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PART III

CHAPTER XVII

HYSTERIA

A NUMBER of cases of a functional character is known in medical literature under the term of hysteria. What the term hysteria denotes is rarely defined, though it seems to connote much to the mind of the medical student. To some, hysteria is only a matter of “fancy” and “innate cussedness.” This point of view is not in accordance with the facts and need not be discussed here, as it is simply a negation of the reality of the phenomena; it is a simple refusal to recognize the validity of the subject-matter. Others define hysteria in terms of “unreasonable will stimuli,” of “sympathies,” of unrelated “parallelism.” It is obvious that such definitions require no discussion. Those, however, who do make themselves acquainted with the phenomena and try to reduce them to a rational order, attempt to give some precise definition to the term “hysteria” with various success. “Hysteria” is defined as a mental disease. It is, however, evident that such a definition is far from being exact and definite. There are many diseases which are mental in character and which can hardly be classed among the hysterias; the different forms of aphasia, the many forms of mania, melancholias, paranoias, etc., are all mental diseases, but they are not hysterias. To define hysteria simply as a mental disorder is as inadequate as to define man as a two-legged animal.

            It is true that very often the psychic aspect of the different forms of disorders that go under the name of “hysteria” must be specially emphasized as against the view that makes of that disturbance a purely bodily affection. This is perfectly legitimate, in fact, indispensable, but it would not do to base on it a scientific definition, not because it is incorrect, but because it is too general, and hence too vague and ambiguous. It is not enough to define a tiger as an animal, but its differentia should be given; in the same way it is not sufficient to define hysteria as a psychic trouble; its differentia should be added.

            What are the special traits or differentiae of the psychic disturbance known under the term of “hysteria”? The traits commonly given as specific of "hysteria" are: mental instability, suggestibility, weakness or lack of willpower, and emotionality. Now these characteristics are certainly very suggestive, but they are not sufficient to single out and denote adequately the type of “hysterical” infirmities. These characteristics, it can be pointed out, are too general, too indefinite and too vague. For mental instability, suggestibility, weakness of will and emotionality are also to be found in many mental diseases of widely different types. Maniacal states or states of general paresis will answer this description. Besides, the traits are so comprehensive as to include mental states which can hardly be regarded as psychic diseases. The mental condition of children and savages presents just these very traits of character; they are mentally instable, they are highly suggestible, their will-power is weak and deficient, and they are highly emotional. And it will certainly be a strain of generalization to regard children and savages as mentally diseased and suffering from hysterical maladies. The concept of hysteria as well as the outline of its nature remains vague, ill-defined and obscure, and covers a vast number of psychopathological functional affections of various forms and types whose physical basis is not of the permanent type of organic lesions.

            A very ingenious theory of the cause and nature of “hysteria” has been recently advanced. According to this theory, the nature of hysteria consists in the abnormally powerful intensity of the sensory components, concomitant with the reproduced ideas and their associated feelings, bringing about an abnormal intensification of these very feelings. In other words, hysteria is defined as a malady of emotional life, an intensification of reproduced emotions brought about by the abnormal intensity of the associated ideo-sensory processes.

            Now it is left untold what those ideo-sensory processes are. Since emotions themselves on any theory, whether peripheral or central, are largely made up of ideo-sensory elements and processes, it is hard to tell how much of the whole generalization is a tautology. The whole theory reduces itself to the very well-known statement that hysteria is simply intense emotionalism. This, however, is nothing but words with but little meaning to them; neither do they define the nature of hysteria, nor do they give the modus operandi of the facts of emotionalism in giving rise to the phenomenon regarded as belonging to the type known as “hysteria.” The intense ideo-sensory elements should be indicated and their relations to the phenomena under investigation should be determined. Nothing of the hind is done and the theory of intense emotionalism is but a repetition of the current popular views on the subject. It is true that an attempt is made to base this popular view on a more firm basis and express it in more exact scientific terms. Hysterical emotionalism is referred to reproduced ideo-sensory elements having an abnormal intensity. This, too, however, is rather vague, as the reproduced elements are not indicated.

            Furthermore, it is hard to understand what is meant by reproduced intense ideas and sensations. Psychologically regarded, this theory, as it stands, is full of ambiguity and does not accord with facts. An idea may be reproduced, but it has no intensity; a sensation has intensity, but then it cannot be reproduced. What the theory affirms is the generalization that all the phenomena falling under the category of “hysteria” may be explained by or traced originally to the intensity of representative life with its accompanying affective states. In other words, hysteria is regarded as a disease of reproductive mental life. Now it does not accord with facts to find intensity as a quality of representative life; an idea may be vivid, but is not intense, and it is wrong to suppose that, however vivid an idea or representation may be, it should ever become a presentation or sensation. An idea of sound does not sound, nor is an idea of redness red, no matter how vivid it may be made. We can no more reproduce or represents sensation than we can add a cubit to our height. Still more difficult is it to realize a reproduction of affective states emotions. If there be such reproduction, then it is certainly of a different type than that of ideas, and the two must not therefore be lumped together into one category.

            From a general consideration of this theory of emotionalism, it is well to enter into a more detailed examination and see how the theory works when applied to the phenomena that go under the comprehensive term of hysteria. Is this theory of reproduced intense emotionalism a working hypothesis? If we inspect closely the phenomena under consideration, we find that they present sensory, motor, ideo-motor and sensori-motor defects; we find that they present anaesthesia of the different senses in various degrees and also amnesia of different forms and types. How arethese facts to be explained on the general theory that takes emotional life as its basis? The anaesthesias are regarded as modifications of peripheral and visceral sensibility, due to the diseased states of the various organs. Now it is these modifications, along with the intense reproduced emotional states, that give rise to the amnesic conditions so often present in patients of the hysterical diathesis. The changes in visceral sensibility work in the same way to bring about amnesia as they do in the “Dämmerzustände” of epilepsy; they so modify the totality of consciousness that certain contents of memory requiring definite mental states for their reproduction cannot be revived. Thus, for instance, the case of Azam, the case of Burret and Bourrou, the case edited by Weir Mitchell, are all referred to the sensory changes found in the peripheral organs. Thus one of the followers of this theory cites cases of Janet, showing such peripheral sensory changes present with the onset of different forms of amnesia and the disappearance of those amnesic states with the return of the sensory states to the normal condition. Thus Janet tells of some of his cases that, with the disappearance of the skin and muscle anaesthesia, the amnesic states have also ceased. In fact, one may even refer to Janet’s law that amnesias come and go with sensory disturbances.

            The factor of sensory disturbances, however, does not seem sufficient to account for all the phenomena, and the other factor, that of intense reproduced affections and emotions, is brought in to bear on the subject. Hysteria, it is pointed out, is characterized by the important symptoms that reproduced emotions manifest themselves with unusual abnormal intensity. It is the abnormal intensity of emotional life, partly dependent on the changes of peripheral and visceral sensibility, so prevalent in hysteria, that is the cause of the amnesic states. A psychological principle is now being drawn that very intense emotional states suppress the reproduction of ideas and memories associated with them. When an idea a is associated with an emotion b, then if the reproduction of this idea a revives the intense emotion b, the emotion b exercises an inhibitive influence on a, the memory a is inhibited and hence amnesia. The adherents of this view attempt to substantiate it by an analysis of cases. The analysis shows that in some cases a strong emotion brings about the hysterical state with its symptoms. Now it is believed that no sooner do these memories arise to consciousness than their accompanying emotions arise, too, and with an intensity so great as to inhibit the very memories and give rise to amnesia.

            Of course, the question arises as to the validity of the principle of having an emotion inhibit instead of fixing the ideas associated with it. For we find that in normal life, as well as in abnormal mental activity, memories become fixed in proportion to the strength of the accompanying affective states and emotions. This objection is overcome by the reply that this holds true only up to a certain degree of intensity of the affective states. When the intensity of the emotions rises beyond a certain point, then, instead of fixing the memory, the emotion inhibits it and produces loss of psychic content, thus giving rise to the different forms of amnesia.

            A closer examination, however, of this theory reveals its questionable character. First of all, it postulates that an emotion revived representatively by an idea differs from the original emotion only in the degree of intensity. This generalization of identifying the qualitative side of presentation and representation and making them differ in degree only is not true to fact. A presentation is not an intense representation, an “intense” idea does not become a sensation, nor is a weak sensation an idea. Affective states and emotions can no more be reproduced by representations, by ideas, than sensations can. Psychologically, it is opposed to facts of observations, and physiologically the theory assumes that the central apparatus and its physiological processes are in structure and function identical with the peripheral sensory organs and their mode of action. One may as well place eyes, ears, nose and tongue in the cerebral lobes. The theory, therefore, cannot be accepted on general grounds, because it is not in accord with the facts of psychology and physiology; in fact, it contradicts their most fundamental principles.

            If now from the general review of the theory, we turn to the facts it is assumed to explain, we find that it is also out of accord with them and that the explanation given is but an apparent one; the very essence of the facts is really ignored. It is contended on this theory that the memories as representations are inhibited by their associated reproduced emotions and hence the amnesic states. Now as a matter of fact, nothing of the kind is really observed in those forms of amnesia that go under the name of hysteria and which, on account of the vagueness of the term and the clustering round it of a great number of invalid concepts, it were better to use the more comprehensive and more adequate designation of “functional psychosis.”

            The phenomena of functional psychosis are in direct contradiction to this theory of inhibitory reproduced affective states and emotions. If the emotion is to keep the associated representation under inhibition, then it is evident that the removal of the emotion will also remove the inhibition; in other words, in order that the amnesia should persist, the association of the emotion with the idea must be stable, permanent and lasting. Most cases of functional amnesia do not reveal the least trace of the presence of emotional states. On the contrary, indifference, affective and emotional, hypoaesthesia or anaesthesia of the emotional life, is most often the case. Even in the cases where emotions do enter as a factor, they do so in the beginning of the attack, and may bring about a psychic trauma, giving rise to the symptoms characterizing the different forms of functional psychosis. Once, however, functional psychosis, with its psychic states, is originated, the emotion itself is no longer active.

            An emotion may work harmful results, somewhat like a physical blow on the head, in producing amnesia; in fact, it may be regarded in such cases as a psychic blow, but it is certainly strange to assert that it is the blow which underlies the nature of the amnesia and is a permanent factor in the psychopathological phenomena, nor can it be asserted that each subsequent attack is preceded by a blow. The blow is absent, but the psychic state persists. The nature of functional psychosis lies not in the blow, but in the pathological neural disturbances with their accompanying psychic manifestations. Functional amnesia is not kept up by the intensity of emotion; the emotion, if it does occur as the occasion of the mental malady, may pass away, but the amnesic condition remains. In many of my cases of functional amnesia, not the least trace of emotion could be discovered.

            Moreover, according to this same theory, sensori-motor changes and disturbances of coenaesthetic sensibility should be observed, but nothing of the kind could be found. With the exception of the amnesia, not the least difference could be found between the normal state and that of the amnesic conditions. In the M. case the amnesia is of systematized character, in the F. ease the amnesia is of a localized character, but in neither could any affective, emotional, nor any sensory changes be found. Even in the Hanna case, where the amnesia was complete and general, the patient possessed excellent self-control, manifested no emotional disturbances and revealed no sensory changes whatever.

            As a matter of fact, when sensory changes do occur in functional psychosis, they are not at all of a peripheral physiological character, but of a purely central and psychic origin, often brought about by suggestion or subconscious auto-suggestion. The key to functional psychosis is not to be sought in its occasional factors and circumstances, such as emotionalism and sensori-motor changes, but they must be looked for in disturbances of a purely central character; they must be sought in psychophysiological dissociations of the central neural apparatus due to the rise and fall of thresholds.

            Furthermore, the very essence of functional psychosis is entirely overlooked by this theory of intense revived emotional states. Neither the seemingly lost sensori-motor impressions nor the memory experiences are really lost in functional psychosis. The apparently lost experiences can be shown to be present in the patient’s subconscious life. The lost content has not vanished from consciousness; it is present there in a dissociated form. Tapped by psychopathological methods, such as distraction, automatic writing, guessing, hypnoidization, and under conditions favorable to the manifestations of subconscious states, the seemingly vanished content suddenly reappears and stands out clear and distinct in the background of consciousness.

            Moreover, it can also be shown that the seemingly anaesthetic spots are really highly sensitive, and the apparently forgotten and lapsed memories are actually present in full to the smallest detail. We may fully affirm the statement which may be termed the paradox of functional maladies that in functional psychosis all losses are present; that all deficiencies are also excesses, that all anaesthesias are also hyperaesthesias and that all amnesias are also hypermnesias.

            So strongly marked is this the case in functional psychosis that some investigators find that what really requires explanation is not the anaesthesias and amnesias, but the hyperaesthesias and hypermnesias. As a matter of fact, the two are inseparable in functional psychosis; they are but two aspects of one and the same fundamental phenomenon of functional dissociation. What is completely lost to the patient’s personal consciousness is present in full in the subconscious dissociated state. The phenomena of functional psychosis originate in psychic dissociation, with its concomitant physiological dissociation of neural systems and elements. Psychologically regarded, functional psychosis is a dissociation of systems of moments consciousness; physiologically regarded, functional psychosis is a disaggregation of neuron systems.