ETYMOLOGY
The term hypochondria is from the Greek - literally 'below the cartilage', referring to the lower ribs and the underlying spleen and liver. Its application to mental states comes from the theory of humours, relating moods to the liver and spleen. Similarly depression was called melancholia, literally black bile. Atrabilious - a favourite term of Carlyles - has the same meaning. Carlyle also uses 'spleen' to refer to his ill-health.
HISTORICAL CHANGE
The modern use of 'hypochondriacal', signifying a morbid preoccupation with health, did not come into general use until the early nineteenth century. In Elizabethan times 'melancholy' was the fashionable term for symptoms of depression, anxiety, and overconcern about bodily health. In the seventeenth century 'hypochondriasis' began to replace 'melancholy' as a label for this wide range of symptoms, often regarded as fashionable.. Cullen, a Scottish physician, labelled hypochondriasis as a neurosis in the late eighteenth century. At this time it began to lose the wider meaning and to be used in the modern sense. When Carlyle uses the term, he does so in this way, but it should be remembered that the Victorians regarded hypochondriasis and other neuroses as somatic disorders that would eventually prove to have a specific cause.
OFFICIAL DEFINITION
DSM III, the internationally recognised classification used by psychiatrists, defines hypochondriasis as an unrealistic interpretation of one's bodily sensations as abnormal, leading to the fear and belief that one has a serious disease. Four major characteristics are usual:
Despite this official definition, there is a widely held view that hypochondriasis is best regarded as a symptom rather than a diagnosis.
ARISTOTLE
Henry Maudsley, a famous Victorian psychiatrist, writing in 1899, recalled that Aristotle was the first to observe that great men are often melancholy and hypochondriacal:
'In them the self-feeling is great; they do not easily subordinate themselves to things as they are, but would have them as they should be; accordingly, when their energies are directed outward to the accomplishment of some aim under the guidance of their superior insight, the earnestness of great feeling inspires their convictions and is infused into their actions; such happy use of their energies freeing them from their melancholy.'
Carlyle illustrates this to some degree. When he first embarked on a new work his symptoms improved; when it was long in the completion, as in the years writing Frederick, the improvement was not sustained.
THE ENGLISH MALADY
There is a tradition of hypochondriasis (in the broader sense) in English literature and life, so much so that it was labelled the English malady, and Cheyne(1733) wrote a book with that title. Earlier, Burton's Anatomy of Melancholy(1651), that great repository of anecdote and information, including Burton's own experience, describes a variety of melancholy he calls 'hypochondriacal or flatuous', which includes such symptoms as: 'fear and sorrow, sharp belchings, fulsome crudities, heat in the bowels, wind and rumblings in the guts, vehement gripings, pain in the belly and stomack....'
Not too different from Carlyle's symptoms.
JAMES BOSWELL
The biographer and diarist was subject to mood swings, and published his many essays in the London Magazine(1777-1783) under the pseudonym 'The Hypochondriack.' Four of them are on the subject of hypochondria and illustrate both the connection between depressive and hypochondriacal symptoms, and the wider use of the term in the eighteenth century. His choice of pseudonym shows that the term was fashionable, and proclaimed ones sensibility.
INTRODUCTION
This is a large subject. I confine myself to views that have been reached by psychiatrists after a century of much research and debate. Those interested in their development should consult Kenyon(1976) and Barsky and Klerman(1983). Much of past research on the subject has been conducted on psychiatric patients, mostly inpatients, whereas most hypochondriacal patients are seen, investigated and treated by physicians and primary care doctors. Most
of those with such symptoms are unwilling to consult psychiatrists, or to consider that psychological factors may be responsible for their symptoms, and many may complain to others but not to their doctors.
A SYMPTOM, NOT A DISEASE
Hypochondriasis is best regarded as a symptom and not as a disease. Bodily symptoms, and hypochondriacal attitudes are common in other psychiatric conditions, especially depression. Hypochondriacal complaints show a continuum from the mild to the severe in the population, as does the tendency to complain as opposed to stoicism. Nearly everyone is hypochondriacal at some time or other to a mild degree. There are variations in time and place which suggest that social factors are important. For example, in popular
stereotypes the French are still thought to be preoccupied with their livers, the Germans with their bowels. Complaining and frequency of visits to the doctor may vary considerably with social class, and with the type of health care available from country to country. Attitudes and beliefs about the body, in health and disease, depend on public knowledge of medicine and biology at different times, and vary at any time with occupation and education. Medical students,
for obvious reasons, are prone to hypochondriacal symptoms during their clinical training.
FREQUENCY.
Hypochondriacal symptoms are common in the population. It is estimated that in primary medical care between 70 and 90% of patients seen are without physical disease, and that only 40% of patients referred to hospital physicians can be given a clear-cut physical diagnosis. The popularity of fringe medicine attests both to the failure of conventional medicine to satisfy its customers, and to the demand for attention
by the large group of complainers without physical disease. Carlyle tried the fringe remedies of his time when he subjected himself to the fashionable 'water cure' at Malvern.
SEX
Men are generally found to be more hypochondriacal. Women are less complaining, although they have more to complain about with menstruation and childbirth. They traditionally give maternal affection and care; men may be more used to receiving, rather than providing, such nurturing and
affection, and thus complain more.
HISTORICAL FACTORS
In Carlyle's time medical diagnosis and treatment was more primitive and limited, and doctors encouraged the use of dangerous medicaments such as mercury in toxic doses. The national diet was poor and stodgy, promoting constipation and often leading to iron deficiency
anaemia, and vitamin deficiencies such as rickets. Carlyle's university education was at a Edinburgh, famous for its medical school, and his own brother was a doctor. As a result he would be well aware of current medical theory and practice.
THE SICK ROLE
Such social considerations have led to the use of such terms as the 'sick role' and 'illness behaviour' '
to describe complaining and invalid attitudes. It follows that such behaviour is learned, probably in childhood. The child finds that being ill has its rewards in terms of care and affection, either when he is ill or from observing some other family member.
We know little of Carlyle's childhood, apart from a few vignettes and anecdotes. He was always his mother's favourite, but he was not unhealthy. He was born and raised in a two roomed house with his parents and nine other children, and must have been exposed to illness, childbearing and death at an early age, seeing his infant sister lying dead in bed, and later his uncle's corpse, which gave him 'a new pang of horror'. From scenes like these he developed a fear of death as a child.
His hypochondriacal behaviour dates from late adolescence, when he abandoned his religious studies, in effect rebelling against his parents wishes. At the same time his mother had a short but serious psychiatric illness, and thereafter the family's general anxiety about mental stability was high. His symptoms caused great alarm at home when his letters arrived and family conferences were held to debate what should be done.
PSYCHOANALYTIC THEORIES
From Freud on, there have been two main strands of psychodynamic theory about the symptoms, and about 'somatisation' - the expression of symptoms in physical form. One holds that hostile and aggressive feelings are turned into physical complaints, the other that the symptoms are a defence against guilt or low self-esteem. there is some experimental evidence to support an association between difficulty in expressing anger and hypochondriacal symptoms. Psychotherapists also stress the role of 'secondary gain', the advantages that can be gained by being a patient; in other words, the sick role already described. Such patients have been shown to have had more than average illness themselves or in their families during childhood.
His concern with his health was not Carlyle's only problem. In the early years it was severe and accompanied by anxiety, and fitted the above definitions well. When he married and moved to London there was a change. For the rest of his life he considered himself unwell - at best not so unwell! - but his physical symptoms were less commanding, and he complained as much of depression as of his 'bile'. He also seems to have accepted in a curious way that he was hypochondriacal and not physically ill, even joke about it with his wife, and was better able to express his discontent directly - as depression - rather than as physical pain.
Other symptoms also have to be considered, notably his obsessive search for silence, and intolerance of noise of any kind; his presumed sexual difficulties and his profound irritability. These are dealt with elsewhere.
His dependent needs are easily demonstrated, and may be the main reason for his hypochondriasis. Throughout her long life he was his mother's favourite child, the oldest of her very large family. Contemporaries remarked that he was more attached to his mother than his wife and confided in her more. His writings after her death make plain the depth of his feeling for her.
Physical symptoms may have been for Carlyle a means of competing with the steady arrival of new babies competing for his mother's love and attention. But there is no record of serious childhood illness - he seems to have been a very healthy child - and his hypochondriasis dates from a time when he had left home and was an adolescent in Edinburgh. His mother shows a similar interest in health matters, and it is in his correspondence with her that he gives the most detailed complaints of his health and ill-health, showing that they were meant mainly for her ears. Even when she is on her death bed he continues to give her bulletins about his own symptoms.
It is also possible that his mother's psychotic illness, soon after the onset of his anxiety and hypochondriasis, raised his own and the family level of anxiety about illness. Carlyle from an early age expressed fears about his mother dying.
Later he made himself dependent on his wife, and the development of this dependence may be seen in the courtship correspondence. Over these long years he can be observed presenting his ill-health to her again and again, and being gratified when it elicits attention and sympathy. At the same time he sets out in detail his views about the dominant role that he will demand as the husband, and the obedience that he expects from his future wife. He is setting up a relationship in which he can have the best of both worlds; when he wants care and nurturing he can play the helpless invalid, while at other times he can be as domineering and masculine as he wishes.
And so it proved in their long marriage - up to a point. Jane wanted 'fathering' in the way that he demanded mothering; her father had died not long before Carlyle came along. This led to clashes, and she responded in identical ways to her husband - she too became hypochondriacal, with similar symptoms, which at least gave them another interest in common.
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