When, indeed, we analyze the foundation of the once predominant opinions of Charcot and his school regarding the sexual relationships of hysteria, it becomes clear that many fallacies and misunderstandings were involved. Briquet, Charcot's chief predecessor, acknowledged that his own view was that a sexual origin of hysteria would be "degrading to women"; that is to say, he admitted that he was influenced by a foolish and improper prejudice, for the belief that the unconscious and involuntary morbid reaction of the nervous system to any disturbance of a great primary instinct can have "quelque chose de dégradant" is itself an immoral belief; such disturbance of the nervous system might or might not be caused, but in any case the alleged "degradation" could only be the fiction of a distorted imagination. Again, confusion had been caused by the ancient error of making the physical sexual organs responsible for hysteria, first the womb, more recently the ovaries; the outcome of this belief was the extirpation of the sexual organs for the cure of hysteria. Charcot condemned absolutely all such operations as unscientific and dangerous, declaring that there is no such thing as hysteria of menstrual origin.[265] Subsequently, Angelucci and Pierracini carried out an international inquiry into the results of the surgical treatment of hysteria, and condemned it in the most unqualified manner.[266] It is clearly demonstrated that the physical sexual organs are not the seat of hysteria. It does not, however, follow that even physical sexual desire, when repressed, is not a cause of hysteria. The opinion that it was so formed an essential part of the early doctrine of hysteria, and was embodied in the ancient maxim: "Nubat illa et morbus effugiet." The womb, it seemed to the ancients, was crying out for satisfaction, and when that was received the disease vanished.[267] But when it became clear that sexual desire, though ultimately founded on the sexual apparatus, is a nervous and psychic fact, to put the sexual organs out of count was not sufficient; for the sexual emotions may exist before puberty, and persist after complete removal of the sexual organs. Thus it has been the object of many writers to repel the idea that unsatisfied sexual desire can be a cause of hysteria. Briquet pointed out that hysteria is rare among nuns and frequent among prostitutes. Krafft-Ebing believed that most hysterical women are not anxious for sexual satisfaction, and declared that "hysteria caused through the non-satisfaction of the coarse sensual sexual impulse I have never seen,"[268] while Pitres and others refer to the frequently painful nature of sexual hallucinations in the hysterical. But it soon becomes obvious that the psychic sexual sphere is not confined to the gratification of conscious physical sexual desire. It is not true that hysteria is rare among nuns, some of the most tremendous epidemics of hysteria, and the most carefully studied, having occurred in convents,[269] while the hysterical phenomena sometimes associated with revivals are well known. The supposed prevalence among prostitutes would not be evidence against the sexual relationships of hysteria; it has, however, been denied, even by so great an authority as Parent-Duchâtelet who found it very rare, even in prostitutes in hospitals, when it was often associated with masturbation; in prostitutes, however, who returned to a respectable life, giving up their old habits, he found hysteria common and severe.[270] The frequent absence of physical sexual feeling, again, may quite reasonably be taken as evidence of a disorder of the sexual emotions, while the undoubted fact that sexual intercourse usually has little beneficial effect on pronounced hysteria, and that sexual excitement during sleep and sexual hallucinations are often painful in the same condition, is far from showing that injury or repression of the sexual emotions had nothing to do with the production of the hysteria. It would be as reasonable to argue that the evil effect of a heavy meal on a starving man must be taken as evidence that he was not suffering from starvation. The fact, indeed, on which Gilles de la Tourette and others have remarked, that the hysterical often desire not so much sexual intercourse as simple affection, would tend to show that there is here a real analogy, and that starvation or lesion of the sexual emotions may produce, like bodily starvation, a rejection of those satisfactions which are demanded in health. Thus, even a mainly a priori examination of the matter may lead us to see that many arguments brought forward in favor of Charcot's position on this point fall to the ground when we realize that the sexual emotions may constitute a highly complex sphere, often hidden from observation, sometimes not conscious at all, and liable to many lesions besides that due to the non-satisfaction of sexual desire. At the same time we are not thus enabled to overthrow any of the positive results attained by Charcot and his school.
It may, however, be pointed out that Charcot's attitude toward hysteria was the outcome of his own temperament. He was primarily a neurologist, the bent of his genius was toward the investigation of facts that could be objectively demonstrated. His first interest in hysteria, dating from as far back as 1862, was in hystero-epileptic convulsive attacks, and to the last he remained indifferent to all facts which could not be objectively demonstrated. That was the secret of the advances he was enabled to make in neurology. For purely psychological investigation he had no liking, and probably no aptitude. Anyone who was privileged to observe his methods of work at the Salpêtrière will easily recall the great master's towering figure; the disdainful expression, sometimes, even, it seemed, a little sour; the lofty bearing which enthusiastic admirers called Napoleonic. The questions addressed to the patient were cold, distant, sometimes impatient. Charcot clearly had little faith in the value of any results so attained. One may well believe, also, that a man whose superficial personality was so haughty and awe-inspiring to strangers would, in any case, have had the greatest difficulty in penetrating the mysteries of a psychic world so obscure and elusive as that presented by the hysterical.[271]
The way was thus opened for further investigations on the psychic side. Charcot had affirmed the power, not only of physical traumatism, but even of psychic lesions—of moral shocks—to provoke its manifestations, but his sole contribution to the psychology of this psychic malady,—and this was borrowed from the Nancy school,—lay in the one word "suggestibility"; the nature and mechanism of this psychic process he left wholly unexplained. This step has been taken by others, in part by Janet, who, from 1889 onward, has not only insisted that the emotions stand in the first line among the causes of hysteria, but has also pointed out some portion of the mechanism of this process; thus, he saw the significance of the fact, already recognized, that strong emotions tend to produce anæsthesia and to lead to a condition of mental disaggregation, favorable to abulia, or abolition of will-power. It remained to show in detail the mechanism by which the most potent of all the emotions effects its influence, and, by attempting to do this, the Viennese investigators, Breuer and especially Freud, have greatly aided the study of hysteria.[272] They have not, it is important to remark, overturned the positive elements in their great forerunner's work. Freud began as a disciple of Charcot, and he himself remarks that, in his earlier investigations of hysteria, he had no thought of finding any sexual etiology for that malady; he would have regarded any such suggestion as an insult to his patient. The results reached by these workers were the outcome of long and detailed investigation. Freud has investigated many cases of hysteria in minute detail, often devoting to a single case over a hundred hours of work. The patients, unlike those on whom the results of the French school have been mainly founded, all belonged to the educated classes, and it was thus possible to carry out an elaborate psychic investigation which would be impossible among the uneducated. Breuer and Freud insist on the fine qualities of mind and character frequently found among the hysterical. They cannot accept suggestibility as an invariable characteristic of hysteria, only abnormal excitability; they are far from agreeing with Janet (although on many points at one with him), that psychic weakness marks hysteria; there is merely an appearance of mental weakness, they say, because the mental activity of the hysterical is split up, and only a part of it is conscious.[273] The superiority of character of the hysterical is indicated by the fact that the conflict between their ideas of right and the bent of their inclinations is often an element in the constitution of the hysterical state. Breuer and Freud are prepared to assert that the hysterical are among "the flower of humanity," and they refer to those qualities of combined imaginative genius and practical energy which characterized St. Theresa, "the patron saint of the hysterical."
To understand the position of Breuer and Freud we may start from the phenomenon of "nervous shock" produced by physical traumatism, often of a very slight character. Charcot had shown that such "nervous shock," with the chain of resulting symptoms, is nothing more or less than hysteria. Breuer and Freud may be linked on to Charcot at this point. They began by regarding the most typical hysteria as really a psychic traumatism; that is to say, that it starts in a lesion, or rather in repeated lesions, of the emotional organism. It is true that the school of Charcot admitted the influence of moral shock, especially of the emotion of fear, but that merely as an "agent provocateur," and with a curious perversity Gilles de la Tourette, certainly reflecting the attitude of Charcot, in his elaborate treatise on hysteria fails to refer to the sphere of the sexual emotions even when enumerating the "agents provocateurs."[274]
The influence of fear is not denied by Breuer and Freud, but they have found that careful psychic analysis frequently shows that the shock of a commonplace "fear" is really rooted in a lesion of the sexual emotions. A typical and very simple illustration is furnished in a case, recorded by Breuer, in which a young girl of seventeen had her first hysterical attack after a cat sprang on her shoulders as she was going downstairs. Careful investigation showed that this girl had been the object of somewhat ardent attentions from a young man whose advances she had resisted, although her own sexual emotions had been aroused. A few days before, she had been surprised by this young man on these same dark stairs, and had forcibly escaped from his hands. Here was the real psychic traumatism, the operation of which merely became manifest in the cat. "But in how many cases," asks Breuer, "is a cat thus reckoned as a completely sufficient causa efficiens?"
In every case that they have investigated Breuer and Freud have found some similar secret lesion of the psychic sexual sphere. In one case a governess, whose training has been severely upright, is, in spite of herself and without any encouragement, led to experience for the father of the children under her care an affection which she refuses to acknowledge even to herself; in another, a young woman finds herself falling in love with her brother-in-law; again, an innocent girl suddenly discovers her uncle in the act of sexual intercourse with her playmate, and a boy on his way home from school is subjected to the coarse advances of a sexual invert. In nearly every case, as Freud eventually found reason to believe, a primary lesion of the sexual emotions dates from the period of puberty and frequently of childhood, and in nearly every case the intimately private nature of the lesion causes it to be carefully hidden from everyone, and even to be unacknowledged by the subject of it. In the earlier cases Breuer and Freud found that a slight degree of hypnosis is necessary to bring the lesion into consciousness, and the accuracy of the revelations thus obtained has been tested by independent witness. Freud has, however, long abandoned the induction of any degree of hypnosis; he simply tries to arrange that the patient shall feel absolutely free to tell her own story, and so proceeds from the surface downwards, slowly finding and piecing together such essential fragments of the history as may be recovered, in the same way he remarks, as the archæologist excavates below the surface and recovers and puts together the fragments of an antique statue. Much of the material found, however, has only a symbolic value requiring interpretation and is sometimes pure fantasy. Freud now attaches great importance to dreams as symbolically representing much in the subject's mental history which is otherwise difficult to reach.[275] The subtle and slender clues which Freud frequently follows in interpreting dreams cannot fail sometimes to arouse doubt in his readers' minds, but he certainly seems to have been often successful in thus reaching latent facts in consciousness. The primary lesion may thus act as "a foreign body in consciousness." Something is introduced into psychic life which refuses to merge in the general flow of consciousness. It cannot be accepted simply as other facts of life are accepted; it cannot even be talked about, and so submitted to the slow usure by which our experiences are worn down and gradually transformed. Breuer illustrates what happens by reference to the sneezing reflex. "When an irritation to the nasal mucous membrane for some reason fails to liberate this reflex, a feeling of excitement and tension arises. This excitement, being unable to stream out along motor channels, now spreads itself over the brain, inhibiting other activities.... In the highest spheres of human activity we may watch the same process." It is a result of this process that, as Breuer and Freud found, the mere act of confession may greatly relieve the hysterical symptoms produced by this psychic mechanism, and in some cases may wholly and permanently remove them. It is on this fact that they founded their method of treatment, devised by Breuer and by him termed the cathartic method, though Freud prefers to call it the "analytic" method. It is, as Freud points out, the reverse of the hypnotic method of suggestive treatment; there is the same difference, Freud remarks, between the two methods as Leonardo da Vinci found for the two technical methods of art, per via di porre and per via di levare; the hypnotic method, like painting, works by putting in, the cathartic or analytic method, like sculpture, works by taking out.[276]
It is part of the mechanism of this process, as understood by these authors, that the physical symptoms of hysteria are constituted, by a process of conversion, out of the injured emotions, which then sink into the background or altogether out of consciousness. Thus, they found the prolonged tension of nursing a near and dear relative to be a very frequent factor in the production of hysteria. For instance, an originally rheumatic pain experienced by a daughter when nursing her father becomes the symbol in memory of her painful psychic excitement, and this perhaps for several reasons, but chiefly because its presence in consciousness almost exactly coincided with that excitement. In another way, again, nausea and vomiting may become a symbol through the profound sense of disgust with which some emotional shock was associated. Then the symbol begins to have a life of its own, and draws hidden strength from the emotion with which it is correlated. Breuer and Freud have found by careful investigation that the pains and physical troubles of hysteria are far from being capricious, but may be traced in a varying manner to an origin in some incident, some pain, some action, which was associated with a moment of acute psychic agony. The process of conversion was an involuntary escape from an intolerable emotion, comparable to the physical pain sometimes sought in intense mental grief, and the patient wins some relief from the tortured emotions, though at the cost of psychic abnormality, of a more or less divided state of consciousness and of physical pain, or else anæsthesia. In Charcot's third stage of the hysterical convulsion, that of "attitudes passionnelles," Breuer and Freud see the hallucinatory reproduction of a recollection which is full of significance for the origin of the hysterical manifestations.
The final result reached by these workers is clearly stated by each writer. "The main observation of our predecessors," states Breuer,[277] "still preserved in the word 'hysteria,' is nearer to the truth than the more recent view which puts sexuality almost in the last line, with the object of protecting the patient from moral reproaches. Certainly the sexual needs of the hysterical are just as individual and as various in force as those of the healthy. But they suffer from them, and in large measure, indeed, they suffer precisely through the struggle with them, through the effort to thrust sexuality aside." "The weightiest fact," concludes Freud,[278] "on which we strike in a thorough pursuit of the analysis is this: From whatever side and from whatever symptoms we start, we always unfailingly reach the region of the sexual life. Here, first of all, an etiological condition of hysterical states is revealed.... At the bottom of every case of hysteria—and reproducible by an analytical effort after even an interval of long years—may be found one or more facts of precocious sexual experience belonging to earliest youth. I regard this as an important result, as the discovery of a caput Nili of neuropathology." Ten years later, enlarging rather than restricting his conception, Freud remarks: "Sexuality is not a mere deus ex machina which intervenes but once in the hysterical process; it is the motive force of every separate symptom and every expression of a symptom. The morbid phenomena constitute, to speak plainly, the patient's sexual activity."[279] The actual hysterical fit, Freud now states, may be regarded as "the substitute for a once practiced and then abandoned auto-erotic satisfaction," and similarly it may be regarded as an equivalent of coitus.[280]
It is natural to ask how this conception affects that elaborate picture of hysteria laboriously achieved by Charcot and his school. It cannot be said that it abolishes any of the positive results reached by Charcot, but it certainly alters their significance and value; it presents them in a new light and changes the whole perspective. With his passion for getting at tangible definite physical facts, Charcot was on very safe ground. But he was content to neglect the psychic analysis of hysteria, while yet proclaiming that hysteria is a purely psychic disorder. He had no cause of hysteria to present save only heredity. Freud certainly admits heredity, but, as he points out, the part it plays has been overrated. It is too vague and general to carry us far, and when a specific and definite cause can be found, the part played by heredity recedes to become merely a condition, the soil on which the "specific etiology" works. Here probably Freud's enthusiasm at first carried him too far and the most important modification he has made in his views occurs at this point: he now attaches a preponderant influence to heredity. He has realized that sexual activity in one form or another is far too common in childhood to make it possible to lay very great emphasis on "traumatic lesions" of this character, and he has also realized that an outcrop of fantasies may somewhat later develop on these childish activities, intervening between them and the subsequent morbid symptoms. He is thus led to emphasize anew the significance of heredity, not, however, in Charcot's sense, as general neuropathic disposition but as "sexual constitution." The significance of "infantile sexual lesions" has also tended to give place to that of "infantilism of sexuality."[281]
The real merit of Freud's subtle investigations is that—while possibly furnishing a justification of the imperfectly-understood idea that had floated in the mind of observers ever since the name "hysteria" was first invented—he has certainly supplied a definite psychic explanation of a psychic malady. He has succeeded in presenting clearly, at the expense of much labor, insight, and sympathy, a dynamic view of the psychic processes involved in the constitution of the hysterical state, and such a view seems to show that the physical symptoms laboriously brought to light by Charcot are largely but epiphenomena and by-products of an emotional process, often of tragic significance to the subject, which is taking place in the most sensitive recess of the psychic organism. That the picture of the mechanism involved, presented to us by Professor Freud, cannot be regarded as a final and complete account of the matter, may readily be admitted. It has developed in Freud's own hands, and some of the developments will require very considerable confirmation before they can be accepted as generally true.[282] But these investigations have at least served to open the door, which Charcot had inconsistently held closed, into the deeper mysteries of hysteria, and have shown that here, if anywhere, further research will be profitable. They have also served to show that hysteria may be definitely regarded as, in very many cases at least, a manifestation of the sexual emotions and their lesions; in other words, a transformation of auto-erotism.
The conception of hysteria so vigorously enforced by Charcot and his school is thus now beginning to appear incomplete. But we have to recognize that that incompleteness was right and necessary. A strong reaction was needed against a widespread view of hysteria that was in large measure scientifically false. It was necessary to show clearly that hysteria is a definite disorder, even when the sexual organs and emotions are swept wholly out of consideration; and it was also necessary to show that the lying and dissimulation so widely attributed to the hysterical were merely the result of an ignorant and unscientific misinterpretation of psychic elements of the disease. This was finally and triumphantly achieved by Charcot's school.
There is only one other point in the explanation of hysteria which I will here refer to, and that because it is usually ignored, and because it has relationship to the general psychology of the sexual emotions. I refer to that physiological hysteria which is the normal counterpart of the pathological hysteria which has been described in its physical details by Charcot, and to which alone the term should strictly be applied. Even though hysteria as a disease may be described as one and indivisible, there are yet to be found, among the ordinary and fairly healthy population, vague and diffused hysteroid symptoms which are dissipated in a healthy environment, or pass nearly unnoted, only to develop in a small proportion of cases, under the influence of a more pronounced heredity, or a severe physical or psychic lesion, into that definite morbid state which is properly called hysteria.
This diffused hysteroid condition may be illustrated by the results of a psychological investigation carried on in America by Miss Gertrude Stein among the ordinary male and female students of Harvard University and Radcliffe College. The object of the investigation was to study, with the aid of a planchette, the varying liability to automatic movements among normal individuals. Nearly one hundred students were submitted to experiment. It was found that automatic responses could be obtained in two sittings from all but a small proportion of the students of both sexes, but that there were two types of individual who showed a special aptitude. One type (probably showing the embryonic form of neurasthenia) was a nervous, high-strung, imaginative type, not easily influenced from without, and not so much suggestible as autosuggestible. The other type, which is significant from our present point of view, is thus described by Miss Stein: "In general the individuals, often blonde and pale, are distinctly phlegmatic. If emotional, decidedly of the weakest, sentimental order. They may be either large, healthy, rather heavy, and lacking in vigor or they may be what we call anæmic and phlegmatic. Their power of concentrated attention is very small. They describe themselves as never being held by their work; they say that their minds wander easily; that they work on after they are tired, and just keep pegging away. They are very apt to have premonitory conversations, they anticipate the words of their friends, they imagine whole conversations that afterward come true. The feeling of having been there is very common with them; that is, they feel under given circumstances that they have had that identical experience before in all its details. They are often fatalistic in their ideas. They indulge in day-dreams. As a rule, they are highly suggestible."[283]
There we have a picture of the physical constitution and psychic temperament on which the classical symptoms of hysteria might easily be built up.[284] But these persons were ordinary students, and while a few of their characteristics are what is commonly and vaguely called "morbid," on the whole they must be regarded as ordinarily healthy individuals. They have the congenital constitution and predisposition on which some severe psychic lesion at the "psychological moment" might develop the most definite and obstinate symptoms of hysteria, but under favorable circumstances they will be ordinary men and women, of no more than ordinary abnormality or ordinary power. They are among the many who have been called to hysteria at birth; they may never be among the few who are chosen.
We may have to recognize that on the side of the sexual emotions, as well as in general constitution, a condition may be traced among normal persons that is hysteroid in character, and serves as the healthy counterpart of a condition which in hysteria is morbid. In women such a condition Has been traced (though misnamed) by Dr. King.[285]
Dr. King describes what he calls "sexual hysteria in women," which he considers a chief variety of hysteria. He adds, however, that it is not strictly a disease, but simply an automatic reaction of the reproductive system, which tends to become abnormal under conditions of civilization, and to be perpetuated in a morbid form. In this condition he finds twelve characters: 1. Time of life, usually between puberty and climacteric. 2. Attacks rarely occur when subject is alone. 3. Subject appears unconscious, but is not really so. 4. She is instinctively ashamed afterward. 5. It occurs usually in single women, or in those, single or married, whose sexual needs are unsatisfied. 6. No external evidence of disease, and (as Aitken pointed out) the nates are not flattened; the woman's physical condition is not impaired, and she may be specially attractive to men. 7. Warmth of climate and the season of spring and summer are conducive to the condition. 8. The paroxysm in short and temporary. 9. While light touches are painful, firm pressure and rough handling give relief. 10. It may occur in the occupied, but an idle, purposeless life is conducive. 11. The subject delights in exciting sympathy and in being fondled and caressed. 12. There is defect of will and a strong stimulus is required to lead to action.
Among civilized women, the author proceeds, this condition does not appear to subserve any useful purpose. "Let us, however, go back to aboriginal woman—to woman of the woods and the fields. Let us picture ourselves a young aboriginal Venus in one of her earliest hysterical paroxysms. In doing so, let us not forget some of the twelve characteristics previously mentioned. She will not be 'acting her part' alone, or, if alone, it will be in a place where someone else is likely soon to discover her. Let this Venus be now discovered by a youthful Apollo of the woods, a man with fully developed animal instincts. He and she, like any other animals, are in the free field of Nature. He cannot but observe to himself: 'This woman is not dead; she breathes and is warm; she does not look ill; she is plump and rosy.' He speaks to her; she neither hears (apparently) nor responds. Her eyes are closed. He touches, moves, and handles her at his pleasure. She makes no resistance. What will this primitive Apollo do next? He will cure the fit, and bring the woman back to consciousness, satisfy her emotions, and restore her volition—not by delicate touches that might be 'agonizing' to her hyperesthetic skin, but by vigorous massage, passive motions, and succussion that would be painless. The emotional process on the part of the woman would end, perhaps, with mingled laughter, tears, and shame; and when accused afterward of the part which the ancestrally acquired properties of her nervous system had compelled her to act, as a preliminary to the event, what woman would not deny it and be angry? But the course of Nature having been followed, the natural purpose of the hysterical paroxysm accomplished, there would remain as a result of the treatment—instead of one discontented woman—two happy people, and the possible beginning of a third."
"Natural, primary sexual hysteria in woman," King concludes, "is a temporary modification of the nervous government of the body and the distribution of nerve-force (occurring for the most part, as we see it to-day, in prudish women of strong moral principle, whose volition has disposed them to resist every sort of liberty or approach from the other sex), consisting in a transient abdication of the general, volitional, and self-preservational ego, while the reins of government are temporarily assigned to the usurping power of the reproductive ego, so that the reproductive government overrules the government by volition, and thus, as it were, forcibly compels the woman's organism to so dispose itself, at a suitable time and place, as to allow, invite, and secure the approach of the other sex, whether she will or not, to the end that Nature's imperious demand for reproduction shall be obeyed."
This perhaps rather fantastic description is not a presentation of hysteria in the technical sense, but we may admit that it presents a state which, if not the real physiological counterpart of the hysterical convulsion, is yet distinctly analogous to the latter. The sexual orgasm has this correspondence with the hysterical fit, that they both serve to discharge the nervous centres and relieve emotional tension. It may even happen, especially in the less severe forms of hysteria, that the sexual orgasm takes place during the hysterical fit; this was found by Rosenthal, of Vienna, to be always the case in the semiconscious paroxysms of a young girl whose condition was easily cured;[286] no doubt such cases would be more frequently found if they were sought for. In severe forms of hysteria, however, it frequently happens, as so many observers have noted, that normal sexual excitement has ceased to give satisfaction, has become painful, perverted, paradoxical. Freud has enabled us to see how a shock to the sexual emotions, injuring the emotional life at its source, can scarcely fail sometimes to produce such a result. But the necessity for nervous explosion still persists.[287] It may, indeed, persist, even in an abnormally strong degree, in consequence of the inhibition of normal activities generally. The convulsive fit is the only form of relief open to the tension. "A lady whom I long attended," remarks Ashwell, "always rejoiced when the fit was over, since it relieved her system generally, and especially her brain, from painful irritation which had existed for several previous days." That the fit mostly fails to give real satisfaction, and that it fails to cure the disease, is due to the fact that it is a morbid form of relief. The same character of hysteria is seen, with more satisfactory results for the most part, in the influence of external nervous shock. It was the misunderstood influence of such shocks in removing hysteria which in former times led to the refusal to regard hysteria as a serious disease. During the Rebellion of 1745-46 in Scotland, Cullen remarks that there was little hysteria. The same was true of the French Revolution and of the Irish Rebellion, while Rush (in a study On the Influence of the American Revolution on the Human Body) observed that many hysterical women were "restored to perfect health by the events of the time." In such cases the emotional tension is given an opportunity of explosion in new and impersonal channels, and the chain of morbid personal emotions is broken.
It has been urged by some that the fact that the sexual orgasm usually fails to remove the disorder in true hysteria excludes a sexual factor of hysteria. It is really, one may point out, an argument in favor of such an element as one of the factors of hysteria. If there were no initial lesion of the sexual emotions, if the natural healthy sexual channel still remained free for the passage of the emotional overflow, then we should expect that it would much oftener come into play in the removal of hysteria. In the more healthy, merely hysteroid condition, the psychic sexual organism is not injured, and still responds normally, removing the abnormal symptoms when allowed to do so. It is the confusion between this almost natural condition and the truly morbid condition, alone properly called hysteria, which led to the ancient opinion, inaugurated by Plato and Hippocrates, that hysteria may be cured by marriage.[288] The difference may be illustrated by the difference between a distended bladder which is still able to contract normally on its contents when at last an opportunity of doing so is afforded and the bladder in which distension has been so prolonged that nervous control had been lost and spontaneous expulsion has become impossible. The first condition corresponds to the constitution, which, while simulating the hysterical condition, is healthy enough to react normally in spite of psychic lesions; the second corresponds to a state in which, owing to the prolonged stress of psychic traumatism,—sexual or not,—a definite condition of hysteria has arisen. The one state is healthy, though abnormal; the other is one of pronounced morbidity.
The condition of true hysteria is thus linked on to almost healthy states, and especially to a condition which may be described as one of sex-hunger. Such a suggestion may help us to see these puzzling phenomena in their true nature and perspective.
At this point I may refer to the interesting parallel, and probable real relationship, between hysteria and chlorosis. As Luzet has said, hysteria and chlorosis are sisters. We have seen that there is some ground for regarding hysteria as an exaggerated form of a normal process which is really an auto-erotic phenomenon. There is some ground, also, for regarding chlorosis as the exaggeration of a physiological state connected with sexual conditions, more specifically with the preparation for maternity. Hysteria is so frequently associated with anæmic conditions that Biernacki has argued that such conditions really constitute the primary and fundamental cause of hysteria (Neurologisches Centralblatt, March, 1898). And, centuries before Biernacki, Sydenham had stated his belief that poverty of the blood is the chief cause of hysteria.
It would be some confirmation of this position if we could believe that chlorosis, like hysteria, is in some degree a congenital condition. This was the view of Virchow, who regarded chlorosis as essentially dependent on a congenital hyoplasia of the arterial system. Stieda, on the basis of an elaborate study of twenty-three cases, has endeavored to prove that chlorosis is due to a congenital defect of development (Zeitschrift für Geburtshülfe und Gynäkologie, vol. xxxii, Part I, 1895). His facts tend to prove that in chlorosis there are signs of general ill-development, and that, in particular, there is imperfect development of the breasts and sexual organs, with a tendency to contracted pelvis. Charrin, again, regards utero-ovarian inadequacy as at least one of the factors of chlorosis. Chlorosis, in its extreme form, may thus be regarded as a disorder of development, a sign of physical degeneracy. Even if not strictly a cause, a congenital condition may, as Stockman believes (British Medical Journal, December 14, 1895), be a predisposing influence.
However it may be in extreme cases, there is very considerable evidence to indicate that the ordinary anæmia of young women may be due to a storing up of iron in the system, and is so far normal, being a preparation for the function of reproduction. Some observations of Bunge's seem to throw much light on the real cause of what may be termed physiological chlorosis. He found by a series of experiments on animals of different ages that young animals contain a much greater amount of iron in their tissues than adult animals; that, for instance, the body of a rabbit an hour after birth contains more than four times as much iron as that of a rabbit two and a half months old. It thus appears probable that at the period of puberty, and later, there is a storage of iron in the system preparatory to the exercise of the maternal functions. It is precisely between the ages of fifteen and twenty-three, as Stockman found by an analysis of his own cases (British Medical Journal, December 14, 1895), that the majority of cases occur; there was, indeed, he found, no case in which the first onset was later than the age of twenty-three. A similar result is revealed by the charts of Lloyd Jones, which cover a vastly greater number of cases.
We owe to Lloyd Jones an important contribution to the knowledge of chlorosis in its physiological or normal relationships. He has shown that chlorosis is but the exaggeration of a condition that is normal at puberty (and, in many women, at each menstrual period), and which, there is good reason to believe, even has a favorable influence on fertility. He found that light-complexioned persons are more fertile than the dark-complexioned, and that at the same time the blood of the latter is of less specific gravity, containing less hæmoglobin. Lloyd Jones also reached the generalization that girls who have had chlorosis are often remarkably pretty, so that the tendency to chlorosis is associated with all the sexual and reproductive aptitudes that make a woman attractive to a man. His conclusion is that the normal condition of which chlorosis is the extreme and pathological condition, is a preparation for motherhood (E. Lloyd Jones, "Chlorosis: The Special Anæmia of Young Women," 1897; also numerous reports to the British Medical Association, published in the British Medical Journal. There was an interesting discussion of the theories of chlorosis at the Moscow International Medical Congress, in 1898; see proceedings of the congress, volume in, section v, pp. 224 et seq.).
We may thus, perhaps, understand why it is that hysteria and anæmia are often combined, and why they are both most frequently found in adolescent young women who have yet had no sexual experiences. Chlorosis is a physical phenomenon; hysteria, largely a psychic phenomenon; yet, both alike may, to some extent at least, be regarded as sexual aptitude showing itself in extreme and pathological forms.
[251]
Genèse et Nature de l'Hystérie, 1898; and, for Sollier's latest statement, see "Hystérie et Sommeil," Archives de Neurologie, May and June, 1907. Lombroso (L'Uomo Delinquente, 1889, vol. ii, p. 329), referring to the diminished metabolism of the hysterical, had already compared them to hibernating animals, while Babinsky states that the hysterical are in a state of subconsciousness, a state, as Metchnikoff remarks (Essais optimistes, p. 270), reminiscent of our prehistoric past.
[252]Professor Freud, while welcoming the introduction of the term "auto-erotism," remarks that it should not be made to include the whole of hysteria. This I fully admit, and have never questioned. Hysteria is far too large and complex a phenomenon to be classed as entirely a manifestation of auto-erotism, but certain aspects of it are admirable illustrations of auto-erotic transformation.
[253]The hysterical phenomenon of globus hystericus was long afterward attributed to obstruction of respiration by the womb. The interesting case has been recorded by E. Bloch (Wiener Klinische Wochenschrift, 1907, p. 1649) of a lady who had the feeling of a ball rising from her stomach to her throat, and then sinking. This feeling was associated with thoughts of her husband's rising and falling penis, and was always most liable to occur when she wished for coitus.
[254]As Gilles de la Tourette points out, it is not difficult to show that epilepsy, the morbus sacer of the ancients, owed much of its sacred character to this confusion with hysteria. Those priestesses who, struck by the morbus sacer, gave forth their oracles amid convulsions, were certainly not the victims of epilepsy, but of hysteria (Traité de l'Hystérie, vol. i, p. 3).
[255]Aretæus, On the Causes and Symptoms of Acute Diseases, Book ii, Chapter II.
[256]It may be noted that this treatment furnishes another instance of the continuity of therapeutic methods, through all changes of theory, from the earliest to the latest times. Drugs of unpleasant odor, like asafœtida, have always been used in hysteria, and scientific medicine to-day still finds that asafœtida is a powerful sedative to the uterus, controlling nervous conditions during pregnancy and arresting uterine irritation when abortion is threatened (see, e.g., Warman, Der Frauenarzt, August, 1895). Again, the rubbing of fragrant ointments into the sexual regions is but a form of that massage which is one of the modern methods of treating the sexual disorders of women.
[257]Les Démoniaques dans l'Art, 1887; Les Malades et les Difformes dans l'Art, 1889.
[258]Glafira Abricosoff, of Moscow, in her Paris thesis, L'Hystérie aux xvii et xviii siécles, 1897, presents a summary of the various views held at this time; as also Gilles de la Tourette, Traité de l'Hystérie, vol. i, Chapter I.
[259]Edinburgh Medical Journal, June, 1883, p. 1123, and Mental Diseases, 1887, p. 488.
[260]Hegar, Zusammenhang der Geschlechtskrankheiten mit nervösen Leiden, Stuttgart, 1885. (Hegar, however, went much further than this, and was largely responsible for the surgical treatment of hysteria now generally recognized as worse than futile.) Balls-Headley, "Etiology of Nervous Diseases of the Female Genital Organs," Allbutt and Playfair, System of Gynecology, 1896, p. 141.
[261]Lombroso and Ferrero, La Donna Delinquente, 1893, pp. 613-14.
[262]Charcot and Marie, article on "Hysteria," Tuke's Dictionary of Psychological Medicine.
[263]Axenfeld and Huchard, Traité des Névroses, 1883, pp. 1092-94. Icard (La Femme pendant la Période Menstruelle, pp. 120-21) has also referred to recorded cases of hysteria in animals (Coste's and Peter's cases), as has Gilles de la Tourette (op. cit., vol. i, p. 123). See also, for references, Féré, L'Instinct Sexuel, p. 59.
[264]Man and Woman, 4th ed., p. 326. A distinguished gynæcologist, Matthews Duncan, had remarked some years earlier (Lancet, May 18, 1889) that hysteria, though not a womb disease, "especially attaches itself to the generative system, because the genital system, more than any other, exerts emotional power over the individual, power also in morals, power in social questions."
[265]Gilles de la Tourette, Archives de Tocologie et de Gynécologie, June, 1895.
[266]Rivista Sperimentale di Freniatria, 1897, p. 290; summarized in the Journal of Mental Science, January, 1898.
[267]From the earliest times it was held that menstruation favors hysteria; more recently, Landouzy recorded a number of observations showing that hysterical attacks coincide with perfectly healthy menstruation; while Ball has maintained that it is only during menstruation that hysteria appears in its true color. See the opinions collected by Icard, La Femme pendant la Période Menstruelle, pp. 75-81.
[268]Krafft-Ebing, "Ueber Neurosen und Psychosen durch Sexuelle Abstinenz," Jahrbücher für Psychiatrie, vol. iii, 1888. It must, however, be added that the relief of hysteria by sexual satisfaction is not rare, and that Rosenthal finds that the convulsions are thus diminished. (Allgemeine Wiener Medizinal-Zeitung, Nos. 46 and 47, 1887.) So they are also, in simple and uncomplicated cases, according to Mongeri, by pregnancy.
[269]"All doctors who have patients in convents," remarks Marro (La Pubertà, p. 338), "know how hysteria dominates among them;" he adds that his own experience confirms that of Raciborski, who found that nuns devoted to the contemplative life are more liable to hysteria than those who are occupied in teaching or in nursing. It must be added, however, that there is not unanimity as to the prevalence of hysteria in convents. Brachet was of the same opinion as Briquet, and so considered it rare. Imbert-Goubeyre, also (La Stigmatisation, p. 436) states that during more than forty years of medical life, though he has been connected with a number of religious communities, he has not found in them a single hysterical subject, the reason being, he remarks, that the unbalanced and extravagant are refused admission to the cloister.
[270]Parent-Duchâtelet, De la Prostitution, vol. i, p. 242.
[271]It may not be unnecessary to point out that here and throughout, in speaking of the psychic mechanism of hysteria, I do not admit that any process can be purely psychic. As Féré puts it in an admirable study of hysteria (Twentieth Century Practice of Medicine, 1897, vol. x, p. 556): "In the genesis of hysterical troubles everything takes place as if the psychical and the somatic phenomena were two aspects of the same biological fact."
[272]Pierre Janet, L'Automatisme Psychologique, 1889; L'Etat mental des Hystériques, 1894; Névroses et Idées fixes, 1898; Breuer und Freud, Studien über Hysterie, Vienna, 1895; the best introduction to Freud's work is, however, to be found in the two series of his Sammlung Kleiner Schriften zur Neurosenlehre, published in a collected form in 1906 and 1909. It may be added that a useful selection of Freud's papers has lately (1909) been published in English.
[273]We might, perhaps, even say that in hysteria the so-called higher centres have an abnormally strong inhibitory influence over the lower centres. Gioffredi (Gazzetta degli Ospedali, October 1, 1895) has shown that some hysterical symptoms, such as mutism, can be cured by etherization, thus loosening the control of the higher centres.
[274]Charcot's school could not fail to recognize the erotic tone which often dominates hysterical hallucinations. Gilles de la Tourette seeks to minimize it by the remark that "it is more mental than real." He means to say that it is more psychic than physical, but he implies that the physical element in sex is alone "real," a strange assumption in any case, as well as destructive of Gilles de la Tourette's own fundamental assertion that hysteria is a real disease and yet purely psychic.
[275]See, e.g., his substantial volume, Die Traumdeutung, 1900, 2d ed. 1909.
[276]Sammlung, first series, p. 208.
[277]Studien über Hysterie, p. 217.
[278]Sammlung, first series, p. 162.
[279]Sammlung, second series, p. 102.
[280]Ib. p. 146.
[281]Sammlung, first series, p. 229. Freud has developed his conception of sexual constitution in Drei Abhandlungen zur Sexualtheorie, 1905.
[282]As Moll remarks, Freud's conceptions are still somewhat subjective, and in need of objective demonstration; but whatever may be thought of their theories, he adds, there can be no doubt that Breuer and Freud have done a great service by calling attention to the important action of the sexual life on the nervous system.
[283]Gertrude Stein, "Cultivated Motor Automatism," Psychological Review, May, 1898.
[284]Charcot's most faithful followers refuse to recognize a "hysteric temperament," and are quite right, if such a conception is used to destroy the conception of hysteria as a definite disease. We cannot, however, fail to recognize a diathesis which, while still apparently healthy, is predisposed to hysteria. So distinguished a disciple of Charcot as Janet thoroughly recognizes this, and argues (L'Etat mental, etc., p. 298) that "we may find in the habits, the passions, the psychic automatism of the normal man, the germ of all hysterical phenomena." Féré held a somewhat similar view.
[285]A. F. A. King, "Hysteria," American Journal of Obstetrics, May 18, 1891.
[286]M. Rosenthal, Diseases of the Nervous System, vol. ii, p. 44. Féré notes similar cases (Twentieth Century Practice of Medicine, vol. x, p. 551). Long previously, Gall had recorded the case of a young widow of ardent temperament who had convulsive attacks, apparently of hysterical nature, which always terminated in sexual orgasm (Fonctions du Cerveau, 1825, vol. iii, p. 245).
[287]There seems to be a greater necessity for such explosive manifestations in women than in men, whatever the reason may be. I have brought together some of the evidence pointing in this direction in Man and Woman, 4th ed., revised and enlarged, Chapters xii and xiii.
[288]There is no doubt an element of real truth in this ancient belief, though it mainly holds good of minor cases of hysteria. Many excellent authorities accept it. "Hysteria is certainly common in the single," Herman remarks (Diseases of Women, 1898, p. 33), "and is generally cured by a happy marriage." Löwenfeld (Sexualleben und Nervenleiden, p. 153) says that "it cannot be denied that marriage produces a beneficial change in the general condition of many hysterical patients," though, he adds, it will not remove the hysterical temperament. The advantage of marriage for the hysterical is not necessarily due, solely or at all, to the exercise of sexual functions. This is pointed out by Mongeri, who observes (Allgemeine Zeitschrift für Psychiatrie, 1901, Heft 5, p. 917): "I have known and treated several hysterical girls who are now married, and do not show the least neuropathic indications. Some of these no longer have any wish for sexual gratification, and even fulfil their marital duties unwillingly, though loving their husbands and living with them in an extremely happy way. In my opinion, marriage is a sovereign remedy for neuropathic women, who need to find a support in another personality, able to share with them the battle of life."
III.
The Prevalence of Masturbation—Its Occurrence in Infancy and Childhood—Is it More Frequent in Males or Females?—After Adolescence Apparently more Frequent in Women—Reasons for the Sexual Distribution of Masturbation—The Alleged Evils of Masturbation—Historical Sketch of the Views Held on This Point—The Symptoms and Results of Masturbation—Its Alleged Influence in Causing Eye Disorders—Its Relation to Insanity and Nervous Disorders—The Evil Effects of Masturbation Usually Occur on the Basis of a Congenitally Morbid Nervous System—Neurasthenia Probably the Commonest Accompaniment of Excessive Masturbation—Precocious Masturbation Tends to Produce Aversion to Coitus—Psychic Results of Habitual Masturbation—Masturbation in Men of Genius—Masturbation as a Nervous Sedative—Typical Cases—The Greek Attitude toward Masturbation—Attitude of the Catholic Theologians—The Mohammedan Attitude—The Modern Scientific Attitude—In What Sense is Masturbation Normal?—The Immense Part in Life Played by Transmuted Auto-erotic Phenomena.
The foregoing sketch will serve to show how vast is the field of life—of normal and not merely abnormal life—more or less infused by auto-erotic phenomena. If, however, we proceed to investigate precisely the exact extent, degree, and significance of such phenomena, we are met by many difficulties. We find, indeed, that no attempts have been made to study auto-erotic phenomena, except as regards the group—a somewhat artificial group, as I have already tried to show—collected under the term "masturbation" while even here such attempts have only been made among abnormal classes of people, or have been conducted in a manner scarcely likely to yield reliable results.[289] Still there is a certain significance in the more careful investigations which have been made to ascertain the precise frequency of masturbation.
Berger, an experienced specialist in nervous diseases, concluded, in his Vorlesungen, that 99 per cent. of young men and women masturbate occasionally, while the hundredth conceals the truth;[290] and Hermann Cohn appears to accept this statement as generally true in Germany. So high an estimate has, of course, been called in question, and, since it appears to rest on no basis of careful investigation, we need not seriously consider it. It is useless to argue on suppositions; we must cling to our definite evidence, even though it yields figures which are probably below the mark. Rohleder considers that during adolescence at least 95 per cent. of both sexes masturbate, but his figures are not founded on precise investigation.[291] Julian Marcuse, on the basis of his own statistics, concludes that 92 per cent. male individuals have to some extent masturbated in youth. Perhaps, also, weight attaches to the opinion of Dukes, physician to Rugby School, who states that from 90 to 95 per cent. of all boys at boarding school masturbate.[292] Seerley, of Springfield, Mass., found that of 125 academic students only 8 assured him they had never masturbated; while of 347, who answered his questions, 71 denied that they practiced masturbation, which seems to imply that 79 per cent. admitted that they practiced it.[293] Brockman, also in America, among 232 theological students, of the average age of 23½ years and coming from various parts of the United States, found that 132 spontaneously admitted that masturbation was their most serious temptation and all but one of these admitted that he yielded, 69 of them to a considerable extent. This is a proportion of at least 56 per cent., the real proportion being doubtless larger, since no question had been asked as to sexual offenses; 75 practiced masturbation after conversion, and 24 after they had decided to become ministers; only 66 mentioned sexual intercourse as their chief temptation; but altogether sexual temptations outnumbered all others together.[294] Moraglia, who made inquiry of 200 women of the lower class in Italy, found that 120 acknowledged either that they still masturbate or that they had done so during a long period.[295] Gualino found that 23 per cent. men of the professional classes in North Italy masturbate about puberty; no account was taken of those who began later. "Here in Switzerland," a correspondent writes, "I have had occasion to learn from adult men, whom I can trust, that they have reached the age of twenty-five, or over, without sexual congress. 'Wir haben nicht dieses Bedürfniss,' is what they say. But I believe that, in the case of the Swiss mountaineers, moderate onanism is practiced, as a rule." In hot countries the same habits are found at a more precocious age. In Venezuela, for instance, among the Spanish creoles, Ernst found that in all classes boys and girls are infested with the vice of onanism. They learn it early, in the very beginning of life, from their wet-nurses, generally low Mulatto women, and many reasons help to foster the habit; the young men are often dissipated and the young women often remain single.[296] Niceforo, who shows a special knowledge of the working-girl class at Rome, states that in many milliners' and dressmakers' workrooms, where young girls are employed, it frequently happens that during the hottest hours of the day, between twelve and two, when the mistress or forewoman is asleep, all the girls without exception give themselves up to masturbation.[297] In France a country curé assured Debreyne that among the little girls who come up for their first communion, 11 out of 12 were given to masturbation.[298] The medical officer of a Prussian reformatory told Rohleder that nearly all the inmates over the age of puberty masturbated. Stanley Hall knew a reform school in America where masturbation was practiced without exception, and he who could practice it oftenest was regarded with hero-worship.[299] Ferriani, who has made an elaborate study of youthful criminality in Italy, states that even if all boys and girls among the general population do not masturbate, it is certainly so among those who have a tendency to crime. Among 458 adult male criminals, Marro (as he states in his Caratteri dei Delinquenti) found that only 72 denied masturbation, while 386 had practiced it from an early age, 140 of them before the age of thirteen. Among 30 criminal women Moraglia found that 24 acknowledged the practice, at all events in early youth (8 of them before the age of 10, a precocity accompanied by average precocity in menstruation), while he suspected that most of the remainder were not unfamiliar with the practice. Among prostitutes of whatever class or position Moraglia found masturbation (though it must be pointed out that he does not appear to distinguish masturbation very clearly from homosexual practices) to be universal; in one group of 50 prostitutes everyone had practiced masturbation at some period; 28 began between the ages of 6 and 11; 19, between 12 and 14, the most usual period—a precocious one—of commencing puberty; the remaining 3 at 15 and 16; the average age of commencing masturbation, it may be added, was 11, while that of the first sexual intercourse was 15.[300] In a larger group of 180 prostitutes, belonging to Genoa, Turin, Venice, etc., and among 23 "elegant cocottes," of Italian and foreign origin, Moraglia obtained the same results; everyone admitted masturbation, and not less than 113 preferred masturbation, either solitary or mutual, to normal coitus. Among the insane, as among idiots, masturbation is somewhat more common among males, according to Blandford, in England, as also it is in Germany, according to Näcke,[301] while Venturi, in Italy, has found it more common among females.[302]
There appears to be no limit to the age at which spontaneous masturbation may begin to appear. I have already referred to the practice of thigh-rubbing in infants under one year of age. J. P. West has reported in detail 3 cases of masturbation in very early childhood—2 in girls, 1 in a boy—in which the practice had been acquired spontaneously, and could only be traced to some source of irritation in pressure from clothing, etc.[303] Probably there is often in such cases some hereditary lack of nervous stability. Block has recorded the case of a girl—very bright for her age, though excessively shy and taciturn—who began masturbating spontaneously at the age of two; in this case the mother had masturbated all her life, even continuing the practice after marriage, and, though she succeeded in refraining during pregnancy, her thoughts still dwelt upon it, while the maternal grandmother had died in an asylum from "masturbatory insanity."
Freud considers that auto-erotic manifestations are common in infancy, and that the rhythmic function of any sensitive spot, primarily the lips, may easily pass into masturbation. He regards the infantile manifestations of which thumb-sucking is the most familiar example (Lüdeln or Lutschen in German) as auto-erotic, the germ arising in sucking the breasts since the lips are an erogenous zone which may easily be excited by the warm stream of milk. But this only occurs, he points out, in subjects in whom the sensitivity of the lip zone is heightened and especially in those who at a later age are liable to become hysterical.[304] Shuttleworth also points out that the mere fidgetiness of a neurotic infant, even when only a few months old, sometimes leads to the spontaneous and accidental discovery of pleasurable sexual sensations, which for a time appease the restlessness of nervous instability, though a vicious circle is thus established. He has found that, especially among quite young girls of neurotic heredity, self-induced excitement, often in the form of thigh-friction, is more common than is usually supposed.[305]