Historical Note THEORIES OF HYSTERIA * THOMAS A. H. MCCULLOCH, M.D: The word hysteria derives from the Greek by stera (uterus). From this is de- rived the Hippocratic theory that hys- teria was caused by the uterus wandering about the woman's body as a free organ, and hysteria was thus limited to women. It was not considered to be a mental disease. Plato adhered somewhat to this theory and wrote in Timaeus that the uterus, becoming angry at remaining un- fruitful, wandered throughout the body and closed up the passages of the breath, and, by obstructing respiration, caused all varieties of disease. Aretaeus of Cappadocia in the second century A.D. believed the disease to be limited to women and that it was due to the migration of the uterus which com- pressed the intestines, giving a choking sensation after the form of epilepsy. Little change in the theory of hysteria took place until the time of Galen, some seven centuries after Hippocrates. Hysteria came then to be thought of as a local suffocation of the uterus and not the wandering of it. During the Dark Ages, possession by the devil was the keynote to hysteria, with an elaborate system of hunting out the possessed by looking for the so-called 'stigmata',-naevi, pigmented spots and anesthesias. With the Renaissance, Para- celsus stated "Mental diseases have noth- ing to do with evil spirits or devils" and used the name chorea lasciua or lascivious dancing for hysteria, thus suggesting the sexual nature of the disease. In the seven- teenth century, Charles Lepois insisted that the cause of hysteria should be sought not in the uterus but in the brain "Post-graduate semmars in the history of psychiatry (Prof. Edward L. Margetts) , Department of Psychiatry, Faculty of Medicine, The University of British Columbia, Vancouver, Canada. Seminar 5 October 1962. ""Revised Nov. 1965. E.L.M. 'Surgeon-Commander, Resident in psychiatry (1962-3), Shaughnessy Hospital, Vancouver, B.C. Canad. Psychiat. Ass. J. Vol. 14 (1969) and that therefore it was also a disease of men. This was implied by Thomas Willis in his advocation of restraint, blows and fetters to induce the mind to give up its arrogance and wild ideas and become meek and orderly. Others, however, still considered the localization of 'hysteria' in the genital area and Lazare Riviere ( 1660) wrote chapters entitled De hy s- terica passione and De furore uterino. William Cullen (18th century) accepted the Hippocratic theory and thought hysteria was due to a displacement of the uterus (particularly the ovary) to the brain which causes convulsions, but could offer no explanation as to how this occurred. It became the custom to prescribe sweet-smelling concoctions at the per- ineum to attract the uterus back into place and to give evil tasting medica- tions 'at the other end' (by mouth) in order to repel the uterus back to its pro- per place. Sydenham theorized that hys- teria in females and its counterpart, hypochondriasis in males, arose "from a disorder (ataxy) of the animal spirits". Franz Anton Mesmer added a new impetus to the theory of hysteria through the interest of John Elliotson and James Braid. The former felt mesmerism was especially useful in hysteria and stated it was the treatment of choice since " ... (hysteria) is not necessarily con- nected with the uterus, nor confined to the female sex, but occurred frequently both in boys and men." The latter wrote a treatise called Neurypnology or the rationale of nervous sleep (1843) and wrote that ansesthesia, automatic obedi- ence and the phenomena of sleep could be explained on the basis of psychological processes. Franz Joseph Gall of Vienna, on the basis of 'organology' and 'crani- 635 636 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL Vol. 14, No.6 oscopy', the forerunner of 'phrenology', advanced the theory that the seat of hysteria lay in the cerebellum because this was the seat of carnal knowledge. The development of neurology raised the conception of the 'nervous' patient to a more respectable and scientific basis, and there was a shift of emphasis from the uterus to that of the nervous system. This was well summed up by Paul Briquet (1859) who did not believe there was a causal connection between sexuality and hysteria. Under the influence of both hypnotism and neurology, Jean Martin Charcot (late 19th century) considered the basis of hysteria to be physical and organic, com- bined with heredity, but still stated that it was to the ovary and the ovary alone that one had to look for the source of the fixed iliac pain of hysterics. He con- cluded that the states observed under hypnosis could only be induced in those people who suffered from hysteria. Al- though well aware of auto-suggestion and the psychological aspects of hysteria, he believed these were due to organic pathology and heredity. In collaboration with Paul Richer he unravelled the puzzle of demoniacal possession by point- ing out that demoniacal possession as re- flected in art was typical of hysteria. Ivan Petrovich Pavlov (early 20th century) postulated that hysteria was the result of conflicting, overwhelmingly strong or weak repetitive stimuli imping- ing on a balanced mechanism of condi- tioning but with the suggestion of physi- cal pathology, since he divided his dogs into types. Hippolyte Bernheim stressed the strong influence of suggestion and auto-sugges- tion in the production of the hysteric's symptomatology, and solved the riddle of the stigmata by pointing out that it was due to suggestibility and to the free reign of the imagination of the 'witches' and the patients. Joseph Babinski further pointed up the role of suggestibility and persuasion by coining the term pithiatism which is derived from Greek roots peitbo (I persuade) and iatos (curable). Joseph Breuer noted that cure of symp- toms occurred when he allowed patients to talk while under hypnosis and to relate what was oppressing their mind. As early as 1880 he stated that hypnosis allowed of a glimpse into the deeper layers of the psychopathological processes. He and Sigmund Freud developed the idea that any experience which roused the dis- tressing effects of fright, apprehension, shame or psychical pain could produce hysterical symptoms, and that the hysteric suffered from painful reminis- cences. They explained hysteria on a physical neurophysiological basis, on ex- citation in the nervous system, with emo- tional and motor discharge or with anomalous or 'hysterical' reactions if this discharge were blocked. Although his ex- planation was initially organic in nature, Freud later evolved the view that dis- turbance of sexuality as psychic trauma, and the repression of ideas from consciousness were of outstanding impor- tance in the pathogenesis of hysteria. He considered hysterical symptoms to be a dissociation of painful ideas from consciousness by a psychic force for the purpose of defence against mental pain. The ideas, being incompatible with consciousness, were converted into symp- toms. These ideas, he believed, were pre- dominantly sexual and repressed out of consciousness. Pierre Janet concluded that in hysteria ideas became dissociated from each other. They become isolated from conscious- ness, fixed because of exhaustion of the higher functions of the brain and the lowering of nervous strength, the result of a weakened nervous system of a con- stitutional nature, from heredity and degeneracy. In contrast to the constitu- tional weakness theory of Janet, Carl Jung considered hysteria to be an exag- geration of the normal attitude which December, 1969 HISTORICAL NOTE 637 was complicated by compensatory re- actions from the unconscious, which showed its opposition to the extravagant extraversion by developing physical symptoms. The theories of hysteria commenced with and have ended with a sexual con- notation. In the beginning, hysteria was considered due to the wandering of the uterus and confined to women. It was then thought to be the result of organic changes in the nervous system. Recent theory explains the illness on the basis of repressed disturbances of sexuality, and recognizes that men also may suffer from it. Noone who is not female can be in a position to make accurate statements about women. .Sex and Character Otto Weininger 1880-1903