Reprinted from the Journal of Nervous and Mental Disease, January, 1894. 
A Further Study of Hysterical Cases 
and their Fields of Vision. 
BY 
JOHN K. MITCHELL, M.D, 
Assistant Physician to the Infirmary for Nervous Diseases, Philadelphia, 
AND 
G. E. DE SCHWEINITZ, M.D., 
Opthalmologist to the Infirmary for Nervous Diseases, Philadelphia. Reprinted from the Journal of Nervous and Mental Disease, January, 1894. 
A Further Study of Hysterical Cases 
and their Fields of Vision. 
BY 
JOHN K. MITCHELL, M.D., 
Assistant Physician to the Infirmary for Nervous Diseases, Philadelphia, 
AND 
G. E. DE SCHWEINITZ, M.D., 
Opthalmologist to the Infirmary for Nervous Diseases, Philadelphia. A FURTHER STUDY OF HYSTERICAL CASES 
AND THEIR FIELDS OF VISION. 
JOHN K. MITCHELL, M.D., 
Assistant Physician to the Infirmary for Nervous Diseases, Philadelphia, 
AND 
G. E. DE SCHWEINITZ, M.D. 
Ophthalmologist to the Infirmary for Nervous Diseases, Philadelphia. 
IN The American Journal of the Medical Sciences, Novem- 
ber, 1889, we described eight cases of hysterical anaes- 
thesia, together with an examination of their fields of 
vision. The present communication comprises a much 
more extensive study of hysterical patients, with special 
reference to disturbances of the general and special 
senses, and includes the records, by way of contrast, of 
other cases in which the neurasthenic element predom- 
inated over pure hysteric manifestations, of two cases of 
spinal injury, with remarkable changes in the visual 
fields, and of one example of pure malingering. 
The literature of the ocular manifestations of hysteria 
is an extensive one, the observation of alterations of the 
color-sense in this affection dating back to Galezowski’s: 
publication in 1865. An analysis of this literature in a, 
purely clinical communication, such as the present is 
intended to be, would be out of place. Those interested 2 
MITCHELL AND DE SCHWEINITZ. 
will find references to the more important papers in our 
previous communication ;x in the thesis of Dr. Pansier,’ 
which contains a complete bibliography up to the spring 
of 1892; in the monograph of Drs. Hermann Wilbrand 
and Alfred Saenger ;3 in a recent paper based upon 
studies in Nothnagel’s clinic in Vienna, by Drs. L. 
V. Frankl-Hochwart and Alfred Topolanski,4 and in the 
brochure of Dr. Wilhelm Koenig.5 
The visual field in each instance was measured with 
the aid of a perimeter; either one modelled after Lan- 
dolt’s plan, or, where the patients were bed-ridden, with 
Schweigger’s hand perimeter. The test objects (white 
and colored) were circular, one and one-half centimetres 
in diameter, set upon a dead black background, and 
fastened to long black handles. Usually, three methods 
were employed, namely: 
(1) The test object was moved from without inward, 
and the point noted where it was recognized in each 
meridian. 
(2) The test object was moved from within outward, 
and the point noted in each meridian where it disap- 
peared. 
(3) The test object was moved from without inward 
along each meridian until it was recognized ; then it was 
moved from this spot outward until it disappeared, and 
the point noted in each meridian midway between the 
point at which it was originally recognized and the point 
at which it disappeared. Thus, it may have been recog- 
nized at 30 degrees and disappeared at 40 degrees; 35 
degrees would be the point marked. 
In some cases all three examinations yielded practi- 
cally the same result; in others the results varied con- 
1 Loc. cit. 
2 Les Manifestations Oculaires de I’hysterie, Paris, 1892. 
3 Ueber Sehstdrungen bei Functionellen Nervenleiden, Leipzig, 
1892. 
6 Über Gesichtsfeld-Hrmiidung und deren Beziehung zur concen- 
triscben Gesichtsfeldeinschrankung bei Brkrankungen des Central- 
nervensystems, Leipzig, 1893. 
4Beitrage zur Augenheilkunde, XI. Heft., 1893, p. 49. HYSTERICAL CASES AND THEIR VISION. 
3 
siderably. The diagrams which accompany this paper 
are all drawn according to the hrst method, many of 
them, however, being the results of numerous examina- 
tions, and, as has just been stated, some of them 
the result of a nearly uniform map with all three meth- 
ods of testing. In recording the field of white, the pa- 
tient was always told that the test object was white, and 
was asked to indicate the moment its movement, when 
entering into the periphery of the visual field, was per- 
ceived ; thus, the field for white becomes equivalent to 
the field for form. It is important, as Frankl-Hochwart 
and Topolanski insist, in examinations of this character 
that the exact method which has been pursued should 
be stated; otherwise there can be no true comparison of 
diagrams from different observers. Even and perfect 
illumination of the perimeter, steady observation of the 
fixation point by the observed eye, and, as far as possi- 
ble, removal of all objects from the immediate vicinity 
which could distract attention, were secured in each in- 
stance. In short, the rules laid down by Wilbrand re- 
ceived consideration. 
A large element of uncertainty enters into the taking 
of a field of vision, especially when the subject is a hys- 
teric patient, and we are keenly alive to the readiness 
with which such patients accept suggestion, to the influ- 
ences of refractive error, of accommodative tire and 
fatigue of the retina, but think, none the less, that with 
the precautions that were taken, and with due allowance 
for factors that cannot be set aside, these diagrams are 
reasonably correct and represent the actual limits of the 
fields for white and colors as they existed at the time of 
examination.1 
Except incidentally, we have not included in these 
examinations special attention to the displacement type 
1 It may be stated that in some of the cases independent fields of 
vision were mapped by Dr. de Schweinitz’s assistant, Dr. Bruner, and 
compared with the original fields. While in no instance was the map 
exactly similar, the main effect was always the same, and where previ- 
ously reversal in the sequence of the colors had been found, it was again 
found on the second examination. 4 
MITCHELL AND DE SCHWEINITZ. 
of the visual field, or that type which was originally de- 
scribed with anaesthesia of the retina. Those interested 
may consult Transactions of the Heidelberg Congress 
for 1887; Archives of Ophthalmology, Vol. XII, 0,428; 
and Vol. XXII, Nr. 2, p. 231. 
As a type of normal visual field, to be compared 
with the maps illustrating the cases, we have assumed 
that Figure 1 fairly represents the physiological limits 
of the field for form and colors. The characterization 
of the form field by a continuous line and of the color 
fields by broken lines, as here represented, has been fol- 
lowed in the other diagrams. 
The following seven cases are classified together, 
chiefly because they are examples of one or other of the 
varieties of anaesthesia which commonly occur in hys- 
terical states. 
Fig. I. 
Diagram of the normal field of vision of the right eye for blue, red 
and green. The outer continuous line indicates the limit of the form 
field ; the broken lines the limits of the color fields. 
Case I.—Hysterical unilateral anaesthesia; binasal 
hemianopsia ; reversal of the color fields. 
L. C.; servant; age eighteen ; single; slight, intelligent 
girl; has at various times in the last year consulted Dr. J. K. 
Mitchell fortriflingnervous symptoms andarathertrouble- 
some dyspepsia. She had frequent vomiting for a time, 
and at one period was thought to have a gastric ulcer, 
but she rapidly improved on milk diet and had for some HYSTERICAL CASES AND THEIR VISION. 
5 
months been in fair health, when in May, 1892, she re- 
turned to complain that her eyes gave her trouble ; she 
stated that she had been operated upon for strabismus 
as a child. Her eyes smarted whenever she was in a 
strong light, and as the glasses she was using were evi- 
dently of little service, she was referred to the service of 
the Polyclinic Hospital for an examination. 
Dr. cle Schweinitz observed that the conjunctiva was 
insensitive on the left side, and Dr. Mitchell found, on 
studying the general sensibility, that there was complete 
left-sided dyssesthesia, including the ocular conjunctiva, 
the leg, arm, chest and face. She could not distinguish 
the head from the point of a pin beyond recognizing it 
as a touch, and even could not perceive a light touch. A 
deep prick was felt as slight pain, but presented the 
characteristic hysterical symptom of not bleeding. If 
not deep it was only recognized as a touch. Two points 
were readily separated at normal distances on the hand 
and face, if somewhat firmly applied to the skin. On 
the right side, though sensation was imperfect, there 
was no marked loss of pain sense. Heat and cold were 
tolerably well perceived on both sides, if the difference 
between them was considerable. 
Examination of the Eyes.—The central vision was nor- 
mal after the correction of a slight astigmatism, and 
there was no abnormality in the fundus oculi on either 
side. Pupillary reflexes normal. 
The field of vision of the right eye consists of a small 
patch of preserved vision upon the temporal side twenty 
degrees in width. Practically, there is absence of the 
nasal half of the field, although the fixing' point is not 
cut exactly by the dividing line, which passes five degrees 
in advance of it on the horizontal meridian. There is no 
field for colors, and there is normal color sense only at 
the fixing point. 
In the left eye the field of vision for form is a small 
patch twenty-five degrees in width upon the temporal 
side. There is entire absence of the nasal half of the 
field, except on the horizontal meridian, where the divid- 
ing line passes five degrees in advance of the fixing 
point. The-fields for colors have the general appear- 
ance of that for form, except the red field, which, on the 
horizontal meridian at the temporal side, is fifteen de- 
grees larger than the form field. The field for green is 
the same size as the blue and form fields, except on the 
horizontal meridian, where it is eight degrees smaller. 6 
MITCHELL AND DE SCHWEINITZ. 
The fields in this case have the general characters of bi- 
nasal hemianopsia, with some irregularity of the divid- 
ing line. 
Diagrams of the fields of vision of Case I. Irregular binasal hemian- 
opsia ; partial reversal in the color fields of the left eye ; color perception 
only at the fixing point in the right eye. 
Fig. ii 
It is certainly very remarkable that this case should 
present such decided hysterical symptoms in the fields 
of vision and yet have so few general hysterical char- 
acters. But for the accident, indeed, of examining the 
eyes for correction, the difficulties of sensation would 
never have been noted. 
Case II.—Hysterical disseminated hyperassthesia and 
anaesthesia; normal form fields; partial reversal of the 
color fields, that for red being greatest in extent. 
C.; female ; native of America; age seventeen; sin- 
gle ; private patient of Dr. S. W. Mitchell. The patient, 
together with some physical failure, probably due partly 
to perverted sexual emotions and to (doubtful) mastur- 
bation, presented an extraordinary picture of moral 
degeneration. Her school life was necessarily closed 
abruptly by the theft of money from a companion’s 
trunk, for the purpose, she said, of procuring a cause 
for worry. Her parents are wealthy, and the money 
was of no moment to her. She did, in fact, burn it. She 
had a devoted woman friend, whom she called her 
“ lover,” and “ wished to marry,” and they exchanged HYSTERICAL CASES AND THEIR VISION. 
7 
ardent love-letters and more ardent embraces. Her 
general health, while less good than formerly, was still 
fair, and her functions tolerably well performed. 
The conjunctivas showed an impaired sensibility, and 
areas of anaesthesia, varying in size and situation, came 
and went upon the body and limbs. Upon one examina- 
tion a number of these “ islands ” would be found, two 
inches or less in diameter, in shape irregular circles or 
ovals. Another day there would be fewer spots of lost 
sensibility, and in different locations. Sometimes they 
were absolutely analgesic, at other times they displayed 
only an impaired touch sense. 
Examination of the Eyes.—Central vision normal, with 
the correction of a compound hypermetropic astigma- 
tism, as follows: 
O. D. -f- 75c axis iosf. 
O. S. -f- 25s-f5oc axis 75f. 
Amplitude of accommodation, with correcting lenses, 
normal; esophoria, 2\ degress; double epiphoria from 
stricture of the lachrymo-nasal ducts. 
In each eye the optic disc is oval, of good color, the 
fundus normal in appearance, and the vessels carrying 
normally tinted blood. Both conjunctivae are slightly 
insensitive. 
The field of vision of the right eye for form is entirely 
Fig. hi 
Diagrams of fields of vision of Case 11, showing normal form field and 
reversal of the red and blue lines, the red field being largest in extent. 8 
MITCHELL AND DE SCHWEIN/TZ. 
normal. Of the color fields, the red is greatest in extent 
and about normal, the blue next in order and contracted. 
The green field, considerably contracted, occupies its 
usual position in the sequence of the colors. In the left 
eye the form field is normal. The red field is the largest 
of the color fields and greater in extent than it should 
be. The blue comes next, and is distinctly contracted. 
The green field is in its normal position, and is some- 
what contracted, although not so greatly as upon the 
opposite side. 
Case 111. Hystero-catalepsy ; disseminated anaes- 
thesia ; great contraction of form and color fields, with 
reversal of the blue and red lines, the red field largest 
in extent, and in some meridians exceeding the width of 
the form field. 
W. R.; female; aged twenty; born in America; pri- 
vate patient of Dr. Weir Mitchell. 
This patient, in March, 1892, when apparently in the 
best of health, fell suddenly into a short fainting fit. On 
returning to consciousness she sobbed violently for some 
hours. This attack was followed by others, with con- 
traction of the left side of the body, spasmodic move- 
ments, complete loss of consciousness and tumultuous 
heart. Sudden recovery was usual, and was followed by 
severe headache and pain in the chest. The later at- 
tacks were not so severe as the first. In the earlier ones 
the movement was confined to one side, but afterward 
affected both. Return to consciousness after these at- 
tacks was instantaneous, like waking from sleep, and she 
complained usually of numbness and soreness of the 
limbs which had been contracted during the attack. 
April 13th, soon after the first attack, she fell into a 
cataleptic state while in a dentist’s chair. She had a 
second attack on the 15th, and one on the 23d, which 
was a long cataleptic condition lasting for twenty min- 
utes. Later ones have been less violent and of less 
duration. 
On examination, the patient was found to be a well- 
made, ruddy, strong-looking girl, with no signs of dis- 
ease, and she confessed upon close questioning that she 
thought frequently the attacks were precipitated by any 
cause which irritated her; for instance, her family’s 
denying her some small pleasure which she desired. 
Examination of sensation revealed a curious condition 
over the whole body. Sensation was impaired to touch, HYSTERICAL CASES AND THEIR VISION. 
9 
to pain and to temperature, but we were distinctly im- 
pressed with the idea that there was an element ot dis- 
simulation in the difficulty of distinction between heat 
and cold. While all sensibility was thus impaired, the 
whole surface of the body was islanded with spots in 
which sensibility was a little better. There were also 
islands in which anaesthesia was complete. 
It was possible to make only two examinations, as 
the patient did not remain long under treatment, being 
here upon a visit on her way to Europe. But on the 
second examination the areas of anaesthesia and sensi- 
bility were quite different from the first examination. 
There was no tenderness of the spine. The knee and 
ankle-jerks were somewhat excessive. The heart was a 
little fast and was easily excited, with a slight blowing 
murmur heard at the base. 
Examination of the Eyes.—Central vision normal after 
the correction of a myopia of 3 D.; and a corneal astig- 
matism of 2 D.; amplitude of accommodation 10D.; esopho- 
ria 1 degree ; right hyperphoria degree. In each eye 
a vertically oval optic disc of good color and the gen- 
eral fundus in healthy condition ; pupillary reflexes 
normal. 
The fields of vision presented marked concentric con- 
traction, with reversal of the blue and red lines, the red 
being largest in extent, and in some meridians exceed- 
ing in limits that of the form field. The green field 
occupied its natural position in the sequence of the 
colors, but was greatly contracted. 
Diagrams of the fields of vision of Case 111. Concentric contraction ; 
reversal of the red and blue lines, the red field exceeding in some merid- 
ians the dimensions of the form field. 
Fig. IV 10 
MITCHELL AND DE SCHWEINITZ. 
The alterations of sensation in this case were curi- 
ous, and the distribution of anaesthesia and dysaesthesia 
in small areas over the body surface varying in situation 
from day to day was very unusual, and, with the 
cataleptic conditions, sufficiently marks the hysterical 
character of the trouble. 
A like variability in position of areas of altered sen- 
sibility was found in the case of K. W. (Case XL), in 
whom anaesthesia and hyperaesthesia were found to ex- 
change places with one another from day to day. 
Case IV. Hysterical local anaesthesia; possible 
spinal injury. Reversal of the color fields, red and blue 
and, partially, green and blue. 
M. D.; aged twenty-four; a native of New Jersey; 
hospital patient of Dr.W. Sinkler. In 1889 had convulsions 
and was unconscious for two days. Dr. C. B. Penrose 
removed the right ovary in May, 1889. After this she 
was better until September, when convulsions reap- 
peared. In October the left ovary was removed. In 
September, 1890, she fell, striking her back. She was in 
bed for three months, and is said to have had spinal 
meningitis. Dr. Joseph Price operated for pelvic ad- 
hesions. On rising found right leg weak, and could not 
lift the foot. Nervous prostration followed, with the 
result of entire loss of power in the right leg. 
There is pain and tenderness in the spine, the back 
gives out on slight exertion, and there is absolute anae- 
thesia of the whole right thigh. The heart, etc., are 
normal, bowels constipated, appetite good. Menses ap- 
peared every two weeks until the ovaries were removed. 
The right leg is feeble and presents the anaesthesia be- 
fore mentioned ; no ataxia ; K. J. normal; no clonus. 
Examination of the Eyes.—Vision in each eye I a 
considerable degree of compound hypermetropic astig- 
matism ; eye-grounds normal. 
In the right eye the form field is about normal. The 
red field is largest in extent, except at the nasal hori- 
zontal meridian, where it is exceeded in extent by the 
green and coincides with the blue. The blue field is 
exceeded in extent by the green at the meridian named 
and in the upper and inner quadrant; elsewhere it ex- 
ceeds the green field in extent. In the left eye the form 
field is normal; the red field is everywhere the greatest HYSTERICAL CASES AND THEIR VISION. 
11 
in extent and about normal in size. The blue field, con- 
siderably contracted, comes next in order, followed by 
the green field, which, at the horizontal meridian of the 
temporal side coincides with the blue line. 
A third diagram of the field of vision is appended, 
taken somewhat later than the other two, and showing 
the same peculiarities even more marked, reversal of 
the red and blue lines being complete. 
Fig. V. 
Diagrams of the fields of vision of Case IV, showing practically nor- 
mal form field, complete reversal of the blue and red lines, and irregular 
partial reversal of the green and blue lines. 
Case V.—Universal hysterical anaesthesia; great 
contraction of visual fields. 
A. C.; female ; married; aged 26, housekeeper ; a 
patient of Dr. Morris J. Lewis, was admitted to the In- 12 
MITCHELL AND DE SCHWEINITZ. 
firraary April 14, 1893. Her previous history was as 
follows: 
She was married at 18, and had previously had good 
health, with the exception that menstruation had always 
been painful. In eight years she had had five children, 
of whom three are living, and two died within the first 
fortnight. 
Following the loss of the last child but one, sixteen 
months since, she began to suffer with constant indiges- 
tion, eructations of gas, poor sleep and increasing vague 
fear, which lately has developed into an acute alarm lest 
she should die at any moment. For weeks before ad- 
mission she had taken no solid food, and very little of 
any kind. She has sometimes stiffness of the jaw, and 
cannot open her mouth. For a week past she has been 
subject to attacks of choking, three or four times daily ; 
has constant epigrastric pain, and has had jaundice on 
several occasions. 
Her weight has diminished by twenty pounds in the 
last year and a half. At the time of admission all these 
difficulties were aggravated by a melancholy and de- 
pressed state of mind, consequent upon her recent 
desertion by her husband. Her tongue was red and 
glazed and denuded in patches, and she suffered a great 
deal from leucorrhoea and bearing-down pains. On ex- 
amination, no trouble was found in the lungs, but the 
second sound of the heart was markedly accentuated. 
She improved, however, very rapidly, both mentally 
and physically, and in a few days was eating 
ravenously, although still suffering from abdominal dis- 
comfort. After one month in the hospital some 
delusions still remained, such as that people were 
talking about her. 
In the middle of June, when the patient was, 
physically, almost well, the discovery was made, upon 
her own complaint, that sensation was disturbed over the 
whole surface. On examination it was found that she 
was almost without pain-sense anywhere in the body. 
Even the tongue shared in this condition of loss of 
sensibility, so that she could not distinguish solutions of 
sugar or salt, or vinegar or pepper. The patient says 
that her attention was called to it by dullness of vision, 
so decided that she could look directly at the sun with- 
out perceiving anything more than a slight luminous 
spot. 
An examination of her sensibility on June 14, 1893, HYSTERICAL CASES AND THEIR VISION. 
13 
revealed complete anaesthesia to touch and pain, with 
the following exceptions : a long narrow area, beginning 
over the middle of the biceps muscle on the right arm, 
extended down the front of the right arm, about two 
inches wide, to the middle of the fore-arm, in which pain 
sensation was slight. At the tip of the right thumb, and 
at the tip of the right middle finger, pain sensation was 
fairly acute. On the left arm a similar condition existed, 
except that the stripe of better perception was narrower, 
and was interrupted at the elbow by an area of complete 
insensibility. On the back of the left hand, the thumb 
from the second joint to the tip, and all four fingers 
from the second joint to the tip, preserved some pain 
and touch sense. On the right side, the tip of the middle 
finger and the tip of the thumb were somewhat sensi- 
tive. On the trunk there were two areas—one some two 
or three inches long in the middle of the right hypo- 
chondrium; one in the left epigastric region, extending 
as high as the sixth or seventh interspace, and only an 
inch or so wide—which were sensitive. Immediately 
below the right clavicle was another small spot where 
touch sense was preserved imperfectly. A line up both 
sides of the neck, from the clavicles to the ears, extend- 
ing on to the cheeks and forward under the eyes and 
over the forehead was also sensitive. On the back there 
was a spot in the cervical spine, another over the mid- 
dorsal region, and a third over the lower lumbar region, 
where sensation was preserved imperfectly; and in the 
middle of the sole of each foot was a small spot where 
pain was perceived. 
This very curious distribution of hysterical an- 
aesthesia lasted only a few days, and, at the end of a 
week, sensation was rapidly returning without any 
special treatment. 
Examination of the Eyes.—Central vision normal; 
slight deficiency in the amplitude of accommodation ; 
no anomalies of the external ocular muscles. Small optic 
discs, moderately hypersemic, with edges slightly veiled; 
pupillary reflexes normal. 
The fields of vision for form are greatly contracted, 
those for colors being proportionately diminished in ex- 
tent ; colors are correctly appreciated, and their fields 
nowhere exceed 10 degrees in extent to either side of 
the fixing point. Even in this limited area there ap- 
peared to be reversal of the red and blue lines, but this 
was not determined with certainty. 14 
MITCHELL AND DE SCHWEINITZ. 
Diagrams of the fields of vision of Case V, showing marked concen- 
tric contraction. 
Fig. VI. 
Case Vl.—Hysterical ptosis and hemianaesthesia; ir- 
regular and varying reversal of the color fields. 
S. B.; aged twenty-one; female; single; a native of 
America; a hospital patient of Dr. Wharton Sinkler’s. 
In 1889 she fell from a horse and has never been well 
since. In July of 1890, a loss of power on the left side 
came on gradually and lasted two weeks. She is com- 
plaining of a tight, girdle sensation around the waist, 
pain across the back, a bursting feeling over the right 
eye, and lack of sensation upon the left side. There is 
no headache ; she is very nervous and sleeps badly ; the 
bowels are regular; the appetite poor. There is com- 
plete left anaesthesia with failure to appreciate the prick 
of a pin over the entire left side, but no demonstrable 
palsy. 
Twenty and thirty times a day, and sometimes of- 
tener, there are attacks of complete ptosis in the left 
eye, lasting from one to fifteen minutes, during which 
time the lid is spasmodically closed, and the eyeball be- 
neath it rolled upward. The attack begins with a curi- 
ous tremor—or, rather, quiver—of the upper eyelid, 
which then spasmodically shuts over the ball, and the 
condition described results. 
Examination of Eyes.—ln each eye there is an oval 
optic disc, a slight crescent at the outer side, some super- 
ficial retinal haze, but, on the whole, fairly healthy eye- 
grounds. The vision is normal in each eye; the accom- 
modation equals .8 diopters ; esophoria, 4 degrees for the 
distant point. HYSTERICAL CASES AND THEIR VISION. 
15 
On March 7, 1891, while the hysterical symptoms 
were in their highest development, the following fields 
were obtained: the white field is the greatest in extent, 
except down and in where it is slightly exceeded in area 
by the blue, yellow and green fields, and up and out 
where, on the meridian of 45°, it is slightly exceeded in 
extent by the yellow field. The blue field is exceeded 
in limit by the red and yellow fields, which for the most 
part run upon the same line, except in the lower and 
inner quadrant, and directly below where the blue field 
is greater in extent; then follows the red field, part of 
the time coinciding with the yellow and part of the time 
passing in advance of it. In this area the red line 
passes to the inner side of the blue and the yellow lines, 
part of the time coinciding with the green until it again 
becomes the greatest in extent, with the exception of 
the yellow, with which it coincides. The green field is 
the smallest in extent of all of the colors, in this partic- 
ular occupying its natural position in the sequence of 
the colors, except down and out in the meridian of 330°, 
where it coincides with the blue field; directly down, 
where it coincides with the red field ; and down and in, 
where for a short distance it lies between red and blue, 
and for a still shorter distance becomes the greatest in 
extent of all the colors, being even in advance of the 
line of the white field. This is in the meridian of 2250. 
The left eye presents similar conditions, as may be seen 
by consulting the diagram. 
It will be noted that in addition to this partial rever- 
sal in the order of the colors, that the extent of all of 
the color fields is greatly in excess of normal, and, as has 
already been noted, is in some instances in excess of the 
white field. 
On May 28, 1891, there had been some improvement 
in the woman’s general condition, although not very 
marked, the ptosis, etc., continuing. A field then taken 
shows the changes similar to those figured. 
In July 29, 1891, when the patient was practically re- 
stored to health, the anaesthesia having disappeared and 
the woman having gotten down to honest work as a 
trained nurse, another color field was taken; which is prac- 
tically normal in all respects,both in extent and sequence 
of colors. 
The sequence of the colors in this case has been de- 
scribed at some length for the purpose of showing what 
irregular and contradictory results may be obtained 16 
MITCHELL AND DE SCHWEINITZ. 
with hysterical patients in such examinations. Practi- 
cally, any sequence could be maintained during the 
hysterical period; any color could be made to yield the 
field of greatest extent, provided it was the first color 
used in the examination. So, also, the patient was open 
to suggestions, and the colors could be made to follow in 
almost any order, and the lines made to cross or recross 
in almost any manner. It is, further, an interesting ex- 
ample of the restoration of the normal visual field after 
the disappearance of the hysteria and its accompanying 
anaesthesia. 
Fig. vii 
Diagrams of the fields of vision of Case VI. Varying and irregular 
reversal of the color fields. 
Case Vll.—Hysterical hallucinations and slight an- 
aesthesia ; normal form and color fields. 
L. M.; female; single; aged thirty-three. This pa- 
tient has a neurotic family history, and has been from 
childhood very nervous. She broke down from over- 
study at the age of sixteen, and had an intestinal trouble 
from which she never entirely recovered. In 1875 she 
had her first hysterical attack, which was renewed in 
1888, and followed by a third in the spring of 1892, just 
before she came under the care of Dr. Weir Mitchell. 
All of these attacks presented somewhat similar feat- 
ures ; rigidity in the neck and legs, with convulsive 
movements of the toes, lasting for an hour or more. In 
the third attack she was delirious. 
She is fantastically peculiar about what she eats, and HYSTERICAL CASES AND THEIR VISION. 
17 
has not, since 1875, eaten ordinary food at all, although 
her appetite is enormous. About one-half of the time, 
beginning a few days before her menstrual periods and 
lasting for about ten days afterward, she suffers from 
indigestion in various forms, and is extremely consti- 
pated. During this time the nervous symptoms are 
much worse. 
In the winter of 1892 she began occasionally to see 
flashes of light, and soon she had visions of coils of 
spotted snakes, and at last distorted faces came fre- 
quently before her. One peculiar symptom, of which 
she made great complaint, was that she could not re- 
strain her mind from carrying on within herself a sort 
of double conversation, in which she asked and answered 
questions—often absurd ones. It usually turned on the 
person she had last seen, or on the next person she 
expected to see, or on any triviality of the day’s doings.. 
She suffered from a slight anaesthesia of the skin 
of the face and from a feeling of numbness, most marked 
on the right side of the head. She was very courageous 
and truthful, and most persistent in carrying out any line 
of treatment laid down for her by which she hoped to be 
benefited. She finally made a good recovery. 
Examination of the Eyes.—Central vision and ampli- 
tude of accommodation normal; orthophoria ; slight cor- 
neal astigmatism, in the right eye, .75 D. axis 135 ; in 
the left eye, .37 D. axis 90; oval optic discs, with exces- 
sive capillarity of their surfaces; no other lesion in the 
fundus oculi. The fields of vision in this case are en- 
tirely normal, both for form and for color. 
Although there was anaesthesia in this case, it was 
of minor character. This should be noted in connection 
with the fact that there was no disturbance in the 
field of vision and in the normal appreciation of the 
colors. 
The following three cases are classified together as 
examples of hysterical hyperaesthesia. 
Case Vlll.—Hysterical hyperaesthesia ; normal form- 
fields ; practically normal color fields ; very slight excess 
of the normal extent of the color lines on the temporal 
side. 
D. L.; female; of Hebrew parentage; aged twenty- 
seven. Private patient of Dr. Weir Mitchell. 18 
MITCHELL AND DE SCHWEINITZ. 
For more than four years the patient was under 
treatment for dysmenorrhoea, prolapse of the left ovary 
and general nervousness. Her cervix uteri has been di- 
lated and dilated again. She has had various neuralgias 
and pseudo-paresis of one limb and another, tender 
spine, tender ovaries, headache, indigestion, rectal and 
vesical tenesmus, vaginismus, and difficulties in the use 
of her eyes have followed in quick succession, new 
symptoms constantly appearing as interest in the old 
ones slackened. Her physician had long suspected mas- 
turbation to be at the bottom of the pelvic neuroses, but 
was unable to prove it, until recently a confession was 
extracted from her of the truth of this suspicion. An 
anxious and sympathetic family witnessed the hysterical 
panorama with ever fresh compassion and ready serv- 
ices. 
This lady belongs to a family, of whom four have 
been under Dr. Weir Mitchell’s care in the last three 
years for neurotic troubles, including a niece of the pa- 
tient, a sister and a first cousin. 
At present she is of fair general appearance, in good 
flesh and of wholesome coloring. 
Her most remarkable and interesting symptom is the 
muscular hyperaesthesia from which she suffers. Press- 
ure over a bone, wrist, tibia, rib or elsewhere seems to 
cause no pain, but touch over a muscle ever so lightly 
and she shrieks and “ flops ” in bed, with hurried or 
sighing respiration and complaint of agonizing pain. 
This condition is worse upon the left side, but even 
there not absolutely universal. There are islands of 
less excessive sensitiveness, but these vary in position 
from day to day. There seems some slight loss of sen- 
sibility to touch with a needle point in places. 
There is ovarian tenderness, especially on the left 
side (the situation of the prolapsed ovary). There is a 
similar excessive spinal tenderness most marked in the 
upper dorsal region ; and, as an exception to the rule of 
pressure over superficial bony surfaces producing no 
pain, over the sacrum. K. J. is excessive,—doubled. 
No ankle-clonus. The heart and lungs are normal, nor 
is there any evidence whatever of organic disease. 
Examination of the Eyes.—Both eyes highly myopic, 
but no lesions in the fundus oculi other than those com- 
mon with high myopia. Owing to the exceeding ner- 
vousness of this patient, it was impossible to make an 
extensive examination of the color fields, and this was HYSTERICAL CASES AHE THEIR VISION. 
19 
limited to four meridians in the right eye. After a 
number of trials the following results were obtained: 
The field of vision is entirely normal in extent, so far 
as form is concerned; colors are appreciated in their 
natural order, and there is no change in the extent of 
the coloi fields, except a slight increase of the normal 
limits on the temporal side. This slight change, how- 
ever, can scarcely be looked upon as of any importance, 
especially as a subsequent examination of the patient 
when she was in much better physical condition, by Dr. 
William Dennett, of New York, showed that it was im- 
possible to get accurate results, although he found, as 
we had done, that there was no lessening of any of the 
fields. Further than this, however, the answers were 
contradictory. He obtained entirely different results in 
almost any part of the field with the same or with dif- 
ferent colors. 
This patient, after long and careful treatment of her 
hysteric difficulties, made an excellent recovery and is 
now perfectly well. 
Case IX.—Hysterical disseminated hypersesthesia ; 
normal form fields; partial coincidence of the red and 
blue lines; contracted green fields. 
H. S.; male; a Russian; aged sixteen ; was sent to 
Dr. J. K. Mitchell by Dr. M. V. Ball in May, 1893, with 
the following history : He had been in this country a little 
more than a year. His general health and appearance 
were fair, and the history of his present difficulty was— 
he had never been free from pain in the feet and lower 
legs since an inflammation of the kidneys following 
scarlet fever when he was seven years old. The pain 
had located itself especially in the right popliteal space. 
This, however, had never been severe enough to 
greatly disturb or annoy him. 
Eighteen months before examination, in the latter 
half of 1891, while in Russia, he began to have pain 
throughout the whole right side of his chest. This 
seemed to extend around the ribs into the back, and 
affected also the feet and knees in a general way. 
These regions, somewhat vaguely described by the pa- 
tient as “ painful,” were also excessively tender to the 
touch, and his statement is that now he suffers con- 
stant pain in the chest on both sides. It is made much 
worse by pressure or movement. There is sharp pain in 20 
MITCHELL AND DE SCHWEINIIZ. 
the hips. The pains, while constant, have yet degrees, 
and are at times more severe than at others, often spon- 
taneously becoming of extreme violence. He has also 
cramping pains in the fingers. All these areas of pain 
are made worse by fright or excitement. 
Upon examination it was found that the chest, especi- 
ally over the sternum, was so sensitive to touch that 
the lightest pressure of a finger appeared to give ex- 
quisite pain. The same was true of the arms and fore- 
arms ; of the face (on both sides) ; of the tibial region in 
both legs, though the left was somewhat more hyper- 
aesthetic, especially just above the ankle. This tender- 
ness was more marked in the fore-arm and hand than on 
the upper arm, and he said that a touch gave a sharp stab- 
bing pain. The nape of the neck was also excessively 
sensitive to pressure. Common sensation was perfect 
throughout the body. The head and point of a pin were 
perfectly distinguished everywhere, but a mere touch 
with the point was said to cause acute pain. 
All these symptoms are worse in bad weather, 
especially when cold or rainy. Heat does not affect 
them. 
The patient’s knee-jerk is normal, and his station 
good. 
Examination of the Eyes.—Direct vision normal; slight 
haze in each retina; otherwise no changes in the fundus 
oculi. A moderate degree of hypermetropic astigmatism. 
The form field in each eye is normal; there is distinct 
contraction of the green field, most marked upon the 
right side, and partial coinciding of the red and blue lines, 
but no reversal. 
In this curious case of general hypersesthesia, there is 
undoubtedly a very large element of hysteria ; how large 
it is difficult to judge. But the patient’s pleasure in 
detailing his symptoms, the dramatic start and expres- 
sion with which he received a finger touch, rendered us 
very suspicious of the whole history. It may be summed 
up as an unusual form of hysterical hypersesthesia. The 
lad is unusually bright and intelligent, and, although 
only a few months in this country speaks excellent 
English, and is a hard student, preparing for college. 
Case X.—Hysterical sciatica and hypersesthesia of 
the left side; form fields normal; slight contraction of 
the color fields on the right side. HYSTERICAL CASES AND THEIR VISION. 
21 
Mrs. R. D., of Mobile, Ala.; private patient of Dr. S. 
Weir Mitchell; aged thirty years ;of Jewish parentage ; 
was married early, and divorced after two years from a 
brutal husband, who has since become insane. 
She has had one miscarriage, and has been treated for 
uterine troubles. She has masturbated since childhood ; 
calmly discusses the habit, and says that she can refrain 
for six months, but that then it takes possession of her 
and she indulges herself freely for two or three weeks. 
She has a highly developed drug habit. For three 
years past she has taken 60 grains of sulphonal at 
night, and McMunn’s Elixir at every period, not because 
she suffered pain, but because she was uneasy and un- 
comfortable, and was relieved by the opium. 
Her complaint is of “agonizing pain ” in the left hip 
and leg, extending into the great toe ; excessive weak- 
ness, headache and sleeplessness. The trouble began 
four years ago with an attack of “ pleurisy,” or, more 
probably, of inter-costal neuralgia. After a few days of 
slight pain in the leg at this time, she found herself one 
night out of bed in an agony of pain, which required 
morphia. The pain has persisted in the whole leg and hip 
ever since, with exacerbations. It has not, however, been 
sufficiently great to prevent her traveling over most of 
Europe and a great part of this continent, where, in the 
intervals of treatment at sanitariums and health-resorts, 
she enjoyed herself by securing a collection of extraordi- 
narily various opinions from physicians of all sorts and 
sects. 
She is quite stout but anaemic, and has the counte- 
nance of a confirmed hysteric. She shrieks if the left 
leg be touched ever so lightly, and, indeed, will hardly 
allow the right one to be handled; exclaims if the bed 
is approached from the left side, and says that she can- 
not use her left arm, because it gives her pain in the 
great toe on that side. At times she will not allow even 
the bed clothes to touch the leg; yet she can and does 
walk about the room without the slightest pain or trouble. 
She has no paralysis, and no enlarged glands or other 
evidence of specific disease. There is slight swelling of 
the left leg about the lower part. She is highly emo- 
tional ; talks cheerfully; has an excellent appetite and 
a great desire for medicine. An examination of the 
abdomen and chest reveals nothing abnormal. 
Examination of the Eyes.—There are no alterations of 
importance in the fundus oculi. With the exception of 22 
MITCHELL AND DE SCHWEINITZ. 
slight contraction of the color fields there is no change; 
the contraction is slightly greater upon the right side 
than upon the left; in fact, the left field is not far from 
normal. 
This is distinctly a case of hysterical imitation of 
sciatica, founded on a real original nerve-pain. 
The following four cases are classified together under 
the general term of major hysteria, because they repre- 
sent the highest types of hysterical manifestations. 
Case Xl.—Major hysteria; hysterical rapid breath- 
ing ; considerable contraction of the visual fields, but no 
reversal. 
The following remarkable case was reported in full 
by Dr. S. Weir Mitchell in a lecture on hysteria, pub- 
lished in the American Journal of the Medical Sciences, in 
March, 1893. The notes, which are very full and cover 
a period of ten years, we give only in abstract, as the 
case is easily accessible. 
K. W.; female; single; aged twenty-eight. This 
patient’s first hysterical trouble was an affection of the 
knee-joint, which was treated at the Infirmary for Nerv- 
ous Diseases and relieved, although it afterwards re- 
lapsed. Her family assert that after this, from July to 
October, 1889, a period of sixty-four days, she remained 
in a trance, brought on by the news of the death of her 
father, and it was said that during this time she took 
neither food nor drink, except that for the last four 
weeks she received daily a small quantity of water by 
the mouth. Strange to say, although she ate nothing, 
she had large passages from the bowels, produced by an 
enema given once a week ! 
On her second admission to the Infirmary for Nervous 
Diseases, March, 1892, she was found to have a respira- 
tion of 120 to 150 a minute, very shallow, almost entirely 
upper-costal in its character and perfectly regular. Her 
pulse at the same time was about 100 a minute. When 
in bed, she could move the left leg perfectly well, even 
against resistance; but she dragged the left foot when 
walking. Station good; knee-jerk increased ; no ankle 
clonus. The tactile sense was hard to determine on 
account of the difficulty of truthful statement by the patient. The left side was more sensitive to pain than 
the right. 
A curious growth on the anterior aspect of the left 
leg was illustrated in Dr. Mitchell’s paper in the American 
Journal, and reported on by Prof. Duhring. The case did 
not do well, and was finally discharged from the hospital, 
practically unimproved. 
Examination of the Eyes.—Conjunctivas insensitive ; 
pupils normal in reaction ; good fusion power ; no lesion 
in the fundus oculi. 
HYSTERICAL CASES AND THEIR VISION. 
23 
In the right eye the form field is normal in extent; 
there is concentric contraction of the color fields, but 
they occupy their normal position. In the left eye the 
same is true, except that there is very considerable con- 
traction of the form field, and that in the horizontal 
meridian on the temporal side the red and blue lines 
coincide. 
A chart of the field of vision (colors), taken during a 
semi-hypnotic condition, showed no material difference 
from the others, save that the fields were more con- 
tracted.1 
Case Xll.—Major hysteria; convulsions; sterno- 
cleido-mastoid and splenius spasm; irregular contrac- 
traction of the visual fields, but no reversal. 
Girl; aged seventeen ; American by birth ; private 
patient of Dr. J. K. Mitchell. 
The family history is a suspicious one. The patient’s 
mother was of a tuberculous race, but died in child-bed. 
She, at one time, used opium to excess. A sister has 
chlorosis; two aunts are “nervous.” The girl’s own 
health has not been first-rate. An attack of diphtheria 
left her extremely susceptible to throat inflammation 
from trifling causes. She is very intelligent, quick, un- 
usually well-read and observant. Her temper is at times 
very violent. 
She returned to school in the fall of 1891, after a sum- 
mer in the country, in excellent health, and undertook 
work as a pupil teacher. She found it trying and gave 
way occasionally to fits of uncontrolled temper. Late 
in November, she began to suffer with pain in the supra- 
orbital region, with a spot of particularly intense pain and 
tenderness on the side of the nose, the neuralgia occa- 
sionally darting backward toward the ear and from the 
1 The diagrams of the visual fields may be seen in Dr. Weir Mitchell’s 
original paper. 24 
MITCHELL AND DE SCHWEINITZ. 
ear down the neck. This was confined to the left side. 
After this had lasted, with short intermissions, for two 
or three weeks, the darting pains began to be accom- 
panied with strong twitching of the muscles of the left 
neck and shoulder. 
When first seen in December, these spasms were 
occurring several times daily and lasting from a few min- 
utes to hours each time. The head was jerked a little 
toward the left with each spasm, and the pain’ was de- 
scribed as intense. The pupils were unaffected during 
the attacks. The left sterno-cleido-mastoid and splenius 
botn contracted, rotating the face toward the right, while 
the head jerked to the left. Sometimes the platysma 
seemed to share in the irritation. 
Treatment was extremely unsuccessful, and the girl 
grew gradually worse, until it became necessary to put 
her to bed, which was done, and absolute rest was in- 
sisted upon. At first, for a time, .she grew a little better, 
then the ache and the convulsive movements of the head 
returned, growing steadily more severe in spite of every 
effort and culminating, in January of 1892, in violent 
convulsions; these began with retraction of the head 
and went even to complete opisthotonos. 
The convulsions were usually, but not always, preced- 
ed by extreme convergent strabismus. In the intervals 
the patient, while sometimes perfectly conscious and 
clear-headed, complained of loss of vision,—the pupils 
were widely dilated, almost entirely insensible to 
light and varied in their relative size, sometimes one 
being the larger and sometimes the other. During this 
whole period, which lasted about six weeks, the excessive 
pain was constant, and it finally became necessary' to 
resort to large doses of morphia repeated throughout the 
day to keep the patient reasonably quiet. She grew 
somewhat better in March, but had one or two violent 
convulsive attacks, the last one with delirium, and in it 
she assaulted her nurses. Her family was worn out and 
the supply of nurses exhausted. Dr. Mitchell had the 
patient removed to the Infirmary for Nervous Diseases. 
She was carried down-stairs in a semi-conscious state, 
wrapped in a blanket, conveyed to the infirmary and 
put to bed, and from that day made a rapid and perfect 
recovery. 
She was seen a year after leaving the Infirmary for a 
slight return of the aches at the base of the brain, but 
she had had no more twitchings with. them. HYSTERICAL CASES AND THEIR VISION. 
25 
Examination of the Eyes.—When first seen, the central 
vision was one-half of normal, the refractive error a 
moderate compound hypermetropic astigmatism and 
slight insufficiency of the external recti muscles; the 
eye-grounds were perfectly healthy. 
The field for white is contracted above and to the 
temporal side in the right eye, and there is also contrac- 
tion of the color fields, most marked for green, but in 
perfectly regular order; there is no crossing of the lines 
and no reversal. The color sense is perfect for all col- 
ors and all shades. 
In the left eye the vision is two-thirds of normal; 
there is great contraction of both form and color fields, 
again in perfectly regular order. The depreciation of 
central vision was accounted for by the refractive error. 
Somewhat later, at the height of the attack, when all 
the major symptoms were most pronounced, there was 
well-marked homonymous diplopia from partial pa- 
ralysis of the left external rectus muscle ; but no change 
in the ophthalmoscopic picture, save some distension of 
the lymph sheaths around the central vessels, and the 
central veins a little larger than normal. It was impos- 
sible to map a color field at this examination. 
Still later, during the patient’s stay in the infirmary, 
a number of fields of vision were mapped out, of which 
the following diagram is an example, showing consider- 
able contraction of the form field, of the blue and red, 
and particularly of the green fields. 
After the patient had recovered, the fields of vision 
were measured again and were perfectly normal in ex- 
tent. 
Fig. viii 
Diagram of the fields of vision of Case XII, showing concentric con- 
ti action, hut no reversal. 26 
MITCHELL AND DE SCHWEINITZ. 
Case Xlll.—Hysterical anorexia; possible tubercu- 
losis ; moderate contraction of the visual fields, but no 
reversal. 
V. 8., a wretchedly thin and anaemic child of seven- 
teen, was brought from Michigan to Dr. S. Weir Mitch- 
ell in the autumn of 1892. She had complete hysterical 
anorexia, and constantly complained of indigestion and 
abdominal pain. Her bowels were obstinately consti- 
pated. She was emaciated to an extraordinary degree, 
very sleepless, and the object of devoted attention from 
her doting parents, for whose benefit a continuous 
dramatic performance went on pretty nearly day and 
night. She may fairly be described as a highly neuras- 
thenic patient, although a suspicion of the possibility of 
tubercular disease of the intestines cannot be denied. 
Examination of the Eyes.—Central vision normal; oval 
optic discs of good color, but retinas slightly hazy ; mod- 
erate hypermetropic astigmatism ; no anomalies of the 
external ocular muscles, save slight esophoria; drooping 
of both upper lids, but hardly sufficient to justify the 
term ptosis; moderate contraction of the form fields, 
and some coincidence of the blue and red lines, but no 
reversal. The green field is proportionately more con- 
tracted than the others, especially upon the right side. 
Case XlV.—Hysterical dyspnoea; hypnotizable sub- 
ject ; general hysterical symptoms ; slight contraction 
of color fields. 
E. W.; aged twenty-one; unmarried. Patient of Dr. 
M. |. Lewis in the Dispensary of the Infirmary. The 
girl had never been in very good health, was subject to 
frequent gastric disturbances, especially a strong ten- 
dency to vomiting on small provocation. 
For some months during her mother’s last illness, in 
which she nursed her, there was a constant uterine flow. 
After this, in June, 1890, two years previous to her first 
visit to the hospital, she had become very much de- 
pressed and run down, and was for some months con- 
fined in her bed with profound depression and general 
nervousness, with hysterical attacks of laughing and 
crying. At the same time, she had a beginning of one 
of the present troubles, namely, stammering when ex- 
cited. She had, too, attacks of fainting, sometimes three 
or four a day, but not of late so often as formerly; pal- 
pitation of the heart, poor appetite, frequent vomiting, 
probably intentional. She seems not ill-nourished, and HYSTERICAL CASES AND THEIR VISION. 
27 
her color is fairly good ; but she sleeps badly, and says 
that she cannot lie down, but must sleep sitting in her 
chair on account of the difficulty of breathing which she 
experiences when recumbent. Being made to lie down 
during the examination, in order to study this difficulty, 
her breathing was found to be somewhat increased in 
rapidity and very irregular while supine. She was not 
flushed or pale at this time; she had no pain ; no heart- 
murmur was audible. 
She had a slight oedema of the feet, and her menses 
occurred every second week. The patient proved to be 
readily hypnotizable, and could be thrown into a minor 
degree of the hypnotic state by mere suggestion. On a 
later occasion her blood was examined, and the number 
of corpuscles found to be 5,200,000 per cmm., and the 
haemoglobin 90 per cent. 
During the preparation for this examination, the 
patient suddenly began to wink very rapidly with both 
eyes. No notice was taken of this, and her finger was 
pricked to draw the blood. The moment that the needle 
touched her, she began to breathe rapidly and noisily ; 
threw her head slowly backwards, closed the eyes, 
breathing more slowly, and thus remained unconscious 
for four or five minutes. She was let alone during that 
time, and presently came gradually to herself, but was 
very shaky and nervous. On a second pricking of the 
finger, she went off again rather more rapidly as the 
finger was stuck, and remained unconscious for about 
one minute. The patient was lost sight of, having left 
the dispensary because she objected to Dr. Lewis’s 
recommendation that she should be- removed from her 
family and surroundings and treated in a hospital. 
Examination of the Eyes.—Ophthalmoscopic examina- 
tion revealed nothing abnormal. The pupillary reac- 
tions were natural, and the excursion of the eyeballs 
good in all directions. The field of vision is normal for 
form, the color fields being slightly contracted, that for 
green being proportionately more contracted than the 
rest of the colors. 
The following four cases are classified together chiefly 
because the most decided manifestation was local in its 
character. 
Case XV.—Hysterical, clonic laryngeal spasm; un- 
contracted form fields; color fields (red and blue) wider 28 
MITCHELL AND DE SCHWEINITZ. 
than normal, with almost complete reversal of the red 
and bine lines. 
A. C.; aged twenty-nine; female; single; book- 
keeper ; Infirmary case. Family history negative; pre- 
vious health good. Applied for treatment December 
2d, 1892, stating she believed the wearing of a pessary 
for eleven months to have been the cause of the present 
trouble. 
The patient is in a very nervous state ; complains of 
“noises in the head” and “flutterings in the chest.” 
There are choreoid twitchings of the body and of the 
eyelids. The larynx is in constant vertical movement, 
140 times a minute. This stops during phonation, on 
deep breathing or upon being ordered to hold her breath. 
The muscles involved are the pharyngeal, palatal, 
laryngeal, digastric, and the muscles going to the hyoid. 
The omohyoids and the sterno-cleido-mastoid are not 
implicated. The sides of the neck are normal, there is 
no exophthalmos and no thyroid enlargement. The 
patient states that the movements do not cease during 
sleep. Speech is not affected. This rapid motion has 
continued for fourteen months and is said to be increas- 
ing. 
The pupils are unsteady. The pulse is 100-120 per 
minute, increasing under excitement. There is no evi- 
dence of valvular lesion. The K, J. is normal. Miss C. 
has various hysterical symptoms, e.g., fancies she can 
see her eyes in the ceiling and of enlarged size. Sensi- 
bility is slightly lessened in the anus. 
Fig. IX 
Diagrams of the fields of vision of Case XV, showing partial reversal 
of the red and blue lines and unusual extent of the red field. Examination of the Eyes.—There are no lesions dis- 
coverable with the ophthalmoscope and no changes of 
importance in the external ocular muscles. The form 
field in each eye is normal; the color fields (red and 
blue) are wider in extent than natural, the red field being 
for the most part greater in extent; the green field, 
about natural in size, is in its normal position. 
HYSTERICAL CASES AAH THEIR VISION. 
29 
Case XVI.—Hysterical contraction of the arm and 
legs ; nearly normal form fields ; practically normal color 
fields, with the exception of green, which was somewhat 
contracted on the left side; partial reversal of red and 
blue lines on the right side. 
J. H.; aged thirty-seven ; female ; single. Private pa- 
tient of Dr. J. K. Mitchell. A hard-worked Government 
clerk, in a responsible position, at the same time carried 
the burden of a large and poor family. 
In 1891, coming suddenly out of a light room into a 
dark hall, she fell over a pile of books and bruised her 
shoulder. Little was thought of the accident at the 
time, and there was no atrophy of the shoulder muscles ; 
but when, after several weeks, she still could not use her 
upper arm or raise it from her side, more attention was 
paid to it. It was found that although there was no 
wasting, there was complete loss of power for voluntary 
movement of the shoulder muscles. This continued in 
spite of every treatment, and soon the forearm began to 
bend and the fingers to draw into the palm. This con- 
traction of the fingers continued, and they soon became 
closely adducted, with the thumb lying in the same 
plane as the fingers. The hand was a little flexed upon 
the wrist, and the palmar fascia, slightly contracted, 
made what we might term a cup-shaped hand. In the 
same way the forearm became more and more rigid at 
right angles to the upper arm, and the upper arm was 
held stiffly to the side, the forearm lying across the body 
at the waist, with the fingers pressing against the right 
side below the breast. With some exertion this con- 
traction could be passively overcome, but the effort 
caused the patient slight pain at the elbow, and more 
pain if an attempt was made to raise the shoulder. 
After some months she had progressive loss of voice, 
so that when Dr. J, K. Mitchell first saw her, in Novem- 
ber, 1892, she could not speak above a faint whisper and 
went about with the arm in a sling, unable to get the 
sleeve of her dress on. In spite of every treatment the 30 
MITCHELL AND DE SCHWEINITZ. 
condition remained unchanged for several months, and 
in February, 1893. a contraction of the legs occurred, at 
first affecting the adductor groups. Soon the thigh mus- 
cles contracted somewhat; the legs were bent upon the 
thighs at a right angle, and this contraction remained 
excessively strong, so that it was only by using an undue 
degree of violence that the legs could be separated from 
one another. 
There was at no time loss of sensation in any part of 
the body. An effort was made to relieve the contraction 
of the arm by cutting some of the tendons, but, of course, 
they could not all be cut. This did no good, and the 
patient remains in this wretched condition, with very 
little prospect of improvement. 
Examination of the Eyes.—Central vision and eye- 
grounds practically normal; no particular change in the 
external ocular muscles. The field of vision of the left 
eye is not far from normal, with slight contraction of 
the green field. On the right side the form field is 
normal. There was reversal of the red and blue lines 
on the vertical meridian, with slight concentric contrac- 
tion of these fields. The green field, decidedly con- 
tracted, occupies its normal position. The left eye watered 
when she masticated, which may have been an hysterical 
symptom, but in the present case was probably con- 
nected with nasal difficulty high up. 
It is to be said that while such a case presents the 
features of an hysterical contraction, there must always 
be a fear that side by side with the hysterical state there 
is a general degenerative change in the spinal cord, and 
the only hopeful feature lies in the fact that these de- 
generative diseases, when associated with hysteria, are, 
for some strange reason, more easily cured than similar 
changes unconnected with hysterical conditions. 
Case XVll,—Hysterical paralysis, with tremor; nor- 
mal form fields; at first, partial reversal of the red and 
green lines (blue being normal in position); later no re- 
versal, but red and green close together. 
Mrs. M. H.; aged fifty-two; private patient of Dr. 
Weir Mitchell; has had five children, of whom three are 
living, and suffered with several miscarriages ; but, until 
the beginning of the present trouble, her general health 
had been fairly good, although she describes herself as HYSTER/CAL CASES AND THEIR VISION 
31 
of a nervous disposition, and she has had occasional 
fainting attacks from childhood. At one time there was 
frequent supra-orbital neuralgia, said to have been ma- 
larial in origin. 
Her present complaint is of pain in and inabilty to 
use the left arm and shoulder, dating from October, 
1892, when she had a fainting attack which lasted an 
hour. She fell upon the floor; but, after a few hours, 
was able to walk upstairs, and was perfectly clear in her 
head; nor was there any trouble with the shoulder until 
the next day, when it felt sore, and trouble in moving it 
developed slowly during the next month, since which 
time it has remained stationary. She is very emotional, 
weeps much, and is subject to fits of great depression. 
She has occasional vertigo; menstruation ceased two 
years ago. 
The patient is very stout. The fore-arm and fingers 
are moved perfectly well. Movements of the left 
shoulder are restricted apparently both by pain and by 
weakness. On attempted passive movement of the 
shoulder, she fixes the muscles strongly and cries with 
pain. On active movement, there is shaking of the fin- 
gers and arms, which, at times, is very rapid and violent. 
This is usually absent when at rest, but is increased by 
emotion and by attention to it. The other arm some- 
times shares in this same movement. The patient says 
that the arm was at one time swollen, but there is now 
neither enlargement nor wasting, and the muscles react 
well to Faradic electricity. 
Sensation is normal in all forms on both sides. There 
is no pain on pressure over the nerves. The knee-jerk 
is very slight. The left biceps jerk very marked; the 
right biceps jerk very slight. Heart and lungs are nor- 
mal. The dynamometer: right 30, left 10. The tremor 
is a large one,—not the fine tremor of a paralyzed arm. 
Examination of the Eyes.—Central vision one-half of 
normal in the right eye after correction of a myopic as- 
tigmatism ; normal in the left eye after correction of a 
compound hypermetropic astigmatism ; no anomalies of 
the external ocular muscles, save slight insufficiency of 
the internal recti; pupillary reflexes natural; slight 
veiling of the margins of the optic discs, which are gray 
in their deeper layers. Macula on the right cornea; 
conjunctiva hypersemic, but not insensitive. The first 
examination of the visual field revealed normal form 
field, contracted color fields, with partial reversal of the 32 
MITCHELL AND DE SCHWEINITZ. 
red and green lines; later normal form field, normal 
blue field, green and red lines not reversed, but close to- 
gether. 
The case seems a bad one of simulated hysterical 
joint lesion with some contractions. The limitation of 
voluntary motion is both from spasm of the muscle and 
from weakness; the limitation of passive motion is 
from the weakness and from pain. 
Case XVlll.—Hysterical night ptosis; normal form 
fields ; blue and red lines normal, but partially reversed ; 
contracted green field, most marked upon the right side. 
Mrs. M.; aged sixty-seven; 2 children. Was always 
nervous and her general health has never been good. She 
has suffered extreme privations and exposures, joining 
her husband in Nicaragua with Walker’s expedition, and 
bearing a child while living there on scanty and bad 
food in an unhealthy climate. She had the severe 
malarial fevers of the region during this time. 
Her family history includes no case of serious nerv- 
ous disease, but the headache of which the patient now 
complains is a hereditary one. From childhood she has 
had, at frequent short intervals, violent head pain, usu- 
ally beginning in the middle of the night and lasting 
till morning. The pain is described as “ dreadful.” It 
begins in the lateral occipital region and spreads rapidly 
over the whole head. It wears off in the morning hours, 
but leaves her prostrated. 
Two years ago she first suffered with spasmodic 
closure of the eyes during the night. She wakes and 
finds herself unable to open her eyes. After some min- 
utes of effort, she succeeds in raising the lids, but they 
at once close firmly again, and only after an interval can 
they be naturally opened once more. There is, at the 
same time, pain and sense of weight in the upper lid. 
In the morning the lids are stuck together and are opened 
with difficulty. This trouble has of late annoyed her 
again, after an absence of nearly two years, coming on 
now after a severe attack of congestion of the liver and 
a cystitis. There are no changes of sensibility to be 
found. 
Examination of the Eyes.—There are no lesions in the 
eye-grounds of consequence, the refractive error being a 
slight hypermetropic astigmatism, the correction of HYSTERICAL CASES AND THEIR VISION. 
33 
which gives normal vision. The eye muscles are suf- 
ficient. 
The form field in each eye is normal. In the right 
eye the red field is the greatest in extent everywhere 
except on the horizontal nasal meridian, where it is ex- 
ceeded in extent by the blue. The green field, consider- 
ably contracted, occupies its normal position. In the left 
eye the red field is again everywhere greatest in extent 
except on the horizontal meridian of the nasal side, where 
it is exceeded in extent by the blue. The green field, 
somewhat contracted above and below, occupies its 
normal position. 
In another color field, taken somewhat later, pre- 
cisely the same conditions obtain, except that the red 
field, again everywhere the largest save on the horizontal 
nasal meridian, considerably exceeds the normal limits; 
Fig. X. 
Diagrams of the fields of vision of Case XVIII, showing partial re- 
versal of the red and blue lines and contraction of the green. 34 
MITCHELL AND DE SCHWEINITZ. 
in fact, it almost equals the ordinary form field. The 
blue field, about normal in extent, follows, while the 
green field, considerably contracted, is in its usual 
position. 
This is evidently a case of spasmodic ptosis, of the 
sort described by Dr. Weir Mitchell in his lectures on 
nervous diseases. It is an hysterical symptom, and 
nearly always nocturnal in its occurrence, as in this 
case. 
The difficulty of drawing a definite line which shall 
separate neurasthenic from hysterical states is illus- 
trated by this patient’s case. 
She would be properly described as a depressed, 
somewhat hypochondriac patient, but she is hardly at an 
age when one would look for typical hysterical develop- 
ments, yet the ptosis is undoubtedly pure hysteria, and 
no organic lesion can be imagined which could cause it 
as a solitary symptom. 
The following cases may properly be classified as 
neurasthenic, and their histories are added in contrast 
to the examples of pure hysteria which have preceded 
them. 
Case XIX.—Cerebrasthenia; practically normal vis- 
ual fields; slight reversal of the red and blue lines on 
the right side. 
C. J. H.; aged forty-five; single; mechanical en 
gineer. The patient was of good habits, worked to ex- 
cess from boyhood, suffered much domestic trouble, 
especially by the death of a near relative from cerebral 
cancer, and had other worries which distressed him 
greatly. 
In 1877 lie was under treatment by Dr. Weir Mitchell 
for excessive irritability about trifles, causeless anxiety, 
etc., and recovered his health. In 1891 new annoyances 
in his family upset him again; he began to fear he 
would die from cerebral cancer, as his relative had done. 
His voice grew husky after talking; he could not articu- 
late properly at times, saying his lips failed him, or he 
could not find the word he wanted. 
Rarely, he had intolerably severe headaches in the temples or at the vertex. He was always nervous and 
frequently dizzy. As the result of his worrying, his 
physical condition became very bad. 
He sold a business which had grown by his painstak- 
ing and ingenuity to great importance, and came to Dr. 
Mitchell again for treatment. His eyes had been exam- 
ined within a year and pronounced good by a competent 
oculist. He was anxious, unable to occupy himself, and 
had never learned to take any interest in matters out- 
side of his business, which rendered his treatment diffi- 
cult. 
HYSTERICAL CASES AND THEIR VISION. 
35 
On examination, his physical condition, while it 
showed a general debility, gave no evidence of. any ma- 
terial lesion ; heart and lungs were sound, bowels and 
digestion fairly good, and the urinary examination nega- 
tive. 
He walked well, though somewhat stiffly. Knee-jerk 
and other reflexes normal. He was anaemic and under- 
muscled, and with a healthy life and out-door occupation 
readily reached a higher standard of health, when his 
cerebrasthenic symptoms soon disappeared. 
Examination of the Eyes.—The refraction was com- 
pound hypermetropic astigmatism, which had been cor- 
rected, and there were no lesions of importance in the 
fundus oculi or in the external ocular muscles.. 
The field of vision of the left eye was practically 
normal, the red and blue lines running rather close to- 
gether ; in the right eye the field also practically normal, 
except for a slight reversal of the red and blue lines 
above. These visual fields corresponded with those 
taken by Dr. Norris some time previous, who found no 
special change, save that the red and blue lines were in 
close proximity. 
Case XX.—Melancholic neurasthenia, with hysterical 
muscular hypersesthesia; normal form fields; partial 
reversal of the blue and red fields; contracted green 
field. 
E. R. S.; aged thirty; has been married nine 
years ; had one child, which lived but a few hours. Fam- 
ily history is good, so far as organic disease is concerned, 
but several brothers and sisters are all of nervous dis- 
positions, and her father suffered with nervous asthma 
throughout many years. The patient cannot remember 
to have been many days without headache since her 
childhood. She is worse since a very severe labor in 
1887, when the cervix uteri and perineum were severely 36 
MITCHELL AND DE SCHWEINITZ. 
torn and a forceps delivery was made under ether. She 
has never recovered from the depression of this illness. 
She is now (October, 1892), very nervous; cries a 
great deal; has constant headache, with periods when it 
is very much worse for a week together. Her whole 
spine is very painful and tender. She is practically bed- 
fast ; the bowels are very troublesome on account of a 
partial inability to retain fasces, from the injury to the 
sphincter muscle in the tear of the perineum, and she 
has constant nausea. She is fat, with an unwholesome 
kind of watery-looking flesh, and she suffers a great deal 
from chronic conjunctivitis. 
Examination of the Eyes.—Vision, after the correction 
of a mixed astigmatism, as follows : 
O. D. So + U2SC axis qs4- 
O. S. 50 + 3.50° axis pof. 
Exophoria 120 ; no lesions in the fundus oculi other than 
those incident to long continued eye-strain ; conjunctiva 
not insensitive, but the papillary layer thickened from 
long-standing inflammation ; refractive and muscular de- 
fects thoroughly corrected with glares and prisms. 
The field varied on different occasions, according to 
the patient’s condition, an average field being the one 
presented in the diagram ; namely, normal form, partial 
reversal of blue and red, and contracted green field, 
most decided upon the left side. At other times, how- 
ever, the visual field was practically normal. It was 
always mapped with great difficulty, owing to the pa- 
Fig. XI 
Diagrams of the fields of vision of Case XX, showing partial reversal 
of the red and blue lines without change in the form fiald. HYSTERICAL CASES AND THEIR VISION. 
37 
tient’s inability to maintain the eye with steadiness, or 
to keep it open, on account of the tendency to lachryma- 
tion. 
The obvious physical troubles were supplemented by 
a very nervous disposition on the part of the patient and 
a tendency to melancholia, and the case is one some- 
what difficult to classify, but should rather be called 
neurasthenic than hysterical. The one marked hys- 
terical symptom was a decided muscular hypersesthesia 
of the shoulders and arms and several areas of extreme 
tenderness in the spine. The vagina seemed also to be 
very irritable, so that a vaginal examination was ren- 
dered extremely difficult, and there was a small fistula 
communicating from the rectum into the posterior 
vaginal wall. 
Case XXl.—Sexual neurasthenia; hysterical halluci- 
nations ; no anaesthesia; irregular reversal of the color 
fields. 
A. B.; a man, aged forty-two; a private patient of 
Dr. Edward Martin; was sent for examination Octo- 
ber 14, 1889, to determine if possible the cause of very 
constant occipital headaches. 
Many of the symptoms of this patient were hysteric- 
al in nature, chiefly in the form, however, of imagin- 
ings. He had at the same time undergone a severe 
mental strain with great affliction in his family, and was 
distinctly melancholic. The optic nerves were slightly 
gray. There was compound hypermetropic astigmatism, 
the correction of which yielded normal vision, but no 
careful field was taken. 
More than a year after this, when his symptoms were 
rather those of neurasthenia, and especially sexual neu- 
rasthenia, a careful color field was taken, and exhibits 
conditions shown in the chart. 
Examination of Eyes.—ln the right eye the white line 
occupied its normal position; the red line was every- 
where the greatest in extent of the color fields. Next 
came the blue above, but this below was exceeded in ex- 
tent by the green field. The yellow line appears irregu- 
larly, part of the time exceeding all of the oolor lines in 
extent, but for the most part occupying the smallest 
area. In the left eye the conditions were very similar, 38 
MITCHELL AND DE SCHWEINITZ. 
except that the red line does not everywhere occupy the 
greatest extent, being exceeded by the green line below 
and also to the nasal side. The yellow line is again for 
the most part the smallest in extent. There was no 
anaesthesia in this case at any time, and with the excep- 
tion of the more or less characteristic color field, not any 
symptoms that were definitely those of hysteria. 
It is extremely difficult to classify this case. At one 
time the symptoms were markedly hysterical in nature, 
and might properly be described as hysterical hallucina- 
tions, and there had been sufficient affliction in his 
family to cause apprehension that true melancholia 
would set in; later the£e gave place to a series of neu- 
rasthenic symptoms, of which the most marked was a 
sexual hypochondriasis. It was during this time that 
the very curious fields of vision were mapped, which in 
their irregular and bizarre character, somewhat resem- 
ble those of Case VI. The patient has entirely recov- 
ered, but has never been willing to submit to another 
examination of his fields of vision. 
Diagrams of the fields of vision of Case XXI, showing irregular re- 
versal of the color lines. Compare with Case VI. 
Fig. XII 
Case XXll.—General neurasthenia ; hysterical, rapid 
respiration ; practically normal visual field. 
R. H. G.; aged thirty-two; a professor of literature; 
an intelligent, hard student, repeatedly overworked, al- HYSTERICAL CASES AND THEIR VISION. 
39 
ways worried by trifles. He has broken down more 
than once, and is now in the Infirmary with a general 
neurasthenic state. Somewhat depressed, with sighing 
rather rapid respiration. A heart strangely irritable, 
running up wildly from trifling exertion or emotion. 
No organic disease, and but little functional disturb- 
ances of any kind beyond this cardiac difficulty, and the 
rapid respiration. 
Examination of the Eyes.-—ln each eye the optic disc 
was of fairly good color, a crescent of choroiditis being 
situated at their outer portions ; the refractive error was 
myopia, and there was moderate insufficiency of the in- 
ternal recti muscles. There is practically no change 
in the visual fields, except slight concentric contraction 
of the color fields, most marked upon the left side, while 
the contraction of the green field is greatest on the 
right side. 
The following cases of spinal injury are added be- 
cause they represent, in a remarkable manner, changes 
in the field of vision, more ordinarily seen in hysteric 
states. 
Case XXIIL-—Spinal injury; hysterical anaesthesia; 
marked irregular contraction of form and color fields, 
with nearly complete reversal of the red and blue lines. 
Female ; aged thirty-nine ; mother of seven children. 
Applied for admission to the Infirmary for Nervous Dis- 
eases May, 1892, complaining of numbness in the spine, 
especially in the back of the neck, which had come on 
since a fall on the back in December, 1890, when she 
struck the nape of the neck and was for a short time 
unconscious. She broke a rib and sprained both ankles, 
and had pain in back of head for some time after- 
wards, being in bed some six weeks. She stated that 
after sitting for a time she found it difficult to rise, and 
that the headache was constant until recently, when it 
had been replaced by the numbness in the spine. 
Sensibility to touch was impaired on both hands, 
more marked in the left, and there was impairment of 
thermal sense. The face, however, was sensitive to heat 
on the left side only. The conjunctivse and the tongue 
were both insensible, and the face generally less sensi- 
tive than the body ; indeed, a prick which brought blood 
produced no expression of pain whatever. 
There was general anaesthesia, more marked on the 40 
MITCHELL AND DE SCHWEINITZ. 
left side. There could be no sensation produced on the 
upper part of the body, even by the electric brush. 
Examination of the Eyes.—The investigation with the 
ophthalmoscope reveals no lesions, and there are no 
changes of importance in the external ocular muscles; 
the pupillary reflexes are normal. The fields of vision 
show very remarkable changes ; namely, marked concen- 
tric contraction of both form and color fields, nearly 
complete reversal of the blue and red fields, and great 
contraction of the green field upon the left side. 
It was apparent that while the original shock and in- 
jury had been considerable, there was no lesion of the 
cord present to account for any of the symptoms, nor 
could anything else but hysteria have been capable of 
producing such a series of symptoms. This was fairly 
proved by the examination of the eyes, and the only 
strong fact against it was the absence of knee-jerk. 
This case of slight spinal injury, with hysterical ad- 
ditions, may be compared with the much more severe 
case of R. N., which follows; 
Diagrams of the fields of vision of Case XXIII. showing general con- 
traction and reversal of the blue and red lines. 
Fig. xiii 
Case XXlV.—Spinal injury; contraction of the color 
fields, and complete reversal of the blue and red lines. 
R. N.; female; aged thirteen. At the age of ten 
years the child fell twenty or thirty feet from a tree. 
There were no bruises or apparent injuries, and she was 
not stunned ; but immediately upon being taken up she exclaimed: “Stretch my arms and legs and fingers and 
toes.” She could not use her arms, hands, legs, feet or 
head, and suffered from a pain so intolerable that she 
could not be moved in any way. The hands and arms 
and the whole anterior aspect of her body as low as the 
hips were extremely sensitive, so that she could scarcely 
be touched, even with a soft sponge. There was early 
and entire loss of sensation to pain and touch below this 
point. She did not pass her water voluntarily from the 
beginning, and after the first few days, for three months, 
there was a constant flow of urine ; since then, however, 
the bladder is able to retain, though not to excrete, the 
urine. The bowels only moved by an enema, and the 
urine was, for the first nine weeks, very pale, almost 
watery, in its color, and extremely abundant. 
After the first few weeks the nervousness passed 
away, and she began to move her head and presently her 
arms. About the same time (the end of the first month) 
the extreme sensitiveness of the arms gradually disap- 
peared. With the exception of the contraction of the 
fingers, she has entire control of her body above the 
waist, although she is easily fatigued by sitting erect in 
a chair, and if the erect position is too long maintained 
begins to feel faint. This was the history up to Decem- 
ber, 1892. 
When the patient was first seen by Dr. S. Weir 
Mitchell (December, 1892), the following notes were 
taken: 
HYSTERICAL CASES AND THEIR VISION. 
41 
As the child lies in bed she cannot move her legs, 
although by a strenuous effort it is possible to make 
some small movements. The fingers are flexed in the 
palm and can easily be passively straightened. This is 
accompanied with some pain. The hands turn inward 
and there is no voluntary movement of the digits. The 
hands can be extended from the wrist, but not flexed, 
adducted or abducted. There is free movement of the 
forearm and shoulder in every direction, but some weak- 
ness. The head and neck are perfectly moved. There 
is complete anaesthesia up to the level of the second dor- 
sal vertebra. On the arms there is anssethesia on the 
ulnar side of the forearm and posteriorly from finger- 
tips to shoulder. The boundaries of sensation for touch, 
pain and temperature correspond, except that on the 
arms pain is felt. Plantar jerks are present. Clonus is 
sometimes present, sometimes absent. No knee-jerks ; el- 
bow-jerks marked; no marked muscular-jerk in legs or 42 
MITCHELL AND DE SCHWEINITZ. 
arms. At times, without apparent cause, the legs become 
suddenly spastic, but usually are perfectly relaxed. On 
waking in the morning the legs are always spastic. Any 
pain, as the prick of a pin, or a Faradic current, causes 
jerking of the entire leg. A prick on the head is felt, 
but incorrectly located, as if the spine could not trans- 
late the nervous message. A prick upon the feet or 
legs, when felt, as sometimes happens, is referred to the 
head; this is true of both touch and pain. There is 
more atrophy in the intrinsic muscles of the hands and 
in all the thumb muscles. There is some atrophy in all 
the arm muscles, especially in the extensors, and the 
legs are a good deal wasted. 
On examination of the spine no deformity could be 
seen. Sensitive spots were developed by percussion, but 
the position of these tender places seemed to vary almost 
minute by minute. During the examination it was 
noticed that the excitement consequent upon it had 
caused profuse sweating of the face, limited entirely to 
the right side. 
The urine was alkaline and contained some pus and 
mucus, but no casts. 
The child was of unusual intelligence, of most amia- 
ble and pleasant disposition, very quick and observing, 
and not at all hysterical. She had, with great pains and 
patience, learned to use her hands, in spite of the con- 
traction of the fingers, so that she writes better than 
most children of her age, and draws quite cleverly with 
a pencil held between the contracted fingers and the 
palm of the hand. 
Examination of the Eyes.—ln each eye there was an 
oval optic disc, the temporal half being pallid, the veins 
full and slight haze throughout the eye-ground. The 
central vision was normal and the accommodation ample ; 
pupillary reflexes natural. 
The field of vision for form in each eye is natural; 
the color fields are contracted, blue and green being 
especially narrowed; there is complete reversal of the 
natural sequence of the red and blue lines, red being 
everywhere larger. 
There was only one opportunity for making this ex- 
amination, but there seems little doubt of its accuracy, 
owing to the unusual intelligence of the patient and the 
entire absence of hysteria or suggestion. For the pur HYSTERICAL CASES AND THEIR VISION. 
43 
pose of comparative examination, a patient in the ser- 
vice of Dr. Weir Mitchell, with paraplegia from upper 
dorsal Potts’ disease, was examined, in so far as the visual 
fields are concerned, without finding any changes what- 
ever resembling those detected in the case just detailed. 
The fields of vision were entirely normal, both for form 
and color, and in the sequence in which the colors were 
appreciated. 
Diagrams of the fields of vision of Case XXIV. Normal form fields ; 
contracted color fields ; complete reversal of red and blue lines. 
Fig. XIV 
Case XXV.-—Hysterical spasm of left arm ; hysteric- 
al paraplegia; general convulsions; malingering; color 
fields normal on one side ; contraction and reversal by 
suggestion on the other. 
M. P.; aged forty-eight; tailor; German - Hebrew; 
married. Was first treated in Dr. Weir Mitchell’s clinic 
at the Infirmary for Nervous Diseases, in 1877. He was 
then affected with a violent and uncontrollable spasm of 
the left arm. There was constant rapid pronation and 
supination of the left hand, flexion and extension of the 
forearm, and slight rotation of the whole limb around 
the shoulder. If he attempted to hold anything in the 
hand the object was thrown violently over his head. 
The patient was lost sight of after a few months, but re- 
turned in May, 1891, with violent movements of the left 
arm and some difficulty in walking. 
The family history presented no cases of nervous or 
mental trouble. The patient was one of fifteen children, 44 
MITCHELL AND DE SCHWEINITZ. 
of whom eight had died in infancy. His own health had 
been always good, until the attack which first brought 
him under observation in 1877. Later in that year he 
noticed a growing weakness of the left arm and of both 
legs, first after sleeping in a draught, and again after a 
small nervous shock. He could move the legs while re- 
cumbent, but after the first few weeks could not stand. 
This paralysis continued seven years, when on the sug- 
gestion of an acquaintance, he tried successfully to walk 
backward. During his son’s serious illness he ran about 
the room for half an hour, but collapsed again after the 
excitement was over. He was treated in Germany and 
partially recovered his power of locomotion, which has 
remained fairly good since, with the peculiarities de- 
scribed below. 
He walks with two canes, holding them straight in 
front of him and leaning but slightly on them. He steps 
very short, but his gait is normal after he once gets 
under way. If he attempts to walk supported by a hand, 
without his canes, he falls in a heap, after apparently 
violent efforts to step forward. He has occasional epi- 
leptiform spasm of the left arm, which may cause gen- 
eral convulsive movements, so violent as to throw him 
down. Consciousness is not affected. These attacks oc- 
cur always after a muscular effort. A very slight sudden 
movement, such as forcibly closing the eyes, is sufficient 
to cause them. Spasms were brought on in hospital by 
massage and by hypodermic injections of water. The 
patient carried his canes and fed himself perfectly, al- 
though if ordered to perform rapid small movements 
with the hands there was some inco-ordination mani- 
fested. 
His station is uncertain with open eyes, much worse 
if the eyes were covered. Sensation is normal in all 
forms. K. J. capricious and variable; reinforcible. 
There is an attempt at ankle-clonus. He has a tender 
spot in the spine over the second dorsal vertebra. 
The patient was highly emotional, delighted with 
being observed as an “interesting case,” and always 
much worse while under observation. 
Examination of the Eyes.—Right eye: nearly round 
optic disc, gray in its deeper layers; scleral ring some- 
what broadened. Veins full and arteries contracted ; 
general rarefaction of the choroid; low myopia. Left 
eye; oval optic disc; scleral ring well marked all 
around, and broadening out into a crescent of choroidal disturbance; deeper layers of the disc gray; pupillary 
reactions prompt. In the right eye, the visual field for 
form and colors is practically normal; only slight con- 
centric contraction of the color lines. In the left eye there 
is restriction of the form field and irregular reversal of 
the color lines. This result was secured purely by sug- 
gestion. After the field of the right eye had "been 
mapped, the ordinary phenomena which take place in 
hysteric cases, so far as the field of vision is concerned, 
were explained, with the result noted in the diagram. 
HYSTERICAL CASES AND THEIR VISION. 
45 
Diagrams of the fields of vision of Case XXV. Practically normal 
right visual field ; irregular reversal in left visual field the result of sug- 
gestion. 
Fig. XV, 
This case was at the last mere malingering. At first 
there was a hysterical element, and the diagnosis made 
by Dr. Weir Mitchell was “ male hysteria.” A full re- 
port may be found in Dr. C. W. Burr’s paper on “ Unu- 
sual Forms of Spasm,”* to which we are indebted for 
the history given here in abstract. 
A rapid recovery resulted upon the withdrawal of 
the allowance made to him by a charitable society. 
It is evident, from an examination of the fields of 
vision of the first series of seven cases, in which one or 
other of the varieties of anaesthesia is a marked symp- 
tom, that the most usual abnormality is a more or less 
complete transposition of the red and blue lines, red 
*JOURNAU OF Mea'TAl, AND NERVOUS DISEASE, May, 1892. 46 
MITCHELL AND DE SCHWEINITZ. 
being the greater in extent. In two instances (Cases I 
and III) the red field is not only larger than the blue, 
but exceeds even the width of the form field, and in one 
(Case IV) there is partial reversal of the green and blue 
lines. Several of the cases, in addition to this abnormal- 
ity in the sequence of the color perceptions, are charac- 
terized by great contraction of the general field (notably 
Cases I and V); in the latter true reversal was not dem- 
onstrated, but the extreme contraction of the field ren- 
dered it difficult to satisfactorily determine this point. 
In one case only (Case VII) are the form and color 
fields normal in extent. As has already been pointed 
out, although there was anmsthesia in this case, it was 
of minor character. 
It is notable that in the patient exhibiting the least 
marked general hysterical symptoms, there is the most 
remarkable deviation from the normal standard 'of the 
visual field, namely, Case I, where, in addition to re- 
versal of the color lines, there is unusual contraction and 
binasal hemianopsia. 
In the cases classified as examples of hysterical 
hyperaesthesia the disturbances in the visual fields are 
of secondary importance ; slight increase of the normal 
extent of the color lines on the temporal side, partial 
coinciding of the red and blue lines, and moderate gen- 
eral contraction, being the only indications separating 
these fields from those which are found in normal indi- 
viduals. Deviations so trifling as these, and so uncer- 
tainly present, cannot be regarded as peculiar to the 
condition. 
■ In the cases classified as major hysteria it is notable 
that although there is contraction of the visual field in 
two of them, there is no reversal, and, in fact, no 
change which may be described as characteristic of the 
hysteric state, in spite of the magnitude of the general 
nervous phenomena. 
In the cases classified together because the most de- 
cided manifestation was local in its character, the visual 
fields present all the varieties of changes common in HYSTERICAL CASES AND THEIR VISION. 
47 
hysteric subjects. Thus, we find practically complete 
reversal of the red and blue lines, partial reversal, rela- 
tively greater contraction of the green than of the other 
fields, and what may be termed varying inequality of 
the fields, namely, sometimes partial or complete re- 
versal of the red, blue and green lines, and, again, fail- 
ure of such reversal, with practically normal extent of 
the color fields. 
It is notable that in the cases of major hysteria there 
is no reversal and also no anaesthesia, and it is equally 
worthy of remark that in the local hysterias, although 
there is no anaesthesia, yet there is also more or less 
complete transposition of the red and blue lines. 
In the cases classified together as neurasthenic pa- 
tients, the changes in the visual fields are not very 
marked, with one exception. True, partial reversal of 
the blue and red lines and contracted green fields are 
evident in two of them, but the marked nature of these 
changes is less evident than in the pure hysteric cases, 
and this has been our experience in a number of other 
neurasthenic patients, whose histories are not included 
in this list. Indeed, in many of them the fields of vis- 
ion are not far from normal, and if they exhibit any type 
of change it is that most often seen in anaesthesia of the 
retina, particularly studied by Wilbrand, a reference 
to which will be found in the earlier portion of the 
paper. 
One of these cases forms a marked contrast, the fields 
of vision being characteristically hysteric in composition, 
namely, Case XXL From the history, however, it is 
extremely difficult to classify this patient, as at one time 
his symptoms were markedly hysteric in nature, and at 
another time distinctly melancholic or neurasthenic. 
The two cases of spinal injury represent in a remark- 
able manner changes in the field of vision. In one (Case 
XXIII) there was hysterical anaesthesia in addition to 
the spinal injury—an implantation of hysteria upon a 
probable organic lesion, and consequently the reversal 
of the red and blue lines might naturally be expected. 48 
MITCHELL AND DE SCHWEINITZ. 
In the other case, with the most characteristic changes 
in the normal appreciation of the colors, and with un- 
doubted organic lesion in the spinal cord, there is no 
good evidence that there was an hysteric element. It is 
a startling case. The changes may be individual, or 
possibly may be due to spinal injury. If due to spinal 
injury, they offer an inviting field for further investiga- 
tion, although, so far as we have been able to carry this 
on by con trasting these fields of vision with other cases of 
spinal disease in about the same region, we have not 
found a similar change in the visual fields. Further 
data on this point are evidently needed. 
The concluding case (XXV) of the series, so evi- 
dently one of malingering, and yet so remarkable in its 
mimicry of symptoms which might be either hysteric or 
organic in their origin, so far as the visual fields are con- 
cerned, is an excellent example of the acceptance of 
suggestion as an aid to establishing the plausibility of 
his case. 
In conclusion we submit the following propositions : 
(i) Achromatopsia, or loss of color sense, as described 
in our previous paper (American Journal of the Medical 
Sciences, November, 1889), i*3 n°t present in the American 
cases, (certainly not as it has been described by Gale- 
zowski and other French observers). 
(2) Reversal in the normal sequence of the colors, so 
that red is the largest field, is usually present when 
there is anaesthesia, but that disturbance of the color- 
sense and anaesthesia do not necessarily belong to each 
other is proven by the fact that we have examined at 
least two cases of universal anaesthesia with no altera- 
tion of the visual fields, and a third case in which, al- 
though there was most marked contraction, reversal was 
not demonstrated. 
(3) The green field is, relatively at least, more and 
more often contracted than the others. 
(4) In the difficult distinction between certain types 
of neurasthenic and hysteric patients, the presence of 
disturbance in the color-sense is of diagnostic import; it HYSTERICAL CASES AND THEIR VISION. 
is less apt to be present in the former than in the latter, 
and yet its absence is of little meaning, as we have not 
found it in many typical cases of hysteria and have 
found it in others which are properly classified in the 
neurasthenic category. 
49 
(5) It is possible that in the rare cases of hysterical 
one-sided or general hyperaesthesia it will be found that 
colors are more acutely appreciated than is normal, and 
that the color fields are correspondingly enlarged, al- 
though we can make this only as a suggestion, having 
received a hint of it in one case, but not having found it 
in others. 
(6) The violence of the hysterical manifestations 
bears no relation to the disturbance of color-sense, 
the most marked change being found in patients 
the least affected nervously, and practically normal vis- 
ual fields where the general symptoms of hysteria, anaes- 
thesia excepted, are of the highest grade. 
(7) Some of the following changes, so far as the field 
of vision is concerned, are likely to be present in cases 
of hysteria: 
(a) Simple contraction of the color fields, with unaf- 
fected form fields. 
(b) Contraction of both form and color fields, the 
green field being relatively more contracted than the 
others. 
(c) Partial or complete reversal of the normal se- 
quence in which the colors are appreciated, most com- 
monly that variety in which the red field is greatest in 
extent. Under these circumstances the color fields may 
be normal in extent, sometimes even wider than is nor- 
mal, or there may be an associated contraction of all the 
color fields. 
(d) Unusual obscurations of portions of the visual 
field, for example, in the form of a hemianopsia,' or 
greater contraction of the fields on one side than on the 
other, the greater contraction usually being found on 
the same side with the anaesthesia. THE ALLIANCE PRESS, 
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