberately simulates hasmatemesis such deception cannot be regarded other than as a manifestation of a pathologic mental state. With no other object than to gain sympathy certainly no normal persons would carry the deception so far as to seek, and to undergo, Visceral and Circulatory Derangements 153 operations for supposed gastric ulcer. This type of deception is malingering only to the same extent as that of cases of hysteria in which simulated anorexia has terminated in death. Surely, malingering for the purpose of exciting sympathy, or wonder, is as much a symptom of hysteria as a psychic hemiplegia or a psychic amaurosis. The differential diagnosis in cases of hysteria presenting haematemesis is extremely difficult. Only those who have had cause to worry much about cases of hysteria whose symptoms in- cluded anorexia, vomiting, localized epigastric pain, tenderness, and perhaps hgematemesis, can appreciate just how difficult the diagnostic problem may become. Even if haematemesis appears in a patient who is known to be a major hysteric, one may not jump at conclu- sions and dismiss the question of gastric ulcer with the inference that the condition is ''only hysterical." In some cases the physician must treat the patient as though the symptoms were due to gastric ulcer, notwithstanding that he may surmise them to be but manifestations of hysteria and knowing that if this be the case his treatment, even if successful as far as the present symptoms are concerned, is almost sure to aggravate the fundamental psychopathic state. A problem that infrequently may confront the surgeon is due to hysteric reproduction of 154 Psychopathology of Hysteria the symptoms of bowel obstruction. In addi- tion to obstinate constipation, abdominal dis- tention, pain and vomiting, the patient may- develop faecal vomiting. In some cases rectal injections of various fluids, including castor oil, have been followed in from 12 to 15 min- utes by expulsion of the injected substance from the mouth. Aerophagia. Swallowing of air frequently occurs as a symptom of hysteria. As a con- sequence of the distress which is occasioned the patient voluntarily belches at frequent in- tervals. Ordinarily an eructation occurs more or less spontaneously; otherwise it must be initiated by gulping of air. The aerophagic is the victim of a vicious circle: she belches in order to relieve her gastric distress, and with each eructation she swallows more air. In case the ingested air is forced through the pylorus meteorism develops. The old theory that attributed meteorism to paresis of the in- testinal muscles with consequent expansion of the gaseous contents of the bowels, is not in ac- cordance with the fact that usually the condi- tion disappears when the patient is anaesthetized. Instead of causing meteorism to vanish the mus- cular relaxation which is induced by ether or chloroform anaesthesia should permit further abdominal distention were the condition due to intestinal paresis. When abdominal distention is produced by Visceral and Circulatory Derangements 155 spasm of the diai)hragm the distention cannot be as great as that due to gerophagia. It is this spastic type which disappears during general anaesthesia, and, as shown by Janet, during laughter, sobbing, and hiccoughing — phenomena which are dependent upon normal activity of the diaphragm. By means of radiographic examina- tions Bernheim found that the diaphragm is low- ered daring meteorism, and that as the abdomi- nal distention is diminished through the agency of suggestion the diaphragm gradually ascends and coimnences to take part in the function of respiration. (Hypnotisme & Suggestion, 1910, p. 380.) Meteorism may lead to enormous distention of the abdomen. The enlargement may be gradual and associated ^dth symptoms of pregnancy, so that in not a few cases of pseudocyesis physicians have been deceived until labor should have com- menced. The production of simple amenorrhoea by expectancy and fear is quite common, and this effect of vaso motor disturbance is much more remarkable than any of the other symp- toms which enter into the make up of pseudocye- sis. The symptoms are due to the patient's con- viction that pregnancy exists, and, needless to say, this belief may be born either of great de- sire for a child, or of intense fear of becoming pregnant. Preston mentions the ludicrous ease of a girl who believed herself to be preg- nant as a result of masturbation and whose abdo- 156 PsychopatJwlogy of Hysteria men was moderately distended. (Hysteria and Allied Conditions, 1897, p. 181.) Wesley Taylor describes a case of hysteric aerophagia in which the abdomen was distended to a degree greater than that of pregnancy at the ninth month. The meteorism of this patient, a girl of twenty years, occurred paroxysmally, and during the height of one of the attacks, the condition somewhat resembled general periton- itis. The attacks appeared as often as every two weeks and lasted as long as ten days or more. The interesting feature of the case was the fact that once she had been subjected to an operation and, on another occasion, she es- caped a second one only because of the rapid disappearance of the distention during etheriza- tion. (Jour.-Record of Med., 1909, p. 74.) In addition to general gaseous distention of the abdomen localized tumor like masses have been known to occur in hysteria. These phan- tom tumors, whether due to localized collections of gas in the intestines or to isolated muscular contraction in the abdominal wall, have been mistaken for real tumors, and even operations have been performed to the chagrin of the sur- geon. The appetite of the hysteric is capricious. In addition to craving unusual articles of diet she may ingest such substances as plaster and hair. Including his own case, Butterworth collected from the literature 42 cases of hair Visceral and Circulatory Derangements 157 ball of the stomach. Of these patients 39 were females. The largest hair cast weighed about six pounds. The final results of 33 eases com- prised 17 laparotomies with one death, 6 deaths from peritonitis and perforation, and 10 deaths from inanition. Thus the outcome was fatal in over half of the cases in which this was known. The correct diagnosis was made before opera- tion in only five instances. (Jour, of the A. M. A., 1909, 2, 617.) It is difficult to conceive the possibility of the production by hysteria of symptoms capable of being mistaken for acute appendicitis, yet such is not rare. Twenty cases of hysteric pseudo-appendicitis were compiled by Karl Urband. A patient of his own developed acutely localized pain and rigidity, associated with slight abdominal distention, vomiting, superficial respiration, temperature 99% and pulse 72. Subsequently these symptoms sub- sided, but several weeks later, following a chill, the temperature rose to 104% and the pulse to 144 only to fall again 'to normal the next day. After twelve more days he had another chill and similar rise in temperature in addition to severe pain in the region of the appendix. At operation the appendix was found to be nor- mal. (Wiener Med. Woch., 1908. p. 1918.) EverjT- one of the usual symptoms of acute appendicitis, including moderate rise of tem- perature, was reproduced by a major hysteric 158 PsychopatJiology of Hysteria who came under my own observation. The elimination of appendicitis was accomplished only by the discovery of two significant fea- tures: during the painful reaction produced by deep pressure over McBumey's point the patient's respiration became deeper than usual, and when the pressure was exerted while the patient's attention was distracted both the rigidity and the painful reaction were found to be absent. Prolonged attacks of diarrhoea or of obsti- nate constipation are common. More impor- tant is the occurrence of what is called mucus, or membranous, entero-colitis. Whether this condition be looked upon as a symptom of hysteria or as an independent clinical entity, the fact remains that it is said to occur only in psychoneurotic persons. The affection is characterized by attacks of severe abdominal pain that may last several days or longer and which are associated with, or are followed by, the presence in the stools of considerable mucus and even blood ; the patient perhaps being free from abdominal symptoms in the intervals be- tween attacks. When the mucus is passed in the form of tubular casts that present the appearance of membranes, the condition is called membranous entero-colitis. Either of these abdominal crises may recur for many years, apparently without being influenced by treatment. Visceral and Circulatory Derangements 159 A patient who presented an admixture of symptoms of hysteria and of psychasthenia for years had been subject to severe attacks which usually followed undue excitement, and which occurred several times a month. During the crises her stools were extremely offensive and consisted lars:ely of mucus mixed, at times, with blood. Rarely casts were passed. While she was travelling in Germany some intra- abdominal operation was performed during one of the attacks, but subsequently recurrences took place as before. Much to my surprise the attacks ceased to appear shortly after the adop- tion of treatment with hypnotic suggestion which was directed mainly against the asso- ciated symptoms. The different abdominal syndromes resulting from hysteria are most resistent to treatment, and each may appear, continue indefinitely, and then disappear suddenly without apparently having been influenced at all by any of the therapeutic measures that had been adopted. Genito-Urinary Derangements. Increased frequency of urination often occurs in hysteria, but more commonly this symptom is caused by a psychasthenic fear that the necessity to urinate will appear at a time when social con- siderations would render the act impossible; the patient urinates, therefore, at frequent intervals in order to avoid such embarass- ment, and, when the fear is well developed, 160 Psychopathology of Hysteria he may refrain even from going to places of amusement or to social events. In such cases the fear results from conscious associa- tion of ideas with the memory complex of some former experience when distress was caused by actual necessity to urinate at a time when the circumstances were such that the act was impossible. In hysteria, on the other hand, the urinary frequency is not associated with fear, and the underlying association of ideas is not consciously known. Further to differentiate the two conditions one might say that the psychasthenic urinates too frequently in order that he may be in a position the longer to hold his urine should this be required, while the hysteric variety is due to unconscious auto- suggestion, and the act of micturition occurs regardless of thoughts of future environment. In psychasthenia the condition is the result of an obsession; in hysteria it is due to what is termed a sensory automatism. As a conse- quence of subconscious ideation the hysteric is subject to hallucinations of imperative sensory impressions from the bladder. Polyuria occurs frequently at the termina- tion of hysteric seizures, and, less often, an increased amount of urine may be passed daily for long periods of time independently of crises and without discoverable cause other than hys- teria. That complete anuria lasting several days Visceral and Circulatory Derangements 161 can occur as a symptom of hysteria has been the subject of much dispute, but more than one case has been recorded in which deception could be eliminated. Less infrequently the daily amount of urine voided has been reduced to a few ounces, or less, and the deficiency has continued for days or weeks at a time. In either case the absence of urgemia is explained by the fact that in these patients anuria is compensated by profuse sweating, vomiting, or diarrhoea. Frequently patients are encoun- tered who maintain either that they do not pass any urine at all, or that the amount has been reduced to a few spoonsful, yet, when kept under supervision, or if catheterized, the re- sults show that deception is being practiced. The majority of cases of hysteric retention of urine are due to the continuation produced by autosuggestion, of the common but tem- porary post-operative retention. In such cases the longer catheterization is continued the longer it wiU be necessary, so that strenuous means should be adopted to cause the patient normally to urinate soon after operations have been performed. Retention often is simulated, and, like anuria, the deception can be exposed by catheterization and close observation. Quite the reverse of the ordinary conceptions of the sexual instinct in hysteria is the actual state of the genital function. Taking into con- sideration the vast numbers of hysterics, rarely, 162 Psychopathology of Hysteria indeed, does the disease produce inordinate desire and gratification. Less infrequently the sexual instinct manifests itself by symbolic mental activity, or by conversion into the physi- cal manifestations of hysteria. Usually the patient not only loses whatever sexual desire she may have possessed, but sexual intercourse becomes repugnant. It is not at all uncommon for patients to remark that since they became nervous they have been sexually indifferent, whereas the opposite formerly was the case with them. It is true, however, that excluding those cases due to cultivation, degeneration, and insanity, the majority of sexual perverts owe their perverse inclinations to associations of ideas which were usually originated in early life. A number of cases have been subjected to psycho-analysis and the reports have been most instructive, both in accounting for con- ditions which heretofore have been erroneously grasped, and in adducing further corroboration of the theory of submerged complexes as the underlying psychic mechanism of the psycho- neuroses. In addition to other manifestations of hys- teria and of psychasthenia a patient who was studied by Sidis was obsessed with ideas of homosexual relations. Hypnoidal psycho- analysis brought out the fact that when the patient was in his eighth year some older schoolmates had forcibly violated him. Having Visceral and Circulatory Derangements 163 informed his parents of the fact he was removed from the school. ''This experience lapsed from his conscious memory, but remained firmly im- planted on his subconscious memory, giving rise to the apparently unaccountable homo- sexual ideas at which he felt so much disgust. The homo-sexual ideas were really foreign to his character and no wonder his whole nature felt revolting disgust towards them. ' ' ( Studies in Psychopathology, Boston Med. and Surg. Jour., Mar. 14 to Apr. 11, 1907.) According to the nature of the perversion itself, and according to the character of asso- ciated symptoms, the patients may be classi- fied either as hysterics or as psychasthen- ics. When the perverse ideation or actual gratification is dependent upon obsessions against which the patient strives in vain the condition may be designated psychasthenic. Besides the instance just mentioned the Hev. A. Kampmeier's case illustrates the character of psychasthenic deviations of the sexual in- stinct. After reading a book which dealt with the evil consequences of sexual irregularities the patient "became very chaste from fear of the horrible consequences of a lapse from vir- tue." Obsessions having developed from the material afforded by the well-meant but de- cidedly pernicious book, the patient suffered much psychic distress and then, as he expresses the outcome: "My demon finally drove me to 164 Psychopathology of Hysteria make true what I imagined would inevitably come about had I not read that book. I gave myself up to sexual excesses, not for the pleas- ure of them, since in my case this was impos- ible, but to make true what I thought would have been my fate." (Confessions of a Psych- asthenic, Jour, of Abnormal Psych., vol. 2, p. 112.) As a slight amount of distress in the ovarian regions may be considered a concomitant of normal menstruation it is just as natural for this normal symptom to become elaborated and fixed by autosuggestion as it is for a sympto- matic anaesthesia or paralysis to become fixed in a similar manner. Therefore, in most female hysterics a suitable foundation is commonly at hand for the development of psychic pains in the ovarian regions. It is unusual for a lap- arotomy to show that both ovaries are entirely free from lesions, negligible or otherwise, and, following the removal of one or both ovaries, the pain is very apt to disappear as the result of the powerful suggestive effects of an opera- tion. These facts account for the former dis- graceful popularity of oophorectomy. Possible suggestive effects being insufficient justifica- tion, gynaecologic operations should never be performed on a hysteric unless the same pro- cedures positively would be indicated in the absence of hysteria. In reference to the relation between the Visceral and Circulatory Derangements 165 psychoneuroses and the pelvic viscera the re- sults of Clara T. Dercura's statistical analysis of 591 gynaecologic patients are most interest- ing. "The above tables," she concludes, "speak for themselves; there is obviously no relation between hysterical stigmata and pelvic disease ; this is likewise true of the symptoms of neurasthenia. That hysteria and neuras- thenia can coexist with pelvic disease goes without saying, just as they may coexist with a brain tumor or a broken leg. The above statistics do not even show that neurasthenia or hysteria exist as frequently in pelvic dis- eases as in other visceral affections. Certainly the above facts prove that operations on the pelvic and other viscera for the relief of ner- vous symptoms have no justification. It is per- fectly clear that no operation should be per- formed which has no positive surgical indica- tions. When this subject is fully understood the fastening up of so-called loose kidneys, the removal of normal ovaries and tubes, of normal uteri, of normal appendices, of pieces of normal coccygeal bone, will cease, as will also repair of trivial cervical lacerations. A careful exam- ination of the records from hospital labora- tories will abundantly testify to this assertion of the removal of normal organs." (Jour, of the A. M. A., March 13, 1909, p. 848.) Circulatory and Trophic Phenomena. Cardiac neuroses seldom are found in hysteria; 166 Psychopathology of Hysteria these conditions being part of the symptom- atology of psychasthenia. Increased frequency of the cardiac rate accompanies hysteric crises for the reason that it is a normal concomitant of emotional excitement or a normal consequence of muscular effort. Less easily understood are some of the vasomotor and trophic manifestations which seem rarely to occur as symptoms of hys- teria, and whose origin in this manner is denied by many. Sudden flushing of the face, coldness, and even local asphyxia, are ordinary symptoms. The effect of the mind upon the vasomotor func- tion is apparent in the anaesthesias both of hys- teria and of hypnosis in that it is difficult some- times to obtain a free capillary flow of blood from anaesthetic regions. More remarkable are the rare instances of spontaneous capillary haemorrhage that occurred in the so-called stig- matics. Of these the best known is Louise Lateau; a typical hysteric in whom haemor- rhages mainly from the hands, feet, fore- head and left side of the chest appeared every Friday during a state of ecstasy in which she acted the crucifixion. The hemorrhages took place even though an apparatus was applied for the purpose of preventing deception. Ac- cording to Dr. Lefebvre about % of a quart of blood was lost each time the haemorrhages oc- curred. Physicians who studied the case came to the conclusion that the phenomena resulted from autosuggestion. With hypnotic sugges- Visceral and Circulatory Derangements 167 tion Bourru and Burot, and Mabille succeeded in producing similar manifestations. Hysteric purpura is an uncommon condition. While examining a hysteric more than a dozen purpuric spots varying in size from i/^ to 3 inches in diameter were found in various parts of her body, yet she had not known that a physical examination was to be made and she denied having been injured in any way. Her blood was found to be normal. The purpuric ■areas did not disappear for more than two weeks. Circumscribed oedema may develop acutely or slowly, and, after lasting an indefinite length of time, it may disappear just as suddenly or gradually. The lesion is white or bluish and pits but little under pressure. When occurring about joints — especially when associated with pain and paresis — the condition may be mis- taken for arthritis. What has been termed hydrops articulorum intermittens is similar to the oedema of hysteria, and it occurs most fre- quently in the functional neuroses. As defined by W. Healy it is: ''A chronic affection char- acterized by an effusion poured out into one or rarely more joints, at regular or irregular intervals, without any ascertainable exciting cause for the recurrence, and without any per- ceptible anatomic alteration as cause or result of the repeated attacks.'' (Surg. Gyn., and Obstet., 1908, p. 466.) The nature of the con- 168 Psychopathology of Hysteria dition is indicated by the fact that psychic in- fluences are ca^jable of inducing attacks, abort- ing them, and even in curing the disease. The possibility that some of the symptoms of hysteria may result from localized areas of angioneurotic cedema in the brain has been sug- gested tentatively by G. L. Walton. (Internat. Clinics, vol. 3, series 18, p. 242.) Hysteric gangrene is another of the mani- festations which is subject to controversy; not only because of the difficulty in explaining its mechanism, but also because of the frequency with which the lesions are the product of de- ception. Thus, Dieulafoy's patient, a male hys- teric, by chemical irritation caused multiple re- curring gangrene which was diagnosed trophic ulceration by a surgeon who amputated one of the patient's arms because of the continued re- currence of the lesions. (La Presse Medicale, 1908, p. 369.) There are numerous instances on record of the successful production, by means of hypnotic suggestion, of dermographia, inflammation, bullae, ulceration, and gangrene. Many of these experiments were conducted under conditions which precluded the possibility of deception. By means of the application of objects with the suggestion that they were hot, it was possible with lima S. to cause skin lesions varying from simple redness to actual ulceration. These reactions were obtained even when the parts Visceral and Circulatory Derangements 169 were carefully bandaged and sealed. (An Experimental Study in the Domain of Hypnot- ism, by Von Krafft-Ebing, Chaddoek trans., 1896.) ' Beaunis described some interesting experi- ments which were performed by Focachon in the presence of Bernheim, Liebault, and him- self. Postage stamps having been applied to the subject's back with the suggestion that they were blisters, bandages were adjusted. Twenty-one hours later a decided inflammatory reaction was found when the stamps were re- moved, and these areas developed, in eight more hours, into blisters. After fourteen days suppuration still continued. On the other hand, by means of suggestion Focachon prevented any reaction from a real blister which was applied to one arm, while a second one placed on the opposite arm produced the usual effect. (Du Somnambulisme Provoque, 1886.) Certainly if such lesions can be produced with hypnotic suggestion then there is no reason why hysteria cannot do likewise. As the influence of emotional states upon the secretions is well known the fact that profuse localized or general sweating may occur in hysteria is accepted without dispute. A remarkable instance has been reported by Curschmann. Attacks of sweating appeared during what the patient believed was influenza, and her daughter became subject to the affec- 170 Psychopathology of Hysteria tion by reason of psychic contagion. Three times daily at a fixed hour, and continuing for a year, as much as 300 c. c. of perspiration was lost at a time. These attacks were unaccom- panied by any other physical or psychic dis- turbances. Both patients recovered under sug- gestive treatment. (Miinch. Med. Woch., Aug. 27, 1907.) With hypnotic suggestion one can readily induce attacks of profuse hyperhidrosis ; it suffices to cause the subject to believe that she is becoming disagreeably warm. Some neurologists contend that there is no such thing as hysteric fever: others are con- vinced that fever can occur as a manifestation of hysteria. Some observers who limit the symptomatology of hysteria to those conditions which can be reproduced with hypnotic sug- gestion would exclude the possibility of hysteric elevations of the temperature. At all events, Von Krafft-Ebing repeatedly was successful not only in causing the temperature of lima S. to vary as much as 2.5° F., but in causing the variations to occur at a fixed hour, and to per- sist for days at a time. Reverting to hysteria, Osier declares that in at least two of his cases a diagnosis other than hysteric fever was im- possible. In one of these the temperature rose to 102 or 103 every afternoon for four or five years. (Principles and Practice of Medicine, 1902, p. 1119.) Visceral and Circulatory Derangements 171 In 1858 a girl who had been found uncon- scious in the street was brought to Bamberger's clinic in a delirious state with a tempera- ture of 106.7° F. The diagnosis was declared to be either typhoid fever or miliary tubercu- losis. The following morning all of her symp- toms had disappeared; she was well. It was found that having been jilted by her lover at a dance she became greatly excited, and, while running home, had fallen unconscious in the street. (Muench. med. Woch., No. 19, 1903.) George L. Walton reports a case of hysteria in which a temperature of 105 was noticed as an isolated symptom that persisted for a week and then gradually dropped to the normal dur- ing the course of several months. In discussing this case Knapp spoke of a case of hysteric hemianagsthesia and hemiplegia in which the temperature varied from 105 to 95. and Court- ney of another hysteric whose temperature had been 100 to lOOYo for several years. (Jour, of Nerv. and Ment. Dis., 1907, p. 266.) Following an attack of influenza the temper- ature of one of my cases of hysteria continued at 99 to 100% for over a month in the absence of any ascertainable cause for the elevation and without its being associated with any other symptoms. When the regular use of the ther- mometer was discontinued the fever immedi- ately disappeared. After reporting two eases of hysteric hyper- 172 PsychopatJCology of Hysteria thermia Von Voss concluded that elevation of the temperature may occur as a manifestation of hysteria in severe cases, and that it often accompanies convulsive seizures. (Deutsche Zeitschr. fiir Nervenheilkunde, Band 30, Heft 3-4.) Naturally, elimination of all possible causes for fever other than hysteria is difficult if not impossible, but careful observation in these and other similar cases which have been reported tend to justify the assumption that variations in the bodily temperature can be produced by hysteria. As already noted the fact that the temperature has been altered through the agency of hypnotic suggestion by more than one observer tends to confirm this belief. CHAPTER VI Psycho-Motor Disorders PARALYSIS. Other than through the agency of accidental occurrences there is no reason why one hysteric should be paralyzed, another afflicted with convulsions, and a third contractured. These conditions, as well as the other innumer- able manifestations which are possible in hysteria, really are potential in every case, and for that reason justly they may be denominated ** accidents." One patient has psycholeptic attacks and another paralysis simply because the first accidentally was exposed to psychic contagion as a result of witnessing an epileptic attack, and the second is paralyzed because he has been subjected to some traumatism which, in his opinion, was capable of inducing paraly- sis. Casual events and the conceptions of the patient determine both the production and the character of the various manifestations. According to Ziehen the symptoms of hys- teria are due to the remarkable vividness with which mental representation occurs in this dis- ease; the idea of paralysis being sufficient to evoke the symptom. As the idea of paralysis may be aroused by numerous kinds of excita- tion so the symptom superficially may appear to be widely varied in its mode of genesis. 173 174 Psych opathology of Hysteria Wlien a patient who has slept with the head! pillowed on the arm develops what should be a transient brachial paralysis the condition may become fixed and continue as a manifestation of hysteria. In the same manner monoplegia may be evolved from the transient motor and sensory symptoms resulting from undue main- tainance of an extremity in a constrained posi- tion. In either instance the paralysis should be accompanied with anesthesia because the- fundamental and temporary organic motor dis- turbance having occurred in association with numbness both of these symptoms would prob- ably become fixed. As the effect, too, of the lay conception that paralysis necessarily must produce numbness, the two conditions are usually found together, and their boundaries may coincide regardless of differences in nerve supply. The pathogenic influence of the same conception is noticeable in those patients who present impairment of strength in members which have become the seat of an9?sthesia of medical origin. For in- stance, the patient is unaware of any disturb- ance of sensation or of muscular power until she is subjected to examination. Then, without being associated with any loss of strength, hemianagsthesia, perhaps, is ''found." Later she returns to complain of muscular weakness of the same side of her body. The majority of paralyses follow traumatism,. Psycho-Motor Disorders 175 and as men are more exposed to injury than are women, it is not surprising that this symp- tom occurs far more commonly in males. In reference to traumatism, one should bear in mind the fact that the "accidents" of hysteria are dependent upon the psychic effects of an injury, and not upon its physical consequences. No matter how severe the traumatism may have been it is only the idea of injury that eventu- ates in hysteric paralysis and other symptoms of the disease. As a matter of fact, in cases of hysteric paralysis following injury^ it is not at all unusual to find that the injury was but a trivial one. Unless deceived by the apparent serious import of the symptom the layman is inclined to attribute such cases to what is pop- ularly termed a vivid iraagination, or, if the case happens to be one in which a law suit is being instituted, the interpretation is more con- temptuous. Besides those patients with hysteric paralyses originating entirely from the psychic effects of an injury not infrequently actual, but transi- tory, paralysis due to traumatism, or pseudo- paralysis of painful injuries, may become elab- orated and fixed as hysteric paralysis that con- tinues after the organic cause has subsided. Thus, paralysis due to traumatic neuritis, or pseudo-paralysis consequent upon the pain of a sprain, may be the source of hysteric paralysis. Two cases which have been reported by 176 Psychopathology of Hysteria Prince illustrate very nicely the genesis of paralysis from negligible injuries : During the Civil War a round shot, after having knocked a tin dipper from the hand of a soldier, passed between his elbow and his side. The wind of the shot threw him to the ground. Upon re- gaining consciousness, twenty-four hours later, he presented the same symptoms, he declared, as when Prince examined him — decided, but not absolute, paralysis and profound anaesthesia of the whole left upper extremity. The other patient had been struck and rendered uncon- scious by some large missile during a battle of the Civil War. His blanket roll had so broken the force of the blow that, at the time, the only sign of injury was ecchymosis below the left shoulder ; yet incomplete hemiplegia and hemi- anagsthesia had developed and persisted. (Amer. Jour, of the Med. Sciences, July, 1892.) During intense excitement a normal indi- vidual may feel that his legs are giving away beneath him. Popularly this fact is well known; hence the expression "to feel weak in the knees." Given a hysteric person who has sustained some emotional shock during which, among other reactions, this feeling of weakness occurred, what is more natural than the devel- opment of hysteric paraplegia as a souvenir of the incident ? It is the evolution of the physical symptoms of hysteria from psychic stresses that led Freud to compare them with the monuments Psycho-Motor Disorders 177 which are erected to commemorate important historical events. The idea of paraplegia may owe its origin to the effects of illness. Anyone who has been confined to bed several weeks with some severe illness is more or less completely unable to walk, or to stand alone, when he first rises from bed. This actual weakness of the lower ex- tremities may continue several days or more, and. in a hysteric, it may persist solely as a fixed and elaborated s^Tuptom of hysteria. In- deed, it is from just such conditions that many of the manifestations are evolved : for all have some definite exciting cause. Our inability to find the precise reason for each symptom that every patient presents is only evidence that our analyses are incomplete, or defective, and not that such symptoms "just happened." A beautiful example of the manner in which an emotional shock — the idea of injury in this case — alone can bring about paralysis is men- tioned by Janet: A man had descended upon the running board of a railroad coach in the attempt, while the train was in motion, to change compartments. As the train was about to enter a tunnel, while he was still on the run- ning board, the idea occurred to him that his left side would be crushed. The terror aroused by this thought caused him to faint, and he fell back into the compartment. Notwithstanding that physically he was uninjured, left hemi- 178 Psychopathology of Hysteria plegia developed. (Major Symptoms of Hys- teria, p. 141.) Whatever the cause, paralysis and other ''ac- cidents ' ' of hysteria may not appear at once : there may be an intervening period of auto- suggestion which may last hours or days, and even weeks. During the interval the pa- tient may not be consciously brooding over the memories of the injury, for these memories may have been dissociated from consciousness. Later some entirely different event may arouse them into pathologic activity with the conse- quent production of a paralysis, an amaurosis, or some other manifestation. So there may occur what may be termed a delayed reaction, or a reaction by substitution. Instead, then, of hysteric paralysis being evolved from an in- jury which might be expected to produce this symptom, the patient may develop, for example, amaurosis because the mental shock set into activity the dissociated memories of some other experience whose logical result, amaurosis, re- mained latent. The diminution of muscular force which is met with so commonly during the examination of hysteric patients cannot be regarded as in- complete paralysis for the reason that it is due entirely to the interference of attention with the muscular efforts which are being tested. Dynamometric investigation of hysterics shows that the gripping force apparently is greatly Psycho-Motor Disorders 179 impaired in over 90% of the cases. But when these same patients shake hands, or when they lift objects which require considerable gripping force, one sees at once that the dynamometric readings cannot be considered indicative of the amount of strength which the patients really possess. In its distribution hysteric paralysis may af- fect a single muscle, or group of muscles, or it may assume the form of a monoplegia, a hemi- plegia, or a paraplegia. Though the paralysis may be complete cases are rarely observed in which the patient is totally unable to use the affected part. Except its tendency to be asso- ciated with anaesthesia, hysteric paralysis fre- quently occurs as an isolated manifestation. Particularly is this true when the symptom is consequent upon traumatism, and when it oc- curs in males. In those confirmed cases of the hysteric habit, or of hysteric malingering in which the disease has become but a useful means to an end, or in which the patient appears to take great pleas- ure in her numerous ailments and who occupies herself agreeably in going from one physician to another or from this clinic to that, hysteric paralysis may be only one symptom of an ex- tensive repertoire. In contradistinction to this type of patient is the manner in which paralysis is regarded by the patient with pure hysteria. Such a patient is often quite contented to per- 180 Psychopathology of Hysteria mit her paralysis to continue undisturbed, and the interference of a physician may be looked upon with indifference, or it may provoke active antagonism. She tranquilly ignores what ordinarily is considered to be a grave symptom, and whether merely inconvenienced, or actually incapacitated, she is totally unconcerned about her condition. Inasmuch as hysteric paralysis is the conse- quence of dissociation of the ability consciously to evoke motor activity in the affected part there should not be any interference with the per- formance of automatic or subconscious acts. Ac- cordingly, not only should we expect, but actu- ally we find, that the paralysis disappears dur- ing sleep, hysteric seizures, and, in fact, when- ever the usual state of consciousness of the patient is in abeyance. The somnambulistic attacks of one of Janet's cases demonstrate the manner in which paralysis disappears during the course of subconscious states. By reason of hysteric paraplegia this patient was confined to bed. At night, however, he jumped out of bed, and, while holding his pillow in the belief that it was his child whom he was saving from the hands of his mother-in-law, he ran out of the room and into the court-yard. Then he climbed to the roof of the hospital. Upon being awak- ened both of his legs again became paralyzed, and it was necessary to carry him back to his bed. Psycho-Motor Disorders 181 As the usual state of consciousness of a patient is in abeyance during profound hypnosis one should be able, through the agency of hypnotic suggestion, to secure free use of muscles which are the seat of hysteric paralysis. By this means not only can one demonstrate the psychic nature of hysteric paralysis and therefore differentiate the affection from one which is organic, but it is possible also to remove the symptom. In most cases the diagnosis is a simple matter if one studies both the symptom and the patient. In the absence of positive differentiating features pertaining to the paralj^sis itself, the discovery of other evidences of hysteria cannot be used as the basis for a diagnosis because of the fre quency with which hysteria and organic disease coexist. The character of the symptom and the absence of qualities essential to organic paralysis alone must be considered. Like the distribution of psychic anaesthesias the muscles involved in hysteric paralysis may not correspond to nerve supply. Except the in- considerable wasting of disuse that may occur in long standing cases there is not any true atrophy of the affected part, nor are there any changes in the electrical reactions. In cases of hysteric hemiplegia the face is rarely involved. On the basis of Briquet's 60 cases of hemiplegia examined before 1859 considerable stress has been placed upon the statement that the left side is affected three times as frequently as the right. 182 Psychopathology of Hysteria Ernest Jones, however, found that the right side was the seat of hemiplegia in 54.2% of 277 cases reported since 1880. (Rev. Neurol, Mar. 15, 1908.) The gait of hysteric hemiplegia differs greatly from that of organic disease. Wlien organic the patient sT\ings the paralyzed leg forward so that the anterior inner surface of the foot describes an arc on the floor; the hysteric drags her par- alyzed limb behind her jast as one would expect in consideration of her conception of paralysis and her lack of knowledge of how a case of or- ganic hemiplegia really should walk. The or- ganic hemiplegic wears out the inner aspect of the toe of his shoe while the hysteric's shoe is more apt to be damaged most at the point. When we exert resistance to the muscular ef- forts of a patient with incomplete hysteric paralysis, and when we study the manner in which the non paralyzed hysteric grips the dy- namometer, we find notwithstanding that the patient appears to be, and is, exerting consid- erable strength, and that he fairly trembles in his efforts to produce still more forcible muscular contraction, yet the results are almost nil. The explanation of this apparent diminution of strength, and of the seeming disproportion be- tween muscular effort and its effects, lies in the fact that the contraction of the muscles which are being tested is almost neutralized by similar activity of their opponents. Psycho-Motor Disorders 183 Of the utmost diagnostic importance is the condition of the tendon reflexes. Regardless of the presence or absence of paralysis the patellar reflexes are slightly, but truly, exaggerated in almost all cases of hysteria. Occasionally the re- flex may appear to be greatly exaggerated, but as this exaggeration usually resembles an inten- tional muscular action it cannot be mistaken for that caused by organic spastic paralysis. On the other hand, the knee- jerks may be greatly in- hibited, or even caused to appear to be lost when the patient concentrates her attention upon the tests and contracts the muscles of the thigh. Those who have attempted to demonstrate a nor- mal knee-jerk in students have encountered this difficulty. Except these kno^^ra variations of the patellar reflex it may be asserted that absolute loss, or that true increase to an extent that is observed in upper motor neuron type of paraly- sis, cannot occur, in a typical manner as the re- sult of uncomplicated hysteria. Momentary loss of the knee-jerks, however, occurred regularly, during the attacks of hysteric petit mal of a patient reported by Putnam. (Personal Expe- rience with Freud's Psychoanalytic Method, Jour, of Nervous and Mental Diseases, 1910, p 670.) It is stated that 2% of presumably normal in- dividuals do not possess knee-jerks. Now, if hysteria developed in any of these it might be thought that the absence of the reflex was due to hysteria. 184 Psychopathology of Eystena In uncomplicated hysteria it is not unusual to elicit a pseudo-clonus, which, unlike true clonus, is not sustained and is semi-voluntary. In ex- ceptional instances typical ankle clonus may oc- cur, but I have never been able to discover this phenomenon among any of my cases until re- cently. The patient was a major hysteric who had been under observation at intervals for four years. Lately the usual type of hysteric hemi- plegia developed and there could not be any doubt concerning the absence of any organic lesion. During one examination a true organic type of sustained ankle clonus was found on the paralyzed side, but there were no other of the physical signs of organic disease. The follow- ing day, while demonstrating the patient before a section of students, it was impossible to elicit even the faintest tendency towards clonus. In a case of hysteric convulsive seizures re- ported by Heard and Diller the patient had bilateral sustained clonus which disappeared after two weeks. The patient completely recov- ered under anti-hysterical treatment. The clonus was believed to be entirely hysteric in origin, and in commenting on the case the opinion is ex- pressed that ankle clonus is not necessarily in- dicative of organic disease ; that it can develop as a manifestation of hysteria. (Ankle Clonus in a Case of Major Hysteria, Jour, of Nervous and Mental Disease, 1910, p. 239.) Like the knee-jerks, the Achilles reflex cannot Psycho-Motor Disorders 185 be abolished by hysteria, and, excluding doubt- ful reactions to plantar irritation, it is improb- able, too, that a typical Babinski reaction can be caused by the disease. As many cases of multiple sclerosis early in their course have been mistaken for hysteria, and as clonus, exaggerated knee-jerks, and the Babinski sign are common symptoms of this dis- ease, it may happen that true organic changes in the reflexes may be discovered in cases of what appear to be hysteria but which, in reality, as later events show, are cases of multiple sclerosis. There are other organic diseases, too, which may be overlooked, and whose alterations in the reflexes may be ascribed to what is a superim- posed hysteria. Probably most authorities believe that the reflex changes typical of organic disease cannot be produced by hysteria. On the other hand, well attested cases of supposedly uncomplicated hysteria have been reported by such observers as Nonne, Marie, Dejerine, Van Gehuchten, etc., in which the Babinski reflex, clonus, and absent or exaggerated patellar and Achilles reflexes have been found. Even if, as these authorities contend, such alterations of the reflexes rarely can occur as manifestations solely of hysteria, the discovery of these changes in a case of the disease argues most strongly for the coexistence of organic nervous disease. 186 Psychopathology of Hysteria Of interest are the results of Knapp's inquiry into the condition of the reflexes in 100 cases of hysteria presenting a difference in sensibility in the lateral halves of the body. He found some exaggeration of the tendon reflexes in 86 cases and spurious ankle clonus in 7 cases. Of 57 cases presenting unequal exaggeration of the tendon reflexes the increase was found twice as often on the ansesthetic side as on the opposite one. True ankle clonus, the Babinski sign, and absence of the patellar reflexes were not observed in any of the cases. Unlike the tendon reflexes impairment, or loss, of the skin reflexes of an anaesthetic part is not uncommon. In 24 cases out of 51 Knapp found the abdominal reflex to be involved in this manner. (Jour, of Nerv. and Ment. Dis., 1910, p. 93.) A valuable means of differentiation between organic and hysteric hemiplegia is afforded by Hoover's complemental opposition sign. (Jour of the A. M. A., 1908, 2, 746.) When a normal individual who is lying upon his back elevates one extended lower extremity the downward pressure of the opposite heel is increased, and when one extended lower extremity is pressed down with some force, the downward pressure of the contralateral limb is lessened. In cases of organic hemiplegia attempts to elevate the paralyzed limb result in increased downward pressure of the opposite heel, even though the paralyzed extremity does not move. Also, eleva- Psycho-Motor Disorders 187 tion of the extended normal limb is accompan- ied by an amount of contralateral downward pressure that is proportionate to the degree of paralysis. If the hemiplegia is hysteric in origin the attempt to raise the paralyzed limb does not increase the downward pressure of the opposite heel, while elevation of the normal limb does produce complemental opposition of the paralyzed side. In the same manner the com- plemental opposition sign may be elicited by having the patient press the extremity down upon the surface upon which he is lying, in- stead of raising, or attempting to raise, the limb. In testing patients with moderate organic ataxia (Jour, of the A. M. A., 1909, 1, 1234.) Hoover found that the amount of complemental opposition is increased whether the patient 's eyes are open or closed. But if the ataxia is extreme complemental opposition is exaggerated when the patient's eyes are open; w^hile it disappears en- tirely if his eyes are closed; the patient then reacting like the hysteric, or the malingerer. As cited by Hoover, Lhermitte found that when paralysis of one lower extremity has been induced by means of hypnotic suggestion the va- riations of complemental opposition are the same as those observed in hysteria and malingering. In experimenting with hypnotic subjects I have verified this when the suggested paralysis was complete; otherwise, complemental opposition may be the same as that observed Tidth organic 188 Psychopathology of Hysteria paralysis. The same holds true of hysteria. In either hysteric or hypnotic hemiplegia the absence of complemental opposition depends en- tirely upon the fact that the patient is so firmly convinced of the reality of her paralysis that she really does not attempt to raise the limb. When hysteric hemiplegia is spastic then com- plemental opposition occurs, but the amount ex- hibited when the patient attempts to lift the paralyzed limb is not as great as when the nor- mal one is elevated. The same result is obtained when testing subjects in whom the condition has been produced by suggestion. The explanation is obvious. Hysteric or hypnotic spastic paraly- sis depends upon a more or less constant rigidity, and when the patient strives voluntarily to use one group of muscles there is a corresponding increase in the amount of contraction of the opposing group with consequent increase in rigidity. Now, if the patient attempts to elevate the paralyzed limb the opposing group of muscles contract sufficiently to prevent the limb from being raised but not enough to maintain the same amount of downward pressure that had been produced by the weight of the limb itself. This result would be expected because the patient's conception of her paralysis mere- ly prevents elevation of the limb and variations in the downward pressure due to its weight do not enter into her subconscious calculations. Consequently, complemental opposition of the Psycho-Motor Disorders 189 other extremity occurs to a degree sufficient to counter-balance this decrease in the weight of the affected extremity. In the examination of modifications of com- plemental opposition Zenner (Jour, of the A. M. A., 1908, 2, 1309,) avers that it is easier to de- tect contraction of the semitendinosus, the semi- membranosus, and the biceps muscles than it is to appreciate variations of the downward pres- sure of the heel. Another sign which is dependent upon com- plemental opposition has been described by Raimiste (Rev. Neurol., Feb. 1909.) While the patient, with both lower extremities abducted, is lying upon a smooth, firm surface the physician requests him to draw, but not to lift, the normal extremity over towards the paralyzed one, and, at the same time, the physician forcibly opposes "the movement. If the hemiplegia is organic, abduction of the paralyzed limb occurs. In like manner abduction of the paralyzed member takes place when both lower extremities are in apposition and the normal one forcibly is pre- sented from being separated from its fellow. A type of progressive muscular atrophy be- ginning in the iliopsoas muscles has been described by Thomas Buzzard, who points out the difficulty of differentiating the condition from some kinds of hysteric paraplegia. (On the Simulation of Hysteria by Organic Disease of the Nervous System, 1891, p. 5.) In cases 190 Psychopathology of Hysteria presenting this unusual variety of onset of pro- gressive muscular atrophy the patient com- plains of weakness in the lower extremities, together with difficulty in ascending stairs, in walking uphill, or in rising from a chair, yet, if the disease is confined to the iliopsoas muscles, examination shows that the reflexes and electrical reactions which are capable of being elicited are normal, and that not any atrophy is in evidence. The diagnosis in such cases depends upon the character of the motor disturbance and upon the absence of signs of hysteria. If the disease has spread to the muscles of the thigh then the loss of the patellar reflexes, changes in the electrical re- actions, and the appearance of atrophy, make the recognition of the disease an easy matter. A paralysis which is accidentally suggested upon a patient owes its continued existence to the patient's belief in his inability to activate the affected muscles. Consequentlj^, if he can be induced to believe that paralysis no longer exists, the symptom will disappear at once, or if he can be convinced that some form of treat- ment is going to "cure" the paralysis, then the condition should vanish either suddenly or gradually. On the other hand, if the patient does not receive any treatment the paralysis wdll continue until some accidental occurrence causes him to recover the use of the affected muscles either by inducing him to expect recov- Psycho-Motor Disorders 191 ery, or suddenly by arousing the conviction that the paralysis no longer exists. It is only by reason of the state of expectancy which is induced in a devout hysteric that sin- cere faith in the miraculous curative virtues of a relic is capable of producing immediate cure of paralysis, amaurosis, etc. Each shrine has its quota of crutches which were discarded by cases of hysteric paralysis that were cured. For the same reason any worthless patent medi- cine, electric belts, tractors, magnets, and kin- dred ''therapeutic" agents vdll be effectual, providing that the patient has sufficient faith in the means. "With most of the monosympto- matic cases it is a question only of combatting one belief with another, and the stronger one wins. Recent hysteric paralysis usually- is very amenable to treatment. On the contrary, long continued paralysis tends indefinitely to per- sist, regardless of treatment. Hemiplegia and two instances of brachial monoplegia had con- tinued for 29, 28, and 30 years respectively, in the three old soldiers with hysteric paralysis reported by Prince. Systematized Paralysis. Paralysis is sys- tematized when it exists only for the conscious performance of certain acts; other forms of conscious activity with the same groups of muscles not being impaired. Through the agency of hypnotic suggestion not only can we 192 Psychopathology of Hysteria produce ordinary psychic paralysis, but sys- tematized paralysis also can be created; and either of such types present all the character- istics of those due to hysteria. If we tell a hypnotized subject that he is unable to walk and then by means of post hypnotic suggestion cause the resulting condition to persist after the hypnotic state has been removed, different types of astasia-abasia can be evolved which cannot be differentiated from the varieties met with in hysteria. Let us consider, then, that hysteric paralysis and systematized paralysis are the consequence of dissociation from conscious- ness either of all forms, or of particular kinds of motor functions in a part or parts, and that this dissociation is affected by autosuggestion. Astasia-Abasia. In the affection kno^n as astasia-abasia the patient is unable normally to stand or to walk without, however, any other kinds of activity of the lower extremities being impaired. Total inability to walk is occasioned when the condition is highly developed. More frequently some peculiar type of gait is pos- sible. Except as the result of abnormal idea- tion astasia-abasia would be impossible. It is only a psychopathic state which is capable of producing inability to walk in a patient whose muscles are not paralyzed or ataxic and who, perhaps, is able to run and to dance. To illustrate a mode of genesis of astasia- abasia, and at the same time to demonstrate the Psycho-Motor Disorders 193 importance of autosuggestion in the produc- tion of symptoms of hysteria, there is no better instance than that afforded by Prince's B. C. A. case of dissociation of personality. (Jour, of Abnormal Psych,, vol. 3, p. 331.) As person- ality C, the patient had witnessed the peculiar gait of a patient with astasia-abasia. The co- conscious personality B, (what might be termed an emancipated subconsciousness) became in- terested in the condition, and later, while thinking deeply on the subject and wondering how it would feel if she were afflicted with the same infirmity, personality C became much excited and the condition developed. Like paraplegia, astasia-abasia may develop from the transitory difficulty in standing, or walking, that a hysteric may experience after having been confined to bed for a number of days by some acute illness. Mutism. Hysteric mutism is the most in- teresting of the manifestations due to system- atized paralysis. It may be looked upon as a S3^stematized paralysis because the articulatory muscles may be affected only for speech. The symptom is decidedly more frequent in males than in females, and often it occurs as a more or less isolated physical manifestation. As noted in the section devoted to audition, hys- teric mutism may be associated with psychic deafness. Having heard of deaf and dumb asylums and of the deaf and dumb the two sen- 194 Psychopathology of Hysteria sory deficits are rather intimately associated in the minds of laymen. As a consequence of this conceptual relationship a hysteric layman who becomes deaf may also develop mutism, or vice versa. Another mode of genesis is by means of fixation and elaboration of an aphonia which was symptomatic of some transient local inflammation. Temporary disturbance, or even total sup- pression, of speech is a normal accompaniment of intense excitement. An angry man often stutters out his rage, or is rendered speechless for a brief period. The tendency of hysteria to appropriate whatever suggests itself during periods of emotional excess, and to elaborate normal reactions, may eventuate in the devel- opment of mutism, or of other speech defects, from just such a transitory difficulty. For ex- ample, a patient reported by 0. S. Hubbard, (Jour, of the Kansas Med. Soc, 1908, p. 451) had become angry and much excited. Mutism developed the evening of the same day; sev- eral hours after he had expressed the opinion that soon he would be unable to talk, ^y means of suggestion, bitter medicine, and mas- sage of the neck, speech was caused to return the following day. Like other phenomena of the disease the symptom may be paroxysmal or constant; paroxysms being aroused by association of ideas. The attacks of mutism occurring in one Psycho-Motor Disorders 195 patient were induced onl}^ by quarrels, and it was found that some few years ago the initial disturbance followed a quarrel with her brother. In her early childhood another pa- tient had fallen from a tree with the conse- quence that a prolonged attack of mutism oc- curred. During the succeeding twenty-five or thirty j^ears she had been subject to paroxysms of mutism that occurred about two or three times a year and which continued for a few weeks ; the longest having lasted three months. Bach of the attacks followed some exciting incident, and the mutism was absolute — she was unable to talk, whisper, or even to whistle. Being accustomed to the seizures she neither feared nor worried about them. An account of an interesting case of mutism that occurred during the seventeenth century was discovered by Jahnel in an old book. Fol- lowing a narrow escape from drowning the patient, aet. 10, developed complete mutism. For fifty years he was able to speak only from noon until one o'clock, and even though no clock was at hand he was accu- rate to a minute in his determination of these hours. Except two or three days before his death only twice was he known to speak at other hours, and on both of these occasions he was ill from fever. (Nerologisches Central- blatt, June 1, 1908, p. 512.) 196 Psychopathology of Hysteria The psychic effects of traumatism and the occasional resistance of hysterical symptoms to treatment is shown in a case reported by J. K. Mitchell. (Jour, of Nerv. and Ment. Dis., 1907, p. 253.) In a male of twenty-two years abso- lute mutism succeeded a stuporous condition which had been induced by the psychic stress occasioned by contact with a live wire, though no other physical effects than a small brush burn of the face were discovered. Once dur- ing the course of the mutism the patient was known unconsciously to have uttered a few words, and, on another occasion, he talked in his sleep. Local faradism, injection of strych- nine, suggestion during a state of light hyp- nosis, general anaesthesia, and attempts at vocal re-education were unsuccessful in causing the return of his speech. Fifteen months after the onset of mutism recovery occurred spontan- eously during a theatrical crisis. On recovering consciousness, after having been injured, one of Bailey's patients had mut- ism in addition to other major symptoms of hysteria. Many months later he was much alarmed, after a second accident, to find that he was talking to himself — the mutism had dis- appeared. The diagnosis, traumatic hysteria, was considered incontestable. (Diseases of the Nervous System Resulting from Accident and Injury, 1906, p. 448.) In the normal person a nightmare usually Psycho-Motor Disorders 197 causes a sense of depression during the follow- ing day. In our relations with psychopathic individuals it is not at all unusual to observe that incidents of dreams have been carried over into the waking state. One of Prince's cases serves nicely to illustrate this mode of genesis of symptoms. (Jour, of Abnormal Psychology, vol. 5, p. 139.) During a terrify- ing dream the patient tried to call to her mother, and, as usually is the case during dreams, she was unable to speak. After wak- ing she could only whisper, and the complete aphonia persisted until relieved by suggestion. Hysteric mutism may be interpreted as a massive dissociation from consciousness of the faculty of vocal expression of language. When mutism is systematized it may be dependent either upon inability to articulate, though inter- nal language is unaffected, or upon dissociation of the memories of certain kinds of words. The defect in the latter instance is more properly classified as a systematized amnesia. Like most other symptoms of the disease all the varieties of mutism readily can be repro- duced by means of suggestion. And whether the affection be caused by hysteria or by inten- tional suggestion, it is the product of a fixed idea. The patient sincerely believes that he is unable to speak, and, therefore, he does not voluntarily try to do so. Or, if at the instiga- tion of others he does attempt to speak, his 198 Psychopathclogy of Hysteria efforts are vitiated by his conviction that they will fail. In other words, no matter how earnest the patient may seem, his attempts to speak necessarily must fail by reason of the autosuggestion of failure that is implied by his lack of conviction in their success. Any method, then, which is capable of arousing the patient's belief in his ability to speak should be successful in the treatment of this condition, and it is this fact which enables the believer in Christian Science, or in faith cure, or in patent medicine, to be cured by these supposed therapeutic agents. The fact that they do cure justifies the use of the principle upon which they are based ; namely, suggestion. Besides mutism numerous speech defects may occur in hysteria. Among these loss of the voice with preservation of whispered speech — aphonia — probably is the most common. Dif- ferent kinds of stammering may occur, and even the scanning speech of multiple sclerosis may be mimicked. In one rather unusual case the patient separated each word and each syl- lable by a short quick inspiration so that his speech resembled that taught to patients as one of the features of a certain method of treat- ment of stammering. Mutism is rare, if it occurs at all, in psychas- thenia; but the majority of inorganic speech dis- turbances other than mutism probably are symp- tomatic of this psychoneurosis. Ordinary stam- Psycho-Motor Disorders 199 mering and other spasmodic vocal affections of like nature almost invariably are due to psychas- thenic tics affecting speech, and their mechanism differs not all from that of other tics, or "habit spasms. ' ' Contractures. When a muscle, or a group of muscles, develops a state of paroxysmal or constant contraction the resulting condition is knov/n as a contracture. Almost invariably contractures are the effect of the psychic stress occasioned by some traumatism; severe, trivial, or supposititious. This symptom is not frequent for the reason that its causes are also the causes of paralysis, and as patients possess greater knowledge of paralysis than of contractures the former are more apt to occur. Like the genesis of paralysis it is not the in- jury itself which causes the symptom, but it is the idea of the injury. In fact, a contracture may appear solely as the result of belief that an injury has been received when, in reality, none had been inflicted. Florence K., for ex- ample, believed that her finger had been kicked. Upon questioning her it was found that she was not sure that her hand actually had been struck. Besides, not any e^^dence of injury could be dis- covered. Immediately after the exposure to in- jury she experienced severe pain, and the little finger became contractured into the palm. The attempts of other physicians forcibly to reduce the contracture had failed because of the in- 200 PsycJiopathology of Hysteria tense emotional reaction provoked by such pro- cedures. On the third day my examination showed that even when moderate efforts were made passively to extend the finger the exaggerated manifesta- tions of pain became excessive, and the more forcible the attempt the more pronounced be- came the contraction of the muscles which were responsible for the condition. The whole hand was cold, perspired freely and presented a de- cided tremor even before any manipulation was attempted. Having hypnotized the patient the finger was straightened without difficulty and without causing any ''pain." When the hyp- notic state was dispelled, however, the contrac- ture reappeared in spite of previous post hyp- notic suggestions which had as their end the prevention of this occurrence. Accordingly, she was hypnotized again, the finger straightened, and a splint applied. "When ''awakened" she expressed surprise at finding her finger ex- tended. After about fifteen minutes the splint was removed and she had no further trouble either from pain or from abnormal muscular contraction. Contractures may occur in any part of the body, and, what indeed is remarkable, even in- voluntary muscles may be affected. Except some of the contractures produced by involuntary muscles all those of hysteria can be duplicated by means of suggestion. Psycho-Motor Disorders 201 When originating from traumatism the loca- tion of a contracture depends upon the site of injury, and the pain which is often found in association either is entirely psychic, as in the case just mentioned, or it is an elaboration of actual pain. Naturally a patient would believe that any injury which is severe enough to re- sult in a contracture should be provocative of considerable pain. When pain, then, is present its severity is apt to be out of proportion to the amount of surgical injury. The recognition of hysteric contractures is usually not difficult. When the affection has ex- isted for a long time and when the associated symptoms are misleading it is quite possible, however, to attribute the manifestations to some organic disease. In fact, even as great a clinician as Osier speaks of having repeatedly demonstrated as a typical example of lateral sclerosis a case of hysteric contracture of paraplegic form. (Practice of Medicine, 1902, p. 1114.) When the symptom is due to hysteria the tendon reflexes are not disturbed as in organic nervous diseases, and the electrical reactions more nearly resemble the normal. If the flexion or extension is not complete examination shows that the contraction of the muscles responsible for the condition is counterbalanced by con- traction of their opponents. Now suppose we examine a case of flexion of the forearm. When 202 Psychopathology of Hysteria we attempt forcibly to extend the forearm the biceps is felt to contract energetically and the counterbalancing contraction of the triceps disappears as onr efforts at extension render this no longer necessary. On the other hand, if we try to increase the amount of flexion of the forearm we find that the biceps relaxes and the triceps becomes tense. If a whole extremity is contractor ed as a re- sult of organic disease it is possible to ex- tend more or less completely one part at a time, but the whole limb cannot be extended at the same time. The amount of extension secured in this manner is augmented when the flexion of neighboring parts is increased. These results cannot be secured with hysteric contractures. Osseous deformities and joint changes ordi- narily do not develop in long standing cases of hysteric contracture. With patients in whom the condition is not highly organized the underlying muscular contraction tends to sub side when the patient's attention is distracted, and the contracture may disappear during sleep, general anaesthesia, the hypnotic state, and during somnambulistic or convulsive at- tacks. The duration of a contracture is variable. Like other symptoms it has been known to per- sist many years. In the treatment of contracture quite com- monly advantage is taken of the relaxing effects Psycho-Motor Disorders 203 of etherization in order to reduce the deformity and to splint the affected part. Having con- vinced the patient that reduction has been effected the contracture does not tend to recur, but it would be preferable to leave the splints in place for several days, or more, according to the duration and the severity of the affection. This means of treatment is to be recommended only as a last resource. Not only is etherization disagreeable and not entirely devoid of danger, but it may serve as the source of various other manifestations of hysteria. Wliether carried to the extent of actual hypnosis or not, suggestion should be quite as effectual, and without any of the disadvantages and dangers of general anaesthesia. In order to obtain the greatest amount of benefit from suggestion it should be reinforced — disguised — ^by the employment of various other agents, such as electricity and massage. Motor Disorders of the Eye. Among the most interesting and the most incomiprehensi- ble of the special types of contractures and paralyses are some of those occurring in the eye. It is impossible, however, to describe each of the many forms of ocular disturbances in a general work, so brief mention is made only of a few. Hysteric contracture of the orbicularis pro- duces unilateral or bilateral drooping of the lids which should not be mistaken for organic ptosis. 204 PsychopatJiology of Bysteria Continual blinking of the lids, blepharoclonus, is less frequent in hysteria than in psychasthenia. Occasionally one meets with hysteric patients who seem unable to displace the eyeballs in any direction, but this apparent ophthalmoplegia externa usually can be demonstrated to be en- tirely subjective. Frequently the condition is apparent only during examination of the ocular muscles — it is suggested upon the patient. Such '^ paralyses" usually disappear when the pa- tient's attention is distracted from the eyes. Four years after having sustained a fracture of the skull and of the second cervical vertebra a male patient developed cerebro-spinal menin- gitis. (N. Y. Med. Jour., Dec. 5, 1908.) During this illness there appeared indisputable organic ophthalmoplegia interna and externa v/hich con- tinued for many weeks after his recovery. Sub- sequently it was noticed that he was unable to move his eyes more than one-fourth of an inch in any direction, and bilateral ptosis was con- spicuous. That the former organic ophthalmo- paresis persisted as a purely hysteric manifesta- tion was made apparent by the disappearance of the paretic sjnuptoms whenever the patient's attention was distracted. Conjugate deviation of the eyes and appar- ent paralysis of associated ocular muscles are readily understood, but it is difficult, indeed, to comprehend how hysteria is capable of causing paralysis of individual ocular muscles — Psycho-Motor Disorders 205 of producing conditions which one cannot vol- untarily reproduce, or which cannot be dupli- cated by hypnotic « suggestion. Nevertheless, quite a tew cases have been reported in which such paralyses have occurred seemingly as manifestations of hysteria. Onuf satisfactorily accounted for a case of hysteric spastic conver- gence and other ocular symptoms as having been due to the elaboration of visual symptoms produced by myopic astigmatism. (Jour, of Abnormal Psychol., vol. 2, p. 155.) Probably it is only our own ignorance which prevents us explaining on psychic grounds all the different hysteric affections of the ocular muscles. As cerebral syphilis often causes isolated ocular palsies that may not be associated with other obvious evidences of the disease, and as the same may occur infrequently with other organic nervous diseases, one should exercise the greatest care before ascribing these signifi- cant affections to hysteria. Quite commonly the pupils are a little larger than usual, and, in rare cases, pronounced mydriasis with loss of the light reflex has been noted. Such conditions are thought to be due to contraction of the dilator muscle of the iris. Redlich (Deutsche Med. Wochenschr., 1908, p. 313,) reported a case in which widely dilated pupils and loss of reaction to light were pres- ent only during hysteric seizures that did not occasion loss of consciousness, and which were 206 Psychopathology of Hysteria characterized by crying out, and muscular activity. The same pupillary phenomena de- veloped when the patient was induced volun- tarily to reproduce the attacks, provided that the muscular contractions were forcible and persistent. He believed that the contraction of the muscles of the neck so irritated the cervical sj-mpathetic as to produce mydriasis, and that in this case the condition was but an exaggera- tion of the dilatation which normally occurs during strong muscular efforts. During the attacks of the case of hysteric petit mal reported by Putnam, and which was mentioned in reference to loss of the patellar reflexes, the patient regularly lost the pupillary light reflex for several minutes. Polyopia and monocular diplopia are so read- ily explained by the assumption that the multi- plication of images is entirely psychic that the involved theory of unequal refraction of the lens due to ciliary contractures need not be con- sidered except, perhaps, in rare instances. Prince's patient with monocular polyopia saw such a large number of images that he had dif- ficulty in counting them. (Amer. Jour, of the Med. Sciences, Feb., 1897.) Motor Trepidation. During the examination of nervous patients often a rapid tremor of small amplitude is noticed when the patient is directed to hold out her hands with the fingers extended. Such a tremor, one Psycho-Motor Disorders 207 which might be accurately designated an at- tention tremor, is dependent upon the famihar effects of conscious attention upon the per- formance of an act, and it is found sometimes even in individuals who do not seem to be ner- vous. More important are the slow tremors of large amplitude that exist independently of ex- amination. These tremors may be localized or general, and they may appear only when the part is at rest or only during use of the mem- ber. The differentiation of the intention tremor of multiple sclerosis from that which may occur as a symptom of hysteria may be difficult when other manifestations are present which are common to either disease. Less frequently, in addition to rest tremor other symptoms of paralysis agitans may be mimicked. Thus a patient reported by Gaussel developed by psychic contagion all of the manifestations pre- sented by a patient with paralysis agitans who occupied the next bed. (Gazette des Hopitaux, Nov. 7, 1908.) The possible causes of hysteric tremor are in numerable. Generally the different kinds of motor agitation are exaggerated but persistent emotional reactions which are elaborated from ones which were normal. While committing a reprehensible act the arm, for instance, which is employed may tremble as normally it might in consequence of emotional excitement. By 208 Psychopathology of Hysteria autosuggestion this normal trembling may be- come fixed upon the patient. When originated in this manner it is a symbol of some repulsive act whose memories, because of their unpleas- ant nature, the patient has voluntarily sup- pressed from consciousness. Another mode in which a localized tremor may be generated is that in which the patient's attention is concentrated upon the activity of some one member while a general trembling is present as the result of some emotional dis- turbance. While shaving a customer a hysteric barber became excited, and the consequent trembling resulted in the infliction of a severe incision. As his livelihood depended upon the steadiness of his hand the barber worried about his mishap. If the accident were repeated he might lose his place. With this foundation of expectant attention what might be expected actually appeared; whenever he attempted to shave anyone, thought about doing so, or even fixed his attention upon his hand, decided tremor developed in the hand which he used in shaving. The surgeon often notices severe trembling of injured limbs. If the patient happens to be a hysteric fixation of this othermse transitory symptom is almost inevitable. Not infrequently the irregular movements of chorea are continued indefinitely through the agency of associated hysteria. Psycho-Motor Disorders 209 The effect of attention upon hysteric tremors is variable. Distraction of the patient's atten- tion may either increase or decrease the inten- sity of the tremor, and concentration of attention upon the affected part may also have the same varying effects. In psychasthenia, however, a tremor always is diminished or caused to disap- pear during distraction of the patient's atten- tion. Rhythmical choreas are characterized by rhj-thmical, purposive, involuntary movements which do not resemble the aimless jerking of chorea ; neither are they like the vibrations of a tremor. Unlike psychasthenic choreiform tics the rhythmical choreas of hysteria do not tend to disappear during distraction of the patient's attention because the whole mechanism is sub- conscious. The agitation may be paroxysmal or more or less constant. In the case of the former each paroxysm is excited by a stimulus which, by association of ideas, provokes into activity the dissociated system. The movements may origi- nate from dissociated ideas concerning the occu- pation of the patient, or they may be represen- tations of some disagreeable experience. Hysteric tremors and rhythmical choreas may be looked upon as rudimentary convulsions. Sometimes they are residues of former convul- sive seizures. Emma F., for instance, had been shot in both arms, and, at the same time, she had received an abrasion of the forehead. Imme- 210 Psychopathology of Hysteria diately she became unconscious and a convulsive seizure appeared — the first she had ever experi- enced. Following this attack she had others during which she screamed and struggled. After these crises had spontaneously disappeared gen- eral trembling and choreiform movements de- veloped and continued for seven years. The only way in which she could prevent her head from participating in this constant motor agita- tion was by means of holding it firmly with her hands. Furthermore, she had suffered from at- tacks of what appeared to be typical migraine since she was injured. Here, then, is a case in which severe general trembling originated from what probably were defensive movements of former somnambulistic attacks, and these seizures, in turn, represented her terror and resistance when she was shot. The original pain produced by the abrasion of her forehead probably served as the source of her "migraine." The tremor, choreiform move- ments, and headaches were readily controlled by suggestion during a state of deep hypnosis, and, after the third treatment, her symptoms en- tirely disappeared. The majority of habit spasm or tics are symp- tomatic of psychasthenia. The psychasthenic tic differs from the rhythmical choreas of hysteria in that to a great extent it is volun- tary. The patient is obsessed with the idea to tique, and temporarily to relieve the mental Psycho-Motor Disorders 211 discomfort due to the impulsion he voluntarily indulges in the spasmodic muscular contraction. When his attention is distracted his tic is less frequent or it disappears, or, to express the condition more correctly, he does not have the tendency to tique when his attention is dis- tracted. The imperative ideation which causes the psychasthenic tic is disposed to be most insist- ent Avhen the spasms are least desired. When in the company of friends, and more par- ticularly strangers, the patient, always em- barrassed and self-conscious, fears that he will be afflicted with his tic, and, being ashamed of it, he apprehends having remarks made about his condition. The consequent state of ex- pectant attention naturally results in the pro- duction, or the aggravation, of the tic. The psychasthenic is able more or less suc- cessfully to resist the impulse to tique until he believes himself to be unobserved. Then he indulges in the relief afforded by a number of quickly repeated spasms which appear, to the chance observer, as if the impulses had been accumulating, or as if the tiquer were at- tempting to insure a succeeding interval of respite by reason of excessive indulgence. On the other hand, the hysteric is not embarrassed by her tic, and, in fact, she may not even be aware of the muscular contractions which are taking place independently of any conscious impulsion. CHAPTER VII Psycholepsy* THE failure of the Salpetriere school, during Charcot's time, to accede the contentions of Berheim, to the effect that suggestion plays a most impor- tant role in the genesis of symptoms of hysteria, resulted in the artificial development, by them, of a type of convulsion which was much less frequently encountered by other observers and which is rarely seen at present, unless produced in a similar manner, or unless accidentally and spontaneously generated. Because of the vast amount of research con- cerning hysteria which was carried out by Charcot and his followers, and because of the persistent manner in which their classic de- scriptions of a single variety of hysteric con- vulsion have been, and are being, incorporated in all text books of nervous diseases, it is quite generally thought that this particular kind of attack is the only one which may be caused by hysteria. Unfortunately, then, our conception of hysteric crises is apt to be confused by these ubiquitous text-book descriptions of manifesta- (*I am indebted to the Editor of the Journal of Ab- normal Psychology for permission to incorporate in this section material drawn from a previous paper entitled "Psychogenetic Convulsions" Jour, of Abn. Psych., vol. 5, p, 1.) 212 Psycholepsy 213 tions which were purely the result of most elaborate, but unconscious, suggestion and of psychic contagion, and which occurred almost exclusively in a comparatively small group of patients in one hospital. Indeed, the majority of text-book considerations of the disease do- not show that there has been any progress in our knowledge of this disease since the time of Charcot. This affects more particularly those who do not specialize in neurology and who are dependent, therefore, upon text-books. Conse- quently, these practitioners are led to infer that hysterics are capable of presenting only one kind of attack — hystero-epilepsy, grande hy- steric, hysteria major — and as the effect of their inference other varieties are most apt to be looked upon as being epileptic in origin. The attack of grande hysteric was divided into five stages: (1) The prodromal stage. (2) The epileptoid stage. (3) The period of clowmism, or of movements of wide range. (4) The period of emotional attitudes. (5) The period of delirium. The following is a sum- mary of descriptions of the whole attack as elaborated by Charcot, Richer, and others of the Salpetriere school: 1. The prodromal stage is characterized by various mental disturbances which may continue even for days, or for weeks, before the onset of the actual seizure. Objectively, the patient's actions de^date markedly from her usual stan- 214 FsychopatJiology of Hysteria dard; mainly because she becomes unusually emotional and irritable. Subjectively, she may experience almost any kind of sensory or psychic disturbances. The premonitory stage terminates with an aura which usually consists of globus hystericus, dimness of vision, tinnitus, etc. Fol- lowing the aura the patient cries out, falls care- fully to the ground, and loses consciousness. 2. The epileptoid stage. This stage consists of a period of tonic rigidity followed by clonic convulsions and concluding with muscular re- laxation and stupor; the whole lasting but a few minutes. 3. The period of clownism then appears. The patient's body is tossed about wildly by reason of forcible muscular contractions — of movements of wide range — and, most characteristically, the highest degree of opisthotonos develops. Towards the close of this period she exhibits manifesta- tions of great fear, or of rage. Tearing her clothes and biting at those who are trying to hold her she acts more like a wild animal than a human being. 4. The period of emotional attitudes gradu- ally develops from that of clownism after the latter has lasted a short time. The attitudes are the dramatic representation of various emotions aroused by the hallucinations which the patient is experiencing, and whose character is depend- ent upon the nature of the primary exciting cause. In fact, the postures and the type of the Psycholepsy 215 subsequent delirium are indices of the patient's ideas at the time. Consequently, they signify the original cause of the condition. 5. The period of delirium is a continuation of the stage of emotional attitudes from which it differs only in that with the gradual return of consciousness the patient gives verbal expression to her hallucinations, and the posturing disap- pears. The entire attack may last from fifteen min- utes to an hour, but, in some cases, the pro- longation of certain stages, or the occurrence of repetitions of some of the stages, or of the whole