Anæsthesia is "the real sigillum hysteriæ."

Studies in the Psychology of Sex, Volume 1 by Havelock Ellis is part of the HackerNoon Books Series. You can jump to any chapter in this book here. AUTO-EROTISM: A STUDY OF THE SPONTANEOUS MANIFESTATIONS OF THE SEXUAL IMPULSE II

AUTO-EROTISM: A STUDY OF THE SPONTANEOUS MANIFESTATIONS OF THE SEXUAL IMPULSE II

Hysteria and the Question of Its Relation to the Sexual Emotions—The Early Greek Theories of its Nature and Causation—The Gradual Rise of Modern Views—Charcot—The Revolt Against Charcot's Too Absolute Conclusions—Fallacies Involved—Charcot's Attitude the Outcome of his Personal Temperament—Breuer and Freud—Their Views Supplement and Complete Charcot's—At the Same Time they Furnish a Justification for the Earlier Doctrine of Hysteria—But They Must Not be Regarded as Final—The Diffused Hysteroid Condition in Normal Persons—The Physiological Basis of Hysteria—True Pathological Hysteria is Linked on to almost Normal States, especially to Sex-hunger.

The nocturnal hallucinations of hysteria, as all careful students of this condition now seem to agree, are closely allied to the hysterical attack proper. Sollier, indeed, one of the ablest of the more recent investigators of hysteria, has argued with much force that the subjects of hysteria really live in a state of pathological sleep, of vigilambulism. He regards all the various accidents of hysteria as having a common basis in disturbances of sensibility, in the widest sense of the word "sensibility,"—as the very foundation of personality,—while anæsthesia is "the real sigillum hysteriæ." Whatever the form of hysteria, we are thus only concerned with a more or less profound state of vigilambulism: a state in which the subject seems, often even to himself, to be more or less always asleep, whether the sleep may be regarded as local or general. Sollier agrees with Féré that the disorder of sensibility may be regarded as due to an exhaustion of the sensory centres of the brain, whether as the result of constitutional cerebral weakness, of the shock of a violent emotion, or of some toxic influence on the cerebral cells.

We may, therefore, fitly turn from the auto-erotic phenomena of sleep which in women generally, and especially in hysterical women, seem to possess so much importance and significance, to the question—which has been so divergently answered at different periods and by different investigators—concerning the causation of hysteria, and especially concerning its alleged connection with conscious or unconscious sexual emotion.[252]

It was the belief of the ancient Greeks that hysteria came from the womb; hence its name. We first find that statement in Plato's Timæus: "In men the organ of generation—becoming rebellious and masterful, like an animal disobedient to reason, and maddened with the sting of lust—seeks to gain absolute sway; and the same is the case with the so-called womb, or uterus, of women; the animal within them is desirous of procreating children, and, when remaining unfruitful long beyond its proper time, gets discontented and angry, and, wandering in every direction through the body, closes up the passages of the breath, and, by obstructing respiration,[253] drives them to extremity, causing all varieties of disease."

Plato, it is true, cannot be said to reveal anywhere a very scientific attitude toward Nature. Yet he was here probably only giving expression to the current medical doctrine of his day. We find precisely the same doctrine attributed to Hippocrates, though without a clear distinction between hysteria and epilepsy.[254] If we turn to the best Roman physicians we find again that Aretæus, "the Esquirol of antiquity," has set forth the same view, adding to his description of the movements of the womb in hysteria: "It delights, also, in fragrant smells, and advances toward them; and it has an aversion to fœtid smells, and flies from them; and, on the whole, the womb is like an animal within an animal."[255] Consequently, the treatment was by applying fœtid smells to the nose and rubbing fragrant ointments around the sexual parts.[256]

The Arab physicians, who carried on the traditions of Greek medicine, appear to have said nothing new about hysteria, and possibly had little knowledge of it. In Christian mediæval Europe, also, nothing new was added to the theory of hysteria; it was, indeed, less known medically than it had ever been, and, in part it may be as a result of this ignorance, in part as a result of general wretchedness (the hysterical phenomena of witchcraft reaching their height, Michelet points out, in the fourteenth century, which was a period of special misery for the poor), it flourished more vigorously. Not alone have we the records of nervous epidemics, but illuminated manuscripts, ivories, miniatures, bas-reliefs, frescoes, and engravings furnish the most vivid iconographic evidence of the prevalence of hysteria in its most violent forms during the Middle Ages. Much of this evidence is brought to the service of science in the fascinating works of Dr. P. Richer, one of Charcot's pupils.[257]

In the seventeenth century Ambroise Paré was still talking, like Hippocrates, about "suffocation of the womb"; Forestus was still, like Aretæus, applying friction to the vulva; Fernel was still reproaching Galen, who had denied that the movements of the womb produced hysteria.

It was in the seventeenth century (1618) that a French physician, Charles Lepois (Carolus Piso), physician to Henry II, trusting, as he said, to experience and reason, overthrew at one stroke the doctrine of hysteria that had ruled almost unquestioned for two thousand years, and showed that the malady occurred at all ages and in both sexes, that its seat was not in the womb, but in the brain, and that it must be considered a nervous disease.[258] So revolutionary a doctrine could not fail to meet with violent opposition, but it was confirmed by Willis, and in 1681, we owe to the genius of Sydenham a picture of hysteria which for lucidity, precision, and comprehensiveness has only been excelled in our own times.

It was not possible any longer to maintain the womb theory of Hippocrates in its crude form, but in modified forms, and especially with the object of preserving the connection which many observers continued to find between hysteria and the sexual emotions, it still found supporters in the eighteenth and even the nineteenth centuries. James, in the middle of the eighteenth century, returned to the classical view, and in his Dictionary of Medicine maintained that the womb is the seat of hysteria. Louyer Villermay in 1816 asserted that the most frequent causes of hysteria are deprivation of the pleasures of love, griefs connected with this passion, and disorders of menstruation. Foville in 1833 and Landouzy in 1846 advocated somewhat similar views. The acute Laycock in 1840 quoted as "almost a medical proverb" the saying, "Salacitas major, major ad hysteriam proclivitas," fully indorsing it. More recently still Clouston has defined hysteria as "the loss of the inhibitory influence exercised on the reproductive and sexual instincts of women by the higher mental and moral functions" (a position evidently requiring some modification in view of the fact that hysteria is by no means confined to women), while the same authority remarks that more or less concealed sexual phenomena are the chief symptoms of "hysterical insanity."[259] Two gynæcologists of high position in different parts of the world, Hegar in Germany and Balls-Headley in Australia, attribute hysteria, as well as anæmia, largely to unsatisfied sexual desire, including the non-satisfaction of the "ideal feelings."[260] Lombroso and Ferrero, again, while admitting that the sexual feelings might be either heightened or depressed in hysteria, referred to the frequency of what they termed "a paradoxical sexual instinct" in the hysterical, by which, for instance, sexual frigidity is combined with intense sexual pre-occupations; and they also pointed out the significant fact that the crimes of the hysterical nearly always revolve around the sexual sphere.[261] Thus, even up to the time when the conception of hysteria which absolutely ignored and excluded any sexual relationship whatever had reached its height, independent views favoring such a relationship still found expression.

Of recent years, however, such views usually aroused violent antagonism. The main current of opinion was with Briquet (1859), who, treating the matter with considerable ability and a wide induction of facts, indignantly repelled the idea that there is any connection between hysteria and the sexual facts of life, physical or psychic. As he himself admitted, Briquet was moved to deny a sexual causation of hysteria by the thought that such an origin would be degrading for women ("a quelque chose de dégradant pour les femmes").

It was, however, the genius of Charcot, and the influence of his able pupils, which finally secured the overthrow of the sexual theory of hysteria. Charcot emphatically anathematized the visceral origin of hysteria; he declared that it is a psychic disorder, and to leave no loop-hole of escape for those who maintained a sexual causation he asserted that there are no varieties of hysteria, that the disease is one and indivisible. Charcot recognized no primordial cause of hysteria beyond heredity, which here plays a more important part than in any other neuropathic condition. Such heredity is either direct or more occasionally by transformation, any deviation of nutrition found in the ancestors (gout, diabetes, arthritis) being a possible cause of hysteria in the descendants. "We do not know anything about the nature of hysteria," Charcot wrote in 1892; "we must make it objective in order to recognize it. The dominant idea for us in the etiology of hysteria is, in the widest sense, its hereditary predisposition. The greater number of those suffering from this affection are simply born hystérisables, and on them the occasional causes act directly, either through autosuggestion or by causing derangement of general nutrition, and more particularly of the nutrition of the nervous system."[262] These views were ably and decisively stated in Gilles de la Tourette's Traité de l'Hystérie, written under the inspiration of Charcot.

While Charcot's doctrine was thus being affirmed and generally accepted, there were at the same time workers in these fields who, though they by no means ignored this doctrine of hysteria or even rejected it, were inclined to think that it was too absolutely stated. Writing in the Dictionary of Psychological Medicine at the same time as Charcot, Donkin, while deprecating any exclusive emphasis on the sexual causation, pointed out the enormous part played by the emotions in the production of hysteria, and the great influence of puberty in women due to the greater extent of the sexual organs, and the consequently large area of central innervation involved, and thus rendered liable to fall into a state of unstable equilibrium. Enforced abstinence from the gratification of any of the inherent and primitive desires, he pointed out, may be an adequate exciting cause. Such a view as this indicated that to set aside the ancient doctrine of a physical sexual cause of hysteria was by no means to exclude a psychic sexual cause. Ten years earlier Axenfeld and Huchard had pointed out that the reaction against the sexual origin of hysteria was becoming excessive, and they referred to the evidence brought forward by veterinary surgeons showing that unsatisfied sexual desire in animals may produce nervous symptoms very similar to hysteria.[263] The present writer, when in 1894 briefly discussing hysteria as an element in secondary sexual characterization, ventured to reflect the view, confirmed by his own observation, that there was a tendency to unduly minimize the sexual factor in hysteria, and further pointed out that the old error of a special connection between hysteria and the female sexual organs, probably arose from the fact that in woman the organic sexual sphere is larger than in man.[264]

When, indeed, we analyze the foundation of the once predominant opinions of Charcot and his school regarding the sexual relationships of hysteria, it becomes clear that many fallacies and misunderstandings were involved. Briquet, Charcot's chief predecessor, acknowledged that his own view was that a sexual origin of hysteria would be "degrading to women"; that is to say, he admitted that he was influenced by a foolish and improper prejudice, for the belief that the unconscious and involuntary morbid reaction of the nervous system to any disturbance of a great primary instinct can have "quelque chose de dégradant" is itself an immoral belief; such disturbance of the nervous system might or might not be caused, but in any case the alleged "degradation" could only be the fiction of a distorted imagination. Again, confusion had been caused by the ancient error of making the physical sexual organs responsible for hysteria, first the womb, more recently the ovaries; the outcome of this belief was the extirpation of the sexual organs for the cure of hysteria. Charcot condemned absolutely all such operations as unscientific and dangerous, declaring that there is no such thing as hysteria of menstrual origin.[265] Subsequently, Angelucci and Pierracini carried out an international inquiry into the results of the surgical treatment of hysteria, and condemned it in the most unqualified manner.[266] It is clearly demonstrated that the physical sexual organs are not the seat of hysteria. It does not, however, follow that even physical sexual desire, when repressed, is not a cause of hysteria. The opinion that it was so formed an essential part of the early doctrine of hysteria, and was embodied in the ancient maxim: "Nubat illa et morbus effugiet." The womb, it seemed to the ancients, was crying out for satisfaction, and when that was received the disease vanished.[267] But when it became clear that sexual desire, though ultimately founded on the sexual apparatus, is a nervous and psychic fact, to put the sexual organs out of count was not sufficient; for the sexual emotions may exist before puberty, and persist after complete removal of the sexual organs. Thus it has been the object of many writers to repel the idea that unsatisfied sexual desire can be a cause of hysteria. Briquet pointed out that hysteria is rare among nuns and frequent among prostitutes. Krafft-Ebing believed that most hysterical women are not anxious for sexual satisfaction, and declared that "hysteria caused through the non-satisfaction of the coarse sensual sexual impulse I have never seen,"[268] while Pitres and others refer to the frequently painful nature of sexual hallucinations in the hysterical. But it soon becomes obvious that the psychic sexual sphere is not confined to the gratification of conscious physical sexual desire. It is not true that hysteria is rare among nuns, some of the most tremendous epidemics of hysteria, and the most carefully studied, having occurred in convents,[269] while the hysterical phenomena sometimes associated with revivals are well known. The supposed prevalence among prostitutes would not be evidence against the sexual relationships of hysteria; it has, however, been denied, even by so great an authority as Parent-Duchâtelet who found it very rare, even in prostitutes in hospitals, when it was often associated with masturbation; in prostitutes, however, who returned to a respectable life, giving up their old habits, he found hysteria common and severe.[270] The frequent absence of physical sexual feeling, again, may quite reasonably be taken as evidence of a disorder of the sexual emotions, while the undoubted fact that sexual intercourse usually has little beneficial effect on pronounced hysteria, and that sexual excitement during sleep and sexual hallucinations are often painful in the same condition, is far from showing that injury or repression of the sexual emotions had nothing to do with the production of the hysteria. It would be as reasonable to argue that the evil effect of a heavy meal on a starving man must be taken as evidence that he was not suffering from starvation. The fact, indeed, on which Gilles de la Tourette and others have remarked, that the hysterical often desire not so much sexual intercourse as simple affection, would tend to show that there is here a real analogy, and that starvation or lesion of the sexual emotions may produce, like bodily starvation, a rejection of those satisfactions which are demanded in health. Thus, even a mainly a priori examination of the matter may lead us to see that many arguments brought forward in favor of Charcot's position on this point fall to the ground when we realize that the sexual emotions may constitute a highly complex sphere, often hidden from observation, sometimes not conscious at all, and liable to many lesions besides that due to the non-satisfaction of sexual desire. At the same time we are not thus enabled to overthrow any of the positive results attained by Charcot and his school.

It may, however, be pointed out that Charcot's attitude toward hysteria was the outcome of his own temperament. He was primarily a neurologist, the bent of his genius was toward the investigation of facts that could be objectively demonstrated. His first interest in hysteria, dating from as far back as 1862, was in hystero-epileptic convulsive attacks, and to the last he remained indifferent to all facts which could not be objectively demonstrated. That was the secret of the advances he was enabled to make in neurology. For purely psychological investigation he had no liking, and probably no aptitude. Anyone who was privileged to observe his methods of work at the Salpêtrière will easily recall the great master's towering figure; the disdainful expression, sometimes, even, it seemed, a little sour; the lofty bearing which enthusiastic admirers called Napoleonic. The questions addressed to the patient were cold, distant, sometimes impatient. Charcot clearly had little faith in the value of any results so attained. One may well believe, also, that a man whose superficial personality was so haughty and awe-inspiring to strangers would, in any case, have had the greatest difficulty in penetrating the mysteries of a psychic world so obscure and elusive as that presented by the hysterical.[271]

The way was thus opened for further investigations on the psychic side. Charcot had affirmed the power, not only of physical traumatism, but even of psychic lesions—of moral shocks—to provoke its manifestations, but his sole contribution to the psychology of this psychic malady,—and this was borrowed from the Nancy school,—lay in the one word "suggestibility"; the nature and mechanism of this psychic process he left wholly unexplained. This step has been taken by others, in part by Janet, who, from 1889 onward, has not only insisted that the emotions stand in the first line among the causes of hysteria, but has also pointed out some portion of the mechanism of this process; thus, he saw the significance of the fact, already recognized, that strong emotions tend to produce anæsthesia and to lead to a condition of mental disaggregation, favorable to abulia, or abolition of will-power. It remained to show in detail the mechanism by which the most potent of all the emotions effects its influence, and, by attempting to do this, the Viennese investigators, Breuer and especially Freud, have greatly aided the study of hysteria.[272] They have not, it is important to remark, overturned the positive elements in their great forerunner's work. Freud began as a disciple of Charcot, and he himself remarks that, in his earlier investigations of hysteria, he had no thought of finding any sexual etiology for that malady; he would have regarded any such suggestion as an insult to his patient. The results reached by these workers were the outcome of long and detailed investigation. Freud has investigated many cases of hysteria in minute detail, often devoting to a single case over a hundred hours of work. The patients, unlike those on whom the results of the French school have been mainly founded, all belonged to the educated classes, and it was thus possible to carry out an elaborate psychic investigation which would be impossible among the uneducated. Breuer and Freud insist on the fine qualities of mind and character frequently found among the hysterical. They cannot accept suggestibility as an invariable characteristic of hysteria, only abnormal excitability; they are far from agreeing with Janet (although on many points at one with him), that psychic weakness marks hysteria; there is merely an appearance of mental weakness, they say, because the mental activity of the hysterical is split up, and only a part of it is conscious.[273] The superiority of character of the hysterical is indicated by the fact that the conflict between their ideas of right and the bent of their inclinations is often an element in the constitution of the hysterical state. Breuer and Freud are prepared to assert that the hysterical are among "the flower of humanity," and they refer to those qualities of combined imaginative genius and practical energy which characterized St. Theresa, "the patron saint of the hysterical."

To understand the position of Breuer and Freud we may start from the phenomenon of "nervous shock" produced by physical traumatism, often of a very slight character. Charcot had shown that such "nervous shock," with the chain of resulting symptoms, is nothing more or less than hysteria. Breuer and Freud may be linked on to Charcot at this point. They began by regarding the most typical hysteria as really a psychic traumatism; that is to say, that it starts in a lesion, or rather in repeated lesions, of the emotional organism. It is true that the school of Charcot admitted the influence of moral shock, especially of the emotion of fear, but that merely as an "agent provocateur," and with a curious perversity Gilles de la Tourette, certainly reflecting the attitude of Charcot, in his elaborate treatise on hysteria fails to refer to the sphere of the sexual emotions even when enumerating the "agents provocateurs."[274]

The influence of fear is not denied by Breuer and Freud, but they have found that careful psychic analysis frequently shows that the shock of a commonplace "fear" is really rooted in a lesion of the sexual emotions. A typical and very simple illustration is furnished in a case, recorded by Breuer, in which a young girl of seventeen had her first hysterical attack after a cat sprang on her shoulders as she was going downstairs. Careful investigation showed that this girl had been the object of somewhat ardent attentions from a young man whose advances she had resisted, although her own sexual emotions had been aroused. A few days before, she had been surprised by this young man on these same dark stairs, and had forcibly escaped from his hands. Here was the real psychic traumatism, the operation of which merely became manifest in the cat. "But in how many cases," asks Breuer, "is a cat thus reckoned as a completely sufficient causa efficiens?"

In every case that they have investigated Breuer and Freud have found some similar secret lesion of the psychic sexual sphere. In one case a governess, whose training has been severely upright, is, in spite of herself and without any encouragement, led to experience for the father of the children under her care an affection which she refuses to acknowledge even to herself; in another, a young woman finds herself falling in love with her brother-in-law; again, an innocent girl suddenly discovers her uncle in the act of sexual intercourse with her playmate, and a boy on his way home from school is subjected to the coarse advances of a sexual invert. In nearly every case, as Freud eventually found reason to believe, a primary lesion of the sexual emotions dates from the period of puberty and frequently of childhood, and in nearly every case the intimately private nature of the lesion causes it to be carefully hidden from everyone, and even to be unacknowledged by the subject of it. In the earlier cases Breuer and Freud found that a slight degree of hypnosis is necessary to bring the lesion into consciousness, and the accuracy of the revelations thus obtained has been tested by independent witness. Freud has, however, long abandoned the induction of any degree of hypnosis; he simply tries to arrange that the patient shall feel absolutely free to tell her own story, and so proceeds from the surface downwards, slowly finding and piecing together such essential fragments of the history as may be recovered, in the same way he remarks, as the archæologist excavates below the surface and recovers and puts together the fragments of an antique statue. Much of the material found, however, has only a symbolic value requiring interpretation and is sometimes pure fantasy. Freud now attaches great importance to dreams as symbolically representing much in the subject's mental history which is otherwise difficult to reach.[275] The subtle and slender clues which Freud frequently follows in interpreting dreams cannot fail sometimes to arouse doubt in his readers' minds, but he certainly seems to have been often successful in thus reaching latent facts in consciousness. The primary lesion may thus act as "a foreign body in consciousness." Something is introduced into psychic life which refuses to merge in the general flow of consciousness. It cannot be accepted simply as other facts of life are accepted; it cannot even be talked about, and so submitted to the slow usure by which our experiences are worn down and gradually transformed. Breuer illustrates what happens by reference to the sneezing reflex. "When an irritation to the nasal mucous membrane for some reason fails to liberate this reflex, a feeling of excitement and tension arises. This excitement, being unable to stream out along motor channels, now spreads itself over the brain, inhibiting other activities.... In the highest spheres of human activity we may watch the same process." It is a result of this process that, as Breuer and Freud found, the mere act of confession may greatly relieve the hysterical symptoms produced by this psychic mechanism, and in some cases may wholly and permanently remove them. It is on this fact that they founded their method of treatment, devised by Breuer and by him termed the cathartic method, though Freud prefers to call it the "analytic" method. It is, as Freud points out, the reverse of the hypnotic method of suggestive treatment; there is the same difference, Freud remarks, between the two methods as Leonardo da Vinci found for the two technical methods of art, per via di porre and per via di levare; the hypnotic method, like painting, works by putting in, the cathartic or analytic method, like sculpture, works by taking out.[276]

It is part of the mechanism of this process, as understood by these authors, that the physical symptoms of hysteria are constituted, by a process of conversion, out of the injured emotions, which then sink into the background or altogether out of consciousness. Thus, they found the prolonged tension of nursing a near and dear relative to be a very frequent factor in the production of hysteria. For instance, an originally rheumatic pain experienced by a daughter when nursing her father becomes the symbol in memory of her painful psychic excitement, and this perhaps for several reasons, but chiefly because its presence in consciousness almost exactly coincided with that excitement. In another way, again, nausea and vomiting may become a symbol through the profound sense of disgust with which some emotional shock was associated. Then the symbol begins to have a life of its own, and draws hidden strength from the emotion with which it is correlated. Breuer and Freud have found by careful investigation that the pains and physical troubles of hysteria are far from being capricious, but may be traced in a varying manner to an origin in some incident, some pain, some action, which was associated with a moment of acute psychic agony. The process of conversion was an involuntary escape from an intolerable emotion, comparable to the physical pain sometimes sought in intense mental grief, and the patient wins some relief from the tortured emotions, though at the cost of psychic abnormality, of a more or less divided state of consciousness and of physical pain, or else anæsthesia. In Charcot's third stage of the hysterical convulsion, that of "attitudes passionnelles," Breuer and Freud see the hallucinatory reproduction of a recollection which is full of significance for the origin of the hysterical manifestations.

The final result reached by these workers is clearly stated by each writer. "The main observation of our predecessors," states Breuer,[277] "still preserved in the word 'hysteria,' is nearer to the truth than the more recent view which puts sexuality almost in the last line, with the object of protecting the patient from moral reproaches. Certainly the sexual needs of the hysterical are just as individual and as various in force as those of the healthy. But they suffer from them, and in large measure, indeed, they suffer precisely through the struggle with them, through the effort to thrust sexuality aside." "The weightiest fact," concludes Freud,[278] "on which we strike in a thorough pursuit of the analysis is this: From whatever side and from whatever symptoms we start, we always unfailingly reach the region of the sexual life. Here, first of all, an etiological condition of hysterical states is revealed.... At the bottom of every case of hysteria—and reproducible by an analytical effort after even an interval of long years—may be found one or more facts of precocious sexual experience belonging to earliest youth. I regard this as an important result, as the discovery of a caput Nili of neuropathology." Ten years later, enlarging rather than restricting his conception, Freud remarks: "Sexuality is not a mere deus ex machina which intervenes but once in the hysterical process; it is the motive force of every separate symptom and every expression of a symptom. The morbid phenomena constitute, to speak plainly, the patient's sexual activity."[279] The actual hysterical fit, Freud now states, may be regarded as "the substitute for a once practiced and then abandoned auto-erotic satisfaction," and similarly it may be regarded as an equivalent of coitus.[280]

It is natural to ask how this conception affects that elaborate picture of hysteria laboriously achieved by Charcot and his school. It cannot be said that it abolishes any of the positive results reached by Charcot, but it certainly alters their significance and value; it presents them in a new light and changes the whole perspective. With his passion for getting at tangible definite physical facts, Charcot was on very safe ground. But he was content to neglect the psychic analysis of hysteria, while yet proclaiming that hysteria is a purely psychic disorder. He had no cause of hysteria to present save only heredity. Freud certainly admits heredity, but, as he points out, the part it plays has been overrated. It is too vague and general to carry us far, and when a specific and definite cause can be found, the part played by heredity recedes to become merely a condition, the soil on which the "specific etiology" works. Here probably Freud's enthusiasm at first carried him too far and the most important modification he has made in his views occurs at this point: he now attaches a preponderant influence to heredity. He has realized that sexual activity in one form or another is far too common in childhood to make it possible to lay very great emphasis on "traumatic lesions" of this character, and he has also realized that an outcrop of fantasies may somewhat later develop on these childish activities, intervening between them and the subsequent morbid symptoms. He is thus led to emphasize anew the significance of heredity, not, however, in Charcot's sense, as general neuropathic disposition but as "sexual constitution." The significance of "infantile sexual lesions" has also tended to give place to that of "infantilism of sexuality."[281]

The real merit of Freud's subtle investigations is that—while possibly furnishing a justification of the imperfectly-understood idea that had floated in the mind of observers ever since the name "hysteria" was first invented—he has certainly supplied a definite psychic explanation of a psychic malady. He has succeeded in presenting clearly, at the expense of much labor, insight, and sympathy, a dynamic view of the psychic processes involved in the constitution of the hysterical state, and such a view seems to show that the physical symptoms laboriously brought to light by Charcot are largely but epiphenomena and by-products of an emotional process, often of tragic significance to the subject, which is taking place in the most sensitive recess of the psychic organism. That the picture of the mechanism involved, presented to us by Professor Freud, cannot be regarded as a final and complete account of the matter, may readily be admitted. It has developed in Freud's own hands, and some of the developments will require very considerable confirmation before they can be accepted as generally true.[282] But these investigations have at least served to open the door, which Charcot had inconsistently held closed, into the deeper mysteries of hysteria, and have shown that here, if anywhere, further research will be profitable. They have also served to show that hysteria may be definitely regarded as, in very many cases at least, a manifestation of the sexual emotions and their lesions; in other words, a transformation of auto-erotism.

The conception of hysteria so vigorously enforced by Charcot and his school is thus now beginning to appear incomplete. But we have to recognize that that incompleteness was right and necessary. A strong reaction was needed against a widespread view of hysteria that was in large measure scientifically false. It was necessary to show clearly that hysteria is a definite disorder, even when the sexual organs and emotions are swept wholly out of consideration; and it was also necessary to show that the lying and dissimulation so widely attributed to the hysterical were merely the result of an ignorant and unscientific misinterpretation of psychic elements of the disease. This was finally and triumphantly achieved by Charcot's school.

There is only one other point in the explanation of hysteria which I will here refer to, and that because it is usually ignored, and because it has relationship to the general psychology of the sexual emotions. I refer to that physiological hysteria which is the normal counterpart of the pathological hysteria which has been described in its physical details by Charcot, and to which alone the term should strictly be applied. Even though hysteria as a disease may be described as one and indivisible, there are yet to be found, among the ordinary and fairly healthy population, vague and diffused hysteroid symptoms which are dissipated in a healthy environment, or pass nearly unnoted, only to develop in a small proportion of cases, under the influence of a more pronounced heredity, or a severe physical or psychic lesion, into that definite morbid state which is properly called hysteria.

This diffused hysteroid condition may be illustrated by the results of a psychological investigation carried on in America by Miss Gertrude Stein among the ordinary male and female students of Harvard University and Radcliffe College. The object of the investigation was to study, with the aid of a planchette, the varying liability to automatic movements among normal individuals. Nearly one hundred students were submitted to experiment. It was found that automatic responses could be obtained in two sittings from all but a small proportion of the students of both sexes, but that there were two types of individual who showed a special aptitude. One type (probably showing the embryonic form of neurasthenia) was a nervous, high-strung, imaginative type, not easily influenced from without, and not so much suggestible as autosuggestible. The other type, which is significant from our present point of view, is thus described by Miss Stein: "In general the individuals, often blonde and pale, are distinctly phlegmatic. If emotional, decidedly of the weakest, sentimental order. They may be either large, healthy, rather heavy, and lacking in vigor or they may be what we call anæmic and phlegmatic. Their power of concentrated attention is very small. They describe themselves as never being held by their work; they say that their minds wander easily; that they work on after they are tired, and just keep pegging away. They are very apt to have premonitory conversations, they anticipate the words of their friends, they imagine whole conversations that afterward come true. The feeling of having been there is very common with them; that is, they feel under given circumstances that they have had that identical experience before in all its details. They are often fatalistic in their ideas. They indulge in day-dreams. As a rule, they are highly suggestible."[283]

There we have a picture of the physical constitution and psychic temperament on which the classical symptoms of hysteria might easily be built up.[284] But these persons were ordinary students, and while a few of their characteristics are what is commonly and vaguely called "morbid," on the whole they must be regarded as ordinarily healthy individuals. They have the congenital constitution and predisposition on which some severe psychic lesion at the "psychological moment" might develop the most definite and obstinate symptoms of hysteria, but under favorable circumstances they will be ordinary men and women, of no more than ordinary abnormality or ordinary power. They are among the many who have been called to hysteria at birth; they may never be among the few who are chosen.

We may have to recognize that on the side of the sexual emotions, as well as in general constitution, a condition may be traced among normal persons that is hysteroid in character, and serves as the healthy counterpart of a condition which in hysteria is morbid. In women such a condition Has been traced (though misnamed) by Dr. King.[285]

Dr. King describes what he calls "sexual hysteria in women," which he considers a chief variety of hysteria. He adds, however, that it is not strictly a disease, but simply an automatic reaction of the reproductive system, which tends to become abnormal under conditions of civilization, and to be perpetuated in a morbid form. In this condition he finds twelve characters: 1. Time of life, usually between puberty and climacteric. 2. Attacks rarely occur when subject is alone. 3. Subject appears unconscious, but is not really so. 4. She is instinctively ashamed afterward. 5. It occurs usually in single women, or in those, single or married, whose sexual needs are unsatisfied. 6. No external evidence of disease, and (as Aitken pointed out) the nates are not flattened; the woman's physical condition is not impaired, and she may be specially attractive to men. 7. Warmth of climate and the season of spring and summer are conducive to the condition. 8. The paroxysm in short and temporary. 9. While light touches are painful, firm pressure and rough handling give relief. 10. It may occur in the occupied, but an idle, purposeless life is conducive. 11. The subject delights in exciting sympathy and in being fondled and caressed. 12. There is defect of will and a strong stimulus is required to lead to action.

Among civilized women, the author proceeds, this condition does not appear to subserve any useful purpose. "Let us, however, go back to aboriginal woman—to woman of the woods and the fields. Let us picture ourselves a young aboriginal Venus in one of her earliest hysterical paroxysms. In doing so, let us not forget some of the twelve characteristics previously mentioned. She will not be 'acting her part' alone, or, if alone, it will be in a place where someone else is likely soon to discover her. Let this Venus be now discovered by a youthful Apollo of the woods, a man with fully developed animal instincts. He and she, like any other animals, are in the free field of Nature. He cannot but observe to himself: 'This woman is not dead; she breathes and is warm; she does not look ill; she is plump and rosy.' He speaks to her; she neither hears (apparently) nor responds. Her eyes are closed. He touches, moves, and handles her at his pleasure. She makes no resistance. What will this primitive Apollo do next? He will cure the fit, and bring the woman back to consciousness, satisfy her emotions, and restore her volition—not by delicate touches that might be 'agonizing' to her hyperesthetic skin, but by vigorous massage, passive motions, and succussion that would be painless. The emotional process on the part of the woman would end, perhaps, with mingled laughter, tears, and shame; and when accused afterward of the part which the ancestrally acquired properties of her nervous system had compelled her to act, as a preliminary to the event, what woman would not deny it and be angry? But the course of Nature having been followed, the natural purpose of the hysterical paroxysm accomplished, there would remain as a result of the treatment—instead of one discontented woman—two happy people, and the possible beginning of a third."

"Natural, primary sexual hysteria in woman," King concludes, "is a temporary modification of the nervous government of the body and the distribution of nerve-force (occurring for the most part, as we see it to-day, in prudish women of strong moral principle, whose volition has disposed them to resist every sort of liberty or approach from the other sex), consisting in a transient abdication of the general, volitional, and self-preservational ego, while the reins of government are temporarily assigned to the usurping power of the reproductive ego, so that the reproductive government overrules the government by volition, and thus, as it were, forcibly compels the woman's organism to so dispose itself, at a suitable time and place, as to allow, invite, and secure the approach of the other sex, whether she will or not, to the end that Nature's imperious demand for reproduction shall be obeyed."

This perhaps rather fantastic description is not a presentation of hysteria in the technical sense, but we may admit that it presents a state which, if not the real physiological counterpart of the hysterical convulsion, is yet distinctly analogous to the latter. The sexual orgasm has this correspondence with the hysterical fit, that they both serve to discharge the nervous centres and relieve emotional tension. It may even happen, especially in the less severe forms of hysteria, that the sexual orgasm takes place during the hysterical fit; this was found by Rosenthal, of Vienna, to be always the case in the semiconscious paroxysms of a young girl whose condition was easily cured;[286] no doubt such cases would be more frequently found if they were sought for. In severe forms of hysteria, however, it frequently happens, as so many observers have noted, that normal sexual excitement has ceased to give satisfaction, has become painful, perverted, paradoxical. Freud has enabled us to see how a shock to the sexual emotions, injuring the emotional life at its source, can scarcely fail sometimes to produce such a result. But the necessity for nervous explosion still persists.[287] It may, indeed, persist, even in an abnormally strong degree, in consequence of the inhibition of normal activities generally. The convulsive fit is the only form of relief open to the tension. "A lady whom I long attended," remarks Ashwell, "always rejoiced when the fit was over, since it relieved her system generally, and especially her brain, from painful irritation which had existed for several previous days." That the fit mostly fails to give real satisfaction, and that it fails to cure the disease, is due to the fact that it is a morbid form of relief. The same character of hysteria is seen, with more satisfactory results for the most part, in the influence of external nervous shock. It was the misunderstood influence of such shocks in removing hysteria which in former times led to the refusal to regard hysteria as a serious disease. During the Rebellion of 1745-46 in Scotland, Cullen remarks that there was little hysteria. The same was true of the French Revolution and of the Irish Rebellion, while Rush (in a study On the Influence of the American Revolution on the Human Body) observed that many hysterical women were "restored to perfect health by the events of the time." In such cases the emotional tension is given an opportunity of explosion in new and impersonal channels, and the chain of morbid personal emotions is broken.

It has been urged by some that the fact that the sexual orgasm usually fails to remove the disorder in true hysteria excludes a sexual factor of hysteria. It is really, one may point out, an argument in favor of such an element as one of the factors of hysteria. If there were no initial lesion of the sexual emotions, if the natural healthy sexual channel still remained free for the passage of the emotional overflow, then we should expect that it would much oftener come into play in the removal of hysteria. In the more healthy, merely hysteroid condition, the psychic sexual organism is not injured, and still responds normally, removing the abnormal symptoms when allowed to do so. It is the confusion between this almost natural condition and the truly morbid condition, alone properly called hysteria, which led to the ancient opinion, inaugurated by Plato and Hippocrates, that hysteria may be cured by marriage.[288] The difference may be illustrated by the difference between a distended bladder which is still able to contract normally on its contents when at last an opportunity of doing so is afforded and the bladder in which distension has been so prolonged that nervous control had been lost and spontaneous expulsion has become impossible. The first condition corresponds to the constitution, which, while simulating the hysterical condition, is healthy enough to react normally in spite of psychic lesions; the second corresponds to a state in which, owing to the prolonged stress of psychic traumatism,—sexual or not,—a definite condition of hysteria has arisen. The one state is healthy, though abnormal; the other is one of pronounced morbidity.

The condition of true hysteria is thus linked on to almost healthy states, and especially to a condition which may be described as one of sex-hunger. Such a suggestion may help us to see these puzzling phenomena in their true nature and perspective.

At this point I may refer to the interesting parallel, and probable real relationship, between hysteria and chlorosis. As Luzet has said, hysteria and chlorosis are sisters. We have seen that there is some ground for regarding hysteria as an exaggerated form of a normal process which is really an auto-erotic phenomenon. There is some ground, also, for regarding chlorosis as the exaggeration of a physiological state connected with sexual conditions, more specifically with the preparation for maternity. Hysteria is so frequently associated with anæmic conditions that Biernacki has argued that such conditions really constitute the primary and fundamental cause of hysteria (Neurologisches Centralblatt, March, 1898). And, centuries before Biernacki, Sydenham had stated his belief that poverty of the blood is the chief cause of hysteria.

It would be some confirmation of this position if we could believe that chlorosis, like hysteria, is in some degree a congenital condition. This was the view of Virchow, who regarded chlorosis as essentially dependent on a congenital hyoplasia of the arterial system. Stieda, on the basis of an elaborate study of twenty-three cases, has endeavored to prove that chlorosis is due to a congenital defect of development (Zeitschrift für Geburtshülfe und Gynäkologie, vol. xxxii, Part I, 1895). His facts tend to prove that in chlorosis there are signs of general ill-development, and that, in particular, there is imperfect development of the breasts and sexual organs, with a tendency to contracted pelvis. Charrin, again, regards utero-ovarian inadequacy as at least one of the factors of chlorosis. Chlorosis, in its extreme form, may thus be regarded as a disorder of development, a sign of physical degeneracy. Even if not strictly a cause, a congenital condition may, as Stockman believes (British Medical Journal, December 14, 1895), be a predisposing influence.

However it may be in extreme cases, there is very considerable evidence to indicate that the ordinary anæmia of young women may be due to a storing up of iron in the system, and is so far normal, being a preparation for the function of reproduction. Some observations of Bunge's seem to throw much light on the real cause of what may be termed physiological chlorosis. He found by a series of experiments on animals of different ages that young animals contain a much greater amount of iron in their tissues than adult animals; that, for instance, the body of a rabbit an hour after birth contains more than four times as much iron as that of a rabbit two and a half months old. It thus appears probable that at the period of puberty, and later, there is a storage of iron in the system preparatory to the exercise of the maternal functions. It is precisely between the ages of fifteen and twenty-three, as Stockman found by an analysis of his own cases (British Medical Journal, December 14, 1895), that the majority of cases occur; there was, indeed, he found, no case in which the first onset was later than the age of twenty-three. A similar result is revealed by the charts of Lloyd Jones, which cover a vastly greater number of cases.

We owe to Lloyd Jones an important contribution to the knowledge of chlorosis in its physiological or normal relationships. He has shown that chlorosis is but the exaggeration of a condition that is normal at puberty (and, in many women, at each menstrual period), and which, there is good reason to believe, even has a favorable influence on fertility. He found that light-complexioned persons are more fertile than the dark-complexioned, and that at the same time the blood of the latter is of less specific gravity, containing less hæmoglobin. Lloyd Jones also reached the generalization that girls who have had chlorosis are often remarkably pretty, so that the tendency to chlorosis is associated with all the sexual and reproductive aptitudes that make a woman attractive to a man. His conclusion is that the normal condition of which chlorosis is the extreme and pathological condition, is a preparation for motherhood (E. Lloyd Jones, "Chlorosis: The Special Anæmia of Young Women," 1897; also numerous reports to the British Medical Association, published in the British Medical Journal. There was an interesting discussion of the theories of chlorosis at the Moscow International Medical Congress, in 1898; see proceedings of the congress, volume in, section v, pp. 224 et seq.).

We may thus, perhaps, understand why it is that hysteria and anæmia are often combined, and why they are both most frequently found in adolescent young women who have yet had no sexual experiences. Chlorosis is a physical phenomenon; hysteria, largely a psychic phenomenon; yet, both alike may, to some extent at least, be regarded as sexual aptitude showing itself in extreme and pathological forms.

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