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Four thousand years of hysteria
Four Thousand
T HE
Years of Hysteria
By WILLIAM F. KNOFF
HISTORY OF PSYCHIATRY is the best textbook of psychiatry. In this “textbook,” hysteria and madness stand out as paradigmatic disorders with a long historical development. Indeed, one who learns as much as he can about the history of hysteria and psychosis will have mastered much of psychiatry. This paper addresses itself to hysteria: How old is it? Can we define it? Is there anything we can do about it? “Hysteria,” as employed in this paper, refers to the traditionally recognized sensorimotor and dysmnesic disorders without organic basis familiar to physicians since ancient times, but never completely understood, even today. Abse, in his recent text, describes (1) a group of physical symptoms without structural lesion; (2) complacency or “belle indifference;” and (3) episodic disturbances in the stream of consciousness ( dissociation). Physical symptoms are not necessarily limited to those under control of the voluntary nervous system. Primary and secondary gain are axi0matic.l Frank has recently commented on the “core of hysteria in every neurosis.“2 “Neurosis,” which includes hysteria, is impossible to define in a way that will satisfy everybody (or perhaps anybody). Conventionally, it is a generic term referring to certain defensive patterns of human expression, based on unconscious conflict, without reality disengagement. Neurotics, in the past and in the present, seem to be people with a special capacity for dissociation. ANTIQUITY Insanity was described in one of the earliest civilizations, the Babylonian, where magico-religious medicine prevailed; it was attributed to the demon Idta.’ Descriptions of behavioral disorders (nosography ) precede the process of naming them (nosology ). Nosography of hysterical phenomena dates back to the medical literature of ancient Egypt (Kahun Papyrus, 1900 B.C.).3 Believed to be a disorder of women, sexual factors were implicitly recognized in the earliest descriptions of hysteria. It was taken for granted in ancient Egyptian medicine that certain behavioral disorders were associated with the generative organs, and specifically with aberrations in the position of the womb.3 This was an organic hypothesis. It was assumed that the patient’s symptoms were caused by the womb which was free to wander about the body. Psychiatry and internal medicine have always been more vulnerable than other disciplines to mythical explanatory ideas because they deal so much with the nonvisible, the intangible (for example, the inside of the body, feelings, thoughts). A popular treatment for hysteria, later practiced in Greece, was fumigation of the vagina. This was designed to lure From the State Uniuersity of New York, Upstate Medical Center, Syracuse, N.Y. WILLIAM F. KNOFF, M.D.: Associate Professor of Psychiatry, State University York, Upstate Medical Center, Syracuse, N. Y. 156
of New
COMPREHENSIVEPSYCHIATRY,VOL. 12, No. 2 (MARCH),
1971
WILLIAM
F.
KNOFF
157
the uterus back to its normal position. Continuity of Egyptian and Greek medical thought is seen in the transmission of views on hysteria.3 The ideas passed from East to West. But the Greeks “had a word for it,” so to speak. The term “hysteria,” from “hystera,” womb, first appeared in the Hippocratic writings. Uterine fumigation was recommended with enthusiasm by Hippocrates and Plato, and, even much later, by Pare. Ilza Veith, who has written the definitive history of hysteria, which has been drawn upon liberally in this section, cites Plato’s Timaeus: “The womb is an animal which longs to generate children. When it remains barren too long after puberty, it is distressed and sorely disturbed, and straying about in the body and cutting off the passages of the breath, it impedes respiration and brings the sufferer into the extremist anguish and provokes all manner of diseases besides.” Veith comments : “This disturbance continues until the womb is appeased by passion and love.“3 We seem to hear an echo of these ideas today in Erik Erikson’s exposition of Womanhood and the Inner Space.4 The Egyptian-Roman view of hysteria, then, was essentially that of a general organic condition. The womb was free to migrate anywhere in the body. If it were dislocated upward, pressing against contiguous organs, it could cause the “globus hystericus,” aching limbs, or “pain in the sockets of the eyes.” Treatment was directed toward luring or driving the disaffected organ back where it belonged. Although the organic point of view (medical model) prevailed for 2 millenia, until the 19th century, intuitive psychological insights were seldom completely lacking. A sexual element is implied in the earliest concepts of hysteria. Zilboorg notes, “The sexual causation of hysteria . . . was not consciously suspected by Hippocrates, but instinctively he must have sensed it, since he considered marriage the best remedy for this affliction . . .“.I This advice remained among the standard prescriptions for 2000 years. Although not in a prescriptive sense, Freud mentioned in 1905 “The possibility of a hysteria being cured by marriage and normal sexual intercourse,“5 Zilboorg calls Hippocrates a medical psychologist. Galen, 6 centuries later, was a better one. He wrote sensitive case histories, elucidating psychogenic and psychosomatic factors (the most famous, perhaps, being that of the lady patient whose love for Pylades, the dancer, was diagnosed by taking her pulse).3 Galen was the first to propose a theory of male hysteria. His ideas show remarkable similarities to Freud’s early, but never abandoned, toxicity theories of the physical neuroses (neurasthenia, anxiety neurosis). You will remember that Freud, using physicochemical concepts, attributed the physical neuroses to dissipation or accumulation of somatic sexual excitation. Galen believed hysteria in male and female was due to retained semen caused by sexual abstinence. (He thought the uterus secreted a substance analogous to semen). Retention of this substance “poisoned” the body.3 That Galen applied his theories in practice is dramatically illustrated by Ilza Veith’s translation of the following paragraph: Following the warmth of the remedies and arising from the touch of the genital organs required by the treatment there followed twitchings accompanied at the same time by
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pain and pleasure after which she emitted turbid and abundant spemr. From that time on she was freed of all the evil she felt. From all this it seems to me that the retention of sperm impregnated with evil essences had-in causing damage throughout the body -a much greater power than that of the retention of the menses.3
Sociological components were not completely lacking from the views of early medicine. With the development of societal organization in Mesopotamia, disease became related to sin. Confession, an historical antecedent of catharsis, became the means of treatment. The concept of disease as punishment for sin was transmitted by the Hebrews to the West and became a part of the Judeo-Christian tradition. St. Augustine, whom Franz Alexander calls “the greatest introspective psychologist before Freud,“6 regarded all human suffering as manifestations of innate evil consequent upon original sin. His Confessions, by the way, written in the fifth century, is an example of selfanalysis which bears comparison to Freud’s. Biological, psychological and social aspects of illness, therefore, were not unknown to our ancestors. Our contemporary model of biopsychosocial man has had a long evolution. If “one picture can be worth a thousand words” perhaps an historical chart can indicate 2066 years. Table 1 illustrates in approximate chronology, some significant biological, psychological, and social concepts from antiquity to the present. A quick glance at the table reveals how organic theories of hysteria have predominated, as in other areas of medicine. Psychosocial concepts, although implied from the beginning, have developed very recently. THE NERVOUS SYSTEM From the time of Hippocrates until Thomas Willis, in 17th century England, hysteria continued to be viewed as a general organic condition. Explanatory notions varied, of course, from humors and strictures, to spleen, animal spirits, and vapors, with a stormy interlude of demonology during the Middle Ages when many mentally afflicted persons were viewed as witches. Willis was a physiologist and neuroanatomist (i.e., the circle of Willis) who began central nervous to narrow the subject down to the “nervous stock”-the system.3 He put the origin of hysteria in the brain. Almost a century later, Robert Whytt, in the same neurological tradition, wrote: A delicate or easily irritable nervous system, must expose a person to various ailments, from causes, affecting either the body or mind, too slight to make any remarkable impression upon those of firmer and less sensible nerves. Thus, any accident occasioning sudden surprise, will, in many delicate people, produce strong palpitations of the heart and sometimes fainting with convulsions. I have known some, even men, whose nervous systems were so delicate and moveable, that a vomit, a smart purge, or the pain raised by a blister, would throw them into convulsive fits.7 (Fig. 2).
The stage was set for William Cullen, successor to Whytt at Edinburgh, to coin the term “neurosis” ( 1769), a neurological concept attributing the condition to “disordered motions or sensations of the nervous system without organic pathology”.* One of the diseases Cullen classified as a neurosis, 2309 years after Hippocrates, was hysteria.
WILLIAM
F.
159
MOFF
Table L-Concepts Somatic
Mystical
Social Communicative
Psychological
Confession Sexuality
Wandering womb Humors Constriction Abstinence and retention Womb affections
Purge of emotions (Aristotle)
Imaginatio Lasciva Hypochondriasis
Demons Vapors Nerves Brain Neurosis ( Cullen )
Animal spirits Passions Nymphomania Animal
Heredity
Degeneration
magnetism Repressed ( Carter
sexuality
)
Psychic trauma Suggestibility Dissociation Defense Conversion Repression Transference Unconscious Sexuality (rediscovered) Oedipus complex
Unconscious language (Feuchtersleben)
Catharsis Symbolism Somatic
language
Interpersonal relations
communications A general concept of nervous disease, neurosis, could only develop as a result of progress in the discovery of the structure and function of the nervous system from the time of Vesalius. As elsewhere in history, new knowledge often leads to overgeneralization and to “fashions” in thought (i.e., Newtonian mechanics, Pavlovial reflexology, the unconscious, etc.). Neurosis, as an overgeneralized explanatory concept became a fashion which is still with us today. As Veith writes in a short paragraph which contains much history: Despite Raulin’s observation of the suggestibility of hysterics, Baglivi’s realization of the impact of emotions on physical health, Sydenham’s assumption of the role of animal spirits, and Willis’ and Whytt’s relation of hysteria to the nervous system, the basic concept of hysteria remained unchanged for two thousand years. The essence of this concept was that hysteria was a physical disorder. It is interesting that the man who introduced the word “neurosis,” and first classified hysteria among the neuroses, Cullen, clung even more firmly to the somatic etiology.3
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HYSTERIA
But Cullen’s “neurosis” was, to some extent, an updated metaphor. At least the imagery was no longer the wandering womb but now motions and sensations in the nervous system. Neurosis became the property of neurology for more than a century until the chain of though which reads Mesmer-CharcotBernheim-Freud began to present a psychology of neurosis. NEW
METAPHORS
Method, data, and metaphor are always interrelated; different methods enable different observations and the development of new metaphors and models. We are continually developing new vocabularies in which to express our observations of human behavior. Principal 19th century contexts, in which basic concepts are still rooted, were “neurology,” “hypnosis” and “cathartic treatment” ( early psychoanalysis ) . Employing what he called “animal magnetism,” Mesmer charismatically demonstrated the effect one mind can have upon another. Developed by others as hypnosis, suggestive therapeutics became an historical precursor of psychotherapy. Hypnosis, then as now, emphasized communication and was, therefore, a departure from the physical and pharmacological methods of traditional medicine. Always regarded with skepticism, hypnosis acquired some respect in the hands of the great Charcot who used it in the first systematic study of neurosis. In Paris in 1885, Freud was his pupil. Later Freud visited Bemheim at Nancy. From 1882, Freud was influenced by the ideas of Josef Breuer. Methodologically, hypnosis brought one mind in contact with another. Explanatory concepts began to tend toward the mentalistic but not entirely away from the somatic. Thus, varying states of consciousness, splits in consciousness, somnambulism, multiple personality, abulia, and other notions were emphasized. Depending on point of view, Charcot stressed clegenmation, Bemheim stressed suggestibility, Janet stressed dissociation, and Breuer and Freud stressed conversion. Freud, particularly, commenced a new departure in observing that “hysterics suffer from reminiscences”.Q He also made one of his few ventures into nosology, dividing neuroses on clinical grounds into two categories: actual neurosis (neurasthenia, anxiety neurosis) and psychoneurosis (hysteria, obsessive-compulsive ) .lo In an historical sense, these categories represented the old and the new: Cullen’s physical neuroses, Freud’s psychoneuroses. In 1894 hysteria became a defense neuropsychosis (psychoneurosis) and the imagery ( in 1895) was twofold: a dissociative split in the mind, and strangulated affect seeking discharge.Q These ideas were developed in conjunction with Breuer whose encounter with his patient, Anna O., had resulted in the idea of catharsis. Psychodynamic and psychophysical metaphors developed together. Breuer’s cathartic method stressed recall of the traumatic memory and abreaction of the affect. (Abreaction was similar to the “‘purge of the emotions” advocated by Aristotle but never specifically related by the Greeks to hysteria).l The concept of defense was Freud’s: the split in consciousness was the result of repression. Freud wrote: “The hysterical patient’s ‘not knowing’ was in fact a ‘not wanting to know’-a not wanting which might be to a greater or less extent conscious~.Q Defense became a core concept in a new psychology.
WILLIAM
F.
KNOFF
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From “strangulated affect” it was not very far to the concept of cowersion. If discharge is blocked (denied direct expression) “The excitation arising from the affective idea is ‘converted’ . . . into a somatic phenomenon”9 With this theorem, physical symptoms of hysteria were for the first time explained psychologically. Advanced in 1895, the theory of conversion, reexamined and revised, remains a major concept in psychiatry. In our 1968 nomenclature it is subsumed, along with dissociation, under “hysterical neurosis.” Rangell’s study has emphasized the ubiquitousness of conversion; it can occur at any stage of development and in a wide spectrum of individual reactions including depression and schizophrenia. I1 Ziegler and his associates have analyzed contemporary manifestations of conversion reactions, particularly pain, as they are related to culture changes. I2 It appears that hysterical patients today communicate more commonly by means of pain syndromes in contrast to the more flamboyant histrionics of hysterics in Freud’s day. And Cleghorn, in a justpublished comprehensive review, concludes: “Hysteria is a term with confusing uses concerning a variety of conditions often with little or no functional relationship.“13 Reminding us that Freud nowhere defined “hysteria,” he reviews subsequent studies and concludes that the attempt to create a syndrome of hysteria has failed. Conversion reactions still remain explicable only in psychological terms, such as suggested by Freud. Freud, even more importantly, recognized the symbolism of hysteria: the somatic phenomena were not merely symptoms but were symbols of repressed memories, affects, conflicts. Symbolism became a major subject matter in psychoanalysis. The notion of somatic or body-language is implicit in the case histories in Breuer and Freud’s Studies on Hysteria, the most important book on hysteria ever written. On page 181, Freud hypothesizes that “both hysteria and linguistic usage alike draw their material from a common source.” The source is bodily feelings. As much like a poet as a scientist, Freud cites a “stab in the heart” or a “slap in the face” as the precursors of figures of speech.’ In 1909 Freud described the “pantomime” of hysterical attacks.l He perceived the parallel between hysterical symptoms and the dream. As Abse states: “The dream is indeed the first member of a series that includes the hysterical symptom, the obsession, and the delusion.“’ People communicate with themselves and others by means of the signs and symbols of conventional language and body language. We are all constantly employing language skills in reading, writing, talking, listening and thinking. Freud observed that words form the major portion of our thought processes. Conversion symptoms are unspoken messages which have social-communicative value. In Fenichel’s description they are “specific representations of thoughts which can be retranslated from their somatic language into the original word language.“l* The retranslation (or reconversion, if you will) is from the obscure code of body language to the conventional code of word language. Conversion, repression and dissociation are interrelated. Conversion always involves some degree of dissociation from consciousness and can be considered, therefore, a limited case of dissociation. The explicit recognition of the social and communicative aspects of behavioral disorders has been one of the major accomplishments of 20th century
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psychiatry. Although, as we have noted, communicative aspects of hysteria were probably surmised by the ancients, it has only been in our time that systematic attempts have been made to decode these communications. By employing principles of symbolic logic, for example, Szasz has defined bodylanguage (communication by means of bodily signs) as “protolanguage.” He writes, “. . . while the task of the physician is to diagnose and treat, the task of the psychoanalyst is to foster the self-reflective attitude in the patient toward his own body signs so as to effect their translation into verbal symbols.“1S “In general,” he notes, “whenever people feel unable-by means of normal mechanisms, such as ordinary speech-to prevail over the significant objects in the environment, they are likely to shift their pleas to the idiom of protolanguage (e.g., weeping, body signs ) .“I5 Characteristically, the hysteric tends to be in relatively powerless social circumstance.* Indeed, the original case material of psychoanalysis is the study of an oppressed female: Fraulein Anna 0. Her case history, with others, is presented in detail in the BreuerFreud book. It is significant to note that the concept of defense originated in these early studies of hysterical women.7 Essentially, what is meant by defense is that direct expression of thoughts and feelings is socially prohibited. Freud repeatedly used the adjective “unacceptable” to describe these thoughts and feelings. Indirect e‘xpression may be permitted, even rewarded. If other means of self-expression are blocked, a person may revert to the language of illness, mental or physical. This idiom is socially acceptable. It is also an appropriate way in which to “converse” with a doctor. The decoded messages of hysteria characteristically read something like this: “Take care of me; there is something wrong with me; excuse me; I can’t help it; I am sick , . . .” The patient may be trying to tell us, indirectly, that there is something wrong with his body (i.e., conversion) or his mind (i.e., dissociation). Genital conflict, as well as oral dependency, are expressed in the rhetoric of hysteria. Needless to say, the lifestyle or “character” of the person similarly displays dependent needs and demands. The state of oppression may become a way of life. As the hysterical patient’s “not knowing” is a “not wanting to know,” so also his oppression is a “not wanting to be free,” self-expressive, and self-responsible. The term “social-communicative” is well-chosen. It indicates that communication always occurs in context; the context is social and cultural. Freud’s early recognition of social and cultural factors is implicit in the concepts of defense, transference and the Oedipus complex. At one time or another in his life’s work, Freud seems to have anticipated practically every major development in psychiatry since his time. For example, the essence of the social-communicative approach is that the person is not viewed as a patient having a disease but as a person signalling distress. This point of view is implicit in the Studies on Hysteria in which Freud indeed did Wharcot’s subjects, inmates of the Salp&triBre, have been described as “the dregs of society.“3 tReichard has presented convincing evidence that Anna 0. was schizophrenic. It is likely that other early psychoanalytic cases were what we today would call “borderline personalities.“l6
WILLIAM
163
F. KNOFF
?aot define “hysteria” but focused his interest primarily on the symptoms which he viewed as communications. From the time of Herbert Spencer onward, social milieu could not be ignored. Dewey, Meyer, Mead, Sullivan, Homey, Parsons, Erikson, and others, have contributed greatly in the past 50 years to the definition of social factors affecting behavior. Classical Freudian theory has been developed and modified to accomodate these factors in the form of adaptational ego-psychology.17 Hysterical neurosis is viewed today in social context, in terms of person-toperson transactions and communications. The long gap from Hippocrates to Thomas Willis, during which hysteria continued to be viewed as a general organic condition, was not to be repeated. In the past 200 years we have gone from Cullen’s nervous disease concept (neurosis) to Freud’s psychological concepts (conversion, Oedipus complex) to today’s broad social-communicative comprehensions of the human being as an information-processing, symbolizing person engaged in transactions with others in sociohistorical context. Our problem now is that of integrating interrelated concepts. It is easy to write a holistic description. It is far more difficult to achieve a unified theory of human behavior, if, indeed, one is even possible.18 SUMMARY
We have briefly noted that the principal models used to conceptualize hysteria, following historical trends, have been organic, demonological, neurological, psychological and social-communicative. This mutable disorder has mirrored the medical and social-intellectual scene for thousands of years. Our current nomenclature (hysterical neurosis) reflects medical history in that it combines two metaphors originating more than 2500 years apart. But it is an anachronism rooted in an organic model more appropriate to 1770 than to 1970. George Rosen’s historical sociology has shown that “From the eighteenth century to the present there has existed the concept that social stress is in some way related to the causation of mental illness.“ls The term “hysterical neurosis” seems to ignore this important intellectual trend. REFERENCES 1. Abe,
D.
W.:
Hysteria
and
Related
Mental Disorders. Bristol, John Wright, 1966, pp. 6, 20, 41-42, 47, 170, 173. 2. Frank, R. L.: Conversion and dissociation. New York J. Med. 69:1872-1877, 1969. 3. Veith, I.: Hysteria: The History of a Disease. Chicago, The University of Chicago Press, 1965, pp. 2, 3,7, 8, 36-38, 132, 170. 4. Erikson, E.: Identity Youth and Crisis. New York, Norton, 1968, p. 261. 5. Freud, S.: Collected Papers, Vol. 3. London, Hogarth, 1953, p. 96. 6. Alexander, F., and Selesnick, S.: The History of Psychiatry, New York, Harper & Row, 1966, p. 13.
7. Whytt, It.: Observations on the Nature, Causes and Cure for Those Disorders Which Have Been Commonly Called Nervous, Hypochondriac, or Hysteric: to Which Are Prefixed Some Remarks on the Sympathy of the Nerves. Edinburgh, Balfour, 1765, p. 115. 8. Knoff, W.: An historical review of the concept of neurosis. Amer. J. Psyhciat. 127: 120-124, 1970. 9. Breuer, J., and Freud, S.: Studies on Hysteria. New York, Basic, 1957, p. 7, 17, 269-270, 181, 206, 269-270. 10. Freud, S.: Collected Papers, Vol. 1. London, Hogarth, 1953, p. 76-106.
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11. Rangell,
L.: The nature of conversion.
J. Amer. Psychoanal 12. Ziegler, Meyer,
E.
tions :a
clinical
F.
Ass. 7:632-662, J.,
Imboden,
: Contemporary
116:901-909,
study.
J.
1959. B.,
conversion Amer.
J.
and reac-
Psychiat.
1960.
13. Cleghom, R. A.: Hysteria-multiple manifestations of semantic confusion. Canad. Psychiat.
Ass. J. 14:539-551,
14. Fenichel,
0.:
Theory of Neurosis.
The
1969. Psychoanalytic
New York, Norton, 1945,
p. 216. 15. Szasz, T. S.: The Myth of Mental
Ill-
ness. New York, Hoeber-Harper, 1961, 129, 130. 16. Reichard, S.: A re-examination
pp.
of studies in hysteria. Psychoanal. Quart. 25: 155-177, 1956. 17. Hartmann, H.: ssays on Ego Psychology. New York, International Universities Press, 1964. 18. Grinker R. (ed. ) : Toward a Unified Theory of Human Behavior. New York, Basic Books, 1967. 19. Rosen G.: Madness in Society. Chicago, 1968,
The University p. 193.
of
Chicago
Press.
T HE
Years of Hysteria
By WILLIAM F. KNOFF
HISTORY OF PSYCHIATRY is the best textbook of psychiatry. In this “textbook,” hysteria and madness stand out as paradigmatic disorders with a long historical development. Indeed, one who learns as much as he can about the history of hysteria and psychosis will have mastered much of psychiatry. This paper addresses itself to hysteria: How old is it? Can we define it? Is there anything we can do about it? “Hysteria,” as employed in this paper, refers to the traditionally recognized sensorimotor and dysmnesic disorders without organic basis familiar to physicians since ancient times, but never completely understood, even today. Abse, in his recent text, describes (1) a group of physical symptoms without structural lesion; (2) complacency or “belle indifference;” and (3) episodic disturbances in the stream of consciousness ( dissociation). Physical symptoms are not necessarily limited to those under control of the voluntary nervous system. Primary and secondary gain are axi0matic.l Frank has recently commented on the “core of hysteria in every neurosis.“2 “Neurosis,” which includes hysteria, is impossible to define in a way that will satisfy everybody (or perhaps anybody). Conventionally, it is a generic term referring to certain defensive patterns of human expression, based on unconscious conflict, without reality disengagement. Neurotics, in the past and in the present, seem to be people with a special capacity for dissociation. ANTIQUITY Insanity was described in one of the earliest civilizations, the Babylonian, where magico-religious medicine prevailed; it was attributed to the demon Idta.’ Descriptions of behavioral disorders (nosography ) precede the process of naming them (nosology ). Nosography of hysterical phenomena dates back to the medical literature of ancient Egypt (Kahun Papyrus, 1900 B.C.).3 Believed to be a disorder of women, sexual factors were implicitly recognized in the earliest descriptions of hysteria. It was taken for granted in ancient Egyptian medicine that certain behavioral disorders were associated with the generative organs, and specifically with aberrations in the position of the womb.3 This was an organic hypothesis. It was assumed that the patient’s symptoms were caused by the womb which was free to wander about the body. Psychiatry and internal medicine have always been more vulnerable than other disciplines to mythical explanatory ideas because they deal so much with the nonvisible, the intangible (for example, the inside of the body, feelings, thoughts). A popular treatment for hysteria, later practiced in Greece, was fumigation of the vagina. This was designed to lure From the State Uniuersity of New York, Upstate Medical Center, Syracuse, N.Y. WILLIAM F. KNOFF, M.D.: Associate Professor of Psychiatry, State University York, Upstate Medical Center, Syracuse, N. Y. 156
of New
COMPREHENSIVEPSYCHIATRY,VOL. 12, No. 2 (MARCH),
1971
WILLIAM
F.
KNOFF
157
the uterus back to its normal position. Continuity of Egyptian and Greek medical thought is seen in the transmission of views on hysteria.3 The ideas passed from East to West. But the Greeks “had a word for it,” so to speak. The term “hysteria,” from “hystera,” womb, first appeared in the Hippocratic writings. Uterine fumigation was recommended with enthusiasm by Hippocrates and Plato, and, even much later, by Pare. Ilza Veith, who has written the definitive history of hysteria, which has been drawn upon liberally in this section, cites Plato’s Timaeus: “The womb is an animal which longs to generate children. When it remains barren too long after puberty, it is distressed and sorely disturbed, and straying about in the body and cutting off the passages of the breath, it impedes respiration and brings the sufferer into the extremist anguish and provokes all manner of diseases besides.” Veith comments : “This disturbance continues until the womb is appeased by passion and love.“3 We seem to hear an echo of these ideas today in Erik Erikson’s exposition of Womanhood and the Inner Space.4 The Egyptian-Roman view of hysteria, then, was essentially that of a general organic condition. The womb was free to migrate anywhere in the body. If it were dislocated upward, pressing against contiguous organs, it could cause the “globus hystericus,” aching limbs, or “pain in the sockets of the eyes.” Treatment was directed toward luring or driving the disaffected organ back where it belonged. Although the organic point of view (medical model) prevailed for 2 millenia, until the 19th century, intuitive psychological insights were seldom completely lacking. A sexual element is implied in the earliest concepts of hysteria. Zilboorg notes, “The sexual causation of hysteria . . . was not consciously suspected by Hippocrates, but instinctively he must have sensed it, since he considered marriage the best remedy for this affliction . . .“.I This advice remained among the standard prescriptions for 2000 years. Although not in a prescriptive sense, Freud mentioned in 1905 “The possibility of a hysteria being cured by marriage and normal sexual intercourse,“5 Zilboorg calls Hippocrates a medical psychologist. Galen, 6 centuries later, was a better one. He wrote sensitive case histories, elucidating psychogenic and psychosomatic factors (the most famous, perhaps, being that of the lady patient whose love for Pylades, the dancer, was diagnosed by taking her pulse).3 Galen was the first to propose a theory of male hysteria. His ideas show remarkable similarities to Freud’s early, but never abandoned, toxicity theories of the physical neuroses (neurasthenia, anxiety neurosis). You will remember that Freud, using physicochemical concepts, attributed the physical neuroses to dissipation or accumulation of somatic sexual excitation. Galen believed hysteria in male and female was due to retained semen caused by sexual abstinence. (He thought the uterus secreted a substance analogous to semen). Retention of this substance “poisoned” the body.3 That Galen applied his theories in practice is dramatically illustrated by Ilza Veith’s translation of the following paragraph: Following the warmth of the remedies and arising from the touch of the genital organs required by the treatment there followed twitchings accompanied at the same time by
158
HYSTERIA
pain and pleasure after which she emitted turbid and abundant spemr. From that time on she was freed of all the evil she felt. From all this it seems to me that the retention of sperm impregnated with evil essences had-in causing damage throughout the body -a much greater power than that of the retention of the menses.3
Sociological components were not completely lacking from the views of early medicine. With the development of societal organization in Mesopotamia, disease became related to sin. Confession, an historical antecedent of catharsis, became the means of treatment. The concept of disease as punishment for sin was transmitted by the Hebrews to the West and became a part of the Judeo-Christian tradition. St. Augustine, whom Franz Alexander calls “the greatest introspective psychologist before Freud,“6 regarded all human suffering as manifestations of innate evil consequent upon original sin. His Confessions, by the way, written in the fifth century, is an example of selfanalysis which bears comparison to Freud’s. Biological, psychological and social aspects of illness, therefore, were not unknown to our ancestors. Our contemporary model of biopsychosocial man has had a long evolution. If “one picture can be worth a thousand words” perhaps an historical chart can indicate 2066 years. Table 1 illustrates in approximate chronology, some significant biological, psychological, and social concepts from antiquity to the present. A quick glance at the table reveals how organic theories of hysteria have predominated, as in other areas of medicine. Psychosocial concepts, although implied from the beginning, have developed very recently. THE NERVOUS SYSTEM From the time of Hippocrates until Thomas Willis, in 17th century England, hysteria continued to be viewed as a general organic condition. Explanatory notions varied, of course, from humors and strictures, to spleen, animal spirits, and vapors, with a stormy interlude of demonology during the Middle Ages when many mentally afflicted persons were viewed as witches. Willis was a physiologist and neuroanatomist (i.e., the circle of Willis) who began central nervous to narrow the subject down to the “nervous stock”-the system.3 He put the origin of hysteria in the brain. Almost a century later, Robert Whytt, in the same neurological tradition, wrote: A delicate or easily irritable nervous system, must expose a person to various ailments, from causes, affecting either the body or mind, too slight to make any remarkable impression upon those of firmer and less sensible nerves. Thus, any accident occasioning sudden surprise, will, in many delicate people, produce strong palpitations of the heart and sometimes fainting with convulsions. I have known some, even men, whose nervous systems were so delicate and moveable, that a vomit, a smart purge, or the pain raised by a blister, would throw them into convulsive fits.7 (Fig. 2).
The stage was set for William Cullen, successor to Whytt at Edinburgh, to coin the term “neurosis” ( 1769), a neurological concept attributing the condition to “disordered motions or sensations of the nervous system without organic pathology”.* One of the diseases Cullen classified as a neurosis, 2309 years after Hippocrates, was hysteria.
WILLIAM
F.
159
MOFF
Table L-Concepts Somatic
Mystical
Social Communicative
Psychological
Confession Sexuality
Wandering womb Humors Constriction Abstinence and retention Womb affections
Purge of emotions (Aristotle)
Imaginatio Lasciva Hypochondriasis
Demons Vapors Nerves Brain Neurosis ( Cullen )
Animal spirits Passions Nymphomania Animal
Heredity
Degeneration
magnetism Repressed ( Carter
sexuality
)
Psychic trauma Suggestibility Dissociation Defense Conversion Repression Transference Unconscious Sexuality (rediscovered) Oedipus complex
Unconscious language (Feuchtersleben)
Catharsis Symbolism Somatic
language
Interpersonal relations
communications A general concept of nervous disease, neurosis, could only develop as a result of progress in the discovery of the structure and function of the nervous system from the time of Vesalius. As elsewhere in history, new knowledge often leads to overgeneralization and to “fashions” in thought (i.e., Newtonian mechanics, Pavlovial reflexology, the unconscious, etc.). Neurosis, as an overgeneralized explanatory concept became a fashion which is still with us today. As Veith writes in a short paragraph which contains much history: Despite Raulin’s observation of the suggestibility of hysterics, Baglivi’s realization of the impact of emotions on physical health, Sydenham’s assumption of the role of animal spirits, and Willis’ and Whytt’s relation of hysteria to the nervous system, the basic concept of hysteria remained unchanged for two thousand years. The essence of this concept was that hysteria was a physical disorder. It is interesting that the man who introduced the word “neurosis,” and first classified hysteria among the neuroses, Cullen, clung even more firmly to the somatic etiology.3
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But Cullen’s “neurosis” was, to some extent, an updated metaphor. At least the imagery was no longer the wandering womb but now motions and sensations in the nervous system. Neurosis became the property of neurology for more than a century until the chain of though which reads Mesmer-CharcotBernheim-Freud began to present a psychology of neurosis. NEW
METAPHORS
Method, data, and metaphor are always interrelated; different methods enable different observations and the development of new metaphors and models. We are continually developing new vocabularies in which to express our observations of human behavior. Principal 19th century contexts, in which basic concepts are still rooted, were “neurology,” “hypnosis” and “cathartic treatment” ( early psychoanalysis ) . Employing what he called “animal magnetism,” Mesmer charismatically demonstrated the effect one mind can have upon another. Developed by others as hypnosis, suggestive therapeutics became an historical precursor of psychotherapy. Hypnosis, then as now, emphasized communication and was, therefore, a departure from the physical and pharmacological methods of traditional medicine. Always regarded with skepticism, hypnosis acquired some respect in the hands of the great Charcot who used it in the first systematic study of neurosis. In Paris in 1885, Freud was his pupil. Later Freud visited Bemheim at Nancy. From 1882, Freud was influenced by the ideas of Josef Breuer. Methodologically, hypnosis brought one mind in contact with another. Explanatory concepts began to tend toward the mentalistic but not entirely away from the somatic. Thus, varying states of consciousness, splits in consciousness, somnambulism, multiple personality, abulia, and other notions were emphasized. Depending on point of view, Charcot stressed clegenmation, Bemheim stressed suggestibility, Janet stressed dissociation, and Breuer and Freud stressed conversion. Freud, particularly, commenced a new departure in observing that “hysterics suffer from reminiscences”.Q He also made one of his few ventures into nosology, dividing neuroses on clinical grounds into two categories: actual neurosis (neurasthenia, anxiety neurosis) and psychoneurosis (hysteria, obsessive-compulsive ) .lo In an historical sense, these categories represented the old and the new: Cullen’s physical neuroses, Freud’s psychoneuroses. In 1894 hysteria became a defense neuropsychosis (psychoneurosis) and the imagery ( in 1895) was twofold: a dissociative split in the mind, and strangulated affect seeking discharge.Q These ideas were developed in conjunction with Breuer whose encounter with his patient, Anna O., had resulted in the idea of catharsis. Psychodynamic and psychophysical metaphors developed together. Breuer’s cathartic method stressed recall of the traumatic memory and abreaction of the affect. (Abreaction was similar to the “‘purge of the emotions” advocated by Aristotle but never specifically related by the Greeks to hysteria).l The concept of defense was Freud’s: the split in consciousness was the result of repression. Freud wrote: “The hysterical patient’s ‘not knowing’ was in fact a ‘not wanting to know’-a not wanting which might be to a greater or less extent conscious~.Q Defense became a core concept in a new psychology.
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From “strangulated affect” it was not very far to the concept of cowersion. If discharge is blocked (denied direct expression) “The excitation arising from the affective idea is ‘converted’ . . . into a somatic phenomenon”9 With this theorem, physical symptoms of hysteria were for the first time explained psychologically. Advanced in 1895, the theory of conversion, reexamined and revised, remains a major concept in psychiatry. In our 1968 nomenclature it is subsumed, along with dissociation, under “hysterical neurosis.” Rangell’s study has emphasized the ubiquitousness of conversion; it can occur at any stage of development and in a wide spectrum of individual reactions including depression and schizophrenia. I1 Ziegler and his associates have analyzed contemporary manifestations of conversion reactions, particularly pain, as they are related to culture changes. I2 It appears that hysterical patients today communicate more commonly by means of pain syndromes in contrast to the more flamboyant histrionics of hysterics in Freud’s day. And Cleghorn, in a justpublished comprehensive review, concludes: “Hysteria is a term with confusing uses concerning a variety of conditions often with little or no functional relationship.“13 Reminding us that Freud nowhere defined “hysteria,” he reviews subsequent studies and concludes that the attempt to create a syndrome of hysteria has failed. Conversion reactions still remain explicable only in psychological terms, such as suggested by Freud. Freud, even more importantly, recognized the symbolism of hysteria: the somatic phenomena were not merely symptoms but were symbols of repressed memories, affects, conflicts. Symbolism became a major subject matter in psychoanalysis. The notion of somatic or body-language is implicit in the case histories in Breuer and Freud’s Studies on Hysteria, the most important book on hysteria ever written. On page 181, Freud hypothesizes that “both hysteria and linguistic usage alike draw their material from a common source.” The source is bodily feelings. As much like a poet as a scientist, Freud cites a “stab in the heart” or a “slap in the face” as the precursors of figures of speech.’ In 1909 Freud described the “pantomime” of hysterical attacks.l He perceived the parallel between hysterical symptoms and the dream. As Abse states: “The dream is indeed the first member of a series that includes the hysterical symptom, the obsession, and the delusion.“’ People communicate with themselves and others by means of the signs and symbols of conventional language and body language. We are all constantly employing language skills in reading, writing, talking, listening and thinking. Freud observed that words form the major portion of our thought processes. Conversion symptoms are unspoken messages which have social-communicative value. In Fenichel’s description they are “specific representations of thoughts which can be retranslated from their somatic language into the original word language.“l* The retranslation (or reconversion, if you will) is from the obscure code of body language to the conventional code of word language. Conversion, repression and dissociation are interrelated. Conversion always involves some degree of dissociation from consciousness and can be considered, therefore, a limited case of dissociation. The explicit recognition of the social and communicative aspects of behavioral disorders has been one of the major accomplishments of 20th century
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psychiatry. Although, as we have noted, communicative aspects of hysteria were probably surmised by the ancients, it has only been in our time that systematic attempts have been made to decode these communications. By employing principles of symbolic logic, for example, Szasz has defined bodylanguage (communication by means of bodily signs) as “protolanguage.” He writes, “. . . while the task of the physician is to diagnose and treat, the task of the psychoanalyst is to foster the self-reflective attitude in the patient toward his own body signs so as to effect their translation into verbal symbols.“1S “In general,” he notes, “whenever people feel unable-by means of normal mechanisms, such as ordinary speech-to prevail over the significant objects in the environment, they are likely to shift their pleas to the idiom of protolanguage (e.g., weeping, body signs ) .“I5 Characteristically, the hysteric tends to be in relatively powerless social circumstance.* Indeed, the original case material of psychoanalysis is the study of an oppressed female: Fraulein Anna 0. Her case history, with others, is presented in detail in the BreuerFreud book. It is significant to note that the concept of defense originated in these early studies of hysterical women.7 Essentially, what is meant by defense is that direct expression of thoughts and feelings is socially prohibited. Freud repeatedly used the adjective “unacceptable” to describe these thoughts and feelings. Indirect e‘xpression may be permitted, even rewarded. If other means of self-expression are blocked, a person may revert to the language of illness, mental or physical. This idiom is socially acceptable. It is also an appropriate way in which to “converse” with a doctor. The decoded messages of hysteria characteristically read something like this: “Take care of me; there is something wrong with me; excuse me; I can’t help it; I am sick , . . .” The patient may be trying to tell us, indirectly, that there is something wrong with his body (i.e., conversion) or his mind (i.e., dissociation). Genital conflict, as well as oral dependency, are expressed in the rhetoric of hysteria. Needless to say, the lifestyle or “character” of the person similarly displays dependent needs and demands. The state of oppression may become a way of life. As the hysterical patient’s “not knowing” is a “not wanting to know,” so also his oppression is a “not wanting to be free,” self-expressive, and self-responsible. The term “social-communicative” is well-chosen. It indicates that communication always occurs in context; the context is social and cultural. Freud’s early recognition of social and cultural factors is implicit in the concepts of defense, transference and the Oedipus complex. At one time or another in his life’s work, Freud seems to have anticipated practically every major development in psychiatry since his time. For example, the essence of the social-communicative approach is that the person is not viewed as a patient having a disease but as a person signalling distress. This point of view is implicit in the Studies on Hysteria in which Freud indeed did Wharcot’s subjects, inmates of the Salp&triBre, have been described as “the dregs of society.“3 tReichard has presented convincing evidence that Anna 0. was schizophrenic. It is likely that other early psychoanalytic cases were what we today would call “borderline personalities.“l6
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?aot define “hysteria” but focused his interest primarily on the symptoms which he viewed as communications. From the time of Herbert Spencer onward, social milieu could not be ignored. Dewey, Meyer, Mead, Sullivan, Homey, Parsons, Erikson, and others, have contributed greatly in the past 50 years to the definition of social factors affecting behavior. Classical Freudian theory has been developed and modified to accomodate these factors in the form of adaptational ego-psychology.17 Hysterical neurosis is viewed today in social context, in terms of person-toperson transactions and communications. The long gap from Hippocrates to Thomas Willis, during which hysteria continued to be viewed as a general organic condition, was not to be repeated. In the past 200 years we have gone from Cullen’s nervous disease concept (neurosis) to Freud’s psychological concepts (conversion, Oedipus complex) to today’s broad social-communicative comprehensions of the human being as an information-processing, symbolizing person engaged in transactions with others in sociohistorical context. Our problem now is that of integrating interrelated concepts. It is easy to write a holistic description. It is far more difficult to achieve a unified theory of human behavior, if, indeed, one is even possible.18 SUMMARY
We have briefly noted that the principal models used to conceptualize hysteria, following historical trends, have been organic, demonological, neurological, psychological and social-communicative. This mutable disorder has mirrored the medical and social-intellectual scene for thousands of years. Our current nomenclature (hysterical neurosis) reflects medical history in that it combines two metaphors originating more than 2500 years apart. But it is an anachronism rooted in an organic model more appropriate to 1770 than to 1970. George Rosen’s historical sociology has shown that “From the eighteenth century to the present there has existed the concept that social stress is in some way related to the causation of mental illness.“ls The term “hysterical neurosis” seems to ignore this important intellectual trend. REFERENCES 1. Abe,
D.
W.:
Hysteria
and
Related
Mental Disorders. Bristol, John Wright, 1966, pp. 6, 20, 41-42, 47, 170, 173. 2. Frank, R. L.: Conversion and dissociation. New York J. Med. 69:1872-1877, 1969. 3. Veith, I.: Hysteria: The History of a Disease. Chicago, The University of Chicago Press, 1965, pp. 2, 3,7, 8, 36-38, 132, 170. 4. Erikson, E.: Identity Youth and Crisis. New York, Norton, 1968, p. 261. 5. Freud, S.: Collected Papers, Vol. 3. London, Hogarth, 1953, p. 96. 6. Alexander, F., and Selesnick, S.: The History of Psychiatry, New York, Harper & Row, 1966, p. 13.
7. Whytt, It.: Observations on the Nature, Causes and Cure for Those Disorders Which Have Been Commonly Called Nervous, Hypochondriac, or Hysteric: to Which Are Prefixed Some Remarks on the Sympathy of the Nerves. Edinburgh, Balfour, 1765, p. 115. 8. Knoff, W.: An historical review of the concept of neurosis. Amer. J. Psyhciat. 127: 120-124, 1970. 9. Breuer, J., and Freud, S.: Studies on Hysteria. New York, Basic, 1957, p. 7, 17, 269-270, 181, 206, 269-270. 10. Freud, S.: Collected Papers, Vol. 1. London, Hogarth, 1953, p. 76-106.
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11. Rangell,
L.: The nature of conversion.
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