The Croonian lectures on the psychology of the special senses and their functional disorders

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THE CROONIAN LECTURES

ON

THE PSYCHOLOGY OF THE SPECIAL

SENSES AND THEIR FUNCTIONAL

DISORDERS

PUBLISHED BY THE JOINT COMMITTEE OF

HENRY FROWDE, HODDER AND STOUGHTON

17 WARWICK SQUARE, LONDON, E.C.4

THE CROONIAN LECTURES ON

THE PSYCHOLOGY

OF THE

SPECIAL SENSES

AND THEIR

FUNCTIONAL DISORDERS

DELIVERED BEFORE THE ROYAL COLLEGE OF
PHYSICIANS IN JUNE 1920

BY

ARTHUR F. HURST

M.A., M.D. Oxon, F.R.C.P.

PHYSICIAN AND NEUROLOGIST TO OUY'S HOSPITAL

LONDON
HENRY FROWDE HODDER & STOUGHTON
Oxford University Press Warwick Square, E.G.

1920

WfiLOGY

Library

PRINTED IN GREAT BRITAIN

BY HAZELL, WATSON AND VINEY.

LONDON AND AYLESBURY.

PREFACE

The Croonian Lectures appeared in a shortened form in the
Lancet soon after their delivery. They are now published in
full with the addition of some illustrative cases.

I am anxious to acknowledge my great indebtedness to
the Medical Officers who worked with me before and since
the War at Guy's Hospital, and during the War in Lemnos,
Salonica, Oxford, Netley and the Scale Hayne Military
Hospital, as most of the investigations upon which these
Lectures are based were carried out in conjunction with
them, and the description of many of the actual cases are
taken from their notes.

I wish especially to mention Major W. Johnson, M.C.,
Major J. L. M. Symns, Major J. F. Venables, Captain A.
Wilson Gill, Captain R. G. Gordon, Captain G. MacGregor,
Captain J. W. Moore of the U.SA. Army Medical Service,
Captain W. R. Reynell, Captain C. H. Ripman, Captain
A. Robin, Captain S. H. Wilkinson, and Dr. R. Gains-
borough.

The frontispiece has been reproduced from a copy of
La Verite des Miracles in the possession of the Royal Society
of Medicine, by kind permission of the Librarian, Sir John
Macalister.

Arthur F. Hurst.
London,

September 1920.

4374oS

CONTENTS

CHAPTER I
Natuee of Hysteria .

CHAPTER II

Cutaneous Sensibility and Cutaneous Anes-

thesia

CHAPTER III

Pathogenesis of Hysterical Cutaneous Anes-
thesia ....... 30

CHAPTER IV
The Superficial Reflexes in Hysteria . . 35

CHAPTER V
Sensibility and Reflexes of Mucous Membranes 42

CHAPTER VI
Cutaneous Hyperesthesia 60

vii

viii CONTENTS

CHAPTER VII

PAQB

Hysterical Pain 63

CHAPTER VIII
Hearing, Listening, and Hysterical Deafness . 60

CHAPTER IX
Hysterical Hyperaceusis 87

CHAPTER X

Seeing, Looking, and Hysterical Blindness 89

Index 123

LIST OF ILLUSTRATIONS

" Miraculous " Cube of Blindness and Hemiplegia.

Frontispiece^

FIG. P^QK

1. Hemi-anjesthesia in Man with Hysterical Fits.

(After Charcot) 6

2. Sleeve Anesthesia in Hysterical Traumatic

Monoplegia. (After Charcot) ... 7

3. Glove Anaesthesia in Hysterical Traumatic

Paralysis of Hand. (After Charcot) . . 7

4. Complete Hemi-anesthesia in " Experimental

Malingering " 9

5. Hemi-anesthesia with Exception of Face in

"Experimental Malingering". . . . 10

6. Anaesthesia of the Whole Arm and Whole Leg in

" ExPERiMENTAi. Malingering " . ... 10

7. Glove and Sock Anesthesia in " Experimental

Malingering " . . . . . . .11

8. Hysterical Anesthesia in Median Nerve Area . 20

9. Hysterical Anesthesia in Musculo-Cutaneous

Area 21

10. Hysterical Anesthesia in Ulnar Nerve Area . 21

11. Hysterical Anesthesia in Median Nerve Distribu-

tion, with Unfelt Accidental Burn . . 22

12. Burn over First and Middle Finger in Hysterical

Anesthesia Area .... (facing) 22

13. Hysterical Anesthesia of Arm following Peri-

pheral Anemia 26

X LIST OF ILLUSTRATIONS

Pia. PAQB

14. Anesthesia in Ischemic Myositis following

Tight Bandaging. (After Purves Stewart) . 28

15. Anesthesia in Ischemic Myositis following In-

fective Thrombosis of External Iliac Artery.
(After Purves Stewart) ..... -28

16. Variations of Pharyngeal Excitability in 170

Non-hysterical Cases 45

17. Variations in Pharyngeal Excitability in Sixty-

four Hysterical Cases ..... 45

18. Variations in Pharyngeal Excitability in

Twenty-four Cases of Hysterical Aphonia and
Ten Cases of Hysterical Mutism ... 45

19. Diagram illustrating Neurones concerned in

Hysterical Deafness and in the Auditory-
motor Reflex 65

20. Hysterical Blepharospasm and Amblyopia of

Four Months' Duration . . . (facing) 100

21 . Hysterical Ptosis with Unilateral Blepharospasm

AND Amblyopia of Four Months' Duration

(facing) 100

22. Hysterical Blepharospasm, Ptosis, and Amblyopia

OF Five Months' Duration . . (facing) 100

23. Hysterical Ptosis of Left Eye and Paralysis of

Left Side of Face with Hysterical Spasm of
Right Side of Face . . . (facing) 104

24. Internal Strabismus of Nineteen Years' Duratiois^

{facing) 112

25. Without-inward Spiral Field of Vision in Right

Eye in Case of Hysterical Paraplegia . .117

26. Spiral Field OF Vision IN Hysteria. (After Purves

Stewart) ........ 117

27. Spiral Fields of Vision in Case of Hysterical

Tremor 118

28. Spiral Fields of Vision in Case of Hysterical

Mutism and Tremor 119

29. Spiral Field of Vision in Case of ** Experimental

Malingering " 120

THE PSYCHOLOGY OF THE
SPECIAL SENSES

CHAPTER I

NATURE OF HYSTERIA

When I received the honour of being invited to deliver the
Croonian Lectures, it seemed to me right that I should
attempt to apply some of the lessons I had learnt during
the war to the problems of civil life. I was fortunate in
having almost unique opportunities for investigating the
neuroses, which occurred so frequently under the excep-
tionally trying conditions the British army had to face on
every front. In the course of my investigations on their origin
and nature I made a number of observations which throw, I
believe, some light on the psychology of the special senses
and the physiology of the reflexes associated with them.
As the most common neurosis affecting the special senses
was hysteria, and as my views on the nature of hysteria
differ from those held by the majority of neurologists, it
will be necessary to explain what I mean by hysteria
before I approach the main subject of these lectures.

Nature and Definition of Hysteria. — The word hysteria
was first used by the Greek physicians to describe what
is known now as an hysterical attack, under the impression
that it was due to an actual displacement of the uterus
into various parts of the body. In course of time
numerous other conditions were recognised as being of
a similar nature, and the word hysterical was used to
describe them all. The etymology of the word coloured all
1

2 PSyCHOLQGX , OF THE SPECIAL SENSES

the theories of the nature of hysteria up to the time of
Charcot, almost every writer believing that it was associated
with pelvic disorders and that it occurred only in women.
Charcot, however, showed that it waa not uncommon in
men, and the earlier idea of its relation in women to pelvic
disorders has been gradually discarded. The conception
of the disease, which I shall use in these lectures, has
nothing in common with the original one, and it might
therefore be considered wise to use some other term than
hysteria to describe it ; but since this word has been accepted
for so long a period by physicians in every country, it
would be impossible to introduce any new term which would
obtain universal approval. The word hysteria is indeed
no more unsuitable than such words as rheumatism and
chorea, which have also lost their original significance.

One common factor in all the symptoms, which are by
universal consent regarded as hysterical, is their origin as a
result of suggestion. When the history of each case is
carefully investigated, it is almost invariably possible to
discover that some event or condition suggested its onset
and led to the exact form of the symptoms present. If
the view be accepted that hysterical symptoms are caused
by suggestion, , they must be capable of removal by
psychotherapy without assistance from any more material
method of treatment. We can thus define an hysterical
symptom as one which has been produced by suggestion
and is curable by psychotherapy.

Physical Stigmata. — Gendrin, in an address to theAcad^mie
de Medicine in 1846, stated his belief that " hysteria is not
only characterised by spasmodic attacks occurring at
intervals, but it is a continuous disease, which in the intervals
always presents characteristic symptoms," the most impor-
tant of which " is a state of general or partial insensibility."
Gendrin's views were to a great extent forgotten until they
were revived by Charcot in 1871. Charcot taught that
hysteria manifests itself in two ways — by persistent symp-
toms or stigmata, of which the patient is unaware, and
temporary symptoms, which are obvious to the patient and
lead him to seek medical advice. The former were supposed

NATURE OP HYSTERIA 3

to be present before the latter appeared and to persist after
they had disappeared. Amongst these stigmata the most
constant, according to Charcot, were retraction of the field
of vision, certain forms of cutaneous anaesthesia, and
pharyngeal anaesthesia. His teaching soon became univer-
sally adopted, and few books on neurology or general medicine
published in the last fifty years fail to mention these stigmata.

One of Charcot's most distinguished assistants, Babinski,
was the first to throw doubt upon the importance of the
stigmata he described. Babinski [^] believes that, they are
not permanent symptoms at all, but, like the more obvious
and temporary symptoms, are produced by suggestion.
Instead of being produced by suggestion on the patient's
part, they are the result of suggestion on the part of the
physician. The evidence brought forward by Babinski in
connection with anaesthesia and retraction of the field of
vision appears to me to be conclusive, and receives further
confirmation from the investigations which I shall presently
describe. We have obtained similar evidence with regard
to pharyngeal anaesthesia, so that the question of the
physical stigmata may be regarded as settled.

Mental Stigmata. — It is so common to regard certain
mental qualities as hysterical, and to apply the term hysteri-
cal to a certain tjrpe of individual, that it requires considerable
courage to reject altogether the doctrine of a specific psychical
disorder to which the name hysteria can be given. But
on examining the literature, it is at once apparent that no
sort of unanimity exists as to what are the specific mental
attributes of hysteria. For several years I accepted the
definition of hysteria as an abnormal mental condition, in
which the individual is unduly prone to develop symptoms
as a result of suggestion. But the experience of the war
has taught us that, given a sufficiently powerful suggestion,
there are probably qio individuals who would not develop
hysterical symptomsl [*]

Abnormal suggestibility, like other mental attributes
commonly regarded as characteristic of hysteria, is un-
doubtedly a most important predisposing cause of hysterical
symptoms, but it is not an essential factor, and cannot

4 PSYCHOLOGY OF THE SPECIAL SENSES

therefore be regarded as an essential part of hysteria. As
it may exist in an individual, who never shows any hysterical
symptoms owing to the absence of adequate exciting causes,
abnormal suggestibility cannot be regarded as a disease,
such as hysteria would designate, any more than irritability
or any other mental attribute is a disease. Unless everybody
can be regarded as a victim of hysteria, as everybody is
liable under sufficient provocation to develop hysterical
symptoms, suggestibility is not the mental basis of hysteria.
Whether a given person will develop hysterical symptoms
under given conditions depends on the degree of his suggesti-
bility and the strength of the suggestion. It is clea^r, there-
fore, that abnormal suggestibility is simply a predisposing
factor, and is no more a part of hysteria than a tuberculous
family history is a part of tuberculosis. Many cases of
gross hysterical symptoms occurred in soldiers, who had
no family or personal history of neuroses, and who were
perfectly fit until the moment that one of the exceptionally
powerful exciting causes, such as occur comparatively
rarely apart from war, suggested some hysterical symptom.
After its disappearance as a result of psychotherapy the
man was once more perfectly fit, and his subsequent
history showed that he remained no more liable than any
of his companions to develop new symptoms.

As soon as it is recognised that the mental stigmata,
which predispose to the development of hysteria, are not
themselves a part of hysteria, it becomes obvious that many
cases of hysteria will be missed if it is only looked for in
so-called hysterical persons. When, on the other hand,
it is remembered that there is nobody who may not develop
hysteria if the provocation is sufficiently great, it must
follow that hysteria is infinitely more widespread than has
generally been supposed.

We thus arrive at the conclusion that, apart from actual
hysterical symptoms, there are no underlying physical or
mental symptoms or groups of symptoms, which precede
and accompany them and persist after their disappearance,
to which the term hysteria can be applied. It is clear,
therefore, that while it is easy to define hysterical paralysis

NATURE OF HYSTERIA 5

and hysterical anaesthesia, as they have certain attributes
which distinguish them from all other forms of paralysis
and anaesthesia, " hysteria " cannot exist in their absence.

(The only possible definition of hysteria is " the condition
in which hysterical symptoms are present," hysterical
symptoms being in turn defined as " symptoms which
result from suggestion and are curable by psychotherapy " ;
hysteria is thus a condition in which symptoms are present
which have resulted from suggestion and are curable by psycho-
therapy. \

REFERENCES

[1] J. Babinski, Oaz. Held, de Med. et de Chir., p. 350, 1891 ; Rev. Neuro-
logiquBf ix. 1074, 1901 ; Sem. Med., xxix. 3, 1909 ; ExposS des Travaux
Scientifiques, p. 203, Paris, 1913.

[2] A. F. Hurst, Seale Hayne Neurological Studies, i. 106, 1918.

CHAPTER II

CUTANEOUS SENSIBILITY AND CUTANEOUS
AN-^STHESIA

( 1) Hysterical Anaesthesia following Hetero-suggestion. —
I have already described how Charcot beheved that
cutaneous anaesthesia was a stigma of hysteria, which was
present before any more obvious
hysterical sjmaptoms developed and
persisted after their disappearance.
It had three characteristic features.
Firstly, it was rarely, if ever, recog-
nised spontaneously by the patient,
and was only discovered in the
course of the physician's examina-
tion. " Hemi-anaesthesia," wrote
Charcot, *' is a symptom, which re-
quires to be sought for. There are
many patients who are quite sur-
prised when its existence is revealed
to them." Secondly, it never caused
any inconvenience to the patient,
who was able to perform movements
with normal accuracy so long as no
paralysis was associated with it, and
it never led to accidental burns or
Fig. 1.— Hemi-ansesthesiain other injuries. Lastly, it always
man mth hysterical fits, occurred in certain characteristic

(After Charcot.)

areas, such as one-half of the body,
the whole of a limb, or the area covered by a glove or
stocking (figs. 1, 2, and 3).
Doubt was first thrown on the truth of Charcot's view

6

CUTANEOUS SENSIBILITY AND ANESTHESIA 7

by Herbert Page, who in his book on Railway Injuries,
published in 1891, asked the question, " May not sometimes
the very examination of a hemi-anaesthetic patient largely
determine the hemi- anaesthesia ? " And he then observed
that " the examination of a patient may sometimes produce
the suggestion whereby ansesthesia results."

Nine years later Babinski failed to find any disturbance

Fig. 2. — Sleeve ansesthesia
in hysterical traumatic
monoplegia. (After
Charcot.)

Fig. 3. — Glove ansesthesia
in hysterical traumatic
paralysis of hand.
(After Charcot.)

in tactile, painful, thermal, muscular, and stereognosis sense
in any of a himdred consecutive cases of hysterical dis-
orders in which he was careful to avoid the possibility of
suggestion. He concluded that the ansesthesia Charcot had
described as so characteristic of hysteria was not recognised
spontaneously by the patient, and did not cause him any
inconvenience, simply because it was not present until it
had been unconsciously suggested by the observer in the
course of his examination.

(i

8 PSYCHOLOGY OF THE SPECIAL SENSES

Babinski went so far as to state that there is no such
thing as hysterical anaesthesia, apart from that produced
by the suggestion of the observer. In a paper on the subject
pubHshed in 1908 [^ I accepted Babinski' s teaching without
reservation, but from time to time since then I have seen
cases in which hysterical anaesthesia appeared to have
developed without any possibility of hetero-suggestion by
a second person. These isolated cases remained unexplained
until recently, when I gradually came to recognise that
certain entirely different classes of hysterical anaesthesia
exist, which difEer from the only form described by Charcot
and the authors of most text-books of medicine and neuro-
logy by showing none of the three characteristic features
mentioned above. The patient is well aware of the existence
of anaesthesia before he is examined ; it causes more or less
inconvenience, and may lead to accidental burns and other
injuries, and the areas of anaesthesia differ materially from
those hitherto regarded as the only ones occurring in hysteria.
The hysterical nature of these varieties of anaesthesia, which
I shall presently describe in greater detail, may be extremely
difficult to recognise, as the anaesthesia is always a sequel
of the anaesthesia caused by some organic condition and
resembles the latter in all its details.. J

In 1917 I carried out some investigations with Mr. R.
Gainsborough on the classical forms of hysterical anaesthesia
described by Charcot. Twenty-nine healthy and intelligent
individuals, of whom twenty-five were medical students,
who had, however, not yet worked in the wards or read any
clinical medicine, were asked to pretend that they had
been in a railway accident, and that they were attempting
to swindle the company by claiming compensation because
of paralysis of the right arm and leg, which they alleged
had resulted. They were to act as well as they could the
part of men trying to persuade the medical examiner that
they were really suffering from paralysis.

We first asked them whether there was anjrthing else of
which they complained besides paralysis of the arm and leg.
The large majority said they were quite sure there was
nothing else, even after being pressed for details. These

CUTANEOUS SENSIBILITY AND ANESTHESIA 9

results correspond with what occurs in patients suffering
from hysterical paralysis. If they have not previously
been examined, they hardly ever volunteer that they have
any anaesthesia. The following leading question was then
asked, " Can you feel as well on your right side as on your
left V Twenty-two out of twenty-seven, including two
who had spontaneously complained of numbness and one
of coldness, said they felt less on the right side than the
left. Another said he felt tingling
on the right side. The remaining
four said they had noticed nothing.
This agrees with an observation
made by Yealland, which I have
since coniSrmed on numerous occa-
sions. On asking a great number
of non-medical individuals the
following question, " Supposing you
had loss of power in your wrist,
fingers, and thumb, would you, or
would you not, lose feeling ? " the
answer he obtained was always in
the affirmative. When asked what
would be the limits of the loss of
feeling, a line was drawn round the
wrist and less frequently round the
forearm, elbow, or shoulder. The
replies to our leading question in
the twenty-seven "malingerers" cor-
respond with the first stage in the
production of hysterical anaesthesia,
the idea of which first enters the patient's head when he
is asked questions on the subject.,^

Cutaneous sensibility was then roughly tested. Six of
the " malingerers " had right hemi-anaesthesia (fig. 4) five
had complete right hemi-anaesthesia except the face (fig. 5),
twelve had anaesthesia of the whole arm and the whole leg
(Fig. 6), one had hyperaesthesia of the whole arm and whole
leg, and four had no anaesthesia.

Seven were asked what the area of anaesthesia would be

Fig. 4. — Complete hemi-
anaesthesia in " experi-
mental malingering."

10 PSYCHOLOGY OF THE SPECIAL SENSES

if only the hand and foot were paralysed : all replied that
they would have anaesthesia of the distal part of the limb
only, and marked out typical glove and stocking areas at
various points up the wrist and forearm and ankle and leg
respectively (fig. 7). I asked several other individuals
what area, if any, of anaesthesia they would expect to
accompany paralysis of the hand, forearm, and whole arm

Fio. 6. — Hemi-ansesthesia
with exception of face
in " experimental ma-
lingering."

Fig. 6. — Anaesthesia of the
whole arm and whole
leg in " experimental
malingering."

respectively. In most cases the area corresponded with the
extent of the paralysis, glove anaesthesia occurring with
paralysis of the hand, anaesthesia up to a line drawn round
the elbow in paralysis of the forearm, and anaesthesia of the
whole arm up to a line drawn through the axilla and over
the shoulder with paralysis of the whole arm.

/The results of these investigations correspond with the
Second stage in the production of hysterical anaesthesia.
An investigation of cutaneous sensibility in suggestible

CUTANEOUS SENSIBILITY AND ANAESTHESIA 11

individuals is very likely to produce anaesthesia, especially
if the way has been prepared by questions on the subject,
though this is not an essential preUminary. The area of
anaesthesia corresponds with the individual's own ideas,
just as in these cases of experimental maUngering. Figures
1 to 6 show areas which are generally regarded as typical
areas of hysterical anaesthesia ; they are really nothing
more than the areas which anybody without knowledge
of physiology would expect to be-
come anaesthetic when the limbs are
paralysed, the same individual varia-
tions being seen in these cases of
*' malingering " as in different cases
of hysterical paralysis.

In all of the eleven individuals
who had hemi-anaesthesia the vibra-
tion sense on the affected side of
the sternum was tested, and was
said to be lost. Six others were
told to pretend they had hemi-
anaesthesia ; the vibration sense was
lost in them also. Three medical
men, who were asked whether they
would lose the vibration sensation
on the right side of the sternum if
they had hemi-anaesthesia, also an-
swered in the affirmative. This
corresponds with the well-known
sign, which has sometimes been re-
garded as evidence of hysteria,
sometimes of malingering, but is reaUy common to both.
( It is what would be expected to occur unless the question
was carefully thought out, when it would be realised that
the sternum vibrates as a whole, so that the vibrations
produced by the tuning-fork would be felt with the normal
half of the sternum whethe^ it was placed to the right or
the left of the middle line. '

(2) Hysterical Anaesthesia following Stupor. — A condition
of stupor was not uncommon in soldiers, who were exposed

Fig. 7. — Glove and sock
anaesthesia in " experi-
mental malingering."

12 PSYCHOLOGY OF THE SPECIAL SENSES

to some exceptional emotional disturbance, when their
resisting power had already become lowered by prolonged
exposure to terrifying experiences, especially if they were
suffering from great physical fatigue, the result of strenuous
exertion, want of sleep, and perhaps insufficient food. In
this condition the patient's mind appears to be so absorbed
with his own innermost thoughts that he gives no attention
to the external world. He appears to see, hear, and feel
nothing. He does not blink when a stick is waved in front
of his face, nor jump when a loud noise is made just behind
him. He pays no attention to tickling or to painful stimuli
applied to his skin. Sooner or later spontaneous recovery
occurred in most cases. After a period of confusion the
patient became normal in every way, and his vision, hearing,
and sensibility to all forms of cutaneous stimuli returned.
In most cases the intermediate period of confusion was very
ehort, but it was sometimes prolonged. If during this
period the patient happened to be under a medical officer,
whose clinical enthusiasm prompted him to make repeated
examinations of his motor and sensory functions, the
patient's dawning interest in the outside world was f ocussed
on these functions, some deficiencies in which thus became
perpetuated as hysterical symptoms. A very striking
example of this was a patient who happened to be the subject
of intense study by a number of neurologists in the early
days of the war, when the true hysterical nature of so-called
" shell-shock " was not fully understood. The sensory
deficiencies natural to a condition of profound stupor
were consequently perpetuated after the stupor disappeared,
and resulted in the most complete and widespread hysterical
loss of all forms of sensaticai, except hearing and seeing,
which I have ever observed.

Total amnesia with hysterical paralysis, contractures,
analgesia and mutism due to emotional strain ; recovery of
memory after twenty-two months, and from paralysis after
twenty-eight months. — Private M., aged 23, with no personal
or family history of neuroses, was slightly wounded in the
thigh in May 1915, after serving from the beginning of
the war. He returned to the front in October 1915. He

CUTANEOUS SENSIBILITY AND ANAESTHESIA 13

was quite fit until February 19, 1916, when he had to be
forcibly prevented from going over the parapet to attack
some German mortars which were firing at his trench. He
then became dazed, and on reaching the aid post he could
not answer questions, but he obeyed simple commands,
such as to put out his tongue. He believed he was still
in the trenches, which were being heavily shelled ; his eyes
were fixed on imaginary trench-mortar shells coming towards
him. His knee-jerks were brisk, there was an extreme
degree of pseudo-ankle clonus, but the plantar reflexes were
flexor. The bowels and bladder remained under control.
Two days later the knees and ankles had become stiff ;
the legs, hands, and face were anaesthetic and analgesic.
When he reached England on March 2, his expression was
apprehensive, and he started at every sound, both when
awake and asleep. In his dreams he saw the ghosts of
Germans he had bayoneted come to take revenge on him,
and he heard them fire at him. He was still unable to speak,
but he answered questions by nods and signs and in writing.
He was able to walk with assistance. He was treated by
hypnotism, and the hallucinations disappeared, but his
physical and mental condition rapidly deteriorated.

I saw him for the first time in December 1916, eleven
months after the onset. He could not speak, and all four
limbs were now completely paralysed, except that he was
able with a great effort to make slight movements at his
left elbow joint. An extreme degree of contracture was
present : the legs were rigidly extended with the feet plantar
flexed ; the arms were extended and the fingers tightly
clenched, though the metacarpo-phalangeal joints were
extended. It was almost impossible to produce any passive
movements, but the contractures were entirely hysterical,
as they relaxed completely under an anaesthetic and during
sleep. Total anaesthesia and analgesia of the whole body,
including the conjunctiva, cornea, and buccal mucous
membrane, were present, except that passive movements
at the elbow were painful, and he occasionally suffered from
toothache. The anaesthesia disappeared, at any rate to
some extent, during sleep. Although deep pressure over

14 PSYCHOLOGY OF THE SPECIAL SENSES

the abdomen produced no sensation, the sensibility of the
bladder and rectum appeared to be present, as he retained
perfect control over them. The sense of taste and the
sense of smell were obviously much impaired and the fields
of vision seemed to be greatly contracted, but hearing was
abnormally sensitive, and the auditory-motor reflex was
extremely brisk. The conjunctival, corneal, and all skin
reflexes were absent. When the contractures relaxed under
partial anaesthesia, the deep reflexes were found to be
normal.

On December 15, 1916, vigorous suggestion with the aid
of an intralaryngeal electrode during light etherisation
restored the power of whispering. It was then found that
the patient had total loss of memory ; he had no idea who
or what he was, he did not realise that his anaesthetic legs
belonged to him, and he had no knowledge of the meaning
of words.

During the following months he learnt to talk a kind of
pidgin-English, but the meaning of every word had to be
taught, and he used each word in his limited vocabulary
for a variety of meanings. All liquids were " tea," and
when petrol was poured into the tank of a motor-car he
was in, he called out " table has tea," table being for some
obscure reason the name he applied to aU vehicles. " Hand"
represented a hand and a glove, and " to hand " was to hit.
A word taught by other patients in fun would never be
given up, so that all forms of meat, chicken, and fish were
called " puss." His only numbers were one and six, which
represented anything more than one, except a very large
number, which was sixty-six, or a still larger number, which
was six-sixty-six. The sight of his own face in a mirror
always terrified him ; he did not realise who it was he saw,
and turned his head away, saying, " No like you, chick."
On seeing in the mirror the face of the sister, who was
standing by his side, he was greatly amused, and said, " See
six sisters." AU attempts to teach ideas of time, space,
and colour failed, and he did not recognise any of his rela-
tions, even when his father was brought to him in the middle
of the night, in the hope that he might know him at the

CUTANEOUS SENSIBILITY AND ANAESTHESIA 15

moment of waking. He remembered recent events, and
called people by names which he invented himself : a bald
patient was " no-hair chick," and men who limped badly
were " no-leg chick " and " six-leg chick " ; all officers in
uniform were " Major " and civilians " Mister," or, if friends,
"Mister Chick."

In spite of treatment no improvement in the condition
of his limbs had occurred by October, 1917, though he was
able to sit up in a chair and enjoyed being taken out of
doors. He delighted in childish toys, and in a general way
his mind was that of a year-old child. He was quite happy,
but he was becoming very emaciated ; it was difficult to
persuade him to eat, as he had completely lost the senses of
taste and smell, and he apparently never felt hungry.

On November 22, 1917, for no obvious reason, he had a
headache, and became excited in the evening. His memory
began to return during the night, and he talked incessantly.
The next day he realised the deficiencies in his speech, and
wished to have them corrected. When told a word, he
repeated it correctly and remembered it, and he began to
form proper sentences. On November 24 I cured a man
suffering from hysterical aphonia with a laryngeal sound in
his presence. Though this had failed on many occasions
since he learnt to whisper nearly a year before, it now cured
him instantaneously, to his intense deHght. He felt some-
thing snap in his head, and immediately afterwards he talked
quite normally, and the memory of his home and his past
life flowed back. His father came the next day, and he
knew him at once. He soon remembered his experiences
in France, but his life in hospital for twenty-one months
was a blank, as it seemed to him that he was in France only
a few days ago. He had a vague recollection of very recent
events, and he knew the men in the ward, but did not
remember friends who had gone out only a week before.
He remembered " feeling funny with a buzzing head," then
" something in his head was suddenly relieved," and the
buzzing stopped when his memory returned.

Complete anaesthesia and analgesia were still present,
and the cutaneous, conjunctival, and corneal reflexes were

16 PSYCHOLOGY OF THE SPECIAL SENSES

absent. With his eyes bandaged, the only difference he
could recognise between hot and cold water, tea and beer,
was that the tea was " sweet " and the beer was " bitter."
Salt was recognised as a powder, but without taste. JeUy
was recognised, as it dissolved so quickly in the mouth,
but butter was also taken to be jelly. Bread was indistin-
guishable from fish, and he could not recognise any difference
whether it was spread with butter, mustard, or salt. Mar-
malade appeared sweet, but was not recognised ; he guessed
that chutney was apple.

His mental condition was now perfectly normal, but for
some time very little improvement occurred in the condition
of his limbs. With re-education the left arm slowly
improved, but it was not until he was transferred to the
Scale Hayne Hospital in April 1918 that any marked
change occurred. At the end of a fortnight his right arm,
which had hitherto remained rigid and paralysed, had
improved so much that he could write long letters, brush
his hair, and feed himself, but all movements were stiff,
shaky, and slow. The left arm improved at the same time,
but there was still no recovery of voluntary power in the
legs. On May 1 a renewed attempt was made to overcome
the rigidity of his legs. This was so far successful that slight
voluntary power returned in the feet. Steady improvement
followed, until all movements became possible, the adductor
spasm of the thighs being the last to relax. By May 31
he could stand with very little assistance, and could perform
all ordinary movements with his arms, though some rigidity
was still present. On June 2, his twenty-fifth birthday,
he stood without support, and after being helped for a few
minutes, he walked without assistance round the quadrangle,
after having been paraplegic for twenty-eight months.
His physical condition now greatly improved, and by
June 20 he was able to take charge of the basket-making
shop. The sensibility of his skin and mucous membrane
slowly returned without special treatment, but was still
somewhat deficient in August. The superficial reflexes
returned pari passu. Thus the abdominal reflexes were
absent so long as anaesthesia was complete. When at

CUTANEOUS SENSIBILITY AND ANESTHESIA 17

length strong faradic stimulation could just be felt on the
left side, a weak reflex appeared on this side. The right
reflex only returned at a later date, when the right side of
the abdomen was no longer completely anaesthetic, but it
was still weaker than the left, corresponding with the fact
that sensibility was more nearly normal on the left than on
the right side. In the same way the corneal and con-
junctival reflexes returned with the return of the sensibility
of the cornea and conjunctiva.

By September 1918 recovery was complete. The last
trace of contracture of the fingers and of unsteadiness in
gait had disappeared. The patient had regained his weight,
and was in every way as fit as when he first joined the army.
He wrote to me at Christmas, 1919, saying that he had been
back at work for over a year and remained perfectly well.

(3) Hysterical Anaesthesia following the Anaesthesia
cansed by Injnry to Peripheral Nerves. — The paralysis and
anaesthesia following an injury to a peripheral nerve, which
are caused by the interruption in the nervous impulses passing
between the central nervous system and the periphery,
may both be perpetuated as hysterical symptoms when the
interruption is no longer present.

A gunshot wound in the immediate neighbourhood of a
nerve produces minute changes in its structure, which
quickly disappear, but, evanescent as these concussion
changes are, they are none the less organic, and the paralysis
and anaesthesia they produce are primarily of organic origin.
The patient may at first make repeated attempts to contract
the muscles supplied by the nerve, but as he invariably
fails, he finally discontinues, and realises that the muscles
are paralysed. If the true nature of the condition is recog-
nised and the patient is encouraged to repeat his attempts
every day, he will find in a very short time that his power
is returning. If, on the other hand, the condition is mis-
understood, and the patient is ordered treatment with
electricity and massage, and is given to understand that
he may have to continue with this treatment for weeks or
months before recovery can take place, the original tendency
to perpetuate the incapacity by auto-suggestion is greatly
2

18 PSYCHOLOGY OF THE SPECIAL SENSES

strengthened by the hetero-suggestion involved in the
treatment, with the result that by the time the nerve has
completely recovered, the organic incapacity is replaced by
an exactly similar hysterical incapacity. In the same way
the primary organic ansesthesia is perpetuated as hysterical
anaesthesia with aU its characteristics unaltered, particularly
if the patient's attention has been drawn to its extent and
its exact nature by the thorough investigations of a keen
and interested medical officer in the early stages, when the
condition was stiU organic.

If the nerve is more seriously damaged, especially if it
has been divided and subsequently sutured, the primary
organic condition lasts for a longer period, and its character-
istics are aU the more likely to become vividly stamped on
the patient's mind, and to become perpetuated as hysterical
phenomena, when recovery from the actual injury at last
occurs.

I am convinced that the voluntary power of paralysed
muscles returns before the response to faradism when an
injured or divided and sutured nerve is regenerating — an
opinion which is shared by most observers. When complete
paralysis has been present for many weeks, it is natural
that a man should cease to make an effort to move the
affected part, so that it is extremely likely that he will not
become aware of his returning power at the first moment
that the regenerating nerve is capable of conveying motor
impulses. If left to himself, he will probably only make
the discovery some weeks later, when a considerable degree
of power has returned and the normal electrical reactions
are re-established. If he is receiving regular electrical
treatment, the discovery of a response to faradism is likely
to prompt the operator to tell him to make an effort to move,
which will in all probability be successful, owing to the
suggestive effect of the ocular demonstration of the move-
ment produced by the electricity. Under more favourable
conditions the patient is seen frequently by the physician,
who encourages him to make daily efforts to contract the
paralysed muscles, with the result that the returning power
is recognised at an early stage — ^frequently before there is

CUTANEOUS SENSIBILITY AND ANAESTHESIA 19

any response to faradism. I believe that the exceptionally
early recovery of function after nerve suture, which is
occasionally observed, is due to the patient having dis-
covered that he can contract the paralysed muscles within
the jQrst few days after the nerve has regenerated sufficiently
for a few feeble impulses to be conveyed along it.

If from the beginning no attention is paid to the anaes-
thesia, it disappears spontaneously when the motor symptoms
are cured. If, however, it has been carefully investigated,
and its extent and nature have become thoroughly recognised
by the patient, it is likely to persist as hysterical anaesthesia.
It can then be cured almost instantaneously by the suggestive
effect of the application of a faradic current, the patient
being first told that his sensation will at once return when
the electricity is applied. He quickly feels the electricity,
and directly afterwards it is demonstrated to him that he
can now also feel the slightest touch as well as pain, and
can distinguish accurately between hot and- cold. This
immediate recovery with suggestion proves that the
condition must be genuinely hysterical.

The exact area involved when the condition is no longer
organic depends largely upon the intelHgence of the patient
and the interest he takes in the examination of his anaes-
thesia, and partly on the physiological and anatomical
knowledge of the observer, who would be likely to influence
the patient by his own ideas on the subject, both whilst the
condition was organic and after it became hysterical, unless
he was unusually expert in avoiding the liability to suggest
what he expected to find. The following three cases are
selected from several we observed in which hysterical
anaesthesia showed a distribution exactly similar to that
produced by an organic injury to a peripheral nerve.

Hysterical ancesihesia of the median nerve following a
wound of the forearm. — Private B., aged 36, was wounded
in the right forearm on September 5, 1918. His hand
became paralysed, and there was anaesthesia in the area of
the skin supplied by the median nerve. After being treated
by massage for three months, he was admitted to Scale
Hayne Hospital, under Captain S. H. Wilkinson, on January

20 PSYCHOLOGY OF THE SPECIAL SENSES

20, 1919. Hysterical contracture of his fingers prevented
him from flexing them, and he complained of numbness
of the thumb and the first two and a half fingers (fig. 8).
He was treated by persuasion and re-education, and at the
end of two days the motor power of his hand was normal.
Sensation was then restored in a few minutes by suggestion
with the aid of faradism.

Hysterical ancesthesia of the cutaneous branch of the musculo-
cutaneous nerve following cellulitis of the upper arm. —
Rifleman T., aged 20, was slightly wounded on September 5,
1918, and was given antitetanic serum under the skin of
the left upper arm. Following this, he developed acute
cellulitis, for which two incisions were made. He was sent
to a hospital in England three weeks later, his arm being
immobilised on a splint. Hysterical monoplegia of the

Fig. 8. — Hysterical anaesthesia in median nerve area.

left arm developed, and for three months he was treated
with electricity and massage. He was transferred to Seale
Hayne Hospital, under Captain S. H. Wilkinson, on January
28, 1919, complaining of inability to close his hand and
anaesthesia in an area which corresponded exactly with that
supplied by the cutaneous branch of the musculo-cutaneous
nerve (fig. 9), which had presumably been inflamed as a
result of the cellulitis. The paralysis was probably hysteri-
cal from the start, and was rapidly cured by persuasion,
sensation being restored in a few minutes by means of
suggestion with the aid of faradism.

Hysterical ancesthesia of the ulnar nerve following a wound
of the forearm. — Shoeing-smith A., aged 22, was wounded
on the inner side of the right forearm on October 2, 1917.
He was unable to flex his fingers, and completely lost the
sensation of the little and the inner half of the ring fingers,

CUTANEOUS SENSIBILITY AND ANESTHESIA 21

and the front and the back of the inner side of the palm of
the hand. He was sent to hospital in England on October
18, 1917, and on February 28, 1918, he had an operation
on the ulnar nerve. No notes are available except that
"the operation was specifically for the ulnar nerve." No
improvement followed, and he was treated by massage and

Fig. 9. — Hysterical anaesthesia in musculo -cutaneous area.

electricity for ten months. He was admitted to Seals
Hayne Hospital, under Captain S. H. Wilkinson, on February
16, 1919, with inability to move the ring and little fingers,
which were held in a semi-flexed position, and there was
anaesthesia in the area of the skin supplied by the ulnar
nerve (fig. 10). By persuasion and re-education for half an
hour the motor power was completely restored, and sensa-

Fio. 10. — Hysterical anaesthesia in ulnar nerve area.

tion returned in a few minutes as a result of suggestion
with the aid of faradism.

Direct treatment of hysterical anaesthesia following a
nerve injury is, however, often unnecessary, even if the
patient is well aware of its existence ; it is sufficient to
point out to him, as in the following case, that as soon as
his power of movement returns, the loss of sensation will
disappear.

Spontaneous disappearance of hysterical ancesthesia of the
ulnar nerve on recovery from associated paralysis. — Private

CUTANEOUS SENSIBILITY AND ANESTHESIA 23

which were fixed in a semi-flexed position. The margin of
the outer side of the nail of the middle finger was ulcerated
over an area the size of a shilling, and on the extensor
aspect of the first finger there was another superficial ulcer
(fig. 11). He stated that two days previously he had tried
to get the feeling back in his fingers and thumb by holding
them in front of the fire. He had been unable to do so,
and had not been aware that he had burnt himself until
the following morning, when he found large blisters had
developed on his fingers.

On the morning of admission his hand was treated by
persuasion and re-education, and at the end of half an hour
he could open and close it quite strongly in a normal manner.
The anaesthesia was treated by suggestion with the aid of
faradism, and in a few minutes his cutaneous sensibility
was completely restored. He had no further trouble with
his hand, the ulcers rapidly healing, and a fortnight later
he was discharged.

Hysterical ancesthesia of the median nerve, resulting in an
accidental injury in the anaesthetic area. — Private L., aged
36, received a penetrating wound of the right forearm on
October 4, 1918. This was followed by loss of muscular
power of the hand and anaesthesia of the area of skin supplied
by the median nerve. The wound was excised at the CCS.
He was admitted to Scale Hayne Hospital, under Captain A.
Robin, on February 20, 1919, with hysterical contracture
of the fingers, the forefinger being rigidly extended and the
hand blue and cold. He had anaesthesia in the area of skin
supplied by the median nerve, and on the outer side of the
second finger there was an ulcerated area about the size
of a shilling, which he stated was caused by his trying to
hold a lighted match a few days previously (fig. 12). The
contracture was cured by re-education and persuasion,
and the anaesthesia disappeared completely within a minute
as a result of suggestion by means of faradism. With the
restoration of the circulation and disappearance of anaes-
thesia the ulcer rapidly healed.

(4) Hysterical Anaesthesia following Cerebral and Spinal
Lesions. — The anaesthesia associated with the paralysis

24 PSYCHOLOGY OF THE SPECIAL SENSES

caused by disease or injury of the brain and spinal cord
may be perpetuated as an hysterical symptom after partial
or complete recovery from the organic lesion, in the same
way as the anaesthesia associated with the paralysis caused
by injury to peripheral nerves. I have not, however, made
many accurate observations on this subject, except in cases
of spinal concussion in which total paraplegia followed a
blow on the back. In such cases signs of organic paraplegia
were often present at first, and anaesthesia was frequently
discovered up to the level of the spinal segment which was
principally involved in the injury. Both paralysis and
anaesthesia sometimes persisted for months or even years
after the organic lesion had so far recovered that it could
no longer be responsible for any disturbances in the spinal
functions. The paraplegia was almost always amenable
to the rapid form of psychotherapy, in which explanation,
persuasion, and re-education resulted in more or less complete
recovery in the course of a single treatment lasting perhaps
an hour. If no attention was paid to the accompanying
anaesthesia at the time, it would always be found to have
disappeared with the paralysis when a careful examination
was made on some subsequent occasion. If, however, the
sensory functions were investigated during the treatment,
they would be likely to persist and require further psycho-
therapy before they finally disappeared. A patient
recovering from paralysis, which was the only symptom in
which he was really interested, as it was the sole cause of
his incapacity, would subconsciously expect any associated
but to him unimportant symptom, such as anaesthesia, to
disappear when the paralysis disappeared ; but if his attention
was directed to his anaesthesia immediately before or during
the treatment, he might very well expect that a symptom
which so greatly interested his physician would require
separate treatment and he would not recover spontaneously.
(5) Hysterical Anaesthesia following the Anaesthesia
caused by Peripheral Anaemia. — (a) Peripheral anosmia
following disuse and vasomotor spasm. — Whenever the hands
or feet of healthy individuals get abnormally cold, the
anaemia resulting from the contraction of the peripheral

CUTANEOUS SENSIBILITY AND ANESTHESIA 25

vessels is accompanied by a feeling of numbness and dimi-
nution in the acuteness of cutaneous sensibility. Individuals
with a feeble circulation are particularly apt to get numb
extremities in cold weather, and in Raynaud's disease a
similar but much more severe anaemia with a greater de-
ficiency of cutaneous sensibility occurs as a result of vaso-
motor spasm, even when the weather is not unusually cold.

A man with a poor circulation knows by experience that
the best means for preventing attacks of peripheral ansemia
is exercise, and that when his hands are becoming abnormally
cold and numb, active movements may restore the circu-
lation and cause the numbness to disappear.

It is natural that the immobility caused by paralysis or
contracture of a limb, whether the latter is organic or
hysterical, should result in deficient circulation, accompanied
by numbness and anaesthesia. As the deficient circulation
is continuous instead of intermittent, as in the conditions
already referred to, the anaesthesia becomes more profound,
especially in individuals who have a feeble circulation.
The anaesthesia may be so severe that the patient may burn
himself without being aware of it, as in the case described
below. When the circulation is temporarily improved by
immersing the limb in hot water, normal cutaneous sensi-
bility returns, and in hysterical cases the improved circu-
lation, which results from the recovery of mobility and
disappearance of spasm under psychotherapy, is immediately
followed by a return of normal cutaneous sensibility, even
if the condition has persisted for months or as long as two
or three years.

If, however, much attention has been paid to the anaes-
thesia, which results from the poor circulation in hysterical
paralysis and contracture, and its exact extent has been
carefully mapped out on several occasions, the symptom
takes such a prominent place in the patient's mind, instead
of being one of which he is hardly aware, that it is very
liable to be perpetuated by auto-suggestion when recovery
from the paralysis and contracture takes place. The patient
does not associate the anaesthesia with the diminished
circulation, but regards it as an independent symptom,

26 PSYCHOLOGY OF THE SPECIAL SENSES

which will require separate treatment by re-education or
suggestion after the paralysis and contracture have been
dealt with. That the anaesthesia is purely hysterical
when it persists after recovery from the paralysis is proved
by its immediate disappearance with psychotherapy,
although this has no effect so long as the paralysis is still
present, as the anaesthesia is then a direct result of the

peripheral anaemia, and
is incapable of amelio-
ration so long as the
latter persists.

Hysterical ancesthesia
following the ancesthesia
caused by peripheral
ancemia associated with
hysterical paralysis of
the hand. — Sergeant H.,
aged 23, underwent an
operation on January
18, 1918, for the re-
moval of a ganglion
from the dorsum of his
left hand. He was dis-
charged to duty six
weeks later, but two
days after returning to
work the hand became
blue and swollen, and
he was readmitted to hospital. The swelling was lanced, a
quantity of pus evacuated, and a splint and fomentations
were applied. The wound had healed four weeks later, but
the splint was kept on another fortnight. The patient then
found that he could not move his fingers, and that his whole
arm was flaccid and useless. He was sent to the electrical
department, and a few days later, while smoking a cigarette
and holding it carelessly in his right hand, he brought the
burning end close to his left hand. A comrade told him to
be careful, but not before he had burnt his finger and caused
a blister to appear. He felt no pain from the bum nor from

Fig. 13. — Hysterical anaesthesia of arm
following peripheral ajiaemia.

CUTANEOUS SENSIBILITY AND ANAESTHESIA 27

the blister, and this was the first time that it had occurred
to him that his hand was anaesthetic. He called the doctor's
attention to it : the arm was examined and found to be
somewhat wasted, but the anaesthesia was not investigated.
A month later the patient was transferred to another hospital,
and here the anaesthesia was tested for the first time, and
was found to extend as far upwards as the neck (fig. 13).

On admission to Scale Hayne Hospital, under Captain
W. E/. Reynell, on May 19, 1918, complete flaccid monoplegia
of the left arm was present, and the hand was blue, cold,
and cedematous. Complete anaesthesia and analgesia were
present over the area, shown in fig. 12. Treatment by
explanation followed by vigorous persuasion and re-education
was sufficient to restore the power of the muscles of the
shoulder and upper arm in about ten minutes ; but there
still remained a very slight degree of wrist-drop, and the
fingers and thumb could not be moved. After a second
treatment, lasting about haK an hour, the power of the fingers
was so far restored that the grip on the dynamometer
registered 110, and the blueness and swelling had completely
disappeared. Two days later the grip was 140, and the
patient took part in boxing practice. A fortnight after
admission the grip was 180, which is above normal for the
left hand, the grip with the right hand being 240. The
anaesthesia, which had not altered in degree or extent, was
now treated by direct suggestion with the aid of faradism ;
normal sensibility of the whole arm was restored in a few
minutes.

It is clear that in this case the primary anaesthesia which
led to the accidental burn was not hysterical. It was
caused by the peripheral anaemia, with which the disuse
resulting from the hysterical paralysis was associated.
When the extent of the anaesthesia was investigated, the
examination resulted in its spread by hetero-suggestion,
a large hysterical element being now present, as the peri-
pheral anaemia could only account for anaesthesia of the
hand and possibly of the forearm. The restoration of the
circulation which followed the cure of the paralysis must
have caused the anaesthesia due to the peripheral anaemia

28 PSYCHOLOGY OF THE SPECIAL SENSES

to disappear ; but as most of the anaesthesia was already
hysterical, this part also became perpetuated by auto^
suggestion, when the original cause was no longer operative.
Consequently the whole of the anaesthesia was ultimately

Fig. 14. — Anaesthesia
in ischsemic myositis
following tight ban-
daging. (After
Purves Stewart.)

hysterical, and, being hysterical,
cured by psychotherapy.

Fig. 15. — Anaesthesia
in ischsemic myositis
following infective
thrombosis of ex-
ternal iliac artery.
(After Purves
Stewart.)

was capable of being

In the rare cases in which the anaesthesia associated with
hysterical paralysis and contracture appears to develop
spontaneously in the absence of any medical examination,
it is probably in the first instance due, as in the case just
described, to the associated peripheral anaemia. It is thus
not primarily hysterical, being only hysterical if it persists
after recovery from the paralysis and contracture.

(b) Peripheral ancemia following obstruction to large blood-

CUTANEOUS SENSIBILITY AND ANESTHESIA 20

vessels. — Injury to one of the large blood-vessels of a limb
results in disturbances of sensation. Mme. Athanassio-
Benisty in 1916 described the sensory disturbances in these
cases as consisting of complete anaesthesia, which extends
over an irregular area bearing no relation to the distribution
of any peripheral nerve. It sometimes involves only the
tips of some or all of the fingers, and in other cases it extends
over the whole hand or foot. The area corresponds with
that in which the vasomotor and trophic changes are most
marked. More recently Purves Stewart, in a description
of the ischsemic myositis resulting from tight bandaging,
ligature of an artery, and spontaneous obstruction of an
artery by thrombosis, gave a similar account of the associated
anaesthesia. As he found that the area involved never
corresponds with that supplied by a peripheral nerve, he
concluded that it could not be due to direct pressure on a
nerve or interference with the blood supply of a nerve.
It is clearly of exactly the same nature as the anaesthesia
already described as resulting from the peripheral anaemia
due to cold in normal individuals, vasomotor spasm in
Raynaud's disease, and disuse in paralysis of a limb. What-
ever the exact explanation of the anaesthesia may be, there
is a great tendency for it to be perpetuated as hysterical
anaesthesia after the original cause has disappeared. The
glove and stocking areas shown in some of Purves Stewart's
cases (figs. 14 and 15) are identical with those produced
by direct suggestion, and although, of course, the origin is
not in these cases primarily due to suggestion, the exact
definition of the anaesthesia corresponds with what the
patient himself would expect, and may perhaps be in part
hysterical from the moment it is mapped out. In the few
cases of this kind I have seen in which the anaesthesia
persisted after the disturbance of circulation had diminished
or disappeared, it was readily cured by re-education or
suggestion.

REFERENCE

[1] A. F. Hurst and S. H. Wilkinson : Seale Hayne Neurological Studies,
i. 171, 1919.

CHAPTER III

PATHOGENESIS OF HYSTERICAL CUTANEOUS

ANESTHESIA

Like all other hysterical symptoms, each of the five classes
of hysterical anaesthesia which I described in my first lecture
is the result of suggestion. In the first class, the classical
form which has alone been recognised in the past, the idea
that a certain area of skin is insensitive to tactile, thermal,
and painful stimuli is in the first instance unconsciously
suggested to the patient by the physician who examines
him. The second class, the anaesthesia which may follow
a condition of stupor, is also due to hetero-suggestion,
although it is preceded by anaesthesia which is neither due
to organic disease nor to suggestion, but is the result of
profound inattention during the stuporose period. In the
remaining classes the anaesthesia is primarily organic in
origin, being caused by disease or injury of the brain, spinal
cord, or peripheral nerves, or by peripheral anaemia. It
makes so great an impression on the patient's mind that
it is perpetuated as an hysterical symptom after the organic
cause has disappeared. This is no doubt in part a result
of auto-suggestion, but it is clear that such auto-suggestion
would very rarely occur if not prompted by a certain amount
of unconscious hetero-suggestion on the part of the physician,
whose interest in the anaesthesia attracts the patient's
attention to what would otherwise be to a great extent
ignored, owing to the small inconvenience the anaesthesia
causes compared with the associated paralysis. So im-
pressed was Babinski with the part taken by the observer
in suggesting hysterical anaesthesia that he expressed his
belief that the condition never occurred in the absence of
such suggestion. Whilst I agree with him so far as the first

30

HYSTERICAL CUTANEOUS ANESTHESIA 31

class of hysterical anaesthesia is concerned, I have certainly
seen cases of the third class — that caused by injury to
peripheral nerves, and possibly in the fourth and fifth
classes, in which any such hetero-suggestion could be
excluded with certainty. Although in most of these cases
hetero-suggestion undoubtedly plays the predominating
part, auto-suggestion generally occurs as well, and in rare
cases it is alone responsible for the production of the anaes-
thesia.

The next question to discuss is by what process anaesthesia
develops when it has once been suggested by hetero-
suggestion, auto-suggestion, or the two combined. I be-
lieve that a consideration of the second class of hysterical
anaesthesia, that following stupor, affords the only satis-
factory explanation. In order to feel, one has to pay
attention. If the whole mind is absorbed with one's
thoughts, tactile and other cutaneous stimuli will not be
felt. Most healthy people are aware of this from their own
experience. If one is intensely interested in the occupation
in which one is engaged, a light touch will not be perceived,
and the discomfort caused by external heat or cold or by
some form of cutaneous irritation will not be felt until the
mind is once more free to attend to such mundane affairs.
The importance of this conception can only be fully realised
by those who have had the opportunity of examining cases
of stupor, such as I have described as occurring in the over-
wrought soldier. The patient's mind was obviously absorbed
in the contemplation of his own thoughts, which were
generally painful in character, and were often so vivid that
they could be correctly described as visual or auditory
hallucinations. Tickling the face or the soles of the feet,
pinching or pricking the most sensitive parts of the skin,
or the application of very hot or very cold objects failed to
elicit the shghtest sign indicating that the individual had
felt anything. The conjunctiva, cornea, and nasal mucous
membrane were equally insensitive, and all superficial
reflexes were aboHshed. Inattention had resulted in anaes-
thesia.

When an individual accepts the suggestion that he cannot

32 PSYCHOLOGY OP THE SPECIAL SENSES

feel over a certain area of skin, he withdraws his attention
from this area, and he consequently no longer feels any
stimuli applied to it. This conception wiU be more fully
discussed later, when I shall show how hysterical blindness
may result from not looking, as without looking it is
impossible to see, and how hysterical deafness may result
from not listening, as without listening it is impossible to
hear. For feeling, seeing, and hearing are active processes,
and require an effort of the will just as much as walking.
The latter becomes automatic in process of time, but if an
individual accepts the suggestion that he cannot walk,
he no longer makes the active effort which is required.
Without this no walking can occur, however automatic the
movement may appear to be in a healthy individual. In
the same way, if an individual accepts the suggestion that
he cannot feel, see, or hear, he ceases to make the active
effort involved in the process of attention to cutaneous,
visual, or auditory impulses. To a normal man, feeling,
seeing, and hearing appear to be the result of cutaneous,
visual, and auditory stimuli, respectively acting upon the
skin, eyes, and ears, a point of view which was ex-
pressed by Wordsworth : —

" The eye — it cannot choose but see :
We cannot bid the ear be still ;
Our bodies feel, where'er they be.
Against or with our will."

But this is, in fact, only true if the individual is actively
attending, although this active attention is as little a
conscious process as the performance of the individual
movements in walking.

A study of the behaviour of the cutaneous reflexes in
hysteria will show that an anatomical basis for hysterical
anaesthesia must exist, which depends upon the removal
of the structural foundation of the psychological process
of attention. A reflex is the automatic response to a
peripheral stimulus and is entirely independent of con-
sciousness. It is thus inconceivable that a reflex could
be abolished unless some alteration had occurred in the

HYSTERICAL CUTANEOUS ANESTHESIA 33

structures which control the reflex arc. The abolition of a
cutaneous reflex in organic disease is, for example, regarded
as a proof of the existence of a lesion interfering with these
structures. Apart from the abolition of the plantar reflex
when the feet have become cold owing to the feeble circu-
lation caused by disuse in hysterical paraplegia, superficial
reflexes are only diminished in activity or entirely abolished
in hysteria in the rare cases of hysterical anaesthesia in which
sensibility is almost or completely absent. In these excep-
tional cases of total anaesthesia the corresponding superficial
reflexes are lost, just as aU superficial reflexes are lost in
the total anaesthesia present in severe stupor. Recovery
from total hysterical anaesthesia, either spontaneously or
as a result of treatment, is accompanied by a return of the
superflcial reflexes, just as they return when a condition
of stupor passes away.

The simplest explanation of the behaviour of the super-
ficial refiexjes in hysterical anaesthesia is that the structural
basis of the psychological act of attention consists in some
change which leads to a diminution in the resistance offered
at each synapsis of the sensory tract. Perhaps this is in
the nature of a throwing out of dendrites, or it may depend
upon some biochemical change in the material which
occupies the space between the dendritic terminations of
adjacent neurones. Whatever it may be, the increased
resistance which is present when attention is very deficient
results in anaesthesia, and at the same time a block is pro-
duced in the reflex arc which results in diminution or /
aboHtion of the reflex.

The usual method of treating hysterical anaesthesia by
means of a strong faradic current depends upon the fact
that the anaesthesia, however severe, is very rarely absolute.
A very powerful stimulus, such as that afforded by a strong
faradic current applied with a wire brush, can break through
the increased resistance at the synapses in the sensory
tract in spite of the almost complete inattention which is
present ; it is consequently felt. Directly this occurs the
patient's dormant attention is awakened : with a little
persuasion, and perhaps some explanatory conversation,
3

U PSYCHOLOGY OF THE SPECIAL SENSES

which may be looked upon as acting, at any rate in part, as
a counter-suggestion to the original suggestion of anaesthesia,
the patient is quickly brought to attend to the stimuli
affecting the previously anaesthetic areas of his skin, and
normal sensibility returns.

If the anaesthesia is absolute, this method cannot be used,
as, however strong the painful stimulus may be, it will not
be felt. In such a case it may be suggested to the patient
that the faradisation of the skin at the boundary of the
anaesthetic area will lead to the progressive retraction of
this area. The most satisfactory method, however, is to
use no suggestion at all, but to explain to the patient why
he cannot feel — that he has become accustomed to pay no
attention to stimuli affecting the anaesthetic area, and that
if he will concentrate his attention on this area sensation
will return. When he understands what he has to do,
recovery of normal sensibility at once returns, and with
the return of normal attention the abnormal resistance
at the synapses disappears and the abolished cutaneous
reflexes reappear.

CHAPTER IV

THE SUPERFICIAL REFLEXES IN HYSTERIA

There has been much controversy about the behaviour
of the superficial reflexes in hysteria. Differences of opinion
are in part due to insufficient knowledge as to the normal
variations in the reflex under different physical conditions.
My investigations on these subjects have been made princi-
pally in connection with the abdominal reflex, but I shall
also refer to some observations on the plantar reflex.

The Abdominal Ileflex. — Authorities differ as to the
frequency with which the abdominal reflex may be absent in
normal individuals. A recent investigation by Soderbergh [^]
on 700 normal individuals between the ages of 2 and 68
shows, however, that in favourable conditions it can almost
invariably be obtained. It is important to adopt a proper
method of examination before concluding that it is absent.
It is particularly difficult to detect in individuals with much
subcutaneous fat or flabby abdominal muscles. It is
necessary to watch both for visible muscular contraction
and for displacement of the umbilicus or middle line. The
epigastric, upper, middle, and lower abdominal reflexes
should be successively tested. The skin is lightly and
rapidly stroked, and care is taken to observe the response
to the first stimulus, as in many cases the reflex rapidly
disappears on repetition. As the cause of this disappearance
does not seem to have been investigated, I recently carried
out some observations with the help of Dr. W. Johnson and
Dr. E. J. Wood in order to determine the effect of varying
physical conditions on the abdominal reflex in normal men.

The flrst problem to decide was whether the diminution
in strength of the reflex on repetition is, as is generally

36

36 PSYCHOLOGY OF THE SPECIAL SENSES

supposed, the result of fatigue, or whether it is due to some
accidental coincident condition, such as the cooling of the
skin which must follow exposure to the air. Cooling of
the skin proved to be the more important factor. In a man
who showed an unusually brisk reflex when his abdomen
was first exposed no reflex could be obtained after an in-
terval of five minutes, the surface temperature of the skin
having fallen from 33*6° C. to 31° C. in the interval. In a
second case the skin on the left side of the abdomen alone
was exposed : measuring the reflex on a numerical basis
from 0 to a maximum response of 6, it was found, when tested
at intervals of a minute, to fall gradually from 3 to 1 at the
end of the eighth minute, the surface temperature having
fallen from 33*5° C. to 28° C. On now exposing the whole
abdomen, the reflex on the right side was found to be still
3 and the surface temperature 33*5° C.

The effect of the temperature of the skin was confirmed
by comparing the reflex obtained on the two sides after
one had been artificially warmed or cooled. The warmer
side always had the brisker reflex. When the temperature
of the two sides became gradually more equal as a result
of exposure, the reflexes also became more nearly equal.
Some inequality was still observed in one case with a
difference of surface temperature as small as 1° C, though
when it had fallen to 0 4° C. the reflexes were equal ; but
in another no definite difference could be seen after the
temperature of the skin on the side which had been cooled
had risen to within 2 5° C. of the other.

It is clear from these experiments that no accurate
observations as to the effect of fatigue can be made until
the temperature of the skin has fallen to a constant level,
as otherwise it would be impossible to separate the effect
of cooling from that of fatigue. When the temperature
is constant we find that fatigue is only of importance if
the skin is stimulated along exactly the same line on each
occasion. If care is taken to stimulate different lines, there
is no fatigue effect, however near the lines may be. But
in the former case the effect of fatigue is very obvious.
In one experiment the temperature and reflex having

THE SUPERFICIAL REFLEXES IN HYSTERIA 37

fallen as a result of exposure from 35° C. to 30° C. and from
6 to 4 respectively, and then remained perfectly constant
for a quarter of an hour, the reflex completely disappeared
at the thirty-seventh stroke repeated along a line 2 J inches
long in a period of thirty-five seconds. The reflex was,
however, still as brisk as ever when tested on a line of equal
length half an inch away on each side. It is clear, therefore,
that the fatigue takes place in the peripheral sense organs,
and not in the reflex centre in the spinal cord. Although
the effort of fall of temperature is always well marked, that
due to fatigue may be very slight or even absent. Thus
in one experiment no diminution in the response occurred
after thirty-five repetitions along exactly the same line
in the course of a minute.

The condition of the bladder was found to exert an
unexpected influence on the reflex. In a boy, whose bladder
was filled to an extent that made him desire to micturate,
no abdominal reflex could be obtained, but directly he had
passed eight ounces of urine a brisk reflex was obtained.

In rare instances we observed variations in the reflex
which we could not explain ; thus a previously brisk reflex
was occasionally found to have almost or completely dis-
appeared after an interval of an hour or two, though there
had been no exposure and the bladder was empty.

Inequality of the reflexes on the two sides of the abdomen
is often regarded as evidence of organic disease. But
before any conclusion can be drawn, it is clear that care
must be taken to ascertain whether the surface temperature
is approximately equal on the two sides. A patient who
had been lying on one side with the lower side in contact
with a hot bottle, or one in whom the bed-clothes had been
carelessly raised during the examination so as at flrst to
expose one side only, would certainly have unequal abdo-
minal reflexes, which might easily be regarded as of patho-
logical signiflcance, though really due to nothing more than
the unequal temperature of the skin on the two sides.

Striimpell and Oppenheim regard the loss of the reflex
as a valuable sign in early disseminated sclerosis ; its almost
constant presence in normal individuals makes its absence

38 PSYCHOLOGY OF THE SPECIAL SENSES

in doubtful cases distinctly important, but only as a con-
firmatory sign, as it is very rarely lost before other more
conclusive evidence of lateral column disease, especially an
extensor plantar reflex, is present. In a series of fifty cases
of disseminated sclerosis examined with Dr. W. Johnson
at Guy's Hospital in 1912 [^] we found that it was absent in
80 per cent., the plantar reflex being extensor in 82 per cent,
on both sides and in 4 per cent, additional cases on one side.
In future it will be advisable to warm the skin over the
abdomen with a hot bottle, and to see that the bladder is
empty before concluding that the abdominal reflexes are
really abolished.

As in rare cases it is impossible to obtain one or both of
the abdominal reflexes, although the plantar reflexes are
normal, it is very important to know whether the reflexes
can be lost or become unequal in hysteria. Babinski has
laid it down as a definite law that hysteria never leads to
any alteration in the cutaneous or deep reflexes, and the
majority of authors agree with him. Thus Williamson has
recently emphasised the supposed fact that the reflexes are
never affected in hysteria as an aid in diagnosing hysterical
from organic anaesthesia. A few writers have, however,
expressed doubt on the question, and the following clinical
and experimental observations prove conclusively that under
certain conditions the abdominal reflexes may be unequal
or lost in hysteria.

I have already described the case of Private M., the
patient who had for nearly two years such complete anaes-
thesia and analgesia of his skin that no stimulus of any
kind, including the strongest faradic current, produced
the slightest sensation. The tone of the abdominal muscles
was good, the patient was thin, and examinations were
made repeatedly over a period of many months under
varying conditions, but no abdominal reflex was ever
obtained. When at last the patient began to use his left
hand, an attempt was made to restore sensation on the
left side of his body by the application of a very strong
faradic current with a wire brush. After several futile
attempts the patient could at length just feel the stimulus

THE SUPERFICIAL REFLEXES IN HYSTERIA 39

on the left side, but the right side was still totally anaesthetic,
and no smaller stimulus produced any sensation on the left
side. The same day a definite abdominal reflex was for
the first time obtained on the left side, but not on the right
side. As sensibility gradually improved the left abdominal
reflex became brisker. After several weeks had elapsed,
the patient being now able to walk, cutaneous sensibility
over the whole body very gradually reappeared without
any special treatment. The right abdominal reflex was
now obtainable, but it was very much weaker than the
left, corresponding with the greater degree of anaesthesia.

We have thus in a single case an example of hysterical
anaesthesia, associated at one stage with complete bilateral
loss of abdominal reflexes and at another with marked
inequality of the reflexes of the two sides.

In 1907 ['] I made several observations on anaesthesia
purposely induced by suggestion in the waking state on
patients suffering from hysterical paralysis. In a few
cases I succeeded in producing a very profound hemi-
anaesthesia on the paralysed side, and in these cases the
abdominal reflex on the anaesthetic side was weaker than
on the other side, and occasionally it was lost, although at
the beginning of the experiment the reflexes were normal.
When as a result of counter-suggestion the anaesthesia
disappeared, the reflex reappeared.

In these investigations a change in the reflex was only
observed when the anaesthesia was very profound, and
corresponding with this, in the only case of hysteria I have
seen in which the abdominal reflexes were affected when
the patient first came under my observation, the anaesthesia
was complete.

The Plantar Beflex. — ^The plantar reflex is affected by
temperature in exactly the same way as the abdominal
reflex, but as the feet are more liable to become cold than
the skin over the abdomen, the influence of temperature
is of still greater importance. It is weU known that absence
of the plantar reflex is most commonly due to cold, and
that a reflex which cannot be elicited at first may be obtained
with more or less ease after restoring the circulation by

40 PSYCHOLOGY OF THE SPECIAL SENSES

exercise or the application of warmth. By noting the
surface temperature we found that as it steadily fell on
exposure the reflex became less brisk, and finally disappeared.
A very slight fall of surface temperature may be sufficient
to produce a remarkable alteration in reflex activity ; thus
a moderately brisk reflex tested at intervals of sixty seconds
became gradually weaker and finally disappeared at the
end of the fifth minute, the surface temperature having
fallen only 2°— from 28° C. to 26° C.

The diminution and loss of the reflex occur pari passu
with the diminution in cutaneous sensibility, which is
produced, as I have already pointed out, by the peripheral
anaemia caused by cold. The loss of the reflex is clearly
due to the deficiency of the afferent impulses from the
skin, which under normal conditions give rise simultaneously
to the sensation of touch and to the plantar reflex. Apart
from the cold feet from which healthy individuals suffer,
the disuse resulting from paralysis, whether organic or
hysterical in nature, is accompanied by diminished circu-
lation and consequent cooling of the surface with loss of
the plantar reflex.

In the case I have already described of universal hysterical
anaesthesia following stupor the plantar reflexes were, like
all the other superficial reflexes, absent. On two occasions
I exposed the patient's feet whilst he was asleep. Stroking
the soles produced a brisk reflex, and he woke up at
the same moment, having apparently felt the touch in his
sleep. The return of sensibility in sleep was thus accom-
panied by return of the corresponding reflex. Immediately
afterwards it was found that complete anaesthesia had
returned, and no reflex could be obtained. When many
months later he recovered from his paraplegia, the anaes-
thesia slowly but spontaneously disappeared, and at the
same time the reflexes could once more be elicited.

It is clear, therefore, that profound hysterical anaesthesia
of the sole of the foot may be accompanied by loss of the
plantar reflex. This is quite independent of any change
in the surface temperature, and must therefore be distin-
guished from the much more comnaon lo9s of the plantar

THE SUPERFICIAL REFLEXES IN HYSTERIA 41

reflex caused by the coldness of the feet in hysterical
paraplegia. In the absence of profound hysterical anaes-
thesia the reflex in these cases returns on warming the feet,
just as it does in organic spastic paraplegia if it cannot at
first be obtained.

The following conclusions may be drawn from these
observations :

(1) The cutaneous reflexes are very easily affected by
slight changes in temperature, being weakened and finally
disappearing with cold, and being exaggerated by warmth.

(2) Fatigue only leads to a diminution or loss of the reflex
if the stimulus is applied along exactly the same line.

(3) The rapid disappearance of the reflex when elicited
several times in the course of examining a patient is thus
due to the fall of temperature of the skin caused by exposure
rather than to fatigue.

(4) Absence or inequality of the superficial reflexes may
occur in association with hysterical anaesthesia.

(5) In the absence of profound anaesthesia absence or
inequality of the superficial refiexes cannot be regarded as
a direct result of hysteria.

(6) Such absence or inequality of the abdominal reflexes,
when the skin of the abdomen is uniformly warm and the
bladder empty, if repeatedly observed, is very suggestive
of organic nervous disease.

REFERENCES

[1] G. Soderbergh, Neurol. Centralhlatt, xxxvii. 234, 1918.

[2] A. F. Hurst and W. Johnson, Ouy's Hospital Reports, Ixvi. 109, 1912.

P] A. F. Hurst, General Practitioner, April 18, 1908.

CHAPTER V

SENSIBILITY AND REFLEXES OF MUCOUS
MEMBRANES

(1) Conjunctival and Corneal Anaesthesia and Beflezes. —

In chapter X I shall refer to the historical case of Madame
Stapart, who was cured of hysterical blindness of ten years'
duration by a supposed miracle in 1728. The contemporary
description of her case shows that the blindness, which
affected her left eye, was accompanied by complete anaes-
thesia of the cornea, conjunctiva, and eyelids, with loss of
the corneal and conjunctival reflexes, a& the finger could
be inserted between the lids without producing any sensation
or movement. Directly she was cured, sensibility returned,
together with the associated reflexes,

A similar anaesthesia was described by Charcot and others
in association with hysterical blindness, and more frequently
with unilateral narrowing of the field of vision, the whole
being part of a more or less complete hemi-ansesthesia.
But none of the numerous patients with hysterical blindness
whom I observed during the war complained spontaneously
of any loss of sensibility of the eyeball or eyelids, and none
showed any evidence of the inflammation, which is liable
to follow injury of an eye which has become anaesthetic
as the result of an organic lesion. In a small number of
my cases, however, anaesthesia was discovered on careful
examination. I believe that in these cases the anaesthesia
was produced by unconscious suggestion on the part of the
observer, as when great care was taken to avoid any possi-
bility of this no anaesthesia was found. A patient with
one blind eye is likely to think that the eyeball will also be
insensitive to touch if his attention is drawn to the subject,

42

SENSIBILITY OF MUCOUS MEMBRANES 43

and he will probably include the eyelids ini his conception
of the eye as a whole, so that they, too, will become
anaesthetic.

In every case in which I have observed hysterical anaes-
thesia of the conjunctiva and cornea, the corresponding
reflexes have been absent and have returned with recovery
of sensibility, the association being of exactly the same
nature as that observed between cutaneous anaesthesia
and loss of reflexes.

In the case of universal and absolute cutaneous anaes-
thesia following stupor described on page 12, there was
total loss of sensibility of the cornea and conjunctiva of
both sides, although central vision at any rate was not
affected. This case afforded a good opportunity of watch-
ing over a long period the slow restoration of sensibility and
of corneal and conjunctival reflexes occurring pari passu.

(2) Pharyngeal Anaesthesia. — Pharyngeal anaesthesia
appears to have been first described as a symptom of hysteria
in 1872 by Anstie. [^] " Anaesthesia is very often found
when looked for," he wrote, " in one situation where its
presence is highly characteristic — the back of the pharynx.
If a patient, not taking bromide, can, without retching,
let you pass the finger well down to the epiglottis, the
diagnosis of hysteria is exceedingly probable." The qualifi-
cation concerning bromides was thought necessary on account
of the observation of Huette in 1850 that the pharynx
becomes anaesthetic and the pharyngeal and palatal reflexes
disappear in patients taking bromide, an observation which
has prompted many physicians to give the drug to patients
before examining them with the pharyngoscope, since this
procedure was first suggested in 1867 by Gasselin. It can,
however, be of little or no real value, as Krosz found in 1876
that it required an enormous dose, such as between 125
and 150 grains taken at one time, to abolish the pharyngeal
reflexes, 100 grains never being sufficient. My own observa-
tions also show that the supposed effect of bromide on the
pharynx, which has been copied from book to book, is
non-existent, as careful measurement of the pharyngeal
excitability in ten cases of epilepsy before receiving

44 PSYCHOLOGY OF THE SPECIAL SENSES

bromide and after taking between 45 and 80 grains a day,
often for several weeks, did not reveal the slightest
alteration.

The question is not merely of theoretical interest, as during
the last few years I have seen many cases diagnosed as
hysterical on account of the presence of pharyngeal anses-
thesia. One neurotic young woman barely escaped with
her life, because the discovery of pharyngeal anaesthesia
led her physician to diagnose an attack of abdominal pain
as hysterical in origin, although the delayed operation
showed she was suffering from acute appendicitis. The
presence of pharyngeal anaesthesia has often been mentioned
in reports on war neuroses as an indication of their hysterical
nature. It is clear, therefore, that the time has come to
decide what value can be placed upon this supposed stigma
of hysteria.

With the aid of Captain E. A. Peters and Major J. L. M.
Symns, I [^J first drew up a scale of pharyngeal sensibility,
beginning with 0, which indicates a complete anaesthesia,
and 1, which indicates deficient sensibility and absence of
all pharyngeal reflexes, and passing up to 7, which indicates
such an extreme degree of hyperaesthesia and such violent
reflex spasms that it is quite impossible to examine the
throat. After a few days' practice we found our standards
were so definite that we always indicated the sensibility
in a given case, examined independently, either by the same
number or occasionally by numbers differing by one, but
never by more. It is not easy to describe the varying
reactions, but the following gives an approximate idea of
the meaning of each number.

0. Anaesthetic and no reflex.

1. Hardly felt and no reflex.

2. Felt easily and very slight reflex.

3. Slight levator reflex.

4. Good levator and slight tensor reflex.

5. Stronger levator and tensor reflex.

6. Very brisk reflex, making examination very difficult.

7. Maximal reflex, making examination quite impossible.

SENSIBILITY OF MUCOUS MEMBRANES 45

We then systematically recorded the sensibility in a large
number of men, some healthy, some suffering from a great
variety of surgical and medical conditions, and others
from definite hysterical symptoms, the nature of which
was always finally confirmed by their cure by means of

25

/

1

20

1

lb

/

'

\

lu

/

\

<

5

L

\

0 12 3 4 5 6 7
Fig. 16. — Variations of pharyn-
geal excitability in 170 non-
hysterical cases.

30

25

/

\

?n

-^

/

\

1"^

\

\

!

XI

z

1

^

0 12 3 4 5 6 7
Fig. 17. — Variations in pharyn-
geal excitability in 64 hysterical

30

2b

s

/

\

20

>

I

15

\

10

/

\

5

/

\

y

0 12 3 4 5 6 7
Fig. 18. — Variations in pharyn-
geal excitability in 24 cases of
hysterical aphonia and 10 cases
of hysterical mutism.

psychotherapy. We made our examination without in-
dicating to the patient what object we had in view. He
was told to open his mouth, and the back of the pharynx
and soft palate were then touched with some blunt object,
the tongue being depressed when necessary. In the rare
cases in which no reflex was produced the man was asked
what he had felt during the examination.

46 PSYCHOLOGY OP THE SPECIAL SENSES

The following table shows the pharyngeal sensibility in
170 individuals with no hysterical symptoms and 64 with
hysterical symptoms. The cases of hysterical aphonia and
mutism, which are included among the latter, are also
analysed separately, because it is often asserted that pharyn-
geal anaesthesia is particularly well marked in hysterical
aphonia.

Type of Case.

Degree of Excitability.

Total.

0

1

2

3

4

6

6

7

Non-hysterical cases
Percentage

Hysterical cases
Percentage

Hysterical aphonia .
Hysterical mutism .

Percentage of aphonics
and mutes

1

0-7

0
0

0
0

0

14

8

4
6

3

0

9

24
14

13
20

6
3

24

42
25

13
20

6

2

21

63
31

19
30

I

25

22
13

8
12

5

1

18

12

7

5
8

0
0

0

2
1-3

2
.3

,1

0

3

170
100

64
99

24
10

100

In several cases of hysterical aphonia, as well as of other
hysterical symptoms, it was found that the pharyngeal
excitability remained unaltered after a cure had been
obtained.

These figures and curves show conclusively that pharyngeal
sensibility is no more deficient in individuals suffering from
hysterical aphonia, or other hysterical symptoms, such as
paralysis, contractures, fits, blindness, or deafness, than in in-
dividuals who neither are suffering nor have ever suffered in
this way, and varies in a similar manner in different people.
When care is taken to avoid suggestion, complete pharyngeal
anaesthesia is hardly ever found, and the comparatively
rare absence of reflexes is met with in normal people just
as often as in patients with hysterical symptoms. The
single case in which complete pharyngeal anaesthesia was
present was that of a stolid individual, convalescent
from neurasthenia due to simple exhaustion. He had
had no hysterical symptoms, and there was no history
of hysterical manifestation in the past. Curiously enough,

SENSIBILITY OF MUCOUS MEMBRANES 47

in the only example of organic disease in a series of
one hundred consecutive cases of aphonia in soldiers, [*]
laryngoscopic examination was unusually easy owing to
the extremely slight degree of pharyngeal sensibility. If
pharyngeal anaesthesia had been taken as a sign of any
value, it would thus often have led to erroneous diagnosis.

These investigations were all made on soldiers, but I
carried out a similar investigation on a large number of
patients at Guy's Hospital a few years ago, and obtained
precisely similar results, although about half of the non-
hysterical patients and nearly all the hysterical ones were
women. Unfortunately the exact figures have been lost,
but they did not differ in any way from the present series.

We may thus conclude that pharyngeal anaesthesia is
not a stigma of hysteria, and that when it is habitually
found by a given observer it must be produced in the
majority of the cases by involuntary suggestion on his
part. As most patients suffering from hysterical symptoms
are abnormally suggestible, it is more likely to be found
by careless examination in such individuals than in others.
As many individuals suffering from organic disease are
equally suggestible, pharyngeal anaesthesia may easily be
produced in them. Conversely, in the not uncommon
cases seen under the peculiar conditions of modern warfare,
in which hysterical symptoms developed as a result of an
overwhelmingly powerful suggestion in men who were
not abnormally suggestible, pharyngeal anaesthesia would
not be produced by careless examination, and the hysterical
nature of the symptoms might be doubted if any importance
were attributed to pharyngeal anaesthesia as a stigma of
hysteria.

In order to explain the frequently repeated assertion
that laryngoscopic examinations are particularly easy to
make in patients with hysterical aphonia, it must be
remembered that about 25 per cent, of patients suffering
from aphonia or other hysterical symptoms have, like a
similar proportion of normal individuals, a comparatively
insensitive pharynx (1 or 2 in our scale). The insensibility
would not be remarked upon in a normal individual ; but its

48 PSYCHOLOGY OF THE SPECIAL SENSES

association with hysterical symptoms would at once strike
an observer who had been taught to regard pharyngeal anaes-
thesia as a stigma of hysteria, and the one case confirming
this would make more impression on his mind than the
three in which the pharynx was more sensitive. Moreover,
our observations show how easily pharyngeal anaesthesia
is produced by suggestion, and a few words of encouragement
by the observer would be enough in many cases to render
a previously sensitive pharynx insensitive, although the
observer might have no notion that his words would have
any such effect. In most individuals the pharyngeal
sensibility remains unaltered on repeated examination ; but
in abnormally suggestible men, whether they are actually
suffering from hysterical symptoms or not, we have fre-
quently been able to reduce the sensibility from 3, 4, or 5 to
1 or 2 by direct suggestion.

In his book on Hysterical Disorders of Warfare, L. R.
Yealland states that " it has been my experience to find in
conditions of hysterical mutism quite a marked sensory loss
over the posterior wall of the pharynx," only strong faradic
shocks being recognised ; " weaker currents were appreciated
in cases of aphonia, and there was no perceptible change
in the stammerers." In striking contrast to this, Liebault[*]
found diminished or complete loss of pharyngeal sensibility
in fifty-two cases of aphonia, but such a degree of hyper-
aesthesia in fifteen mutes and eight stammerers that he was
unable to examine the larynx of any of them. These
contradictory results can only be explained by the effect
of unconscious suggestion on the part of the two observers,
each of whom examined his patients with the idea already
fixed in his mind that he would find increased or diminished
sensibility, as the case might be, for our observations,
described above, prove that the pharyngeal sensibility
shows exactly the same variations in mutism, aphonia,
and stammering as in normal individuals.

(3) Rectal Anaesthesia. — The only other mucous membrane
which requires brief consideration is that of the rectum, as
numerous French writers, ever since Gendrin first referred
to the condition in 1846, have regarded anaesthesia of the

SENSIBILITY OF MUCOUS MEMBRANES 49

rectal mucous membrane as a cause of constipation. It
is curious that not one of them should have taken the trouble
to investigate the sensibility of the rectum in normal
individuals. In my Goulstonian Lectures on the Sensibility
of the Alimentary Canal [^] I described how I had found that
the mucous membrane of the rectum is totally insensitive
to tactile, thermal, and painful stimuli, so that whatever
importance deficient sensibility of the muscular coat of the
rectum may have in the production of dyschezia, anaesthesia
of the mucous membrane is the normal condition, and
neither a result of hysteria nor a cause of constipation.

REFERENCES

[1] F. E. Anstie, Lancety 1872, ii. 842.

p] A. F. Hurst and J. L. M. Symns, Review of Neurology and Psychiatry^
i, 1918 ; and Seale Hayne Neurological Studies, i, 1918.

['] A. F. Hurst and A. W. Gill, Seale Hayne Neurological Studies, i. 150,
1918.

[*] G. E. Li6bault, Orandes Questions Medicales d^Actualite : Rev. Qen.
de Path, de Ouerre, p. 245, Paris, 1917.

1^1 A. F. Hurst, The Sensibility of the Alimentary Canal, London. 1911.

CHAPTER VI

CUTANEOUS HYPER.ESTHESIA

If the view be accepted that the physical basis of attention
to sensory stimuli is a diminished resistance at the synapses
in the sensory tract involved, and that hysterical anaesthesia,
with the corresponding loss of reflexes, is caused by inatten-
tion, it is easy to explain the occurrence of hysterical hyper-
sesthesia. When for any reason an individual's attention
is fixed to an abnormal degree on sensations coming from a
certain area of skin, the resistance at the synapses in the
tract conveying impulses from this area to the brain is
diminished to a greater extent than under normal conditions.
It may be supposed that whilst ordinary attention results
in a considerable degree of approximation of the dendrites
of adjacent neurones at each synapsis, the excessive attention
in hysterical hypersesthesia results in still greater approxi-
mation owing to the extreme degree of projection of the
dendritic terminations. Whereas the abnormally great
resistance at the synapses in hysterical anaesthesia results
in diminution or loss of the corresponding reflexes, the
abnormally small resistance at the synapses in hysterical
hypersesthesia results in their exaggeration.

I do not propose to discuss the causes of hysterical
hyperaesthesia at any length. But I should like to draw
attention to the frequency with which cutaneous hyper-
aesthesia results from unconscious hetero-suggestion on the
part of the observer in exactly the same way that hysterical
anaesthesia so often arises. This is seen most frequently
in connection with the areas of cutaneous hyperaesthesia
which are supposed to occur in association with visceral
disease. In my first enthusiasm for the brilliant investi-

60

CUTANEOUS HYPERESTHESIA 51

gations on the subject by Head, which I read as a student
in 1903, I found that I could confirm his observations in
every case which I examined. Being particularly interested
in the cutaneous hypersesthesia associated with digestive
disorders, I acquired the habit of mapping out Head's area
in every case diagnosed as ulcer, and watching its retraction
from day to day as improvement occurred, until it finally
disappeared, when it was assumed that the ulcer had healed.
My first doubt on the subject arose when I had the oppor-
tunity in 1909 of seeing ten patients operated on by Moynihan
for duodenal ulcer. I had examined them with great care
the previous day, and I had entirely failed to find any
cutaneous hyperaesthesia, but the ulcer was none the less
demonstrated in nine out of ten of the cases at the operation.
From that time I have never been able to find any evidence
of cutaneous hypersesthesia in cases of gastric or duodenal
ulcer, although I have repeatedly searched for it. Whereas
the majority of my earlier cases had occurred among highly
suggestible, chlorotic girls, who had up to that time been
regarded by most physicians as particularly subject to
gastric ulcer, Moynihan's patients were mostly middle-aged,
phlegmatic Yorkshiremen. With greater knowledge of the
symptoms of ulcer and of the conditions which simulate it,
and improved accessory methods of diagnosis with the
aid of the X-rays and chemical examination of the gastric
contents and faeces, it has become recognised that chronic
ulcers are comparatively rare among chlorotic girls, the very
people who were formerly supposed to be most subject to
them, and in whom hypersesthesia would be most easily
suggested. In examining for hypersesthesia it must be
remembered that unless the greatest care is taken to avoid
the possibility of suggestion, it is very easy to produce
hypersesthesia in the area in which it is expected. When
improvement occurs under treatment, both the physician
and patient expect the area to become smaller; and so,
indeed, it does, but not as a result of the healing of the
ulcer, but of the physician's hetero- and the patient's auto-
suggestion. I have now many times suggested an area of
hypersesthesia away, replaced it by anaesthesia, or transferred

52 PSYCHOLOGY OF THE SPECIAL SENSES

it to the opposite side after it had been carefully marked
out by one of my clinical clerks. I have no doubt that the
areas of hypersesthesia had been suggested, just as I had
suggested similar areas before I learnt how to avoid doing so.

I do not mean that Head's areas are always produced
by the suggestion of an observer looking for hypersesthesia
in a certain zone, when the patient is unduly open to
suggestions of the kind owing to abnormal suggestibility
and to the presence of symptoms, such as pain, which draw
his attention to the area as the probable seat of disease.
But I believe that they occur so rarely in diseases of the
oesophagus, stomach, intestine, liver, and pancreas as to be
of no diagnostic value. Only in diseases of the kidney,
which lead to distension of the pelvis, does true cutaneous
hypersesthesia appear to be of some frequency ; but even
in these conditions the areas of skin involved are much
less constant than is often supposed.

It is interesting to note that when areas of cutaneous
hypersesthesia unconsciously suggested in the way I have
described are unilateral, the abdominal reflex obtained
from the suggested area is brisker than that on the other
side, confirming the view I have advanced of the physical
basis of hysterical hypersesthesia. The reflex becomes
normal once more when the hypersesthetic area disappears
as a result of suggestion.

CHAPTER VII

HYSTERICAL PAIN

It is a matter of common experience that pain is increased
by attention and diminished by inattention. In all proba-
bility individual variations in sensibility to pain depend
largely upon the varying ease with which the attention can
be diverted by an effort of will from the seat of pain. The
anatomical basis I have suggested as an explanation of
variations in cutaneous sensibility to tactile stimuli can
probably be extended to explain variations in sensibility
to pain. In this connection I have already referred to the
hysterical analgesia which is often associated with hysterical
anaesthesia. In the converse condition an individual may
be unusually sensitive to pain owing to his inherited mental
characteristics, or he may become so owing to exhaustion,
insomnia, and sepsis, and the demoralisation which prolonged
and excessive pain may induce. This acquired sensibility
to pain was comparatively common in soldiers. A man
may train himself to such an extent to feel pain that the
diminished resistance at the synapses in the tract conveying
painful impulses to the brain may persist after the primary
cause of pain has been removed. The persistent pain
is hysterical, being suggested by the original organic pain,
and being curable by psychotherapy.

A patient may continue to feel pain after his diseased
appendix has been removed as the result of very slight
painful impulses produced in the deep tissues and scar,
which an average individual would ignore. The following
is one of several cases of the kind which I have observed
both in soldiers and civilians. A fuller description of several
of these has been published by S. H. Williamson. [^]

63

54 PSYCHOLOGY OF THE SPECIAL SENSES

Hysterical pain following appendicectomy, cured hy psycho-
therapy.— Private G., aged 24, had had over two years'
active service in France and Italy, when he developed an
acute attack of appendicitis on July 6, 1918. He was
operated upon the same night, two tubes being inserted.
He was transferred to a hospital in England, and was
allowed to get up on August 16. Since then he had had
constant sharp pain in the region of the scar. He was sent
to his depot, and told that the pain would go in time. He
was given clerical work, but could not do it, and was trans-
ferred to Scale Hayne Hospital, under Captain S. H. Wilkin-
son, on December 21, 1918. He complained of constant
pain in the region of the scar, especially when in bed. In
a long therapeutic conversation it was explained to him
that the original pain had made a great impression on his
mind, because at the time he was physically and mentally
tired from constant active service for over two years ; in
spite of the fact that the cause of the pain had gone, his
mind had got so accustomed to feeling the pain that he
continued to feel it. The pain disappeared completely,
and two days later he was given work in the farm. There
had been no return of pain when he was discharged a month
later.

The pain felt in the scars of wounds long after they have
healed is, I believe, in many instances of the same nature.
It has generally been ascribed to nerve fibres becoming
involved in scar tissue, but nothing abnormal may be found
at operation, or complete excision of the scar may produce
no improvement, the pain persisting in the new scar. We
saw numerous cases of this kind, which were often associated
with hysterical paralysis or contracture, in which severe
pain was rapidly cured by psychotherapy.

Hysterical painful scar following a compound fracture, cured
hy psychotherapy. — Driver L., aged 19, was kicked by a
horse on the left leg on August 6, 1918, and sustained a
compound fracture of the tibia and fibula. He was in
bed for eight weeks, and when allowed up complained of
constant pain over the fracture. He was admitted to
Seale Hayne Hospital, under Captain S. H. Wilkinson, on

HYSTERICAL PAIN 55

November 12, 1918, walking with a marked limp, tilting
his pelvis down to the left with every step he took, and
complaining of severe pain over the scar, which was red and
tender. It was explained to him that as soon as his gait
was corrected and he walked properly he would find that
his pain would disappear. In twenty minutes he was
running quite normally, and admitted that he had no pain.
When discharged he was fit in every way, having had no
return of pain during the month he had been working
on the farm.

It is generally assumed that the headache following the
explosion of a shell in the immediate neighbourhood,
especially if consciousness was lost, is due to concussion.
If this is correct, so-called " shell-shock headache " is of
exactly the same nature as the headache which follows
concussion in civil life. It is well known that the most
effective treatment of the latter is rest, but that if insufficient
rest is taken in the earliest stage the headache is likely
to be prolonged for an indefinite period. This has proved
to be the case in " shell-shock headache," and all who have
had such cases under their care must have been struck by
the extreme difficulty of relieving the headache by ordinary
means. The analgesic drugs, which give, at any rate,
temporary relief for most forms of headache, are either
entirely without effect or only produce a slight amelioration
of the pain. If a considerable period has elapsed since
the onset of the headache, during which the patient has been
getting about, a renewed period of rest is generally of
comparatively little use. In a number of cases I was
struck by the complete relief which immediately followed
a lumbar puncture, but unfortunately this was rarely
permanent, and often only lasted for a day or two. I
was at the time unable to explain this, as the fluid was
never under increased pressure, so that it did not seem
possible that the improvement was due to the reduction
of an abnormally high intracranial pressure.

The following case seems to give a clue to the explanation
of the persistence of the headache in some of these cases. [*]

" Shell-shock " headache, cured by hypnotism. — Corporal

56 PSYCHOLOGY OF THE SPECIAL SENSES

H. served from August, 1914, and remained well until he
was blown up in November, 1917. He was away from his
unit for a month on account of a stammer and tremor.
He then returned to duty, but was wounded in April, 1918.
He was now sent to hospital, and after six months' treatment
for neurasthenia was admitted to Seale Hayne Hospital,
under Captain C. H. Ripman, in October, 1918. He was
shaky, and complained of a heavy pain in the head during
the day, which had been present ever since he was blown up.
During the whole night he sat up in bed holding his head
and crying with pain. In spite of the severity of the pain
he was not inclined to make much of it during the day.
He was treated with drugs, none of which had any effect.
Hypnosis was consequently tried. The headaches improved
at once. After the first treatment he slept through the
night, and he had no headache the next day. After three
treatments he felt perfectly well, and became one of the
most lively men in the ward, having previously spent all
day curled up on his bed and aU night crying with pain.
He was discharged a month later, and wrote in February
1919 to say that there had been no return of his headache.
In this case, in spite of the extreme severity of the head-
ache, complete relief was produced by suggestion without
any accessory factor coming into play. It is inconceivable
that suggestion, by which is meant the communication
of a proposition without giving adequate and logical grounds
for its acceptance, could have produced such a result in a
headache of organic origin. Consideration of this case
points to the possibility that the relief produced in our
earlier cases by lumbar puncture was due to suggestion,
and the absence of any relief with ordinary analgesic drugs
could be explained on the assumption that the headache
was of entirely psychical origin. It is probable, therefore,
that the long-continued and intractable headache following
the concussion caused by a high-explosive shell is fre-
quently caused by the perpetuation by auto-suggestion of a
headache, which is at first organic in origin and a genuine
result of concussion. Being produced by suggestion and
cured by psychotherapy, it can be correctly called hysterical.

HYSTERICAL PAIN 57

The chronic headache which follows concussion in civil
life is probably often of similarly hysterical origin.

Hysterical headache following concussion. — ^A lady, 49
years old, an artist by profession, fell on her head in
February 1917 as the result of a collision with a motor-
lorry whilst she was driving a dog-cart. She was badly
shaken, but was not rendered unconscious. Severe head-
ache developed immediately afterwards. It persisted all
day, and at night prevented her sleeping. She did not
improve in spite of wearing spectacles for astigmatism and
giving up painting and reading since her accident. In
October 1918 she was told that the pain was rheumatic,
and was ordered a strict diet and massage for her head.
After this she became terrified of cold and damp, and kept
indoors almost all the time ; but whenever the weather was
bad, the headache was much aggravated, although this
had not hitherto been the case.

I saw her for the first time on March 1, 1919, when I
explained to her that the headache was simply a perpetu-
ation of that due to the original concussion. I told her
that as the effects of the latter had long ago passed away
she would no longer have any headache if she ceased to
expect it. I explained to her that it was clearly not due
to her astigmatism, as her glasses had not helped her, and
she was no better when she did not read or paint, and that
the failure of her dietetic precautions and staying indoors
had proved that it was not rheumatic. On my advice
she gave up her glasses, and began to read and paint, and
she went out whatever the weather was like. I saw her a
week later, and she had only had one slight headache,
which had come on during a rain-storm, this having been
apparently again suggested by the weather. Further
explanation resulted in complete disappearance of the
headache, in spite of taking no further precautions to
prevent it. She was given no drugs, and the various
medicines she had taken before, both during the day and
at night for her insomnia, were discontinued. From the
first conversation she slept perfectly well. She wrote on
April 16 to say she was still free from headache.

58 PSYCHOLOGY OF THE SPECIAL SENSES

In the following case the primary pain was caused by
gross organic disease.

Hysterical pain following the removal of a gainful growth. —
A man of 63 had been suffering for some weeks from slight
supra-orbital neuralgia on the right side, when he was
knocked down by a cyclist and rendered unconscious for
thirty-six hours. After this the pain was greatly exag-
gerated, and produced severe insomnia. Six months later
the right antrum was found to contain pus ; after it had
been drained, it was discovered that the abscess was secondary
to a growth, which was subsequently removed completely.
Instead of disappearing, the pain became worse than ever.
It persisted in spite of two injections of alcohol, which
produced anaesthesia in the area supplied by the lower
two branches of the trigeminal nerve. Numerous drugs
were tried without benefit, and the patient became pro-
gressively more demoralised, until four months after the
operation he was continually screaming out with pain, and
could get no sleep either by day or night. He took very
little food, and was in a condition of profound exhaustion
when, at this stage, I saw him for the first time. As there
was no sign of recurrence of the growth, it appeared possible
that the pain was due to the hysterical perpetuation and
exaggeration of what was at first organic. The growth had
probably caused the original neuralgia, and this was aggra-
vated by the accident which had involved the antrum. As it
was quite impossible to reason with the patient, I attempted
to hypnotise him. I did this with much less difiiculty
than I had anticipated, and I then suggested that he would
have no more pain, but would have a long sleep. During
the next twenty-four hours he kept quite quiet, and slept
the greater part of the time. I hypnotised him on four
other occasions, and also tried to make him understand
whilst he was awake the nature of his pain, and how he
could control it. It is four months since I first saw him,
and although there have been occasional slight recurrences
of pain, these have been insignificant, and he continues
to sleep well, and now takes an interest in his surround-
ings, no further drugs having been required.

HYSTERICAL PAIN 69

Hysterical pain is a very real thing, and cannot be dis-
tinguished from pain caused by organic disease by its
character, or by the absence of associated sympathetic
phenomena. It may, for example, give rise to tachycardia,
dilatation of the pupils, pallor, and sweating, if the original
organic pain did so, because the afferent tract of the reflex
paths involved offers so little resistance to impulses excited
by peripheral stimuli that the latter still produce marked
effects, even when they are so slight that if the patient would
cease to expect pain and thus allow the normal resistance to
return, they would either produce no effect at all or only
an insignificant amount of pain and little or no sympathetic
reflexes.

REFERENCES

P] S. H. Wilkinson, Seale Hayne Neurological Studies , i. 327, 1920.
[2] A. F. Hurst and C. H. Ripman, Seale Hayne Neurological Studies,
i. 193, 1919.

CHAPTER VIII

HEARING, LISTENING, AND HYSTERICAL

DEAFNESS

Hysterical deafness is probably less rare in civil life than
has generally been supposed. In this chapter its etiology
will be primarily discussed in the light of experience gained
from the observation of numerous cases occurring in soldiers,
among whom it was comparatively common, and of a small
number of severe cases in civilians.

The noise and concussion produced by the explosion of
a shell of high power in the near neighbourhood frequently
caused deafness. The patient was dazed or unconscious
as a result of the explosion, and when his mind became
clear again he discovered that he could not hear. Both
ears were generally affected, but the one on the side more
exposed to the explosion of the shell was often deafer than
the other. The initial deafness was doubtless due to
concussion of the internal ear, as it was sometimes associated
with vertigo and temporary nystagmus. One or both
drums were often perforated owing to the sudden enormous
change in atmospheric pressure. Such a perforation did
not greatly affect the prognosis, as the tear generally healed,
and if no hysteria developed normal hearing was restored.
Sometimes, perhaps, the ossicles were dislocated by the force
of the explosion, in which case some permanent impairment
of hearing would result.

The deafness might pass off in the course of a few hours,
but more frequently it lasted for a few days. If it persisted
for a still longer period, it was almost always hysterical,
at any rate in part. The initial concussion deafness made
such an impression on the mind of the soldier that, on

60

HYSTERICAL DEAFNESS 61

coming to himself, whether he had actually lost consciousness
or not, his first thought was for his hearing, and he might
be so convinced that he was permanently deafened that he
became actually deaf as a result of auto-suggestion. This
was especially likely to be the case if for any reason the
idea of deafness had previously entered his mind ; it was
for this reason that a large proportion of cases occurred
in men who had old disease of the ear.

The temporary deafness, which was a familiar condition
before the war, both in gunners and other people who were
exposed to the frequent repetition of loud noises, might
in the same way become perpetuated and exaggerated by
auto-suggestion.

Lastly, organic deafness, especially if the onset is acute,
as in that due to involvement of the auditory nerve trunk
in cerebro-spinal meningitis, may remain complete after
the disappearance of the active disease has been followed
by sufficient restoration of the damaged structures for a
certain amount of hearing to have returned. This,
again, is due to auto-suggestion, the final deafness being
organic with a superadded hysterical element, which is
capable of removal, like all hysterical symptoms, by psycho-
therapy.

If left untreated without any encouragement, and
especially if steps are taken to teach the patient lip-reading,
he will become more and more convinced that he is per-
manently deaf, the effect of the original auto-suggestion
being increased by the unconscious hetero-suggestion of
those in charge of the patient. One of the worst cases I
have seen was that of a man, who was told by an aurist
that his case was hopeless because he had already been
deaf for four months without any improvement occurring.
Prolonged psychotherapy was required to cure him. If
he had been told that the kind of deafness from which he
suffered never lasted for more than four months, and that
he would certainly be well in a week, rapid recovery would
have resulted.

Pathogenesis. — Hearing does not consist merely of the
perception of impulses conveyed to the brain when the ear

62 PSYCHOLOGY OF THE SPECIAL SENSES

is stimulated by sound waves. It is an active process, and
in order that sounds may be heard the individual must
listen. Inattention during a dull sermon results not only
in absence of perception of the words said, but of total
deafness to the sound of the preacher's voice. It is clear
that impulses to the cortical centre of hearing must be
actually interrupted by inattention. The most satisfactory
theory is that in the act of listening the resistance at the
various synapses in the auditory path becomes diminished
by some such process as a throwing out of dendrites, which
brings those of contiguous neurones into more intimate
connection. In inattention the synapses are unswitched,
the resistance being increased by the retraction of the
dendrites.

In animals there is an obvious motor element in listening
in addition to the sensory element just considered. This
is seen in the movements of the external ear, which is most
obvious in those which depend upon flight, prompted by
the acuity of their hearing, for safety from their enemies.
If one pays attention to one's own sensations in the act of
listening, it appears as if some active motor process was
taking place in the ear. This probably consists in the
simultaneous contraction of the stapedius and tensor
tympani muscles, which exert tension on the chain of
ossicles in opposite directions. Their function appears to
be to regulate the balance of the stapes, and so modify the
intravestibular pressure that the cochlea may act at its
maximal efficiency. The small muscles of the external
ear are generally regarded as rudimentary and functionless
structures in man. Keith has pointed out that muscles
which are never used tend in the course of many generations
to disappear. But the muscles of the external ear are
invariably found in man, and therefore differ from those rudi-
mentary muscles which have either disappeared altogether
or are only found in a minority of human beings. They are,
moreover, as well developed in man as in apes. It thus
appears probable that they are not so inactive as is generally
supposed, and that their activity is not confined to the
occasional display of their power by the comparatively

HYSTERICAL DEAFNESS 63

small number of individuals who can voluntarily move
their ears.

How strong the muscles may be was well shown in the
case of a soldier, who constantly saw in his dreams a German
whom he had bayoneted in the face ; at the same time
he developed a bilateral spasm of his face, which recurred
every few seconds. Every muscle supplied by the facial
nerve was involved, including those of the ear, the movements
of which were extraordinarily well marked, although the
patient had never been able to move his ears voluntarily.
When the dreams disappeared as a result of psychotherapy,
the spasms also ceased.

On closely watching the ears of a man who was listening
intently, I found that a definite movement always took
place. I have since confirmed this in several individuals.
In some cases the outer edge of the auricle moved outwards
and forwards on listening to a sound in front, and inwards
towards the side of the head on listening to a sound behind.
The most vigorous movements I have seen occurred in a
man who could move his ear voluntarily, and who was also
aware that he moved it when he listened intently. It is,
of course, obvious that these movements are mere remnants
of the big movements in animals, which have the object of
concentrating as many sound waves as possible in the
external auditory meatus, but they are sufficient to explain
the constant presence of the muscles in human beings.

The contraction of the stapedius and tensor tympani
might be thought to play a more important part, but careful
observations made with W. M. MoUison failed to show the
slightest alteration in the process of hearing in complete
unilateral facial paralysis, including presumably the stape-
dius muscle.

When a man is temporarily deafened by a loud noise or
by some recoverable disease, he finds that he is unable to
hear, however much he tries, and consequently after a time
he gives up trying. That is to say he ceases to listen, and
when the cause of the deafness at last disappears, he has
become so convinced that he cannot hear that he makes
no further attempt to listen. Although the sound vibrations

64 PSYCHOLOGY OF THE SPECIAL SENSES

reach his ears in the normal way, they do not give rise to
the sUghtest auditory sensation because of this inattention :
he is then suffering from hysterical deafness, the inability
to hear having been suggested by the original organic,
though temporary, deafness. Severe hysterical deafness
developed in a soldier while he was the only Englishman
in a German prison ; he ceased to pay attention to what
was said, as he could understand nothing, and in time he
ceased even to hear the unintelligible conversation of his
companions. His hysterical deafness was rapidly cured
by psychotherapy when a year later he came under the
care of Major J. F. Venables at the Scale Hayne Hospital.

In hysterical deafness the synapses at one or more of
the cell-stations in the auditory path to the cerebral cortex
(fig. 19) must therefore be unswitched, possibly as a result
of retraction of the dendrites. Further evidence for this
follows from a study of the auditory-motor reflex.

Auditory-motor or Jump Be flex. — A sudden noise normally
causes an individual to jump, and often to blink, and the
pupils dilate ; the " jump," at any rate, is a protective
reflex, and represents the preparation for flight or fight.
The blinking cannot be suppressed by the majority of people,
although expert revolver-shots are said to acquire inhibitory
power over it. It is very doubtful, however, whether they
ever suppress the pupil reaction.

An officer, whose left motor cortex had been almost
completely destroyed, went to the Man that Stayed at Home
about four months after he was wounded. His right arm
jumped violently when the gunshot rang out on the stage,
although no trace of voluntary movement returned until
three months later. The efferent part of the reflex is thus
sub-cortical. In certain war neuroses of emotional origin,
in which the reflex is exaggerated, jumping continues
during sleep and deep hypnosis, although the patient does
not hear the noise which induces it even in a dream. The
afferent part of the reflex is thus also sub-cortical, the
reflex being quite independent of actual hearing.

Experiments on animals by Sherrington and Forbes [^]
confirm the conclusion we reached from clinical observations

HYSTERICAL DEAFNESS

65

— ^that the auditory-motor reflex is a function of the mid-
brain. They showed that both the posterior corpus quadri-
geminum and the medial corpus geniculatum are concerned.

PapiHo-dilator
ftores, via
lateral columns
of cord, tst s
2"° dhrsal roots
t cervical
sympaihetit.

Sup.
Olive

LOWER ZND OF PONS.

COCHLEA,

Fig. 19. — Diagram illiistrating neurones concerned in hysterical
deafness and in the auditory-motor reflex.

The close relation of these centres to the blinking and the
sympathetic pupilo-dilator centres in the neighbourhood
of the third nerve nucleus, and to the anterior corpus
quadrigeminum and red nucleus, in each of which a de-
6

66 PSYCHOLOGY OF THE SPECIAL SENSES

scending motor tract originates, gives an anatomical basis
for this view (fig. 19). In the experiments of Sherrington
and Forbes on cats, sounds, especially barks, yowls, and
whistles of birds, excited orientatic reflex movements of
the pinna and neck after the complete removal of the
cerebral hemispheres, striata, and thalamus. Reflex move-
ments expressive of anger and aggression — lashing of the
tail with bristling of its hairs, and flexion and extension
movements of the limbs — ^were also produced. In our
cases of complete bilateral deafness the auditory-motor
reflex was completely absent, but returned simultaneously
with the restoration of hearing as a result of psychotherapy.
A very nervous but totally deaf mute remained completely
unmoved, never jumping or showing a flicker of his eyelids
during one of the severest thunderstorms I have known,
and yet the next day he was completely cured by suggestion
under partial anaesthesia.

A sHght reflex was present in most cases of severe but
incomplete hysterical deafness, but it became less marked
and sometimes disappeared completely or was confined to
a slight dilation of the pupil when the test was repeated.

The abolition of the auditory-motor reflex in absolute
hysterical deafness makes it clear that one or more of the
unswitched synapses in hysterical deafness must be at the
level of the reflex, or still lower — in the auditory nucleus
or one of the intermediate cell-stations, the superior olive
and the nucleus of the lateral fillet, or perhaps in all
(fig. 19).

The persistence of the deafness during hypnosis and
natural sleep shows that when the inattention of hysterical
deafness has lasted for a considerable period, the unswitching
of the synapses is more profound than that which normally
occurs during deep sleep, in which the synapses can always
be forced by a loud noise.

Diagnosis. — ^In the observations I carried out at Netley

with E. A. Peters [^] we found it necessary to discard almost

all the criteria formerly used in the diagnosis of organic

deafness from deafness due to hysteria or malingering.

(1) History. — Complete bilateral deafness following the

HYSTERICAL DEAFNESS 67

explosion of a powerful shell was generally hysterical,
though a lesser degree of asymmetrical organic deafness
of a more or less permanent nature might be produced at
the same time owing to perforation of the drum or haemor-
rhage into the middle ear, both of which were often followed
by otitis media, or to dislocation of the ossicles. It is still
doubtful whether absolute organic deafness ever results
from haemorrhage into the internal ear following aerial
concussion, as no anatomical evidence of such an occurrence
has yet been forthcoming. Deafness following an acute
illness, especially cerebro-spinal meningitis, is at any rate
in part always organic, but we have found that the deafness
may be increased as a result of auto-suggestion, no spon-
taneous improvement in function occurring when the
anatomical condition improves.

(2) Other evidence of hysteria. — Our investigations have
shown that hysterical symptoms may develop in the most
normal individuals if the suggestion which provokes the
symptoms is sufficiently powerful. No more powerful
suggestion of deafness could be imagined than the organic
but temporary deafness caused by the noise of an explosion
in the immediate neighbourhood. It is therefore not
surprising that hysterical deafness has occurred almost as
frequently in soldiers who have no personal or family
history of neuroses as in those with a neuropathic pre-
disposition. Deafness has consequently been the only
hysterical symptom in many of the cases. When, however,
the onset was associated with extremely terrifying cir-
cumstances, some of the physical results of fear, such as
mutism and tremor, were often perpetuated as hysterical
symptoms. Thus hysterical deaf mutism was quite common.
In two cases sand was thrown into the patient's eyes from
the sand-bags on which the shell exploded, and the hysterical
deafness was accompanied by hysterical blindness, which
followed the conjunctivitis caused by the irritation of the
eyes with the sand.

The only conclusion which can be drawn from these facts
is that while the association of deafness with mutism or
with tremor is very suggestive of hysteria, hysterical deafness

68 PSYCHOLOGY OF THE SPECIAL SENSES

occurs most frequently in otherwise normal individuals
with no symptoms or history of neuroses.

(3) The supposed association of hysterical ancesthesia of
the external ear with hysterical deafness. — Ever since Briquet['j
in 1859 described the association of hysterical deafness
with anaesthesia of the external ear, this has been regarded
as an almost constant phenomenon. The accepted teaching
of neurologists on the question may be gathered from the
article on hysteria by Oppenheim in his Lehrbuch der N erven-
kranhheiten, in which he states that hysterical deafness is
frequently accompanied by localised anaesthesia of the
external ear, unless anaesthesia of the whole side of the
body is present. As recently as March 1918, Yealland, in
his book on Hysterical Disorders of the War, states that in
hysterical deafness " as a rule there is some sensory loss
to pin-pricks over the skin covering the mastoids." Among
aurists Politzer refers to the same association of symptoms.

J. L. M. Symns, R. Gainsborough, and I [*] noted the sensi-
bility of the external ear in a series of twenty-nine soldiers,
all suffering from organic deafness, due to various causes,
and of varying degrees of severity. The ears were first
touched lightly with a finger or some wool, sometimes
beginning with the deafer ear, sometimes with the ear
which was less deaf or normal ; at the same time the patient
was asked, " Which side do you feel more distinctly V
A similar comparison was then made between each ear
and the cheek on the same side. In twenty-eight out of
the twenty-nine cases hearing was distinctly better on one
side than the other, and in several the latter was normal.
Eighteen of the twenty-eight had partial anaesthesia, and
four had hyperaesthesia of the affected ear ; the better ear
was normal in every case. In the single case in which the
deafness was equal in the two ears there was no anaesthesia ;
but this man did not appreciate that he was deaf at all, a
slight degree of deafness having only been discovered when
the ears were examined on account of other symptoms.
The six cases of asymmetrical deafness, in which no anaes-
thesia or hjrperaesthesia was found at the first examination,
were then examined again, but a gross form of suggestion

HYSTERICAL DEAFNESS 69

was now employed, the patient being asked the following
questions : " You feel my finger less clearly when I touch
this ear (the deafer one) than this one, do you not ?" and
" You feel me touch this ear (the deafer one) less clearly
than your cheek, do you not ?" Four out of the six patients
answered " Yes " ; in the remaining two the degree of
deafness was very slight. In several of the patients anaes-
thesia was found to be very well marked, and was associated
with complete or partial analgesia. So real was this loss
of sensation that one patient was subsequently seen putting
a pin through the lobe of his ear for the amusement of the
other men in his ward.

In a case of severe bilateral hysterical deafness examined
in the same way, both ears were found to be completely
anaesthetic. In a second case, in which one ear was totally
deaf owing to organic disease and the other had been totally
deaf owing to hysteria, but was now only partially deaf as a
result of psychotherapy, the organically deaf ear was found
to be anaesthetic, and the hysterically deaf ear was normal,
corresponding with the fact that the deafness of the former
was much more severe than that of the latter. A gun-layer
with severe hysterical deafness on an organic basis, but with
no other nervous symptoms, who was totally deaf in one
ear and almost so in the other, showed no difference between
the sensibility of the external ear on the two sides, both
being perfectly normal, and attempts to suggest a deficiency
completely failed.

It is thus clear that the supposed association of hysterical
anaesthesia of the external ear with hysterical deafness is
a complete fallacy, and that anaesthesia is likely to occur
in a deaf ear if looked for, whether the deafness is organic
or hysterical, so long as the individual is sufficiently
suggestible and not too well educated. Thus in all the
above cases the patients were soldiers who had been on
active service, and our experience has shown how remarkably
suggestible the majority of war-worn soldiers are, even in
the absence of any hysterical or other nervous symptoms.
The results obtained with ordinary hospital patients was
consequently less striking. Among four adult male civilians,

70 PSYCHOLOGY OF THE SPECIAL SENSES

three females, and two boys, all of whom were deaf in one
ear or deafer in one than in the other, only one of the adult
males had an anaesthetic external ear. When, however,
they were shown two test-tubes, one of which was said to
contain hotter water than the other, and were asked to say
which side was touched with the hotter tube, eight out of
nine said that the deaf (or deafer) ear felt the heat more
than the other ear, although in every case the same tube
was used for touching both ears.

Ten well-educated individuals, who were asked whether
they would expect any difference between the sensibility
to touch in the two external ears if they were deaf on one
side only, replied in the negative. On the other hand,
seven indifferently educated men all replied in the affirmative.
The difference is simply due to the fact that no inteUigent
man would expect his external ear to be anaesthetic if he
were deaf, but a man of less education would act upon the
suggestion implied in the question without criticising it.
The greater frequency of grotesque hysterical symptoms
among hospital than private patients, and among private
soldiers than officers, is doubtless due to the greater intelli-
gence and greater development of the critical faculties to
the latter.

(4) Bone and air conduction. — ^When deafness is not
absolute, a tuning-fork can still be heard by bone conduction
(positive Rinne's test). This shows that the deafness does
not depend on changes in the middle ear, even when these
are present. But it does not distinguish between the nerve
deafness due to organic disease and that due to hysteria.
Moreover, the test can only be applied in the slighter cases,
as in many instances deafness is absolute and no hearing
is possible, whether the sound is conducted by bone or
through the air. The vibration of a tuning-fork held on
the mastoid process is, however, often felt, and the aerial
vibration caused by very loud noises is occasionally appreci-
ated, even when no sound is heard.

(5) Auditory-motor reflex. — In absolute deafness, whether
due to organic disease or hysteria, the auditory-motor
reflex is absent, but in partial deafness, whether organic or

HYSTERICAL DEAFNESS 71

hysterical, if a sound can be heard at all, it may produce a
reflex. If a reflex is present, but the patient says he can
hear nothing at all, he is probably a malingerer, but so long
as he admits that he can hear something, the test does not
help in distinguishing between organic deafness, hysterical
deafness, and malingering.

(6) Persistence during sleep. — ^As hysterical symptoms are
due to suggestion, it might be expected that they would
not persist during sleep, and Babinski regards this as a
definite law. My experience agrees with his with regard
to all other hysterical symptoms which I have investigated,
such as paralysis, contractures, and anaesthesia. I have
seen several deaf mutes, and one aphonic, who talked
naturally in their sleep, and a man with hysterical amnesia
had nightmares referring to his period of amnesia. But
hysterical deafness, the behaviour of which during sleep
does not appear to have been tested by Babinski, is an
exception. Thus, greatly to my surprise, I found it quite
impossible to wake two of my patients, who were suffering
from total hysterical deafness, and were sleeping in a hut
by themselves, by shouting or by making other very loud
noises within a foot of their heads. I convinced myself
that deception was impossible, and the hysterical nature
of the deafness in both cases was at a later date conclusively
proved by their instantaneous recovery with powerful
suggestion. In one patient a slight twitch of the eyelids
was sometimes observed with a particularly loud noise,
but not in the other. It seems probable that a malingerer
could be detected by this test, as he would certainly
wake if a loud noise was made when he was asleep,
whereas in hysterical and organic deafness waking does not
follow.

(7) Effect of hypnosis. — I had expected that hearing would
return in hysterical cases during hypnosis, but I found it
quite impossible to make deaf patients, whom I had deeply
hjrpnotised, obey any command or show any signs of hearing,
and no auditory-motor reflex was produced. The unswitched
synapses thus appear to remain unswitched during hypnosis,
as they do during sleep.

72 PSYCHOLOGY OF THE SPECIAL SENSES

(8) Character of the voice. — In almost all cases of severe
deafness due to organic disease the character of the voice
changes. It is difficult to understand why there should
be any difference in the effect of total deafness on the voice,
whether it is organic or hysterical, as the change is simply
a result of the patient's inability to hear his own voice.
Although in some of our hysterical cases the typical voice
of the organically deaf developed, the majority showed no
change in timbre or intonation. In the three cases I have
seen which dated from early infancy, the patients had learnt
to talk, but their speech was of the very indistinct type
which is characteristic of deaf-mutes who have been taught
to speak without ever having heard.

(9) Lip-reading. — When a deaf man teaches himself
lip-reading, his deafness must be of a high degree. Several
patients with hysterical deafness learnt it with remarkable
rapidity, so that it cannot be regarded, as has been suggested,
as a sign of organic disease. On the other hand, it is
very unlikely that a malingerer would ever learn lip-
reading.

(10) Vestibular symptoms and reactions. — Disturbances
in the vestibule as a result of concussion may cause spon-
taneous nystagmus, which may be accompanied by giddiness
and staggering, but these symptoms rarely last for more
than a few hours.

We found that the only test upon which almost complete
reliance can be placed in the diagnosis of absolute hysterical
deafness from absolute organic deafness is the presence
of normal vestibular reactions in the former and their loss
in the latter. The vestibular reactions are entirely beyond
the control of the will, and it is therefore inconceivable
that they should disappear as a result of suggestion. As
hysterical symptoms are always caused by suggestion,
the vestibular reactions must remain unaffected in hysterical
deafness. On the other hand, it is highly improbable that
any organic lesion could damage the cochlea or the cochlear
nerve or nucleus on both sides sufficiently to cause total
bilateral deafness without at the same time damaging the
vestibules or vestibular nerves or nuclei, so that total

HYSTERICAL DEAFNESS 73

organic deafness is almost certain to be accompanied by
deficiency in the vestibular reactions. The only exception
of which I have heard is a case reported by Eraser [*] of a
congenital deaf man, in which microscopical examination
of both inner ears showed that the organ of Corti was so
malformed that hearing was almost abolished, while the
vestibules were normal. The caloric reaction was noted
on both sides some days before death, and a normal response
was obtained.

The vestibular test has proved of great value in cases of
total deafness. But it must be remembered that in partial
organic deafness the vestibular reactions may be lost in
severer cases and exaggerated in slighter cases ; any
hysterical element which may be present in such cases can
only be recognised by the improvement which follows
psychotherapy.

The vestibular reactions may be investigated by the
rotation, caloric, or electrical tests, in all of which nystagmus
and giddiness occur in normal individuals, but not if the
vestibules or vestibular nerves are damaged. We have
generally employed the rotation test, as it requires no special
apparatus, the patient turning rapidly round five times in
one direction and subsequently in the opposite direction.
The character and degree of the nystagmus on looking in
the direction opposite to the rotation is estimated, and the
subjective and objective evidence of vertigo is investigated.
The rapidity of the movements of the eyes and their dura-
tion should be the same when the individual is rotated
clockwise or counter-clockwise. If any inequality is observed,
one vestibule must be involved and the other spared, or one
must be involved more than the other. An equally simple
and satisfactory test ["] is for the patient to turn five times
round a walking-stick, which he holds in the erect position,
with his back bent so that his forehead rests upon the handle
of the stick ; he then attempts to walk along a straight
line marked on the floor. A normal individual diverges
from the line in the same direction as he has been turning,
the angle being equal whether he turns to the right or left ;
but in severe bilateral vestibular disease he walks straight

74 PSYCHOLOGY OF THE SPECIAL SENSES

forward, or if the ears are unequally affected, the angle
differs according to the direction he turns.

The following remarkable case well illustrates the fallacious
character of the criteria which were formerly regarded as
sufficient to make a definite diagnosis of organic deafness.

Absolute functional deafness in a young man of eighteen
dating from infancy. — G. C, a deaf-mute, 18 years old, ap-
pears to have become deaf after a fall on his head some time
between the age of three and nine months. His mother is
certain that he could hear as a small baby, but she noticed
that he was deaf before he was a year old. Sir Dundas
Grant saw him when he was three years old. He has kindly
looked up his old notes, from which it appears that although
there was then " a little trace of hearing," he concluded that
he must " be classed with the deaf-mutes." With great
difficulty he was taught to speak, but he has the character-
istic, extremely indistinct speech of a deaf-mute. He does
not remember ever having heard anything at all, except on
rare occasions during the last few years, when he thinks
he has sometimes heard a loud noise, though possibly he
reaUy only felt the vibrations of the sound. When I first
saw him in May 1919, he appeared to be totally deaf, but
there were no signs of middle ear disease, and the vestibular
reactions were perfectly normal. The auditory-motor
reflex was completely absent. I explained to him by means
of lip-reading, at which he is an expert, that he could not
hear because he had never tried to listen, and if he once
made an effort to listen he would begin to hear. On this
first visit he was taught to listen sufficiently to hear his name
called close to his ear ; this was, so far as he remembered,
the first word he had ever heard. The same day he heard
his bicycle bell and a motor horn for the first time. During
the course of the next three weeks, in which it was impossible
to give him more than an occasional short lesson, he learned
to hear a number of words, each of which had to be taught
separately, as although he could hear the sound, it conveyed
nothing to him until he realised what the word was by lip-
reading. When once learnt he could understand it on a
future occasion, but found it extremely difficult to continue

HYSTERICAL DEAFNESS ' 75

to listen for more than a few minutes, so progress was slow.
At his best he could hear a familiar word from the other
side of the room without the voice being raised, but fre-
quently it was necessary to shout a word into his ear. At
the same time he improved sufficiently to be able to hear
all ordinary sounds. He could hear a band, and he could
hear notes played on the piano, but he had no idea of pitch,
and could not distinguish one note from another. The
auditory- motor reflex was now normal.

He is still making slow but steady progress. His father
says that he now almost always looks up at once when
anybody speaks, and that he seems to hear most sounds
without any obvious effort. The diminished resistance in
his auditory tract is further shown by the fact that he now
sometimes wakes when a cock crows, although before treat-
ment was begun the deafness was complete when he was
asleep as well as when he was awake. When I last saw
him on July 20, 1920, he could hear a watch ticking three
inches away from his left ear, and could repeat words he
had never heard before if they were spoken several times
distinctly, but not loudly, near his ear. At the same time
his speech has slightly improved.

Although his hearing is still far from normal, there is
every reason to hope that considerable further improvement
will take place.

In this case a young man of eighteen had been a deaf-
mute from infancy, and the many aurists who had seen him
in the past regarded his condition as obviously incurable ;
the complete absence of anj^hing in himself or his relations
which could be regarded as pointing to a tendency to
neuroses, the absolute loss of bone and air conduction and
of the auditory- motor reflex, the persistence of deafness
during sleep, the characteristic speech of the deaf-mute
who has painfully acquired the power of making himself
understood, and his great skill as a lip-reader, might have
been taken to prove beyond the shadow of a doubt that the
deafness was organic. But the vestibular reactions were
normal, and acting upon this alone, we were able to prove
the functional nature of the condition by restoring his

76 PSYCHOLOGY OF THE SPECIAL SENSES

powers of hearing by means of psychotherapy. The deafness
which developed when he was about three months old must
have been due to some organic but evanescent lesion. It
occurred at a period when he was just learning to listen,
and consequently interrupted his development in this
direction. When the organic cause disappeared he had
become unaccustomed to listen, and he never learnt to do
so again. The deafness was thus really functional and
therefore capable of being cured by psychotherapy.

A proper understanding of the psychological process
involved in listening, and of the disturbance in the process
which results in hysterical deafness, should lead to a great
improvement in the treatment of the latter. When
hysterical deafness is associated with mutism it requires
no special treatment, as hearing almost invariably returns
spontaneously when speech is restored. In order to make
this still more certain, the patient must be convinced that
directly he speaks he will hear his own voice, and that
he will then hear everything clearly. There is rarely any
difficulty in curing the mutism by simple explanation and
persuasion, though in our earlier cases we occasionally
resorted to the suggestion produced by applying faradism
to the larynx or making the patient excited with an anaes-
thetic. In the following two cases the latter method cured
the deaf-mutism, but was followed by partial amnesia.

Hysterical deaf-mutism following shell- explosion : cured
by suggestion with etherisation and followed by partial
amnesia. — An Australian soldier, aged 22, wrote the following
letter to his relations on August 21, 1916. " You may be a
little surprised to hear that I am in the hospital suffering from
shell-shock, which has taken away my speech and hearing.
It is some sixteen days now since it happened. . . . We
were in the trenches and going for dear life, when two of
us spotted a German machine gunner in a hole, so we made
up our minds to have him. We made a charge at him, and I
just remember getting to him when a high-exposive shell
burst at my head ; it seemed as if it burst inside my head ;
everything went black. I tried to call out and couldn't, and

HYSTERICAL DEAFNESS 77

I could not hear my mates — only just a terrible bursting
in my head all the time. I never remembered anything more
until I came to on the boat. . . . The doctors have told me
that I will get all right in time. ... I saw a good deal of
France. . . . There is not a young man there who is not in
the Army. The girls and women work in the fie "

The letter ended abruptly at this point, as I then came
to examine him. The previous day I had hjrpnotised him
without di£&culty, but was unable to make any effective
suggestions, as the deafness persisted during the hypnotic
sleep, so that the suggestions did not reach the higher centres
of his brain, and were consequently not acted upon either
whilst he remained asleep or after he awoke. He was so
deaf that he heard nothing at all during an exceptionally
violent thunderstorm. He was not only unable to speak,
but could make no sound of any kind and could not cough.

As no improvement had taken place, he was given ether,
after being told in writing that it would have the effect
of restoring his speech and hearing. He began to struggle
after a first few whiffs, and long before he was anaesthetised
he began to repeat the word " Mother," first in a whisper,
then louder and louder until he shouted it with a stentorian
voice that would have filled the Albert Hall. The etherisa-
tion was then discontinued, his limbs never having become
relaxed. As he came round, I told him to say various words,
which he repeated after me, and I then carried on a continuous
conversation with him. When the effects of the ansesthetic
finally passed away, he was talking with a normal voice and
he had completely recovered his hearing.

His memory, which had previously been unaffected, was
now a complete blank from a short time before he was blown
up to the moment he had regained consciousness. He
had no recollection of having lost his speech or hearing ;
he was astonished to see the letter he had begun, as he
remembered none of the events described in it, and he did
not remember having seen me before. In all other respects
his memory was perfect.

In this case the patient became speechless from fright at
the sound of the explosion, and deaf from the accompanying

78 PSYCHOLOGY OF THE SPECIAL SENSES

noise ; almost immediately afterwards he lost consciousness
as a result of the aerial concussion. The moment he re-
covered consciousness the fact that he had lost his power of
speech and hearing after the explosion recurred to his mind,
and as a result of auto-suggestion these disabilities were
perpetuated. The subconscious inhibition of speech and
hearing was broken down as a result of the loss of control
of the higher over the lower cerebral centres when he was
under the influence of ether. By keeping these faculties
continuously at work whilst the effects of the ether passed off,
their recovery was maintained when consciousness returned.

Amnesia following recovery from deaf -mutism. — Sergt.
H., a New Zealander, was admitted under my care on
September 25, 1916. He was completely deaf and dumb, and
wrote the following history of his case. ' ' About September 1 7 ,

our brigade was in support behind F . A shell landed

on a cookhouse, killing one and wounding two others, and
as the Germans were bombarding very casually (about one
shell a minute) I thought there was time to get those fellows
in. I had just got to them — the cookhouse was fifty yards in
rear of the trenches in the open — when the enemy opened
battery fire and violently bombarded the sector with large
shells. My man, whose both legs were broken, made pro-
gress very slow, and another shell landed within six feet of us,
a piece of it hitting me in the back. I remember getting
to the dressing station somehow or other, and next found

myself in E four or five days after. I could not walk,

talk, or hear. I have all other faculties and can understand
and think clearly. I am just beginning to walk a few steps
at a time. The M.O. at the hospital in France told me it
was only a matter of time and I would be all right."

On October 1, as there was still no return of hearing or
speech, he was given a little ether, and after a good deal of
persuasion, his speech and hearing were restored. When he
regained consciousness he could hear and speak perfectly,
but he believed that it was May 25, 1915, and thought the
" boys were kidding him " when they told him he was in
England, as he had no recollection of having left New
Zealand and imagined he must be in the Porarua lunatic

HYSTERICAL DEAFNESS 79

asylum. The following is an extract from an account he
wrote of his doings on what he believed to be the previous
day. " On May 24, I went to church for my organ lesson
at 8 p.m., and afterwards had the treat of my life. Mr. F.
played the pick of musical compositions until 11 p.m.
That night will ever stand out as one of the most enjoyable
of my life. ... On Tuesday night I went to Mr. B.'s house
to bid farewell to Wilf. and Rol., who are going to the war.
I don't think things are so bad as to warrant my throwing
up my billet, as yet, and I told them so. Besides, I would
miss that examination. Of course, if the worst comes to the
worst I will go to the front."

His general health rapidly improved, and in a few days,
with encouragement and re-education, he learnt to walk quite
well. But the blank in his memory persisted, and at the
beginning of December, when he returned to duty, he was
still unable to remember anything between May 25, 1916, and
October 1, 1916, which appear to him to be consecutive days,
and he had to learn his drill again, as he had no recollection
of his military training.

Uncomplicated hysterical deafness is much more difficult
to treat, and for a time our results were less satisfactory
than in any other hysterical condition. For this reason
we were induced to employ various forms of suggestion,
although we realised that the methods were not really
satisfactory. Suggestion under hypnosis was never of
any use, as the patient remained deaf whilst hypnotised,
and consequently heard none of the suggestions which
were made to him. Electricity as a means of suggestion
was sometimes successful, but often failed. In a number
of cases of absolute bilateral deafness, which had resisted
all other forms of treatment for some months, we performed
" fake " operations, making a scratch behind the ear in
the incompletely ansesthetised patient.

Hysterical deafness following exposure to a shell explosion
cured by a fake operation. — Lance-Corporal M., 26 years old,
was blown up by a shell on August 29, 1916. He became
completely blind, deaf, and dumb, although he did not

80 PSYCHOLOGY OF THE SPECIAL SENSES

lose consciousness. His sight returned the following day.
On reaching England he was able to read and write, and he
talked in his sleep. In spite of treatment with encourage-
ment, electricity, and etherisation, no further improvement
occurred until one night in November, when he woke up
and asked the sister for a drink. After this he was able to
talk normally, but the deafness remained.

He came under my care at Netley on March 21, 1917,
seven months after the onset of the deafness. He was
found to be completely deaf both to air and bone conduction,
though he could feel the vibration of a tuning-fork on his
mastoids. A loud noise just behind his head caused a
slight tremor of his hands, blinking, and dilatation of the
pupils, although he heard nothing ; a slighter reaction was
produced on the second and third occasion when the noise
was repeated ; after this it disappeared completely, and
did not return again.

As the vestibular reactions were found to be unaffected,
it seemed probable that the internal ear was free from
organic changes. This was rendered still more likely by
the fact that immediately after the explosion the deafness
was associated with mutism, which is always hysterical
when it develops after a shock of this kind. The patient
was hypnotised by being made to stare at a lens for fifteen
seconds, but the deafness persisted : he could not be made
to respond to any suggestion, as he was unable to hear, and
a loud noise produced no auditory- motor reflex, the pupils
as well as the eyelids remaining fixed. The deafness also
persisted during natural sleep, as it was found impossible to
wake the patient by shouting " fire " and by banging a poker
against a coal-scuttle within a few inches of his head, and no
reflex flicker of his eyelids was observed. In the morning
he had no recollection that anything unusual had occurred
during the night. Suggestion with the aid of electricity,
in which he had great belief, and attempts to re-educate
the sense of hearing with various noises completely failed.
He was, however, suddenly and completely cured by a
" fake " operation on his ear on April 20, to his intense
delight, as he had recently become extremely depressed

HYSTERICAL DEAFNESS 81

at the absence of any sign of improvement after more
than seven months. His hearing was accurately tested
the next day, and it was found that it was perfectly
normal both to air and bone conduction, and the auditory-
motor reflexes had returned. He was discharged to duty
three weeks later, feeling perfectly fit. He visited the
hospital on June 29, a few days before he returned to
Prance ; his hearing was normal, and he was well in
every way.

This method of treatment was not invariably successful,
and at the best it was not one which could be regarded as
desirable, as it is much more satisfactory for the patient
to understand the exact means by which he has been cured
than for him to be fooled into a cure by gross suggestion.
With increased understanding of the psychological basis
of hysterical deafness we were able during the last year
of the war to cure a large majority of cases by the most
rational form of psychotherapy — explanation, persuasion,
and re-education. The patient is made to understand by
written explanations how he has become deaf, and how the
original cause of his deafness has now disappeared : as the
deafness was at first organic, he could not hear, however
much he listened, and consequently after a time he ceased
to listen at all. He is next persuaded to listen intently,
and is taught that listening is just as active a process as
moving, and requires a conscious effort on his part until
it becomes automatic once more.

Even when a man has completely recovered his hearing,
it may take some time before he becomes accustomed to
the new conditions, especially if he has been deaf for a long
period. When caught unawares he often fails to hear,
though directly he perceives he is being spoken to he listens,
and can then hear even with his eyes closed, so that lip-
reading cannot help him. In severe cases he may hear the
sound of the voice without being able to distinguish what
is said. Re-education is then required in order that the
sounds the patient hears, but at first cannot interpret,
can be understood, that words which must at first be
6

82 PSYCHOLOGY OF THE SPIlOIAL SENSES

repeated separately from each other can be used in con-
tinuous sentences, and that the voice which must at first be
raised can become progressively more quiet. A similar
method of re-education can be employed for the many
people who are suffering from some incurable form of
deafness, who can in this way be taught to make the most
of what powers of hearing they still possess.

Similar re-education methods were used by Gordon
Wilson ['] in the treatment of hysterical deafness in soldiers,
and since these observations were made my attention has
been drawn to a series of papers on the subject published in
1912 and 1913 by Maurice, [*] of Paris. He points out that
in almost every form of deafness some improvement results
from re-education. He has introduced a very costly noise
machine or " kinesiphone " with the object of re-educating
the power of hearing, but this does not appear to have any
advantage over the simpler methods I have described.
These have been used with success in a small number of
very severe civilian cases, of which the following is an
example.

Hysterical deafness after being struck by lightning ; great
improvement with psychotherapy nine years later. — Mr. S.,
aged 55, was struck by lightning in November 1911, when
in New South Wales. His horse was killed under him,
and he was left for dead by his companion who was riding
with him. He was subsequently picked up and carried
to a hospital, where he remained unconscious until the
sixteenth day. A burn was found extending from the back
of his head down the left side of his body to the hip. When
he recovered consciousness he found that he had completely
lost his hearing, and that his legs and arms were numb
and partially paralysed. He slowly regained his power
of movement, but continued to feel peculiar sensations in
his limbs. The deafness was associated with a continuous
noise in his head, which reminded him of escaping steam.
It was so persistent that it often rendered it difficult for
him to get to sleep.

When he left hospital he was told that his deafness
was due to fracture of the base of the skull, caused by

HYSTERICAL DEAFNESS 83

the violence with which he struck the ground when he
fell from his horse, as bleeding had occurred from his
right ear.

When I first saw him in March 1920, I found that his
vestibular reactions were perfectly normal. He could not
hear a whisper at all ; loud- spoken words were only heard
within 2J inches from the left ear and one inch from the
right. Low notes were heard better than high ones. There
was no paralysis, but he complained of inability to walk
more than a short distance, and he was still troubled with
unpleasant sensations in his limbs. I could find no evidence
of organic disease, and regarded the deafness as probably
hysterical in origin. This opinion was confirmed by Mr.
W. M, Mollison, who could find no evidence of disease in
either ear.

I explained to him that the terrific noise of the thunder-
clap had produced temporary organic deafness, and that
this was the last impression he had before he lost conscious-
ness. It was quite impossible that the deafness was due
to a fracture of the base of the skull injuring the auditory
nerves, as he had been told, as in that case the vestibular
nerves would have been involved at the same time. I
pointed out that having once been deafened he had ceased
to listen, and that when the temporary changes produced
by the noise had disappeared he could have heard again,
but he had become so impressed by the fact that he was
deaf that he had not tried to listen. He at once improved
when he realised that in order to hear he had to listen
actively. I gave him a few lessons myseK, and he then
continued to train himself whilst at home in Scotland. On
the railway journey he foimd that he could hear what other
people were saying in spite of the noise of the train, although
he had never been able to do this before, and when he got
home he found he could hear the voices of his relations
which he had not heard since the accident. He trained
himself to listen to everything that was happening around
him, and for the first time since 1911 he could hear the
singing of birds, footsteps in his neighbourhood, and clocks
striking.

84 PSYCHOLOGY OF THE SPECIAL SENSES

Although in the past it had been impossible for anybody
to wake him by noises, he now found that quite slight noises
might wake him in the night, so that whatever the basis
of the hysterical deafness might be, it clearly persisted
during sleep, but was now no longer present. When I last
saw him on June 16th, he could carry on an ordinary
conversation without difficulty. Mr. MoUison found that
with the right ear, which had been previously almost totally
deaf, he could now hear clearly spoken words at a distance
of eighteen inches, and with the left ear he could hear
quietly spoken words six feet away and a whisper at one inch.
He himself has noticed that even when his better ear is
covered, he can carry on a conversation if the words are
spoken slowly and clearly. At the same time his general
health has greatly improved, and the noises in his head
have almost disappeared. Whilst he learnt to give greater
attention to sounds, he gave less attention to sensations
coming from other parts of his body, and consequently the
parsesthesia of his limbs gradually disappeared.

In the following case, that of a thirteen-year-old deaf-mute,
who had already with great difficulty learnt to talk, remark-
able improvement in hearing has occurred as a result of
psychotherapy with the aid of some physical treatment,
which by itself could have had but little effect.

Absolute functional deafness dating from infancy associated
with slight organic middle-ear deafness. — Bertha M., aged 13,
was seen by Mr. W. M. Mollison and me on March 8, 1920.
As far as her parents could tell, she had never heard anything,
but it was not recognised with certainty that she was com-
pletely deaf until she was two. Her adenoids were then
removed, but no improvement occurred. Her parents are
not related, and the only other member of the family who is
deaf is her nine-year-old brother. In his case there was no
indication of middle- ear disease and the vestibular reactions
were almost completely absent, so we made no attempt to
treat him by physical or psychical methods, as we regarded
the prognosis as hopeless. Both children had the typical
speech of deaf-mutes. Mr. Mollison found that the girl's

HYSTERICAL DEAFNESS 85

left membrane was dull and somewhat retracted, the right
being more normal in appearance. The tonsils were buried
and remains of adenoids were still present. A loud shout
could not be heard, and no tuning-fork could be heard either
through air or bone. There was some doubt as to whether
she could faintly hear a high note produced by the monocord
( 4 "6 cm. ). The auditory-motor reflex was absent. Rotation
and syringing with cold water gave normal vestibular
reactions, but the giddiness and nystagmus were slight in
degree.

Owing to the presence of vestibular reactions it was thought
that the condition might prove to be wholly or in part
hysterical. At the same time it seemed likely that the best
results would be obtained by removing as far as possible the
very slight physical abnormalities which were still present,
as quite apart from the direct effects which might result
therefrom, the operation might hasten improvement by its
suggestive influence.

On April 4, 1920, Mr. MoUison inflated the Eustachian
tubes under a general anaesthetic ; the tonsils were enucleated
and the adenoids curetted. A week later, when the first
treatment by re-education was given, she was still completely
deaf. In simple language I explained to her that listening
was an active process and that^ she must no longer maintain
a passive attitude towards external sounds as she had done
in the past. At the end of the lesson, for the first time in her
life, she could hear a little. I showed her mother and gover-
ness how to continue with the education, and when I saw
her again on July 10, 1920, the improvement was most
remarkable. It was now possible to carry on a conversation
with her by talking loudly into her ear, and the day before
her governess had told her a complete fairy story in this
way. She is now having all her ordinary lessons by ear
in addition to the special lessons in listening, and there
seems every prospect of her ultimately hearing almost
normally.

In this case naso-pharyngeal infection had apparently led
to severe middle-ear catarrh in early infancy, and the resulting
organic deafness had been perpetuated and exaggerated by

86 PSYCHOLOGY OF THE SPECIAL SENSES

the interruption in the normal process of education in
listening to and interpreting sounds.

[1] C. S. Sherrington and A. Forbes, Amer. Journ. of Physiology, xxv. 367,
1914.

[2] A. F. Hurst and E. A. Peters, Lancet, ii. 517, 1917 ; and A. F. Hurst,
Seale Hayne Neurological Studies, i. 279, 1919.

[3] P. Briquet, Traite de V Hysteric, p. 295, 1859.

[*] A. F. Hurst, J. L. M. Symns, and R. Gainsborough, Ret^iew of Neurology
and Psychiatry, i., 1918 ; and Seale Hayne Neurological Studies, i. 19, 1918.

[»] J. S. Fraser, Lancet, ii. 872, 1917.

[•] D. E. J. Moure and R. Pietri, Rev. de Laryngologie, d' Otologic, et de
Rhinologie, xxxviii. 153, 1917.

['] J. L. Gordon Wilson, Brit. Med. Journ., i. 867, 1917.

[»] G. A. Maurice, Treatment of Deafness by Re-education of the Power* of
Hearing, Paris, 1913.

CHAPTER IX

HYSTERICAL HYPERACEUSIS

The nervous individual, who has a brisk auditory-motor
reflex which results in " jumping " at the least sound, is
familiar in civil life. An exaggeration of this condition
was a common symptom in soldiers suffering from all forms
of war neurosis which were emotional in origin. In its
most marked form the patient jumped violently with sudden
sounds, which could hardly be heard at all l^y an ordinary
individual, and louder sounds produced violent universal
tremors. The condition persisted during sleep, the patient
showing the same exaggerated response to sounds, which
did not necessarily wake him, although they generally
slept more lightly than they had done before the war. The
type of sound which produced this reaction was always
one which was in some way reminiscent of shell explosions
or other sounds of battle. Many patients realised this
quite clearly in their waking state. In one severe case of
the kind, the patient, when deeply hypnotised, told me
that he was always listening for shells, and jumped whenever
a sound reminded him of them, although he had been
unable to explain the symptom when he was awake.

I have already described the experimental and clinical
observations which prove that the auditory-motor reflex
is a mid-brain phenomenon. I believe that its exaggeration
in certain neuroses can be readily explained as a result of a
mechanism exactly the reverse of that which leads to its
abolition in hysterical deafness. Whereas in hysterical
deafness the patient does not listen, a soldier who is in a
state of constant terror becomes accustomed to listen for
shells with abnormal concentration, and this concentration

87

88 PSYCHOLOGY OF THE SPECIAL SENSES

may persist when he is no longer at the front and no shells
are bursting. Instead of the resistance at the synapses
in the auditory tract being increased as in hysterical deafness,
it is diminished owing to the extreme degree with which
the dendrites are extended. This results in an abnormally
brisk auditory- motor reflex and probably also in abnormally
acute hearing. We only tested the power of hearing
accurately in one patient, in whom the jump reflex was
excessively developed. Captain E. A. Peters and I found
that he could hear sounds at a distance four times as great
as the average individual, which means that his power
of hearing was sixteen times greater than the average, as
the intensity of sound diminishes inversely as the square
of the distance. His acuity of hearing was most remarkable.
Sentences whispered in one corner of a large room so quietly
that a group of officers in the centre heard no sound at all
were correctly repeated by him, although he was sitting
in the opposite corner. The hyperaceusis and jump reflex
were quite uninfluenced by the administration of one hundred
grains of bromide a day, and were only slightly reduced by
plugging the ears with plasticine.

The increased resistance at the synapses in hysterical
deafness persists during sleep. In the same way the
diminished resistance in hyperaceusis persists, as the patients
wake with unusual ease in response to sounds, and also
show a brisk jump reflex even when they do not wake.

CHAPTER X

SEEING, LOOKING, AND HYSTERICAL BLINDNESS

In Chapter VIII the psychology of hearing was discussed.
It was shown how in order to hear it was necessary to
listen, and that the process of listening involved some
change at each synapsis in the auditory tract from the
cochlea to the cerebral cortex, as a result of which resistance
to auditory impulses was diminished.

In order to see it is necessary to look. Looking involves
a process in the visual tracts strictly comparable to what
occurs in the auditory tracts in listening. But, in addition
to this, the action of a number of muscles is called into
play, comparable to what I described in regard to listening,
although the movements involved are more important
and require much more delicate adjustment. Two distinct
elements thus require consideration — the afferent, involving
the visual tracts, and the efferent, involving certain motor
tracts.

(a) The Afferent Element. — Inattention is rarely so
profound in normal individuals that no visual impulses
reach the brain at all, although complete absence of hearing
not infrequently results from extreme inattention. It
is common enough for visual impulses to be so blurred that
a man, wrapped up in his own thoughts, does not see the
approach of a friend, but he would always avoid obstacles
if he were walking, and he would be aroused by the sudden
approach of an object to his eye ; the latter would also
give rise to the flinch reflex.

In the condition of stupor, which was not imcommon in
soldiers who had been exposed to exceptionally terrifying
ordeals, the mind appeared to be so completely absorbed

90 PSYCHOLOGY OF THE SPECIAL SENSES

with thoughts which had no connection with the patient's
present surroundings that he did not respond to any impulses
from the outside world. He appeared to be blind, deaf,
and anaesthetic ; he gave no flinch (visual- motor) or jump
(auditory- motor) reflex, cutaneous (tactile-motor) reflexes
were often though not invariably abolished, and the pupil
contracted sluggishly or not at all on exposure to light.
In spite of this he could feed himself if food were put in
front of him, and did not stumble against obstructions if he
were taken for a walk, and he occasionally showed a slight
response to certain loud sounds, so that vision and hearing
were clearly still possible ; but it was difficult or impossible
to induce the patient to look or listen even for a few seconds
at a time. Exactly the same thing occurs in somnambulism.
The doctor, seeing Lady Macbeth walking in her sleep,
exclaims, " You see, her eyes are open," and the gentleman
replies, " Ay, but their sense is shut."

In the chapter on " Hearing, Listening, and Hysterical
Deafness," it was explained how the idea of being unable
to hear, suggested by temporary organic deafness, might
give rise to a continued absence of listening and consequent
deafness after the organic cause had disappeared. In the
same way any condition which has led to complete though
temporary blindness may suggest to the individual that
he has lost his sight for ever : this is particularly likely
to be the case if the temporary blindness is produced
suddenly under terrifying conditions, as, for example, by
the explosion of a powerful shell in the immediate neigh-
bourhood. The slower onset of the temporary blindness
in gassing, although the surrounding conditions might be
equally terrifying, generally resulted in less profound
hysterical blindness. When the suggestion that the sight
is permanently lost has become thoroughly accepted, the
individual will cease to look. The visual tract is no longer
prepared for sight by attention, and visual impulses conse-
quently cease to pass up to the brain. In the act of looking
the resistance at each cell- station in the tract is diminished
by some such process as a throwing out of dendrites or an
alteration in the electro-chemical condition of the synapses.

HYSTERICAL BLINDNESS 91

Consequently visual impulses not only give rise to no
visual perception, but the flinch reflex and in the most
severe cases even the pupil reflex to light disappear, as
the resistance to the impulses, even at the lowest synapses,
is too great to be overcome. More commonly the impulses
produced by a very bright light can still break through
the resistance, so that the light is perceived and a sluggish
reflex to light is obtainable, but the flinch reflex is still
completely abolished.

When, as a result of psychotherapy, the patient realises
that he can really see if he only chooses to look, he once
more throws out the dendrites or otherwise reduces the
resistance in the visual path, and vision returns, the pupil
and flinch reflexes becoming normal again at the same
moment.

Injury or disease of the visual centre in the occipital
cortex is the only organic condition leading to blindness in
which the lower visual centres are unaffected. It might
be expected that the flinch reflex would remain unaltered,
corresponding with the persistence of the auditory- motor
reflex in decerebrate animals. This is not, however, the
case, as Gordon Holmes, [^] in his unique experience of head
injuries during the war, found that the flinch reflex was
always lost in the blind fields of vision. This corresponds
with the experimental observations of Sherrington, who
found that the reflex was always abolished in decerebrate
animals, even when the anterior corpora quadrigemina
remained intact, although the auditory-motor jump reflex
remained unaffected. It is not at first clear why the latter
should persist while the flinch reflex should disappear.
But Sherrington points out that it is not every sound which
can produce the auditory-motor reflex in decerebrate animals,
but that shrill peculiar sounds are the provocative ones,
mere loudness appearing to be of no importance. As the
effective sounds are neither injurious nor painful, they
must have some other meaning, possibly connected with
the sexual life of the animal. On the other hand, the
retinal stimulus which gives rise to the flinch reflex may
perhaps require remembered experience in order to be

92 PSYCHOLOGY OF THE SPECIAL SENSES

effective. Thus the reaction of blinking is anticipatory,
the response being to threatened injury and not to actual
injury. As memory and anticipation depend upon higher
centres than the corpora quadrigemina and geniculata,
the reflexes are abolished both in animals and man when
the cortical centres are thrown out of action. The flinch
reflex is thus a true visual reflex, being dependent, as von
Monakow [*J was the first to show, on visual perceptions.
Yet how instinctive a reaction it is to a threatened blow is
shown by Darwin's observation that he could not repress
his blink when a snake on the other side of the glass of the
snake cage at the Zoo struck at him.

It is clear, from what has been said, that in the absence
of abnormality in the eyes there is no means of determining
with certainty whether absolute blindness in the whole
fields or in homonymous areas is organic or hysterical, as
the flinch reflex is lost in both.

(b) The Efferent Element. — With the afferent element
set in readiness, visual impulses reach the occipital lobes,
but nothing is seen clearly until the eyes are opened, the
extrinsic muscles work in thorough co-ordination, so that
the object to be looked at is brought into the centre of the
field of vision of both eyes, and the ciliary muscles contract
just sufficiently to bring it into correct focus. All these
motor processes may be impaired as a result of suggestion,
either alone or in addition to the afferent element already
described. How this occurs can best be understood by a
consideration of the hysterical disorders of vision which
follow gassing.

Exposure to mustard gas is followed in a few hours by
pain in the eyes, which is increased by exposure to light.
Conjunctivitis, blepharitis, and in rare cases keratitis, quickly
develop. As long as pain and photophobia are present,
the swollen lids remain closed. This is partly due to
inactivity of the levator palpebrse superioris muscles, for
the patient makes no effort to open his eyes, knowing that
if he were to do so the exposure to light would cause pain.
It is partly due to a protective reflex, which results in over-
action of the orbicularis palpebrarum muscles, particularly

HYSTERICAL BLINDNESS 03

if the patient does try to open his eyes. The object of this
is to protect the eyes from being irritated by light ; it is
accompanied by reflex lachrymation, as a result of which
irritating material is washed away. The inflammation
gradually subsides, the reflex blepharospasm and lachry-
mation disappearing pari passu. At the same time the
majority of patients realise that they can now open their
eyes without hurting them, and in most cases they
do so.

In individuals, however, who have become abnormally
suggestible as a result of the stress and strain of active
service, and in others who for any reason are particularly
anxious about the condition of their eyes, the normal results
of the conjunctivitis become perpetuated by auto-suggestion,
to which may sometimes be added the hetero- suggestion
caused by injudicious treatment, such as the prolonged
use of eye-shades and dark glasses, which give rise to an
exaggerated fear in the patient's mind of the consequences
of having been gassed. The voluntary inactivity of the
levator palpebrse superioris becomes perpetuated as an
involuntary inactivity, which may amount to actual
paralysis, the condition being now one of hysterical ptosis.
In rare cases the hysterical paralysis of the levator palpebrse
may spread, hysterical paralysis of the whole of the face
resulting (case 8). A patient who finds himself unable to
open his eyes by contracting his levator palpebrse muscles
often attempts to compensate for this by contracting his
frontalis muscles, and if the attempt meets with sufficient
success to enable him to see through the chinks between
his eyelids, he does this more or less constantly. The reflex
blepharospasm is perpetuated as hysterical blepharospasm,
which is generally most obvious when the patient attempts
to open his eyes voluntarily, the eyes becoming more tightly
closed than ever. The paralysis of the levator is thus
accompanied by spasm of the orbicularis, just as hysterical
paralysis of one group of muscles in a limb is often accom-
panied by hysterical spasm of the opposing group of muscles.
The spasm often involves the neighbouring muscles or even
all the muscles supplied by the facial nerve. Any attempt

94 PSYCHOLOGY OF THE SPECIAL SENSES

to pull the eyes open meets with great resistance, and a
peculiar thrill is often felt owing to the irregular contraction
of the orbicularis muscle. In some cases, after it has become
possible to open the eyes voluntarily, the ptosis and blepha-
rospasm manifest themselves intermittently in the form
of attacks of blinking, especially on exposure to a bright
light. Although hysterical ptosis and hysterical blepharo-
spasm are generally present together, either may be present
alone, and the proportion of one to the other may be
different in the two eyes, as in case 8.

In total blindness due to severe bilateral optic atrophy
the eyes are kept open during the day, and look straight
forward, but they close during sleep. An uneducated man,
however, if told to pretend that he is blind, generally closes
his eyes, and when they are forced open, or he is told to
open them, he at once turns them upwards in order to keep
the pupils covered by the lids. Conversely, if he is for any
reason unable to open his eyes, he wiU very likely imagine
that he is blind. Hysterical ptosis and blepharospasm
are thus often accompanied by hysterical amblyopia, the
patient having so convinced himself that he cannot see
that he makes no attempt to look when his eyes are at
last opened. When the lids are forced apart, the eyes
generally turn involuntarily upwards to protect them from
the light. The pupils are consequently stiU hidden, and
vision is impossible. Even when the lids are sufficiently
separated to expose the pupils, the patient can only see
indistinctly, and in rare cases he cannot see at aU. The
indistinct vision is due to a combination of hysterical
paresis and spasm of accommodation. A man with normal
vision relaxes his ciliary muscles to look at the distance,
and contracts them to look at a near object. A man who
is convinced that he cannot see, fails to regulate the activity
of his ciliary muscles correctly when he opens his eyes.
Instead of relaxing them when he wishes to look at a distant
object, he throws them into spasm, and he also fails to
see near objects clearly, as he does not contract them to
the correct extent. He has, in fact, lost control over ac-
commodation, and, believing himself blind, looks at nothing.

HYSTERICAL BLINDNESS 06

The external ocular muscles may remain inactive as
hysterical external ophthalmoplegia — a very rare condition,
which I have, however, seen occasionally — or, much more
frequently, certain muscles may be thrown into spasm in
the attempt to bring them into action after long disuse,
and hysterical strabismus results. Thus hysterical spasm
of convergence is often seen when the eyelids are forced
open, in addition to the contraction of the superior recti,
which tends to keep the pupils hidden under the upper lids.
In consequence of these abnormalities of accommodation
and convergence, the patient sees nothing clearly, but he
is not completely blind. Complete hysterical blindness,
which is rare in cases of this kind, is due to the patient
being so convinced that he cannot see that he does not use
his visual centres at all ; the psychology of this condition
has already been described.

The following cases of hysterical disorders of vision have
been selected from the large number I have seen as illustra-
ting what I have already said concerning their pathogenesis.
They also throw light on several questions connected with
the ocular movements and reflexes, which have been the
subject of controversy in the past. For the description
of the majority of cases I am indebted to the medical
ofl&cers who worked with me at the Scale Hayne Hospital,
especially Captain A. Wilson Gill, Captain C. H. Ripman,
and Captain R. G. Gordon. [']

In the first case the blindness was the most nearly
absolute I have seen result from hysteria. It is of excep-
tional interest, as it is also the only case in which the reflex
contraction of the pupils to light was abolished. So far
as I am aware no similar case has hitherto been described.

Casel. — Total blindness with loss of pupil reflexes following
shell-concussion : hysterical nature proved by rapid cure by
psychotherapy after persisting for four years. — Pioneer B.,
aged 41, went to France in September 1914. After six
weeks' fighting he was stunned as the result of the explosion
of a shell in his immediate vicinity. In the evening he
noticed he could not see clearly, and attributed this to the

96 PSYCHOLOGY OF THE SPECIAL SENSES

shock of the explosion. He at once feared he would lose
his sight : his eyelids began to droop, and he had difficulty
in focussing near objects. He was sent to England, where
the use of eye- drops and dark glasses confirmed his fears,
and in a short time he became totally blind. Early in 1915
he was discharged as permanently unfit, receiving a full
pension for total blindness. He was examined every six
months after this, but no treatment was given. In November
1918 he was seen by Mr. J. R. Rolston, of Plymouth, who
recognised the condition as hysterical, and advised his
transfer to Seale Hayne Hospital, where he was admitted
on November 13, 1918. He presented the picture of the
typical blind beggar of the street. Unshaven, unkempt,
and dirty, and wearing a pair of dark glasses, he came
supported by his wife, while in his hand he carried a thick
stick to help to guide himself. Whilst wearing the glasses
he kept his eyes open, but could see nothing ; when they
were removed he was unable to raise the lids owing to severe
blepharospasm, except in a darkened room.

Treatment was commenced the same evening, and in a
short time the blepharospasm was overcome, and the patient
opened his eyes, but he was still totally blind. The pupils
were then found to he widely dilated, with no trace of reaction
to light. The flinch reflex was completely absent in both
eyes. Ophthalmoscopic examination showed nothing ab-
normal, and a definite diagnosis of hysterical blindness was
made. Explanation as to the nature of his condition and
encouragement to use his eyes rapidly led to partial
restoration of vision, but at the end of two hours he still
stumbled over objects placed in his path. After a rest of
an hour, treatment was continued and further slight
improvement occurred. In attempting to focus his eyes
he made strong contractions of the muscles of the neck,
similar to those seen in the spastic variety of hysterical
aphonia when the patient attempts to speak.

The next morning he was taken out of doors, and distant
objects were soon recognised. An endeavour was then
made to teach him to focus his eyes on nearer objects, and
by the evening he could read 6/24 at 20 feet. The excessive

HYSTERICAL BLINDNESS 97

contractions of the neck muscles continued, however, but
by encouraging him to relax they gradually disappeared,
and vision steadily improved. He was still inclined to
stumble over objects placed in his path, but this was merely
due to inattention. On November 25 he could read with
each eye in turn 6/12 at 20 feet, and he could spell words
printed in small type, but as he was almost completely
illiterate he could not pronounce them. The flinch reflex
and the normal pupillary reactions to light had returned
the first evening.

The patient was also completely deaf in the left ear on
admission ; he was given instruction in listening, and at
the end of a week he could hear normally. When seen four
months later, in February 1919, he was at work as a watch-
maker and gramophone repairer.

Whilst a man is still dazed as a result of being blown up
by a high- explosive shell, he pays no attention to any
external stimuli, and may be regarded as psychically blind,
deaf, and anaesthetic. His sight, hearing, and cutaneous
sensibility generally return as he regains consciousness,
but if there is anything which draws his attention to his eyes,
the blindness may persist as a result of auto-suggestion.
The following is one of seven cases seen with Major A. W.
Ormond,[*] in which sand was blown into the men's eyes
from the sand-bags of the parapet on which the shell exploded.
The irritation it caused drew their attention to their eyes,
and resulted in blepharospasm and amblyopia, which per-
sisted long after every sign of conjunctivitis had disappeared.
These early cases were the only ones in which h3rpnotism
was used.

Case 2. — Hysterical blindness following exposure to a shell
explosion cured by hypnotism. — The patient, aged 22, was
looking over a parapet at Gallipoli on July 18, 1915, when
a shell struck the sand-bags in front of him. He remembers
the sand being thrown up into his eyes, after which he fell
back and knocked his head. He was unconscious for
twenty-four hours. His first impression on regaining
consciousness was extreme irritation in his eyes. He tried
7

98 PSYCHOLOGY OF THE SPECIAL SENSES

to open them, but found he could not do so. His mind
thus became concentrated on his eyes, and owing to the
confusion which is common among the uneducated between
inability to open the eyes and blindness, he became absorbed
with the idea that he was blind, and that he would never
be able to open his eyes or see again. The impairment of
other functions, which was doubtless present at first, re-
mained unnoticed in this greater trouble, except for some
loss of hearing, which quickly disappeared. The condition
of his eyes had not altered when I first saw him on September
17, 1915. He was quite blind, and there was a constant
flicker of his eyelids, which were kept almost closed. On
forcibly opening his eyes they were found to be turned
so far upwards that it was diJBficult to see even the iris.
A few fragments of sand were still embedded in the con-
junctiva, but not in the cornea ; there was no inflammation.
The inability to open the eyes and the idea of blindness
were thus perpetuated by auto-suggestion, and persisted long
after the inflammation caused by the dust had disappeared.
The patient was easily hypnotised, and whilst asleep he
was told that he would be able to see when he woke up.
The moment he awoke the suggestion was repeated very
forcibly, and his eyes were held open. He cried out that
he could see, tears ran down his cheeks, and he fell on his
knees in gratitude, as he had thought that he was perma-
nently blind, and believed that his sight had been restored
by a miracle. When seen again on September 20, the
external appearance of his eyes was normal, and he said
that he was able to see as well as he had ever done. There
was some opacity of the vitreous of the left eye, which was
doubtless a result of injury at the time of the explosion.
There had been no return of symptoms, and the patient
was well in every way when I last saw him on September 30.
His vision was 6/6 in the right eye and 6/36 in the left.

In the next case the blindness was so typical of what
would be expected to follow a wound in the occipital region
that no doubt was felt as to its organic nature. The
sequel, however, proved that it was due to the perpetuation

HYSTERICAL BLINDNESS 99

by auto-suggestion of the organic blindness, which had
been caused by concussion rather than destruction of the
visual centres in the occipital cortex. The patient, realising
that he was blind in certain directions, ceased to look in
these directions ; the dendrites were perhaps retracted
at the synapses in the affected tracts, and the flinch reflex
consequently disappeared. When at last the oedema and
other changes produced by the initial concussion of the
occipital cortex had disappeared and vision was again
possible, the patient had become so accustomed not to
look in the blind fields that no spontaneous improvement
occurred.

Case 3. — Hysterical blindness in three quadrants of the
visual field, following organic blindness caused by a wound in
the occipital region, and associated with hysterical deafness. —
Private W., aged 22, was wounded over the lower part of
the right occipital region near the middle line on June 7,
1917. He was unconscious for five days, and was then
trephined. On admission to Netley on July 6, 1917, he was
completely deaf in both ears, but as the vestibular reactions
on rotation were normal, the deafness was regarded as
hysterical. It was noticed that he had difficulty in seeing,
and that he held anjrthing he wished to read low down on
the right side, although he volunteered no complaint about
this, and only spoke about his deafness. On further
examination it was found that he was totally blind except
in the right lower quadrant of the field of vision of both
eyes, the blindness being what might be expected to result
from the wound, which had probably involved the whole
of the visual centre on the right side, but only the lower
part of the calcarine cortex on the left. An attempt was
made at the end of August to cure the hysterical deafness
by a pseudo- operation, the patient being told that a cut
behind his ear would certainly restore his hearing. Nothing
was said to him about his blindness, which was regarded
as organic. The " operation " resulted in immediate im-
provement in his hearing, as it at once became possible to
carry on a conversation with him by shouting. Quite
unexpectedly it was found that his vision was now absolutely

100 PSYCHOLOGY OF THE SPECIAL SENSES

normal, the blindness having been cured by the suggestive
effect of the " operation."

I shall now describe the different varieties of hysterical
visual disturbances, which were such a frequent result of
gassing. The first case is an example of the common form
in which both eyes were equally affected ; the patient was
unable to open his eyes owing to a combination of hysterical
ptosis and blepharospasm, and when the eyes were opened
he only saw very indistinctly.

Case 4. — Hysterical blepharospasm , ptosis, and amblyopia
of four months^ duration. — Gunner K., aged 33, had been
in France seven months, and for most of the time was on
duty behind the firing line, because his nerves were not
equal to life at the front. In December 1917 he was
blown up, and was then very shaky and frightened. He
was gassed on April 9, 1918. Next morning he was unable
to open his eyes. When admitted to Scale Hayne Hospital,
under Captain C. H. Ripman, in August 1918, he could only
see indistinctly through the narrow slit which he could
produce by a great effort between his eyelids by strong
contraction of his frontalis muscles, and he used his hands
to steer himself. A thrill caused by contraction of the
orbicularis muscles was distinctly felt in the lids when an
attempt was made to force them open (fig. 20).

The orbicularis spasm relaxed, and he recovered the power
in his levator palpebrse muscles in five minutes as a result
of persuasion, and he was then quickly trained to see
perfectly well. For a time he was inclined to blink and to
let the upper eyelids droop a little ; this was due to per-
sistence of slight ptosis, caused by hysterical paresis of the
levator palpebrse muscles, and not to spasm of the orbicularis,
and in order to counteract the ptosis he continued to wrinkle
his forehead. He made a slow but steady recovery from
this habit, and was discharged from hospital completely
cured a few weeks later.

In cases 5 and 6 one eye was more severely affected than
the other. There must always be some explanation for

^

'••• . ! ••- • •

Fig. 20. — Hysterical blepharospasm and amblyopia of four
months' duration.

(a) Before treatment.

(6) After one hour's treatment.

Fig. 21. — Hysterical ptosis with unilateral blepharospasm and amblyopia
of four months' duration.

(a) Before treatment. (h) After half-an-hour's treatment.

Fig. 22. — Hysterical blepharospasm, ptosis, and amblyopia of five months'
duration.

100]

HYSTERICAL BLINDNESfe'-' ' '•' • lOV

an asymmetrical condition resulting from "a c^'dsh 'l^liibH
would be expected to act symmetrically. In hysteria
the explanation is always a psychical one. In the cases
in which visual symptoms were more marked in one eye
than the other after gassing it was found that the patient
had for some reason been anxious about the vision of the
former, which may, in fact, have been less acute than the
other on account of an error of refraction.

Case 6. — Hysterical ptosis with unilateral blepharospasm
and amblyopia cured in an hour. — Corporal B. was gassed
in France in Jime 1918. This resulted in severe conjuncti-
vitis. As he could not open his eyes, he was afraid he might
go blind. He was particularly anxious about his left eye,
as it had always been weak and subject to inflammation
and styes.

In order to protect the eyes from the pain caused by
exposure to light he had kept the lids closed, and when the
inflammation had subsided he found he was unable to open
them. If the left lid was raised, he experienced great dis-
comfort, and everj^hing seemed blurred. The right eye
was not painful, and he could see clearly with it; but in
order to do so he had to raise the lid by contracting the
frontalis muscle, as he could not use his levator palpebrse
(fig. 21 (a)).

He was admitted to Scale Hayne Hospital, under Captain
R. G. Gordon, on October 23, and an hour's persuasion was
sufficient to induce him to use the proper muscles and to
relax the spasm of the right frontalis (fig. 21 (6)), but the
spasm tended to relapse for a few days unless he paid
special attention to it. The vision of the left eye quickly
returned with re-education of accommodation.

The next case is of interest in connection with the part
taken by the frontalis muscle in ptosis. It is generally
taught that hysterical ptosis can be distinguished from
ptosis due to organic disease by the fact that the latter is
accompanied by compensatory over-action of the frontalis
muscle in the effort to keep the eye open, whereas this
never occurs in the former condition. Thus Purves

10!^ PSYCHOLOGY OF THE SPECIAL SENSES

'Stewart ['j and Oppenheim ["] make the distinction without
mentioning the possibility of exceptions. In the following
case, however, and also in cases 4, 5, and 7, there was as
marked compensatory over-action of the frontalis (figs. 20,
21 (a), 22 (a), and 23 (c)) as occm*s in any case of organic
paralysis. The complete recovery after a few minutes'
treatment by psychotherapy, although the ptosis had per-
sisted without alteration for a considerable time, confirmed
the diagnosis of hysteria. It is not surprising that the
belief that compensatory action of the frontalis only occurs
in organic ptosis should prove erroneous, as it would seem
very natural that a man, who was unable to open his eye
by contracting the levator palpebrae superioris, should
attempt to do so with his frontalis muscle, and it is obvious
that in organic ptosis the over-action of the frontalis is
purely voluntary. As the exact manner in which hysterical
ptosis manifests itself depends simply on the patient's own
conception of a drooping eyelid, it would be astonishing if
the frontalis did not always contract, and in all the cases of
pure hysterical ptosis which I have examined the frontalis
did in fact contract. It is clear, therefore, that the sup-
posed distinction between organic and hysterical ptosis,
which has been copied from one book to another, cannot be
regarded as of any value in diagnosis.

Case 6. — Hysterical blepharospasm, ptosis associated with
over-action of the frontalis, and amblyopia, following gassing
and cured by psychotherapy. — Corporal H., aged 22, was gassed
on May 20, 1918. He was admitted to hospital the same
day with conjunctivitis, his eyes being tightly closed.
Thirteen days later he was able to open his left eye, but the
right one still remained closed, and he thought he was
blind in that eye. Early in June he was transferred to a
military hospital in England, where he remained for a
fortnight. He was then sent to a V.A.D. hospital, and
treated with electricity and daily eye-baths with no
improvement. He was admitted to Scale Hayne Hospital
on October 22, under Captain S. H. Wilkinson, with the
right eye tightly closed owing to unopposed spasm of the
orbicularis, but the left eye was kept partially open as a

HYSTERICAL BLINDNESS 103

result of continuous contraction of the frontalis muscle
(fig. 22 (a)). Vision was so indistinct that he could only see
with difficulty, and he was quite unable to read. No
conjunctivitis was present, but at the corner of the right
eye there was a scar on the skin about the size of a two-
shilling piece. This was caused by a nsevus having been
burnt off when he was a child ; he had always believed
that this had impaired the sight of his right eye. After
being in France for a few months, he noticed that the sight
of the right eye was becoming more " blurred," and when
he was gassed he was at once terrified that he would be
completely blinded in this eye. He was treated by ex-
planation and persuasion, and in half an hour the orbi-
cularis spasm of the right side and the ptosis of the left
were overcome (fig. 22 (6)). He was then quickly trained to
focus his eyes, so that his vision became quite normal
except for some myopia of the right eye, which had always
been present, and was doubtless the real cause of this eye
being the weaker one.

In the following case the ptosis which was present on
one side spread so as to produce facial paralysis, which was
complete except for the frontalis, which attempted to
counteract the paralysis of the levator palpebrse superioris.
The platysma was also involved, contrary to what would
be expected from Babinski's teaching, as he regards
paralysis of this muscle in facial paralysis as a definite sign
that the condition is organic. This is not, however, the
only case I have seen in which Babinski's platysma sign
has proved to be misleading. Whilst the ptosis spread to
produce facial paralysis, the blepharospasm of the affected
side spread to produce facial spasm.

Case 7. — Hysterical left facial paralysis and ptosis^ right
facial spasm, paralysis of right arm and both legs, aphonia and
dysarthria, and amblyopia, following"* gassing. — Lieutenant B.,
aged 28, was gassed on April 24, 1918. He remained quite
blind and very hoarse for about six days. When sent to
England on May 3 he could see a little, and could talk
fairly weU. On reaching the hospital, however, he could

104 PSYCHOLOGY OF THE SPECIAL SENSES

hardly open his eyes, and he was very breathless. The base
of the right lung was dull, and crepitations were present ;
his sputum was bloodstained. He improved, but the
left side of his face and his right arm and leg became
paralysed during the next few days. He gradually lost
the power of speech ; he could not phonate at all, and could
only make unintelligible, whispering sounds. He was
unable to open his mouth, and could thus only take fluid
food. A few days later the left leg became swollen, and a
tender spot developed over the femoral vein, apparently
due to thrombosis. The other leg soon became affected
in the same way to a less extent, but rapid improvement
occurred, so that the last trace of swelling had disappeared
by June 10.

When I first saw him on June 16 his eyes were closed,
and there was a constant spasm of the whole of the right
side of the face, especially involving the orbicularis palpe-
brarum and levator anguli oris (fig. 23 (a)). The left side of
the face, including the platysma, was completely paralysed,
except for the frontalis, which contracted with excessive
vigour in the patient's efforts to overcome the ptosis
(fig. 23 (c)), which was present on both sides in addition
to the spasm on the right side, and prevented him from
seeing unless he held his left eye open with his fingers
(fig. 23 (6)). When the left upper lid was held open and
the right lids pulled apart, it was found that there was a
marked squint due to spasm of the internal recti. The
masseters were tightly contracted, so that he could not
open his mouth. Spasm was also present in the left side
of the tongue, so that when later he was able to open
his mouth and put out his tongue it went to the left.
The right arm and leg were completely paralysed, and he
was only able to move the left leg with difficulty. With
simple persuasion and re-education in breathing he quickly
learnt to phonate, and then gradually learnt to articulate
clearly. The ptosis of the left eye was overcome by per-
suasion without difficulty. The spasm of the muscles of
the right side of the face slowly improved with massage
and stretching the muscles by pulling the eyelids apart and

(a) Position at rest,
showing double ptosis,
right-sided facial spasm
and left-sided facial
paralysis.

(6) Same as (a) with left eye-
lid raised so as to see. This
could not be done with the right
eye owing to spasm.

(c) Voluntary effort to open eyes, resulting in over-action
of left frontalis although left side of face is paralysed, and
spasm of right side of face including platysma.

Fig. 23. — Hysterical ptosis of left eye and paralysis of left side of face
with hysterical spasna of right side of face.

1041

HYSTERICAL BLINDNESS 105

pulling down the upper lip, which was gripped with on©
finger inside the mouth and the other outside. When at
last he was able to open the right eye it was foiuid that he
could hardly see with it, but with simple explanation and
persuasion the amblyopia disappeared. The severe internal
strabismus, which was present when both eyes were open,
gradually disappeared as he became accustomed to using
his eyes. With some difficulty he was taught to balance
himself whilst standing, after which he quickly learnt to
walk. He was treated at intervals from 10 a.m. until
6.30 p.m., by which time he could walk normally. His
right arm had now recovered without special treatment,
and for the first time since the onset of symptoms he was
able to write. He could talk with a normal voice, but in a
somewhat laboured manner. The paralysis of the left side
of the face and the ptosis had completely disappeared,
but there was still some slight spasm of the right side,
although he could now open the eye and see quite clearly,
and there was no squint.

It is difficult to account for the extraordinary variety
of hysterical symptoms which developed in this officer;
but from his history it is apparent that whilst some were
produced by auto-suggestion, others probably developed
as a result of unconscious suggestion on the part of those
who examined him. He must have been constitutionally
suggestible, and the stress and strain of active service, and
particularly a heavy bombardment with gas shells every
night before he was finally gassed, must have rendered
him still more suggestible. As was so often the case in
the war, most of the hysterical symptoms developed gradu-
ally during the stages of his journey to the base and thence
to England, whilst some only appeared after his arrival at
an Enghsh hospital. The reflex protective aphonia, which
resulted from the irritating action of the gas on his throat,
was perpetuated by auto-suggestion. The pulmonary
thrombosis, which appears to have developed on his way
to England, led to further respiratory symptoms, which
were exaggerated and perpetuated by auto-suggestion,
so that to the original aphonia was added a severe dysarthria.

106 PSYCHOLOGY OF THE SPECIAL SENSES

Frequent examinations of his nervous system must have
unconsciously given rise to the idea in his mind of the
paralyses and spasms affecting various parts of his body,
and the original protective closure of his eyes was per-
petuated as blepharospasm on the right side and ptosis on
the left, the former spreading so as to involve the whole of
the side of the face and the latter becoming complicated
by left- sided facial paralysis. The closure of the eyes led
by auto-suggestion to the idea of blindness.

As his hospital was twenty miles away I had only one
other opportunity of treating him before his discharge, but
in spite of this he remained fit except for an attack of
phlebitis and a periodic left-sided headache, which made
him wonder whether he was not still suffering from organic
brain disease. In February 1920, however, he intervened
in a domestic dispute between his sister and her husband,
immediately after which several of his original symptoms
recurred. He was readmitted into hospital, under Dr. S. H.
Wilkinson, on April 21, 1920, with blepharospasm of the
right eye, flaccid paralysis of the right arm, spastic paralysis
of the right leg, and great difficulty in articulation. It was
explained to him that, owing to the doubt in his mind as to
the continued existence of brain disease because of the pain
in the left side of his head, and knowing, as he did, that the
left side controlled the right side of the body, his mind was
just waiting for an excuse to produce the old symptoms
again, and this excuse was afforded by the excitement of
his intervention in the family squabble. Explanation was
followed by persuasion and re-education, and in the course
of an hour all the symptoms had disappeared.

In the following case continuous blinking was associated
with deficient vision.

Case 8. — Hysterical amblyopia and blinking following irrita-
tion by a lachrymatory shell. — Private B., aged 44, was gassed
in May 1916 by a lachrymatory shell. Next day he was able
to carry on, but he constantly blinked and his vision became
somewhat defective. The blinking and defective vision
continued, but he did not go into hospital until April 1917.

HYSTERICAL BLINDNESS 107

The thorough examination of his eyes which was repeated
in three different hospitals appears to have made him fear
there was something serious the matter and to have led by
suggestion to severer blindness, as the amblyopia and
blepharospasm now became steadily worse. The case was
diagnosed as disseminated sclerosis and subsequently as
cerebellar tumour on account of the swaying gait, which
was, however, simply an exaggerated result of defective
vision. On admission to Netley in September 1917 his
vision was 3/60 in both eyes ; he was constantly blinking
and had a staggering gait. He was too stupid for treatment
by explanation to be effective, but suggestion with the aid
of faradism applied to his eyelids caused the blinking to
stop, and his vision and gait became normal for the first
time for sixteen months. The next day the blinking had
returned, but he again improved as a result of further
suggestion, and a week later he was discharged to duty.

In the following case hysterical blindness occurred in a
one-eyed man. The exciting cause would probably have
been insufficient to have affected him had he not been
living in perpetual fear that something might deprive him
of the sight of his remaining eye.

Case 9. — Partial hysterical blindness following shell-
concussion in a one-eyed man. — Sapper C, aged 28, lost his
left eye in 1914 as the result of a shot-gun accident. When
he enlisted in 1917 the vision of his right eye was 6/6. He
went to France in May 1918 to work on the railway. In
June 1918 an aeroplane dropped a bomb about twenty-five
yards away, but did not hit him. The force of the explosion,
however, was sufficient to dislodge his glass eye from its
socket, and simultaneously his right eye became completely
blind. The total blindness only lasted for a few days, but
very defective vision persisted. He also noticed that erect
objects, such as telegraph poles, appeared to be distorted.
He passed through several hospitals, where the hysterical
nature of the condition was recognised. He was still uncured
when he was admitted to Scale Hsbjne Hospital, under
Captain A. W. GiU, on October 26, 1918.

108 PSYCHOLOGY OF THE SPECIAL SENSES

On examination there were no signs of disease in the eye.
The pupil was of small size, and reacted briskly to light,
but on attempting to focus an object he contracted the
muscles of his neck, rotating his head to the right side, and
alternating slight variations in the size of the pupil were
evident. When he tried to read he held the book low
down, and either to the left or right side. At a distance
of two feet from the eye he could see objects distinctly,
but anything nearer or beyond this limit was blurred and
indefinite. The flinch reflex was completely absent. His
mental attitude was one of great anxiety, and he was con-
siderably depressed at the possibility of complete blindness.

He admitted that he went to France in considerable fear
lest anything should happen to cause the loss of his one eye.
The shock of the bomb explosion was sufficient to drive out
his artificial eye, and this immediately suggested to him
some damage to the other eye. Treatment directed towards
relieving the patient's fears and encouraging him to relax
his ciliary muscle was speedily followed by complete recovery,
with return of the flinch reflex. Inequality of the pull of
the ciliary muscle on the lens accounted for the distortion
of upright images. On discharge from the hospital some
weeks later his vision was 6/6.

In the next case the primary irritation of the eyes was
caused by a sand-storm. It is of interest as showing two
forms of hysterical blindness in one individual ; in the right
eye the motor element was alone affected, but in the left
eye, which was more severely damaged in the sandstorm,
so that the suggestion of blindness must have been stronger
in connection with this eye, severe psychical blindness was
present as well. The latter was almost as complete as the
blindness of both eyes in case 1, and corresponding with this
the pupil of the left eye was dilated compared with the
other, and only responded very sluggishly to light.

Case 10. — Hysterical blindness following sand-storm :
twenty-six months^ duration ; cured by psychotherapy. —
Private F., aged 62, was caught in a sand-storm in December
1916, without any protection for his eyes. He developed

HYSTERICAL BLINDNESS 109

intense conjunctivitis and keratitis, with severe pain and
photophobia, and was unable to open his eyes. Despite
the fact that the inflammation and pain gradually dis-
appeared, he was still unable to open his eyes when he was
sent home from Egypt. In March 1917, no improvement
having occurred, he was discharged from the Army as
permanently unfit, with a disability of 100 per cent.

On February 10, 1919, he was admitted to Scale Hayne
Hospital, under Captain A. W. Gill. He wore a pair of
dark glasses, on removal of which he was found to have
severe bilateral blepharospasm. With explanation and
persuasion the spasm of the orbicularis muscles and the
spasm of convergence, which was also present, were speedily
overcome. It was then found that the left eye was com-
pletely blind, so that the patient could not distinguish light
from darkness and could face the sun without blinking.
The vision of the right eye was very defective, but he could
pick out large objects and name some of them correctly.
The pupils were unequal in size, the left being slightly the
larger. Reaction to light was normal on the right side,
but very sluggish on the left. Reaction to accommodation
was irregular, but was sometimes brisk in both eyes. The
blink reflex was present on the right side, but was completely
absent on the left. Ophthalmoscopic examination showed
that the retinse were normal. There was no conjunctivitis,
but slight keratitis was present in both eyes, being most
marked in the left. Captain R. Jaques, who examined
him for us, reported : "I can find nothing to account for
the defect in vision. The corneal nebulae are not sufficient
for this."

Complete recovery followed psychotherapy : the pupils
became equal in size and reacted normally, and a brisk
flinch reflex was present on both sides. In the case of the
right eye aU that was required was to teach the patient to
regulate the action of the ciliary muscle, relaxing it for
distant objects and contracting it for near objects. In the
case of the left eye it was necessary first of all to convince
him that he would be cured, and then to encourage him
to look with it.

110 PSYCHOLOGY OP THE SPECIAL SENSES

There has been much discussion in the past as to whether
homonymous hemianopia can ever be hysterical. Several
cases, however, have been described. The following case
is of interest, as hemianopia of one eye was associated with
partial blindness of the whole field of the other eye.

Case 11. — Hysterical blindness of one eye and hemianopia
of the other cured by psychotherapy. — Bombardier U., aged 25,
developed severe conjunctivitis as the result of a bom-
bardment with mustard-gas shells on March 21, 1918.
After three weeks' treatment he was able to open his eyes,
but found that he was almost completely blind in the left
eye, being able to see only a white mist, while with the
right eye he could see imperfectly. He was admitted to
Scale Hayne Hospital, under Captain A. W. Gill, on November
5, 1918. The eye specialist's report accompanying him
stated " left eye completely blind, right eye 6/24."

On admission there was no conjunctivitis and no sign of
corneal scarring. The pupils were equal in size, and reacted
sluggishly to light and accommodation. The left eye was
completely blind, and the flinch reflex was absent. With
the right eye he could see distant objects clearly. On
attempting to read with the right eye he held the book
slightly to the right side so that the light from the book fell
on the nasal half of the right retina, the temporal half of
which appeared to be blind. The flinch reflex was abolished,
except when the direction of the blow was towards the
nasal half of the right retina. Peripheral vision as tested
with the moving finger was extremely defective in the right
eye. Ophthalmoscopic examination showed the presence
of a tiny foreign body embedded in the lens of the left eye,
but no other organic changes were apparent. As the
result of psychotherapy, complete recovery resulted in each
eye, both for near and distant objects, and the flinch reflex
was completely restored.

The presence of a small foreign body in the left lens,
which had apparently been driven in some time before,
had given rise to no visual trouble at the time, beyond
making the patient aware that the vision of the left eye
was less good than that of the right. This no doubt accounted

HYSTERICAL BLINDNESS 111

for the more complete hysterical loss of vision in this eye
after the gassing. Believing that he was completely blind
in the left eye, he appears to have subconsciously come to
the conclusion that he would necessarily be blind to every-
thing on his left side, and in this way the loss of the nasal
half of the field of vision of his right eye was suggested.

The next three cases have no connection with the war,
although two of them occurred in soldiers. For different
reasons in each case, the patient had unconsciously taught
himself to ignore the retinal impressions produced by one
eye to such an extent that it had become blind, the condition
being exactly analogous to the hysterical blindness already
described. In the first case the patient taught himself
to see once more with the blind eye when he began to lose
the sight of the other as a result of optic atrophy. In the
other two cases vision was restored by psychotherapy.

Case 12. — Hysterical blindness of left eye ; recovery of left
eye following loss of sight of right eye caused by syphilitic
optic atrophy. — John P., aged 40, received a blow over the
left eye in 1915 ; he could not open it, but on raising the
lid he found he was blind. During the next eight months
he regained the power of the levator palpebrse superioris,
but he could still only see with his right eye. He was able
to carry on with his occupation as a brass-worker until
August 1919, when he found that vision with his right eye
was becoming blurred by an orange- coloured mist. He
now covered his right eye with a shade, and quickly taught
himself to see almost perfectly with his left eye, which he
had thought was blind. When he came under observation
in October 1919 it was found that the recent loss of vision
in his right eye was due to advanced optic atrophy, and the
slight deficiency in the left eye was due to slight changes
of the same nature. The right pupil reacted to accommo-
dation but not to light ; the left pupil responded to both.
There were no other physical signs of disease. The Wasser-
mann reaction of both blood and cerebro-spinal fluid was
positive, and 54 lymphocytes per c.mm. were found in the
latter, together with slight excess of globulin. The optio

112 PSYCHOLOGY OF THE SPECIAL SENSES

atrophy was obviously of syphilitic origin, but there were
no signs either of general paralysis or tabes. Anti- syphilitic
treatment was given, but no change in vision resulted.

The blindness of the left eye following the blow was
suggested by the pain and bruising, which prevented the
patient from raising the lid. Four years later loss of sight
in his other eye prompted him to try to see with his left
eye, and to his surprise he found he could soon see fairly
well. In order to abolish the blurred image produced by
the right eye he covered this up. The slight deficiency in
vision which persisted in the previously blind eye was not
hysterical like the original total blindness, but was caused
by a slight degree of optic atrophy.

In the next case the patient had a congenital defect of
one eye, which led to deficient vision. He had learnt to
neglect what he saw with this eye, but still retained some
vision in it, when at the age of fifteen, for no obvious reason,
he became almost totally blind in it. The blindness was
suggested by the defective vision caused by the congenital
abnormality, and was cured by psychotherapy. It could
thus be correctly regarded as hysterical.

Case 13. — Combined hysterical and organic blindness in the
right eye ; hysterical element cured by psychotherapy after four
years. — Private M., aged 19, had never seen as clearly with
his right eye as with the left. In 1914, while working as a
clerk, he noticed that the right eye was becoming blind,
and in February 1918, when he enlisted, he could only
just distinguish light from dark with it. Captain R. Jaques
found a persistent hyaloid artery passing from a posterior
polar cataract to the optic disc. With very little persuasion
he was taught to use the right eye again so well that he
could read with it when the other was covered without
difficulty. The pupil reactions were present in each eye,
but the flinch reflex was totally abolished until vision was
restored, when it became quite normal.

A severe squint dating from childhood in a man of 25
would not at first be regarded as likely to be hysterical.

HYSTERICAL BLINDNESS 113

But in the following case, not only the squint, but also the
associated loss of vision in the affected eye, appear to have
been of this nature. It is well known that when diplopia
develops in adults they unconsciously train themselves to
ignore one image ; the same thing occurs in children who
develop a permanent squint. The eye which ceases to be
used in this way becomes more or less completely blind.
After it has persisted for several years it is generally held
that the blindness is permanent, and that even if an
operation is performed to bring the eyeball into a central
position, no improvement in vision is likely to occur.
Moreover, in the event of an injury occurring to the sound
eye sufficient to cause blindness, the previously squinting
eye is generally said to be only capable of recovery if the
squint has not been in existence for more than six or seven
years.

Case 14. — Hysterical blindness in a squinting eye ; improved
by psychotherapy after persisting for twenty years. — Rifleman
B., aged 25, at the age of six was frightened by a performing
bear, and his mother states that he has squinted inwards
with the left eye ever since, although she is confident that
there was no squint prior to this event. On admission to
Scale Hayne Hospital, under Captain A. W. Gill, on July 19,
1918, with hysterical paralysis of the right hand, which was
cured the following day, the left squinting eye was found
to be almost completely blind (fig. 24 (a)). There was no
paralysis of any of the ocular muscles. Captain Jaques
found + 3 diopters of hypermetropia in each eye.

There is no adequate explanation why squinting should
result from an error of refraction which is equal in the two
eyes. It seemed probable, therefore, that the squint was
really a result of the fright caused by the bear. This might
have caused an hysterical convulsive seizure, associated
with squinting, as is so often the case in the convulsions
of children. It was assumed that the squint had become
perpetuated as an hysterical symptom, and an attempt was
therefore made to treat both the squint and the blindness
by psychotherapy. The patient was quicldy taught to
keep the two eyes nearly parallel (fig. 24 (6)). He was then
8

114 PSYCHOLOGY OF THE SPECIAL SENSES

shown how to use his left eye, and at intervals the right
eye was kept covered in order that the other should be in
constant activity. We did not, however, succeed in curing
the squint completely, although the patient could overcome
it whenever he tried, and vision had so far recovered in the
formerly blind eye that the patient could read large type
when the other was covered.

The disturbances in vision so far described were in-
dependent svmptoms, and filled the whole clinical picture.
Hysterical blindness may also occur in one eye associated
with paralysis of the same side, as in the following case,
the graphic description of which we owe to Carre de Mont-
geron (vide frontispiece). ^

Hysterical hemiplegia and hemiancesthesia with total blind-
nesSy immobility y ancesthesiay and loss of conjunctival and
corneal reflexes of the corresponding eye. — On December 24,
1717, Marie-Jeanne, the 27-year-old wife of Fran9ois Stapart,
of Epernai, was seized with " apoplexy." After three days
of fighting between life and death, the attack left her with
paralysis and loss of sensation affecting the whole of the
left side. " Of all the parts involved in this sad malady,'*
wrote Montgeron, " the eye was the most seriously affected ;
the roots of the optic nerve of the left side were entirely
enveloped in the obstruction of the brain ; and as this
nerve is the immediate organ of vision, the obstruction
which deprived it of all action rendered it absolutely incapable
of perceiving light. At the same time, the other nerves
which serve for the movements and procure the sensibility
both of the globe and the eyelids were equally completely
obstructed ; thus the eye and the lids lost all sensation
and remained immobile. . . . The insensibility was so
great that one could easily put one's finger between the
lids and touch the eyeball without causing any movement
or pain." That is to say, she was not only completely
blind in the left eye, but the orbicularis was paralysed,
the lids, conjunctiva, and cornea were anaesthetic, and the
conjunctival and corneal reflexes were abolished. In the
next six months the patient gradually regained the use of

HYSTERICAL BLINDNESS 115

her arm and leg, but the condition of the eye had remained
unaltered, when nearly ten years later she had a second
attack, which again affected her left side, and from which
she again recovered. She was scarcely convalescent when
she was struck down a third time, but on this occasion the
paralysis of the left side was complete. The arm hung
useless by her side, and she could only move with difficulty,
dragging her useless left leg behind her. The muscles of
the arm and leg became atrophied, and the skin cedematous.
Being convinced that no human resources could help her,
and recalling how she had heard that one Anne Angier
had been cured of paralysis, which had affected her for
twenty-one years, as a result of the intercession of M. Rousse,
she determined to visit his tomb in the Chapelle de Ste.
Anne at Avernai. " She was fortified in this resolution
by a dream, which she took for a message from heaven.
It seemed to her that she had been transported in the
night to the tomb of M. Rousse, and that there the
most perfect recovery had suddenly been vouchsafed to
her."

On May 16, 1728, in spite of the opposition of the church
authorities, because Rousse had not been canonised, she
visited his tomb. Here she was suddenly seized with
violent pain in her hand and eye ; strength returned to her
left hand so that she could join it with the right in prayer,
and to her leg so that she could kneel. The eye which
had been blind for ten and a half years, recovered its sight,
its power of movement, and its sensibility. The recovery
from the hemiplegia, hemianaesthesia, and blindness was
complete, and there had been no relapse when Carr6 de
Montgeron wrote his Verite des Miracles nineteen years later.

In the following case it was easy to recognise that the
blindness in one eye was the direct result of unconscious
medical suggestion, whilst the patient was being examined
on account of the hysterical hemiplegia for which he had
been admitted into hospital. Being paralysed on his
left side, he at once came to the conclusion that his vision
was investigated because it was expected that the left eye

116 PSYCHOLOGY OF THE SPECIAL SENSES

would be affected, and this was sufficient to suggest impaired
vision.

Case 16. — Hysterical blindness of left eye associated with
hysterical hemiplegia cured by counter-suggestion. — In
October 1917, following a blow on the right side of the head,
Pensioner S. developed left-sided facial paralysis and weak-
ness of the left arm and leg. He was unconscious at first,
and remained in bed until May 1918. He was discharged
from the army with 100 per cent, disability in June 1918,
and was admitted to Scale Hayne Hospital on March 4, 1919.

Complete left hemiplegia of the flaccid variety was
present. All reflexes were normal, and the paralysis was
typically hysterical in character. When the fields of vision
were examined, it was found that the left eye was partially
blind. The patient expressed great anxiety on this score,
as he had not noticed it before. It was at once recognised
that the loss of vision was caused by the suggestion of the
examination, and by counter-suggestion the blindness was
just as quickly removed. The hemiplegia was subsequently
cured by psychotherapy.

Narrow and Spiral Fields of Vision in Hysteria, Malingfer-
ing, and BTenrasthenia. — Retraction of the field of vision has
been regarded as the most characteristic " stigma " of
hysteria since Charcot first drew attention to it in 1872.
Janet [^] considered it to be " the emblem of hysterical sensi-
bility in general," and it led him to describe hysteria as a
condition due to " retraction of the field of consciousness."
Among ophthalmologists de Schweinitz [•] regards this sign
as "a permanent stigma " of hysteria, and believes its
value as an aid to diagnosis to be " exceedingly great."
But Babinski [^"] found no change in the field of vision in
any of a series of a hundred consecutive cases of hysteria,
examined in great detail by methods which excluded the
possibility of suggestion. Morax, ["] a former assistant of
Charcot, from whom he learnt the supposed significance
of the retracted field of vision, at first continued to find
it in almost every patient suffering from hysterical symptoms.
But over twenty years ago he became a convert to Babinski' s

HYSTERICAL BLINDNESS

117

views, and since then he has not seen a single case of
hysterical retraction of the field of vision. As it is almost
impossible to avoid suggesting a narrow field of vision
with the perimeter in highly suggestible individuals, he
estimates the fields with the finger or other familiar object
in hysterical patients, and although this may appear at
first to be less accurate, it has the great advantage of making
it easy to avoid suggesting abnormalities in the course of
the examination.
In spite of the comparatively frequent occurrence of the

Fio. 26. — Without-inward spiral field of vision FiG. 26. — Spiral field of vison in hysteria,
in right eye inicase of hysterical paraplegia. (After Purves Stewart.)

various hysterical disturbances of vision I have already
described, I have never seen patients with hysterical
symptoms affecting other parts of the body who sponta-
neously complained of disabilities resulting from a narrow
field of vision, however closely they were cross-examined
on the subject. But if a narrow field of vision is produced
by testing with the perimeter, the patient may subsequently
complain of considerable inconvenience as a result of the
cutting off of his peripheral vision.

In association with Major J. L. M. Symns [^*] I examined
numerous soldiers suffering from various war neuroses,
who were abnormally suggestible as a result of the stress

118 PSYCHOLOGY OF THE SPECIAL SENSES

and strain of active service, some, but not all, of whom were
suffering from gross hysterical symptoms. We never
found any retraction of their field of vision until the perimeter
was used. But the perimeter invariably resulted in the
suggestion of a narrowed field, however carefully it was
used. Moreover, if the examination was continued after
the first field was marked out, a spiral field was always
obtained (fig. 25) identical with that which has hitherto been
regarded as a stigma of hysteria (cf. fig. 26). We believe
that the reason why a spiral field of vision, which is the

Fia. 27. — Spiral fields of vision in case of hysterical tremor,
(o) Left eye : within-outward spiral field.
(6) Right eye : within-outward spiral field.

natural result of continued suggestion, has not been found
in a larger proportion of hysterical cases showing a narrow
field of vision is simply because it has not been looked for,
the examiner being content when he has marked the limit
of vision a single time in each direction.

It has generally been taught that a spiral field of vision
is a result of fatigue, and it has even been stated that it is
more frequently a symptom of neurasthenia than of hysteria.
We have found that this is not the case, the inward spiral,
which has hitherto alone been described, being a result of
the method employed in using the perimeter. An outward
spiral is always obtained, instead of an inward one, if the

HYSTERICAL BLINDNESS

119

white disc of the perimeter is moved outwards instead of
inwards, as is commonly done (fig. 27). In the description
of the perimeter given in fom* books on ophthalmology,
two on nem-ology, and one on clinical methods, which we
consulted, instructions are given to move the disc from
without inwards. By varying the direction in which the
disc was moved we could produce an inward spiral one day
and an outward spiral another day with the same eye, or an
inward spiral with one eye and an outward spiral with the
other at the same time (fig. 28). There is no question of

Fig. 28. — Spiral fields of vision in case of hysterical mutism and tremor,
(a) Left eye : without-inward spiral field.
(6) Right eye : within- outward spiral field.

any special suggestions made by us in our method of using
the perimeter, as identical results were obtained by other
observers, who marked out the fields of vision for us without
knowing the nature of the cases or the object we had in
view in obtaining the tracings.

In the observations on " experimental maHngering,"
which I described in chapter I, we asked twenty- seven
individuals, who were pretending to be paralysed on the
right side, and none of whom had mentioned any disturbance
in vision when detailing their symptoms, whether they
could see as well with the right eye as the left : seven replied
that they had noticed some impairment of vision in the

120 PSYCHOLOGY OF THE SPECIAL SENSES

right eye. On testing the field of vision with a finger
no narrowing was observed, and they explained that the
deficiency they had spoken about was a blurring or general
loss of clearness of vision. But when tested with a perimeter
all of the seven showed a narrow field on the right side, and
one had a slighter narrowing on the left side. In the only
two cases in which it occurred to us to continue the investi-
gation after the first field had been marked out a spiral was
obtained (fig. 29), which was identical in character with

that supposed to be
characteristic of hys-
teria.

Ocular Anra in
Hysterical Pits. — I
believe that hysteri-
cal fits are much
more common than
is generally supposed,
and that many such
cases are diagnosed
as epilepsy and
treated for years
with bromides. It
has been said that
a definite aura is
uncommon in hys-
teria but common before true epileptic fits. I am con-
vinced that this is incorrect, and that some kind of
warning invariably precedes an hysterical attack. It is,
indeed, this " warning," which acts as the suggestion,
which is the exciting cause of each fit. A symptom which
has once produced an attack wUl be likely to produce
another whenever it recurs, because it subconsciously re-
minds the patient of his earlier attack, and thus suggests
that another will occur.

I have seen several cases of hysterical attacks which were
preceded by a visual aura. Most of the cases in soldiers
dated from a period of strenuous activity in the glare of
Mesopotamia. In the following case, in which the attacks

Fig. 29. — Spiral field of vision in case
of " experimental malingering."

HYSTERICAL BLINDNESS 121

consisted of headache and loss of consciousness, and not of
epileptiform convulsions, an understanding of the psycho-
logical processes involved resulted in immediate recovery
from a very incapacitating condition which had persisted
for two years.

Hysterical photophobia with attacks of headaches and loss of
consciousness. — Captain S. was wounded in the head in
1915. He was temporarily paralysed on the right side, and
suffered from violent headaches, which culminated in loss
of consciousness. He gradually improved, and no more
attacks occurred after the end of 1916. He went back to
France in 1917. Soon afterwards he had some acute
mental disorder, for which he was in hospital for five months ;
after this he was invalided out of the service, but was fit
enough to be sent to Greece on diplomatic duty. In 1918
he went to Salonica for an operation to be performed on
his heel. Some ether appears to have been accidentally
dropped into his eyes during the operation, as when he came
round from the anaesthetic he found his eyes were so painful
that he could not open them, and he thought he had lost
his sight. At the end of a month he could see a little, but
he could not read, and had always to wear the darkest
glasses he could get, as directly his eyes were exposed to
the daylight he had a violent headache, which was followed
in a few minutes by complete loss of consciousness.

I first saw him in February 1920. It was very difficult
to examine his eyes, as he kept them tightly closed when the
dark glasses were removed. Even when he was wearing
them he never opened his eyes widely, but he could see
enough to get about without assistance. He was very
depressed about his condition. His arm and leg were
quite well, and there were no physical signs of organic
disease. There was a slight depression of the skuU in the
region of his wound, but it was not tender, and there was
no bony deficiency.

I explained to the patient that when the removal of the
bandages from his eyes for the first time after they had
been injured was followed by a headache, he subconsciously
associated this with the headaches which had followed the

122 PSYCHOLOGY OF THE SPECIAL SENSES

wound to his head, and that he had consequently suggested
to himself the same sequel — loss of consciousness. The
attacks of headache followed by unconsciousness now
became associated in his mind with his eyes instead of with
the original injury to his head. Consequently an attack
occurred every time he removed his dark glasses, and for
this reason he feared to face the light. The blepharospasm
and deficient sight were produced in the way I have already
described in connection with the hysterical disorders of
vision caused by gassing. Having discussed this explanation
with him in great detail, I promised him he would recover
completely when he came to me for treatment the next
day. He arrived fully convinced he would be cured, having
thoroughly grasped the explanation I had given him of the
origin of his symptoms. Without difficulty I persuaded
him to remove his dark glasses, keep his eyes widely open,
and accommodate his vision for near and distant objects.
For the first time for two years he was able to keep his eyes
open without getting a headache, and an hour later he
went for a walk in the sun without glasses. In the five
months which have since elapsed he has had no further
attacks of headache and loss of consciousness, and he is
shortly returning to his diplomatic duties.

REFERENCES

P] Gordon Holmes, Brit. Journ, of Ophthalmology, ii. 363, 449, and 606,
1918.

P] 0. von Monakow, Die Lokalisation im Oroaahimy p. 319, Wiesbaden,
1914.

P] A. F. Hurst and C. H. Ripman, Seale Hayne Neurological Studies,
i. 146, 1918 ; and A. F. Hurst and A. W. Gill, Seale Hayne Neurological
Studies, i. 297, 1918.

[*] A. F. Hurst and A. W. Ormond, Brit. Med. Journ., January 1, 1916.

P] Purves Stewart, Diagnosis of Nervous Diseases, 4th ed., p. 467, 1916.

[•] H. Oppenheim, Lehrbu^h der Nervenkrankheiten, ii. 1237, 1908.

P] Carr6 de Montgeron, La Verite des Miracles, vol. ii., Cologne, 1747.

P] P. Janet, Etat mental des hysteriques, 1911.

P] De Schweinitz in Posey and Spiller's The Eye and Nervous System,
p. 625, 1906.

P®] J. Babinski, Semairte medicale, xxix. 3, 1909.

P^i Quoted by Babinski and Froment, Hystirie, Pithiatisme, p. 66, Paris,
1917.

P*] A. F. Hurst and J. L. M. Symns, Seale Hayrw Neurological Studies,
i. 1, 1918.

INDEX

Abdominal reflex, in disseminated
sclerosis, 37

in hysteria, 36

influence of fatigue on, 36

influence of temperature on, 36
Anaesthesia, conjunctival, 42

corneal, 42

cutaneous, 6

pharyngeal, 43

rectal, 48
Auditory motor reflex, 64
Aura, visual, in hysterical fits, 120

Blepharospasm, hysterical, 93
Blindness, hysterical, 89

Corneal anaesthesia and reflexes, 42
Cutaneous anaesthesia, 6
Cutaneous hyperaesthesia, 60

Deaf mutism, 74
Deafness, hysterical, 60
Disseminated sclerosis, abdominal
reflex in, 37

Fields of vision in hysteria, 116
Fits, hysterical, 120

Headache, hysterical, 65

Head's areas, 51

Hearing, 60

Hyperaceusis, hysterical, 87

Hyperaesthesia, cutaneous, 50

Hysteria, abdominal reflex in, 35

anaesthesia, 6

blepharospasm, 93

blindness, 89

conjunctival reflex in, 42

corneal reflex in, 42

deafness, 60

definition of, 1

fields of vision, 116

fits, 120

headache, 55

hyperaceusis, 87

hyperaesthesia, 60

pain, 58

pharyngeal anaesthesia in, 43

plantar reflex in, 39

ptosis, 93, 102

pupil reflex in, 91, 96

stigmata, mental, 3

stigmata, physical, 2

superficial reflexes in, 3d

Listening, 60

Mucous membranes, reflexes of, 42
sensibility of, 42

Pain, hysterical, 53
Pharyngeal anaesthesia, 43
Plantar reflex, 39
Ptosis, hysterical, 93, 102
Pupil reflex in hysteria, 91, 96

Rectal anaesthesia, 48
Reflex, abdominal, 35

auditory-motor, 64

flinch, 91

plantar, 39

pupil, 91, 96

superficial, 35

Spiral fields of vision, 116
Stigmata, hysterical, 2
Stupor, 11

Vision, fields^of, 116
psychology of,^89

123

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