On the pathology and treatment of hysteria

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ON THE

PATHOLOGY AND TREATMENT

or

HYSTERIA.

PATHOLOGY AND TEEATMENT

HYSTERIA.

EOBEET BRUDENELL CARTER,

LONDON:
JOHN CHURCHILL, PRINCES STBSBT, SOHO.

MDCCDLIU.

/j,-/, £^_ ZdT.

O. sad i. AdUrdt Priatan, BartholooMw OIom.

TO

THE MEMORY

OF

STEPHEN MACKENZIE,

THESE PAGES

ABE AFFECTIONATELY PEDICATED.

PREFACE.

In adding another publication on Hysteria to those
which have already issued from the press^ the author
is especially anxious to call the attention of his readers
to the circumstances under which the book before them
has been produced.

He had the privilege of enjoying for several years
the friendship of the late Mr. Mackenzie^ who was ex-
tensively known by his successful treatment of the
most inveterate hysterical disorders.

It had long been Mr. Mackenzie's wish and inten-
tion^ to publish the results of his extended experience^
but this intention was frustrated by his sudden and
untimely death.

The author being well acquainted with his opinions,
and having constantly witnessed and assisted in his
practice, has determined to lay a sketch of them before
the profession, being strengthened in this determina-
tion, by observing, that the tide of medical and phy-

Vlll PREFACE.

Biological literature is approaching very near to views,
which Mr. Mackenzie had long advocated in private.

Mr. Mackenzie left no papers behind him, and
hence there is much reason to fear that, a vast amount
of practical knowledge, on an obscure and difficult
subject, has been entirely lost. The author is able
distinctly to refer to him, the views hereafter to be
stated, with regard to the primary and tertiary
paroxysms ; and also the system of treatment, recom-
mended in coniplicated hysteria; but for all other
parts of the book, he must take fall responsibility
upon himself.

Leytonstone, near London;
December^ 1852.

CONTENTS.

CHAPTER I.

PAOK

The Eitects op Emotion 1

CHAPTER II.
The Hystebic Pakoxysm 28

CHAPTER in.
The Mobal State and Motives . . . .50

CHAPTER IV.
Complications 60

CHAPTER V.
The Hypotheses op poemer Wbitees . . 79

CHAPTER VI.
Treatment 91

CHAPTER Vn.
Hysteria among the Poor 152

THE PATHOLOGY AND TREATMENT

OP

HYSTERIA.

CHAPTER I.

THE EFFECTS OF EMOTION.

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 unpa-
ralleled 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

1

2 PATHOLOGY AND TREATMENT

such cannot be called hysterical aflfections, without con-
siderable risk of those evil consequences, which so often
follow the attempt to give a definite name to an un-
known quantity. Ignorance is thus veiled under a
disguise which imitates, in some degree, the appearance
of knowledge; and a phrase, representing only the
algebraic a?, 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. For the rapid
development of neurological science during the last few
years, and the changes which are being daily wrought
in the opinions once considered its established laws,
afford such ample scope for the growth of speculation
and hypothesis, that the inquirer has no safety except
in the framing of exact conceptions ; or in the distinct
avowal of ignorance on those subjects which have not
yet been thoroughly explained. The technicalities,
behind which this ignorance vainly endeavours to con-
ceal itself, are like the clouds which veil the sides of
some lofty mountain, insufficient, indeed, to lessen its
apparent magnitude, or to hide the difficulties of the
ascent, but nevertheless shrouding the path in ob-
scurity, and besetting the traveller with danger; so
that all who aspire to be guides, should ascertain that
their portion of the way, however limited, does not
lead on into these regions of peril and of mist.

By hysteria, then, is intended a disease which com-
mences 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

OF HYSTERIA. 3

attack of laughter or sobbing ; and in others^ producing
very energetic involuntary movements^ maintained
during a considerable time, and occasionally termi-
nating 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. In a
large number of cases, the " fit '' thus produced will
not return ; but when it does so, the exciting cause of
the next two or three attacks is often obscure, and
then, after a while, the convulsions occur frequently,
when no reason whatever can be assigned for their
commencement; although, if the patient be vexed or
thwarted, they are pretty sure to follow. This state,
which may be called simple hysteria, and consists in
the liability to fits of greater or less severity, either
with or without distinct intervals of remission and per-
fect 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 " fons et origo mali,'' is sometimes suflfered 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. But an endeavour will
be made to show, that this convulsive paroxysm is the
essential characteristic of the disease ; and that all other
phenomena manifested during its course, are non-
essential and secondary : so that the reader is

4 PATHOLOGY AND TREATMENT

requested to postulate thus much^ until he has con-
cluded his perusal; and to dismiss for a time the
recollection of all cases^ professedly hysterical, which
have not had their commencement in the manner
indicated above.

Before examining the circumstances under which
the first hysteric fit is originated, or the reasons which
justify the prominent position thus assigned to it, a
short time will be usefully bestowed, in reviewing that
mental state so often associated with hysteria, which
we comprehensively designate emotion; in order to
point out what physical changes may often be referred
to its operation, and to pave the way for the study of
its effects, in relation to the subject-matter of these
pages.

Emotions are described by Dr. Brown as "vivid
feelings, arising immediately from the consideration of
objects perceived, or remembered, or imagined, or from
other prior emotions ;'' and by Dr. Carpenter, as
"sensations, associated with an idea of pleasure or
pain.^' The last quotation may, perhaps, be rendered
more expressive, by prefixing to it Dr. Brown^s " vivid;''
while the first serves admirably to explain the manner
in which these sensations are aroused, i. e. by objects,
either perceived, or remembered, or imagined, or by
(the remembrance of) other prior emotions.

Whenever an emotion is experienced in any strong
degree, its existence will not be found to remain as a
matter of mere intellectual consciousness ; but on the
contrary, always to manifest itself by the production of
certain effects, either upon the intellect and will, or
upon the physical organism. In the former case, it
appears to exercise a continuous influence, which does

OF HYSTERIA. 5

not involve any sudden exhaustion of its own force;
but in the latter, it speedily discharges or expends
itself.

EflTects exclusively mental, are observed under the
influence of the depressing emotions; as grief, or
anxiety ; but only when these are very powerful. The
condition produced is that which we describe in com-
mon parlance, by saying that a person is stunned by
the shock of a calamity, or is stupified by terror.
When fully established, it in great measure destroys
volitional control over the current of thought; the mind
being wholly employed in contemplating the cause of
excited feeling ; and the power of directing appropriate
action being either weakened or lost. Such cases some-
times terminate fatally, — death being produced partly
by that concentration of nervous force, which is re-
quired by the unwavering attention, and which involves
a corresponding withdrawal of its directing agency from
the functions of organic life ; and partly by absolute
exhaustion both of body and mind. But, in the ma-
jority of instances, recovery may be expected, gradual,
from the lapse of time; or immediate, either by
removal of the original causes of emotion, or, more
frequently, by the production of those physical effects
which have next to be considered.

Effects upon the physical organism may either fol-
low those which have already been described, or they
may be manifested primarily, as the immediate results
of the emotional state; the latter being by far their
most common order of appearance. It is evident that
the nervous system is the only possible means through
which they can be produced ; and that, consequently,
they must be limited to disturbance of those organs

6 PATHOLOGY AND TREATMENT

and functions which are most immediately under its
influence; while it is found that the spinal and the
sympathetic nerves are the parts of the system most
frequently concerned in their development. To the
former may be attributed perversions of ordinary sen-
sation, and automatic contraction of voluntary muscles;
to the latter, changes in the circulation, perversions of
secretion, and contraction of the involuntary muscles.
These various departures from health are witnessed in
every degree of intensity; singly, or in every possible
combination, and diflfering under different circum-
stances, in every conceivable way; but they are all
alike in affording speedy and evident relief to the emo-
tion itself, which is, so to speak, exhausted in producing
them, and which appears to be correlated to its effects.

Perversions of ordinary sensation are not common
in healthy persons, although of frequent occurrence in
the hysterical. But it is from the former only that il-
lustrations will now be taken; and, perhaps, the best
one, as being the most common and the most easily
verified, is that cessation of toothache which so often
takes place from the alarm incident to preparations for
extraction, — when fear alone is found to render the
nerve insensible to the irritation, either of atmospheric
air, of fragments of food, or of the acrid matters re-
sulting from caries. Many of the anaesthetic and
hypersesthetic phenomena of hysteria can be referred to
the same category, and will be more fully discussed
hereafter ; but the instance cited is sufficient to esta-
blish the principle laid down.

Of the various effects produced by emotion, auto-
matic contraction of voluntary muscles is the most
universal and familiar, being witnessed as the result of

OP HYSTERIA. 7

excited feeling of all kinds and in every degree* In
the state of health it seldom exceeds the involuntary
performance of some definite act; but under certain
conditions of exalted sensibility, the movements be-
come objectless or convulsive. Several groups of
muscles are prone to be affected ; and they may be ad-
vantageously considered in their order of liability, as
follows :

Muscles of expression,

„ concerned in the performance of any ha-
bitual gesture or trick,
„ of respiration,
„ of locomotion.

The facial muscles are controlled by emotional states,
in a manner that is not only very interesting in itself,
but especially as throwing much light upon many pro-
blems in hysterical pathology. In early childhood
they are employed in the performance of two distinct
classes of movements, of which the first, or involuntary,
are designated expressions ; and the second, or volun-
tary, grimaces. As age advances, the movements in-
cluded in each class become much more numerous, and
the former are brought in some degree under volitional
control; but this is accomplished in a manner which
marks their distinctive characters even more strongly
than before. The range both of automatic and volun-
tary movements differs widely in different countenances;
but any grimace within the power of the individual to
accomplish, is produced by an effort of the will similar
to that exerted in closing a hand, or raising an arm,
attention being directed to the thing to be done, and a
distinct conception of the desired movement being

8 PATHOLOGY AND TREATMENT

formed in the mind^ before it can be executed. But it
will be quite evident, upon very cursory observation,
that expressions are never called forth in this way ; and
that persons wishing to convey by the countenance a
feeling which they do not really entertain, such as
decent sympathy and compassion for some misfortune
related to them, but which does not affect their inte-
rests ; will attain their object, not by the exercise of
any control over the face, but by thinking of the proper
emotion, and surrendering their features to its influ-
ence. And it will also be found that the completeness
of^ch/an expression depends entirely upon the degree
in ^i\ch the mind can be directed to the contemplation
of the appropriate state of feeling, being much greater
when this can be distinctly remembered than when it
has to be imagined ; so that young and joyous people
find it no easy task to express by looks a sympathy
which they do not experience, while those who have
felt sorrow can reproduce and maintain its aspect with
little difficulty. But it is worthy of remark, that the
power of remembering or imagining emotions, so as
to obtain their eflfect upon the face, is capable of being
greatly increased by practice, a fact which explains the
improvement of actors — so far as gesture is concerned.
Indeed, the stage most strikingly confirms and illus-
trates the last few sentences, professors of the histrionic
art being natural, only so far as they can merge per-
sonality in the feelings sought to be portrayed ; and
being hard and forced, in exact proportion to their own
consciousness of efibrt. Again, the difierence between
volitional and emotional movements of the face, is
shown by the circumstance that, whereas the former
are never excited, except by an effort of the will, the

or HYSTERIA. 9

latter not only take place independently of it, but can
seldom be entirely prevented, even by its most de-
termined exercise. The immobility of countenance
ascribed to King William the Third, to Prince Talley-
rand, and to the North American Indians, is probably
an exaggeration of the truth, but admits of explanation,
in so far as it was real, on the ground that their cha-
racters and training were such as to check the develop-
ment of emotiveness, and to transform passions into
habits of thought. Nothing, however, shows more
clearly the relief afforded to emotion by its effects,
than the comparative ease with which the features can
be controlled, under circumstances which allow them
to be withdrawn from observation occasionally, even if
but for a moment at a time, so as to give the excited
feeling its play.

The facial automatic movements are very numerous
and complex, and differ from those of other muscles in
being differently associated for each well-defined emo-
tion — so that no feeling ever produces the expression
commonly assigned to its opposite. There is an appa-
rent exception to this rule, in the fact that many per-
sons experience a strong propensity to laughter (without
any ludicrous image being aroused), under circum-
stances that would be commonly thought painful and dis-
tressing. The seeming incongruity may be explained,
by supposing that this laughter is primarily diaphrag-
matic, as a consequence of embarrassment, and that the
facial movements are superadded &om habitual asso-
ciation. Sometimes, however, the proper expression may
be prevented from appearing by strong voluntary action
of neighbouring muscles, which are not concerned in
its formation; as when the lips are bitten in an en-

1§

10 PATHOLOGY AND TREATMENT

deavour to conceal anger. But the general coincidence
of feeling and expression is such as to justify the belief
that each emotion has its own distinct action upon the
system; and^ although this distinctness is not so
plainly shown in any other part of the body, still it
is more or less indicated in all.

The muscles concerned in the performance of any
habitual gesture or trick, stand next to those of ex-
pression in their proclivity to emotional movements;
such actions being always performed with unusual
rapidity and energy, when the persons prone to them
are influenced by any excited feeling, or by any causes
of anxiety or embarrassment. This fact is very gene-
rally recognised, and authors constantly avail themselves
of it, in order to give life and individuality to unreal
characters. But the movements in question may be
exemplified, without trespassing on the domain of
fiction, not only in the case of individuals who practise
some evident trick, but in those also, whose calling
requires the constant exercise of certain groups of
muscles. Pianists, for instance, perform the " deviFs-
tattoo" more frequently and decidedly than other
persons. Such movements are seldom the subjects
of consciousness, when resulting jfrom emotion, even if
they are so under ordinary circumstances; and thus
both snuff-taking and drinking may be accomplished
without the knowledge of the individual. Many occu-
pations of a less hurtful kind, which by practice have
become mechanical, are occasionally pursued in the
same manner ; and a lady may often be seen to obtain
relief under excitement, from the resources contained
in her netting-box or work-basket. These actions are
chiefly remarkable, as showing that the selecting power.

OF HYSTERIA. 11

which we have seen to be exercised by different
emotions upon the face^ is capable of being merged in
the exalted activity either of certain muscles,— or of
the nerves supplying them; so that every kind of
feeling produces precisely the same effect, except in so
far as intensity is concerned; and the distinctive
character assigned in the last paragraph to each, can
no longer be observed.

The muscles of respiration have next to be considered,
and the principal of these, the diaphragm, is the
one most frequently affected, although the intercostal
and scapular muscles are often associated with it,
especially in the deep inspiration which precedes a sigh,
or an expression of surprise. The acts of laughter and
sobbing, and the repressed breathing of eagerness, are
examples of the emotional respiratory movements,
which, like those of the face, can seldom be restrained
by the will ; although, unlike them, they can be pro-
duced by its direct influence, as well as by remember-
ing or imagining the kindred feelings. They are for
the most part expressive of the kind of emotion aroused,
although some persons are prone to laughter imder
all varieties of excitement ; and with such, as has been
already stated, the facial movements often accompany
the diaphragmatic.

The muscles of locomotion, (including those of the
upper extremities) come next in order ; and their emo-
tional movements differ from voluntary ones, chiefly in
being more violent. They are seldom produced except
by anger or fear ; and being much opposed to the habits
of civilized life, even these feelings are usually diverted
into another channel, unless very powerful, when they
break down all the barriers of custom, and the man.

12 PATHOLOGY AND TREATMENT

whether furious or panic stricken, surrenders himself to

the impetus of passion. But these emotions, if yielded

to, rapidly gain power over the locomotive apparatus, as

is seen in the conduct of irritable people, who pace up

and down a room — or otherwise move about, even under

slight provocation. When habitual restraint is not

practised, as in children or half-civilized nations, these

movements are very numerous and frequent. The

former shake themselves and dance with passion, while

the most extreme instance furnished by the latter, is

the Malay custom of '^ running a muck."

There yet remain certain emotional movements
which cannot be referred to any particular group of
muscles; but may be classed under the two heads of
restlessness and trembling. Their occurrence is so
common that it is hardly necessary to cite instances,
as every reader will be able to furnish them from his
own observation; but they are highly important, as
displaying the lowest degree of that general mobility of
the muscular or nervous system, which, when more
strongly developed, manifests itself in the form of a
convulsion, on the application of some adequate ex-
citing cause.

The effects of emotion which are probably produced
through the agency of the sympathetic nerve, have
been alluded to under the three heads of changes in
the circulation, perversions of secretion, and action of
involuntary muscles ; each of which divisions will require
a passing notice.

Changes in the circulation probably depend entirely
on an influence exerted upon the capillary vessels.
They may be either plus or minus with regard to any
individual organ, and mostly take place either in the cuta-

\

OF HYSTERIA. 13

neous surface of the face and neck; or in secreting
structures ; the blush of shame or anger, and the pallor
of fear or hatred, sufficiently exemplifying their occur-
rence in the first-named situation. The glands liable
to emotional congestion are those which, by forming
their products in larger quantity, subserve to the gra-
tification of the excited feeling. Thus blood is directed
to the mammae by the maternal emotions; to the
testes, by the sexual ; and to the salivary glands, by the
influence of appetizing odours ; while, in either case, the
sudden demand may produce an exsanguine condition
of other organs, and may check some function which
was being actively performed; as, for instance, the
digestive.

Perversions of secretion have been so fully described
by Dr. Carpenter,^ that it is unnecessary to make any
but the briefest mention of them here. They are most
strikingly evident in the milk, which is changed in
quality by all emotions; and in the matters poured
fourth by the intestinal glandulse, which often become
so acrid under the influence of fear, as to produce
immediate defecation. But secretion, in that larger
sense, which may be taken to include the nutritive
processes, is not less under the influence of emotions,
than is the function of a single gland. Thus individuals
are said to be worn down by grief or care ; and although
it is possible that in them emaciation may be due to a
concentration of nervous force upon the parts sub-
servient to intellectual exertion, still an instance will
shortly be related, in which acute inflammation and
death of tissue resulted immediately from strong emo-
tional excitement; and in all probability •the rarity of

* Principles of Human Physiology, 3d ed., p. 474.

14 PATHOLOGY AND TREATMENT

such cases depends entirely on the circumstance, that
an easier outlet is commonly furnished by other chan-
nels. Perversion of secreting action sometimes affects
only the quantity of the product, increasing this very
largely when there is no increased demand for its use;
and suddenly suppressing it when there is nothing in
the nature of the emotion itself to cause a revulsion of
blood from the suffering organ. The flow of tears
illustrates the former position, and the latter is exem-
plified in a practice, mentioned by Dr. Carpenter^ of
detecting a thief in an Indian household by causing
each of the servants to chew a portion of rice for a few
minutes ; the offender being distinguished by the com-
parative dryness of his mouthful. But it often happens
that the gland thus affected is of such importance in
the economy, that any interruption of its office is fol-
lowed by serious disturbance of the general system.
The author has more than once witnessed severe jaun-
dice occurring in this way, and is fully persuaded not
only that emotion is a frequent source of all those dis-
eases which plainly depend on arrest of secretion, but
also that, by a modified operation of the same kind, it
produces many derangements of health which are usu-
ally referred to the influence of other and more evident
agents.

The heart and the gravid uterus are the only invo-
luntary muscles which can be seen to respond to the
stimulus of excited feeling. The parietes of the intes-
tine probably do so ; but it is impossible to distinguish
certainly their primarily emotional actions from those
secondary ones which depend upon vitiated secretion.
The heart is very easily and quickly influenced, its

» Op. cit.

OP HYSTERIA. 15

pulsation being increased alike by joy or anger, hope
or fear, and in a measure which corresponds pretty
closely, cateris paribus, to the degree in which they
are experienced. The uterus possesses a greater amount
of resisting power, abortion being seldom produced for
the first time by mental disquietude, unless its opera*
tion is either prolonged or unusually powerful. Tem-
porary cessation of its contractions during labour is said
to be sometimes caused by fear or surprise, especially
when these depend upon the presence of an unknown
accoucheur. But the truth of this opinion may be
doubted, on the ground that the usual eflfect of emotion
is to produce, not relaxation, but contraction of muscle;
that there are very few labours in which the pains in-
crease steadily from the commencement, without occa-
sional periods of flagging, any one of which may
easily coincide with the entrance of a stranger; and,
lastly, that labour never appears to be retarded by the
total absence of the medical attendant, every practi-
tioner having often found his patient delivered on his
arrival at the house, although she had been in a state
of much terror and anxiety during the whole of the last
stage, from the very circumstance that he was not at
hand to reassure her.

Having thus seen that it is the natural tendency of
an emotion to discharge itself either through the mus-
cular^ the secreting, or the sanguiferous system, it
remains to examine how far the unfailing adaptiveness
of nature has been displayed in the selection of these
channels; and what amount of benefit results from their
employment, over and above the expenditure of a force
which would be injurious if retained. And this in-
vestigation will be materially assisted by extending it.

16 PATHOLOGY AND TREATMENT

not only beyond the limits of civilization, but also
beyond the human species. For instance^ sudden
defecation as a consequence of terror, does not much
improve the position of a naughty schoolboy. But when
we consider that it is the first eflFect produced by the cry
of hounds upon all beasts of chase, its general utility in
the animal kingdom becomes at once apparent. The
action upon the muscles is evidently intended to facili-
tate all measures of defence or flight ; and it is probable
that in the lower animals, the nervous system is so
organized, as to produce one of these results imme-
diately and instinctively. But in man, whose move-
ments should all be controlled and guided by the
mandates of the will, emotion at first produces only a
condition of mobile excitement, or increased readiness
to obey those mandates; and this, if not suitably
directed, wastes itself in the accomplishment of object-
less contractions. And on this view of the subject, it
is possible that the human face, with its thousand
varying expressions, may serve the office of a safety valve
for this mobility, during the time that is required by the
judgment for deciding upon the most appropriate course.
At least, it is worthy of notice, that in the lovrer animals,
whose emotional actions (like those of the countenance
in man), are all instinctive, no play of feature is
observed, their so-called expressions depending entirely
either upon differences in the activity, and hence in the
position, of their organs of special sense, or else upon
their preparations for attack.

The formation of vitiated secretions, furnishes an
important weapon of defence to some animals, as the
polecat and skunk ; but beyond this, the author is not
aware that they answer any useful purpose in the

OF HYSTERIA. 17

economy; and it must be confessed, that effects of this
kind seem more essentially morbid than any others.
Abundant secretion is generally demanded for some
evident object, as in the case of nurses; and the
lachrymal glands, from their especial proneness to in-
creased action during childhood, would seem to afford a
harmless outlet for the same nisus at times when there
is no special organ to receive its force.

Changes in the circulation may be considered as
ministering in great measure to the demands made upon
the glandular structures. In the human species, the
superadded phenomena of blushing and pallor are less
easily to be accounted for, unless indeed the capillaries
of the face may be looked upon as holding an office
analogous to that which has been suggested for its mus-
cles ; namely, as serving to sustain the first operation of
a newly aroused force, until the mind has determined
upon its ultimate direction.

Although three principal channels for the discharge
or expenditure of emotion have been pointed out and
separately discussed, yet it is not intended to convey
that they may not all be employed, either simultaneously
or successively, for the relief of the same feeling.
Indeed, when the more ordinary effects are produced,
such as blushing, lachrymation, gesture, sobbing, &c.,
two or more of them frequently coincide; but when
some less usual outlet has been found, the whole force
is generally concentrated upon the suffering organ.
The first named and most common consequences, even
when not useful in themselves, seem to permit the
accomplishment of a harmless explosion ; the strength
of which is still further diminished by the number of
organs acted upon. But when, in a desperate effort to

18 PATHOLOGY AND TREATMENT

avoid the external manifestations of feelings these outlets
are wilfully closed; the imprisoned power is driven to
seek another openings and probably discovers one in a
part of the system which is usually exempt from emo-
tional influences^ but which^ under such circumstances^
receives their entire shocks and suffers from its conse-
quences in the highest degree.

When two sets of muscles are accustomed constantly
to act in unison^ as those of the face with the dia-
phragm^ their association under the influence of excite-
ment may, perhaps, be caused by their own interde-
pendence. But effects produced simultaneously upon
muscles and glands must be deemed coincident only,
because, however frequently connected, each is some-
times manifested singly. Thus all the facial and dia-
phragmatic movements which usually attend upon
weeping may be performed during sleep, as a conse-
quence of distressing dreams, without any secretion of
tears taking place ; and again, these may be shed with-
out any distortion of the countenance.

There is yet another effect of emotion, often seen in
combination with those already noticed, especially with
muscular movements, and requiring mention here, be-
cause it is very liable to be erroneously interpreted.
It is the influence exerted upon the cerebrum itself,
which, shown by the extreme volubility of persons
labouring under excitement, and by the swift succession
of their thoughts, would suggest to a casiial observer
the notion of absolute increase in the energy of cerebral
action. But this view is a mistaken one, as may be
seen by contrasting the readiness of emotion with the
readiness of wit. The first is confined to a particular
subject, and excludes, by a species of monopoly, all

OF HYSTERIA. 19

considerations and impressions not in accordance with
the dominant idea; while the last involves the rapid
contemplation of many things apparently diverse^ and
the nice perception of analogies between them. The
mental activity of the emotional states is therefore due,
not to a more energetic action of the hemispherical gan-
glia, but to the concentration of their powers upon one
point ; or, in other words, to an act of attention, which
is usually quite independent of the will.

The agencies chiefly concerned in counteracting emo-
tions may be considered under two heads : first, as
checking their development; secondly, as hindering
the production of their effects. And if the emotions
be collectively considered, the only power capable of
accomplishing the former object will be found to reside
in the constant exercise of judgment, or, that is, in the
frame of mind commonly designated '^ philosophical.^'
Taken singly, each one may be kept at rest by some
habitual feeling or belief; as, for instance, shame, by
vanity and self-esteem ; grief for others, by selfishness ;
anxiety, by the doctrines of fatalism. In this way the
stoicism of some Indians and Mahometans is probably
to be accounted for. But these habitual feelings may
almost be looked upon as chronic emotions, already in
possession; and they have no protecting action, save
against their oppositea. Thus vanity would do nothing
towards repressing anger, but would rather increase the
liability to it ; and the same holds good of all analogous
states. Lastly, the operation of judgment in preventing
emotion is quite independent of moral excellence or
depravity, and is witnessed equally, in extreme instances
of each, as in Sir Isaac Newton • and Caesar Borgia.
Hence it follows, that it is impossible to predicate with

20 PATHOLOGY AND TREATMENT

absolute certainty the moral state of those persons who
are especially prone to excited feelings, although the
continued indulgence of these has an effect upon the
mind much more uniform than that of their continued
repression.

The power of judgment against emotion is most
strikingly illustrated by an extended comparison be-
tween the sexes, in whom the general predominance of
reasoning and feeling respectively, is universally ac-
knowledged, although, probably, not to the extent in
which it actually obtains. A recent writer in the
^ Edinburgh Review ' has well described this ^' organic
difference," which he regards as subservient to the
office of maternity 5 and the author would propose the
contrasted proclivity of the male and female to hysteria
as a measure of its degree, believing that the range of
emotional instincts in woman is very large indeed, and
that it includes many actions apparently volitional.

Even when an emotion is fairly established, its effects
upon the musciilar system are under the control of the
will in some degree, and for a certain time ; but as
each of the opposing forces is liable to numerous varia-
tions of strength, so neither the degree nor the time
can be exactly estimated. And if the emotion be not
in its very nature transient, its influence is found to
possess a cumulative character, so that after being kept
down for a longer or shorter period, it often breaks
forth at last with increased violence, and through more
dangerous channels. Such being the case, it is evident
that the will cannot be usefully exerted in a direct at-
tempt to restrain the external manifestations of feeling,
because it is almost certain to be conquered by them
at last^ leaving the system minus the amount of power

OF HYSTERIA. 21

which has been expended in a fruitless effort. But the
will may often aid in preventing graver consequences^
by guiding the motor impulse to some outlet^ through
which it may be harmlessly expended. Locomotion^
or any active bodily exercise may be made available for
this purpose, and under certain circumstances, very
energetic movements will be required for its fulfilment.
It is recorded, that Runjeet Singh, on hearing the
terms of a treaty proposed to him by the British go-
vernment, sprang upon horseback, and galloped furiously
for many miles, before he felt sufficiently master of him-
self to continue the negotiation without expressing his
resentment ; and, although such an instance is excep-
tional, yet it serves to illustrate a principle of very exten-
sive application, and of great importance in a remedial
point of view. The effort of will does not require to be
continuous, because when the desired action is once esta-
blished, it will go on (unless voluntarily interrupted)
until the emotion has exhausted its force.

The relative intensity of different kinds of feeling,
and the amount of influence which they severally exert,
will be foimd to depend in some measure upon peculia-
rities of individual temperament ; partly upon the tran-
sient or permanent character of the causes which have
excited them; and chiefly upon those circumstances,
differing for every individual, which may either permit
the expression, or require the concealment, of each.
And, therefore, it is reasonable to expect that an emo-
tion, which is strongly felt by great numbers of people,
but whose natural manifestations are constantly re-
pressed in compliance with the usages of society, will be
the one whose morbid effects are most frequently wit-
nessed. This anticipation is abundantly borne out by

22 PATHOLOGY AND TREATMENT

facts; the sexual passion in women being that which
most accurately fulfils the prescribed conditions^ and
whose injurious influence upon the organism is most
common and familiar. Next after it in power^ may be
placed those emotions of a permanent character^ which
are usually concealed^ because disgraceful or unamiable^
as hatred or envy; after them others equally perma-
nent, such as grief or care, but which, not being dis-
creditable, are not so liable to be repressed ; and, lastly,
a large class depending upon transient and temporary
causes, or else deemed laudable and proper. Of these,
the first division may be represented by anger, and the
second by joy, pride, pity, and affection.

It has been seen that in the lower animals, the effects
produced by emotional excitement are immediately
made subservient to some useful purpose, having re-
ference either to the reproduction of the species, or to
the preservation or sustentation of the individual ; and it
is probable that in them, each kind of feeling is invariably
followed by its special and proper consequences. But
in man such is far from being the case, and even when
no effort is made to check the natural action, this is
often diverted into other channels by unforeseen or
accidental circumstances; so that, in considering the
causes which determine each effect, it is necessary to
add two secondary ones to that which is primary and
normal, namely, the nature of the emotion itself. They
are, attention, by which the force is directed upon
some part of the organism; and morbid excitability,
by which some part is rendered especially prone to re-
ceive it.

Effects determined by the nature of emotion do not
vary with the nice gradations and delicate shades of

OF HYSTERIA. 23

feeling which, as the oflfspring of modern civilization,
have gained distinguishing names in modem language;
but they express with tolerable distinctness the diflfer-
ence between exciting and depressing passions, or
between the three conditions of mind which may be
typified by joy, anger, and fear. The first is chiefly
expended upon the organs of respiration, circulation,
and digestion, stimulating all of them to more energetic
action; the second upon the facial and locomotive
muscles; and the last upon the secreting apparatus.
But human emotions are so frequently complex, that
two or more directing forces may often oppose each
other ; leaving the result to be determined by some new
element, such as those which have been mentioned
above, and now claim to be considered somewhat more
in detail.

When any portion of the organism is the subject of
continued and close attention, it is not only very prone
to gradual changes of nutrition, but it is also rendered
liable to be the outlet for any strong emotion which is
experienced at the same time. This is well exemplified
by the uterus. A woman in the educated classes of
society, who becomes pregnant and miscarries, is fre-
quently informed that she will probably miscarry again;
and, during her next pregnancy, this probability cer-
tainly occupies her thoughts, and, perhaps, preys upon
her mind. Under the first and best supposition, the
uterus is prepared to yield to the effects of any acci-
dental emotion; and, under the second, the anxiety
itself, by its continued operation, is fully adequate to
the production of the much dreaded evil. But among
the rural peasantry, who often think an abortion a
piece of good luck, and whose attention is exercised

24 PATHOLOGY AND TREATMENT

upon other subjects^ (if exercised at all)^ the case is
widely different. These women frequently miscarry,
being necessarily much exposed to the physical causes,
but they seldom do so on two or more successive occa-
sions. Nothing is more common than for the same
woman to abort several times, but she will give birth
to living children between her miscarriages ; while, in
the higher ranks, the occurrence of such a misfortune
in one pregnancy, is justly thought to indicate the ex-
treme probability of its repetition, and to call for the
most stringent precautions during the whole period of a
subsequent gestation.

A very remarkable example of the power of attention
to direct the emotional influence, has lately been related
to the author by a medical friend, under whose obser-
vation it fell, and whose exactitude and veracity may be
implicitly relied upon. A lady, who was watching her
little child at play, saw a heavy window- sash fall upon its
hand, cutting off three of the fingers, and she was so
much overcome by fright and distress, as to be unable
to render it any assistance. A surgeon was speedily
obtained, who, having dressed the wounds, turned him-
self to the mother, whom he found seated, moaning,
and complaining of pain in her hand. On examination,
three fingers, corresponding to those injured in the
child, were discovered to be swollen and inflamed,
although they had ailed nothing prior to the accident.
In four and twenty hours incisions were made into
them, and pus was evacuated, sloughs were afterwards
discharged, and the wounds ultimately healed. Now,
there can be no doubt that, in this case, the mother's
emotion was directed, by observation of the parts in-
jured, upon the corresponding parts of her own system.

OF HYSTERIA. 25

there working a change in the circulation or nutrition^
ffufScient to excite acute inflammatory action.

Morbid excitability of some part of the organism^ is
very evident in the incipient stages of chorea, when
any emotion will serve to develop the disorder; and
also in all those cases of gesture which have been
already noticed. Debility, or recent disease of any
organ, or important functional changes in it, are suflS-
cient to produce this condition. Thus, in anaemia, the
heart would palpitate as a consequence of mental changes
more readily than in health. Again, the emotions
very frequently occasion relapse after illness, especially
when this has involved secreting or muscular organs ;
and violent anger after delivery, is among the most com-
mon causes of puerperal peritonitis.^ Morbid excitability
may also aflfect the whole system, increasing the general
proclivity to emotional influences, rather than the
susceptibility of individual parts. In either form, it is
increased and maintained by everything which affects
the health injuriously, and especially by circumstances
and habits which diminish richness of blood and tonicity
of fibre.

The subject-matter of the foregoing pages may be
briefly expressed in the following propositions :

1. That emotion is a force adequate to the pro-
duction 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 debili-

• Dr. Ramsbotham's Reports of the Royal Maternity Charity; Med.
Gaz., Sept. and Oct., 1851.

2

26 PATHOLOGY AND TREATMENT

tating 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 fre-
quently 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 pro-
minent 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-Chirur-
gical Review,* 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

^ No. XVI, p. 416 ct seq.

OF HYSTERIA. 27

of certain portions, and corresponding torpor of the
rest.

Having thus brought together the chief facts con-
cerning the emotional states, as witnessed in healthy
persons, the next chapter will be devoted to the hysteric
paroxysm.

CHAPTER II.

THE HYSTERIC PAROXYSM.

The description contained in the foregoing chapter,
of the more ordinary phenomena resulting from emo-
tional excitement, has been chiefly intended to illustrate
the kind of eflfect which it produces upon the system
or in other words, to express the nature, without ex-
hausting 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 com-
bination. 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 /eeJ-
ingSy 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 en-

^

TREATMENT OF HYSTERIA. 29

deavouring 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 postu-
lated 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 sud-
denly 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 famOy 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 irre-

30 PATHOLOGY ANB TREATAIENT

giilar 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 do-
mestic 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 recoiu'se 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, Avhich lasted nearly an hour, and yielded in
its turn to sleep. The patient was left sleeping shortly
lifter 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 preg-
nancy. 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

OF HYSTERIA. \M

The first inference deducible from these two eases 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 sub-
sequent 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 board-
ing-schools, and may be set on foot by so many causes,
that it is needless either to cite examples or to illus-

freedom from " nervousness'* may be formed from the circumstance that,
when the crotchet was fixed in the foetal 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 !''

32 PATHOLOGY AND TREATMENT

trate 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 con-
tinued peril, offer for the most part a method by which
escape can be effected; and, under such, emotion ex-
pends itself either in facilitating volitional, or in di-
recting instinctive action. In the male sex, the ac-
complishment of this object generally exhausts its
power ; but in the female, a hysterical attack is some-
times seen after escape from very perilous situations,
and especially after the exhibition of considerable (so-
called) 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 out-
ward 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 pe-
culiar to women. Indeed, among the ancients, it is
very likely to have been so; but the advances of modem
civilisation and refinement have nurtured and increased

OF HYSTERIA. 33

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 natu-
ral conformation which causes the former to feel, under
circumstances where the latter thinks ; and partly be-
cause 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

2§

34 PATHOLOGY AND TREATMENT

failure of emotion, when excited, in producing its legiti-
mate eflPects; 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 in-
quiry, we are met by the ancient maxim, " Salacitas
major, major ad hysteriam proclivitas," and are com-
pelled by it to investigate the power of the sexual
passion, as compared with that of feelings more gene-
rally acknowledged.

If the aphorism above quoted may be supposed to
have been substantially correct at the time of its enun-
ciation, 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 modem 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 periyiitted its free ex-
pression. It may, therefore, be infeiTed, as a matter
of reasoning, that the sexual emotions are those most
concerned in the production of the disease, as it is seen

OF HYSTERIA. 3i>

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-emi-
nence.

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 numeri-
cal proportion which exists between the diflPerent states.
Hence many endeavours have been made to discover
a comimon action exerted by them all, and (without re-
gard to the cases in which none of them are apparent,)
the phenomena have been accounted for by the em-
ployment of a word which is useful to express igno-
rance rather than knowledge ; that is, they have been
referred to irritation of the uteinis and ovaria. But it
is hardly necessary to say, that the existence of many
well-authenticated instances of masculine hysteria ren-
ders this explanation utterly untenable, while, at the
same time, the emotional doctrine aflPords 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 theioretical conclusion arrived at in a
foregoing paragraph, namely, that the sexual passion is

36 PATHOLOGT AND TREATMENT

more concerDod than any other single emotion^ and^
perhaps^ as much as all others put together^ in the pro-
duction 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 conse-
quence of medical treatment. Faulty menstruation,
whether local or constitutional, will have a similar
effect j 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, cceteris 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 in-
stanced 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, conva-
lescence from acute illness, or the cachexia resulting
from neglect of sanitary regulations, may all be re-
garded as increasing the procUvity to hysteria, whatever
be the kind of feeling immediately concerned in its
production.

OP HYSTERIA. 37

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 disr
orders, the emotion is rendered permanent and engross-
ing, 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 oflFer
no resistance to its efiects, 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 indi-
viduals. 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 in-
fluences, 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

38 PATHOLOGY AND TREATMENT

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 in-
fluence 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 aflPorded 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 pa-
roxysm; and in the other, a gush of tears is the
precursor of its termination, — the difference in point
of time depending upon the oflSce 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 HYSTERIA. 39

of its exciting cause,) generally leaves her, to all ap-
pearance, in the same condition as before. But this
appearance is fallacious, — a very important change
having been wrought in her system, by which her sus-
ceptibility 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 in-
adequate 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

40 PATHOLOGY AND TREATMENT

herself. But this lady, by carefully avoiding all causes
of emotion, and by directing its influence, when be-
ginning 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 under-
stand, 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 inva-
riable 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 a£Pected 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 com-
munity 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

OF HYSTERIA. 41

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 ex-
pect 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 symp-
toms. Moreover, it will rarely happen that several
women are together, of whom none have had their
liability to primary hysteria increased by former pa-
roxysms ; 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 dif-
ferences of their resisting power. And lastly, it is
possible that the attacks may not be primary, but of a
totally different kind, which wiU 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 Uke
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 ex-'
citing 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

42 PATHOLOGY AND TREATMENT

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 eniotion is
thus recalled in so distinct a manner, that she is very
likely again to be subjected to its eflfects. 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 re-
called in the one case, or to obtrude itself unasked in
the other, that its return in a degree suflBcient to
estabUsh 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

OF HYSTERIA. 43

upon it, are frequently found to possess irresistible
attractiveness. Besides all this, there is the grati-
fication 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 emo-
tion, 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 re-
membrance of the emotions to which the primary fit
has been due ; and to call those tertiary, that are de-
signedly excited by the patient herself through the in-
strumentality 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 afibrded 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 pro-
duction 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, invo-
luntary 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

44 PATHOLOGY AND TREATMENT

almost tetanoid susceptibility is the result ; and partly
that^ connected as these causes generally are^ with dis-
appointed sexual desire^ the catamenial period acts^
probably through the medium of sensations, as a con-
stantly 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 nerrous 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, be-
cause 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 symp-
tom present; A lady has lately been under my care,
in whom a primary paroxysm resulted from circum-
stances which brought domestic distress of long con-
tinuance to a climax, and in whom the sexual passion

\

OF HYSTERIA. 45

was much involved. Two hours after the fit she lapsed
into a state of incoherence, one idea only having pos-
session 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 menstru-
ation, unless in the very rare cases where the first ex-
citing cause was quite independent of amatory disap-
pointments or desires.

The efltects 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

46 PATHOLOGY AND TREATMENT

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 eflfbrt of the will, presents many remarkable
characteristics. In some persons of great original sus-
ceptibility, 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 circum-
stances which would expose the patient to serious dis-
comfort or real danger, but at a time and place dis-
creetly 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 ab-
sence of mental disturbance ; and, in many cases, by

OF HYSTERIA. 47

the presence of some of those symptoms hereafter to be
discussed as complications^ all of which are quite pecu-
liar 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 consider-
ably 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 suffioient
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 sur-
render, and might be prevented under the pressure. of
an adequate motive. This fact was remarkably illus-
trated 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 pro-
duced 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, never-
theless, the same scene was acted over again a day or
two afterwards, with the diflference, that two or three
women were attacked, and this number increased con-
siderably on subsequent occasions. The aflfair 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

48 PATHOLOGY AND TREATMENT

in execution on a day when seven of them were at-
tacked 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 em-
ployed, 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 efiect
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 ana-
logous 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 experi-
mentally, and from time to time, in every individual case.

OF HYSTERIA. 49

Finally, every variety of paroxysm, when fairly es-
tablished, 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
stem 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 com-
prehension of which must be the basis of all successful
treatment, will furnish the subject-matter of the fol-
lowing chapter.

CHAPTER III.

THE MORAL STATE AND MOTIVES.

The motives by wliicli 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 famished 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 con-
dition ; 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 in-
fluence 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 con-
nected with sexual excitement, leaves behind it, when
otherwise recovered from, any abiding increase of erotic

TREATMENT OF HYSTERIA. 51

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
eases there is little room even for this amount of dis-
turbance, 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 ab-
sence of temptation. In the first place it may be re-
marked 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 conse-
quences 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 examina-

52 PATHOLOGY AND TREATMENT

tion 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 con-
sequence 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 grati-
fication 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 advan-
tageously divided into two classes, which fade imper-
ceptibly into each other, and yet present a sufficiently
marked diflference 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 in-
justice. And where this training is withheld by the

OF HYSTERIA* 63

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 tlie
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 fol^th
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 ex-
pense of any pain or inconvenience ; and in this form
it may be regarded as the chief source of tertiary hys-
teria, and of all its manifold complications.

It must not be supposed that this craving for sym-
pathy 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

54) PATHOLOGY AND TREATMENT

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 dram-
drinking over the bodv, 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 tempo-
rary 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 occur-
rence 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 some-
what on the wane j 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

OF HYSTERIA. 65

thought unsafe that the subject of them should be left^
lest worse fortune should attend her on the next occa-
sion. 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 at-
tention of relatives will again begin to flag, and the vigi-
lance 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 suffer-
ings of the invalid are limited to her knee joint or her
spine, as the seat of substantive disease, and to innume-
rable 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

^6 PATHOLOGY AND TREATMENT

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 de-
scribed, 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 prac-
tices cannot be continued long, in either case, without
leaving behind them, even when abandoned, some evi-
dences of their former supremacy, in a permanent
lowering of the moral tone, and in a diminished sensi-
bility 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 origi-
nated by the disappointment of sexual desires (as dis-
tinguished 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

OF HYSTERIA. 57

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 them-
selves, 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 introspec«»
tivehess is quite as constant as the duplicity, and is
quite as essential to the existence of voluntary hys-r
teria,* 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 en-
grossed 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 be-
come wearisome, when brought into competition with

3§

58 PATHOLOGY AND TREATMENT

the all-absorbing topic of health; and that, conse-
quently, 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 be-
lieve them. Small, or very enthusiastic religious com-
munities, are the most usual victims of this kind of
imposture, which is constantly practised upon the be-
nevolent 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 be-
yond the simulation of ordinary ailments, to do some-
thing 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 de-
votion must be added to that of miraculous disease.

OF HYSTERIA. 59

But tliis 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 de-
pravity, 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 abso-
lutely 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 au-
thority 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 im-
possible for the moral state to remain stationary; and
that discipline which is sufficient to prevent retro-
gression, 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 IV.

COMPLICATIONS.

The word complication^ as applied to hysteria^ has
been already stated to denote an ailment or symptom
arising during the progress of the disease^ and de*
pendent npon^ though not in any way essential to it ;
and those affections of the hip^ knee^ or spine^ to which
the term hysterical is commonly prefixed^ have been
cited as examples in point.

It has been also said^ that the conditions described
as primary and secondary hysteria^ are not liable to
complications ; because in them the emotional influence
is too powerfully and too generally exerted to leave
room for the existence of distinctly local affections;
and although it is occasionally limited for a time to
individual organs^ yet even then their disorder is
evidently an essential part of the systemic disturbance.

But in the intervals which separate the different
tertiary or voluntary paroxysms from each other, the
body is sufficiently free from morbid action to allow of
this being set up by various external agencies ; and in
the increasing desire for the sympathy of friends, there
is a reason why any addition to her apparent sufferings
is particularly grateful to the patient, and why any
sensations likely to afford this indulgence should be
carefully fostered and encouraged.

In this manner are frequently originated some
curiously mixed conditions, in which a nucleus of real

TREATMENT OF HYSTERIA. 61

disease becomes the foundation of a very dispropor-
tionate superstructure; and at a still later stage of
hysteria, there are many apparently formidable dis-
orders in which such a nucleus does not exist, but
which are entirely accomplished by malingering.

The complications of hysteria may, therefore, be
divided into the real and the simulative, the former of
these two classes being made up, — firstly, by various
actions of the kind which Dr. Carpenter has described
as ideo-motor ; and secondly, by local congestions.

The ideo-motor complications consist of certain
muscular movements, produced in the same manner as
the tertiary paroxysm, by dwelling upon ideas to
which the same acts have formerly responded, — the
idea being also guided in its operation by close volun-
tary attention to the parts which it is intended to
influence. They often originate in the fact that
some part of the body possesses greater sensibility
to emotion than others, either from original con-
struction, or from being more frequently subjected to
its operation; and that this therefore is the first to exhibit
its effects, and the last to cease from doing so. Under
such circumstances, it is easy to conceive that the part
would be influenced by an amount of recollection in-
sufficient to produce an universal paroxysm ; and the
patient would soon discover, that a little purely local
convulsion obtained for her more attention, and excited
more wonder, than a " fit '^ of any duration or severity.
The writer has been made acquainted with a case, in
which very rapid rotation of the thigh was performed
in this way, after a long course of tertiary convulsions.
The head of the femur was each time partially dislo-
<;ated from the acetabulum, being brought back again

62 PATHOLOGT AND TREATMENT

with a siCap ; and this sound was often counted sixty
times in a minute^ the movement being continued with
the same rapidity for many hours in succession. Opis-
thotonos may be similarly induced, although it is more
common in secondary cases ; and an immense number
of like examples might easily be collected from medical
works and periodicals.

Vomiting is^ perhaps^ the most important of all
these ideo-motor acts^ because it frequently^ in its
tum^ exerts an injurious influence on the system. It
is accomplished by the recollection of some disgusting
object, which may either be remembered from ex-
perience of its effects, or imagined in anticipation of
them ; the selection, in the first case, depending entirely
upon accidental circumstances in the former life of the
patient; in the latter, upon her - inventiveness, — a
faculty which was once exercised in the conception of
a "putrid cat pudding.^' Whatever is selected will
answer its purpose with a speed proportioned to the
susceptibility of the individual ; and although several
periods of meditation may be required to produce the
first attack of sickness, each one will facilitate future
proceedings, until at last the image is no sooner pre-
sented to the mind, than its contents are ejected by
the stomach. The habit is most frequently practised
after a meal, and it is attended with some danger of
becoming permanent, and independent of the will ; so
that food shall not long be retained, even when no effort
has been made for its expulsion.

Violent fits of noisy coughing may be classed with
the other local affections of the muscular system, and
admit of being produced in the same manner. They
are referred by Dr. Laycock to irritation of the pulmo-

OF HYSTERIA. 63

nary mucous membrane, — a cause scarcely likely to be
removed by that which he immediately afterwards
describes as "moral treatment/^ to wit, the threat of
the actual cautery. There is no doubt, that coughs
depending upon such irritation are under the control
of the will to a certain extent, especially when its
energy is increased by a powerful motive ; but it needs
only the experience of one attack of bronchitis, to
prove that this control can do nothing more than delay
their performance. On the other hand, coughing can
be accomplished by most persons, as a purely volitional
act, without the existence of any irritation whatever;
and the effect of remembered emotions would seem to
be exerted in rendering this act paroxysmal and violent,
and in preventing the fatigue which would be con-
sequent upon severe voluntary effort.

It is highly probable that hysterical distortions are
usually dependent upon ideo-motor action of the mus-
cles concerned in producing them, because the amount
of force which they will resist is greater than the patient
could contend against in ordinary circumstances, and
because the time necessary for fixing a limb by inaction,
after the manner of the Hindoo Faqueers, is seldom
allowed to elapse before treatment is had recourse to.

All the ideo-motor acts differ from those dictated by
the will, in the rapidity and force with which they can
be performed, and in the length of time for which they
can be continued — characters resembling tho^e of the
spinal reflex movements. They differ from consensual
actions, according to Dr. Carpenter, in requiring, not
merely the reception of a sensation, but the formation
of an idea, the cerebrum, and not the sensorium, being
their centre of reflexion. Thus, whilst yawning may

64 PATHOLOGY AND TREATMENT

be consensually excited by the sight or sound of the
act in another^ it may also be excited (at least in
persons already predisposed to it by fatigue) by the
very mention of the subject. The emotional actions
are regarded by Dr. Carpenter as bearing the closest
relation to the ideo-motor ; but as distinguished from
them by the association of sensorial pleasure or pain
with the fundamental idea^ and he thinks it one of the
most characteristic peculiarities of the hysterical state^
that pleasure is morbidly associated with many ideas
which ordinarily excite pain. Thus the hysterical girl,
though originally amiable and disinterested^ derives a
strange satisfaction from the sight of the anxiety, and
even the distress, of her friends ; and, though previously
truthful, enjoys the idea of deceiving them.^

The greater energy and longer duration of all auto-
matic acts, as compared with voluntary ones, may be
used to distinguish between complications of the former
kind, and those bearing some resemblance to them,
which are purely simulative. Moreover, the latter are
perfectly under command, both with regard to termi-
nation and commencement, but the former, in many
cases, with regard to commencement only, because it
would seem that every emotion generates a certain
amount of force, and continues its operation until this
amount is exhausted. This diagnosis is of some im-
portance j for, although the object and intention of the

• Dr. Carpenter's views on these subjects were first developed in the
* British and Foreign Medical Review,' vol. 22, p. 488 ; but they will be
found fully expressed in his * Human Physiology,' 4th edition, chap. xiv.
The term ideo-motor, as expressive of the reflex action of the cerebrum,
when uncontrolled by the will, was first employed by him in a lecture at
the Royal Institution, in May, 1852.

OF HYSTERIA. 65

patient is the same in either case^ and is only carried
into eflfect by diflferent agencies, yet it will be seen
hereafter, that exact knowledge of the methods pursued
very much facilitates the conduct of treatment, and adds
materially to the prospects of success.

The congestive complications of tertiary hysteria may
be referred for the most part to that effect of attention
which has been before alluded to, as working permanent
changes in the circulation of organs brought under its
influence, and their occurrence is farther due to the
insalubrious and debilitating practices implied in the
existence of the disease itself; which, by weakening
the tone of the heart, and of the system generally, and
by impoverishing the blood, tend to the production of
local congestions of a passive or asthenic character.
These often arise as the result of sedentary habits, even
when there is no apparent circumstance to determine
blood to any one part of the system in preference to
others ; and the liability to them is of course greatly
increased, when such circumstances are in active and
continual operation.

The methods by which attention can be fixed upon
any individual organ are threefold j and depend, in the
first place, upon its known subserviency to the kind of
emotion which has been excited ; in the second, upon
sensations arising within itself; and in the third, upon
the operation of external agencies, as from witnessing or
hearing of the diseases and sufi^erings of others. The
first kind of action can scarcely be exerted except upon
the reproductive system, but the other two are not
subject to any limitations.

The hysterical afiections of the uterus and ovaria
have always held a most prominent position among the

66 PATHOLOGY AND TREATMENT

disorders under consideration^ and from their frequency
and variety have been, in all ages, looked upon as having
some share in the causation of the associated conditions,
an opinion which is certainly so far correct, that all the
phenomena of secondary hysteria are frequently aggra-
vated at each menstrual period. But reasons have been
given in a former chapter, for believing that sensations
connected with the catamenia act simply by the recall
of emotions ; and in every instance of this kind which
the writer has been able to observe or hear of, menstru-
ation has been a painful process, and therefore especially
likely to exert such an influence. In one, the particu-
lars of which were kindly furnished by Dr. Carpenter,
and in which the periodical increase of severity was
strongly marked, a very considerable degree of dysme-
norrhoea existed independently of the hysteria, and was
cured after its cessation, by gradual dilatation of the
OS uteris the latter disease having first yielded to emo-
tions counteracting those by which it was produced.

The female reproductive organs having a cause
peculiar to themselves to make them the subjects of
attention, and being equally exposed with all the rest
of the body to the influence of sensations and of sug-
gestions from without — suffer from determination of
blood more frequently and more severely than any
other parts. The power of the last-mentioned cause
has been greatly extended and increased by the re-
searches of gentlemen engaged in the treatment of
uterine disease, and by the consequent discovery that
a very large number of our countrywomen are invalided
by some of its numerous forms. It is scarcely possible
at present for an hysterical girl to have no acquaintances
among the many women who are subjected to the

i

OF HYSTjERlA. 67

speculum and caustic, and who love to discuss their
symptoms and to narrate the sensations which attend
upon the treatment. These patients would probably
give the impression that a little leucorrhoea^ a backache,
and a few blushing affirmatives to leading questions^
would be deemed sufficient to justify an examination ;
and that this might be expected to reveal abundant
grounds for farther treatment. In many cases ladies
are quite ignorant of the nature of the remedies ad-
ministered to them ; and even if they heard the name of
Indian hemp, would scarcely know the purposes for
which it has long been used by the Hindoos ; but still
they may possibly find out by observation that the
speculum becomes more grateful to their feelings the
oftener it is applied, and that the wish for it is in some
degree excited by each successive dose of the medicine ;
an induction which, when arrived at, they are very
likely t6 communicate to their friends. So much has
been written on this subject by abler men, that some
apology is demanded for alluding to it here ; but this
may be furnished by the plea that the indiscriminate
employment of the speculum is both a disgrace to the
medical profession, and a misfortune to the female sex,
in a nation where chastity and modesty have been
esteemed and practised as amongst us. Not long since
I travelled in a railway carriage with a stranger, who
presently entered into conversation, and said (without
knowing the profession of his fellow-passengers) that he
had applied caustic to the wombs of twelve women on
that morning, making the statement with an air of
great exultation, and proceeding to describe himself as
a country general practitioner, and a resident in South
Wales. Soon afterwards, wishing to test the efficacy

68 PATHOLOGY AND TREATMENT

of the treatment^ I requested a friend, who was medical
officer to a large metropolitan parish district^ to allow
me the charge of twenty cases, for which he deemed
the caustic suitable. The women were all poor, un-
healthy, and badly nourished — and in all the uterus
was congested, with a voluminous cervix, and patulous
orifice. The majority of them had ^ome degree of
prolapsus — all had leucorrhoea, and nearly all the con-
dition described as exulceration. From their condition
in life, constitutional treatment was attempted under
very disadvantageous circumstances, and it was impos-
sible to obtain the recumbent position ; but scarification
and cauterisation of the cervix uteri were diligently had
recourse to, and injections of various kinds were also
employed. Six months of this treatment left nineteen
of the women in exactly the same state as when it was
commenced^ but in the remaining case the patient went
to Hastings during the latter half of the time — was
separated from her husband, had abundance of good food
and plenty of rest, and came home perfectly well, having
used no local remedy but the daily injection of cold water.
Every one of the patients promised to abstain from
sexual intercourse ; but, of course, this promise was not
kept ; and there was a certain appearance of the ex-
ulceration, which always seemed to indicate the recent
contact of seminal fluid.

If these twenty cases may be considered as throwing
any light upon the true value of local treatment in
congestive afi^ections of the uterus, it surely behoves
every practitioner to be most chary of its employment^
and to leave no other means untried before recom-
mending its adoption ; even if only on the ground that
it is liable to abuse by designing and dishonest men ;

OF HYSTERIA. 69

or by lascivious patients, to whose passions it is scarcely
the proper office of our art to minister. If regarded as
a dernier ressort, even for married women, the speculum
would lose none of its utility, and would be infinitely
less liable to abuse ; and there is much reason to think
that many uterine diseases of the virgin, have a decided
tendency towards spontaneous cure. Those occurring
as complications of hysteria may certainly be removed
in a very simple manner, which will be ftdly described
hereafter ; and no one who has once realized the amount
of moral evil wrought in girls thus suffering, whose
prurient desires have been increased by Indian hemp,
and partially gratified by medical manipulation, can
possibly deny that the remedy, even if effectual, is
infinitely worse than the disease. I have, more than
once, seen young unmarried women, of the middle-
classes of society, reduced, by the constant use of
the speculum, to the mental and moral condition of
prostitutes; seeking to give themselves the same
indulgence by the practice of solitary vice ; and asking
every medical practitioner, under whose care they fell,
to institute an examination of the sexual organs. An
eminent obstetrician of the present day, has said that
there can be no more objection to the use of instruments
for examining the uterus than to the use of a spoon
for looking into the throat ; but this gentleman, unless
the depth of his devotion to science has left him little
leisure for the study of human nature, must have
intended to limit the application of his remark to the
pathological conditions of the organs themselves ; the
negation of a moral difference being an absurdity too
palpable to impose on any person not totally devoid
both of sense and decency ; and being contradicted at

70 PATHOLOGY AND TREATMENT

once by the diflferent manner in which the necessity
for the two proceedings would be stated to the
patient.

The uterine complications of hysteria consist chiefly
of symptoms which plainly indicate congestion of the
suffering organ^ such as sensations of weight and drag-
ging ; lumbar and inguinal pains ; leucorrhoea and
neuralgia; combined with various disorders of men-
struation. They are usually associated with a very
peculiar moral state, arising from the habit of contem-
plating and discussing the sexual organs, and by this,
almost without any previous history of the case, their
true character may be often recognised. The patients
have a tendency to relate their sensations in filthy and
wearisome detail; often volunteering the information
that they have undergone manipulation and the specu-
lum at the hands of various doctors; and evidently
loving to be questioned on matters that would make
modest women blush. Such persons, a few years ago,
were almost limited to the class whose hysteria depended
directly upon the frustration of desire ; but the recent
increase of uterine disease, has produced many of them,
among the tertiary cases resulting from general dis-
content.

The reality of the symptoms complained of may
often be a matter of doubt ; but the question can be
cleared up by the careful observation of a trustworthy
nurse. If there be leucorrhoea, or disordered men-
struation, it is fair to infer that some of the sensations
described are actually experienced, although perhaps
not in the degree stated by the patient, whose cue
it will be to exaggerate existing conditions before
proceeding to draw upon her imagination for others.

OF HYSTERIA. 71

It should be remembered that all the hypersemic con-
ditions are of common occurrence, and that to infer
deception where it is not practised, would be to give
the supposed malingerer a very low estimate of the
discernment brought to bear upon her case.

The congestive aflfections of the liver, and of the
radicles of the vena portse, hold a prominent place
among those produced by suggestion from without,
although, probably, less common now than they were
in the palmy days of blue pill, when the first-named
organ was considered to be the seat of all diseases.
Hypochondriac pain, constipation, jaundice, haemor-
rhoids, are among the ailments which may be referred
to their operation, together with others which it is not
needful to particularise.

The eflfect of sensations arising within the body, in
fixing attention upon their seat, and thus increasing
them through the agency of vascular changes, is well
illustrated by the neuralgi^, most of which are in-
debted to this action for their continuance, and many
for their commencement, when the original sensation
has not been morbid in character or intensity. The
constancy with which neuralgia produces congestion of
the surrounding structures need scarcely be mentioned;
and as this result does not appear to be in any respect
a remedial efl^ort of nature, but, on the contrary, one
calculated to prolong and increase suflFering, it may
fairly be regarded as an accident of the disorder,
caused by that attention which cannot be withheld
from a painful part, and which numbers hypersemia
among its most familiar consequences.

An attempt to enumerate all the conditions which
may be met with in hysterical women as a consequence

73 PATHOLOGY AND TREATMENT

of local congestions^ would swell these pages much
beyond their intended limit, and would answer no useful
purpose on account of the essential versatility of the
disease in which these conditions are included. By
their multitude andviriety, and by the different phases
of that which is essentially the same symptom^ every
definition is eluded and every effort at description
baffled ; while their generic resemblance at once makes
that character manifest to the eye, which it is scarcely
possible to express in words. In estimating the causes
mentioned as commonly producing congestion, and the
consequences said to follow from it, the reader is re-
quested to bear in mind that these causes act, and these
consequences are produced, upon persons debilitated
by the habits, if not by the reality, of illness; and who,
by constant surrender, have greatly increased their ori-
ginal susceptibility to all emotional influences, whether
exerted upon some single organ, or having a more ex-
tended and general operation.

The compUcations of tertiary hysteria which are not
to be included in either of the above-mentioned classes,
but which owe their existence entirely to the ingenuity
and deceptivity of the patient, furnish an interesting
and somewhat complicated subject for research, although
a full notice of them would probably be more amusing
than beneficial. They are usually suggested by some
illness which has formerly been suffered or witnessed,
or to which there is an admitted hereditary tendency;
and they are apt to occur or to increase suddenly, under
circumstances calculated to heighten the alarm neces-
sarily connected with their appearance. Some of them
are mere tricks ; others must be described as disorders
artificially produced; but all are intended to answer the

OF HYSTERIA. 73

same purpose^ and to excite sympathy by an appearance
of dangerous or uncommon disease.

Haemoptysis and lisematemesis are perhaps the most
common purely simulative complications. The former
may be imitated by applying leeches to the inside of
the mouthy the latter by swallowing and vomiting the
blood of animals; while the preparations of digitalis
and antimony have been had recourse to, in order to
counterfeit the constitutional effects of loss of blood.

Swelling of a joint is occasionally excited by artificial
means^ of which the application of a tight ligature is
the most common. The swelling, when produced, may
be maintained for a time, or even rendered permanent,
by the effect of attention in determining blood to the
part.

Suppression and retention of urine are very common
hysterical phenomena ; the secretion being drank, or
otherwise concealed, in the former case, and the action
of the detrusor muscle being wilfully resisted in the
latter. The size and dilatabiUty of the female bladder,
allow this retention to be practised for a considerable
time ; but it is well known to yield to the determined
withholding of the catheter, and may often be over-
come by a basin of ice cold water unexpectedly dashed
upon the pubes^ as the patient is rising from a warm
bath. Foreign substances^ such as oil, blood, charcoal
powder, and various colouring matters, are sometimes
added to the urine after it is voided, although such
admixtures could scarcely impose on any but unprofes-
sional persons.

Constipation is frequently caused by voluntary effort,
which postpones for a time the demand for relief.
When associated with feigned abstinence^ such evacua-

4

74 PATHOLOGY AND TREATMENT

tions as do take place are usually concealed ; but im-
postures of this kind cannot be carried on without the
collusion of other persons, and are immediately detected
when this is eflfectually guarded against. In any en-
deavour to expose them, due regard should be had to
the capacity of the rectum ; to the time during which
complete abstinence may be borne with the aid of
practice, and to the very small quantity of food which
will support life, in an individual who is kept warm, and
not called upon for exertion.

Uterine disorders are occasionally selected by the
hysterical malingerer, although they arise most fre-
quently in the manner already adverted to. Local
irritants have been introduced into the vagina in order
to procure discharges, and the menstrual fluid has been
mixed with various substances, calculated either to in-
crease its apparent quantity, or to change its healthy
character.

Diseases of the skin are sometimes simulated, and
ulcers are produced by the appUcation of corrosive sub-
stances, which may then often be detected by chemical
examination of the discharges. A lens will generally
discover particles of cantharides on the small bullse to
which hysterical women are liable ; and in these cases,
as in most others, there is no difficulty in justifying
suspicion, when once it is aroused ; but unfortunately,
it is frequently sufl^ered to sleep too long.

Pain, of every possible description, will be com-
plained of as a complication of hysteria. It is often
feigned, often real, — and when real, always exaggerated;
but no certain rule can be laid down for discriminating
between the conditions, except that of close observation,
which must be practised against every species of hys-

OF HYSTERIA. 75

terical ailment, and which seldom fails to determine its
exact character.

The diagnosis between the ideo-motor, the congestive,
and the simulative complications, will not be a matter
of great diflBculty, if it be borne in mind that the first
are limited to the muscular system, and that they in-
clude vomiting and paroxysmal cough, in addition to
the aflfections which have been denominated "partial
chorea/^ It is probable that they are sometimes
simulated; but everything which it is plainly beyond
the voluntary power of the patient to accomplish, may
be described and treated as ideo-motor.

The remaining disorders are found to fade imper-
ceptibly into each other; many which were feigned
at first, becoming real under the influence of attention ;
and many realities being so much exaggerated, as to
lose their original verisimilitude beneath a number of
superincumbent sensations. But a distinctive character
may be assigned to each one at some period of its ex-
istence — and in order to ascertain this it is necessary
to watch the patient very closely — and especially with
reference to all the means by which the disease she
professes to suffer under could be imitated ; to observe
narrowly the habitual state of the pulse, and its changes
under the influence of pain or medicines ; to examine
all secretions that can throw any light upon the ques*
tion; and to obtain frequent and minute descriptions
of the symptoms, noticing all the discrepancies or
novelties as they arise. It is especially necessary never
to put a leading question, unless it be. a misleading
one ; and these should be sparingly employed, for fear
of exciting suspicion. It will be found an useful pre-
caution to inquire at the close of each interview, if

76 PATHOLOGY AND TREATMENT

there be any other source of suflTering, over and above
those which have been discussed ; for by so doing, an
opportunity is aflforded of fixing the exact commence-
ment of every fresh complaint. The investigation
should be conducted, as far as possible, without the
knowledge of the patient, by the aid of relatives or
attendants, to whom no doubts of the reality of the
case should be hinted, until they have given place to
certainty; the obtaining of which is the more desirable^
because, although the ideo-motor and the simulative
complications both spring directly from the same ani-
mus; it may be doubted how far those of the congestive
order do so, and how far the sufferer may have cogni-
zance of her own share in their production and main-
tenance. The author has seen some hysterical women
whom he believes to be quite ignorant of the self-
imposed character of their maladies — while at the same
time, gladly availing themselves of them for the
gratification of the morbid craving after sympathy. It
is evident that such persons, if taxed with imposture,
would deny the charge, not only in words, but as a
consequence of genuine conviction.

The complications of hysteria have been discussed
thus briefly, for a reason which will be very apparent
in the sequel ; but which it may, nevertheless, be ex-
pedient to mention here. The author has been led to
consider them, not as so many distinct diseases, each
the subject of a special pathology and special thera-
peutics ; not in their superficial character, as irritable
stomach, congested uterus, or torpid liver ; but, to re-
peat himself, as the complications of hysteria, as the
manifestations through individual organs (often deter-
mined by almost accidental causes) of that exalted sus-

OF HYSTERIA. 11

ceptibility to the effects of emotion, and that insatiable
desire for the notice of others, which were described
before any of these local aflfections came under con-
sideration. With this view, he proposes to combat the
tendency to the recall of injurious emotions, to withr
draw the stimuli to the performance of ideo-motor acts,
to divert attention from the parts on which it has ex-
erted a hurtful influence, and to defeat endeavours to
imitate disease ; but not to single out for special attack
those parts which have been rendered obnoxious to it
by diversities of taste, of temperament, or of circum-
stance. Such are the agencies most frequently con-
cerned in localizing hysterical disorder, and the sys-
temic condition cannot be removed, and can scarcely
be ameliorated, by attempting to drive it from, one
outlet to another, while it too often happens that such
a plan, by fixing attention still more firmly upon the
organ selected for treatment, sows in it the germs of
disease by which life is embittered or destroyed, when
the hysteria itself has long been removed, by removal
of the conditions which produced it.

Lastly, it should be remarked, that local disorders
analogous to those which have been described, depend-
ing upon the same motives, and arising in the same
manner, may be met with in women who have not suf-
fered the hysteric paroxysm, but whose immunity from
it has been due either to their own want of lively feel-
ing, or to the circumstance that they have never been
subjected to any strong excitement by which a primary
attack could be produced. The paroxysm being con-
sidered as a surrender to emotion, by which the influence
of this force, and also that of attention, is materially
increased, it is evident that persons who have not

78 TREATMENT OF HYSTERIA.

yielded to it will be less liable than others to the reali-
ties of local hysterical disorder/ such as the ideo-motor
and congestive affections ; and, consequently, that the
simulative element will decidedly predominate in their
diseases, which are almost limited to paralysis, and to
disorders of the spine and joints. These patients present
all the symptoms by which local hysteria is commonly
recognised, such as excessive cutaneous tenderness,
which is diminished by distracting the attention ; and
they are for the most part possessed of ill-regulated
minds and ungovemed tempers, in which obstinacy and
sullenness are the most strongly-marked qualities.
Their comparative immunity from the effects of atten-
tion, enables them to maintain an appearance of ill
health for a very considerable time, without that risk of
permanent evil consequences, which would attend upon
the same symptoms, if occurring as complications of
the tertiary paroxysm.

1 The increased susceptibility to emotional inflnences, which results
from habitual surrender to them, is. well, and curiously illustrated by the
tongue — which in women who have often had the paroxysm, becomes
coated by any trifling excitement of the feelings; as may be seen by
making an hysterical patient angry, and observing the organ before and
after doing so. The thick coating left by a primary attack will be familiar
to most readers.

\

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 origi-
nated 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 enter-
tained by authors, may be arranged as follows : — 1 .
Hysteria has been referred to a morbid condition of the
uterine nerves by Cullen, Pinel, Lieutaud, Louyer-
Villermay, and Foville, &c. ; and to chronic inflamma-
tion of the uterus by Pujol. 2. A morbid condition
of the stomach with imperfect digestion, producing, ac-

80 PATHOLOGY AND TREATMENT

cording to Cheyne and Parry, acid humours, and in the
opinion of Pitcaim, imperfectly concocted blood, affect-
ing 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 nu-
merous other writers. 6. 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 gan-
glionic 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, GriflSn, 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 re-
specting 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 Mor-
gagni, 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 produc-
tive of irritation in various viscera may occasion the
nervous disturbance producing hysteria ; but Dr. Cop-
land thinks it essential that the nervous or vascular
condition of the sexual organs should first be affected."^

' Library of Medicine, art. Hysteria.

OF HYSTERIA. 81

It is very generally admitted^ that the diflSculty 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 sys-

tem.

3. „ requiring the existence of specific dis-

order in important or vital organs.

4. The views of Cheyne, Parry, and Pitcairn, re-

cently 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 ampli-
fication. 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

4§

82 PATHOLOGY AND TREATMENT

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 patho-
logy, 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 pro-
nounced 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 imtenable by the occurrence of mas-
culine 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 few
years one or two well-marked cases have been treated
in Guy^s Hospital.

OF HYSTERIA. 83

3. The doctrines which refer the phenomena in
question to specific disorder of important organs^ con-
tradict 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 dis-
orders 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
estabHshing the fact that the true pathology of hysteria
is not expressed by any of them, serve yet another and

84 PATHOLOGY AND TREATMENT

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 efiPects 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 Tiews of Cheyne, Parry, and Pitcaim, which
are expressed by " a morbid condition of the stomach,*'
producing either '^ acid humours'' or *^ imperfectly
concocted blood, aflfecting the brain through the arte-
ries," are those which come next under consideration,
and which, after being referred to these authors for
their first enunciation, may be expressed in the patho-
logical 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 Pitcaim 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 circum-
stance that, at first sight, it appears to meet the ne-
cessity for some agency coextensive with the whole
system, as a cause of the simultaneous or successive

OF HYSTERIA. 85

derangement of numerous organs and functions^ and as
an explanation of the transitory character of the symp-
toms 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 over-
turn, — 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
Sequent 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 per-
manent disorder of their nutrition." ^

^ British and Foreign Medico-Chirurgical Review, January, 1850.

86 PATHOLOGY AND TREATMENT

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 pro-
duce 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 abun-
dantly 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, dif-
fering 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 suflScient. 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 elimi-

OF HYSTERIA. 87

nation has been accomplished, such as rheumatism and
gout. All morbid conditions which are certainly
known to depend upon an animal poison^ either en-
gendered 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 pro-
duction, 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 sud-
denly, 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 mor-
bific matters, tells against the toxic hypothesis even
more strongly than either of the two preceding ar-
guments; because, whenever a poison can be demon-
strated, 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,

88 PATHOLOGY AND TREATMENT

is hardly borne out by facts. In the first place^ the
urine itself scarcely difiers from water in its compo-
sition; and probably depends entirely upon transu-
dation 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, re-
sembling 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 di-
versity 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

>

OF HYSTERIA. 89

inflaence of emotion itself, by altering the processes of
secretion and nutrition, may engender certain morbid
products within the body, and that these may be con-
cerned 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 ad-
vancement 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 sa}dng, that some cachexia has been deemed neces-
sary 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 patho-
logical 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

90 TREATMENT OF HYSTERIA.

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 mus-
cular 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 insufl&ciency 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 abun-
dantly 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.

N

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 well-
marked 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 con-
tinued 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

92 PATHOLOGY AND TREATMENT

it ; because in many cases their moral eflfect 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

\

OF HYSTERIA. 93

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 involun-
tary 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 com-
plicity 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

94 PATHOLOGY AND TREATMENT

exhibited until his suspicions are aroused. The pro-
fessional man who has once sanctioned imposture, by
sending medicines 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 aflfection, 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 retri-
bution, 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 con-
trol 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
curedy one was twice readmitted within three months.
There can scarcely be any other class of patients to

OF HYSTERIA. 95

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 coun-
teracting influence, &om 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 intel-
lectual exertion.

In secondary hysteria, where the disturbing emotion
is subjective, benefit will accrue from any excitement,
whether of mind or feehngs, which is produced through
the agency of external things.

86 PATHOLOGY AND TREATMENT

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 pro-
duce 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 abun-
dantly 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, dif-
fering 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 eli

OF HYSTERIA. 87

nation has been accomplished^ such as rheumatism and
gout. All morbid conditions which are certainly
known to depend upon an animal poison^ either en-
gendered within the body^ or introduced into it from
without^ niay, 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 bo analogy between hysteria and syphiUs.
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 pro-
duction, 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 sud-
denly, from the mere desire to please one of the
opposite sex j 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 mor-
bific matters, tells against the toxic hypothesis even
more strongly than either of the two preceding ar-
guments; because, whenever a poison can be demon-
strated, 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
flow of urine, which often terminates a paroxysm;
idea that this accomplishes an act of excretion,

86 PATHOLOGY AND TREATMENT

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 pro-
duce hysteria in persons whose health is apparently
good, upon the indeterminate duration of the disease,
and upon the absence of any natural eflfbrt to eliminate
morbific matters from the system.

The power of emotion to produce hysteria, is abun-
dantly 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, dif-
fering 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 elimi-

OF HYSTERIA. 87

nation has been accomplished, such as rheumatism and
gout. All morbid conditions which are certainly
known to depend upon an animal poison, either en-
gendered 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 pro-
duction, 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 sud-
denly, 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 mor-
bific matters, tells against the toxic hypothesis even
more strongly than either of the two preceding ar-
guments; because, whenever a poison can be demon-
strated, 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,

100 PATHOLOGY AND TREATMENT

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 re-
spects 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 de-
bility ; 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 cha-
racter 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
suUenness, a more circuitous manner of proceeding may
be necessary, aided, perhaps, by the intervention of
parents or other relatives. The precise manner of pro-
cedure must always be dictated by individual discretion
and tact, or by the nature of the materials available to

OF HYSTERIA. 101

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 in-
eluded pathetic theatrical or operatic representations,
and most kinds of social dissipation. It is also desi-
rable 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 indi-
vidual, 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 dia-
meter 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

102 PATHOLOGY AND TREATMENT

be able to direct the force of emotion, when beginning
to be felt, upon voluntary action of the muscular sys-
tem, 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 diflScult 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 been 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.

OP HYSTERIA. 103

are generally too great to permit the application of the
remedies most likely to be effectual. When one feel-
ing 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 practi-
tioner 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 statis-
tical information on this point; and there can be no'
question as to the propriety of avoiding the inaccurate

104 PATHOLOGY AND TREATMENT

exactness of false numbers. Deaths except from inter-
current 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 treat*
mentj 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 import-
ance, 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 de-
scription 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 necessi-
tate the use of stimulants, or other means demanded
by sudden emergencies ; and, therefore, undivided at-
tention 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

OF HYSTERIA. 105

obtain the complete and permanent abandonment of
all imitations of disease ; and not only entirely to with-
draw 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 eflfectually 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 decep-
tive 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 over-
throw in a moment, the improvement which it had
taken weeks to eflfect. Moreover, when disease has
been simulated, the very progress of the cure almost
establishes the fact of imposture ; and it is highly con-
ducive to the future well-being of the suflFerer, that she
should not know this imposture to be perceptible to
her friends. The dread of losing caste by such a dis-
covery, 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,

5§

106 PATHOLOGY AND TREATMENT

the sygtem 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 ex-
citing 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 em*
barrassing to encounter. When thus opposed, the
professional adviser who would endeavour to imfold 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 con-
dition 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 sys-
tematic 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, espe-

%

OF HYSTERIA. 107

cially 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 con-
sider 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.

108 PATHOLOGY AND TREATMENT

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 produc-
tion 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

OF HYSTERIA.. 109

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, wiU
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 what-
ever 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. Some-?

110 PATHOLOGY AND TREATMENT

times 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

s

OF HYSTERIA. Ill

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 be 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 un-
sparingly 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 feeUng being quietly
and dispassionately laid down, and the probable motives
for each new trick being described. When this his-
torical 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

112 PATHOLOGY AND TREATMENT

upoQ 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 Ler 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 con-
tinued 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
suflScient 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 mani-
fested, 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 un-
desirable 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

OP HYSTERIA. 113

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 recom-
mended 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 en-
couraged to exertion by the threat of exposure, if she
fails to get rid of each symptom within the specified time.
And when once anv 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 im-
pressible 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 inter-
locutor. 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

114 PATHOLOGY AND TREATMENT

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 ex-
tended to the length of six miles, bringing her home
desperately tired, but with her lameness cured com-
pletely 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 anger or im-
patience. 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

OF HYSTERIA. 115

common-place, diflPering 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
^quit 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 ex-
culpatory 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 idea«
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 peri>

116 PATHOLOGY AND TREATMENT

suasiveuess 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
truths 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 unrufQed
temper ; and no one who felt these qualifications failing
him in the hour of need, should continue the conver*
sation for another moment, but should break it off on
any available pretext, and resume the thread undef
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 dis-
crimination 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 HYSTERIA. 117

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 congra-
tulate 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 only admitting the
enemy, but also rendering inefficient the weapons of
defence.

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

118 PATHOLOGY AND TREATMENT

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 dis-
course 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 treat-
ment, 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 ex-
cited, 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 eflFect 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, bv
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.

OP HYSTERIA. 119

In the majority of instances, the charge of habitual
deception, and self-produced illness, will be met by ex-
pressions 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 deahng 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 com-
mand 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 eflfect which he produces,
but £dso 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

120 PATHOLOGY AND TEEATMENT

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 unioni
workhouse of an agricultural district. But any modi-
fications 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 practised, 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 practised,
than which nothing could be more opposed to the at*
tainment 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 house-
hold must do their part, out of consideration for the
delicate health of the invalid, which requires strict re-
gularity 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 in-
veterate habit, common to all these patients, of talking

OP HYSTERIA. 121

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 opportimity 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 differ-
ently his family would look upon her, if they only knew
what he could tell them ; and not only should he ob-

6

122 PATHOLOGY AND TREATMENT

serve this precaution^ but he should also make a point
of treating his patient with marked courtesy, in the
presence both of his own fiamily and of strangers^ m
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 selec-
tion,^ 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,

* A young lady uader the author's treatment, fixed upon prolapgut
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
motheri. 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.

OF HYSTERIA. 123

•

tind 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 per-
plexed about the case.

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 pro-
fession, and also afford one of the most cogent arguments
in favour of removing the patient to his house. The

124^ PATHOLOGY AND TREATMENT

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
an attack of severe haemoptysis. Feeling himself
powerless against this, the reverend gentleman sent for
the village-doctor, who, on his part, resorted to vene- *
section 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 speedy
while it is most probable that a strange practitioner
thus hastily called in would not be placed in pos-
session 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 th^
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

OF HYSTERIA. 125

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 in-
tensity. 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. Dis-
eases of the spine and joints will be occasionally fixed
upon, but they may be managed without much
diflSculty. 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 en-
tails the much lamented necessity of excluding her from

126 PATHOLOGY AND TREATMENT

sometliing agreeable^ as a dance or a pic-nic 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 neuralgiae 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 suflFering, especially when
her past history is fiilly 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 non-
reality 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

OF HYSTERIA. 127

over all their movements. If they obtain food surrep-
titiously, 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 con-
sequently, 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

128 PATHOLOGY AND TREATMENT

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 in*
stinct 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

^

OK HYSTERIA. 129

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 circum-
stances, 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
eflPect, 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,

6§

180 PATHOLOGY AND TREATMENT

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 shoidd be placed
under the most favorable hygienic circumstances, with
regard to diet, exercise, locality, and habits.

Thus their food should be plain, simple, and nutri-
tious, 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

OP HYSTERIA. 131

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 pos-
sible. 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 phy-
sician, 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 se-
vere 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 ob-
servance of them, and to ascribe all manner of symptoms
and sensations to any accidental or unavoidable short-
coming 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 adminis-

132 PATHOLOGY AND TREATMENT

tratiou 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 purga-
tive, which I had placed in the patient^s hands over-
night, 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 fore-
going 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 prac-
tices. But this is not enough for the accomplishment
of a permanent cure, except in recent cases, and in per-
sons 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 endea-
vour 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

OF HYSTERIA. 183

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^ succe|s may be
reckoned on with very tolerable confldence. 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 in-
creased 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 circum-
stances, 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

134 PATHOLOGY AND TREATMENT

its prosecution. It must therefore be sometbing which
he understands himself^ and in which he can always keep
before his patient^ so as to be appealed to on any
doubtful pointy 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 con-
dition. These must be rendered available whenever
they can^ so as to avoid the drudgery of a commence-
ment, 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 know-
ledge 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 compara-
tively 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 ;

OF HYSTERIA. 135

and the patient should, of course, be in turn encouraged
by victory, and stimulated by defeat.^

Reading wiU 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 inju*
rious 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 con-
versation and comment; and, in point of fact, of
examination. If the result be satisfactory, nothing

* This iS| perhaps, the place in which to notice the statements of
Dr. Laycock, 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, t. 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
aniipals 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 sub-
jected 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 modem 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.

136 PATHOLOGY AND TREATMENT

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
keepings and by inducing the patient to try and carry
out its precepts^ for doing which all facilities must be
afiforded 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 pro-
gress 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.

OF HYSTERIA. l37

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 per-
formance 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 lights
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 avocatioa
with which she is sought to be tempted, must be brought
out for her especial benetit, but before her attention is
called to it, must be already going on for the amuse-
ment or instruction of somebody else. And even then
it will seldom be politic to recommend it in so many
words j but matters should be so managed, as to
ensure that there is something qf interest to be seen

188 PATHOLOOr AND TREATMENT

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 wearinesa 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 invita-
tion to see the next experiment being th^n 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 with-
out distinctly realizing that all hysterical women are way-
ward, 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 pheno-
mena, 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 wiU 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 remem-
bered, 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

OF HYSTERIA. 139

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

140 PATHOLOGY AND TREATMENT

involye 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
amoimt 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

OF HYSTERIA. 141

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 com-
panionship, 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 per-
manent 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 j
but every one is aware that external good conduct is
often produced by motives, which, if not exactly
blatneable, would scarcely be confessed to by those
whom they actuate. And it is to these motives that

142 PATHOLOGY AND TREATMENT

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 rights
might have been inefifectually preached till doomsday.

The manner of affording religious instruction to
hysterical women, must depend very much upon local
circumstances ; and the di£5culties 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 ob-

OF HYSTERIA. 143

tained^ it must be used and appreciated as a most
important aid ; but there is yery 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
b6 provided for beforehand.

The greatest difficulty likely to occur, is the com-
bination 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 her-
self 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 simu-
lated disorders, the character of the intruder should
be at once recognised, and its nature confessed, in order
to sustain a consciousness of the skiU 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,

144 PATHOLOGY AND TREATMENT

that the existence of real danger, throws hysteria into
temporary abeyance. But if the real ailment is of a
chronic character; and is, comparatively speakings of
little importance ; or if^ although arising in the course
of treatment, it does not threaten any serious con-
sequences, then two courses are open to the prac-
titioner, 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 scrutinising 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 aflPord relief by hygienic
measures, which can always be recommended and
enforced, on the groimd 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 extin-
guished the hysteria, and has been in its turn over-
come 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

OF HYSTERIA, 145

will be suflPering 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 circum-
stances, 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 tt) 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

T

146 PATHOLOGY AND TREATMENT

of the reader, and will perhaps render it desirable to say
a few words, as to the conditions under which the treat-
ment of an hysterical girl may be undertaken. Enough
has been already stated, to show that the person con-
ducting 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 hys-
teria, 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 diflSculty in obtaining the complete control
which is necessary, and the relatives will often think
themselves quite competent to exercise a general sur-
veillance over the treatment, and to question the pro-
priety 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 cha-

Olf HYSTERIA. 147

racter 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 attain-
ment of an improper object. But in chronic and
obstinate cases, the moral perversion, although not re-
cognised 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.

148 PATHOLOGY AND TREATMENT

When it has been necessary that the deceptiye
character of the case should be explained^ this must
always be done as a matter of confidential communica-
tion, 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 aflPord 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 difierence 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 destnactive 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 suUenness as their most

OF HYSTERIA. 14^9

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 sufiicient 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 per-
manent 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 trust-
worthy 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 diflSculty 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

150 PATHOIX)GT AND TREATMENT

the simulative practices have been thoroughly aban-
doned^ it is thought fit to send the patient home to her
friends^ some precautions must be adopted against the
return of the ^sease. 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 snfiered 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 efiect of this visit being carefully watched.
During its continuance, a return of hysteria is scarcely
possible, and it will afibrd a proof to relatives of the
reality of the cure, which will render them suspicious
of all subsequent illnesses. One such period of pro-
bation 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 en-
deavoured to describe, has been tested for many years,

OF HYSTERIA. 151

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 com-
mencement, 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 ulti-
mately 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.

CHAPTER VII.

HYSTERIA AMONG THE POOR.

All the varieties of hysteria, are of frequent occur-
rence among the poorer classes of society, a fact easily
ascertainable by observation of hospital or parochial
practice, although at present there are many and in-
surmountable obstacles, in the way of an exact nume-
rical statement concerning their prevalence. At the
London Hospital, fifty-three cases are recorded to have
been admitted as in-patients, during the five years an-
tecedent to 1852, showing an average of more than ten
annually. The average annual number of the physi-
cian^s female in-patients, for the same time, was 240, so
that one twenty-fourth of this number are stated to
have been hysterical. But this account is open to a
very serious source of fallacy, being founded on the
cursory examination which precedes the admission of a
patient, and not being corrected by the subsequent
history of the case, so that a woman may be admitted
as the subject of paralysis, or epilepsy, and mentioned
as such in the register, although her physician pro-
nounced her to be hysterical on the first visit made
after her entrance. And as it is scarcely possible
to mistake another disease for hysteria, while the
opposite error is by no means of infrequent occurrence,
it is manifest that this erroneous record must under-
state the actual number of hysterical patients. It

TREATMENT OF HYSTERIA. 153

may be relied upon as far as it goes^ but it is impos-
sible to say by how many units^ the number fifty-three
falls short of the reality. At other hospitals the same
difficulty stands in the way, and at most of them, an
accurate statistical table would not adequately express
the proportion borne by hysteria to other ailments,
because the authorities very often refuse it admission,
and would almost always fill up a limited number of
beds, with complaints more amenable to ordinary treat-
ment, or involving greater danger to the life of those
suffering from them.

But it is very obvious that the importance of a dis-
ease, cannot always be expressed by the mortality
immediately resulting from it, and that when arising
from the influence of moral agencies, its effects upon
society may be altogether independent of its power to
destroy life. Such is especially the case with hysteria,,
which, although without a place in the tables of the
Registrar General, yet, in all classes, withdraws a vast
number of women from the active duties of life, and
more or less permanently, incapacitates them for their
fulfilment, while it may also be regarded as an ordinary
cause of insanity, and as being much concerned in the
first errors of many prostitutes. On all these points I
have vainly endeavoured to obtain statistical informa-
tion, but have been reluctantly compelled to abandon
the hope of doing so, and to substitute for figures, an
appeal to the individual experience of the reader, in
the full conviction that this will bear me out, not only
with regard to the extreme prevalence of the disease,
but also with regard to its very disastrous conse-
quences.

In the lower classes of society, the sufferers from

154 PATHOLOGY AND TREATMENT

hysteria are chiefly to be met with among the more
respectable, who, resisting the normal effects of pas-
sion, fall victims to the abnormal, and among such, the
secondary form is more frequent, than under any other
circumstances. In hospitals the tertiary disorder is
the one generally met with, and the occasional occur-
rence of a primary fit, is not thought, among the poor,
to require any systematic medical treatment.

The prospect of spontaneous recovery from secon-
dary hysteria, must necessarily depend, in a great
degree, upon the former mental activity of the patient,
which would not only oppose the complete occupation
of the thoughts by any single idea, but would also
increase the number of associations, through which new
matter could be introduced. Next in importance,
would be the number and character of the events
occurring around her, by which these associations
could be aroused; there being a manifest interdepend-
ence between the last two sources of improvement.
Hence a cottage-girl, whose education has been limited
to a little laborious reading and writing, and whose
home is a scene of unbroken monotony, has very little
chance of getting well, except by the slow and gradual
wearing out of her primary emotion, while at the same
time, being subjected to its effects for a very long
period, it is quite possible that an extremely excitable
condition of the nervous system may remain, even
when the feeling itself has been forgotten. I have
met with a case in which a long succession of secon-
dary phenomena, continuing for many years, left an
exaggerated degree of that state which is called '^ sen-
sitiveness" by the professors of animal magnetism.
The patient, (a middle-aged single woman, and the

OF HYSTERIA. J 55

daughter of an agricultural labourer,) was, for the most
part, in a quiescent state, but any unexpected sight or
sound, or the blowing of a stream of cold air, or the
pointing of a finger, caused a short convulsive shudder,
and a low moaning, which appeared to be quite inde-
pendent of volition, and occurred very frequently
during sleep, obviously in connection with dreams.
Again, it is easy to conceive that, over and above these
obscure physical changes, the constant direction of the
mind upon one train of thought, must, if long conti-
nued, involve a great liability to some permanent alter-
ation in its powers, and hence to various kinds of
insanity. This supposition is thoroughly borne out by
an examination of lunatic asylums; and it follows that,
the hysteria of the lower classes, although seldom fatal
as such, is not a disease which should be ignored and
neglected, but on the contrary, one which demands
from the scientific practitioner no small degree of
attention and care, coupled with an earnest endeavour
to remedy that deficiency of means for its relief, which
probably depends more upon the neglect of the profes-
sion, than upon the obstinacy of the disorder. And in
this good work, the philanthropist may go hand in
hand with the physician, and may lend his aid to
counteract the great mass of moral evil, which is
implied by the prevalence of hysteria. Over and above
that gratification of irregular desires, which is often the
first step in a headlong descent to prostitution, there
are many other ill consequences, minor in themselves,
and yet, in the aggregate, most grave and important.
Lying, in some of its forms, is a necessary concomitant
of the tertiary disorder, and may exhibit itself, either
in unblushing hypocrisy, or in the grossest imposture,

156 PATHOLOGY AND TREATMENT

in either ease bringing every other variety of vice in
its train, and generally leaving, when the period of the
emotions has passed by, a miserable and malicious old
woman, devoid of every estimable or kindly feeling,
and exemplifying humanity in its most degraded form.

Nor less should hysteria be an object of interest to
the political economist, from its effect in diminishing
or destroying the usefulness of large numbers of people.
Other diseases which have a similar effect, must be
regarded as irremediable evils, or as evils remediable,
only by the completion of vast schemes of sanitary and
educational improvement. But there is no ground
for such an opinion concerning hysterical disorders,
which at their outset are almost always manageable, if
the proper means be employed; and there is much
to encourage the belief, that a more effectual know-
ledge of their nature would certainly reward the dili-
gent inquirer.

But it is impossible to deny that both the pathology
of hysteria, and the investigation of agencies which
should be prophylactic or curative against it, have
been treated with unmerited and almost criminal ne-
glect, no increase of knowledge having been gained on
either of these questions, at all commensurate with the
abundant opportunities of observation, or with the
general progress of medical science. A patient suffer-
ing from paralysis or spinal disease will be diligently
treated and carefully observed, but when once her ail-
ments are decided to be hysterical, a sort of despair
too frequently seizes upon her medical attendants.
Her disease not being dangerous to life, and being
likely to get well spontaneously at some future time,
the sufferer is left unaided, often without any exact

OF HYSTERIA. 157

scrutiny of the method in which that amendment is
brought about, which nature will so often accomplish,
but which, had its character been clearly understood,
it would have been the province of art to imitate and
to assist.

It would, perhaps, be difficult to trace the causes
which have led to this neglect of hysteria, as far as
past generations are concerned; but in the present
day, two are chiefly remarkable ; namely, the natural
tendency to regard that problem as insoluble, towards
whose solution so little progress has been made; and,
secondly, the inadequacy of the existing means for the
relief of the disorder.

But little argument is required, to show that hys-
teria cannot be cured, except by accident, in an ordi-
nary hospital. It is very true that some individual
complication may be broken through, that a contracted
joint may yield to the cold douche, or that a convulsive
paroxysm may for a time be prevented from appearing ;
but the principles and motives of the patient remain
unchanged, and there is no machinery which can be
brought to bear upon them. It has been already
stated, that of the fiftv-three cases mentioned in the
register of the London Hospital, only twenty-three are
said to have been cured, and that of these cured pa-
tients, one was twice re-admitted within three months
of her first discharge. The record is also remarkable,
as showing the short period during which hysterical
women are kept under treatment, this often not ex-
ceeding a few days, and being a tacit confession that
nothing could there be done for them. And if the
internal economy of a hospital be considered, it is seen
to furnish conditions more likely to develop the disease

158 PATHOLOGY AND TREATMENT

than to repress it. The publicity of a ward furnishes
abundant opportunities for display^ the neighbouring
patients are often good listeners^ and lavish of their
sympathy; and the frequent presence of numerous
students must not be altogether left out of the ac-
count.

The home of an hysterical girl can scarcely ever be
the scene of her cure, for reasons which it is unne-
cessary to repeat, and it must, almost of necessity,
retard the progress of her recovery. This being the
case, and the method of treatment which has been
described being utterly out of the reach of the poor,
it follows that great benefits might reasonably be ex-
pected from the formation of a special institution, in
which this method, with the variations suggested by
experience, might be thoroughly carried out, and in
which accurate and careful research might be made,
into the exact nature of many obscure and highly-
interesting phenomena, of which nothing is well ascer-
tained but their occunrence.

The foundation of special hospitals, notwithstanding
that it is in most cases of questionable advantage, is
yet so thoroughly sanctioned by English usage, and, in
the case of hysteria, is so much more required than
for any other disease, that I do not hesitate to call the
attention of the reader to the outline of a plan which
has long held possession of my thoughts, and which,
at some future time, I hope to see fully carried
out.

A hospital for hysteria would require to be placed
in an open and airy situation, and to have around it a
space for the recreation and exercise of the inmates.
It might be conveniently managed of almost any size.

OF HYSTERIA. 159

but no relief could be given to out-patients^ although
those discharged from the house might be required to
pay a few visits, as a precaution against relapse.

The cases admitted might include all varieties of the
disorder, and the hospital should be free to all women,
either during, or directly after, the paroxysm, while
patients recommended by governors should be required
to produce satisfactory medical certificates of the nature
of their disease, before being considered eligible for
admission.

The wards might contain a large number of beds, if
adequate provision was made for their ventilation, and
this arrangement would be desirable, as serving to
diminish the number of attendants. Each ward would
require one or two padded rooms, similar to those used
in lunatic asylums, in which a patient might be placed
during the continuance of a paroxysm, and which
should be so contrived as to afford facilities for unseen
and unsuspected observation of her conduct.

The institution should be made industrial, and in
some degree self-supporting — while at the same time
gymnastic exercises, and a discipline approaching to
pugilistic " training/^ would be required for many of the
patients, none of whom, unless when in bed, or actually
under the paroxysm, should ever be suffered to remain
in idleness. For the purposes of occupation a garden
and dairy should be provided, and all household work
should be made available. Perhaps no small benefit
would accrue, from placing the hospital in communi-
cation with some emigrant societj^ and from instructing
such inmates as were willing, in the duties of a colonist's
wife. At all events, work of some sort there must be,
and the more both of interest and of fatigue that could

160 PATHOLOGY AND TREATMENT

be attached to it, the more benefit would result from its
performance.

The matron and nurses would have to be selected
with great care and judgment; and to be thoroughly
instructed in the duties that would devolve upon them,
before hysterical patients could be placed under their
care. Their appointment should be controlled by the
medical staff, which should consist of visiting and
resident officials, in number proportioned to the size of
the institution.

From a hospital of this description it would be just
and reasonable to expect great benefits, not only to the
patients actually treated, but also to society at large,
from the opportunity which it would aSbrd for the study
of many obscure conditions of the nervous system, and
of the consequences resulting from them. To attain
this end, close clinical observation would be necessary,
assisted by chemistry, by the microscope, and by care-
fully-prepared analytical and statistical tables ; and the
investigations thus undertaken should be considered as
one of the primary objects of the charity, and as having
a claim upon its funds, equally with the support and
treatment of the inmates. The non-recognition of this
principle by the founders of our various hospitals, has
caused the waste and loss of information of priceless
value, and compels physicians, in the present day, to
gain for themselves the knowledge, which might have
been stored up by their predecessors.

And as it is among the wealthy and luxurious that
diseases of the nervous system are most common, an
institution devoted to their investigation and relief,
would have especial claims upon the support of the
rich, over and above its appeal to that benevolence.

OF HYSTERIA. 161

which in England is never appealed to in vain. Each
contributor to such a hospital as this^ may furnish the
means of rescuing some member of his own household
from disease or deaths and every gift may not only
confer advantage upon some individual now, but may
also extend its benefits to the remotest posterity.

These suggestions have been introduced, with the
wish to ascertain the feeling of the medical profession,
on the subject to which they refer; and the amount
of co-operation to be hoped for from its members, if
a scheme for a hospital for hysteria should ever be
brought before the public. T now leave them to the
consideration of my readers, fully persuaded that, if
their verdict be favorable, no long time will elapse,
before the existing medical charities of this country,
have yet another added to their number.

FINIS.