Body: | On the Pathology and Treatment of Hysteria
Robert Brudenell Carter
1853 AD
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Introduction:
In 1853 AD, Robert Brudenell Carter, world renounced
ophthalmologist, wrote his first book on hysteria and faking insanity.
Having concluded much of insanity was pure faking, he lost interest in
psychiatry and specialized in eye surgery. It is a truly remarkable, "must
read" book. Most important, Carter recognized that the physical symptoms
were caused by the power of the mind: "That emotion is a force adequate to
the production of very serious disorders in the human frame, acting upon
the muscular, vascular, and secreting organs, and causing various
derangements both of their structure and function,-the proclivity to its
influence being greatly increased by the operation of all debilitating
agents, whether local, or general, and by all circumstances tending to make
individual parts the subjects of attention." While psychiatrists in the
1940's actively treated hysterics as insane because of physical problems
with their bodies, Carter saw the symptoms as having their origin in the
freewill of the human spirit: "in some cases, to a short attack of laughter
or sobbing; and in others, producing very energetic involuntary movements,
maintained during a considerable time, and occasionally terminating in a
period of catalepsy or coma". He also mentions: epileptic type fits,
vomiting, drooping eyelids, muteness. For this reason, he would oppose the
chemical psychiatrists today who always prescribe drugs that never cure:
"Against ... hysteria ... I should regard all medicines to be absolutely
useless and inert." It is clear that Carter viewed hysteria as a blatant
and deliberate deception where a person acts like they are insane or sick
in order to gain sympathy, attention or be excused from life's
responsibilities and be catered to. In the case of Sarah W. he noted, "the
convulsive movements continued for upwards of two hours without the
smallest abatement; and then, becoming gradually less violent, were at last
succeeded by a state of perfect catalepsy, which lasted nearly an hour, and
yielded in its turn to sleep" Carter viewed both men and women as
hysterics, but noted: "greater proclivity of the female sex to hysteria,
and also for the absolute rarity of its occurrence in man". Although he is
wrong about the sex drive being the etiology of hysteria, "Women of strong
[sexual] passions ... are especially liable to hysterical attacks." he
correctly identified that much of mental illness was like a cunning stage
performance for personal gain. "The subjects of tertiary hysteria may be
advantageously divided into two classes, which fade imperceptibly into each
other, and yet present a sufficiently marked difference in their respective
types. The first will comprise women whose sexual propensities have been
disappointed, but whose lot in life may be in all other respects desirable;
and the second those in whom some form of envy or discontent is the
predominant feeling." Carter describes their motives as being driven by
"envy", "discontentment" unhappy with their position in life, "desire for
sympathy" ... "an union of selfishness and deceptivity, allied in order to
indulge that desire for sympathy" Carter lays "down rules for the detection
of malingerers" and describes the mentally ill: "ingenuity of the
performer" ... "The motives by which hysterical women are actuated, in the
performance of their objectless deceptions and self-imposed penances, are
remarkable no less for their strength than for their obliquity". Narcissism
is always present, since the mentally ill get all kinds of undue sympathy
and attention. "It is scarcely to be doubted, that if a girl who has
thought herself neglected and uncared for, becomes the subject of a primary
paroxysm, her chief feeling on recovering from it will be one of
gratification at the fuss that has been made about her, and at the
temporary oblivion to which all other things and persons have been
consigned in honour of her illness". This is shockingly opposite to what
mental health officials do today when they lie to the public that mental
illness is just like a heart attack, which demands no personal
accountability or fault and heaps of sympathy. But Carter understood 150
years ago, that people deliberately fake a mental illness: "discovered her
own power of producing an attack" ... "an extraordinary development of
cunning, by means of which hysterical women often carry out most
complicated systems of deception, and succeed in baffling". Since hysterics
love attention and to be considered special and unique, Carter has this
advice: "destroy the impression, that there is anything remarkable, or
singular, in the particular case under consideration, which must always be
spoken of as most ordinary and common-place". Carter noted that upstanding
women in churches were often targets of sympathy: "Small, or very
enthusiastic religious communities, are the most usual victims of this kind
of imposture, which is constantly practiced upon the benevolent ladies of a
village". Unlike many of the mad doctors before him, Carter openly
recommended hysterics attend church as a positive cure: "Whenever,
therefore, the kind of religious teaching which is likely to be beneficial,
can be obtained, it must be used and appreciated as a most important aid".
Carter practiced "moral treatment" which avoided the outright torture of
the previous century seen in most mad houses, but specifically targeted the
hysteric's personal conduct and thoughts in order to bring them into
repentance for their sins. Although he noted that torture did work in some
cases, he opposed them at ineffective because the hysteric often had the
will to endure in order to escape detection as a faker. "Moral treatment
has been put in practice against hysteria in a very large number of cases,
by the use of various harsh measures ... in isolated cases, been
exceedingly successful; thus showing that some right principle was involved
in their application"... "these harsh measures failed more frequently than
they succeeded". While he accepted the fact that torture indeed "cured" in
some cases, he realized that most hysterics were prepared to endure even
torture, to gain the desired sympathy, attention and special privileges
associated with "being sick". "that a girl who yielded to a few duckings
[cold water baths], and a little discomfort, would have to suffer the
disgrace and degradation consequent upon detected imposture; while one who
passed safely through the ordeal, would be considered by her friends to be
really the victim of disease; and the discerning doctor who subjected her
to harsh treatment, would be condemned by them as a monster of ignorance
and inhumanity ... that a certain amount of perseverance on her part, will
exalt her into a martyr in the eyes of her family, and will enable her to
bid defiance to professional denunciations". In other words, by enduring
the torture, she got way more sympathy and attention than if she had not
been tortured. It also made her look morally better than the very doctors
who were fully aware of her fraud. "the system which is about to be
described, acts by wearing out the moral endurance of the patient, and also
by taking from her all motives for deception, or for the voluntary
production of convulsive attacks" In the first stage of treatment, Carter
recommends deceiving the deceiver! "indulge her in every trifling bad habit
(that of breakfasting in bed for instance) ... some pleasantly-flavored
medicine ... completely deceive her as to the nature of the treatment which
she has to undergo". Then when she has been observed for some time with her
guard down confront and rebuke the hysteric and attempt to bring them into
repentance: "commence by a positive assertion that she has nothing at all
the matter with her, and is, in reality, in perfectly good health ; her
ailments being, one and all, fraudulent imitations of real disease. Such a
statement will usually be met by an indignant but still half-frightened
denial of its truth ... exhibit violent anger ... obstinate taciturnity
[silence] and sullenness ... expressions of anger and wonder, mingled with
tears and sobs ... a tempest of indignation, violently repudiates the
charges brought against her ... jumps up from her chair, overturns it, and
exhibits furious passion ... as the storm of her words has abated for lack
of breath, she must be told to sit down, and to conduct herself like a lady
... obstinate, irritable, and frivolous. ... the patient is very ingenious,
and practises many devices before yielding ... [they] trust in their
sullenness as their most effectual shield". In other words, hit dogs howl.
Today, this kind of reaction is to be always expected when treating the
mentally ill, when you tell them they do not suffer from a chemical
imbalance, there is nothing wrong with their body, and their problems are
the result of their own personal and moral choices and they are to be held
at least partly personally responsible for their problems. Carter suggests
blackmailing the hysteric by "exposing the fraud" unless they quit acting
insane. It worked! "he will abstain from exposing her, either to the
members of her own family or of his, so long as she manifests a sincere
desire for amendment" ... "The dread of losing caste [shame] by such a
discovery, would be a strong inducement to a girl who was under treatment
in her own home, to hold out to the very last, and would keep alive a
motive, which it should be the first object of the medical attendant to
destroy. Now and then cases will be met with, in which the patient is
heartily weary of, and sorry for, the system of deception which she has
commenced, and waits only for the smallest help from a wise and friendly
hand, to abandon practices which she would have left off before, had she
known how to do so without exciting the suspicions of her friends." He even
suggests assisting the faker from shame, by inventing cures that are as
false as the disease being faked. This was in order to create the false
appearance to the hysterics friends and family that they really were
suffering from a bodily disease. "she must be well assured herself that
these pretended remedies are perfectly inoperative; and she must be
encouraged to exertion by the threat of exposure, if she fails to get rid
of each symptom within the specified time". He gives a timeline for the
patient to obey, in order to make it appear she is being cured slowly over
time: "any self-produced ailments besides the hysteric paroxysms, as
vomiting, ptosis [drooping eyelids], aphonia [muteness], or the like, she
should be told to leave them off within a certain time, as a week or a
fortnight." Carter notes that often hysterics chose to display the wrong
symptoms of a disease exposing her "forked tongue" of deception, but others
are almost perfect chameleons of deception that only a trained medical
doctor can discern. "she will almost inevitably either be unfortunate in
her original selection, or inconsistent in her collocation of symptoms, and
thus betray the cloven foot; but when a cunning woman, in playing her last
stake, simulates a disease which she has had ample opportunities of
observing ... her medical attendant will have need of all his
discrimination". He stresses that the treatment must "conduce to her
humiliation and shame, must be brought fully before her" ... "until ... the
patient exhibits signs of contrition and regret ...any sign of penitence".
... "She must be told, at first, that the way in which she is treated will
depend entirely upon her own behaviour, and that if she manifests causeless
sulkiness or rudeness, she will be left to her own companionship, and to
her own resources for amusement and occupation, until she has made proper
atonement for her error" Carter notes that godless people will fix
themselves because of "The fear of shame and exposure, the fear of the
world's opinion, the desire to gain credit for resolution, or self denial,
or cleverness, will often produce a change of action in persons with whom
the fear of God is an empty sound, and to whom the necessity of doing
right, might have been ineffectually preached till doomsday." They may have
not listen to God in the Bible, but they are still concerned with self
preservation. Many cases of mental illness today would be almost instantly
cured if mental health officials stopped telling people its not their
fault, that they are not responsible for it, that it is the same as any
other medical condition and placed the blame for their own condition
squarely upon their own heads. He highlights that mental illness patients
are fundamentally liars and deceivers who are clever actors in their own
play whom he has caught red handed in the act: "I have often been
complained to in the morning, about the severe operation of a purgative,
which I had placed in the patient's hands overnight, and which had just
before been brought back to me, by a servant who had found it concealed in
her bedroom." Carter notes a few problem areas like the friends and family
of the hysteric who blindly accept the deceptive act of insanity: He places
the blame on the parents of hysterics: "who have been treated with
excessive and ill-judged indulgence by their parents, who have perhaps been
delicate and sickly in early life, and whose moral training has, on this
account, been neglected". These parents have as much trouble accepting
responsibility for their children's hysteria as the hysteric themselves!
Carter note he often hears from parents: ""My daughter, is a religious,
moral, and well-conducted young woman, quite incapable of such practices as
those which you impute to her; and from our knowledge of her character, we
are satisfied that you are mistaken in her case." The parents will never
learn that their darling daughter has already admitted she is faking to the
doctor. He notes that hysterics will often write letters and make phone
calls to rally up support in one last vain attempt to admit the lies and
deception: "she will often endeavour to escape from it, by writing letters
to her friends, full of the bitterest complaints and the most doleful
lamentations". Often families of the insane are more of a problem than the
one mentally ill. Carter states that his system has a 100% success rate
over many years and hundreds of cases: "The system of treatment which I
have thus endeavoured to describe, has been tested for many years, and in a
great number of cases, but always with success" ... "The process is always
troublesome, and often difficult, but I have yet to hear of the case, in
which it would ultimately fail of success". Like many medical students
today who consider a career in psychiatry, see it for the deceptive
confusion it really is, then chose to specialize in a real medical career,
Carter left psychiatry and became a world class eye surgeon. His book on
hysterics should have been the writing on the tombstone that exposed
insanity for what it really is and psychiatry as quackery and junk pseudo
science. But the Devil was raising to power, two of his demon angels:
Sigmund Freud and Charles Darwin's Origin of the Species in 1859 AD. The
result is the chemical psychiatry we see today. (On the Pathology and
Treatment of Hysteria, Robert Brudenell Carter, 1853 AD)
"One of the striking differences between the psychiatric literature
of the nineteenth and twentieth centuries is the great freedom with which
sexual matters are discussed at the present time and the important role
attributed to disturbances of sexual drives in causing psychological ills.
Perhaps Freud's work more than anything was responsible for this
transformation though few would go so far as to agree that a 'sexual
neurosis' is the basis of all mental illness. Yet this doctrine was not as
novel as it seems. The original observations on which Freud based his
conclusions were made on what were considered classical cases of hysteria,
that protean malady the cause of which the ancients traced to the
wanderings of the womb. This idea had long been relinquished in face of
growing anatomical knowledge (Jorden 1603) but the 'uterine doctrine' as it
was called persisted in varying guises, from a reciprocal influence between
nervous system and uterus (Willis 1667) to the body being poisoned by
noxious humors (Digby 1658) or vapours (Blackmore 1725) rising from it. At
the same time the importance of the mental manifestations of hysteria came
to be appreciated (Sydenham 1682) and there emerged a combined theory by
which its psychological disturbances were attributed to the physical
effects of disorders of the female sex organs, especially those arising
from unsatisfied desire. It merely remained for Freud to take the final
step in the evolution of the old concept of hysteria as a physical disease
caused by uterine pathology to hysteria as a psychological entity caused by
'psycho-sexual' disturbances explained by the vicissitudes of the sexual
instinct. The transitional stage between the somatic and psychological
theories is well illustrated in the extract quoted here. Its author was in
general practice in Leytonstone; later he became an ophthalmologist of
repute. It is worth noting that he specifically refuted the idea of an
hysterical 'constitution' or 'diathesis' which is still found in some
modern textbooks; and that he considered 'the existence of many
well-authenticated instances of masculine hysteria' rendered any
etiological theory in terms of 'irritation of the uterus and ovaria . . .
utterly untenable' whereas 'the emotional doctrine [in its physical
effects] affords an easy and complete solution of the difficulty' and
particularly 'the sexual feelings, because they are both more universal and
more constantly concealed than any others'." (300 years of Psychiatry,
Richard Hunter, 1963, p 836)
On the Pathology and Treatment of Hysteria, Robert Brudenell Carter, 1853
AD
Robert Brudenell Carter (1828-1918)
F R C S, founder of the Nottingham Eye Infirmary 1859 and the
Gloucestershire Eye Institution 1862 ; surgeon to the Royal Eye Hospital,
Southwark; ophthalmic surgeon to St George's Hospital and the National
Hospital for Paralysis and Epilepsy, Queen Square
On the pathology and treatment of hysteria, 1853 London, Churchill (pp.
x-Fi6i) pp. 1-3, 28-9, 33-4
SEX AND HYSTERIA
The word Hysteria has been used by medical writers to express so many and
such various kinds of disease, that it is necessary, at the very
commencement of these pages, to assign some limit for its wide
significance, and to lay down clearly what morbid conditions its employment
is intended to convey. For these it would, perhaps, be easy to find a more
appropriate name; but still, the one which has been selected comes armed
with all the prestige of familiar acquaintance, and avoids all the
obstacles which hinder the adoption of a new nomenclature; while the author
would fain hope that an attempt to rescue it from inexactness unparalleled
in scientific phraseology, will find favour in the eyes of his brethren. It
has commonly been made to include a large number of symptoms, referable to
disease of the medulla spinalis, or its membranes; to hypochondriasis; or
to simple malingering; and such cannot be called hysterical affections,
without considerable risk of those evil consequences, which so often follow
the attempt to give a definite name to an unknown quantity. Ignorance is
thus veiled under a disguise which imitates, in some degree, the appearance
of knowledge; and a phrase, representing only the algebraic x, is
considered explanatory of the phenomena ranged under it, - a mistake too
often productive of false reasoning upon all medical questions, and
especially to be deprecated when the derangements of the nervous system are
the subjects of discussion .. .
By hysteria, then, is intended a disease which commences with a convulsive
paroxysm, of the kind commonly called 'hysterical'. This paroxysm is
witnessed under various aspects, and in various degrees of severity, being
limited, in some cases, to a short attack of laughter or sobbing; and in
others, producing very energetic involuntary movements, maintained during a
considerable time, and occasionally terminating in a period of catalepsy or
coma. The diagnosis (in so far as rules for it can be written down,) rests
mainly upon the absence of epileptic characteristics, and the existence of
some evident exciting cause, such as sudden fright, disappointment, or
anger . . . Simple hysteria . . . consists in the liability to fits of
greater or less severity, either with or without distinct intervals of
remission and perfect health, is subject to many complications, which
constitute the various disorders known as hysterical spine, hysterical
knee, hysterical neuralgia, &c., and may be classified in a way to be
considered hereafter. Complicated hysteria generally involves much moral
and intellectual, as well as physical, derangement, and when it is fully
established, the primary convulsion, the Tons et origo mali,' is sometimes
suffered to fall into abeyance, and is lost sight of and forgotten by the
friends of the patient, their attention being arrested by the urgency of
new maladies .. .
The effect of emotion in producing hysteria has long been a matter of
common observation, and is distinctly recognised by many authors on the
subject, but they have all regarded it only as an exciting agency, which
required for its operation the prior existence of some unknown
constitutional state. As a first step in endeavouring to demonstrate the
groundlessness of this opinion, it may be well to cite two cases which have
fallen under my own observation, and in which the idea of an hysterical
diathesis could only be supported by the kind of argument known among
logicians as a vicious circle, namely, by inferring its existence from the
occurrence of that event which it has been postulated in order to explain
.. .
If the relative power of emotion against the sexes be compared in the
present day, even without including the erotic passion, it is seen to be
considerably greater in the woman than in the man . . . But when sexual
desire is taken into the account, it will add immensely to the forces
bearing upon the female, who is often much under its dominion; and who, if
unmarried and chaste, is compelled to restrain every manifestation of its
sway . . . It may, however, be remarked, that in many cases of hysteria in
the male, the sufferers are recorded to have been 'continent', a
circumstance which may have assimilated the effects of amativeness upon
them to those which are constantly witnessed in the female . . . And at the
outset of this inquiry, we are . . . compelled to investigate the power of
the sexual passion, as compared with that of feelings more generally
acknowledged . . . For while the advance of civilisation and the ever-
increasing complications of social intercourse tend to call forth new
feelings, and by their means to throw amativeness [from phrenology: sex
drive] somewhat into the shade, as one powerful emotion among many others,
still its absolute intensity is in no way lessened, and from the modern
necessity for its entire concealment, it is likely to produce hysteria in a
larger number of the women subject to its influence, than it would do if
the state of society permitted its free expression. It may, therefore, be
inferred, as a matter of reasoning, that the sexual emotions are those most
concerned in the production of the disease.
=====
p25
The subject-matter of the foregoing pages may be briefly expressed in the
following propositions:
1. That emotion is a force adequate to the production of very serious
disorders in the human frame, acting upon the muscular, vascular, and
secreting organs, and causing various derangements both of their structure
and function,-the proclivity to its influence being greatly increased by
the operation of all debilitating agents, whether local, or general, and by
all circumstances tending to make individual parts the subjects of
attention.
2. That these derangements are much more common in the female than in the
male,-woman not only being more prone to emotions, but also more
frequently under the necessity of endeavouring to conceal them.
The phenomena consequent upon the act of attention have already been
referred to, in mentioning its power to direct emotions upon any organ, or
group of organs ; and there can be no doubt that it plays a very prominent
part in the production of many hysteric states, especially such as depend
upon intellectual or sensorial disturbance, or upon actual changes in the
nutrition of parts. An able summary of its effects has lately appeared in
the ' British and Foreign Medico-Chirurgical Review,1 and the reader is
referred to this for farther information; but it may be stated here, that
they differ from those of emotion, chiefly in requiring a longer time for
their production, and in being of a more chronic character. The force of
attention does not seem to be exhausted by the production of material
changes, but on the contrary, to gain strength by exercise; and any
permanent alterations which it works may be regarded as the results of a
continued effort, rather than of a sudden shock. It is capable of producing
much functional disturbance of the brain, and apparently acts by altering
the balance of power between the various ganglia, of which the encephalic
mass is composed, so as to occasion exalted activity of certain portions,
and corresponding torpor of the rest.
CHAPTER II.
THE HYSTERIC PAROXYSM.
The description contained in the foregoing chapter, of the more ordinary
phenomena resulting from emotional excitement, has been chiefly intended to
illustrate the kind of effect which it produces upon the system or in other
words, to express the nature, without exhausting the scope, of its
operation. For there are some persons, among whom a few men, and perhaps
the greater number of women, may be included; who exhibit under the
influence of excited feeling, more than one of its described effects,
manifested often with striking irregularity, and in various diversities of
combination. In such individuals the aggregate result is commonly
denominated an hysteric paroxysm; and this, when depending upon an emotion
excited directly by objects perceived, or remembered, or imagined, I
propose to distinguish as a primary paroxysm, reserving the consideration
of those caused by remembered feelings, as distinguished from objects,
until the nature and consequences of the primary attack have been
discussed.
The effect of emotion in producing hysteria has long been a matter of
common observation, and is distinctly recognised by many authors on the
subject, but they have all regarded it only as an exciting agency, which
required for its operation the prior existence of some unknown
constitutional state. As a first step in endeavouring to demonstrate the
groundlessness of this opinion, it may be well to cite two cases which have
fallen under my own observation, and in which the idea of an hysterical
diathesis could only be supported by the kind of argument known among
logicians as a vicious circle, namely, by inferring its existence from the
occurrence of that event which it has been postulated in order to explain.
Miss A-, aged 25, a resident in London, had been engaged for several
years, and had suffered, both in health and spirits, from the continued
postponement of her marriage. She went to visit some country friends, in
whose society she was able to forget her cares and to regain her strength,
so that she came back to town much better than she had left it, and,
indeed, in a state of perfect health. But during her absence from home, a
younger sister had accepted a matrimonial offer, the fulfilment of which
was arranged to take place very speedily. On her return, Miss A- found
the intended bridegroom staying in her mother's house; and thus had her
sister's prospects of immediate happiness suddenly placed before her, to be
mentally contrasted with her own disappointments and anxiety. She had only
been about an hour in a railway carriage, but expressed herself as being
tired by her journey, and sat in silence, apart from the rest of the family
group, dwelling upon the conflicting emotions called up by the scene before
her. After doing so for about an hour, she rose from her seat, saying that
she felt poorly, and, making a great effort at self-command, she tried to
leave the room, but was stopped by an hysteric paroxysm before this object
could be accomplished. It was not very violent, for, after a short period
of sobbing and irregular movements, a copious flow of tears took place; and
being then laid upon a bed, she soon cried herself to sleep. The next
morning she did not feel anything amiss, and had not lost any of the
benefits which had accrued to her from change of air and scene.
Sarah W-, an industrious and hard-working domestic servant, in the
employment of a small farmer, was seen one evening by her mistress, sitting
idly near some neglected occupation. On being asked what she was about, the
girl rose from her chair, and instantly fell to the ground in a violent
hysteric fit. Medical aid was promptly obtained, and the routine measures
of cold affusion, burnt rag, and sal volatile, were diligently had recourse
to, but in spite of them all, the convulsive movements continued for
upwards of two hours without the smallest abatement; and then, becoming
gradually less violent, were at last succeeded by a state of perfect
catalepsy, which lasted nearly an hour, and yielded in its turn to sleep.
The patient was left sleeping shortly after midnight, and, when visited in
the morning had no other ailments than a headache, and a swollen lip from
the too free application of ammonia. A smart mercurial purgative was
administered, and on the next day she resumed her duties; but was very soon
discovered to be some months advanced in pregnancy. It was ultimately found
out, that on the night of her illness she had held a meeting with her
seducer, in order to tell him of her state, and that he had then positively
refused to marry her, -a refusal on which she seemed to have been
brooding when interrupted by the entrance of her mistress. This girl was
delivered at full time by the operation of craniotomy, in consequence of
contracted pelvis; and some notion of her courage and freedom from "
nervousness" may be formed from the circumstance that, when the crotchet
was fixed in the fetal spine, observing traction only to be made during the
pains, she herself frequently gave the signal of their commencement, by
exclaiming " Now then, Sir, pull away!"
The first inference deducible from these two cases is that, under certain
circumstances, an hysteric paroxysm may be produced in a perfectly healthy
woman, who is not the subject of any especial proclivity to it, and upon
whose system no appreciable influence has been exerted, excepting that of
strongly-excited feeling; which, in the absence of all evidence to the
contrary, must be received, in such cases, as the cause of the subsequent
phenomena.
And if the convulsive fit be examined by the light thus thrown upon its
origin; and if observation be limited for a time to the first instance of
its occurrence in each individual, it will be seen that some strong emotion
is the only invariable precursor of its presence, and seemingly, the only
thing at all essential to its production. Sometimes the emotion will be of
a secret character (as in each of the cases just quoted), and may require
both patience and tact for its discovery; but it may be taken as an
invariable rule, that the paroxysm will be violent in exact proportion to
the length of time during which the feelings giving rise to it have been
concealed.
Speaking with reference to the female sex only, the most common of these
feelings is terror; and the most violent is the sexual passion.
An hysteric paroxysm produced by terror, is so common among servant-girls,
and in fourth-rate boarding-schools, and may be set on foot by so many
causes, that it is needless either to cite examples or to illustrate the
kinds of alarm which are most likely to furnish them. The attack does not
usually commence until the first apprehension has in some measure yielded
to a feeling of security, and consequently it is most apt to occur, either
where the fear has been out of proportion to the danger, or where the
danger itself has been only momentary. Circumstances which entail real and
continued peril, offer for the most part a method by which escape can be
effected; and, under such, emotion expends itself either in facilitating
volitional, or in directing instinctive action. In the male sex, the
accomplishment of this object generally exhausts its power; but in the
female, a hysterical attack is sometimes seen after escape from very
perilous situations, and especially after the exhibition of considerable
(socalled) presence of mind, which, in such cases, is probably purely
instinctive; and in conjunction with the subsequent hysteria, may be taken
to denote that the emotional stimulus is more easily exhausted by the
performance of voluntary movements, requiring cerebral activity; than by
those which, although similar in outward appearance, are of a reflex or
automatic character. There does not appear to be any a priori reason for
supposing that any individual, whether male or female, is totally exempt
from liability to primary hysteria; but in considering the circumstances
which are most favorable, or most opposed to its development, our attention
is at once arrested by a strongly-marked difference between the sexes; a
difference so great that the disease was named, and long thought of, as if
peculiar to women. Indeed, among the ancients, it is very likely to have
been so; but the advances of modern civilisation and refinement have
nurtured and increased many feelings in man to which he was almost a
stranger in rude and barbarous times. The circle of masculine emotions
having thus been manifestly widened, it is not unreasonable to suppose that
some evident effects have resulted from the change; and that as the
feelings became more vivid, the physical organism has been more and more
subjugated to their influence.
If the relative power of emotion against the sexes be compared in the
present day, even without including the erotic passion, it is seen to be
considerably greater in the woman than in the man, partly from that natural
conformation which causes the former to feel, under circumstances where the
latter thinks; and partly because the woman is more often under the
necessity of endeavouring to conceal her feelings. But when sexual desire
is taken into the account, it will add immensely to the forces bearing upon
the female, who is often much under its dominion; and who, if unmarried
and' chaste, is compelled to restrain every manifestation of its sway. Man,
on the contrary, has such facilities for its gratification, that as a
source of disease it is almost inert against him, and when powerfully
excited, it is pretty sure to be speedily exhausted through the proper
channel. It may, however, be remarked, that in many cases of hysteria in
the male, the sufferers are recorded to have been " continent/' a
circumstance which may have assimilated the effects of amativeness upon
them to those which are constantly witnessed in the female. In others, some
emotional cause is assigned to the attack, and the Emperor Napoleon is said
to have had a paroxysm in his boyhood, as a consequence of wounded pride.
On the whole, it appears reasonable to ascribe the comparative immunity of
man, not so much to the failure of emotion, when excited, in producing its
legitimate effects; as to the fact that in him strong emotion is a matter
of comparatively rare occurrence, scarcely called forth except to demand
immediate and energetic action of some other kind.
Having thus been able to assign a satisfactory reason for the greater
proclivity of the female sex to hysteria, and also for the absolute rarity
of its occurrence in man, the next question which arises will have
reference to the especial proneness of some individuals among women, and to
the great and striking difference which exists in this respect. And at the
outset of this inquiry, we are met by the ancient maxim, " Salacitas major,
major ad hysteriam proclivitas," and are compelled by it to investigate the
power of the sexual passion, as compared with that of feelings more
generally acknowledged.
If the aphorism above quoted may be supposed to have been substantially
correct at the time of its enunciation, there is no adequate reason for
thinking that it does not apply to the present state of society. For while
the advance of civilisation and the ever-increasing complications of social
intercourse tend to call forth new feelings, and by their means to throw
amativeness somewhat into the shade, as one powerful emotion among many
others, still its absolute intensity is in no way lessened, and from the
modern necessity for its entire concealment, it is likely to produce
hysteria in a larger number of the women subject to its influence, than it
would do if the state of society permitted its free expression. It may,
therefore, be inferred, as a matter of reasoning, that the sexual emotions
are those most concerned in the production of the disease, as it is seen
among the poor and ignorant; but that in the higher glasses there are many
other kinds of feeling, which, in the aggregate, are able to dispute for
the pre-eminence.
The greatest difficulty which has hitherto presented itself to writers on
the disease under consideration, has depended upon its distinct
association, in the majority of cases, with the sexual propensities of the
female, and with derangements of her sexual organs, while, at the same
time, it cannot be connected with any one kind of derangement rather than
with others, or with desire rather than with loathing, except in the usual
numerical proportion which exists between the different states. Hence many
endeavours have been made to discover a common action exerted by them all,
and (without regard to the cases in which none of them are apparent,) the
phenomena have been accounted for by the employment of a word which is
useful to express ignorance rather than knowledge; that is, they have been
referred to irritation of the uterus and ovaria. But it is hardly necessary
to say, that the existence of many well-authenticated instances of
masculine hysteria renders this explanation utterly untenable, while, at
the same time, the emotional doctrine affords an easy and complete solution
of the difficulty, on the ground that the disorder is very frequently
connected with the sexual feelings, because they are both more universal
and more constantly concealed than any others.
The word " hysteria," the hypothesis of irritation, and the universal
consent of the medical profession, may all safely be appealed to, as
bearing out, by actual experience, the theoretical conclusion arrived at in
a foregoing paragraph, namely, that the sexual passion is more concerned
than any other single emotion, and, perhaps, as much as all others put
together, in the production of the hysteric paroxysm.
This being so, it is evident that any circumstances which direct attention
to the reproductive system, will tend to increase materially the proclivity
of the persons exposed to them, and to establish trains of thought of the
kind most likely to originate the disease. Such conditions are furnished by
all morbid conditions of the uterus, whether they only excite sensations,
or whether they are fixed upon the mind of the patient in consequence of
medical treatment. Faulty menstruation, whether local or constitutional,
will have a similar effect; and it will be found that, although affections
of this kind often arise consecutively to hysteria, still that women
suffering from them are more liable than others, caeteris paribus, to be
the subjects of that disorder.
Women of strong passions, who are separated from their husbands, either
permanently or for a time, are especially liable to hysterical attacks.
This is well instanced by the wives of sailors, or other men, who are
constantly taken from home by their occupation.
Next to the reproductive instincts as a cause of the disease, may be
arranged various states of constitutional debility, which, by weakening the
body, greatly diminish the power of resisting emotional influences. In this
way anaemia, chlorosis, any morbid diathesis, convalescence from acute
illness, or the cachexia resulting from neglect of sanitary regulations,
may all be regarded as increasing the proclivity to hysteria, whatever be
the kind of feeling immediately concerned in its production.
There are, therefore, two distinct classes of agencies by which an
individual may be subjugated to a given amount of emotional influence more
completely than would be possible without their operation. By the first of
them, as illustrated in uterine or menstrual disorders, the emotion is
rendered permanent and engrossing, being continually recalled to the mind
by sensations or accidental associations, when, of its own force, it would
probably have passed by and have been forgotten. By the second, the emotion
is neither strengthened nor retained, but the body itself is so weakened as
to offer no resistance to its effects, either by directing or by absolutely
counteracting them.
Hence, it may be concluded, that the power which an emotion will exercise,
in producing an hysteric fit, depends upon circumstances, which are
themselves liable to vary, both in the same and in different individuals.
They are chiefly, the intensity of the emotion itself, and the
concentration or diffusion of its action, as opposed to various degrees of
susceptibility or resisting power; and it is evident that these forces are
of a character to place peculiar difficulties in the way of their exact
estimation. The circumstances by which the first of them is modified or
guided, will presently be referred to, and the consideration of the last
may, with propriety, be postponed to the chapter on the toxic hypothesis;
it being only stated here, that there is probably no woman, not past middle
age, in whom a paroxysm could not be produced by purely moral influences,
without any previous derangement of her health, and without the necessity
for any excitement of her sexual organs.
The first hysteric fit varies very much both in duration and severity; but
its general characters are much the same in all cases, and are too well
known to require an elaborate description. Usually commencing by two or
three deep and hurried inspirations, these are followed by the sensation of
globus; by various irregular muscular movements; by withdrawal, more or
less complete, of the power to balance and sustain the body; sometimes by
sensorial dirturbance: and, in a few instances, by catalepsy. These
symptoms either terminate suddenly, by diversion of the emotional influence
into some new channel, or else in the long and deep sleep of exhaustion,
which is often preceded by a state of death-like stupor. When the former of
these events takes place, relief is most commonly afforded by energetic
action, either of the kidneys or of the lachrymal glands. In the one case,
a quantity of limpid urine is evacuated immediately after the paroxysm ;
and in the other, a gush of tears is the precursor of its
termination,-the difference in point of time depending upon the office of
the bladder as a containing viscus. Sometimes both pairs of glands are
found to co-operate in the work of elimination; but it is not easy to
discover the circumstances which either excite or prevent their action.
Perhaps, as there is an evident natural tendency to diffuse the effects of
emotion, their concentration upon one channel may be considered a more
morbid action, and may be thought to indicate, that a more injurious
influence has been exerted upon the system; than when several organs have
been called upon to afford relief.
An hysteric paroxysm, occurring for the first time in a healthy woman,
(whether terminating by some sudden glandular action, or by the gradual
wearing out of its exciting cause,) generally leaves her, to all
appearance, in the same condition as before. But this appearance is
fallacious,-a very important change having been wrought in her system, by
which her susceptibility to the influence of feeling has been greatly
increased; so that the effects either of the same, or of any fresh emotion,
will be much more powerful than they previously would have been, and a
second paroxysm may be set on foot, by circumstances altogether inadequate
to the production of the first. It is evident, that this change may be
concealed, in certain cases, by the withdrawal, whether accidental or
designed, of everything conducive to excitement; and the repose thus
obtained, if continued for a sufficient length of time, will restore to the
body its former amount of resisting power. The period of rest necessary for
this purpose, can only be approximatively ascertained, but it may be taken
to bear a constant ratio to the length and severity of the fit; and,
consequently, to be greatest when this has not been abbreviated by the
secretion of tears or urine. In some cases, as for instance, in that of the
girl Sarah W-, the increased proclivity is not likely to be observed,
because so restrained by native dulness and want of sensibility, that it
still requires a more than ordinary stimulus for its manifestation. But
there is no reason to regard such individuals as furnishing exceptions to
the rule; and among educated or naturally sensitive persons, the difference
is always strongly marked. Thus, Miss A- suffered from several paroxysms
subsequently to the first one, which has been described; and some of them
were produced by such trifling alarms, that their occurrence became a
source of serious uneasiness, both to her family and to herself. But this
lady, by carefully avoiding all causes of emotion, and by directing its
influence, when beginning to be felt, upon the performance of energetic
voluntary movement, has now enjoyed a long period of exemption from
illness, her improvement having been greatly promoted by her own good sense
and strong determination, which have enabled her both to understand, and to
follow out, the principles laid down for her guidance.
It has been already stated, with regard to the primary paroxysm, that some
strong emotion is the only invariable precursor of its presence, and
seemingly, the only thing at all essential to its production. But this view
may possibly be objected to, on the score of those attacks which have been
referred to an imitative propensity, and which befall many women at the
same time; among whom there are, probably, some who have not been affected
before. This supposed imitative propensity will scarcely be found adequate
to the explanation of the phenomena, because the persons coincidently
attacked are usually those who have community of interests and feelings; as
the inmates of a workhouse, the pupils at a school, or the servants in a
house; whereas, imitation generally has reference to the conduct of people
superior in some way to those practising it; and hence would only come into
play as a spring of action, if the hysteria of the mistress was found to be
commonly reproduced in her servants, of the governess in her pupils, of the
matron in the paupers under her control. But such is far from being the
case; and paroxysms occurring simultaneously, or nearly so, in persons
whose positions are coequal, may often be referred to the sympathy
naturally existing between them, and to the emotions called forth by the
sight of any punishment, indignity, or wrong, befalling one individual, but
which each of the others may expect to suffer in turn. These reflected
feelings would seldom, it is true, be so vivid as the direct ones; but, in
many cases, their intensity would be increased by alarm at the condition of
the first patient, and their influence would be directed, by attention to
her symptoms. Moreover, it will rarely happen that several women are
together, of whom none have had their liability to primary hysteria
increased by former paroxysms ; and when these have yielded easily, both
the alarm and the attention of those previously unaffected, are likely to
be greatly increased. Of course it will occasionally happen, that the same
cause acts at the same time upon many persons, producing in all of them,
effects similar in kind, but varying with the differences of their
resisting power. And lastly, it is possible that the attacks may not be
primary, but of a totally different kind, which will be presently
considered under the name of tertiary hysteria,
When a primary paroxysm has ceased, and the lapse of a few hours has
removed the feelings of languor and exhaustion that commonly succeed to it,
the remaining effects may be expressed by saying, that it produces
increased proclivity to the occurrence of others like itself, from
subsequent emotions of a different kind, and that it leaves its subject
very liable to a second, arising from the mere remembrance of the original
exciting cause, if this be brought vividly before the mind within a short
time after the cessation of the first attack. Sometimes the fit occasions a
visit on the same day, or on the next, from some kind relation or
sympathising neighbour, and to her the whole story is related, and its
minutest particulars are dwelt upon in the hearing of the patient, whose
original emotion is thus recalled in so distinct a manner, that she is very
likely again to be subjected to its effects. When thus arising, the second
fit is seldom so severe as the first; but it leaves a greatly increased
liability to subsequent ones, whether produced in the same way, or by fresh
causes of excitement. It follows, therefore, if the first emotion was
agreeable in its character, and furnished a pleasant subject for
contemplation, or if it was engrossing and permanent, so as to be
voluntarily recalled in the one case, or to obtrude itself unasked in the
other, that its return in a degree sufficient to establish a convulsive
paroxysm, is a matter of great inherent probability, as it is found to be
one of daily occurrence, such being usually the history of a few attacks,
immediately after the first, in cases of confirmed hysteria. Under such
circumstances, it cannot but become a matter of observation to the patient,
that the recollection of a certain event, or train of thought, is usually
followed by the fit, and it perhaps occurs to her to ascertain by
experiment, whether the association be invariable, or only accidental. She
finds that, by dwelling upon the proper subject for a time, and by
withdrawing, as far as possible, the usual control of the will from the
muscular system, an attack may always be produced; and having once gained
this knowledge, she has many temptations to its exercise. It is highly
probable that the sensations commonly experienced during the paroxysms, are
in themselves agreeable,-the emotions producing it are often decidedly
so,-while the fuss and parade of illness, and the sympathy consequent
upon it, are frequently found to possess irresistible attractiveness.
Besides all this, there is the gratification of exercising a newly-acquired
power; and when the whole of these inducements are summed up, they leave
little room for wonder, at the occurrence of voluntary hysteria.
The word primary being reserved to express the paroxysms produced by some
original and fresh emotion, to the action of which the system has not
before been subjected, I propose to distinguish as secondary, the attacks
following the suggested or spontaneous remembrance of the emotions to which
the primary fit has been due; and to call those tertiary, that are
designedly excited by the patient herself through the instrumentality of
voluntary recollection, and with perfect knowledge of her own power to
produce them.
Before proceeding farther, it is perhaps allowable to point out the close
and remarkable analogy which exists between the expressions of the facial
muscles and the paroxysms of hysteria; and to remark on the support which
is afforded by this analogy to the above-written views concerning the
origin of the latter.
The secondary paroxysms have been accounted for by supposing that the
emotions concerned in their production are either pleasant subjects for
contemplation, or else that they are engrossing and permanent. In the
former case, the attacks are soon superseded by those of the tertiary kind,
the patient becoming aware of her power to produce them; but in the latter,
involuntary hysteria is often established as a severe and lasting disease,
partly from the circumstance that while the causes of excited feeling are
fresh in the mind, the fits are apt to recur so frequently that a condition
of almost tetanoid susceptibility is the result; and partly that, connected
as these causes generally are, with disappointed sexual desire, the
catamenial period acts, probably through the medium of sensations, as a
constantly returning means of their recall. In this way may be explained
those anomalous cases which present, in rapid succession, the symptoms of
the most severe diseases of the nervous system, being, by turns, tetanic,
paralytic, hyperaesthetic, and moreover often exhibiting the infinite
variety of mental and sensorial disturbances consequent upon that
derangement of the encephalic balance, which has been enumerated among the
effects of attention. It is worthy of remark, that patients suffering in
this way never present any distinctly local affections, excepting such as
are quite independent of the hysterical condition; and their exemption from
the various disorders hereafter to be mentioned as complications, may often
be used as a valuable aid in diagnosis.
The state last described, which, for the sake of brevity, may be
denominated secondary hysteria, is often very embarrassing and persistent;
but there is little danger of mistaking it for a more serious disease,
because its pathognomonic shiftiness is in most cases strongly marked, and
because it seldom assumes all the essential characteristics of any one in
particular. Such an error is most likely to take place when the mental
disturbance predominates over the physical, and when, at some given time,
delirium is almost the only symptom present; A lady has lately been under
my care, in whom a primary paroxysm resulted from circumstances which
brought domestic distress of long continuance to a climax, and in whom the
sexual passion was much involved. Two hours after the fit she lapsed into a
state of incoherence, one idea only having possession of her mind, and
being made the subject of much rambling talk. The principal symptoms
besides delirium, were heat of head and excessive restlessness, but the
pulse never rose to more than 80 beats in the minute. This condition lasted
nearly a week; and then, after a day or two of improvement, terminated in
complete recovery, no hysterical disorders succeeding to it, and nothing
but the previous circumstances of the case having distinctly pointed to its
character. But, generally speaking, the diagnosis is not difficult, and it
will be much facilitated by careful observation of the pulse, the frequency
of which will correspond pretty closely with the degree in which the
muscular system is involved. A distinctly paroxysmal character must not
always be expected in secondary hysteria, a succession of various morbid
phenomena being to the full as common as remission of them all; but the
symptoms will usually be aggravated during menstruation, unless in the very
rare cases where the first exciting cause was quite independent of amatory
disappointments or desires.
The effects of secondary hysteria upon the system are very seldom
permanent, the morbid state having a natural tendency to wear itself out,
and not leaving, of necessity, any organic changes. While existing, it
diminishes the liability to a primary attack, because all other emotions
are excluded by the one in possession, whose hold must be materially shaken
before there can be a fresh excitement of the feelings, which, when
produced, never fails to weaken it still more. Hence the endeavour to
produce pleasurable emotions forms an important part of treatment in the
later stages of the disease.
The tertiary form of the hysteric paroxysm, which is excited through the
instrumentality of the memory, by a direct effort of the will, presents
many remarkable characteristics. In some persons of great original
susceptibility, the power of producing it is quickly gained; but in others,
many trials will be required before its occurrence becomes a matter of
absolute certainty. The way in which these trials are suggested to the mind
has already been described; and the first which are made, though far from
bestowing the degree of dexterity which may ultimately be attained, yet
afford quite sufficient encouragement to the learner to induce perseverance
in her efforts, until at last, the power of producing a paroxysm may be
compared, both in its extent and nature, to that exercised by a finished
actor over the muscles of his face. Attacks of this kind may be
distinguished from primary hysteria by the frequency with which they occur
in the absence of any exciting cause; by their never being produced under
circumstances which would expose the patient to serious discomfort or real
danger, but at a time and place discreetly chosen for the purpose; and by
observing many little arrangements contrived in order to add to their
effect. Thus the hair will often be so fastened as to fall at the slightest
touch, in most "admired disorder;" and many analogous devices will be had
recourse to, their number and variety depending upon the ingenuity of the
performer, and the extent of her resources. The diagnosis from secondary
hysteria, besides resting upon the last-described characters, will be aided
by the absence of mental disturbance; and, in many cases, by the presence
of some of those symptoms hereafter to be discussed as complications, all
of which are quite peculiar to this form of the disorder.
The continual production of tertiary hysteric fits greatly diminishes the
liability to those of a primary character; because, by requiring
concentration of mind upon one train of thought, they narrow very
considerably the circle of original emotions.
Paroxysms of the primary and secondary kinds may often be induced by the
operation of an exciting cause so powerful, that no effort of the will
would be sufficient to prevent their taking place, even if it succeeded in
delaying them for a time. But such cases are rare when compared with those
in which the occurrence of the fit, although not volitional, is yet a
matter of surrender, and might be prevented under the pressure of an
adequate motive. This fact was remarkably illustrated in a workhouse which
was under the charge of the writer in a season of agricultural distress,
and which consequently contained a number of healthy young married women,
who were separated from their husbands and children; and among whom
hysteria was a matter of daily occurrence. The first fit was produced by an
altercation with the master about a matter of diet, and the spokeswoman of
the complainants was the person to suffer. She was duly ducked; but,
nevertheless, the same scene was acted over again a day or two afterwards,
with the difference, that two or three women were attacked, and this number
increased considerably on subsequent occasions. The affair became such a
nuisance, that it was determined to try and abate it, by rendering hysteria
unpopular among the women themselves; and the plan decided upon was put in
execution on a day when seven of them were attacked together. They were
ordered to be carried into a large dormitory, and four of the unaffected
ones were assigned to each patient, with directions to sit by her bedside,
and gently to restrain her arms and legs during the convulsion; the master
and matron being instructed personally to superintend the due performance
of the task, and to take care that not one of the twenty-eight extempore
nurses should have either food or rest until the hysteria of the patient
under her charge had ceased. The first recovery took place in five hours,
and the last not until the lapse of fourteen , and as the whole business
began in the evening, it was productive of no small discomfort to the
watchers. It was found that the hysterical women were terribly abused by
the others for several days; and, it being given out that the same system
of treatment would always be employed, the attacks ceased entirely from
that time, each of the inmates being well aware that an hysteric fit would
make her the most unpopular person in her ward.
In conclusion, it is necessary to observe that fits of the ordinary kind do
not appear to exercise any effect upon the consciousness of the patient,
who is generally well aware of all that passes around her, and distinctly
remembers it on recovering, although an admission that she does so can
seldom be obtained, except through a catch question. In secondary hysteria,
with much sensorial disturbance,-as, for instance, during the existence
of double consciousness, or any analogous state, it is most probable that
the pre-occupation of mind would prevent the perception of external things;
but the fact would have to be ascertained experimentally, and from time to
time, in every individual case.
Finally, every variety of paroxysm, when fairly established, passes from
under the control of the will, and continues for a period commensurate with
the intensity of the original or induced emotion, unless when this is
diverted into other channels during the continuance of the convulsion.
There is an apparent exception to this rule, caused by irregular movements
of a kind which bear to true hysteria the relation of a grimace to an
expression, and which are immediately checked by the threat of a douche, or
even by the presence of a stern and unsympathising person. They are usually
practised by girls who have not acquired the power of producing the
tertiary fit, and who vainly try to do so by commencing that part of it
which they fancy they can imitate,-a system of procedure which materially
lessens their chances of ultimate success, by dividing that attention which
alone can ensure it. Such persons have nothing in common with the subjects
of tertiary hysteria but their motives; and these, the right comprehension
of which must be the basis of all successful treatment, will furnish the
subject-matter of the following chapter.
CHAPTER III.
THE MORAL STATE AND MOTIVES.
The motives by which hysterical women are actuated, in the performance of
their objectless deceptions and self-imposed penances, are remarkable no
less for their strength than for their obliquity, and by reason of both
have furnished a theme for endless speculation; while the right
comprehension of them has been in great measure prevented by the want of a
definite distinction between the involuntary and the self-produced disease.
In the former, including the primary and secondary paroxysms, there is very
little change in the moral condition ; very little, that is, of a permanent
character. The temporary alteration is mainly due to a sudden ascendancy of
pre-existing feelings; and even in the cases of secondary hysteria, where
this is most strongly marked, such feelings are found to return to their
former level, as the disorder weakens its hold under the influence of time
or treatment. The occasional occurrence of nymphomania may be taken as a
case in point, and may be explained on the ground that attention to the
emotions concerned in producing hysteria has weakened the sense of decency
for a time, by engrossing the whole nervous force for the contemplation of
an object of desire. But it will not be found that an attack of the
secondary kind, however protracted, and however much connected with sexual
excitement, leaves behind it, when otherwise recovered from, any abiding
increase of erotic passion, the morbid change having been relative, rather
than absolute, and depending upon a withdrawal of the mind from ideas of an
opposite tendency. In primary cases there is little room even for this
amount of disturbance, because the health continues unaffected between the
fits, and the exciting cause is usually exhausted in producing them; while
in secondary hysteria of an abiding character, there is always an unnatural
exaltation of some kind of feeling, this being either dependent upon, or
closely connected with, the one concerned in originating the paroxysms. The
state thus induced may be compared to a dream, in which the train of
thought is not directed or controlled by the knowledge or observation of
the dreamer; and the parallel is also just when extended to the recovery
and the awakening; for in either case the mind returns immediately to its
former and proper balance. But in those cases where the patient discovers
her own power over the paroxysm, and immediately proceeds to exercise it,
there is in general a speedy and very lamentable change; although it seldom
happens that former good conduct has been due to anything better than the
absence of temptation. In the first place it may be remarked that tertiary
hysteria can scarcely be produced, unless the exciting emotion be of an
agreeable and of a secret character, and therefore likely to be recalled
and dwelt upon, before experience has taught the consequences of its
return. Feelings of a pleasurable kind, which can be confessed and freely
acted upon, never excite even secondary attacks; for although in their
first gush a primary paroxysm may often be produced, yet afterwards they
have an abundance of outlet, both in talk and action. And it will be found
on examination that there are scarcely any kinds of feeling which will
fulfil the above-named conditions, excepting those connected with the
amatory instinct, and the passions of jealousy and envy, in so far as these
depend upon an overweening estimate of the merits of their subject. The
emotions likely to be secretly dwelt upon as a consequence of the pleasures
derived from them are thus reduced to a very small number; and it is
evident that a young woman whose chief enjoyment rests either upon a
complacent contemplation of her own perfections, mingled with an angry
sense of the neglect shown to them by her associates, or else upon an
imagined gratification of her sexual desires, is not in the best possible
frame of mind for withstanding the pressure of a new temptation; such as is
held out by the discovery that she can, at will, produce an apparently
serious illness, and thus make herself an object of great attention to all
around her, and possibly, among others, to the individual who has been
uppermost in her thoughts.
The subjects of tertiary hysteria may be advantageously divided into two
classes, which fade imperceptibly into each other, and yet present a
sufficiently marked difference in their respective types. The first will
comprise women whose sexual propensities have been disappointed, but whose
lot in life may be in all other respects desirable; and the second those in
whom some form of envy or discontent is the predominant feeling. Such
persons are most commonly to be found in families where partiality is shown
towards some of the children on the score of personal or intellectual
advantages, and where the neglected ones have no judicious moral training
to aid them in bearing the injustice. And where this training is withheld
by the carelessness or incompetence of parents, it is often sufficient for
the partiality to be manifested by society, if the occasions for doing so
are marked and frequent, or if they involve much disappointment to the
victim. There are few situations more exposed to this description of trial
than that of a plain girl who accompanies her pretty sisters to a ball, and
spends her evening in seeing them dance, and the next day or two in hearing
them describe and discuss their various partners. But it would be endless
and useless, even if possible, to enumerate all the circumstances most
favorable to the development of envious or discontented feelings, and every
remedial purpose will be answered by pointing out the results which such
development can produce.
There is, perhaps, no mental instinct so universal throughout the whole
human race, as the desire for sympathy, which, even in those characters
where it is generally dormant, can almost invariably be called forth by
sorrow or neglect, in a degree adequate to furnish a new and powerful
motive. Such being the case with man, it is found to be so with woman in a
tenfold ratio, the desire itself being actually stronger, and the sense of
self-dependence being comparatively feeble, so that, in her, the desire
often amounts to a morbid and insatiable craving, which must be gratified
at the expense of any pain or inconvenience; and in this form it may be
regarded as the chief source of tertiary hysteria, and of all its manifold
complications.
It must not be supposed that this craving for sympathy can ever be suddenly
brought into full operation, or that it ever arises but as a result of the
continued and improper indulgence of its slighter forms, because this would
be to assign to it somewhat of a maniacal character, and to fall into an
error often committed by those who limit their observation to its most
marked examples. The power it exercises over the mind bears considerable
resemblance to that of opium or dramdrinking over the body, and is not
without parallel in many other psychical demands which may be similarly
induced; as, for instance, in the craving after social excitement which so
often follows upon a lengthened course of fashionable dissipation.
It is scarcely to be doubted, that if a girl who has thought herself
neglected and uncared for, becomes the subject of a primary paroxysm, her
chief feeling on recovering from it will be one of gratification at the
fuss that has been made about her, and at the temporary oblivion to which
all other things and persons have been consigned in honour of her illness.
This feeling is not likely to be diminished after the occurrence of other
fits; and, on the contrary, there will be many circumstances tending to
encourage it, such as anxious and minute inquiries on the part of the
medical attendant about the manner in which they have commenced, with a
view to diagnosis between hysteria and epilepsy. This point being duly
established, the attention and anxiety of friends is found to be somewhat
on the wane; and if by this time the patient has discovered her own power
of producing an attack, she will probably exercise it at night, a device
which answers the double purpose of reopening the epileptic question, and
of creating more stir than the same occurrence would have done in the
day-time. By and bye the paroxysms will occur in circumstances of apparent
danger; as near to a fire-place, or to a piece of water; and, although
neither burnt nor wetted, it will be thought unsafe that the subject of
them should be left, lest worse fortune should attend her on the next
occasion. Moreover, her friends will imagine that the disease may be
epilepsy after all; and they may thus be led to seek the opinion of various
physicians, who, for the most part, will not be in possession of all the
data required for forming a decisive one, and who will, therefore, leave
the question in greater obscurity than before. All this will have
ministered so much, and for so long a time, to that desire for sympathy
which was at first unexpectedly gratified, that its strength will have
greatly increased, and that its demands will have become irresistible,
except by the exercise of much fortitude and strength of mind; but, in the
meanwhile, the attention of relatives will again begin to flag, and the
vigilance of the once constant companion to relax, so that it will be
necessary to discover some new claim upon the solicitude of others, and to
find some new source of supply for the insatiable craving. In this
necessity most of the complications of tertiary hysteria take their origin;
and to its ever increasing force may be ascribed their progress and
multiplication, until, in some cases, the paroxysm is altogether
discontinued, and the sufferings of the invalid are limited to her knee
joint or her spine, as the seat of substantive disease, and to innumerable
accessory aches and pains, which are useful in warding off too close
scrutiny from each other.
The moral state which results from tertiary hysteria in the second class of
cases, may, therefore, be summed up as an union of selfishness and
deceptivity, allied in order to indulge that desire for sympathy which is
the chief motive of action, the others being only means for attaining an
end. The victims will present many differences of apparent character, some
seeming to be devout, others frivolous, but in all of them, on close
examination, the same chief traits may be discovered- of selfishness that
will indulge its own small caprice at the cost of real suffering to others,
and of mendacity that verges upon the sublime, and that never fails, like
that of the lacquey in ' the Rivals,' " having told one lie, to endorse it
with another."
It must not be considered that the conduct thus described, involves the
same amount of depravity that it would do in persons not hysterical; and
the proper light in which to regard it, is as analogous to the schemes by
which individuals, who are otherwise upright and well principled, will gain
for themselves the means of indulging a morbid craving. Nevertheless, such
practices cannot be continued long, in either case, without leaving behind
them, even when abandoned, some evidences of their former supremacy, in a
permanent lowering of the moral tone, and in a diminished sensibility to
the boundaries of right and wrong. But under judicious management, these
evil results may be in a great degree prevented, if the duplicity has not
extended itself beyond the simulation of disease.
The class of cases in which hysteria has been originated by the
disappointment of sexual desires (as distinguished from affection), have
usually a somewhat different history, and are not attended by the same
amount of moral obliquity, their complications being often of the purely
congestive kind, and depending upon the attention paid to certain organs,
under the influence of emotions to which they minister. The tertiary
paroxysm, under such circumstances, is induced with extreme facility, and
is seldom given up so long as any hysterical disorder continues; but the
patients are more amenable to treatment than others, as they often appear
to continue in ill health from not clearly seeing their way out of it, and
are most glad to abandon the wretched habit to which they have surrendered
themselves, when once the means of doing so are made plain to their
comprehension.
The long continuance of tertiary hysteria frequently produces a marked
diminution of intellectual power and range, as a consequence of the
thoughts having been chiefly occupied upon matters of a purely personal
kind; such as the symptoms, sensations, and feelings experienced by the
patient, or the methods by which she intends to simulate new diseases. This
introspectiveness is quite as constant as the duplicity, and is quite as
essential to the existence of voluntary hysteria; because, without it, the
caution necessary to avoid detection could scarcely be maintained. Its
evident effects consist chiefly of a constant tendency to talk about
ailments, and to exaggerate their severity, even in places and
circumstances least adapted for such conversation; but the extent to which
this habit is practised, although often considerable, furnishes but an
imperfect idea of the degree in which the mind is engrossed by the
reflections giving rise to it. The subject of tertiary hysteria may be said
to spend her time in thinking how to answer inquiries after her health, and
to be always paying an amount of attention to her sensations, equal to that
excited in ordinary patients by the questions of a physician. Being thus
occupied, it follows of necessity, that ordinary employments,
accomplishments, or studies, lose their interest and become wearisome, when
brought into competition with the all-absorbing topic of health; and that,
consequently, the taste for them is weakened or destroyed, and the pursuit
of them abandoned,-to the destruction of any intellectual or aesthetic
improvement which had formerly resulted from their culture, and often to
the permanent weakening of the higher attributes of mind.
The cerebral force which is thus withdrawn from the noblest and most useful
method of its exercise, does not appear to remain dormant, but to be in
many cases expended in an extraordinary development of cunning, by means of
which hysterical women often carry out most complicated systems of
deception, and succeed in baffling the watchfulness, even of very close
observers; although it must be confessed, that their credit is usually
first established, and their early essays at fraud supported, by those who
have, at least, the wish to believe them. Small, or very enthusiastic
religious communities, are the most usual victims of this kind of
imposture, which is constantly practiced upon the benevolent ladies of a
village, and has been enacted upon a larger stage within the last few
years;-in the case of the young women whose history was brought before
the English public by the pen of the Earl of Shrewsbury.
When the duplicity of hysteria takes a larger range than is required for
obtaining domestic and private sympathy, and exerts itself in an ambitious
endeavour to become widely famous, it must of necessity step beyond the
simulation of ordinary ailments, to do something at once fascinating and
unique. Religious sympathies, as being the most universal, are those most
commonly appealed to; and in order that the appeal may be successful, the
semblance of extraordinary devotion must be added to that of miraculous
disease. But this semblance involves utter destruction of the reality; and
the woman who has lent herself to it, will be rendered more thoroughly
corrupted in heart and mind, than she could be by any other species of
depravity, so that it would be impossible to reckon upon success in any
endeavour for her amendment.
When habits of falsehood and deceit have not been carried on upon a scale
to involve the destruction of their counteracting principles, still they
will, in most cases, be continued after the abandonment of all absolutely
hysterical practices; and when the paroxysms and the complications are no
longer troublesome, the patient will often be as obstinate, irritable, and
frivolous as ever. Impulses of temper will long retain the authority they
had usurped, when the powers of intellect and will vacated their seats of
government; and except under very careful supervision, there will, for some
time, be danger of relapse. But in these respects it is impossible for the
moral state to remain stationary; and that discipline which is sufficient
to prevent retrogression, will also be sufficient to produce improvement,
and, if duly continued, to ensure recovery.
Finally, it may be remarked, that, besides these general motives and means
of action, there may be others peculiar to each individual, and discernible
by close observation of conduct, or by minute analysis of the early
history. Such are not necessary, and are seldom present; but when existing,
a full knowledge and appreciation of them will be found valuable, as
furnishing an important key to the more general features of the case.
CHAPTER V.
THE HYPOTHESES OF PREVIOUS WRITERS.
It has been stated in a former chapter, that although the power of emotion
in producing hysteria has been universally recognised, still it has been
recognised as an exciting cause only, and, consequently, as requiring the
prior influence of predisposing agencies, the nature and operation, of
which have been made the subjects of much fanciful and ingenious
speculation, and have given rise to numerous hypotheses, which require
notice, both from their various degrees of plausibility, and from the
sagacity of the authors by whom they have been originated or maintained.
Before attempting an inquiry into the individual merits of these doctrines,
it is necessary to obtain a general view of their character and bearings,
for which purpose I shall avail myself of a quotation from Dr. Theophilus
Thompson, by whom they have been arranged with much conciseness and
lucidity.
After noticing the purely uterine doctrines of the ancients, Dr. Thompson
thus proceeds:
" The principal views which have since been entertained by authors, may be
arranged as follows:-1. Hysteria has been referred to a morbid condition
of the uterine nerves by Cullen, Pinel, Lieutaud, LouyerVillermay, and
Foville, &c.; and to chronic inflammation of the uterus by Pujol. 2. A
morbid condition of the stomach with imperfect digestion, producing,
according to Cheyne and Parry, acid humours, and in the opinion of
Pitcairn, imperfectly concocted blood, affecting the brain through the
arteries, and to gastro-enteric inflammation by Broussais. 3. Congestion of
the lungs and heart by Highmore, and of the vena portae by Stahl. 4. A
morbid condition of the nervous system generally by Desmoulins, Loob,
Pomme, Lorry, Whytt, Tissot, Boerhaave, Hoffman, Sauvages, Andral, and
numerous other writers. 5. A morbid condition of the brain or cerebral
nerves by Lepois, Willis, Barbeyrac, Georget, and Brachet. 6. A morbid
condition of the spinal cord by several recent authors; and of the
ganglionic system by Van Swieten, Lobstein, and Willis. Amard ascribes
hysteria to disorder of the lower portion of the spinal cord. Frank, M.
Colson, Drs. Bradley, Brown, Darwall, Griffin, and Marshall, refer it to a
more or less general irritation of the same organ; and Tate to spinal
irritation connected with irregular or defective catamenia.
"The information afforded by morbid anatomy respecting hysteria being
almost entirely of a negative character, affords us but little assistance
in the attempt to determine its essential character. Villermay has quoted
cases from Diamerbroeck, Vesalius, and Morgagni, to prove the frequent
coexistence of disease of the ovaries. Georget has endeavoured to connect
the phenomena with changes in the brain, and Broussais, with morbid
appearances in the intestinal canal. . . .... Dr. Conolly is of opinion,
that causes productive of irritation in various viscera may occasion the
nervous disturbance producing hysteria; but Dr. Copland thinks it essential
that the nervous or vascular condition of the sexual organs should first be
affected." Library of Medicine, art. Hysteria.
It is very generally admitted, that the difficulty of curing a disease,
bears an exact ratio to the number of infallible specifics against it,
which from time to time have been discovered; and if, by a parity of
reasoning, we may estimate the difficulty of accounting for it, by the
number of hypotheses to which its phenomena have been referred, the
prospect opened up by the foregoing paragraphs is certainly the reverse of
encouraging. Nevertheless, the various doctrines they contain may perhaps
be so arranged in a more general classification, as to exhibit the actual
principles involved in each; and these principles, when arrived at, may be
considered more easily than could the details of their application. For
this purpose they may be stated in the following manner:
1. Doctrines altogether indefinite.
2. requiring the female reproductive system.
3. requiring the existence of specific disorder in important or vital
organs.
4. The views of Cheyne, Parry, and Pitcairn, recently revived and extended,
in the form of a "toxic hypothesis."
It is unnecessary to point out the incompatibility of these different
teachings with each other, because it shows too plainly upon the simple
statement, to admit of being made more evident by any amount of
amplification. The truths which they respectively express will furnish more
appropriate subjects for discussion.
1. The first class may be illustrated by a sentence, which Dr. Thompson
uses to express the views of many eminent writers; namely, "a morbid
condition of the nervous system generally." It is sufficiently evident that
this, even if it happen to include the truth, does not in any way advance
our knowledge respecting it; and further, that no definite argument could
possibly be raised on a foundation so shifting and unstable. It being
generally allowed that the nervous system is the seat of hysteria, the
sentence referred to, if applied to the disease when actually existing, is
simply an identical proposition, and its truth cannot be denied without a
contradiction in terms, unless when cited as a protest against the
doctrines of Highmore and Stahl. If so used it will include the emotional
pathology, and almost every other. But if it be said that there exists "a
morbid condition of the nervous system generally," prior to the occurrence
of an hysteric paroxysm, no reply is possible, except that such an
assumption is entirely gratuitous, and has no shadow of evidence on which
to rest; while, at the same time, there are many facts diametrically
opposed to the opinion, and plainly showing that an attack may very
speedily be excited, in persons who should be pronounced healthy by any
possible test, if applied a few hours, or even minutes, before its
occurrence.
2. All views which ascribe the hysterical condition to changes in the
female reproductive system, are at once rendered untenable by the
occurrence of masculine hysteria. The existence of this disease was long
doubted, and has been denied by Dr. Laycock ; but the evidence in favour of
it is too strong to be shaken by merely negative testimony; and within the
last fewyears one or two well-marked cases have been treated in Guy's
Hospital.
3. The doctrines which refer the phenomena in question to specific disorder
of important organs, contradict each other almost sufficiently for their
own refutation, and are, moreover, open to two very strong objections. In
the first place, the morbid conditions which they describe are not of
universal occurrence in hysteria; and frequently exist without its
supervention, under circumstances which present no apparent obstacle to the
production of their legitimate effects. In the second, the disease itself
is too shifting and variable to depend upon any definite change in any
individual organ. This truth is very forcibly conveyed in ordinary medical
parlance, and is fully recognised by that general consent of the profession
which will seldom be found to err; the word ' hysterical' being used to
denote, of any given symptom, that no such change has been concerned in
producing it. And moreover, if the disorders enumerated be examined in
their usual method of occurrence, they will not be found to present
irregular or uncertain symptoms; but such as, varying within limits more or
less extended, have yet a direct relation to the part affected, and in the
great majority of cases, serve clearly to establish its identity. Hence, it
is manifestly impossible to assign congestion of the lungs and heart, or
any analogous conditions, as being the causes of hysteria, without, on the
one hand, abandoning all attempt at exactness of thought and diction; or on
the other, postulating the superaddition to them of some unknown quantity,
whose nature cannot be shown, and whose very existence has to be imagined.
But these conflicting hypotheses, while conclusively establishing the fact
that the true pathology of hysteria is not expressed by any of them, serve
yet another and a very important purpose. There being incontestable
evidence to show that hysteria is independent of other diseases, these
hypotheses are alone a sufficient proof that they frequently coexist with
it; and, therefore, that diseased persons are more liable than others to
its attacks, a conclusion which might have been anticipated, from the
effects of ill health upon the resisting powers opposed to emotion. Reasons
have already been assigned, for considering uterine or ovarian disorders to
involve an especial proclivity, and to explain the greater unanimity with
which they have been regarded as the causes of hysterical phenomena.
4. The views of Cheyne, Parry, and Pitcairn, which are expressed by " a
morbid condition of the stomach," producing either " acid humours" or "
imperfectly concocted blood, affecting the brain through the arteries," are
those which come next under consideration, and which, after being referred
to these authors for their first enunciation, may be expressed in the
pathological language of the present day. Dr. Laycock, in so many words,
assigns the materies morbi of gout as the cause of hysteria, thus following
in the footsteps of the first two authors; and Pitcairn has his disciples
amongst those who do not ascribe the phenomena to a specific poison, but to
the debility consequent upon impaired nutrition, aided by the abnormal
reaction on each other of fluids and solids not perfectly elaborated.
The toxic hypothesis, in either of these forms, is unquestionably more
pleasing and attractive than many others which have been advanced, from the
circumstance that, at first sight, it appears to meet the necessity for
some agency coextensive with the whole system, as a cause of the
simultaneous or successive derangement of numerous organs and functions,
and as an explanation of the transitory character of the symptoms by which
this derangement is made known. But without pausing to consider whether a
more perfect explanation be afforded, by the existence of a force capable
of influencing every part of the body, and more than one part at once,
having its direction determined either by internal conditions or external
agencies, and liable to be exhausted in the production of its effects, or
to be suddenly removed by removal of its exciting cause;-without pausing
on this question now, and without inquiring how far the inherent
probability of the humoral doctrines is diminished by their duplex
character, it may be well to examine the evidence on which their
pretensions are founded, and to test their applicability to the phenomena
which they have been said to explain. Such an investigation could easily be
extended to great length,-but as it is the principal object of these
pages to establish, rather than to overturn,-the most important facts of
the case, and the conclusions that they appear to justify, will be stated
in the briefest possible manner.
The arguments on which the necessity for a toxic agent has been assumed,
are derived from three chief sources; namely, the absence of structural
lesion, the almost invariably feeble health of the patient, and the
frequent coexistence of some marked cachexia. Hence, humoral pathologists
have been led " to imagine the existence of some morbid matter in the
blood, capable of exciting undue and irregular activity of all parts of the
nervous centres, but not tending to produce a permanent disorder of their
nutrition." British and Foreign Medico-Chirurgical Review, January, 1850.
The counter-statements by which these arguments are met, may also be
arranged under three heads, and they depend upon the power of moral
agencies to produce hysteria in persons whose health is apparently good,
upon the indeterminate duration of the disease, and upon the absence of any
natural effort to eliminate morbific matters from the system.
The power of emotion to produce hysteria, is abundantly illustrated by the
majority of first attacks, and especially by the cases of Miss A- and
Sarah W-, as related in a former chapter. These patients, differing in
everything else, resembled each other in point of health, both being to all
appearance perfectly well; and there can be no reason for postulating an
unknown and inappreciable cause, in the presence of one that is evident,
and probably sufficient. If the ordinary effects of excited feeling were in
no way analogous to the hysteric paroxysms,-if hysteria, in most
instances of its occurrence, was either plainly independent of emotion, or
plainly connected with the operation of a poison,-then there would be
reason for overlooking the former agency, where its presence was
indisputable; and for imagining the latter, where evidence of its existence
might be wanting. But under the actual circumstances of the case, such a
course could scarcely be called philosophical; and its adoption might well
suggest the idea of a struggle for victory, rather than of a search after
truth.
The indeterminate duration of the disease presents a very striking contrast
to the course of many which are unquestionably humoral, such as fever, or
the exanthemata; and one scarcely less evident, to those which give way
only when a definite amount of elimination has been accomplished, such as
rheumatism and gout. All morbid conditions which are certainly known to
depend upon an animal poison, either engendered within the body, or
introduced into it from without, may, with the single exception of the lues
venerea, be referred to one of the above-mentioned classes; and it would be
waste of time to prove that there is no analogy between hysteria and
syphilis. Hysteria has been compared to other diseases of the nervous
system, such as chorea, to which it plainly offers many points of
resemblance. But the toxic origin of chorea is a matter of mere hypothesis;
and the only conditions which always coincide in its production, are,
emotional excitement, and debility of the muscular system, which may of
themselves be quite sufficient to explain the phenomena. At all events, it
is very difficult to imagine a blood-poison as the cause of symptoms,
which, after existing for months or years in varying degrees of intensity,
will cease almost suddenly, from the mere desire to please one of the
opposite sex; and the difficulty is much increased by the consideration,
that this poison has never been pointed out, except as manifested in its
supposed operations.
The absence of any natural effort to eliminate morbific matters, tells
against the toxic hypothesis even more strongly than either of the two
preceding arguments; because, whenever a poison can be demonstrated, this
effort is universal, and often constitutes the most striking symptom of the
disease. But in hysteria, no evidence of it can be discovered, except it be
the flow of urine, which often terminates a paroxysm; and the idea that
this accomplishes an act of excretion, is hardly borne out by facts. In the
first place, the urine itself scarcely differs from water in its
composition; and probably depends entirely upon transudation through the
Malpighian bodies, owing its small but variable proportion of organic
substances, to the liquid previously poured into the bladder. In the
second, its discharge generally coincides with a flow of tears, and, in
slight cases, only one pair of glands will be affected, their single action
being sufficient to bring the paroxysm to an end. But it is scarcely
possible to conceive any community or vicariousness of function between the
kidneys and the lachrymal glands; and yet, such there must be, if this
watery urine contains any important matters. Moreover, it may be observed
that, in young children, whose tears are called forth by very trifling
causes, an abundance of urine, resembling that of hysteria, will be passed
under the influence of strong emotional excitement,-a fact which has been
noticed by Dr. West, in his description of the night-terrors of infancy.
Dr. Laycock asserts that the urine of hysterical patients presents many and
various morbid deposits,-a circumstance to be expected from their
insalubrious practices; but the very diversity of these deposits is a
forcible argument against their subservience to any special function, and
Dr. Laycock does not appear to think that any one of them, commonly or
universally, coincides with the termination of the disease. If it did so,
there would be no difficulty in obtaining abundant proofs of its discharge.
On the whole, the evidence appears to tell with irresistible weight against
the idea of a blood-poison, as necessarily concerned in the production of
hysteria; but there is some reason for supposing that the influence of
emotion itself, by altering the processes of secretion and nutrition, may
engender certain morbid products within the body, and that these may be
concerned in the causation of some hysterical symptoms. Such an hypothesis
is supported by many well-known facts, although discountenanced by the
absence of any evident act of excretion. It is therefore a proper subject
for diligent inquiry; but in the present state of knowledge it is better to
avoid impeding advancement by vague speculation; and therefore to regard
emotion chiefly as concentrating upon an organ or organs, the nervous
force, which, in a state of health, is diffused over the whole system. This
view being provisionally adopted, the effects of excited feeling must be
supposed to exhibit expenditure of force, rather than elimination of
matter.
There is yet another aspect in which the toxic hypothesis must be regarded,
and this may be expressed by saying, that some cachexia has been deemed
necessary to the existence of hysteria in its aggravated forms, although
not required for the production of a single paroxysm. There can be no doubt
that this opinion is in some measure correct; but its advocates have often
fallen into the twofold error of selecting some single diathesis as
pre-eminently powerful, and of forgetting that their doctrine is contained
in a pathological theorem of much more general application. The degree in
which each individual cachexia may diminish the resistance to emotional
influences, could only be exactly determined by carefully prepared
numerical statements; and in the absence of these, every observer is likely
to take a view more or less biassed by the diseases of his locality, and by
the class of patients chiefly falling under his observation. As the result
of the most extended inquiries I have been able to make, I have concluded
that, in large towns, and among the wealthier and more luxurious classes,
gout decidedly predominates over other diatheses as a predisposing agency,
and that it appears to produce an especial proclivity to hysterical
affections of the muscular system. But even in towns, many other systemic
states frequently exert a similar influence; in many agricultural
districts, where gout is extremely rare, especially among the poor,
hysteria prevails in all classes, and is most commonly associated with
anaemia; while in proportion to the number of cases, and on a principle
which has already been explained, diseases of the uterine system tend to
the production of hysteria, more powerfully than any other morbid states,
whether general or local.
Lastly; the insufficiency of depraved nutrition or feeble health to excite
the disease, is shown in a striking manner by the most degraded classes in
the metropolis and other manufacturing towns. Among these, the young women
are very badly situated with regard to sanitary conditions, and to physical
health and welfare; but ignorance narrows their emotions almost to the
bestial limit, their passions are abundantly gratified by a system of
promiscuous concubinage, and their hysteria seldom exceeds a primary
attack, under the influence of jealousy. Surely they are sufficient to
overthrow the idea, that blood-poisons can have much to do with the more
aggravated cases which present themselves as we ascend the social scale.
CHAPTER VI.
TREATMENT.
In considering the principles which may be laid down as guides in the
treatment of hysteria, it is necessary first to decide how far the causes
of morbid action are under the control of therapeutic agents; and whether
these possess the power, either of removing them, or of counteracting their
operation. And if the disease be examined under the simplest conditions of
its existence, in the form of a wellmarked primary paroxysm, which has been
suddenly produced by grief, or anger, or desire, in a previously healthy
person, this will not be found susceptible of abbreviation by any of the
means which are commonly employed on such occasions, and which are used
rather to calm the anxiety of friends and bystanders, by an appearance of
treatment, than from any assured belief in their efficiency. On the
contrary, such a paroxysm will often increase and reach its acme during the
sedulous application of burnt rags and stimulating vapours to the nostrils,
and notwithstanding the continued administration of various medicinal
agents; while, at the same time, it will frequently yield to the secretion
of tears or urine, before any endeavours to influence its course by
remedies have been commenced. It is said that cold enemata, or cold vaginal
injections, will often terminate a paroxysm; but I have had no experience
of their utility, and am not disposed to gain it; because in many cases
their moral effect would be unquestionably hurtful. And if it be
considered, that a certain amount of emotion will produce an attack in
almost any woman, however healthy; the conclusion is almost inevitable,
that we shall be disappointed in the action of tonics or other medicines,
given when the disease is quiescent, with a view to diminish the
excitability of the nervous system, and thus to prevent or delay the
recurrence of morbid action; unless, at the time of their administration,
especial care be taken to shut out all sources of injurious excitement.
For, as it has been shown that the liability to the hysteric paroxysm bears
an exact ratio to its past frequency; so also the reverse of this rule
holds good, and nothing tends so much to fortify the body against its
recurrence, as the repose gained by staving off attacks, through the
careful withdrawal of all causes likely to produce them. But to aim at such
a result, by the administration of medicines, is to ascribe to them the
power of working an organic change in the nervous constitution, and must
necessarily bring useful remedies into disrepute, by employing them for a
purpose which is not within their scope of action.
It has been already said, that the existence of any morbid condition or
diathesis, increases the proclivity to hysteria, by its debilitating effect
upon the system; and it is therefore quite obvious, that, when primary
attacks supervene upon anaemia, or struma, or other analogous states, the
most effectual remedies against these states should be administered, and
will often prove highly beneficial. But it must not hence be supposed, that
steel or cod-liver oil have in any degree cured hysteria. They have simply
strengthened the body, and thus rendered it more able to resist the
pressure of emotional influences.
And if we may regard the disease to be one of the misfortunes entailed upon
the civilised female by the conditions of her existence, and the mobility
of her nervous centres; and if we find that medicines not only fail to
exert much influence, (if any,) upon the involuntary paroxysm during its
course, but that they are also powerless to avert its occurrence, when the
exciting cause has been applied with sufficient intensity; still less can
they be expected to prevent or to shorten the voluntary convulsion. The
patient has obtained a certain power over herself, of which, when once
gained, she probably can never be deprived, and which neither steel, nor
valerian, nor quinine can do anything to weaken. Moreover, it is a power
which becomes rapidly more extensive and complete, depending, as it does,
upon a chain of associations, in which each link is strengthened by every
instance of its exercise, until at last the fit responds almost instantly
to the effort of the will.
The action of medicinal agents upon the hysterical, becomes injurious so
soon as they discover, and exercise, the power of producing a tertiary
paroxysm. Until that time arrives, mineral tonics and nervine stimulants
may be harmlessly administered; but as soon as the deceptive element comes
into play, the practical complicity of the medical attendant is sought as
one of the patient's most secure strongholds, and frequently is quite
essential to the success of her schemes. Hence arises that insatiable
desire for remedies, with which all who have seen tertiary hysteria are
familiar, and that excess of confidence in the practitioner, which is
always exhibited until his suspicions are aroused. The professional man who
has once sanctioned imposture, by sending mediciues for the cure of
self-produced illness, becomes at once an ally, whose aid is the more
important for being unconsciously rendered. And, moreover, when to the
voluntary production of convulsive attacks, is added the simulation of
disease in some individual organ, the frequent application of medicines for
the relief of the local affection, and the medical belief in its reality
which such applications imply, is likely to hasten the arrival of that last
epoch in the history of simulative hysteria, when the continued attention
necessary from the malingerer brings its own retribution, and actually
produces the morbid condition which she has feigned.
The accuracy of the view thus taken of the action of medicine might easily
be verified by an appeal to the ordinary results of treatment; but from the
want of accurate statistical information, these results can only be
furnished by individual experience. Dr. Copland states that " there are few
diseases less under the control of medicine than hysteria;" and there can
be little doubt that many persons would coincide in this opinion, who,
nevertheless, would have no idea that medicine could be positively
injurious. I have obtained the particulars of fifty-three cases treated in
the London Hospital, of which twenty-three were discharged cured, one as
refractory,-and the remaining twenty-nine were said to be relieved; an
expression which a very small amount of improvement is thought to justify,
as may be gathered from the circumstance, that of the cases cured, one was
twice readmitted within three months. There can scarcely be any other class
of patients to whom such statements would apply,-and they seem sufficient
to prove unquestionably, that medicines, diet, and other strictly
therapeutic agencies, are entirely unable to control the disease.
Being thus compelled to abandon the idea of gaining efficient aid from the
weapons by which other disorders are so often vanquished, the question
necessarily arises, -how far we may be successful in obtaining a
counteracting influence, from powers analogous to those by which the
disease has been excited ? how far, that is, we may depend upon moral
treatment as a substitute for medicinal ?
It is sufficiently evident that no emotions could exert a permanent action
on the system, if those opposed to them could always be brought into play
when needed. But we have no certain means of exciting any given feeling,
even when the mind is comparatively quiescent, much less when it is engaged
by others of a different order,-and least of all when it is engaged by
them in a morbidly extreme degree.
But there are other and less direct methods in which moral treatment may be
applied most beneficially, and the objects which should be aimed at by its
influence, must differ with the three varieties of hysteria which have
already been described.
In primary cases, nothing must be attempted beyond the withdrawal of all
causes of excitement, and the endeavour to substitute for them incentives
to intellectual exertion.
In secondary hysteria, where the disturbing emotion is subjective, benefit
will accrue from any excitement, whether of mind or feelings, which is
produced through the agency of external things.
In the tertiary form of the disease, the principal object should be, to
remove the motives of the patient, by defeating the ends which she proposes
to herself for attainment.
Moral treatment has been put in practice against hysteria in a very large
number of cases, by the use of various harsh measures, which, although
rudely and imperfectly devised, without a proper selection of suitable
patients, and without the assistance of any feeling but fear, have yet, in
isolated cases, been exceedingly successful; thus showing that some right
principle was involved in their application. But, from the want of due
discrimination between the varieties of the disease, -from neglect of the
fact, that a well-established paroxysm is quite independent of the
will,-and from imperfect observation of the individual character of the
patient, these harsh measures failed more frequently than they succeeded,
and at last fell into well-merited disuse. For neither the cold dash, nor
the infliction of pain, will exert the smallest influence, over the course
of a convulsive attack of average severity; and even if the punishment thus
administered were postponed to the interval between the paroxysms, in the
hope of preventing their subsequent occurrence; reason and experience would
go hand in hand to condemn it, as being, in most cases, utterly inadequate
to the production of the desired end. In support of this view, it is only
necessary to urge the very principle on which the treatment rests, that is,
the general predominance of moral over physical agencies, and to point out,
that a girl who yielded to a few duckings, and a little discomfort, would
have to suffer the disgrace and degradation consequent upon detected
imposture; while one who passed safely through the ordeal, would be
considered by her friends to be really the victim of disease; and the
discerning doctor who subjected her to harsh treatment, would be condemned
by them as a monster of ignorance and inhumanity.
Besides this consideration, it must be remembered, that the patient often
inflicts upon herself, much more pain than any medical attendant could
possibly propose. The frequent application of moxas and blisters sinks into
insignificance, as a matter of suffering, when compared with the various
and ingenious devices, by which the hysterical will endeavour to imitate
the aspect of disease. And it may well be doubted, whether the treatment by
cold affusion, which was once so much in vogue as a domestic remedy against
the hysteric paroxysm, is felt by the patient as an inconvenience, when
once she is thoroughly under the control of the convulsive action. The only
cases in which the dread of cold water is effectual in preventing an
attack, are those where the patient is filling some subordinate or menial
situation, which would be forfeited by continued illness; and is away from
her home and friends; so that she cannot reckon upon an opportunity of
holding out, against the unpleasant remedy, for a sufficient time to change
the feelings, and to work upon the sympathies, of the unprofessional
persons around her. If she requires an excuse for abandoning her
employment, then a somewhat similar combination of circumstances may render
the disease exceedingly severe.
But it will almost invariably be found, that a young woman who is living at
home will have too much courage and endurance to be beaten by the torture,
and that a certain amount of perseverance on her part, will exalt her into
a martyr in the eyes of her family, and will enable her to bid defiance to
professional denunciations.
The harsh treatment which has been alluded to, could only be consistently
employed, by persons who had a practical belief in the control of the
patients over their own diseases, and it would, therefore, be quite
inapplicable to secondary hysteria, if the views which have been taken of
that affection are correct; for the use of the moxa or cautery, to frighten
away involuntary sensorial or muscular disorder, could only be likened in
its barbarity, to the flagellation which was once deemed salutary in the
management of lunatics. But in the cases of tertiary paroxysm, with
simulative complications, the principle of appealing to a moral agency must
be the basis of all successful methods of cure, although it is quite
possible to divest this principle, of everything which could be deemed
objectionable or severe in practice.
The treatment of primary hysteria, necessarily resolves itself into two
considerations, embracing respectively, the measures to be adopted during
the continuance of the paroxysm, and those most likely to prevent its
recurrence.
The paroxysm itself requires very little management, the first thing
desirable being the unfastening of all tight articles of dress, whether
stays, or bands encircling the neck. In severe cases, a bed or mattress on
the floor is the safest place, and there can be little doubt that the
convulsion should be allowed to work itself off, even if there existed any
certain means of interrupting its course. If the patient can be made to
swallow, a stimulating diuretic, such as gin and water, may be
administered; and, at the same time, an attempt should be made to excite
lachrymation by irritating vapours, or by bruised onion. In this way it may
be possible to obtain the action of additional channels of discharge, into
which a portion of the emotional force would in most cases be diverted.
But, unless the attempt to do so was speedily successful, it should be
abandoned, because nothing is certainly known of the conditions which
concentrate or diffuse the effects of excited feeling. It is reasonable to
suppose, that all organs are more liable to be influenced, during exalted
functional activity, the mammae evidently being so; but whilst in ignorance
of other aiding or counteracting agencies, it would be imprudent to use
very strenuous endeavours for producing such exaltation by artificial
means. If, therefore, there is an evident disposition for the attack to
expend itself upon the muscular system, the room should be cleared of all
but one attendant, who should be enjoined to keep perfectly quiet, and
simply to watch the course of events. The paroxysm will then pass gradually
into deep and quiet slumber, from which the patient will awake with some
feelings of languor and indisposition, and frequently with a thickly-coated
tongue. A gentle but efficient purgative should then be administered,
containing some mercurial preparation, unless under special circumstances,
which might chance to centra-indicate its employment. When free evacuation
of the bowels has been obtained, it will be necessary to ascertain the
events to which the illness has been due, and to direct attention upon
measures of a prophylactic tendency. For this purpose the state of health
must first be thoroughly investigated, and any functional disorder must be
made the subject of appropriate treatment, especial regard being had to the
free and normal action of all emunctories, among which the skin must not be
forgotten. The inquiry should extend itself to the daily habits of the
patient, to exercise, to diet, and to sleep, there being few persons, whose
practices in these respects do not offer a large scope for improvement. If
there be no evidence of local functional disorder, there will often be some
morbid constitutional state, such, for instance, as anaemia, acting as a
cause of debility ; and this will require to be corrected by the aid of
medicines, it being borne in mind, that they are administered with the
single view of strengthening the patient, by the removal of depressing
agencies, and not as having, in themselves, any power over the occurrence
of hysteria.
The emotion which has been excited, and the causes of its excitation, are
the next questions to be answered, and their solution will often lie upon
the very surface of the case. When it does not do so, the method of inquiry
must depend very much upon the personal character of the patient; and if
she be a stranger, it will mostly be prudent to take some little time
before coming to a decision about it. With a straightforward or
clear-headed girl, direct questioning in private, and under the seal of
professional confidence, will usually attain the desired end; but if there
be stupidity or sullenness, a more circuitous manner of proceeding may be
necessary, aided, perhaps, by the intervention of parents or other
relatives. The precise manner of procedure must always be dictated by
individual discretion and tact, or by the nature of the materials available
to work with; and it may be stated as a rule, that the deeper the emotions
lie, the greater is the importance of discovering them.
There are, of course, many kinds of feeling by which a paroxysm may be
excited, but which are not likely to recur, even a second time. Extreme
terror may be mentioned as one of these: and there are many other emotions
which may be called forth by some unusual combination of events. From their
influence, secondary hysteria is not to be feared; and the worst effect
likely to follow, is the occurrence of other primary attacks from the
operation of comparatively trivial causes.
Under such circumstances, it is not necessary to adopt any precautions
against the return of that feeling which was first called forth; but the
patient and her friends should be cautioned to avoid everything likely to
produce emotion of any kind; and there are some things which may be pointed
out, as especially likely to exert such an influence. Among them may be
included pathetic theatrical or operatic representations, and most kinds of
social dissipation. It is also desirable to enjoin regular daily exercise,
not confined to a lounging walk, but carried to the point of fatigue, with
a view to diminish the mobility of the muscular system. This may be
advantageously accomplished by a heavy wheel, having a handle, by which it
is to be turned, the weight being adapted to the strength of the
individual, and care being taken that the hands are used alternately. The
wheel should be fixed against a wall or post, its axle being about breast
high, and its diameter being such as to raise the hand turning it, above
the head. By means of this wheel, or of some similar contrivance, an
intelligent patient will almost always be able to direct the force of
emotion, when beginning to be felt, upon voluntary action of the muscular
system, and thus to prevent many a paroxysm which would otherwise certainly
have taken place. The same end might often be attained by some intellectual
exercise; but as the power of abstraction is difficult to acquire, and
cannot be certainly tested, the wheel is the safest remedy to advise.
Exciting emotions, which are neither told as part of the case by the
friends of the patient, nor readily confessed to by herself, are, for the
most part, of an amatory or of an envious character; and it is evident
that, in most instances, they would be very likely to return spontaneously,
and hence to establish a secondary paroxysm. In such cases, it is
imperatively necessary to use all endeavours for discovering the secret,
and then to take such measures as its nature may suggest, for turning the
thoughts into some other direction. Intellectual exertion, active exercise,
and the changes of scene and objects afforded by travelling, are among the
means most conducive to this end; and they must be modified and adapted to
suit the habits or position of the individual. But unless the patient is
ready and willing to lend her own assistance, or unless the feeling aroused
be of a very transient nature, none of these means will secure a very great
success; and in cases where a secondary paroxysm has beem produced by
sexual feeling, most parents would do well to permit what they considered a
mesalliance, rather than to risk the chances of recovery.
When secondary hysteria is once established, very little can be done in the
way of curative treatment. The preoccupation of mind, and the physical
disorder, are generally too great to permit the application of the remedies
most likely to be effectual. When one feeling is in possession of the
thoughts, and has produced an intellectual state much akin to reverie, it
is plain that the effect of time in removing it can only be very gradually
produced, because not aided by observation of the events, which that time
brings in its course. Nevertheless, the prognosis of secondary hysteria
may, in most cases, be favorable, and the progress towards recovery may
generally be made evident, by directing attention upon successive stages of
the disease, the period of natural recovery being sometimes postponed until
the age for strong emotions has passed by. But as soon as some positive
improvement can be recognised, any circumstance capable of giving a new and
powerful bias to the thoughts, is always followed by speedy and beneficial
changes, so that the excitation of pleasurable emotions may be looked upon
as the most important of remedial measures. Unfortunately, the means of its
application are often wanting, and can seldom be created artificially; but
it must rest with the practitioner to seize upon every possible opportunity
which is afforded by their presence.
Among the unfavorable terminations of secondary hysteria, insanity will
hold the most prominent place, and is, undoubtedly, very frequent,
especially among the humbler classes. A visitor to the Middlesex County
Asylum at Hanwell, cannot fail to be struck by the number of " hysterical
cases." But from the indefinite manner in which the word "hysterical" has
been used, it is impossible to obtain trustworthy statistical information
on this point; and there can be no question as to the propriety of avoiding
the inaccurate exactness of false numbers. Death, except from intercurrent
disease, is of very rare occurrence, and may generally be attributed to
exhaustion, from excessive movement and interrupted nutrition.
Against secondary hysteria, as against primary, I should regard all
medicines to be absolutely useless and inert. The existence of the disease
may sometimes involve functional disorder of a kind to require treatment;
or exhaustion calling for stimulants; but these are accidental conditions,
in no way essential to the disease itself, and not likely to remove it when
they are taken away.
The treatment of tertiary hysteria has next to be considered, and the other
forms have been somewhat briefly dismissed, in order to afford to this the
space which is required by its prevalence, by its importance, and by the
degree in which it is amenable to well-directed efforts for its cure.
The tertiary paroxysm and the complications are so seldom separated, and
when separated, demand so little variation of the general plan, that in the
following description they will both be discussed together.
Against the compound disease presented by their combination, medicines are
quite as powerless as against the involuntary paroxysm, and, as has been
already shown, can scarcely fail to exert an injurious moral influence.
Moreover, it will seldom happen that self-produced disease proceeds so far
as to necessitate the use of stimulants, or other means demanded by sudden
emergencies; and, therefore, undivided attention may generally be given to
measures directed against the causes of morbid action, measures which, in
most cases, may be carried out so efficiently, as to obtain the complete
and permanent abandonment of all imitations of disease; and not only
entirely to withdraw the motives for the production of convulsive action,
but also to put in their place the strongest inducements for the
preservation of health.
And it must be stated in limine, that no system of moral treatment can be
effectually carried out, so long as the patient remains in her own home;
and, although it is possible that, in some mild cases, an attempt at doing
so might be successful, still this success could not often be obtained, and
could never be confidently predicted, as, whilst at home, the patient will
always possess the means to baffle the plans of her medical attendant, and
will not fail to use them, if the deceptive element be at all a
strongly-marked feature of her case. And not only will there be this
difficulty, but also the much greater one, which would arise from the
interference and doubts of the parents and friends of the patient, who
would always have it in their power, by foolish good nature or improper
sympathy, to overthrow in a moment, the improvement which it had taken
weeks to effect. Moreover, when disease has been simulated, the very
progress of the cure almost establishes the fact of imposture; and it is
highly conducive to the future well-being of the sufferer, that she should
not know this imposture to be perceptible to her friends. The dread of
losing caste by such a discovery, would be a strong inducement to a girl
who was under treatment in her own home, to hold out to the very last, and
would keep alive a motive, which it should be the first object of the
medical attendant to destroy. Now and then cases will be met with, in which
the patient is heartily weary of, and sorry for, the system of deception
which she has commenced, and waits only for the smallest help from a wise
and friendly hand, to abandon practices which she would have left off
before, had she known how to do so without exciting the suspicions of her
friends.
But such individuals form a small minority of the hysterical; and in the
greater part of the cases, we must look for a degree of perversion of the
moral sense, which is most painful to witness, and often most embarrassing
to encounter. When thus opposed, the professional adviser who would
endeavour to unfold the tangled web presented to him, and who seeks, by the
aid of moral treatment, to check vicious propensities, and to induce the
abandonment of vicious habits ; while he calls in the aid of regimen and
exercise against the nucleus of real disease, which is always to be found
in such cases, must, as the first and most essential condition of success,
demand that the patient be placed under his roof, as only when there, can
she truly be described as under his treatment. And if this demand be not
acceded to, he will act wisely in declining to interfere with an
individual, who will probably damage his reputation, and who certainly will
not add to it.
The first step towards the commencement of systematic treatment must be the
discovery of any special motives by which the patient may be influenced.
For the attainment of this end, it will of course be necessary to make the
most minute possible inquiries among the members of her family, or among
those persons with whom she was chiefly thrown at the commencement of her
illness, as to the circumstances that immediately preceded it, and to learn
every thing that they can impart with regard to her habits and her
associates, especially those of the opposite sex. It will also be necessary
to inquire exactly what ailments she has suffered from, subsequently to the
first paroxysm; and if any variety of uterine disorder finds a place in the
list, the exact time at which it was added to the other affections must be
noted; and also the kind of treatment to which she has been subjected for
its alleviation or cure. These points being ascertained, a few days may be
advantageously devoted to close observation of the patient, who, being made
to feel as much at home and at her ease as possible, should be encouraged
to talk freely, both of her past and present ailments, as well as of her
pursuits, accomplishments, tastes, and feelings. Whilst all this is being
done, it will be well not to require from her a very rigid conformity to
the rules or hours of the family in which she is domesticated, but to
indulge her in every trifling bad habit (that of breakfasting in bed for
instance), which she may consider proper in her state of illness, and the
checking of which would create an unpleasant feeling in her mind, and
render her morose or uncommunicative. By a short period of such treatment
as this, the vigilance which her change of abode would necessarily arouse,
will be in some measure laid asleep, and the prompt administration of some
pleasantly-flavored medicine, as a remedy for the first ailment she
complains of, will, in all probability, completely deceive her as to the
nature of the treatment which she has to undergo, and will lead her,
perhaps to simulate a new disease, but at all events, to return with full
vigour to the practice of the old ones, which would have been suffered to
rest in abeyance, whilst she was making her observations, and deciding upon
her course of action.
But by the time this effect has been produced, her medical attendant should
also have formed, and maturely weighed, his opinion of her case; should
have observed what parts of it constitute an individuality, and separate
the patient from her sisters in misfortune; and should have determined what
amount of real illness there may be blended with it, with especial
reference to the condition of the lungs and heart, to the action of the
liver, to the state of the blood and the general activity of the
circulation, and to the menstrual function.
It will be found useful to make memoranda of these observations in any
short form, to serve for reference in case of need, if it be desired to
refresh the memory on any point connected with the history or symptoms of
the patient, without, at the same time, directing her attention to it by
interrogation; and it will be advisable, moreover, to add to these
memoranda, from time to time, a statement of the progress of the case,
which shall include everything of importance as it happens, and thus carry
on the history, to the time when the treatment terminates.
It has been already stated, that the system which is about to be described,
acts by wearing out the moral endurance of the patient, and also by taking
from her all motives for deception, or for the voluntary production of
convulsive attacks; and the method by which this is accomplished must of
course vary, in some degree, with the varieties of individual temperament,
and with the diversities of particular cases. But, as a general rule, the
medical man under whose care the patient is placed, having satisfied
himself thoroughly of the nature of her ailments, and having obtained the
information indicated in the last paragraph, should wait a little while for
some complaint of illness to be made to him, or for the occurrence of an
hysteric paroxysm. To which form of the disorder priority is given, will
depend very much upon the character of the patient, and may be taken as an
indication of her intention, either to feel her way cautiously on the one
hand, or to take her new friends by storm on the other.
Supposing that priority is given to the convulsive paroxysm, the attack
will in all probability occur during a meal, or when there are strangers
present, or at some most inconvenient time and place, and it may on this
account be necessary to have the patient removed to her bedroom. In such
case she should be carried there as quickly as possible, placed upon the
floor, and immediately left quite alone, the door being shut, and no one
being suffered to open it on any pretext whatever until the patient does so
herself. But if the room in which the attack takes place can be spared for
a few hours, it should be cleared and shut up in the same manner, and in
either case especial care must be taken not to give utterance to a single
expression, either of sympathy or of alarm. After the lapse of a longer or
shorter time, often at the next meal, and sometimes not until the next
morning, she will present herself as usual, and will perhaps offer some
apology, or express some regret for her illness. This should be graciously
received; and then every attempt on her part to return to the subject must
be carefully and industriously foiled, no inquiries being made about her
health, and all complaints being interrupted, by the introduction of
ordinary conversational topics. If the patient, after the attack, appears
and behaves much as usual, it will be best to wait awhile and watch her
proceedings. Sometimes the habit is to produce a convulsive paroxysm only
at the menstrual period, or at certain definite times, having some shorter
interval; and with such individuals it is best to defer the admonitory
discourse, which is the further step in the treatment, until after the
arrival of the next occasion on which a paroxysm may be expected, and in
the hope of that expectation remaining unfulfilled.
If the paroxysms have occurred irregularly, a day or two should be allowed
to elapse before any conversation is held with her on the subject of her
ailments, as this time will allow the excitement of her nervous system to
abate, and will moreover afford an opportunity of introducing the subject
unexpectedly.
And this first conversation with an hysterical girl, is a thing that must
not be hastily or lightly undertaken, for upon the method of its
performance will chiefly depend the success of after management. However
much the practitioner may possess of firmness, coolness, and tact; however
much knowledge of human nature generally, and of the character of the
individual under his charge, he will have commenced a task in which none of
these powers or acquirements will be found either redundant or superfluous.
He will be called upon to place unwavering trust in his own professional
opinion, and to act upon his faith; to express himself with such
determination as to show the hopelessness of a contest with him; and to
keep his temper under circumstances of the strongest provocation, while at
the same time he soothes the wounded vanity or the awakened anger of his
auditress, comforts her with the hope of amendment, and invites her, by
manner and tone, as well as by words, to repose confidence in his
friendship, and to aid him in his efforts for her good.
The chief object to be attained, is to produce full conviction on the part
of the patient, that her medical attendant thoroughly understands her case,
and knows, not only how many of her symptoms or ailments are self-produced,
but also the exact manner or train of thought, by which they are set going
on each occasion; and the plan which will he found available for this
purpose in the greater number of cases, and with some slight modifications,
perhaps in all, is to commence by a positive assertion that she has nothing
at all the matter with her, and is, in reality, in perfectly good health ;
her ailments being, one and all, fraudulent imitations of real disease.
Such a statement will usually be met by an indignant but still
half-frightened denial of its truth; and it should be immediately and
unsparingly followed up, by a complete analysis of the case, from its
commencement to that time. Of such analyses no two will be quite alike,
except only in their general features. The first hysteric paroxysm should
be taken as a starting point, and the emotions which produced it should be
described and censured. This done, the case must be, as it were, built up
and put together by the speaker, the share in its production of every
vicious propensity or selfish feeling being quietly and dispassionately
laid down, and the probable motives for each new trick being described.
When this historical sketch is completed, the attention of the patient
should be drawn to the effect of her conduct upon her own physical and
moral health, and to the terrible degradation of her state. She should be
made to picture to herself the effect which would be produced upon any
indifferent person, or casual acquaintance, by her mind being stripped bare
before them, and exposed in all its deformity, and any or every part of her
past conduct, which can conduce to her humiliation and shame, must be
brought fully before her, and its true stamp and character explained; this
plan being continued until either the resources of the speaker are
exhausted, or until, as will now and then happen, the patient exhibits
signs of contrition and regret.
In either case, and especially in the latter, the tone of conversation must
be changed. If what has been said appears to produce but little effect, it
will be sufficient to add that her condition is not irretrievable; but
that, on the contrary, if she behaves well, she shall be assisted to
discontinue her bad habits, and to regain her position in society, with
which assurance she may be left for a time to her reflections.
But if any sign of penitence or regret be manifested, this assurance will
not be sufficient. The patient will require more tender treatment; and the
evidence of a wish for better things, small though it may be, should be
carefully fostered and encouraged. For this purpose she should be assured
that, with good conduct on her part, there is every prospect of her
complete moral restoration; that the endeavours of her professional friend
shall steadily be directed to the attainment of this object; and that he
will abstain from exposing her, either to the members of her own family or
of his, so long as she manifests a sincere desire for amendment. It would
be unwise and undesirable to represent the task before her as an easy one;
but she should be assured of its possibility, and that every necessary help
shall be afforded her. If there be any self-produced ailments besides the
hysteric paroxysms, as vomiting, ptosis, aphonia, or the like, she should
be told to leave them off within a certain time, as a week or a fortnight.
They should be discontinued one by one, and some trifling remedy should be
recommended for the relief of each, as for instance, a lotion or gargle, or
the taking a little cold water in the morning, in order to furnish the
patient with an ostensible reason for being better, and to enable her to
keep up appearances with those around her. But she must be well assured
herself that these pretended remedies are perfectly inoperative; and she
must be encouraged to exertion by the threat of exposure, if she fails to
get rid of each symptom within the specified time. And when once any bad
habit has been abandoned in this way, the rest of the victory is easy and
certain. The threat of exposure is rendered doubly terrible to the patient,
by the knowledge that she has furnished proof against herself of imposture;
and that the statements of her medical attendant are thus rescued, by
positive evidence, from the imputation of being mere opinions. Sometimes,
in dealing with very impressible temperaments, it may be desirable to
insist on the immediate abandonment of some deception; and the patient,
surprised out of presence of mind, will often yield to the demand, and will
thus, in a moment, place herself completely in the power of her
interlocutor. A striking instance of this fell under the author's
observation some time ago, in the case of a lady, who, among other
ailments, said, that she was rendered lame by acute pain in the sole of the
foot, and who actually submitted to an operation, at the advice of a late
very eminent surgeon, for the relief of this pain. After the nature of her
illness had been described to her in the manner before mentioned, it was
insisted upon that she should immediately take a walk, which the gentleman
who accompanied her extended to the length of six miles, bringing her home
desperately tired, but with her lameness cured completely and for ever, and
with all her other complaints at his mercy, to be discontinued in whatever
order, and whatever time, seemed to him most judicious. After the lapse of
three months, she returned home perfectly well, and has never again
manifested any hysterical tendencies.
It will, however, be too often found, that the deadened moral sense of an
hysterical woman requires many and strong appeals to rouse it from slumber;
and that the first stimulus will, for some time, require to be frequently
repeated, in order to strengthen, or even to maintain, the impression that
has been made. In all cases it will be necessary to use plain words, and to
convey the ideas of selfishness and falsehood by their simplest names, and
not under the disguise of polite and elegant periphrasis. The patient needs
to hear the truth, and to have her conduct put before her, in a light which
no ingenuity of hers can possibly pervert into the interesting or romantic;
while at the same time, all this must be done with a degree of self
possession and good temper on the part of the operator, which will show him
to be uttering his real opinions, and not caricatures of them, dictated by
auger or impatience. Care must also be taken to destroy the impression,
that there is anything remarkable, or singular, in the particular case
under consideration, which must always be spoken of as most ordinary and
common-place, differing from others of the same kind, only in the greater
or less amount of deception which it may contain.
The points which will chiefly require attention in the conduct of such a
lecture as has been described, are two in number. First, it is necessary
never to bring any particular accusation against the patient, unless
convinced of its truth; that is, never to specify a motive at haphazard, of
which she may be able to acquit herself; but to deal in generalities when
doubtful, leaving it to the conscience and self-knowledge of the person
addressed, to fill up the outline in the right way, and to give credit to
her accuser for a more intimate knowledge of the workings of her mind, than
in reality he may happen to possess. By acting in this way, it is often
possible to gain important information from the exculpatory speeches of the
patient herself, pregnant as they will generally be, with hints of her real
motives. But she must never be immediately convicted from her own lips; and
her words should never be quoted against her, lest she should be taught
caution, and thus one fountain of knowledge would be sealed up. The ideas
contained in her defensive speeches may be remembered, and presented to her
afterwards in a somewhat different dress, so that they shall almost appear
to be an expression of her unspoken thoughts; and shall thus strengthen her
belief in the completeness of the mental scrutiny, to which she should feel
herself subjected.
Next, or perhaps equal in importance, is the necessity to avoid everything
which approaches to exaggeration or rhodomontade, -everything which the
patient can feel to be beyond the strictest limits of truth. There is no
persuasiveness half so powerful as the persuasiveness of simplicity; and it
will be found that every exaggeration, either of a fact or of an, offence,
subtracts from conviction even more than it adds to truth, and weakens, in
no small degree, the authority and consideration of the person using it.
Hence, no one should risk a discussion with an hysterical patient, who
cannot reckon upon perfect coolness and unruffled temper; and no one who
felt these qualifications failing him in the hour of need, should continue
the conversation for another moment, but should break it off on any
available pretext, and resume the thread under more favorable
circumstances.
When the convulsive paroxysm forms part of the illness for which the
patient is placed under medical care, it will be best to defer the first
lecture until after a convulsion has been produced, in order that its
hysteric character may be verified by actual observation, and in order to
perplex the patient by the withholding of all the various kinds of
treatment, which she has been accustomed to suffer during its continuance;
but when the " fits " have been entirely superseded by the simulation of
local diseases, the time for explaining the .nature of the case, and the
plan of treatment to be pursued, must be selected by the medical attendant,
with reference to the peculiarities of the individual, and to the time that
he may require for unsuspected observation of her character, or to the
opportunities which the changing phases of her mind may afford him. "When
the ice is once broken, the subject may be resumed at almost any time; but
too much discrimination cannot be exercised, in the selection of the moment
for striking the first blow; for upon its direction and force, will depend
the patient's measure of the power against which she has to contend, and
therefore, the probable inclination of her mind towards submission or
resistance. And if she be made to feel that this power is too strong to be
effectually withstood, and if her confidence in her own resources be thus
shaken, a great deal will have been done, although there should not be even
a tacit acquiescence in the statements made to her, and although there be
nothing else, on which the operator can congratulate himself. No hysterical
woman can by any possibility hold out for a long time against this kind of
treatment; but the length of the siege which she is able to maintain, will
depend quite as much upon the amount of her trust in her own powers, as
upon the actual ingenuity and cunning which she calls to her aid. A traitor
in the camp is as mischievous in mental, as in physical warfare; and doubt
is the most dangerous of traitors, not ouly admitting the enemy, but also
rendering inefficient the weapons of defense.
The way in which different women will receive such an address as that which
I have described, will of course vary very much in different cases; but
will yet vary within such limits, that the methods of resistance they have
recourse to, admit of easy classification. Some will eagerly grasp at the
prospect of emancipation from the system of deception which they have
pursued, and which they have not relinquished of themselves, only because
the very act of doing so seemed to confess imposture. Of those who deny the
charges brought against them, some will have recourse to the paroxysm to
terminate an unpleasant conversation; others will exhibit violent anger;
and others, obstinate taciturnity and sullenness; these last being by far
the most difficult to deal with.
The production of the hysteric paroxysm, if it could be accomplished as
soon as the tenour of the first discourse became apparent, and repeated
whenever an attempt was made to return to the subject, would be a most
efficient method of defeating any system of treatment, which required for
its completion that the patient should be talked to; but it fortunately
happens that, the mechanism by which a voluntary convulsion is excited,
requiring, as it does, an act of memory, and, therefore, a momentary
abstraction of the mind from present events, is rendered powerless for a
time, by any circumstance which strongly engages the attention of the
patient, an effect which it should be the constant aim of the operator to
produce and maintain, and which the very nature of his subject is almost
sufficient to ensure, on the occasion of the first lecture. The paroxysm is
most likely to occur, when the subject is resumed for the first time; and
then it will, perhaps, be tried as an experiment, especially by those
patients who have not previously gone through this part of their
performance, in the presence of their new doctor. They must be treated in
the manner described above, by being left quite to themselves until they
return to their ordinary state of being, when a hope may be politely
expressed, that they have not suffered much fatigue from their severe
exertion; and a question may be put, as to how long they continued to
practise it. In this way they will find, that the only effect of the
paroxysm, is to make them appear ridiculous, and when subjected to any real
emotion, they would rather strive against than encourage it.
In the majority of instances, the charge of habitual deception, and
self-produced illness, will be met by expressions of anger and wonder,
mingled with tears and sobs. But these will offer a very feeble resistance
to the force of truth; and the woman who at first, in a tempest of
indignation, violently repudiates the charges brought against her, will
speedily quail before a calm and exact delineation of her character and
motives, and will often, even in the first conversation, yield some vantage
ground which she will never be able to regain. In dealing with such people,
it is only necessary to meet violence by passive resistance, and to assume
a tone of authority, which will, of itself, almost compel submission. Thus,
if a patient jumps up from her chair, overturns it, and exhibits furious
passion, so soon as the storm of her words has abated for lack of breath,
she must be told to sit down, and to conduct herself like a lady. So, if
she interrupts the speaker, she must be told to keep silence and to listen;
and must be told, moreover, not only in a voice that betrays no impatience
and no anger, but in such a manner as to convey the speaker's full
conviction, that the command will be immediately obeyed.
The patients who use obstinate silence as their weapon of resistance, are
by far the most difficult to deal with, not only because they deprive the
speaker of any sure measure of the effect which he produces, but also
because they are, for the most part, women of unimaginative and
unimpressible minds; whose moral sense is deficient rather than blunted,
and in whom the original causes of hysteria are likely to have taken deep
and permanent root. Such persons are to be found in all ranks of life; but
in the educated classes (save some rare exceptions) only where real
intellectual culture has been neglected. They become more and more common
as we descend the social scale, and may usually be found in their highest
state of development, in the union workhouse of an agricultural district.
But any modifications of the ordinary plan required by such persons, are
necessary rather during the progress of treatment, than at its
commencement, and will, therefore, be most appropriately discussed
hereafter.
The indulgence which has been recommended to be practiced, during the
period of observation, must cease so soon as the system of treatment is
fairly commenced. By this, it is not intended to convey, that any, the
slightest harshness, is to be practiced, than which nothing could be more
opposed to the attainment of the desired end. But there must be no lying in
bed after the hour at which other members of the household assemble; no
breakfast in bed, on any pretence whatever; and no breakfast at all, if the
patient does not choose to rise in proper time for it. She must be told,
plainly and firmly, that the rules and habits of the family in which she is
residing, cannot be deviated from in the smallest degree in favour of
pretended illness, and the principle thus laid down must be consistently
and strictly acted upon. But it must be acted upon tenderly and kindly, as
well as strictly; and the unprofessional members of the household must do
their part, out of consideration for the delicate health of the invalid,
which requires strict regularity of hours and habits, and not from any
apparent knowledge of the real state of the case. They must also be called
upon for assistance in suppressing the inveterate habit, common to all
these patients, of talking about their ailments, and must be instructed to
say, with every appearance of sympathy, that they cannot listen to the
story of her symptoms or sufferings, because talking about them would be
injurious to her. It follows, as a matter of course, that no one in the
house must ever put a question about her health, or must ever remember
during the day, that she had complained of headache or backache in the
morning. And nothing will do so much towards breaking the habit of constant
introspectiveness, as the knowledge that there will be no opportunity
whatever of communicating its results ; and that, if these be dragged into
the conversation, a deafness, of the kind said to be most complete, will
immediately seize upon the persons addressed; who will always, at that very
moment, be taking deep interest in some one or other of the topics of the
day. Of course, the art of managing thus is not to be acquired without some
practice, but it is far from being so difficult in reality as it appears
upon paper; and the medical practitioner who chooses to undertake his part
of the good work, may feel quite assured that, with a little prompting, the
tact and dexterity of his wife and daughters may be safely and entirely
relied upon.
And here it should be observed, that the professional man must always make
every communication which either expresses or implies his view of the case,
a matter of confidential and private conversation, and that he must never
allow the smallest hint of it to escape in the presence of the patient and
other persons, in order that he may always have it in his power to use the
threat of exposure, and to suggest to her how differently his family would
look upon her, if they only knew what he could tell them; and not only
should he observe this precaution, but he should also make a point of
treating his patient with marked courtesy, in the presence both of his own
family and of strangers, in order that she may feel herself to be actually
receiving all the respect and politeness due to the most exemplary of her
sex, and that she may know herself to be so treated, only upon the
sufferance of her medical attendant.
Having thus laid down the manner in which a system of moral treatment may
be commenced, it still remains to consider the way in which it will require
to be continued, in that very large number of cases, where the only effect
produced at first upon the patient will be a resolution to hold out to the
last, and to disprove charges, of which, nevertheless, she feels the truth.
For this purpose, the chief means at her command will be the simulation of
disease, and she will either select a complaint which she has had
opportunities of observing in her own family, or among her friends, or else
one which is suggested to her at the moment by some passing event. In the
latter case she will almost inevitably either be unfortunate in her
original selection, or inconsistent in her collocation of symptoms, and
thus betray the cloven foot; but when a cunning woman, in playing her last
stake, simulates a disease which she has had ample opportunities of
observing, and which has, perhaps, already proved fatal in the case of a
relative, her medical attendant will have need of all his discrimination,
and of all his self-reliance, to avoid even the appearance of belief in
what is unreal; and to avoid the still more fatal error of neglecting
actual disease.
It forms no part of my task to lay down rules for the detection of
malingerers, or even to recapitulate what has been written on the subject
by others, especially as the discovery of imposture must always depend, in
the main, upon individual acuteness and tact. But in a doubtful case it
would be proper to treat the disease as real, in the full assurance that
the truth must soon be discovered, and with the resource of representing
the treatment to have been intended simply as the punishment for an attempt
to deceive. By acting thus, no great harm can be done, as the occurrence of
serious mischief will be provided against, and any satisfaction which the
patient may at first feel, from the presumed success of her schemes, will
be speedily changed into a state of mind much less agreeable to herself.
Whatever decision the medical attendant may arrive at, he should judge and
act entirely upon his own responsibility, because, to call in the aid of
another opinion, however valuable it might be with reference to the
particular question, would show, beyond a doubt, that he was really
perplexed about the case.
A young lady under the author's treatment, fixed upon prolapsus uteri as
her disease, and was cured by being told that she would give rise to
unpleasant suspicions by talking of it, as it was peculiar to mothers. It
was, subsequently, discovered, that a servant in the house was really
suffering from the complaint in question, and that she had told this lady,
who was not aware that the girl had first entered the family as a
wet-nurse.
The difficulties arising from the simulation of new diseases, constitute
the chief reason why the treatment which it is the object of these pages to
describe, can only be carried out by a member of the medical profession,
and also afford one of the most cogent arguments in favour of removing the
patient to his house.
The author has been informed of an instance, in which a clergyman, who had
been made acquainted with the outline of the system, attempted to carry it
through; but he was stopped in mid-career by a leech or two introduced into
the patient's mouth, so as to produce fin attack of severe haemoptysis.
Feeling himself powerless against this, the reverend gentleman sent for the
village-doctor, who, on his part, resorted to venesection and astringents,
and gave a new lease to the disease of the knee-joint, which had
constituted the original ailment.
And in the same way, if a lady was taken under treatment in her own home,
it would always be in her power to select a suitable time for alarming her
friends by the sudden occurrence of severe pain, or haemorrhage, or some
other ailment, which would appear so perilous as to induce them to obtain
medical assistance with the greatest possible speed, while it is most
probable that a strange practitioner thus hastily called in would not be
placed in possession of the materials for a correct judgment, and would
hastily have recourse to some active treatment, the impropriety of which,
even when it was pointed out to him, he might not afterwards be able to
discern; and thus, between conflicting opinions, the friends of the patient
would be very apt to decide in favour of their natural sympathies, and
against the idea of simulation. After the treatment has been commenced, and
after the first two or three trials, there is seldom much trouble with the
hysteric paroxysm, which, if entirely neglected, is not prone to recur. In
one instance which fell under the observation of the author, the paroxysm
had occurred every night whilst the patient remained at home, commencing
soon after she reached her bedroom, and being indicated by rappings and
other noises, which collected her sympathising friends to behold her in
violent convulsions on the floor. When she was placed under the plan of
treatment which is being described, after the first lecture, she was sent
to bed every night with a very short piece of candle, (care was taken that
she had no private means of procuring a light,) and no one was permitted to
go near her, however loud or strange were the noises proceeding from her
room. It is scarcely necessary to add that this trick was very speedily
discontinued, although for the first few nights, in consequence of there
never being any evidence in the morning, that the noises were heard at all,
they increased very much both in duration and intensity. And thus, in the
space of a week or two, a stop was put to these convulsive attacks, for
which she had probably taken every remedy in the Pharmacopoeia.
Various disorders of the uterine system may be used by these patients as
their last resource, and various ingenious devices are now and then
resorted to, for the production and maintenance of artificial discharges.
The foot-note to page 122 indicates a good method of meeting all complaints
of this kind. The patient should be told that she has put her story
together badly, and that some of the symptoms she describes, must have been
suggested to her by the sufferings of married women among her
acquaintances. Diseases of the spine and joints will be occasionally fixed
upon, but they may be managed without much difficulty. The presence of the
patient at meal times must be steadily insisted upon, and her lameness must
never be remembered or noticed, except when it entails the much lamented
necessity of excluding her from something agreeable, as a dance or a picnic
party. If recourse be had to ligatures, or other methods of producing
artificial swelling, they will soon be found out, and their mode of
operation should be explained to the patient, with any comments which may
be deemed suitable to the occasion.
The neuralgias are very difficult and troublesome to manage, inasmuch as
the occurrence of actual pain is by no means improbable. It is unnecessary
to do more than suggest, that careful and minute observation of the
patient, cannot fail to throw much light on the reality, or the amount of
her suffering, especially when her past history is fully known. Any obvious
disorder of the secretions, or any decided anaemia, would be important
evidence in favour of veritable disease; but where these were wanting, and
where there was the appearance of extreme pain, the author would think it
legitimate to use chloroform, ostensibly as a sedative, but also with the
view of producing a dreamy condition, in which any suggestion from without,
if in unison with the patient's own feelings, would produce a response
which might clear up the question. And when all doubts are done away with,
as to the reality or nonreality of the symptoms complained of, the
difficulty of relieving them in the one case, and of checking deception in
the other, may be considered as half overcome.
Many patients will abstain almost entirely from food for several days,
declaring that they have no appetite, and in reality intending to produce
alarm in the minds of those around them. With such it is of course
necessary to discover whether or not their abstinence is genuine, and to
keep a strict but unobtrusive watch over all their movements. If they
obtain food surreptitiously, it is well to allow them to follow their own
devices for a day or two, and then to tell them carelessly, that it would
be less trouble to eat proper meals, than to have recourse to such a
miserable subterfuge. But very often no such discovery as this will be
made, for hysterical women bear very long periods of abstinence with
impunity, and one lady under my treatment suffered nothing but coffee to
pass her lips for ten consecutive days, and it is worthy of remark that she
drank the pure infusion, without either sugar or milk. But this fasting is
a dangerous practice- perhaps more so than any other of the various
schemes by which these patients endeavour to delude their friends-and I
have heard, from a very credible, though not a professional informant, of
an instance in which complete failure of the digestive power, and
consequently, death from starvation, followed as the effect of prolonged
abstinence, which the patient on her deathbed confessed to have been
entirely voluntary, and to have been persisted in, for the purpose of
exciting sympathy and commiseration. Hence it is doubly necessary that the
loss of appetite should not produce any of its desired effects, and that
the patient should on no account be permitted to see that any anxiety or
attention is excited by it. She must be asked to eat at meal times,-but
if she decline doing so, or if she take food upon her plate and send it
away untouched, no notice must be taken, and her reply, or conduct,
whatever it may be, must be treated as a matter of course. Perhaps she will
express a desire to remain in her bedroom during meal times, not having any
wish for food, and such a request should be met, on the part of the lady of
the house, by a ready and cheerful acquiescence, and sometimes by a playful
reproach of her unsociability, but never by any the least expression of
surprise. A patient thus treated, will soon discover that she is torturing
herself for nothing, and her appetite will gradually return-a change
which should not produce a single observation or remark from those around
her, however much they may be secretly gratified and reassured by it.
The diagnosis of real from pretended anorexia is very simple at the
commencement, for if hunger be felt, the sight and odour of food will
excite the salivary glands to the performance of their function, and the
patient will be forced to swallow frequently, in order to get rid of the
superabundant secretion. Doubtless, after a few occasions of forced
abstinence, this test could no longer be relied on, but there is a period
in every case, when it can be applied with perfect confidence.
Constant vomiting is, in its possible results, almost as dangerous as long
fasting, and a case may easily be conceived, in which the patient would
find it impossible to lay aside the habit she had contracted. Under such
circumstances it would be proper to call the instinct of self-preservation
to our aid, and to frighten her thoroughly, with regard to the consequences
of her misconduct, saying, moreover, that the habit might still be broken
at that particular time, although if longer indulged in, it would probably
have a fatal termination. Food should only be given in very small
quantities at a time, and that in the liquid form, on the principle laid
down by the late Dr. William Hunter, and the patient must be strictly
enjoined to abandon the practice within a specified time. But before
proceeding thus, there must be full assurance that the trick has passed
beyond the ordinary control of the will, lest by the manner of regulating
the diet, we minister to the hysterical desire. In the absence of this
assurance, the general plan of treatment must be strictly carried out, the
patient being made to take her meals alone, and to remain in seclusion
until the sickness is over.
It would be waste of time, to enumerate the endless varieties of disease,
which may be simulated at the period now under consideration. They will all
be attempted by some persons-one only by others. But they are attempted
under very disadvantageous circumstances, and are not likely to be nearly
so well done, as were the complaints under which the patient suffered at
her own home. There, her history was built up by degrees, and no suspicion
was at first excited, while her female friends contributed their quota to
the tale, by recounting analogous cases, and the doctor his, by putting
leading questions. Here, she is thrown entirely upon her own resources,
with the necessity of producing a new set of symptoms, with the certainty
that every blunder will tell against her, and knowing that the person whom
she tries to deceive, is carefully on the watch against imposture.
And whatever be the kind of disease fixed upon by the patient, the
principle on which the treatment is conducted must be the same, and has
been fully laid down in the preceding pages. Deception is had recourse to,
for the production of a certain definite effect, and it requires to be
steadily counteracted by an entire withdrawal of sympathy, while at the
same time the patient is treated with every possible kindness, courtesy,
and consideration, wherever there' is no question of illness involved. When
the means used to imitate morbid action can be discovered, they must be
pointed out, and upon all practicable occasions, the first warning as to
the effects of hysteria, and the substance of the first lecture, must be
reverted to, and insisted upon, while the threat of exposure is used to
accelerate tardy progress-and encouragement is given to every indication
of a desire for amendment. It is scarcely necessary to repeat that the
effect of such a system as this, is to withdraw, by the withdrawal of
sympathy, all motives for continued imposture, and to arouse, by the fear
of real physical illness and of social degradation, strong inducements to
the preservation of health.
There are still many useful and important accessories to the cure of
tertiary hysteria, which may be summed up briefly, by saying that the
sufferers should be placed under the most favorable hygienic circumstances,
with regard to diet, exercise, locality, and habits.
Thus their food should be plain, simple, and nutritious, all highly spiced
and stimulating dishes being forbidden, together with all alcoholic or
fermented liquors, excepting a little bitter ale. The principal meal should
be taken in the middle of the day, and a sufficient interval must elapse
for proper digestion, before the arrival of the next.
Exercise is of the first importance; but so much has been already written
on this subject by others, that it need not be farther insisted upon here,
and the same remark will apply, to the question of locality and habits.
But it is very possible to fall into grave error with regard to all matters
of this kind, by representing some particular rule of conduct, or kind of
food, or manner of exercise, or place of abode, to be essential to the well
doing of the patient. For it often happens, that she may herself take
pleasure in what is thus recommended for her; and that the treatment itself
may become a matter of indulgence, to be prolonged as much as possible. And
even if this be not so, the hysterical desire will be most dangerously
gratified, by any strict law of this kind. Thus, the author is acquainted
with a lady for whom horse exercise was prescribed by her physician, and
who, consequently, cannot be kept in health without it. She is one of a
large family; and the practical result of the treatment has been, to afford
an indulgence to an hysterical malingerer which is a severe tax upon her
parent's income, and which is quite beyond the reach of her well-conducted
sisters. Again, any minute directions as to diet, or exercise, or habits,
enable the patient to make a fuss about the daily observance of them, and
to ascribe all manner of symptoms and sensations to any accidental or
unavoidable shortcoming in this respect; so that the safest plan is to
obtain conformity to the rules and habits of a well ordered family, and,
contentedly resigning the benefits which might accrue from Utopian hygienic
schemes, to assure the patient that whatever circumstances she is placed in
at that time, are the best for her health. The same rule will apply to the
use of remedies against constipation, about which there is often much
trouble. Care must be taken not to administer the required purgative at
regular intervals; for however desirable it may be to obtain daily
evacuation of the alimentary canal, it is still more so not to furnish the
smallest ground for valetudinarianism; and in the administration of this,
the only medicine allowable in tertiary hysteria, it is necessary to be as
chary as possible, and to be quite sure whether each dose supplied, has or
has not been taken. I have often been complained to in the morning, about
the severe operation of a purgative, which I had placed in the patient's
hands overnight, and which had just before been brought back to me, by a
servant who had found it concealed in her bedroom.
The process which has been described in the foregoing pages, may be briefly
characterised as a process of destructiveness, its object being, in the
main, to break up and destroy bad habits and deceptive practices. But this
is not enough for the accomplishment of a permanent cure, except in recent
cases, and in persons of naturally good disposition. When hysteria has
existed for any length of time, and especially in cases where the original
moral and intellectual training has been very defective, something more is
required than merely to exorcise the demon. He will return, and he must
find his dwelling newly tenanted, as well as "swept and garnished," in
order that by the second defeat he may be finally driven forth. And to
obtain this end, there must be a constructive, as well as a destructive
system, and the two must advance together, the endeavour being made to
plant right principles and feelings, as fast as the rooting up of evil ones
makes room for them.
And this work of construction, or, in other words, of moral and
intellectual improvement, is beset with innumerable difficulties. It is, in
fact, to train those, who have all the instability of childhood, joined to
many of the vices and passions of adult age; whose moral sense, perverted
originally by disease, is deadened by the continued practice of deceit; and
whose faculties, long exerted chiefly in self-inspection, are blunted,
alike to the beauties of nature, and the attractions of art. But although
the task is no easy one, still there is nothing of the impossible about it;
and if undertaken in the right spirit, success may be reckoned on with very
tolerable confidence. Time is one of the most important conditions; and
this given, there are very few cases so bad that they must be despaired of.
The first step is to be taken, by endeavouring to work upon the kindly
feelings of the patient, and to make her like the persons among whom she is
thrown, who should all behave towards her with much gentleness and
courtesy, making a point of cheerfully rendering her any small services or
good offices in their power, but letting it be understood that these are
entirely voluntary. Then, as soon as her professional adviser feels that he
has gained a hold upon her, it must be increased by his showing interest in
all her occupations and pursuits, condemning such of them as are frivolous
and puerile, and recommending others in their room, which should be chosen
from their suitability to the character of the patient, or from accidental
circumstances, permitting them to be advantageously followed. Thus, music,
reading, or chess, would be fixed upon, from considerations peculiar to the
individual, while sketching or botany would be available only in certain
localities. But whatever the pursuit may be, the great object is, that it
be followed in earnest, and that the doctor should place himself in a
position to watch and foster its progress, and to render frequent
assistance in its prosecution. It must therefore be something which he
understands himself, and in which he can always keep before his patient, so
as to be appealed to on any doubtful point, or called in to remove any
unforeseen difficulty.
In the selection of a pursuit, much will of course depend upon the
intellectual powers of the patient, and much upon the habits and tastes
which she may have formed, prior to the development of the hysterical
condition. These must be rendered available whenever they can, so as to
avoid the drudgery of a commencement, which would probably disgust a
capricious girl, however attractive might be the pursuit to which it led;
music, drawing, languages, and chess, must therefore be reserved for
patients who have some previous knowledge of them; but as this falls to the
lot of most hysterical women in the middle and upper classes, the
reservation, as far as they are concerned, is comparatively unimportant.
These four pursuits all offer peculiar advantages, because the progress
made, and therefore the degree of attention bestowed upon them, admits of
easy measurement. Which of the first three is fixed upon, should depend
entirely upon the taste and inclination of the patient herself; but when
the selection is made, it is well to discover some especial merit in her
performance, which renders it advisable to encourage such decided natural
talent, by the aid of the best instruction which the neighbourhood can
supply. The object of this is, of course, to keep the patient up to the
mark, and to leave her less time for introspectiveness. Chess is a valuable
study for a clever woman who likes it, but it requires a tolerably good
player in the family before it can be made available for remedial purposes;
and the patient should, of course, be in turn encouraged by victory, and
stimulated by defeat.
This is, perhaps, the place in which to notice the statements of Dr.
Layeock, with regard to the deleterious influence of music. The author has
not seen any facts which tend to support these views, and is strongly of
opinion, that when hysteria is developed, music, i.e., piano ^or
harp-playing, is a very valuable remedial occupation, from its affording
employment both to mind and fingers-and from its always presenting to an
amateur fresh difficulties to be surmounted. He is not desirous to open a
discussion in this place, concerning the probable effect of music in the
production of hysteria; but will only observe, that its action upon animals
and savage men, is likely to be very much more powerful, than upon European
young ladies of the nineteenth century, in whom not only has the nervous
system of the individual been inured to it from earliest childhood, but
whose ancestors, both male and female, have been subjected to the same
hardening process for several generations. ' Alexander's Feast' would
scarcely have been read with pleasure, if Dryden had selected his own royal
master, as the hero of the story; or to come still nearer home, if it had
been written by a modern poet, about a young lady of our own day. And if it
be urged, that the want of visible and immediate response to the stimulus
of music, depends upon the controlled deportment required by modern
civilization; still there is the testimony of lunatic asylums, where music
is found to be a very feeble agent, in complete opposition to this
argument.
Beading will only be found advantageous under peculiar circumstances.
Silent reading encourages reverie; and reading aloud, unless it be
particularly well done, is a nuisance to everybody within hearing, while
the matter read is at least as likely to be injurious as beneficial. A
moderate amount of it should not be interfered with; but where there is a
tendency to excessive reading, this should be carefully watched, authors
and books should be suggested, and the volumes read should be made the
subjects of frequent conversation and comment; and, in point of fact, of
examination. If the result be satisfactory, nothing more need be done than
to encourage the occupation; but if otherwise, an endeavour must be made
carefully and gently to divert the attention into some other channel. This
may be done by obtaining a book upon some practical subject; such, for
instance, as bee keeping, and by inducing the patient to try and carry out
its precepts, for doing which all facilities must be afforded her.
The study of any department of natural history, of entomology for example,
or of botany, has much to recommend it, as combining bodily exercise with
mental application. But unfortunately the usefulness of botany, for this
purpose, is terribly curtailed by its complicated nomenclature, and
redundant technicalities, at which ladies always take speedy alarm, and, as
it must be confessed, not without reason. Still, under the guidance of an
ingenious preceptor, these difficulties may be, in some degree, avoided,
until sufficient progress has been made to give the inclination to grapple
with them fairly,-and in case of failure, an attempt may be made to lead
up to botanical study, through the practice of floriculture, a pursuit in
which most ladies can be engaged without much persuasion, and which may
usefully occupy their time in the many delicate processes which it
requires, and in the almost unlimited scope which it affords, for the
display of taste and judgment.
The physical sciences will occasionally be found attractive, and the
smallest manifestation of a taste for them should be eagerly seized upon.
It would be well that a house destined for the reception of hysterical
women, should contain, in its domestic arrangements, ingenious and simple
instances of their application, which might have the effect of calling
forth inquiry into the principles of action, and the means by which these
can be made available. A small stock of electrical and chemical apparatus,
suited to the performance of simple and intelligible experiments, would
also be found useful in withdrawing the attention of the patients from
themselves. An astronomical telescope may be looked upon in the same light,
as, indeed, may all means and appliances for carrying on any pursuit or
investigation whatever. But the most important element of all, is the
cultivation, on the part of the professional man, of a clear, simple, and
familiar style of exposition, by which the subject spoken of may be
invested with the greatest possible degree of interest, and illustrated by
examples suited to the taste or capacity of the person addressed, while
anything resembling a declared lecture, or an uncalled for display of
knowledge, must be carefully and sedulously avoided.
It must not be inferred from what has been said, that an hysterical woman
is to be seized upon, and told that she is about to be taught astronomy, or
botany, or something else that is worth knowing. On the contrary, the
object in view should be concealed as carefully as possible, and the
approaches to it made with most guarded steps. No pursuit or avocation with
which she is sought to be tempted, must be brought out for her special
benefit, but before her attention is called to it, must be already going on
for the amusement or instruction of somebody else. And even then it will
seldom be politic to recommend it in so many words; but matters should be
so managed, as to ensure that there is something of interest to be seen
when she is accidentally present, and this she should be asked to look at.
But even if she does so with evident pleasure, there must be no hurry to
improve the opportunity, and if a few sentences of explanation be deemed
advisable, the smallest sign of weariness or of flagging attention must be
the signal to terminate them -while, if possible, they should be
concluded at the moment when attention is most fully aroused; an invitation
to see the next experiment being then admissible.
And no one must undertake the task which I have attempted to describe,
without full knowledge of the mental characteristics with which he has to
deal, or without distinctly realizing that all hysterical women are
wayward, irritable, capricious-that those of them who have been most
richly endowed by nature, have yet, by the constant direction of the mind
upon subjective phenomena, either much diminished, or temporarily
destroyed, the power of fixing it upon external objects, and that the great
bulk of them are weak and silly by original conformation. For no other
considerations will keep alive the patience which is necessary in all
dealings with them, or will support the confidence which is required, to
bear a hundred consecutive disappointments with composure.
In the management of all attempts to provide a pursuit for an hysterical
woman, it must be remembered, that the primary object is occupation of her
thoughts for a certain time, and not the attainment of excellence in the
pursuit itself. This being so, a subject should never be persevered with,
when it has become wearisome or distasteful, but an endeavour should be
made, to meet the craving for novelty of a restless mind, by timely and
suitable changes, so that there will always be something going on, which
can be watched and noticed, and which may serve to divert attention from
fancied ailments.
With regard to moral training, in its restricted sense, very little can be
said beyond the expression of general principles, which are almost
self-evident. The most obvious vice will generally be falsehood,- and,
indeed, if this was abstained from, there would be very few which a lady
could practise. It is scarcely necessary to say, that a good example is
almost essential to reformation, and that, consequently, those having
charge of the hysterical cannot pitch their own standard of honour and
veracity at too high a point. Next in importance after this, is the rule to
preserve, if it be possible, the self-respect of the patient, who should
never be exposed as a liar, if the exposure can by any means be avoided.
She must be freely and openly censured for her fault by her medical
adviser, but by him only, and by him always in private. When it is deemed
expedient, she may be trusted in some small matter where no great harm can
be done, her promise being first pledged to some particular mode of action
-and more and more confidence may be reposed in her by degrees, there
being nothing so likely to cure habitual falsehood, as the very fact of
being trusted.
Faults of temper form, as it has been said, an essential part of the
hysterical disorder, and are, therefore, always to be expected from its
victims. With these a great deal may be done in the way of precaution, by
keeping off the occasions of evil; for if ill-temper be but seldom called
forth, it will not respond very readily, even when the exciting cause is
applied. Faults of temper, not being commonly considered to involve any
great amount of moral degradation, may be censured whenever they are
manifested, as such censure does not involve the infliction of public shame
-and they will be much restrained, if the patient knows that any
indulgence in them will be immediately noticed and condemned. But in
private they should be represented in their true light, as involving an
amount of moral degradation unequalled by any single vice, as springing
entirely from the most contemptible of human passions, and as reducing
their victim to the level of the drunkard, without affording the excuse of
intoxication.
Again, faults of temper must be made, in some measure, to work their own
punishment, by regulating the deportment of the domestic circle towards the
person guilty of them. They are most frequently found in girls who have
been treated with excessive and ill-judged indulgence by their parents, who
have perhaps been delicate and sickly in early life, and whose moral
training has, on this account, been neglected. Such patients are not
rendered amenable to discipline without great difficulty, and their
hysteria is generally of the most inveterate kind; the primary emotion
having often been caused by the disappointment of some improper desire,
acting upon a mind unused to contradiction, and their feigned diseases
often being carried on for the gratification of purely vindictive feelings,
against the parents, or others, who have been at last compelled to thwart
them, and whose lax rule is too often justly chargeable with all the
subsequent misconduct of their children.
When ill-temper appears to have been produced by such, influences as these,
and when there is every reason to suppose that the patient has been
surrounded by persons more or less dependent upon her caprices, it is
necessary to begin, by making a total change in this respect. She must be
told, at first, that the way in which she is treated will depend entirely
upon her own behaviour, and that if she manifests causeless sulkiness or
rudeness, she will be left to her own companionship, and to her own
resources for amusement and occupation, until she has made proper atonement
for her error. A disposition to behave ill to servants, must be met by
directing them to perform their duties about her room or person in total
silence, and to leave as soon as these are accomplished; the reason of this
conduct being explained, at the time when the order is given. A few days of
such treatment, will often produce a very striking and beneficial change in
the actual conduct, but of course it will be dictated, simply by motives of
policy. The only hope of permanent improvement rests on the continuation of
such treatment, for a time sufficiently long to produce the formation of
good habits, during the growth of which, every endeavour must be sedulously
made to point out the advantages accruing from them, and also to furnish
the patient with such occupations or pursuits, (in the way already
indicated) as shall save her from the ill-temper of ennui. Persons
requiring this kind of discipline, will not often be found sufficiently
ductile for the engrafting of good principles upon them, at least, within
the time that can be given to the task; but every one is aware that
external good conduct is often produced by motives, which, if not exactly
blameable, would scarcely be confessed to by those whom they actuate. And
it is to these motives that an appeal must frequently be made, in the moral
management of the hysterical, with the hope that good conduct, however
induced, will in time become habitual, and that then more real progress
will be made. The fear of shame and exposure, the fear of the world's
opinion, the desire to gain credit for resolution, or self denial, or
cleverness, will often produce a change of action in persons with whom the
fear of God is an empty sound, and to whom the necessity of doing right,
might have been ineffectually preached till doomsday.
The manner of affording religious instruction to hysterical women, must
depend very much upon local circumstances; and the difficulties attending
this part of the subject are much heightened by the fact, that very many of
them profess great religious zeal, and are sedulous in their attendance
upon religious ordinances. It is scarcely possible to do more than lay down
a general rule, the application of which to particular cases, must be the
task of individual discretion. All that tends to produce emotion; all
exciting sermons, made the vehicles of extreme theological opinions; all
that appeals to the imagination; and everything which can be perverted into
a means of gratifying prurient desires, (as, for instance, the ordinance of
confession,) must be totally and positively forbidden. On the other hand,
nothing is so much to be desired, as the teaching of religious truth in
sobriety; and with constant and especial reference to its effects, when
duly received, upon daily life and conduct; and in producing a habit of
self-denial, which is manifested by more certain indications, than the
observance of an occasional fasting day. Whenever, therefore, the kind of
religious teaching which is likely to be beneficial, can be obtained, it
must be used and appreciated as a most important aid; but there is very
much, miscalled by the same name, that cannot do good, and is nearly
certain to do harm. With this single caution, the customs of a
well-regulated English family will be sufficient for the attainment of the
desired end.
And having thus sketched an outline of the plan of treatment to which the
patient should be subjected, it would not be easy to do much more, or to
lay down any precise rule, which might not require to be broken, more
frequently than to be observed. Any one who possesses tact and temper,
together with the necessary professional skill and acumen, will not find it
difficult to modify the application of the principle, in such a way as to
adapt it to exceptional cases, which could scarcely be provided for
beforehand.
The greatest difficulty likely to occur, is the combination with the
hysterical state, of some veritable disorder, which appears to require
medical treatment, as, for instance, a disease affecting the skin; and in
such case, the amount of attention given to this, must depend upon the
degree in which the patient shows herself amenable to discipline, and will
vary also with the length of time during which the non-hysterical affection
has existed. If this should supervene whilst moral treatment is actually in
progress for the cure of simulated disorders, the character of the intruder
should be at once recognized, and its nature confessed, in order to sustain
a consciousness of the skill of the medical adviser. Then, if the disease
be one which endangers life; or which may, if neglected, permanently injure
the person suffering from it, recourse must immediately be had to the usual
remedies; and it will always be found, that the existence of real danger,
throws hysteria into temporary abeyance. But if the real ailment is of a
chronic character; and is, comparatively speaking, of little importance; or
if, although arising in the course of treatment, it does not threaten any
serious consequences, then two courses are open to the practitioner, who
must be guided in his choice, mainly by the intensity of the hysterical
diathesis in each particular case. Either he may use remedies very
cautiously, watching the mental pulse of his patient from day to day, and
carefully scrutinizing the reality of each symptom that is mentioned to
him, so as to take every possible precaution against the employment of the
disease for improper purposes, or else he may pursue a line of conduct
which, in the majority of cases, will be both safer and less troublesome,
by saying that the real malady is of no importance, and that it shall be
cured whenever a certain farther progress has been made, in the abandonment
of pretended ones. In the meantime, an endeavour must be made to afford
relief by hygienic measures, which can always be recommended and enforced,
on the ground of their general salubrity, and fitness for healthy persons.
We may learn from the annals of hydropathy and homoeopathy, how far chronic
diseases are susceptible of alleviation and cure, without the aid of those
agents, to which the term medicinal is limited in common parlance.
When some acute disease has for a time extinguished the hysteria, and has
been in its turn overcome by the employment of active remedies, a condition
will frequently arise which combines the stages of convalescence and
relapse, and which requires the most careful and judicious management. The
patient will be suffering in reality from the languor and debility of
recent illness, and will not only blend with this, symptoms of her own
making, in such a manner as to render an exact analysis of the case very
difficult, but will also exaggerate that which really exists, making the
most of all her abnormal feelings. Under such circumstances, it will
scarcely be possible to gain ground against the hysteria, but it will be
quite possible, in the majority of cases, not to lose any; and thus to keep
a good position for recommencing treatment, as soon as it may seem
desirable to do so.
There is one important class of ailments, which has been already adverted
to, but which it will perhaps be well to notice again in this place;
namely, the various local congestions which may arise in all persons of
languid circulation and sedentary habits, and the seat of which appears
generally to be determined by the attention of the patient, whether this be
voluntary or involuntary. It is unnecessary to recapitulate what has been
stated in the foregoing pages concerning affections of this kind; and the
object of recalling them to the recollection of the reader, is to except
them from the number of really morbid conditions which require ordinary
medical treatment. Real they are in some degree, but nevertheless, proper
exercise and cold bathing will give tone to the circulatory system, while
the withdrawal of sympathy and commiseration, will effectually keep down
the amount of attention which is bestowed by some young women, upon the
"torpid liver" or the "exulcerated" uterus.
The degree of authority over the patient which I have always presumed the
medical attendant to possess, will perhaps be one of the first things to
strike the attention of the reader, and will perhaps render it desirable to
say a few words, as to the conditions under which the treatment of an
hysterical girl may be undertaken. Enough has been already stated, to show
that the person conducting it must not have his wishes thwarted by any
agencies from without, and I myself would always stipulate for a complete
transfer of parental authority, before undertaking a case of complicated
tertiary hysteria, with any confidence as to the results. The patient
should be placed exactly in the position of a child at school, where the
command of the master is enforced by the parent, even if the latter does
not perfectly agree with him. As soon as the hysterical girl discovers the
trap into which she has fallen, she will often endeavour to escape from it,
by writing letters to her friends, full of the bitterest complaints and the
most doleful lamentations. The probability of her doing so must be stated
to them beforehand; and they must be told, that if the event justifies the
prediction, it will be necessary to punish her by prohibiting
correspondence altogether; the medical attendant himself, in such case,
writing to the friends at regular intervals. There will often be difficulty
in obtaining the complete control which is necessary, and the relatives
will often think themselves quite competent to exercise a general
surveillance over the treatment, and to question the propriety of this or
that procedure. But no privilege of this kind must on any account be
allowed; because, even if their judgments were always correct, such an
exercise of them would tend to lower the professional man in the opinion of
the patient, by establishing a court of appeal from his decision. If the
laity could be made to understand the essentially simulative character of
complicated hysteria, and the amount of moral delinquency involved in it,
they would accede readily to all demands for full control over the unhappy
victims; but too frequently, at the very time when the disease would be
most amenable to treatment, any true and fair statement of the case would
be indignantly repudiated by the parents: " My daughter," they would
exclaim, " is a religious, moral, and well-conducted young woman, quite
incapable of such practices as those which you impute to her; and from our
knowledge of her character, we are satisfied that you are mistaken in her
case." When this line of argument is to be expected, the best plan is to
set forth the true pathology of the symptoms, and to endeavour to win
confidence by an exact delineation of habits; but to treat the motives as
being impulsive, and of a kind more allied to insanity, than to the
dictates of right reason, seeking the attainment of an improper object. But
in chronic and obstinate cases, the moral perversion, although not
recognised in the diseases themselves, has generally made itself seen and
felt in the character and habits; and those having the control of such a
person, will feel at once the force and truth of a thorough analysis of the
case, and will seldom place any difficulties in the way of a plan, which
holds out some hope of a brighter future. It will be found best always to
make the full demand at first, saying that the power given will be
exercised as occasion may require; and great care must be taken not to
consult with relatives, but always to inform them. By this they will be
prevented from volunteering any opinion as to the management of the case;
or if they are not prevented, still the opinion given may be
unceremoniously rejected.
When it has been necessary that the deceptive character of the case should
be explained, this must always be done as a matter of confidential
communication, and relatives must be strictly enjoined not to let the
patient know, that her secret has been betrayed to them. If she became
aware of this, the threat of exposure would lose half its force.
The time which will be required for conducting the moral treatment of
tertiary hysteria to a successful conclusion, is subject to infinite
variations. In recent cases, and with well-disposed young women, a month or
two will often suffice; but where the disease is of long standing, or where
the patient is very ingenious, and practises many devices before yielding,
a much longer period will be required. It will always be imprudent to
promise a cure within any definite time, because the doing so, would afford
to the patient the strongest possible inducement to hold out beyond it. She
must distinctly understand that she will remain under treatment until she
is cured, and that obstinacy on her part will only prolong an unpleasant
process.
The difference in the time required for the cure of long-standing cases, as
compared with recent ones, will not be seen in the conduct of the
destructive process, but chiefly, in the passive resistance of the patient
to the formation of good habits. Until these have made some progress, there
is little or no security against relapse, and there are probably no two
persons, in whom the time required for their culture would exactly, or even
very nearly, coincide. The sullen women, who have been already mentioned,
resist them with the greatest pertinacity, and trust in their sullenness as
their most effectual shield. With these it is useless to expect a
thoroughly satisfactory result. They are not formed of the silk-purse
material, and moral treatment usually comes too late to change the
tendencies of a vicious character; but still, time, patience, and firmness,
will work wonders even with them. In undertaking the care of such a person,
it will be prudent to fix two years as the shortest time in which anything
like permanent improvement can be expected, although a few weeks will
always be sufficient to get rid of pretended illness, and of violent
outbreaks of temper.
The individuals requiring the longest period of treatment, and in whom the
smallest amount of permanent improvement is to be hoped for, are those who
have long suffered from simulative or congestive uterine disorders,-a
result to be expected from the moral influence which these cannot fail to
exert, especially when associated, as they often are, with the practice of
onanism. In some cases, where this practice is suspected, it would be
desirable to have a trustworthy person as sleeping companion to the
patient; and it might, under certain circumstances, be proper thoroughly to
discuss the subject with her, and openly to tax her with the crime. But the
whole affair is so involved in difficulty and obscurity, and there would be
so little to encourage perseverance, that most persons would be inclined to
leave such a girl to her fate, and those willing to undertake her
management, should feel themselves possessed of the qualifications,
required for modifying the general principles of operation to meet the
exigencies of any particular case.
When, after a time has elapsed, commensurate with the magnitude of the
evils to be combated, and after the simulative practices have been
thoroughly abandoned, it is thought fit to send the patient home to her
friends, some precautions must be adopted against the return of the
disease. In mild or recent cases, or when treatment has been readily
responded to, it will be sufficient to rely on the threat of exposure, and
to state, in a final lecture, that the true character of the ailments shall
be unsparingly pointed out to relatives and friends, in the event of any
endeavour to resume them. The case book already mentioned may be exhibited,
and the materials for carrying out the threat, may thus be shown to exist.
The friends of the patient must be made to promise, in her hearing, that
the smallest indication of a tendency to relapse shall immediately be
communicated, and then she may be suffered to depart, in the full assurance
that the work of cure is done.
But in chronic or very obstinate cases, it will be necessary to retain even
a stronger hold than this, and to relax it very gradually, the patient
being allowed to return home on a visit, before she does so permanently,
and the effect of this visit being carefully watched. During its
continuance, a return of hysteria is scarcely possible, and it will afford
a proof to relatives of the reality of the cure, which will render them
suspicious of all subsequent illnesses. One such period of probation will
generally answer every purpose; but it should always be terminated by a
return, however brief, to the house of the medical attendant, in order to
show that his opinion, will continue to serve the friends as a rule of
conduct.
The system of treatment which I have thus endeavoured to describe, has been
tested for many years, and in a great number of cases, but always with
success. Wherever parents have zealously co-operated, and have lent the
entire weight of their authority, this success has been complete; and in
the few cases where their confidence has been practically withheld, and
where they have aided the patient in evading perfect control, it has still
extended to the entire abandonment of disease, at least during the period
of observation. But it need hardly be said that, in the present state of
popular feeling about hysteria, the cases submitted to such discipline have
all been of the very worst and most intractable kind, the laity being
unable to see the reasonableness and necessity of the plan, in the earliest
stages of the disorder, Hence there have been no opportunities of testing
its utility at the very commencement, except such as have been afforded by
cases of tertiary hysteria, occurring in the families of intimate friends,
and in these the success has been invariably rapid and complete, a week or
two often sufficing, not only for the removal of very urgent symptoms, but
also for the satisfactory conclusion of the whole process, and for the
return of the patient to her home.
The system is therefore laid before the profession in full and perfect
confidence of its sufficiency, and in the assurance, that the patients
curable by its means, are utterly beyond the reach of the materia medica.
The process is always troublesome, and often difficult, but I have yet to
hear of the case, in which it would ultimately fail of success; and I offer
it to my brethren as a remedy, which is, humanly speaking, certain, against
one of the most unmanageable diseases they are ever called upon to contend
with.
not the complete book.
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