CHAPTER IX

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