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A DIFFERENT DRUMMER: ROBERT B. CARTER AND NINETEENTH CENTURY HYSTERIA ALISON KANE, B.A. Department of Clinical Psychology Fordham University Bronx, New York ERic T. CARLSON, M.D. Director Section on the History of Psychiatry New York Hospital-Cornell Medical Center New York, New York

F EW psychiatrists, psychologists, or other workers in the field of mental health have ever heard of the 19th century physician Robert B. Carter. When his writings on hysteria are mentioned in modern publications the references to him are very brief, and they treat his views merely as an interesting footnote or side issue.1 Nevertheless, Carter's theories on the disease are as sound and logical as those of the older and better established physicians of his day, and, in many respects, more progressive. This paper will investigate Carter's ideas on hysteria within the context of 19th century medicine. Robert Brudenell Carter was born in 1828 in Little Wittenham, a small English village not far from London. He was educated in private schools and began his medical studies as an apprentice to a general practitioner, undoubtedly Dr. Stephen Mackenzie, who shared his knowledge of hysteria with Carter.2 When Carter was 19 he entered the medical school of the London Hospital, and at 23 he became a member of the Royal College of Surgeons. Since he lacked the money necessary to complete his training for the Fellowship of the Royal College of Surgeons, he opened a practice in the north of London. During this time he wrote his two works on hysteria. He hurried to finish the second book because in 1854 he left for Turkey to serve as staff surgeon during the Crimean War. For reasons that are still unknown, when Carter returned to England after the war his interests completely changed direction and he devoted the rest of his medical career to ophthalmology. In 1868 he moved to London and was

Vol. 58, No. 6, September 1982 520 A. KANE AND E. 5 2A AEAD .TT. CARLSONALO elected a member of what is now the Royal Eye Hospital; he had become a Fellow of the Royal College of Surgeons four years earlier. From 1870 to 1883 he was ophthalmic surgeon to St. George's Hospital and lecturer in ophthalmic surgery at the hospital's medical school. He also conducted a large ophthalmic practice and found time to write regular articles for both the Lancet and the London Times. According to all accounts, Carter was very successful in his field. As one person testified, "He was a popular man and a capital speaker," and as an ophthalmic surgeon he was ''one of the most accomplished men of his day.'"3 After a long and productive life, Robert Carter died in 1918, at the age of 91. During the period when Carter wrote about hysteria, English physicians had conflicting opinions about the description, etiology, and treatment of the condition. The least controversy appears in the various descriptions of the disease. Virtually all accounts written during the 1840s and early 1 850s state that hysteria is primarily a woman's disease but in rare instances it occurs in men. The condition is not limited to one socioeco- nomic class, but can strike any person, rich or poor. Although the most obvious characteristic of hysteria is its acute paroxysm, or fit, it can manifest a strikingly wide range of symptoms. In fact, most physicians stressed that hysterical symptoms are so varied that they can mimic almost any known disease. Although descriptions of hysterical paroxysms differ in details, a mod- erately severe episode might be characterized as follows: Preceding the paroxysm, the patient may experience a sense of general uneasiness, headache, and cramp. The paroxysm itself often starts with the feeling that a ball or solid body is located in the abdomen. This peculiar sensation of "globus" ascends through the chest and into the neck, where it becomes lodged in the throat. Other symptoms may follow, including convulsions, paralysis, a feeling of coldness and stiffness in the legs or trunk of the body, noise in the ears, vertigo, or loss of consciousness. The entire paroxysm can last from a few minutes to several hours, and often ends with a flood of tears or a burst of laughter, a sudden outcry, or excretion of a large quantity of pale urine. Once the fit is over, the patient may have no recollection of what occurred during it, yet at the same time may be able to repeat what others discussed around her during that period. If the paroxysm was the only symptomatic episode involved in hysteria, the disease would be relatively easy to diagnose. Unfortunately for 19th century physicians, a host of other complaints could emerge during the course of the illness. Various accounts of the disease list such symptoms

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as nausea and vomiting, anorexia or excessive hunger, menstrual and uterine disorders, constipation, neuralgia, coughing or sneezing fits, respiratory problems, bloody or urinous discharges from the skin and sense organs, ischuria, sensory disturbances, swelling of joints, spinal tender- ness, and paralysis of every conceivable type. Some cases might include sleeplessness, somnambulism, catalepsy, delirium, spectral illusions, or double consciousness. Symptoms could be even more unusual, running the gamut from howl- ing and panting, to simulated pregnancy, to "clavus hystericus," the impression that a nail is being driven into one's forehead. In the middle of the 19th century, physicians were describing psychological as well as physical symptoms. The hysterical patient is almost always portrayed as overly sensitive and easily excited. Not only does she display excessive emotional responses in the face of ordinary occurrences, she also tends to exaggerate her symptoms and any suffering she is going through. She may exhibit capricious preferences or aversions to the people and objects around her. Sometimes the patient appears restless and impa- tient; her movements are quick and hurried, her behavior nervous and fidgety. At other times she seems bored, listless, indifferent toward life. And, whatever her mood, it is liable to change from one hour to the next. At her worst, a hysteric displays "insane cunning," aimed at deceiving the people around her, a motive that could lead an otherwise dignified hysterical lady to lie outrageously. Although the above characteristics fit our contemporary conception of a hysterical personality, Carter and his colleagues did not extract this hypothesis from their general descriptions of hysterical symptoms, even though they occasionally did speak of a "hysterical temperament." Presented with such a wide and confusing range of hysterical symptoms, it was extremely difficult for physicians to arrive at a satisfactory etiological theory of the disease. By the 19th century most physicians realized that the uterus was not the primary seat of hysteria, and also agreed that hysteria involved the nervous system in some way. Beyond this, specific theories on causation varied almost as much as the hysterical symptoms. Robert Carter first published his ideas about the disease in 1853, in his compact and well organized book, On the Pathology and Treatment of Hysteria. Carter took a new direction in explaining the etiology of the illness. Unlike most contemporary English physicians, he emphasized the influence of emotions on the nervous system and the body. Before

Vol. 58, No. 6, September 1982 522 A. KANE 52 A.KN ANDN E..TT. CARLSONALO discussing his specific theory of hysteria, it will be helpful to review some of his views on the structure and function of the nervous system in his first book, but he expands and elaborates on it in his second book, On the Influence of Education and Training in Preventing Diseases of the Ner- vous System (1855). The nervous system, as Carter described it, includes both nerves and "nervous centres." The sympathetic or ganglionic system subserves growth and nutrition, while motion, sensation, and thought arise from the cerebrospinal axis. The nerves serve as conductors between other parts of the body and the four nervous centers, which include the cerebrum, the sensorium, the cerebellum, and the spinal cord. The spinal cord is concerned with producing motion, and all of the body's efferent nerves, plus most of its afferent nerves, are connected to it. The sensorium, located at the summit of the cord and next to the brain, is the seat of all bodily sensation and the feelings connected with the brain's ideas, although it, too, is involved in producing some movement. Like the spinal cord, it receives some afferent nerves from the sensory organs and from the body surface. The "crowning portion," or cerebrum, is the locus of human volition and of such intellectual functions as thought, memory, imagination, judgment, and so forth. The cerebellum puts various coordi- nating and inhibiting controls on the motor impulses. When either a spinal or a sensorial impression is transmitted to the cerebrum, an idea is excited within the brain. The formation of the idea is accompanied by a liberation of force or energy. The concept of nervous force becomes important for Carter but he develops it incompletely. This force may be expended by travelling downward, through the sensorium and the spinal cord, and acting upon the muscles and organs of the body. Otherwise, the force may remain in the brain to produce trains of thought and thus discharge itself.4 When an idea is connected to some vivid feeling (or "sensorial impression" as it is felt in the sensorium) of pleasure or pain, they together form an emotion. Carter obtained his concept of emotions from a contemporary English physiologist, William B. Carpenter, and from the earlier Scottish physician-philosopher, Thomas Brown. Once an emotion has formed, it can discharge its concomitant force through the body via the nervous system. This emotional force is similar to and probably the same as nervous force. Carter ascribed the origin of this force to God, who placed a vital force or vitality in the human body. The nervous centers are, for Carter, laboratories for the manufacture of this vital force. In this process

Bull. N.Y. Acad. Med. NINETEENTH CENTURY HYSTERIA 523 z~~~~~NNTET CETR HYTRI 2 the grey matter disintegrates (he implies but does not state that this is a chemical process) and then must be restored through nutrition. More force is produced than is needed for local consumption. The extra force is distributed and then used up, as mentioned above, through nervous channels. To explain this distribution, Carter uses two analogies: a hy- draulic model of illuminating gas flowing through pipes in a home lighting system and, when he is impressed by the speed of nervous impulses, he refers to the marvelous speed of the electric telegraph. This nervous force can be further subdivided into two types: instinctive and volitional. The instinctive or automatic is independent of self-control, fast in action, and very energetic. As he stated, no one ever tired of breathing. The volitional, in contrast, is purposeful, languid in action, and productive of fatigue. The emotional force produced is very energetic because it is an accu- mulation of the sensorium. As Carter states, this energy does more than produce a "mere consciousness"; it affects the flow of ideas, sensation, and motion. Nervous energy is largely expended through the peripheral nervous system, which Carter subdivided into the spinal and sympathetic systems. Sensation and motor responses (both voluntary and automatic) are produced by the spinal system. Sensory sensitivity can be both increased and decreased. He presented an example of normal anesthesia occurring from fear when a person with a toothache goes to a dentist and, as the moment of extraction approaches, loses all sense of pain. Emotion- al force can also be expended through a wide variety of muscular contrac- tions. For example, contraction of the facial muscles, the respiratory muscles, or the locomotor muscles may occur. Human facial expressions that accompany feeling states in themselves are a useful outlet for emotional energy. Carter noted that even respiration serves as a bodily "safety valve" by discharging emotional force through the accessory actions of sighing, sobbing, and laughing. Muscles subserving locomotion respond primarily to the emotions of anger and fear. Reminding us of the much later writings of Walter Cannon, he states that the muscular system is organized to respond by either flight or defense. Emotions also exert their influence through the sympathetic system. Strong emotion may increase circulation and cause one to blush, or may decrease blood flow and make one unusually pale. The sympathetic system also controls the body's involuntary muscles. Thus, emotions can induce contraction of the heart, the gravid uterus, and possibly the intestines. In addition, through its influence on secretions, the sympathetic

Vol. 58, No. 6, September 1982 -524524 A. KANE AND E. T. CARLSON system may lead to jaundice, changes in milk production, tears, or "dry mouth. "5 Carter recounts an interesting anecdote in connection with the phenomenon of dry mouth. According to the custom in India, when thievery has taken place within a household, each servant is forced to chew on a portion of rice for a few minutes. The culprit, who presumably is more fearful than his fellow servants, is then singled out by the dryness of his mouthful. Carter only suggests, and it is not much more than a hint, that the cerebrum itself provides a third outlet for nervous force. Energy is expended when a train of ideas forms within the cerebrum. This train is really an association, and it is not surprising that Carter discusses it, because association of ideas was a widely accepted concept in philosophi- cal psychology in Carter's time. According to Carter, however, nervous force can be expended much more easily through bodily outlets than through the cerebrum. As we shall show in our discussion of tertiary hysteria, repetitive emotional thinking is more likely to create harmful energy than to drain it off. Carter makes emotional energy the primary factor in his theory of hysteria. He divides hysteria into three stages. The primary paroxysm is the direct and immediate result of pent-up or undischarged emotional force. As indicated above, symptoms are caused by the action of the emotional force on the muscular, vascular, and secretory systems. These systems may be involved singly, simultaneously, or sequentially in any order. To Carter, it appears as if the weakest organ of the body becomes the target of any unexpended energy, and therefore leads to the greatest disturbance. This concept is highly reminiscent of the later "organ inferi- ority" theories of Alfred Adler. Carter's description of the primary attack is brief, and essentially corresponds to those of contemporary physicians. As the primary paroxysm follows its natural course, it usually exhausts the emotional force which produced it. Therefore, the first paroxysm may often be the last and only attack. The risk, however, is that the original emotion is not totally expended, in which case a secondary reaction usually occurs. The mere recollection of the object or the cause of the original emotion can also produce a secondary attack. Often a person will dwell upon some associated pleasant emotion, or he might be unwillingly overpowered by an unpleasant one. Either way, there is a good chance that a secondary paroxysm will take place. Following the primary attack, the patient's natural susceptibility to sensory impression or feelings increases through some unspecified mecha-

Bull. N.Y. Acad. Med. NINETEENTH CENTURY HYSTERIA 525 nism; consequently, a secondary paroxysm may be excited by circum- stances which would have been inadequate to precipitate the primary attack. If the secondary paroxysm does not exhaust the exciting emotion, then more attacks will take place. Simultaneously, each succeeding fit increases the individual's susceptibility to feeling, so with every attack the probability of another attack increases. If the original exciting emotion turns out to be "engrossing and permanent," then involuntary hysteria becomes established as a chronic or permanent disease.' Carter was not alone in connecting emotions with hysteria. For exam- pfe, the British physician Theophilus Thompson wrote in 1840 that certain types of excitement, including such emotions as grief, joy, "unrequited affection," jealousy, disappointment, and surprise, may induce hysterical symptoms.8 Ten years later William Carpenter asserted that the convulsive actions of hysteria are associated with "emotional conditions of the mind."9 Nevertheless, Carter himself drew a fundamental distinction between his own view and those of other physicians. Other authors saw emotions as triggers or exciting agencies that require the prior existence of some constitutional weakness or susceptibility before they can operate to produce hysteria. For example, Thompson also said that emotions lead to hysterical symptoms only if the nervous system is already susceptible. Carter, on the other hand, believed that emotional energy could produce hysterical symptoms in otherwise healthy men and women. The only necessary precursor of an attack is the presence of some undischarged, strong emotion.'0 At least one contemporary physician discussed the influence of emotions along terms somewhat similar to Carter's. The mental physiologist Thomas Laycock published a treatise on hysteria in 1840, in which he writes that nearly one third of all his recorded hysterical cases had originated from some "depressing mental emotion" such as grief or sorrow. Laycock holds that all hysterical cases present an "increased affectibility" of the nervous system, along with a morbid state of the blood. He speculates that when an individual experiences some powerful emotion, his blood undergoes a change. The altered blood affects the nervous system, which in turn produces hysteria-" Therefore, even though they differ as to the exact steps involved in the process, both Carter and Laycock believed that emotions have the ability to alter the normal bodily state and to produce hysteria. It is important to note, however, that neither Laycock nor the other physicians of Carter's time present the effect of emotions as the central point in their theories of

Vol. 58, No. 6, September 1982 526 A. KANE AND E. T. CARLSON hysteria. Even Laycock states that the morbid state of the blood may actually stem from many different causes, including diseases of the mucous membranes, poisoning of the blood stream, lack of muscular exercise or of fresh air, improper diet, masturbation, and general excitement of the brain and nervous system.-2 Only Carter makes emotions the pivotal factor in his etiology. Carter's depiction of emotional force as the cause behind hysteria clearly allows for the presence of both male and female hysterical patients. Yet he provides several reasons why hysteria is more common among women than men. To begin with, women are more prone to becoming emotional than are men. Reasoning predominates in men, and feeling in women. Carter is not precisely certain what accounts for this difference between male and female reactions, but suggests that it is probably organic. A woman's "natural conformation" will cause her to feel in the same situation where a man will think. Because their main biological function is maternity, women have a naturally wide range of emotional responses. In addition, the emotions that lead to hysterical paroxysms are often linked to sexual desire. A woman's menstrual period, through the medium of sensation, will each month remind her of this sexual desire, and may subsequently lead to hysterical attacks. There is also a social explanation for the high proportion of female hysterics. Men are freer to be physically and sexually active than women, so their emotions are discharged through regular outlets instead of through hysterical fits.13 According to Carter, those emotions which are talked about or acted upon and are thus reduced, or emotional energy which is expended in physical activity will not excite hysterical paroxysms. Only pent-up emotional energies are dangerous. But why do certain emotions remain undischarged in the first place? There are two answers to this question. First, some emotions, particularly if they are strong and sudden, have a naturally paralyzing effect upon their organs of discharge. Second, an emotion may remain undischarged because the individual voluntarily represses it and keeps it concealed from other people.'4 Carter adds that women are under greater social pressure to hide their true feelings than are men. For instance, sexual passion and unrequited love are two common emotional reactions in people. Yet because they are afraid of the scorn and pity of their female peers, women will not openly discuss an instance of disappointed love. At the same time, women cannot attempt to satisfy their sexual passion, for they will face severe public censure.'5 Because

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women must so often keep their emotions secret and cannot act upon them, they are rendered more susceptible than men to hysteria.16 Fear and terror are also common emotional precursors of hysteria. Usually a person's fear will be dissipated by the activity involved in escaping from the danger. However, if the danger subsides before he can escape, or if he is somehow prevented from discharging energy in the form of action, then the emotion remains pent up. Obviously, women, who have less chance than men actively to respond to fearful situations, will be more likely to have hysterical reactions caused by fear. Other emotions that may induce hysteria include hatred and anger, affection and joy, envy, grief, pride, and pity. 17 In one intriguing passage of his second book, Carter notes that the disappointment stemming from unrequited affection may be a more complicated emotion than it first appears to be. Such disappointment can arise partly from the wish to escape from control or life at home, or from desire for the freedom and increased social status a woman may get with marriage. The disappointment may also result from a sense of personal injustice in the situation or from wounded pride. 18 All three categories of hysterical paroxysms have emotional energy as their basic mechanism, but distinctly separate from the primary and secondary types is the tertiary hysterical response. The primary and secondary paroxysms are involuntary, whereas the tertiary attack, at least initially, is voluntarily produced. A tertiary paroxysm develops in the following manner: If secondary attacks continue over a long period of time, eventually the patient may deduce that the recollection of a certain event or thought will be followed by a fit. By dwelling on that specific thought and its concomitant emotions, and by withdrawing as much as possible the control of her will, the patient can purposely excite a paroxysm.19 All attacks of this sort are tertiary. There are several reasons why a person might wish to produce a hysterical attack. The sensations experienced during the paroxysm may themselves be agreeable and rewarding. Even more gratifying is the attention and sympathy often lavished upon patients after each attack. Carter writes that the desire for sympathy is a universal mental instinct, but is 10 times more powerful among women than men, while a sense of self-dependence is much weaker in women. Accordingly, women are more likely than men to produce tertiary paroxysms. Yet not all women are equally prone to this type of hysteria. The most likely candidates are women whose sexual propensities have been disappointed or who feel envious, neglected, or discontented with life or a specific aspect of their

Vol. 58, No. 6, September 1982 A. KANE AND E. T. CARLSON 52852 A. KAEADE T A O lives. Many times, says Carter, those women whose predominant emotion is envy were raised in families where partiality was displayed toward other siblings by the parents. Later on, society may take over the parents' role, and help to produce hysterical women who feel chronically jealous of those around them.20 As tertiary hysteria proceeds along its course, the sympathy and attention of the patient's friends and relatives may wane. At this point the hysteric must discover some way to retain the solicitude of those around her. To do this, she can diversify her repertoire of symptoms to include hysterical complications. Complications may begin very early in the tertiary phase and alternate with the paroxysms or may start later and eventually replace the other symptoms of the paroxysms altogether. Hys- terical complications range from one end of the symptomatic spectrum to the other, but Carter organizes them into two main types: real and simulative. The real category is further broken down to include both congestive and ideo-motor complications. Simulated complications may be either artificially produced disorders or merely tricks created by the patient. In both cases, the malingerer's symptoms are usually suggested by those of an illness which she has previously suffered or by those that she has observed in someone else. Truly amazing are the extremes to which malingerers will go to produce their symptoms. Carter writes of girls who bound their limbs with tight ligatures to induce swelling of their joints. Patients may burn their skins with corrosive substances to form ulcerations or place local irritants into their vaginas to create discharges. Two common complications are hemop- tysis and hematemesis, the former produced by applying leeches inside the mouth, the latter by swallowing and then vomiting the blood of animals. Hysterics may also try to fake various symptoms by adding such foreign substances as oil, blood, or charcoal powder to their urine."2 The congestive complications are the first of the real kinds which may be formed in tertiary hysteria. They are caused by attention, which is defined as the "prolonged occupation of the brain by a single idea, or of the sensorium by a single feeling. "22 Attention directs nervous force toward certain bodily organs, and this force then alters the circulation to these organs. Uterine and ovarian disorders are the most frequent congestive complications, but the complications may also involve the liver and nerves in producing neuralgias. Carter includes an interesting qualification in his discussion of congestive complications. He states that it is doubtful "... how far the sufferer

Bull. N.Y. Acad. Med. NINETEENTH CENTURY HYSTERIA 529 may have cognizance of her own share in their production and mainte- nance. [This] author has seen some hysterical women whom he believes to be quite ignorant of the self-imposed character of their maladies.... "23 Unfortunately, he does not explain precisely why the patient may be unaware of her part in producing her congestive complications, but a possible answer lies in his discussion of the pathways of nervous force. Usually, according to Carter, as each idea in a cerebral train of thought communicates an impression to the sensorium, the individual becomes aware of each successive idea. If some ideas send no impressions to the sensorium, they do not become "subjects of consciousness."24 Now sup- pose that the idea which occupies the subject's mind during the act of attention, and which directs energy towards a particular organ, sends no impression to the sensorium. The person will not be conscious of the idea nor of the fact that the act of attention is producing the congestive complication. This is part of what Carpenter called "unconscious cerebration" and Laycock "reflex cerebral function." Carter calls the second kind of real complication "ideo-motor," a term he borrowed from William Carpenter. Ideo-motor complications consist of muscular reactions to a cerebral idea. A frequent example of an ideo- motor complication is vomiting, which may be induced by dwelling on the idea of some disgusting object. The object may be either imaginary or remembered, and Carter suggests the idea of putrid cat pudding as one graphic example of an imaginary disgusting object. A second common ideo-motor complication is a fit of violent coughing.25 How do ideo-motor complications develop? Carter writes that certain ultimate changes occur in the cerebrum when an impression reaches it. First, cerebral sensations, or ideas, are formed. Second, volitional force may be discharged, which either produces voluntary action or suppresses involuntary movement. Instead of this, however, a purely automatic or instinctive force may be discharged, producing involuntary action. Ideo- motor complications consist of these involuntary responses. To produce an ideo-motor movement, an impression travels to the cerebrum and a dominant idea forms, but the force connected to this idea is immediately diverted from the cerebrum. The force passes through the sensorium on its way to the spinal cord, and is manifested in muscular activity. No train of ideas forms, and judgment is not involved in producing these responses. Carter mentions yawning as one example of a normal ideo-motor action. The very idea or sight of yawning often forces a person to yawn, whether he wishes to or not.26

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Carter's writings on the ideo-motor response and tertiary hysteria illustrate a trend in neurology and psychiatry that began earlier in the 19th century, when increasing clarification of the function of the spinal cord led to a description of the spinal reflex. It was only a question of time before the concept of reflex activity would be applied to the brain, particularly to the cerebrum.27 Essential to this development are the works of Thomas Laycock, whom Carter cites. Laycock, in his 1840 A Treatise on the Nervous Diseases of Women, discusses the capacity for imitation to occur in a social setting. He notes that imitative movements are "excito- motory," or muscular reflexes, and he adds that they are stimulated into action by ideas. He also points out, as Carter does a few years later, that ideas can be precipitated through direct sensory impressions (such as viewing a paroxysm in others) or through recollection.28 Laycock fully develops these concepts in his 1845 paper "On the Reflex Function of the Brain." Based on his knowledge of comparative physiology and on the consistency of the laws of biological function, he concludes that the type of reflex seen in the spinal cord continues up into the brain proper. He reasons that if the gray matter of the spinal cord subserves the spinal reflex, then the gray matter of the cerebrum probably subserves a cerebral reflex. To illustrate his views, Laycock uses the example of hydrophobia caused by rabies. When a hydrophobic patient tries to take a sip of water and liquid touches his lips, his mouth clenches and he may go into various types of involuntary spasms. The sight or sound of water also leads to uncontrollable spasms. Most important of all for Laycock's theory, merely hearing the word "water" may send hydro- phobes into convulsions. Thus, an idea by itself can automatically lead to a bodily response.29 A few years later Carter applied this concept directly to hysteria in his explanation of ideo-motor complications. Besides coughing and vomiting, it helped to explain all kinds of spasms (such as opisthotonus) and convulsive movements which appeared so commonly in the hysteric. Although the paroxysms as well as the complications of tertiary hysteria are voluntarily induced, if they continue over a long period of time they may become uncontrollable. To prevent others from knowing that her symptoms are purposely stimulated or completely faked, the patient must focus most of her attention on herself and her ailments. She spends inordinate amounts of time thinking about how to answer questions about her health, and becomes preoccupied with the emotions that produce her particular symptoms.30 Consequently, the tertiary hysteric turns increas-

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ingly introspective; her ideas become limited to those suggested by bodily sensations. But, Carter states, voluntary attention becomes involuntary if it is practiced repeatedly. The patient soon finds herself unable to stop thinking of the emotions that produce her paroxysms, and her introspective ideas become automatic. The hysteric increasingly loses her control over her symptoms until finally her illness is completely out of her hands. 31 Although habitual attention takes away the hysteric's power over her illness, it can also be mastered by the patient and used to prevent the original onset of progress of the disease. According to Carter, "...as excessive passion [emotion] is nearly always based upon a mistaken or exaggerated notion, the habit of forming precise ideas will greatly check the emotional tendency; and the causes of anger or of fear will frequently dwindle into insignificance before the eye of reason."32 To cultivate exact thinking, the individual should make a habit of directing his attention toward the "points of resemblance between related ideas." This way mistaken notions will not be formed, and will not help to create inappro- priate emotion. One way to develop precise ideas is to speak accurately. Carter warns that exaggeration is the most harmful of the many types of verbal inaccuracy, and should be stopped early on by monitoring the child's use of the superlative.33 Carter provides some concrete advice on what tasks girls should per- form to strengthen good habits and to prevent their emotions from becoming excessive. The art of drawing, especially drawing from life, should be encouraged, for it directly leads to an apreciation of form, size, and distance, and indirectly helps to form "habits of exactness." Doing fancy work can have either a beneficial or a negative influence on a young woman. If she concentrates on creating the designs, she can improve her intellect. If she merely copies the designs of others, however, she will be exercising her eyes and hands, but will also be allowing her thoughts to wander. This, of course, will not encourage precise thinking, and may be doubly harmful if she begins to dwell on particular emotional ideas. Carter is also unhappy with the effect that music can have on young women. When girls learn to play a musical instrument, they improve their sensorial acuteness and their mechanical dexterity but they do not exercise their intellectual judgment. Moreover, through the process of association certain ideas may be linked to specific musical pieces. If these ideas are emotional, then the reading or practicing of such pieces will stimulate an undercurrent of emotion. By weakening reason and exciting emotions,

Vol. 58, No. 6, September 1982 532 A. KANE AND E. T. CARLSON practicing music can indirectly produce hysteria. Carter feels that women should try to learn music as a science, and turn it from a physical activity into an intellectual pursuit.34 Throughout his first two books Carter shows that he was aware of the latest medical thought on hysteria and on the nervous system, but he transcends the views of his contemporaries and presents some unique ideas on the etiology and treatment of the disease. In explaining hysterical paroxysms and complications, Carter focuses on the power that emotions and ideas have over the body both consciously and unconsciously and voluntarily or automatically. This orientation anticipates the psychological direction taken by later writers about hysteria. Yet, in spite of, or perhaps because of, the novel quality of his theories, Carter's work does not appear to have made a significant impression on his peers. Lancet mentions his first book favorably, but dismisses his second, and none of the English, French, or German psychiatric journals consider his works at all.35 In the 1855 edition of his Principles of Human Physiology William Carpenter does briefly mention Carter's Hysteria. Other authors, however, either ignored or were unaware of Carter's books. We can only speculate on what Robert Carter's influence might have been had he continued to write about hysteria and other nervous diseases. Whatever impact Carter may or may not have had, we see him as a part of a trend that builds to the end of the century and culminates in the thought of Jean-Martin Charcot and Pierre Janet in France and Sigmund Freud in Austria. These later authors were particularly concerned with unconscious functioning. Laycock, Carpenter, and Carter focussed increasing attention on how an idea can become connected with an emotional force that causes a bodily response. Charles Darwin (1872), for example, dealt in detail with the outlet of emotional energy in facial expression. Although he cited Laycock and Carpenter, he did not mention Carter. By 1889 Janet had extended this concern to a wide variety of unconscious behaviors which he called automatisms. Under this rubric he included such topics as: induced somnambulism (hypnosis), catalepsy, alternating memories (multiple personality), absentmindedness, and automatic writing and talking. His proposal of the idea of dissociation had a large impact in France and in the United States. The study of more specific hysterical symptoms, particularly paralysis, grew through Russel Reynolds (1869) and the studies of hypnosis and hysteria by Charcot. Freud, as a student of Charcot, explored the unconscious through the techniques of hypnosis and free association, and thereby developed his

Bull. N.Y. Acad. Med. NINETEENTH CENTURY HYSTERIA 533 ideas about repression, a concept that served as a counterpoint to dissociation.36 Carter lived to see all the ferment stimulated by these physicians' attempts to understand the enigma of hysteria. Whether he knew about it in his new role as a leading ophthalmologist we do not know, but he could have felt considerable satisfaction in having been an early pioneer in exploring the role of emotionally laden ideas, both conscious and unconscious, in hysteria.

NOTES A ND REFERENCES 1. An exception to this is Veith, I.: Hyste- 6. Ibid., p. 14. Carter said this practice was ria: The History ofa Disease. Chicago, described previously by Carpenter, W.: The University of Chicago Press, 1965. Principles of Human Physiology. Lon- pp. 199-210. don, Churchill, 1855, 3rd ed., p. 474. 2. Stephen Mackenzie (?- 1851) was a phy- 7. Carter, R. B.: Hysteria, pp. 39-44, 51. sician who practiced close to London in Diseases, pp. 125-27. the town of Leytonstone where he ran a 8. Thompson, T.: Hysteria. In: A System of fair-sized private institution for the treat- Practical Medicine, Tweedies, A. edi- ment of acute and chronic hysterics. He tor. London, Whittaker, 1840, II, pp. died suddenly when his head hit a curb- 221-23. stone after he was thrown from his car- 9. Carpenter, W. B.: Principles of Human riage. Carter warmly acknowledged his Physiology. Philadelphia, Lea and intellectual indebtedness to Mackenzie, Blanchard, 1850, 4th ed., p. 376. particularly when it came to the under- 10. Hysteria, pp. 28-31. standing of primary and tertiary parox- 11. Laycock, T.: An Essay on Hysteria. ysms of hysteria and the treatment of the Philadelphia, Haswell, Barrington and more complicated cases. That Carter Haswell, 1840, pp. 113, 185-86. continued in the vicinity is indicated by 12. Laycock, T.: A Treatise on the Nervous the fact that the preface of his first book Diseases of Women. London, Long- was dated December 1852 in Leyton- man, Orme, Brown, Green, and Long- stone. As Mackenzie never published mans, 1840, pp. 83, 153. any of his observations, Carter's book 13. Hysteria, pp. 20, 32-44. served, in a fashion, as a memorial to his 14. Diseases, pp. 123-125. mentor. Dr. Mackenzie sired two fam- 15. Hysteria, pp. 21-26, and Diseases, pp. ous physician sons, Sir Morell (1837- 127, 355-56. 1892) and Sir Stephen (1844-1909). 16. When Carter discusses sex and its rela- 3. James, R. R.: Robert Brudenell Carter. tionship to hysteria, he does so in terms Br. J. Ophthalmol. 25:330-37, 1941. of the repression of sexual passion. Oth- See also obituaries in the Br. Med. J. er physicians instead focus on sex as and Lancet for November 2, 1918. related to disease and dysfunction of the 4. Carter, R. B.: On the Influence of Edu- reproductive organs. See Veith, op cit. cation and Training in Preventing Dis- pp. 202-03 and also Hollander, M. H.: eases of the Nervous System. London, Conversion hysteria: a post-Freudian re- Churchhill, 1855, pp. 3, 15, 47. Cited interpretation of 19th century psychoso- hereafter as Diseases. cial data. Arch. Gen. Psychiat. 26:311- 5. Carter, R. B.: On the Pathology and 14, 1972. Treatment of Hysteria. London, Chur- 17. Hysteria, pp. 22-24, 102. chill, 1853, pp. 4-18. Cited hereafter as 18. Diseases, p. 356. Hysteria. 19. Hysteria, p. 42.

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20. Ibid., pp. 43, 52-55. 28. Laycock, T., op. cit., pp. 105-08, 179- 21. Ibid., pp. 72-74 and Diseases, p. 225. 82. 22. Diseases, p. 142. 29. Peter Amacher points out how important 23. Hysteria, pp. 65-72, 76. the views of association psychology 24. Diseases, p. 57. were in the development of Laycock's 25. Hysteria, pp. 61-64. theories. Amacher, P.: Thomas Lay- 26. Diseases, pp. 60-62. cock, I. M. Sechenov, and the reflex arc 27. Franklin Fearing traces the development concept. Bull. Hist. Med. 38:168-83, of the concept of motor automatisms in 1964. Laycock, T.: On the reflex func- his book Reflex Action: A Study in the tion of the brain. Br. For. Med. Rev. History of Physiological Psychology. /9:298-311, 1845. Baltimore, Williams & Wilkins, 1930. 30. Hysteria, p. 57. He shows that by the 18th century the 31. Diseases, pp. 24, 157-63. distinction between simple reflexes and 32. Ibid., p. 364. voluntary action was already blurring, 33. Ibid., pp. 312, 328. paving the way for new concepts of auto- 34. Ibid., pp. 433-37. matic movement. For the history of un- 35. Lancet, 1:60, 1853. conscious cerebration, see Mark Alt- 36. Ellenberger, H.: The Discovery of the schule's Roots of Modern Psychiatry. Unconscious. New York, Basic Books, New York, Greene & Stratton, 1957, 1970. pp. 56-83.

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