519 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 estab- lished 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 hyste- ria 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 Bull. N.Y. Acad. Med. NINETEENTH CENTURY HYSTERIA 521 as nausea and vomiting, anorexia or excessive hunger, menstrual and uterine disorders, constipation, neuralgia, coughing or sneezing fits, respi- ratory 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 psycho- logical 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 symp- toms, 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, al- though 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 impres- sion" 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.