Phantoms

When the eleventh volume of the Archives de Neurologie appeared in 1882, it contained an extended medical study by a physician whose name remains to this day little known outside France.^[1] He was Jules Cotard, a French neurologist born in 1840 who had studied medicine in Paris with Paul Broca and Afred Vulpian before working under Jean-Martin Charcot at the famous clinic of the Salpêtrière Hospital. Cotard began his essay with a tribute to C. Lasegue, the physician who had published “an important report” in 1856 on melancholic ailments, paying particular attention to persecution delirium. Cotard recalled that the 1860s and 1870s had witnessed significant progress in research into the diverse symptoms and structures of melancholia.^[2] But much more was still to be learned in the study of melancholia. Scholars, he noted, “have offered careful descriptions of simple melancholia, melancholia with stupor, and anxious melancholia; they have established that these forms are often intermittent, that sometimes they become continuous and chronic.”^[3] Nonetheless, Cotard wrote, “the characteristics and the successive phases of the delirium that end in this chronic state have not, to my knowledge, been the object of any study equivalent to the study offered for persecution delirium.”^[4]

Cotard declared that he would now “exhibit a particular development of delirium,” to which, in accordance with scientific custom, he proceeded to assign a technical name: “negation delirium.”^[5] He quickly explained the designation. “If one asks them what their name is,” Cotard wrote, introducing the ailing patients he would now discuss, “they do not have one.” If one asks them their age, “they do not have an age.” “Where were they born? They were not born. Who were their father and mother? They have no father, mother, and no children.”^[6] But these melancholics of negation presented the physician with a further characteristic, which was even stranger, for it touched on the physiological object of medicine itself: the body. When asked if they suffered from headaches, stomach aches, or “pains in any part of the body whatsoever,” these delirious patients answered in terms no less astonishing for their simplicity. “They have no head. They have no stomach. Some,” Cotard wrote, “have no body.”^[7]

A few pages later, the psychiatrist offered a summary typology of the ailments he believed himself to have identified. Before introducing a host of clinical evidence, he explained that he would adopt a threefold system of classification, distinguishing between several categories of a single malady: those “cases in which negation delirium presents itself in its simplicity”; those in which negation delirium is, by contrast, “symptomatic of general paralysis”; and finally, those in which negation delirium is associated with persecution delirium, constituting “forms of complex alienation,” such as “ideas of ruin, guilt, distrust, and persecution” which “almost all other authors” had failed to tell apart from straightforward melancholic delirium. As illustration, Cotard proceeded to offer a selection of clinical cases, drawn from the notes he had taken as a practicing physician at the psychiatric center of Vanves in the 1860s, 1870s, and 1880s:


Cotard published reports of a total of eleven such cases, to which he added a series of bibliographic indications for further study, as well as a synoptic table in which he presented the similarities between the negation delirium he had observed and the persecution delirium considered by others before him.^[12] By the conclusion of the second portion of his study, which bore the programmatic title “On Negation Delirium” (“Du délire des negations”), the defining traits of the new ailment were beyond all doubt. The various melancholic patients the French psychiatrist had observed suffered, in different ways, from a single sensory delusion: with great insistence, they all felt the lack of bodily parts that they nevertheless did, by all objective accounts, possess. 


Cotard’s two-part paper of 1882 was followed by three further clinical and theoretical contributions to the study of forms of melancholic deliria: an essay on “Loss of Mental Vision in Anxious Melancholia” published in 1884, an inquiry “On the Psychomotor Origin of Delirium” of 1887, and a note on “Enormity Delirium” which appeared in 1888.^[13] That year the psychiatrist’s contributions were abruptly interrupted: the French physician had been assiduously treating his own daughter at Vanves when he acquired and succumbed to a case of diphtheria. Three years later, in 1892, his colleagues dedicated the third annual conference of their association for the study of mental illness to his memory.^[14] The report on the “conference of Blois,” as it is called, contains mention of contributions by such figures as Falret, Garnier, Charpentier, and Jules Séglas, who had himself published a response to Cotard’s “Negation Delirium” as early as 1887, entitled “Anxious Melancholia with Negation Delirium.” It is at this point that the psychological phenomenon identified by Cotard can be said to have entered the clinical vocabulary of nineteenth-century French psychiatry as a whole, above all through its definition as a “psychic state proper to the chronically anxious,” and, therefore, less as a “delirium” in its own right than as a “syndrome”: “the Cotard syndrome,” as E. Régis baptized it at the conference of 1892, and as it would subsequently be known.^[15]

Discussing the curious syndrome in a lecture on “Anxious Melancholia and Negation Delirium” given and published in 1894, Jules Séglas argued that the ailment identified by Cotard could in fact manifest itself in several distinct forms, which ought to be clearly separated by the clinician and the theorist.^[16] Each form of the malady could be defined, he argued, by the type of object it involved. An anxious melancholic may, first, deny aspects of his or her “moral or intellectual personality.” “He would then declare, for example, ‘that he no longer has a heart, no longer has feelings, no longer has a mind, and that he no longer thinks.’”^[17] He may also negate objects in the external world. “One shows him a flower,” for instance, “and he denies that it is a flower; there is nothing around him, neither things nor people; he is in a void.”^[18] And, finally, he may deny his “physical personality.” “This,” Séglas wrote, “is the hypochondriac of negation,” the figure so vividly evoked in Cotard’s first essay. “The patient says: ‘I no longer have blood; I no longer have veins; I no longer have a brain; I no longer have genital organs. I am as empty as a cupboard.’”^[19]

Such symptoms of unease may appear to be remarkable and even unique. But they bear more than a passing resemblance to a better-known set of sensorial delusions identified in modern medicine only a few years earlier in the US. Barely a decade before Cotard revealed his findings to French psychiatry, Silas Weir Mitchell had described and analyzed a startling variety of perceptions that he attributed to bodily parts he boldy named “phantom limbs.” A physician in the Army, Weir Mitchell had collected ample evidence of the phenomenon working in the Civil War and in its aftermath. “Nearly every man who loses a limb,” Weir Mitchell explained, “carries about with him a constant or inconstant phantom of the missing member, a sensory ghost of that much of himself, and sometimes a most inconvenient presence, faintly to be felt at times, but ready to be called up to his perception by a blow, a touch, or a change of wind.”^[20] “There is something almost tragical, something ghastly,” he commented, “in the notion of these thousands of spirit limbs haunting as many good soldiers, and every now and then tormenting them with the disappointments which arise when, the memory being off guard for a moment, the keen sense of the limb’s presence betrays the man into some effort, the failure of which of a sudden reminds him of the loss.”^[21] Like a specter, the phantom limb could fade away, only to return unanticipated years after its disappearance, and then to vanish again; but even when felt as present, the neurologist explained, the absent member could not clearly be situated with respect to the seen body, being “rarely felt as a whole.”^[22] With the sensed body, without being one with it, the “ghostly members” introduced into the field of bodily sensation a perplexing perception, which seemed hardly a perception at all.


To be sure, certain differences between the sensory delusions identified in the 1870s and 1880s in the United States and in France are beyond all doubt. The first of the two ailments is neurological in nature and can be explained with reference to the functions and dysfunctions of the sensory apparatus in its physiological structure. The malady described by Cotard, which is psychiatric and psychological in kind, points, by contrast, to an anxious melancholia. But the sensation of the phantom limb and the perception of the negated part also bear resemblances that can hardly be denied. To be more precise, one seems, in truth, the mirror image of the other. A moment’s reflection suffices to grasp the point. Those who suffer from what the American physician termed “neural maladies of stumps” feel limbs they do not possess, just as if they did; those who suffer from “deliria of negation” fail to sense the limbs they, in fact, do possess. One might easily multiply such formulations. The patients described by Weir Mitchell sense in their bodies a presence none but they can see; those identified by Cotard, instead, sense in their bodies absences that none but they will grant. The first of the two sets feel themselves to possess that which, by all accounts, they lack; the second feel themselves to lack that which, by all appearances, they do possess. 


In all these variously deluded sensations, the reality of one fact cannot be denied. The nineteenth-century perceptions of parts in presence and in absence remit those who feel them to a being, affirmed or negated, which is neither a thinking thing within them nor an extended thing beyond them, neither their own consciousness and mind nor any worldly object clearly external to themselves. In feeling themselves to be more and less than they seem beyond all doubt to be, the veteran and the melancholic patients bear witness to a common difficulty of representing the nature and parts of their own organic mass. They suffer from a disturbance of the faculty that the nineteenth-century physicians, and many after them, called “coenesthesis”: the sensation of the organism as a living mass. Feeling the presence of limbs where they are absent, sensing the absence of parts where they are present, the patients described by Weir Mitchell and by Cotard cast an unexpected light on the perceptions that sentient beings possess of their own bodies. For those perceptions, the nineteenth-century figures all suggest, are perceptions of phantoms: beings that, felt in presence or in absence, are by scientific standards none at all. 


“Delusion” is one name for such a feeling, which cannot be referred to any object seen and named by the specialists in the study of the body and the soul. And the neurological and psychiatric patients described by Cotard, as by Weir Mitchell, seem without doubt to have been, in part, deceived about the internal and external extensions of the bodies they called their own. But the truth of the matter is more complex than such a summary judgment would suggest. For however deranged they seemed and still seem today, the sensations of the nineteenth-century patients contained at least one veritable discovery. All the men and women who failed to feel themselves where they truly were, like those who felt themselves to be where they in fact were not, perceived a fundamental fact few scientists and thinkers in their age and after it have registered with equal force: the ultimate delusion may be to believe that sentient beings, in sickness or in health, could perceive their bodies to be wholes composed of anything but ghostly parts.