It was not possible any longer to maintain the womb theory of Hippocrates in its crude form, but in modified forms, and especially with the object of preserving the connection which many observers continued to find between hysteria and the sexual emotions, it still found supporters in the eighteenth and even the nineteenth centuries. James, in the middle of the eighteenth century, returned to the classical view, and in his Dictionary of Medicine maintained that the womb is the seat of hysteria. Louyer Villermay in 1816 asserted that the most frequent causes of hysteria are deprivation of the pleasures of love, griefs connected with this passion, and disorders of menstruation. Foville in 1833 and Landouzy in 1846 advocated somewhat similar views. The acute Laycock in 1840 quoted as "almost a medical proverb" the saying, "Salacitas major, major ad hysteriam proclivitas," fully indorsing it. More recently still Clouston has defined hysteria as "the loss of the inhibitory influence exercised on the reproductive and sexual instincts of women by the higher mental and moral functions" (a position evidently requiring some modification in view of the fact that hysteria is by no means confined to women), while the same authority remarks that more or less concealed sexual phenomena are the chief symptoms of "hysterical insanity."[[259]] Two gynæcologists of high position in different parts of the world, Hegar in Germany and Balls-Headley in Australia, attribute hysteria, as well as anæmia, largely to unsatisfied sexual desire, including the non-satisfaction of the "ideal feelings."[[260]] Lombroso and Ferrero, again, while admitting that the sexual feelings might be either heightened or depressed in hysteria, referred to the frequency of what they termed "a paradoxical sexual instinct" in the hysterical, by which, for instance, sexual frigidity is combined with intense sexual pre-occupations; and they also pointed out the significant fact that the crimes of the hysterical nearly always revolve around the sexual sphere.[[261]] Thus, even up to the time when the conception of hysteria which absolutely ignored and excluded any sexual relationship whatever had reached its height, independent views favoring such a relationship still found expression.
Of recent years, however, such views usually aroused violent antagonism. The main current of opinion was with Briquet (1859), who, treating the matter with considerable ability and a wide induction of facts, indignantly repelled the idea that there is any connection between hysteria and the sexual facts of life, physical or psychic. As he himself admitted, Briquet was moved to deny a sexual causation of hysteria by the thought that such an origin would be degrading for women ("a quelque chose de dégradant pour les femmes").
It was, however, the genius of Charcot, and the influence of his able pupils, which finally secured the overthrow of the sexual theory of hysteria. Charcot emphatically anathematized the visceral origin of hysteria; he declared that it is a psychic disorder, and to leave no loop-hole of escape for those who maintained a sexual causation he asserted that there are no varieties of hysteria, that the disease is one and indivisible. Charcot recognized no primordial cause of hysteria beyond heredity, which here plays a more important part than in any other neuropathic condition. Such heredity is either direct or more occasionally by transformation, any deviation of nutrition found in the ancestors (gout, diabetes, arthritis) being a possible cause of hysteria in the descendants. "We do not know anything about the nature of hysteria," Charcot wrote in 1892; "we must make it objective in order to recognize it. The dominant idea for us in the etiology of hysteria is, in the widest sense, its hereditary predisposition. The greater number of those suffering from this affection are simply born hystérisables, and on them the occasional causes act directly, either through autosuggestion or by causing derangement of general nutrition, and more particularly of the nutrition of the nervous system."[[262]] These views were ably and decisively stated in Gilles de la Tourette's Traité de l'Hystérie, written under the inspiration of Charcot.
While Charcot's doctrine was thus being affirmed and generally accepted, there were at the same time workers in these fields who, though they by no means ignored this doctrine of hysteria or even rejected it, were inclined to think that it was too absolutely stated. Writing in the Dictionary of Psychological Medicine at the same time as Charcot, Donkin, while deprecating any exclusive emphasis on the sexual causation, pointed out the enormous part played by the emotions in the production of hysteria, and the great influence of puberty in women due to the greater extent of the sexual organs, and the consequently large area of central innervation involved, and thus rendered liable to fall into a state of unstable equilibrium. Enforced abstinence from the gratification of any of the inherent and primitive desires, he pointed out, may be an adequate exciting cause. Such a view as this indicated that to set aside the ancient doctrine of a physical sexual cause of hysteria was by no means to exclude a psychic sexual cause. Ten years earlier Axenfeld and Huchard had pointed out that the reaction against the sexual origin of hysteria was becoming excessive, and they referred to the evidence brought forward by veterinary surgeons showing that unsatisfied sexual desire in animals may produce nervous symptoms very similar to hysteria.[[263]] The present writer, when in 1894 briefly discussing hysteria as an element in secondary sexual characterization, ventured to reflect the view, confirmed by his own observation, that there was a tendency to unduly minimize the sexual factor in hysteria, and further pointed out that the old error of a special connection between hysteria and the female sexual organs, probably arose from the fact that in woman the organic sexual sphere is larger than in man.[[264]]
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]]