The Anosognosic’s Dilemma: Something’s Wrong but You’ll Never Know What It Is (Part 2)
http://opinionator.blogs.nytimes.com/2010/06/21/the-anosognosics-dilemma-somethings-wrong-but-youll-never-know-what-it-is-part-2/
2. The Illness of Doubt:
Everyone Poisons Himself in His Own Way
June 11, 1914. In a brief communication presented to the Neurological Society of Paris, Joseph Babinski (1857-1932), a prominent French-Polish neurologist, former student of Charcot and contemporary of Freud, described two patients with “left severe hemiplegia” – a complete paralysis of the left side of the body – left side of the face, left side of the trunk, left leg, left foot. Plus, an extraordinary detail. These patients didn’t know they were paralyzed. To describe their condition, Babinski coined the term anosognosia – taken from the Greek agnosia, lack of knowledge, and nosos, disease. [13]
I want to draw attention to a mental disorder that I had the opportunity to observe in cerebral hemiplegia, which consists in the fact that patients seem unaware of or ignore the existence of their paralysis . . . .
One such patient . . . hit by left hemiplegia has largely maintained her intellectual and affective faculties, for many months. She remembered past events well, was willing to talk, expressed herself correctly, her ideas were sensible; she was interested in persons known to her and asked about new people . . . No hallucinations, delirium, confusional state, confabulation. What did contrast with the apparent preservation of intelligence of this patient was that she seemed to ignore the existence of a nearly complete hemiplegia, which she had been afraid of for many years. Never did she complain about it; never did she even allude to it. If she was asked to move her right arm, she immediately executed the command. If she was asked to move the left one, she stayed still, silent, and behaved as if the question had been put to somebody else.
There were many unanswered questions in Babinski’s original paper. Did the anosognosic patient have absolutely no knowledge or some limited knowledge of her left-side paralysis? Was there a blocked pathway in the brain? Was the anosognosia an organic (or somatic) disease? Or a derangement of thought? Was she in some sort of trance? Babinski also noted that many of his anosognosic patients developed odd rationalizations. When he asked them to move their left (paralyzed) arms, they would decline to do so, offering a myriad of implausible excuses. (Furthermore, not all of his patients with left-side paralysis were clueless about their condition. Some patients had knowledge of their paralysis but were oddly indifferent to it. For these patients, Babinski coined the term anosodiaphoria, or indifference to paralysis [14]. )
Babinski was focused on one central question.
Do we have to admit . . . that anosognosia is real? I am not able to state this, and it has been impossible for me to interrogate the patients in a sufficient way to be sure about this point . . . [15]
Is it real? What is Babinski asking? Is it organic, a pathology of the brain? Is it psychological? Moreover, is it feigned?[16] We have been abandoned in a hall of mirrors. The disease that calls into question our connection to reality may itself be an illusion.
The contemplation of anosognosia leads to many questions about how the brain puts together a picture of reality and a conception of “the self.” It also suggests that our conception of reality is malleable; that it is possible to not-know something that should be eminently knowable.[17] It may also suggest that it is possible to know and not-know something at the same time. But additionally, it puts the question of how we “know” things at the heart of a neurological diagnosis, and raises questions about how we separate the physical from the mental.
The Babinski Sign, the most famous of his discoveries, is a straightforward attempt to reveal the existence of an underlying pathology (damage to the spinal cord or brain) from a simple objective test.
Babinski diagramU.S. Army Field Guide
The key is the flexation of the big toe. Stroke the sole of the foot. Does the big toe flex up or down? Up — not so good; down — pretty much O.K. And you don’t have to ask the patient, “How are you feeling?”
Babinski’s central concern was the black box of the mind and of the brain. How can we tell what is going on inside of us? Or anybody else, for that matter?
Babinski (as well as Freud) was a student of Charcot, who held the first chair of neurology at the Salpêtrière, a massive Parisian hospital complex and the center of French neurological science by the end of the 19th century. Charcot’s main focus was on hysteria, a vaguely defined disease that he believed could be tracked back to an organic defect of the nervous system — a brain tumor or spinal lesion. [18]
Babinski had been Charcot’s chef de clinique in 1885-1886 and had participated in a number of “performances” with hysterical women incarcerated at the Salpêtrière. Most of them involved hypnosis in one form or another. There is a famous 1887 painting (“Une leçon clinique à la Salpêtrière”) by André Brouillet — a copy of it hung in Freud’s offices in Vienna and later directly over his psychoanalytic couch at Maresfield Gardens, London.[19] Blanche Wittman, one of Charcot’s patients, is shown fainting in Babinski’s arms — several commentators have suggested that she appears to be in the throes of orgasm — while Charcot is lecturing to an enraptured all-male audience.[20]
André Brouillet, “Une Leçon Clinique à la Salpetrière,” 1887 André Brouillet, “Une Leçon Clinique à la Salpetrière,” 1887
A similar experiment at the Salpêtrière involving hypnosis and suggestion, and also “starring” Wittman, was described by another one of Charcot’s students, the physician Gilles de la Tourette. [21]
Tourette hypnotized Blanche W. in front of colleagues and other people, including the playwright Jules Claretie, and then ordered her to commit a crime.
Tourette: When you will be awake, you will poison Mr. G. . . .
Blanche W.: “But why do you want me to poison Mr. G.? He has done nothing to me, he’s a nice guy. I want you to poison him . . . I am not a criminal. I have no poison, perhaps I could stab him with a knife or shoot him with a gun . . . ?
Tourette: Here is a glass, I am pouring some beer and adding the poison. Now, you need to have Mr. G. drink it . . . Whatever happens, you will not remember, if questioned, that I told you to poison Mr. G.
Blanche W.: Alright, sir.
Then the patient was awakened by blowing air on her eyes. She said hello to the assembled people, chatting with Claretie, before saying to Mr. G.:
Blanche W.: My God! It’s really hot, aren’t you thirsty? I am dying of the heat. You must be thirsty . . . Here we are. (Offering the glass with the imaginary poison.) Please drink . . .
Mr. G.: Thank you, but I am not thirsty, however, I will agree to take it, but not without a kiss . . .
Blanche W.: You are demanding, but . . .
Then Mr. G. drank from the glass and fell to the floor. His body was carried out of the room. Blanche W. was then questioned. When asked whether she knew there was poison in the glass, she said there was none.[22] [23]
What are the doctors trying to demonstrate?[24] In Tourette’s psycho-drama did Wittman know that she was committing a murder? Or were Tourette’s instructions locked away in some dark corner of her brain, completely inaccessible? Was she faking it? Playing along, hoping to convince the doctors that she was doing their bidding, when she was doing nothing of the kind?[25]And what about Brouillet’s painting? It has been endlessly reproduced, but what does it portray? Were the doctors creating a delusion for Wittman or for themselves? I keep thinking of Freud’s patients supine on his rug-draped couch, staring up at a perverse spectacle of modern medicine.
couchFreud Museum, London
Charcot died of a sudden heart attack in 1893. Subsequently, his various theories of hysteria were attacked by his followers and eventually abandoned. In 1901 Babinski put forth the idea of hysteria without organic causes, hysteria that was caused by “auto-suggestion” and could be cured by “persuasion.”[26] For this condition, he coined yet another neologism: pithiatism — from the Greek words for persuasion and curable. And in 1909, Babinski published his coup de grâce, his paper on the “dismemberment” of hysteria.
All doctors now realize that the domain of traditional hysteria has been stretched beyond measure and that, at least, its supposed ability to duplicate the most diverse illnesses, “to do everything,” as it was formerly said, has been singularly exaggerated. This is an established point; but it interests me to investigate the grounds that gave rise to the former conception and the reasons that led to its abandonment. In my opinion, hysteria’s overextension has three principle causes: 1) diagnostic errors; mistaking organic afflictions for hysterical ones; 2) ignorance of the importance of deception, and classifying simulated phenomena as hysterical due to a lack of vigilance; 3) conflating nervous states that should properly be distinguished from one another.[27]
Three principles. One, diagnostic errors and three, errors of taxonomy (of nosology). But what about two? What if hysteria is unreal — the product of a willful mind, not bodily dysfunction — a performance, not a disease? I suppose the logical next question is whether it is a disorder at all. Perhaps it simply embodies a different way of interacting with the world?
The implications were unavoidable and quickly captured the imagination of the burgeoning Surrealists, who had strong connections to the evolving field of neurology. André Breton, a leader of the Surrealist movement, had been an intern in neurology during the Great War (at the hospital of St. Dizier) and a student of Babinski. Babinski, for his part, had inscribed a copy of his book “Hysteria or Pithiatism” to Breton, predicting that he would have a “great medical future.” [28]
DESCRIPTIONL’Association Atelier André Breton Andre Breton as a neurological intern, 1916.
DESCRIPTIONProperty of the Bogousslavsky Foundation Library A copy of “Hysteria or Pithiatism” signed by Babinski and inscribed to André Breton.
By 1928, Breton and fellow Surrealist Louis Aragon had written an encomium to Babinski. Entitled “The 50th Anniversary of Hysteria,” it celebrated the end of hysteria as a diagnosis and was accompanied by four photographs of Augustine, one of Charcot’s most famous patients who has since been called the “pin-up girl” of the Surrealists.[29] Breton and Aragon quoted a 1913 monograph of Babinski’s with great approval.
We surrealists insist on celebrating the 50th anniversary of hysteria, the greatest poetic discovery of the latter 19th century . . . M. Babinski, the most intelligent man who has tackled this question, dared to publish in 1913 the following: “When an emotion is sincere and profound, and it stirs the human soul, there is no room for hysteria.” And in that we have the best so far that we have been given to learn. [30]
Fifty Years of HysteriaLa Revolution Surrealiste, number 11 “Fifty Years of Hysteria” article by Andre Breton and Louis Aragon
Clearly Breton was an admirer of Babinski’s work, but it appears the influence might have been reciprocal. “Les Détraquées”(which could be translated as “The Cranks” or “The Deranged Women”), a 1921 play, was featured in Breton’s novel “Nadja.”[31] In the play, set at a private girls’ boarding school, the lesbian headmistress and a dance instructor torture and murder a young student. The authors were “Palau” and “Olaf.” Palau was a known actor and sometime author. But who was Olaf? His identify was not revealed until 1956 (in the first issue of Breton’s magazine, Le Surrealisme, même). Olaf was Babinski.
Babinski attended the premiere of “Les Détraquées” with a fake beard — using yet another alias, “Alfred Binet.”[32] The critics hated it, but Breton was smitten, and despite his avowed antipathy to the theater, attended repeat performances.
I will no longer postpone expressing the unbounded admiration I felt for Les Détraquées, which remains and will long remain the only dramatic work . . . which I choose to recall.
Photograph from NadjaL’Association Atelier André Breton Still from “Les Detraquées” as seen in Nadja.
He included in “Nadja” a photograph of the actress who played Solange, the dance instructor; a scene from the play (with an inscription that reads: “The child of a moment ago enters without a word . . .”); and a bizarre synopsis, culminating with:
. . . .The child’s bloody corpse appears, head downward, and falls onto the floor. The scream, the unforgettable scream.
I asked a friend of mine, Paul Jankowski, a professor of French history at Brandeis, to have a look at the text of the play. I was afraid of the idiomatic French and wanted to make sure I wasn’t missing anything. Ironically, the play repeats many of the themes that characterize the “performances” at the Salpêtrière — the preoccupation with persuasion and crime, and the process of remembering and “remembering nothing” that seems to be a cornerstone of human experience. But here the doctor-hero solves a crime rather than provokes one. And women are preying on each other. There is a curious detail, however. The doctor clearly believes that Solange and the headmistress are acting under some other form of mental compulsion of which, he appears to suggest at the end, they are mostly unaware.
The doctor deduces instantly that the first girl found at the bottom of a well, supposedly a suicide, and the current victim who supposedly fled the premises, were in fact murdered by the directress and the dance instructor. The inspector asks the doctor how they can now be so calm and untroubled after they had murdered someone only hours ago. The doctor explains: “Everyone poisons himself in his own way . . . anything is good to excite the nervous system . . . stronger and stronger sensations are needed . . .” and hence on to sexual perversion and sadistic murder . . . that she (the directress) remembers nothing at this point, her crisis is over, and “at least to the laymen, is as sane and inoffensive as you and me . . .”
After the student is found strangled and covered with blood, he demands not prison for these two ladies but “le cabanon,” the solitary cell where dangerous lunatics were locked up in the past. The last words are those of the inspector, “But what’s the difference?” Curtain.
In “The Surrealist Manifesto,” Breton writes,
If in a cluster of grapes there are no two alike, why do you want me to describe this grape by the other, by all the others . . . ? Our brains are dulled by the incurable mania of wanting to make the unknown known, classifiable . . . It is pointless to add that experience itself has found itself increasingly circumscribed. It paces back and forth in a cage from which it is more and more difficult to make it emerge . . . Forbidden is any kind of search for truth that is not in conformance with accepted practices . . .
Both Babinski and the Surrealists shared a common concern — an obsession with consciousness, the nature of the ineffable and “the incurable mania” of trying to classify the unknown. But in 1932, the last year of his life, Babinski wrote an intriguing letter to his friend, the Portuguese physician Egas Moniz. The letter is riddled with doubt — not just about interpreting experience, but also about the value of knowledge itself.
In the present circumstances, in the middle of so many tragic events, one may also wonder if science deserves to be the object of a cult. The most admirable creations of the human mind, contrary to all expectations, have had as their main effect destruction and massacre; with a bit of pessimism, one may curse advances in knowledge and fear that someday some discovery might have as a consequence the destruction of mankind . . . [33]
The letter ends on a somewhat more positive note but that need not concern us here.
I would like to provide one additional detail. Babinski was called in to attend Marcel Proust, and was present when the prince of the subjective died in his cork-lined bedroom on Nov. 18, 1922. The final scenes have been described in a number of biographies. This account comes from William Carter. It is Babinski who tells the truth to the family at the bitter end. Inured to sentiment, focused on evidence, he was the only one present who was not in denial.
A short time later Robert [Proust’s brother, also a doctor] sent for Drs. Bize and Babinski. At approximately four o’clock, the three doctors conferred in the bedroom while Celeste listened, fearful that Proust heard everything. Robert suggested an intravenous injection of camphor, but Babinski said: “No, my dear Robert. Don’t make him suffer. There is no point.” Then Bize left. When Celeste showed Dr. Babinski to the door, she made a desperate plea: “Professor, you are going to save him, aren’t you?” Babinski took her hands in his and looked into her eyes: “Madame, I know all you have done for him. You must be brave. It is all over.” [34]
Marcel Proust on his DeathbedThe J. Paul Getty Museum, Los Angeles Marcel Proust on his Deathbed, November 20, 1922, by Man Ray.
In the next part, we will further examine the legacy of Joseph Babinski and the tragic case of an American president with anosognosia.
FOOTNOTES:
[13] “Contribution a l’ étude des troubles mentaux dans l’hémiplégie organique cérébrale (anosognosie)” ["Contribution to the study of mental disorders in organic cerebral hemiplegia (anosognosia)"], Revue Neurologique (Paris) 1914 (XXXVII): 845-848, quoted in Chris Code, Claus-W. Wallesch, Yves Joanette, and Andre Roch Lecours (editors), Classic Cases in Neuropsychology II (Brain Damage, Behaviour, and Cognition), 2001: 177.
[14] Babinski coined many other terms, from cerebellar catalepsy and volitional equilibrations, to hypermetry, thermal asymmetry, spondylotic pseudo-tabes, and physiopathic disorders. A cornucopia of neurological neologisms. Borges has his own parable about nomenclature and taxonomy in his story The Analytical Language of John Wilkins, in which he remarks “. . . it is clear that there is no classification of the Universe not being arbitrary and full of conjectures. The reason for this is very simple: we do not know what thing the universe is.”
[15] Quoted in Code et al, 178.
[16] Babinski was very much concerned with this possibility. He writes, “. . . it is known that many patients, by coquetry, pride and vanity try to conceal the afflictions they are suffering, but in this case, the concealment would be utterly futile, since the existence of the blockade could not escape anyone’s attention.” Babinski, J., “Contribution to the Study of Mental Disorders in Cerebral Organic Hemiplegia,” in the Proceedings of the Neurological Society of Paris meeting of June 11, 1914.
[17] The question of whether anosognosics don’t know they’re paralyzed, cannot know it, or know it in some sense but can’t admit to it is part of ongoing research on the nature of anosognosia. V. S. Ramachandran in “Phantoms in the Brain” has used his various mirror-boxes, ice-water inner-ear irrigations, etc. to tease out these distinctions. I have discussed some of these issues with Ramachandran in Part 4.
[18] Andrew Scull calls it “a chameleon-like disease that can mimic the symptoms of any other, and one that seems to mold itself to the culture in which it appears.” “Hysteria: The Biography,” Oxford University Press, 2009, p. 6. An excellent article covers some of these issues: Mark Micale, “Disappearance of Hysteria: A Study in the Clinical Deconstruction of a Diagnosis,” ISIS, vol. 84, no. 3. Micale writes, “[Charcot] believed the disorder traced to a physical defect of the nervous system . . . Nonetheless, 19th century theories of hysteria remained wholly speculative,” p. 503.
[19] http://www.freud.org.uk/photo-library/detail/40068/
[20] “She swoons over the outstretched arm of his assistant, Joseph Babinski, her pelvis thrust forward, her breasts barely covered by her blouse and pointing suggestively toward the professor, her head twisted to the side and her face contorted in what looks like the throes of orgasm,” from Andrew Scull, “Hysteria,” p. 119.
[21] Brouillet is illustrating a different scene than the one described by Tourette, but it is unclear whether the painting is of a specific scene or a composite. A more detailed description of what the painting portrays will be the subject of a future essay.
DESCRIPTIONGutenberg.org A clinical lecture at “La Salpêtrière.”
[22] Tourette claimed that these “crimes” could only occur in a laboratory setting. No one could be compelled to commit a crime using hypnosis. Years later, however, he was shot by one of his patients who had been hypnotized.
[23] Julien Bogousslavsky, Gilles de la Tourette’s criminal women: The many faces of fin de siècle hypnotism, quoting Gilles de la Tourette, “L’hypnotisme et les états analogues au point de vue médico-legal,” pp. 131-5.
[24] One commentator writes, “. . . women were portrayed as suggestible automata, marionettes in the hands of masterful men who hypnotized them into reenacting scenarios of slavish obedience . . . ” Ruth Harris, “Melodrama, Hysteria, and Feminine Crimes of Passion in the Fin de Siecle,” History Workshop, No. 5 (1988).
[25] In “The Story of San Michele,” Axel Munthe, a Swedish psychiatrist and contemporary of Charcot and Babinski, provides a devastating critique of these “stage performances.” It is worth quoting at length. “To me who for years had been devoting my spare time to study hypnotism these stage performances of the Salpêtrière before the public of Tout Paris were nothing but an absurd farce, a hopeless muddle of truth and cheating. Some of these subjects were no doubt real somnambulists faithfully carrying out in a waking state the various suggestions made to them during sleep — post-hypnotic suggestions. Many of them were mere frauds, knowing quite well what they were expected to do, delighted to perform their various tricks in public, cheating both doctors and audience with the amazing cunning of the hystériques. They were always ready to ‘piquer une attaque’ of Charcot’s classical grande hystérie, arc-en-ciel and all, or to exhibit his famous three stages of hypnotism: lethargy, catalepsy, somnambulism, all invented by the Master and hardly ever observed outside the Salpêtrière. Some of them smelt with delight a bottle of ammonia when told it was rose water, others would eat a piece of charcoal when presented to them as chocolate. Another would crawl on all fours on the floor, barking furiously, when told she was a dog, flap her arms as if trying to fly when turned into a pigeon, lift her skirts with a shriek of terror when a glove was thrown at her feet with a suggestion of being a snake. Another would walk with a top hat in her arms rocking it to and fro and kissing it tenderly when she was told it was her baby. Hypnotized right and left, dozens of times a day, by doctors and students, many of these unfortunate girls spent their days in a state of semi-trance, their brains bewildered by all sorts of absurd suggestions, half conscious and certainly not responsible for their doings, sooner or later doomed to end their days in the salle des agités if not in a lunatic asylum.”
(This description, which has never appeared in the French editions of “The Story of San Michele,” was the subject of some controversy. Soon after it was published, Charcot’s son went on the attack, claiming that Munthe had not in fact been the elder Charcot’s student (as Munthe had claimed). Under pressure from Charcot’s family, Munthe’s translator omitted the chapter on the Salpêtrière from the initial French edition, and subsequent French editions remain incomplete. If the reader finds himself compulsively interested in this issue, as I did, there is an excellent biography of Munthe, Bengt Jangfeldt, “The Road to San Michele,” p. 295ff.)
[26] M.J. Babinski, “Définition de l’hysterie,” Revue Neurologique, 1901.
[27] M.J. Babinski, “Démembrement de l’hysterie traditionelle: pithiatisme,” 1909.
[28] Mark Polizzotti, “Revolution of the Mind: The Life of André Breton,” Black Widow Press, 2009. Polizzotti writes: “Babinski inspired in Breton an intense admiration. He had been the first to distinguish neurology and psychiatry as separate disciplines . . . Perhaps most memorable in Breton’s eyes was the combination of ‘sacred fever’ and casual aloofness that Babinski displayed while handling his patients.”
[29] Augustine finally escaped from Charcot’s hospital and then disappeared into obscurity.
[30] La Révolution Surrealiste, No. 11, (1928).
[31] “Le Grand Guignol: le théâtre des peurs de la Belle Epoque,” ed. Agnès Pierron. Paris, 1995, pp. 808ff.
[32] A French psychologist (who died in 1911), famous for the development of intelligence testing. Another joke?
[33] Egas Moniz, “Dr. Joseph Babinski,” Lisboa Medica 1932, as quoted in Jacques Philipon and Jacques Poirier, Joseph Babinski: A Biography, Oxford University Press, 2008. Egas Moniz won the Nobel Prize in 1942 for the development of the prefrontal lobotomy and later died from injuries inflicted by a mental patient he had operated on.
[34] William Carter, Marcel Proust: A Life. Yale University Press, 2002, pp. 807-8.
