Psychopathology of hysteria

Preface

Than hysteria, probably there is not any disease which is more interesting, which has been more misunderstood, which is capable of causing a greater diversity of manifestations, and about which more has been written. Its absorbing interest is due mainly to the peculiar character and unlimited possibilities of its expression. Surely, a disease is worthy of the consideration which has been bestowed upon hysteria when it is capable of causing such diverse symptoms as paralysis, convulsions, blindness, multiple personality, and which can occur in epidemics that, in the past, have caused greater disturbance to whole nations than a war would have occasioned. Its history and literature, which would fill a spacious library, show that from the days of the Grecian oracles, or of the sibyls of even more distant ages, to the present trance mediums, the unfortunate victims of the disease have been subjected alternately to persecution as witches and demons, or to devotion as the inspired source of wisdom and of supernatural knowledge.

It is only recently, and through psychologic means, that hysteria is beginning to be understood. The credit for elucidation of problems of the disease is due principally to the French. In fact, the psychology characteristic of their nation truly may be said to have been based upon studies of the abnormal psychology of hysteria. The present era of enlightenment concerning the disease may be considered to have been initiated by Bernheim. It is his interpretation— which to a great extent has stood the test of time — of the phenomena of hypnotism that enabled this earnest investigator to grasp the mysteries of hysteria in a manner which never before had been possible. In spite of the greatest opposition and acrimonious controversy, his views of the causation and nature of many of the symptoms of hysteria are obtaining at last the recognition and acceptance which they deserve. Babinski, for instance, the most ardent of the revisionists, eagerly contends now, as Bernheim insisted many years ago, that suggestion is of the utmost importance in the genesis of symptoms of the disease. It is to Janet that credit is due for the theory that dissociation of the personality is the underlying mechanism of hysteria, and also for innumerable and valuable experimental researches concerning the psychic nature of the disturbances of sensory perception. Of great importance, too, was his exposition of the somnambulistic qualities of many of the manifestations. In this country, the most fruitful investigations have related to dissociation of the personality ; a subject which has received considerable attention. Probably the most extensive and the

Preface 5

most valuable contributions on the clinical study of this condition have been made by Morton Prince and by Boris Sidis.

Finally, the studies of Sigmund Freud, subjected at first to neglect and later to opposition, now are exerting an enormous influence in revising our conceptions of hysteria. The exhaustive manner in which this Austrian studied his cases is remarkable. Not only have his observations been a revelation of the importance of psychic insults in the etiology of the disease, and of the remarkable manner in which dissociated or submerged memory complexes dominate the hysteric, but they have been of the greatest consequence in showing how normally one's actions arid mode of thinking are largely determined by motives of which one is unconscious.

In spite of the multitudinous volumes in which the disease, or certain of its symptoms and mental states are described, but few English books have appeared in which the disease as a whole has been treated on the basis of the results of modern psychopathologic researches. In the belief that such a volume may not overburden the already great ranks of those dealing with the disease, the author has modestly attempted to meet this deficiency. In conclusion, this work is based upon, in fact is an exposition of, the modern conception of hysteria as entertained by the foremost contemporary students of abnormal psychology. A not inconsiderable amount of personal experimentation and clinical investigation has been drawn upon, and, not desiring the responsibility to rest upon the shoulders of others, it is necessary to acknowledge, also, that some personal views concerning the disease and its symptoms have been incorporated.

Philadelphia, Pa.

Contents

CHAPTER , PAGE

Preface 3

I Preliminary Considerations 11

CHAPTER I Preliminary Considerations

THE normal personality may be regarded as a highly mutable synthetic product of memories of past instruction and experiences as modified by present perceptions, either of external stimuli — exogenous — or of the countless number of various sensory impressions arising as a result of the activity of the different structures of the body — endogenous or coenesthetic. By reason of the modifying influence of present external stimuli one's personality seems to undergo the greatest variation in accordance with the difference in his reactions to diverse environments; the mode of reaction suitable for one kind of environment being of pathologic import if displayed in another. As the memories of all experiences are fused with the personality, and as memories are never destroyed except by gross organic disease of the brain, every event in a person's life inevitably exerts an influence upon his individuality — upon his manner of reacting to his environment.

In connection with the laws that "all nervous function is conditioned upon sensation/' and that all sensory impressions invariably become transformed into immediate or delayed movement, or action, W. K. Walker states: "That which is present in the mind at any given instant is therefore due to its past experiences; to previously experienced sensations, impulses, ideas, and emotions. These 'stored up' 'sensations tend to final transformation into action' — that is, either action or restraint of action, — not only according to the laws governing all neural and mental manifestations in general, but, in particular, with the gradually acquired habit of reaction of the individual organism." (Med. News, Jan. 28, 1905.)

By saying that we have forgotten something, we mean only that we are unable at the time to reproduce the memory — to raise the memory above the threshold of consciousness. In spite of our efforts to recall them, such memories remain dormant only because we have been unable to obtain the proper association of ideas, and at any subsequent time reproduction can be effected, providing that the proper stimulus is called into play. Now, even though events have been "forgotten," still their dormant memories continue subconsciously to influence the actions, feelings, and mode of thinking of the individual. We act more or less in accordance with our feelings and our general conceptions, and though we may forget in what manner these have been originated, yet the influence ofHhe underlying forgotten occurrences persists. One may not remember just how the knowledge was first acquired that heat may cause pain, but the deficiency in our ability to reproduce these memories does not impair the value of a conception which has largely been the product of painful experience.

The acquisition of knowledge, through personal experience, requires at first the conscious memory of particular causes and effects, but later, these details subside below the level of consciousness, unless the occurrence has been noteworthy, and only general conceptions remain. Consequently, my knowledge that fire may cause pain does not necessitate recollection of the many times when fire has caused me to experience pain. In this respect, then, a certain amount of submergence of memories is a normal concomitant of psychic development, and its value lies .in the freedom which it insures from being mentally encumbered with countless and useless facts. Accepting as true these well known characteristics of the human mind we may conclude that, excepting possible hereditary factors and the effects of education, an individual's personality is of a certain nature, mainly because of the character of memories of countless experiences in which he has taken part; these memories, whether conscious or submerged, becoming

14 PsycJwpathology of Hysteria

integrals in the continual growth of the personality.

It is for this reason that one evil act paves the way for another, and that no one can do wrong once with the intention afterwards to forget about the unpleasant act, and thus be free from harmful consequences. Each act or thought of an individual tends towards the recurrence of similar acts or thoughts — the production of a habit. In terms of materialism, this fact is explained as being the result of lowered synapsal resistance. Otherwise, a certain kind of reaction having occurred in response to a given stimulus, we assume that, whether conscious or dormant, the memory of the experience largely determines repetition of the same reaction when a similar stimulus occurs. The economics of this tendency are easily grasped, for all forms of normally automatic activity are but examples of acquired reflexes due to habitual modes of volition, and if it were not for such automaticity one's attention would constantly be employed by the performance of the ordinary acts of life, at the expense of higher forms of activity and of acquisition of knowledge.

To the normal process of forgetting, let us apply the term dissociation with the understanding that this designation implies merely that though certain memories have subsided below the level of consciousness their influence still persists in that they exert a continual effect upon modes of thinking and of acting. In discussing this question Ernest Jones has written: "We are beginning to see man not as the smooth self-acting agent he pretends to be, but as he really is, a creature only dimly conscious of the various influences that mould his thought and action, ... " (Rationalization In E very-Day Life, Jour, of Abnormal Psych., Vol. 3, p. 168.) No matter if one does think that he knows the mechanism and all the motives of any given act or thought, these have been originated or modified by memory complexes which are more or less completely dormant. Upon becoming acquainted with an estimable person, and without knowing the cause, one may experience towards him an "instinctive" dislike. Later, the true reason flashes into mind: it was because the object of aversion resembles another individual who had wronged him in some manner.

If Ave should stop a moment to consider one of our most cherished ideas, perhaps we would not be able to recall the reasons which had led us to the adoption of that particular belief ; yet we know that there were a number of factors which determined its growth, and which continue subconsciously to control us. Often we hear some one honestly make a positive assertion with all the assurance that would be warranted by thorough knowledge of the subject.

Let a question arise concerning the grounds for his convictions and at once he is at a loss for data with which he can justify his assertion, even though he knows that formerly he was cognizant of these.

Our supposed knowledge of the motives for our thoughts and actions is exceedingly superficial and illusory, and constantly we are the unconscious slaves of our past. In this sense, at least, we have not any freewill, and we are but the automata with superadded consciousness about which so much has been written ; reacting as we do to our present environment, according to the influence, more or less unconscious to us, of the past surroundings in which we have been placed merely as a matter of accident, as far as our own inclinations were concerned. In the last few years even more acceptably might have been written Spinoza's celebrated remark to

the effect that " men think themselves free,

inasmuch as they are conscious of their volitions and desires, and never even dream in their ignorance, of the causes which have disposed them to wish and desire." (Ethica, Elmes trans.)

To illustrate the agency of subconscious memory complexes there is no better example than the "Frost King" episode in the case of Helen Keller. When twelve years of age Miss Keller wrote a story, which she called the "Frost King," and it was published in one of the Perkins's Institution Reports. Afterwards it was discovered that this story was a duplicate in ideas — and in places even words — of another story which had been read to her three years before, or a little over one year after she had acquired the faculty of language — the sign language. Miss Keller was totally unable to remember the original, and, until convinced by the facts of the case, she was equally positive that hers was entirely the product of her own mind. (The Story of My Life, 1903.) It must be remembered that this excellent instance of unconscious plagiarism is an unusually exaggerated one, because of the limited amount of knowledge possessed at that time by Miss Keller, and because of the fact that by reason of certain mental characteristics and of the difficulties under which she labored what she had once learned subsequently tended to almost complete reproduction, without, however, being coupled with the associated ideas of source. For this reason a thought might be considered by her to be original, when, in reality, it arose from her subconscious store-house of what had been read to her. The Hindoo cycle, in the case of Helene Smith, almost parallels the above occurrence both in the accuracy and in the unconsciousness of the plagiarism. (Flournoy: From India to the Planet Mars, 1901.)

The tendency to unconscious plagiarism is not abnormal; nor is it unusual. Let one who is open to conviction read an authoritative book.

If lie reads much, a year later he may be unable to recall the facts and theories which it contained, but, nevertheless, these continue to exert an influence in determining his own conceptions, though he may be unaware of the fact. A year or so later let him read the book again, and he will be surprised to find that beliefs which he thought not only were original but were of recent origin, were really derived from his first reading of the work.

The following quotation from Hammond is a fine example of the activity of normally forgotten memories: "A friend has related to me some circumstances in his own case similar to the above, and illustrating the same points. In the course of his practice as a lawyer, it became necessary for him to ascertain the exact age of a client, who was also his cousin. Their grandfather had been a rather eccentric personage, who had taken a great deal of notice of both his grandsons — his only direct descendants. He died when they were boys. My friend often told his cousin that if his grandfather were alive there would be no difficulty at getting at the desired information, and that he had a dim recollection of having seen a record kept by the old gentleman, and of there being some peculiarity about it which he could not recall. Several months elapsed, and he had given up the idea of attempting to discover the facts of which he had been in search, when, one night, he dreamed that his grandfather came to him and said: 'You have been trying to find out when

J was born; don't you recollect that one

afternoon when we were fishing I read you some lines from an Elzevir Horace, and showed you how I made a family record out of the work by inserting a number of blank leaves at the end? Now, as you know, I devised my library to the Kev. . I was a d — d fool for giving him books which he will never read! Get the Horace, and you will discover the exact hour at which J was born. ' In the morning all the particulars of this dream were fresh in my friend's memory. The reverend gentleman lived in a neighboring city ; my friend took the first train, found the copy of Horace, and at the end the pages constituting the family record, exactly as had been described to him in the dream. By no effort of his memory, however, could he recollect the incidents of the fishing excursion." (Sleep and Its Derangements, 1869.) What is of particular interest in this case, is the fact that the dissociation was so complete that conscious recollection was impossible, yet complete synthesis was obtained during the dream. Furthermore, in the waking state, the lawyer was totally unable to recognize the personal nature of the memories which had been recovered.

Now, let us suppose that independently of consciousness dissociated, or submerged, memories become integrated with one-another, or that a massive dissociation of complexes from consciousness should occur, in consequence of some psychic insult, and that the dissociated fragment of what constituted the more or less normal personality took on activity irrespective of the present states of consciousness of the individual. Such processes naturally constitute pathologic disaggregation of personality, and if the offshoot were massive enough, a secondary personality would be produced.

As a working hypothesis let us postulate that all the functional neuroses, or more properly psychoses, are dependent upon disintegration of personality, and that as such they are merely the result of pathologic exaggeration of what is a normal component of psychic development. Then neurasthenia, psychasthenia, hysteria, and multiple personality would be clinical syndromes having a common origin; the underlying disintegration being rudimentary in the first instance, more decided and often suspected even by the patient in the second one, still more developed and not surmised by patients suffering with the ordinary types of hysteria, and massive enough to be complete in the condition known as multiple personality.

By means of this prevalent and well founded hypothesis, almost every symptom of hysteria can be explained as satisfactorily as the manifestations and pathologic changes of any organic disease. Accordingly, amnesia results from abnormally complete or massive dissociation from consciousness of certain memories, and the proof of its functional character can readily be adduced by means of reproduction of the lost memories through the agency of certain well known procedures. Anaesthesia, analgesia, amaurosis, deafness, etc., would imply, on the other hand, that sensory perceptions had not become integrated with consciousness — that they had been appropriated, so to speak, by the dissociated components of the former personality. Experimentally, this explanation has been amply verified.

After adducing experimental observations of Pierre Janet, Paul Janet, Binet, Pitres, and Bernheim, concerning phenomena of hysteria, no less authority than William James states: "It must be admitted, therefore, that in certain persons, at least, the total possible consciousness may be split into parts ivhich coexist but mutually ignore each other, and share the objects of knowledge between them. More remarkable still, they are complementary. Give an object to one of the consciousnesses, and by that fact you remove it from the other or others. Barring a certain common fund of information, like the command of language, etc., what the upper self knows the under self is ignorant of, and vice versa." (The Principles of Psychology, Vol. 1, p. 206, 1905.)

At best, our knowledge of mental processes is superficial. Moreover, the difficulty of describing normal and abnormal psychic phenomena is great. Any language necessarily must be a faulty vehicle for conveying the thoughts of one individual to another. A group of words is incapable of reproducing in one person the exact conceptions of another. To this difficulty is added one's inability to describe briefly and accurately any process. Suppose we subject a remark to the same kind of criticism that would be attracted by the description of a mental process. By reason of poverty of words and inexactness of verbal representation we say briefly that a cigarette is smoking, and that a man is smoking, or that the paper burns, and that he is burning the paper. In reality, the man neither smokes nor burns the paper, and, to say nothing of his own part in these acts, these phrases are most superficial and condensed representations of a variety of most complex chemical processes. In the same manner causation always must be obscure. What was the cause of destruction of the paper? The immediate one was oxidation. This was superinduced by heat which the man had applied. But then the endless chain arises concerning the causes of the man wishing to destroy the paper that was not destroyed, but whose chemical components were merely dissociated, to be recombined in a different manner and with the addition of oxygen.

In describing the psychic mechanism of hysteria we say that the disease is caused by dissociation of consciousness, and that this process causes increased suggestibility, then, in the next breath, that further dissociation may result as the effect of this symptom. These statements only imply, however, that a vicious circle is formed. The same process is apparent in the use of hypnotism. By means of suggestion a subject is hypnotized. The increased suggestibility produced by this state of dissociation then enables us to induce more readily further dissociation.

Two individuals being exposed to the same psychic stress, one may develop hysteria, and the other psychasthenia ; the difference in the two syndromes being equivalent to difference in the modes of feeling, thinking, and acting of the two persons. The condition of the one who developed psychasthenia is said to be due to dissociation of the personality and that as a consequence, fear and expectant attention appear as symptoms. Then, like the vicious circle of hysteria, these symptoms, by causing further dissociation, induce various other phenomena.

In a gross materialistic way the pathologist is satisfied when, with the assistance of stains, microscope, and other laboratory apparatus, he finds that certain lesions occur more or less constantly in some disease. He seems to be contented with this knowledge — he has discovered the cause of a disease — yet the discovery of these lesions does not explain the cause for the same reason that dissociation of personality does not account for the production of the psychoneuroses. There is an inherent tendency for one to believe that he knows much about a disease merely because he possesses some knowledge of the anatomical changes which are really concomitants or secondary causes. To say that lesions of the islands of Langerhans are the cause of diabetes does not explain the disease. Not only is there a cause, or causes, for this sclerosis, but there may be a whole succession of pathological processes that precedes its development. The greater part of pathology consists only in a superficial knowledge of terminal processes, and the only advantage it has over psychopathology is that scales, test tubes, and a microscope lend an aspect of scientific precision which cloaks in a satisfactory manner our real ignorance of causality. In spite of what the materialistic pathologist would have one believe, psychopathology is not entirely a matter of groundless theories based upon the morbid introspection of deviates. With the assistance of association reaction time experiments, the psychogalvanic reflex, pulse reactions, etc., the psychologist can "measure" the emotions and detect and reveal subconscious ideation.

In the early studies of hysteria, and, in fact, even to the present, it was customary to describe a number of symptoms as characteristic, or stigmatic, of the disease. Among the most important were anaesthesia and concentric contraction of the visual fields. We are beginning to understand, now, that these "stigmata" are only accidental phenomena, which, except when created by reason of faulty methods of examination, are rather unusual if not rare. It was only by reason of the suggestive technique of the ordinary examination that, until recently, the occurrence of "stigmata" was so common.

The recent discussion of hysteria before the Paris Neurological Society brought out the quite general recognition of the fact that the symptoms of the disease, as many have intimated for years, are caused by suggestion, and that what have been called the stigmata usually owed their origin to examinations by physicians who disregarded, or were unaware of, the effects of suggestion in causing the conditions which they sought. Certain members averred that by attempting to avoid the pathogenic effects of suggestion during their examinations of hysteric patients, they no longer find anaesthesia and the like, provided that the patients had not been examined previously by others. In fact, the tendency of some of the members seems to have been to ascribe to suggestion all the symptoms of the disease. According to Babinski, for instance, a patient is not hysteric whose symptoms are incapable of being reproduced by suggestion

26 Psyclwpathology of Hysteria

and removed by persuasion. Yet Babinski was one of those who formerly opposed the contentions of Bernheim, to the effect that the stigmata of hysteria are merely the product of suggestion. Consequently, his present views possess greater significance than if he had upheld the theory from the beginning.

If it is desirable to establish stigmata of hysteria let us confine ourselves to the only symptom which is characteristic of the disease. The only one whose presence is at all constant, and whose pathogenic importance cannot be overestimated, is pathologic increase in suggestibility. This veritable stigma has been a prolific cause of blunders in the past studies of the disease. It is by reason of its agency that any enthusiastic investigator ordinarily and unintentionally can cause whatever he may wish to find in support of his views ; no matter what these may be. Thus, one can appear to demonstrate that the symptoms of hysteria are due only to intentional simulation, or that any symptom is essential to the existence of the disease. At la Salpetriere, for instance, there was created a typical epidemic of hysteric convulsions which influenced for years the study of hysteria, and which was the effect solely of an elaborate suggestive training and of psychic contagion.

Since Bernheim 's recognition of the danger of misinterpretation of the occurrence of symptoms of hysteria through the more or less unconscious use, or rather abuse, of suggestion by the observer, the understanding of the disease has advanced considerably at the expense of numerous theories and classic experiments which owed their very existence to suggestion. Many years elapsed, though, before the full significance of the well known cautionary "beware of suggestion" of this pioneer became appreciated. The delay was due to the powerful antagonism exerted by Charcot in consequence of his total disbelief in the effects of suggestion. In fact, the experiments of Charcot and his followers upon hysteric patients were rendered valueless by reason of their disregard of suggestion. To no other factor than ignorance of the possibilities of suggestion can be ascribed the ludicrous experiments and theories of Luys,* and others of the Salpetriere school, concerning the wonderful effects of magnets, of metals, and of medicine in sealed glass tubes.

It has been demonstrated conclusively, that because of this increased susceptibility to suggestion, so invaluable for therapeutic purposes, prolonged, unnecessary, and repeated neurologic examinations of hysterics, their association with other victims of the disease, and their demonstration before clinics, where they hear

(•Reported and exposed by Ernest Hart in Hypnotism, Mesmerism and the New Witchcraft, 1896.)

descriptions of their symptoms and of the disease, both create symptoms and prolong those already in existence. Therefore, one can readily appreciate that the earnest and faultily conducted studies and the clinical exploitation of these cases formerly was responsible for an incalculable and irreparable amount of injury.

Recognizing the importance of increased suggestibility in producing symptoms, we can commonly interpret the classic stigmata as artificial creations. As such, they have almost as much diagnostic value as formerly; providing that their production, which usually cannot be considered justifiable, is thought necessary. Then, too, the acceptance of these views leads to a better understanding of the symptomatology of hysteria, and, furthermore, we will have advanced one step in the pursuit of the first cause.

With the justification afforded by the conceptions of the modern French neurologists, as briefly indicated in these few prefatory notes, the symptomatology of hysteria will be largely considered upon a basis of suggestion, and the effects of the abnormally great suggestibility in creating or in modifying symptoms intentionally will be reiterated with the purpose of calling attention to the possibilities of unconscious abuse of this characteristic of the disease.

A fact which must be borne in mind, one which a priori must be true, is that each person's hysteria must differ just as the mental characteristics of all individuals vary. Moreover, the kind of symptoms possessed by a patient depends entirely upon the nature of the incidental exciting causes, upon the personal equation, upon psychic contagion from others, and upon the effects of accidental suggestion.

Bernheim believes that it is impossible to deiine hysteria because it is hot a morbid entity. According to Lasegue hysteria never has been denned and it never will be. In a more hopeful spirit Grasset does not despair of any progress, but he believes that the definition is still impossible. In spite of the restrictions of these, and other neurologists, the definitions of hysteria, like those of insanity, are almost as numerous as the writers who have described the disease. Having the sanction, then, conferred by numerous precedents, and recognizing the impossibility to define satisfactorily such a protean malady, the following may be regarded merely as a provisional definition:

Hysteria may be designated a psychoneurosis, or so-called functional nervous disease, which, tending to develop particularly in those predisposed by neuropathic heredity and by vicious environment, is dependent upon disintegration of personality and is characterized by symptoms originating from the morbid control of the body by subconscious states; whose symptoms can be shown to be but exaggerations or perversions of normal modes of feeling, of thinking, and of acting; a disease which is distinguished by a peculiar type of temperament, faulty adaptability to environment, pathologic increase in suggestibility resulting in the liability to develop many kinds of phenomena, and the possibility of the appearance of any one or more of a vast number of " accidents " arising. from morbid ideation.

CHAPTER II Etiology

HEREDITY. In common with the other psychoneuroses, hysteria is thought usually to occur in those whose nervous system is rendered, as a consequence of neuropathic heredity, more susceptible than usual to functional derangement. Undoubtedly this is true, but the occurrence of hysteria does not necessarily always imply the instrumentality of heredity, or the existence of a state of organic nervous degeneracy. In fact, the family history is above reproach in about 10% to 20% of cases of hysteria. If one accepts the extreme views upon degeneration promulgated by Nordau* and others, then but few families could be considered entirely free from some variety of hereditary psychopathic taint.