HYSTERIA
The word 'hysteria', like 'lunacy', is evidence of a belief now
discarded. When the theory of demoniacal possession ceased to satisfy
the desire for reasons, and material explanations were sought for
certain conditions, it was supposed that the uterus (Greek, _hystera_)
came adrift from its position and wandered about the body, producing the
condition thenceforward known as hysteria. Advancing knowledge killed
this theory, but the influence of the word remained and the disease was
attributed to some derangement or irritation of the uterus and its
associated organs. Charcot, of Paris, showed the mental origin of
hysteria, but, becoming lost in a maze of hypnotism and suggestion, he
described as symptoms of the disease various manifestations which were
really called up by himself or his assistants. There are medical men who
still insist on a bodily cause, but such causes serve merely as pegs on
which to hang the symptoms.
As usual, I shrink from a definition, but in this case I have good
reason. Every writer who describes hysteria expresses his own ideas
about it, and as the ideas of no two writers are alike some definitions
scarcely seem to refer to the same subject.
Here is a definition by Babinski, a French writer of international
reputation:--
'Hysteria is a peculiar psychical state capable of giving rise to
certain conditions which have features of their own. It manifests
itself in primary and secondary symptoms. The former can be exactly
reproduced by suggestion in certain subjects and can be made to
disappear under the sole influence of suggestion.'
And here is one by Pierre Janet, a man of equal eminence:--
'Hysteria is a form of mental depression characterised by
retraction of the field of personal consciousness, and a tendency
to complete division of the personality, and subconscious mental
conditions grow and form a kind of second personality.'
And here are a few words from Ernest Jones, the chief exponent of
Freud's views in this country:--
'It is in the excessive tendency to displace affects by means of
superficial associations that the final key to the explanation of
abnormal suggestion is to be sought. Even if it were true, which it
certainly is not, that most hysterical symptoms are the product of
verbal suggestion, the observation would be of hardly any practical
or theoretical interest.'
When the reader has finished this chapter he will perhaps return to
these definitions, and see how each represents one aspect, and how the
best understanding is reached by a consideration of all of them.
The Great War has provided plenty of material for the study of hysteria,
and French and German writers have dealt extensively with it. The
paucity of English writings on the subject may indicate a smaller amount
of material, but there has been sufficient considerably to increase our
knowledge. The common form of hysteria is a mimicry of bodily disease;
pains, paralyses, contractions and joint affections most often occur,
though fits and trances are typical and there are few diseases which are
not imitated. Hysteria therefore has a superficial resemblance to
malingering, or the conscious simulation of disease for a definite end,
and many people find it hard to conceive any difference between the two.
Various criteria have been given to distinguish them, but, in my
opinion, when the question arises the distinction can rarely be made
upon physical grounds and is chiefly a matter of judgement concerning
the honesty of the patient; that is to say, the hysteric believes in his
disease as a reality, but the malingerer knows that it is fictitious. I
believe there is no definite line between the groups, though some
authorities assert that they are quite distinct. Practical experience
proves that in many cases there is an intense desire for cure which
cannot be reconciled with any consciousness of simulation, and the
apparently heartfelt gratitude often shown by the patient on recovery is
further proof of the reality of this desire.
It is a matter for regret that we have no word to take the place of
'hysteria', which is a mark of superstition; the only excuse for its
use being that every one knows that it does not mean what it says.
Popular and even professional ideas concerning hysteria are so far from
the truth that it is a pity a new word is not employed. If a man has
fought bravely for years and at last succumbed in his effort to forget
the horrors he has seen, it sounds an insult to say he is suffering from
hysteria. Yet the newer term of 'shell-shock' was worse, for it conveyed
a totally false idea of causation and treatment: to regard as due to the
concussion of a shell symptoms which are of purely mental origin led to
muddled thinking.
A common history in these cases was that the man became 'unconscious'
after a shell explosion, and on returning to consciousness found himself
mute, shaky, or paralysed. These facts led to the belief that the
condition was actually due to the physical effect of an explosion,
'shell-shock' and 'concussion' being regarded as almost synonymous. But
the same symptoms occurred when there was no question of concussion,
whilst the recoveries, often sensationally reported in the press, after
accidental or deliberate stimuli of various kinds were on all fours with
the cures wrought by Christian Science or the pilgrimage to Lourdes.
Hence the hysterical nature of the symptoms became evident and the
concussion theory faded away.
When one of these patients is encouraged to talk he often tells how he
had felt himself overpowered by the horrors of his surroundings and
forced to make increased efforts to keep going and avoid showing his
condition to his fellows--in other words, to repress his emotions. The
strain continuing, the shell-burst proved the last straw, and his
repressed feelings broke into consciousness and took possession of it;
this is what the man called being 'unconscious', but the condition is
really an abrupt dissociation. In course of time--hours, days, or even
weeks--he comes to himself again, and once more his feelings are buried;
but now he is a hysteric, and his buried feelings--his dissociated
stream--produce and maintain his symptoms.
In whatever way the hysteria arises the developed symptoms are the
result of a mental activity which is powerful enough to overcome for a
long time the desire for recovery. There are two streams of thought--the
one desirous of cure and the other engaged in keeping up the
symptoms--and we recognise an extreme example of continuous
dissociation, in which the main stream is not only unaware of the
existence of the other and unable to control it, but in which the
results produced by the dissociated stream are antagonistic to the
desires of the main personality.
This conception accords fairly well with Janet's definition as given
above, but though it gives us a description of the disease and indicates
its relation to other phenomena we have yet to understand why the
dissociation occurs. This is a difficult problem, and one to which
several answers can be given. I have suggested one above, and Freud
supplies another, which he applies not only to hysteria but to allied
nervous conditions. What follows is not an exposition of his ideas, but
rather my interpretation of such as are acceptable and useful to me. A
complex, which according to Freud usually centres around an infantile
sexual desire, is repugnant to the consciousness and becomes repressed
as a result of conflict in just the same way as a memory is repressed.
The complex is kept thrust down in the unconscious, but always tends to
produce effects; it may do so in dreams or may obtain symbolic
representation in the form of a neurosis, especially in times of stress.
Besides the primary aim of expressing repression by a symbolic
representation, Freud admits a 'secondary function' of the neurosis by
which the patient may derive some advantage from the disease.
Here is a case capable of explanation by the Freudian hypothesis: A man
said he had fallen on to the blade of an aeroplane propeller and bruised
his neck; he complained of severe pain in one side of his neck, with
twitching of the arm on the same side, which continued for months. It
was found that the patient, who was apprenticed to engineering, had such
a deep-seated fear of making mistakes that he had sometimes stayed at
the workshop for hours after the day's work was over in order to
familiarise himself with the use of tools; but in spite of this his fear
increased, until the handling of a file or spanner produced feelings of
anxiety. Then he joined the army. Being put to work at aeroplanes he
tried to do his duty and succeeded so far as to be made a corporal,
saying never a word about his fears and banishing them as far as
possible from his thoughts. At last the repression broke forth and took
symbolic form in pain, the expression of his fear of the machinery which
was blamed as its material cause. No account can picture the emotion
produced by the recall of this complex, and it was evident that his
feelings were intense and of more importance to him than one unfamiliar
with such cases would suppose. His pains ceased when the cause had been
revealed, and, what is very important, when he was told that he could
not be expected to work at machinery. It must be added that the
out-and-out Freudian would not be satisfied with this explanation; he
would trace the cause of the original fear of making mistakes, and would
expect to find it in some repression of infantile desires or fears.
Certainly I have a feeling that the case had only been half
investigated, but it will serve as a simple example of symbolic
representation.
The 'secondary function' of this neurosis is plain: the patient
succeeded in keeping away from machinery all the time the pain lasted,
and his anxiety symptoms were powerful enough to lead to his removal to
another kind of work.
This leads on to Adler's theory,[15] which, like Freud's, is based upon
conflict and repression, but regards the hysteria as derived from the
'Will to Power'. The potential neurotic has a feeling of inferiority
combined with a desire to be master of his own fate, and, since direct
attainment of this desire is impossible, the end is striven for by a
fantasy or fiction produced by the unconscious. This view, thus baldly
put, shows a relation between hysteria and malingering, and, returning
to the case of the prentice engineer, we can see his work in the shop
becoming more and more distasteful whilst his anxiety tended to become a
means of escape; then in the army the neurosis took a more determined
form which might be confounded with malingering by an observer who
assumed that all actions were the result of conscious motives.
[Footnote 15: _The Neurotic Constitution._ Kegan Paul.]
My present opinion is that the theory of repression offers the only
explanation of many cases of hysteria. This applies particularly to
those cases where the symptoms represent a permanent state of
embarrassment or fear, such as stammers and tremors, and to the
unreasonable fears and impulses, the phobias and obsessions, of the
war-strained soldier. As an example I will quote a case of a soldier who
had an impulse to attack any single companion, which was cured by
bringing into consciousness the repressed memory of a gruesome
hand-to-hand fight in which he killed his opponent. The repression was
so complete that after its first revival under hypnosis it was
'forgotten' again and again at subsequent interviews in the waking
state. This example illustrates Freud's 'tendency to displace affects.'
The repressed complex contained within itself the impulse to fight;
this 'affect' reached consciousness and an object had to be found for
it, the object being the single companion of the patient.
As regards those hysterias in which the secondary function is
conspicuous, I incline to the 'Will to Power' theory, and add to it the
'repression of the consciousness of deceit.' To illustrate this, let us
trace the growth of a case of hysteria. Imagine a girl who is
'misunderstood', who has her round of daily tasks and feels that she was
meant for higher things, that she ought to be loved and obeyed instead
of being subject to the will of others. To no one can she tell her
thoughts and troubles, sympathy is denied her, and she sees no hope of
satisfying her desires or changing her position in the world.
Or imagine another type, the pampered girl who has never had to face a
trouble or unpleasant task and has come to regard her own wishes as the
supreme law, until at last the time comes when some desire, some wish
that she cannot or will not face and conquer, remains ungratified. She
feels the need to express her feelings, to obtain that sympathy that she
thinks she deserves.
In either case there comes the hysterical manifestation, and here I will
quote from Jung[16]:--
'But, the astonished reader asks, what is supposed to be the use of
the neurosis? What does it effect? Whoever has had a pronounced
case of neurosis in his immediate environment knows all that can
be "effected" by a neurosis. In fact there is altogether no better
means of tyrannising over a whole household than by a striking
neurosis. Heart attacks, choking fits, convulsions of all kinds
achieve enormous effects, that can hardly be surpassed. Picture the
fountains of pity let loose, the sublime anxiety of the dear kind
parents, the hurried running to and fro of the servants, the
incessant sounding of the call of the telephone, the hasty arrival
of the physicians, the delicacy of the diagnosis, the detailed
examinations, the lengthy courses of treatment, the considerable
expense: and there in the midst of all the uproar, lies the
innocent sufferer to whom the household is even overflowingly
grateful, when he has recovered from the "spasms".'
[Footnote 16: Loc. cit., p. 389.]
But the end is not always thus. There are victims of hysteria whose
symptoms continue for months or years, till cure seems impossible,
although, as I have said before in this chapter, there is present in the
consciousness a strong desire for recovery. Let us imagine the patient
complaining of severe pain in one foot: the sympathising friends tend
her with care and affection, the doctor suspects the early stage of some
bone disease, and, as is the fate of so many practitioners, he is urged
by the friends to say 'what is the matter.' Then the supposed disease
receives a name, muscular action pulls the foot into an abnormal
position, deformity appears, and if the true nature of the disease is
now discovered not only the patient but the friends and family need the
most careful treatment.
What has been happening all this time in the mind of the patient? We
will assume that she knew at the beginning that her pains were
fictitious; what course is now open to her if she wishes to end the
deceit when her friends, by their pardonable credulity, have allowed
themselves to be deceived and her troubles have been accepted by the
doctor as real? Her pride or self-respect prevents open confession, and
in her ignorance of the course of the supposed disease she thinks an
unexpected recovery will reveal the fraud. Here are the materials for
another mental conflict, and her alternatives are:--
1. To solve the conflict by confession or recovery, and I have shown the
difficulties of this course.
2. To build a logic-tight compartment; to say, for example, 'They have
never given me a chance, and now I am quite right in imposing upon them
as long as I can.' But her feelings concerning right and wrong are
probably too strong to maintain this attitude indefinitely.
3. To repress the consciousness of deceit and maintain her symptoms as
the price of her peace of mind.
This last course is followed, and the patient is now a Dissociate. In
the dissociated stream are:--
1. The original desires which led to the manifestation of disease--the
desire for sympathy, the desire to have her own way, the 'Will to
Power.'
2. The knowledge of deceit.
3. The mechanism for maintaining the symptoms--the pains, the paralysis
or contracture.
This stream is now independent of the main personality and out of its
control; as far as the patient knows her pains are real, her deformity
is a disease, and whoever doubts it is not only ignorant but cruel. We
can now understand the capriciousness of the hysteric, her moods and
contrary ways. On the one side is a mind with ordinary motives, and on
the other is the split-off portion containing the complexes catalogued
above. If the reader thinks this conception brings us back to the old
one of demoniacal possession I will admit that the only difference lies
in the definition of the demon.
The description of this imagined case will perhaps be acceptable to
those who believe in the connection between hysteria and malingering.
This connection I at one time emphasised, and I still believe that in
some cases the repression of a knowledge of deceit plays an important
part in the development of the disease. But motives are derived more or
less from the unconscious, and when the unconscious elements predominate
we approach the condition in which there has never existed any
consciousness of deceit. The case of the soldier with an obsession to
attack his companion does not admit of the hypothesis of a stage in
which the symptom was due to a conscious desire to any end: but his
repression might have shown itself, let us suppose, in a paralysis of
his legs as a symbol of exhaustion or terror. Then we should have a
hysteria in which there had never been any deceit complex, though in the
absence of knowledge of the workings of the patient's mind a firm
believer in the 'Will to Power' theory might attribute the origin of the
condition to a definite desire to escape the strain of war.
I can now state that some of the results of conflict between desire and
reality form a graduated series, beginning at cases of conscious
simulation, then passing on to those of hysteria with repression of the
knowledge of deceit, and ending with cases where deceit has never
existed; but no one theory explains satisfactorily the origin of all
cases of hysteria.
It is difficult to understand those cases in which the hysteric inflicts
injuries upon him or herself; the individual who thrusts needles into
his body and comes to hospital again and again to have them removed is a
curious but not very uncommon object. An ophthalmic surgeon of my
acquaintance had a patient who placed irritants under the lid of one eye
till the sight was lost and the organ was removed, and the process was
begun on the remaining eye before the trick was discovered. Such things
occur in the history of malingering, and what the consciousness can do
the dissociated stream is equally capable of doing: the only difficulty
is the very practical one of believing that the patient can carry out
the necessary action without being fully aware of what is happening,
unless we assume an abrupt dissociation with the main personality
temporarily abolished.
Certain hypnotic experiments throw light upon this difficulty, which
also occurs in connection with some spiritualist phenomena. It has for
long been disputed whether mental processes can produce bleeding into
the skin or blisters upon it. Such bleedings were the 'stigmata'
representing the marks of the Crucifixion, that have been described as
appearing upon the bodies of religious devotees, and they have been
thought to be real and due in some way to auto-suggestion.
Hysterical subjects often show the production of raised wheals if the
skin is lightly stroked with the finger-nail or the head of a needle;
one can write a word upon the skin and watch it become visible. This is
purely a circulatory phenomenon, but experiments have been made under
hypnosis in which the skin is touched with a pencil and the subject is
told that he is being burnt and that a blister will follow. Success has
been claimed for this experiment, but one source of error is hard to
exclude. If a blister appears the next day, and the subject is known to
be an honest man with no end to gain by cooking the experiment, an
observer might be inclined to accept the result as due to the direct
influence of suggestion; but the subject is, by the terms of the
experiment, in a state of dissociation, and in the dissociated
personality exists the suggestion that a blister should appear. In
addition there exists the desire to carry out the wishes of the
hypnotist, and since this is out of the control of the main personality
whose honesty is accepted as sufficient guarantee against fraud he must
nevertheless be regarded as willing and eager to produce a blister.
Milne Bramwell[17] quotes a case in which suggestion, under stringent
conditions, apparently produced blistering: the subject's arm was then
enveloped in bandages in which sheets of paper were incorporated, and
after further suggestion and a night's rest it was found that, although
the subject had been watched continually, she had succeeded in
penetrating the bandages with a hair-pin. A further experiment, in which
the arm was enveloped in plaster of Paris bandage, gave a negative
result. This experiment is very valuable; it does not disprove the
possibility of producing blisters by suggestion, but it does prove that
if we judge the Dissociate by ordinary standards we expose ourselves to
victimisation. If I were the subject of such an experiment I should
certainly require that every precaution should be taken to prevent me
from producing a blister by mechanical means.
[Footnote 17: _Hypnotism_, 3rd ed., 1913. Wm. Rider & Son.]
Now let us consider the signs of the disease. In the chapter on
suggestion I showed that in a limb paralysed by hysteria the loss of
sensitiveness, the so-called hysterical anaesthesia, resulted from a
desire on the part of the patient that the doctor should find what he
was looking for, and this desire I called receptivity. The receptivity
is at first necessary to keep up the deception, for the patient does not
know the symptoms of the simulated disease, and must always be on the
alert to pick up hints. When dissociation occurs, the receptivity finds
its place in the split-off stream, forming part of the mechanism for
keeping up the symptoms; but having passed out of the control of the
main personality it tends to become exaggerated and misdirected.
Hence the hysteric becomes very suggestible and all kinds of fantastic
symptoms may be produced. If the resistance to recovery is not great
then suggestion may even remove symptoms, just as it created them; and
if we now turn back to Babinski's definition we shall find that it fits
into our theories, although it concerns itself with only a restricted
view of the subject.
Since one object of the dissociated stream is to maintain the symptoms,
it follows that any method that will remove them may abolish the
dissociation, though still leaving the patient with those desires and
conflicts, conscious or unconscious, which preceded their appearance and
which form the so-called 'hysterical predisposition'. This explains the
success which has followed the employment of exorcism, Christian
Science, nasty drugs, cold water, electric shocks, persuasion, or rest
cures; and to this list, I hasten to admit, some people would add
treatment according to the method of bringing repressions into the light
of consciousness.
I have tried to make clear the subject of hysteria for the following
reasons: There is at the present day no school of believers desirous of
attributing supernatural causes to the disease, and therefore I am
spared the task of attacking a mass of credulity; and, further, the
mental processes are identical with those shown in other phenomena
concerning which credulity is still powerful. I can now proceed to show
how the theory of dissociation explains the production of the spuriously
supernatural by the apparently honest.