On the Pathology and Treatment of Hysteria
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Introduction:
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.
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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.
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