Hysteria: The Rise of an Enigma

J. Bogousslavsky

• Publisher: S. Karger
• Year: 2014
• ISBN:
  9783318026474
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Hysteria is probably the condition which best illustrates the tight connection between neurology and psychiatry. While it has been known since antiquity, its renewed studies during the 19th century were mainly due to the work of Jean-Martin Charcot and his school in Paris. This publication focuses on these early developments, in which immediate followers of Charcot, including Babinski, Freud, Janet, Richer, and Gilles de la Tourette were involved. Hysteria is commonly considered as a condition that often leads to spectacular manifestations (e.g. convulsions, palsies), although both structural and functional imaging data confirm the absence of consistent and reproducible structural lesions. While numerous hypotheses have tried to explain the occurrence of this striking phenomenon, the precise nosology and pathophysiology of hysteria remain elusive. This volume offers an enthralling and informative read for neurologists, psychiatrists, and psychologists, as well as for general physicians, historians, and everyone interested in the developments of one of the most intriguing conditions in medicine.

Bogousslavsky J (ed): Hysteria: The Rise of an Enigma. Front Neurol Neurosci. Basel, Karger, 2014, vol 35, pp 181-197
DOI: 10.1159/000360242

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History of Physical and ‘Moral’ Treatment of Hysteria

Emmanuel Broussolle^a · Florent Gobert^a · Teodor Danaila^a · Stéphane Thobois^a · Olivier Walusinski^b · Julien Bogousslavsky^c

^aCentre de Neurosciences Cognitives, Service de Neurologie C, Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon, Université Claude Bernard Lyon I, Lyon, and ^bFamily Physician, Private Practice, Brou, France; ^cCenter for Brain and Nervous System Diseases, GSMN Neurocenter, Clinique Valmont, Glion/Montreux, Switzerland

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Abstract

This historical review presents the advances made mostly during the last 200 years on the description, concepts, theories, and (more specifically) cure of patients suffering from hysteria, a still obscure entity. The denomination of the syndrome has changed over time, from hysteria (reinvestigated by Paul Briquet and Jean-Martin Charcot) to pithiatism (Joseph Babinski), then to conversion neurosis (Sigmund Freud), and today functional neurological disorders according to the 2013 American Neurological Association DSM-5 classification. The treatment was renewed in the second half of the 19th century in Paris by Paul Briquet and then by Jean-Martin Charcot. Hysterical women, who represented the great majority of cases, were cured by physical therapy (notably physio-, hydro-, and electrotherapy, and in some cases ovary compression) and ‘moral’ therapies (general, causal therapy, rest, isolation, hypnosis, and suggestion). At the turn of the 19th and 20th centuries, psychotherapy, psychoanalysis, and persuasion were established respectively by Pierre Janet, Sigmund Freud, and Joseph Babinski. During World War I, military forces faced a large number of posttrauma neurosis cases among soldiers (named the ‘Babin-ski-Froment war neurosis’ and Myers ‘shell shock’, in the French and English literature, respectively). This led to the use of more brutal therapies in military hospitals, combining electrical shock and persuasion, particularly in France with Clovis Vincent and Gustave Roussy, but also in Great Britain and Germany. After World War I, this method was abandoned and there was a marked decrease in interest in hysteria for a long period of time. Today, the current treatment comprises (if possible intensive) physiotherapy, together with psychotherapy, and in some cases psychoanalysis. Antidepressants and anxiolytics may be required, and more recently cognitive and behavioral therapy. Repetitive transcranial magnetic stimulation is a new technique under investigation which may be promising in patients presenting with motor conversion syndrome (motor deficit or movement disorder). Functional neurological disorders remain a difficult problem to manage with frequent failures and chronic handicapping evolution. This emphasizes the need for therapeutic innovations in the future.

© 2014 S. Karger AG, Basel

A number of historical reviews on hysteria have been published, particularly on the description of its large clinical spectrum and the pathophysiological hypotheses that were made about this still complex entity. The present dissertation is aimed at giving an overview of the various treatments of hysteria employed over the centuries, mostly from the 17th century until contemporary times. These include physical therapy (notably physio-, hydro-, and electrotherapy) and ‘moral’ therapies (general, causal therapy, rest, isolation, hypnosis, psychic therapy, and persuasion). In order to achieve this challenging goal, a brief recall on the changes of concepts concerning hysteria will be presented for each part of this essay. In a chronological order we will consider (1) the pre-Charcot era until Briquet's contribution in the mid-19th century; (2) the changes made by Charcot, his students, and his contemporaries, notably the use of hypnosis and suggestion; (3) the new steps formulated by Janet and Freud, as well as Dejerine and Sollier at the turn of the 19th and 20th centuries; (4) the Babinski concept of pithiatism and persuasion at the very beginning of the 20th century; (5) war neurosis, shell shock, and ‘torpillage’, which were particularly studied during World War I, and (6) the progressive evolution of physical and psychological therapeutic approaches after World War II and during the recent decades.

From the Ancient Times to the Mid-19th Century before Charcot

Antique Times

Although the term hysteria comes from a Greek word and refers to the uterus, this entity was first mentioned more than 4,000 years ago in Egyptian medicine [1]. During the Greek and Roman times, Hippocrates and Galen presented hysteria as a syndrome resulting from the migration of the uterus upward in the body and classified it as a mental illness.

The 17th and 18th Centuries and the Inventive Work of Sydenham, Cullen, Ferriar, de La Mettrie, and Mesmer

In the late 17th and during the 18th centuries, several British physicians contributed to the study of diseases of the nervous system and notably hysteria [1]. Thomas Sydenham (1624-1689) supported the idea that hysteria resulted from the ability to mimic various diseases in relation with emotional troubles. William Cullen (1710-1790) was one of the first to present a nosological classification of nervous and mental diseases. He identified the neuroses among which he believed hysteria should be assigned to [2, 3]. In 1795, the term hysterical conversion was proposed for the first time by John Ferriar (1761-1815), who classified hysteria with visceral spasms [1, 4].

In the mid-18th century, Julien Offray de La Mettrie (1709-1751), a French philosopher who owes his fame to his materialist ideas, reported on a case of ‘grande hystérie’ (hysteria-epilepsy), almost 150 years before its full description [5].

In the late 18th century, Franz Anton Mesmer (1734-1815), an Austrian physician, came to Paris and proposed to treat hysterical patients as a group with magnetism using a magnet [6]. In 1784, however, the method, also called ‘mesmerism’, was criticized by a council of experts, who stated that this method had no scientific basis and should therefore no longer be used [1]. Nevertheless, mesmerism remained popular, and may be considered as a precursory step before the advent of hypnosis in the 19th century.

Pinel and Esquirol: The Founders of Psychiatry in the Early 19th Century

The turn of the 18th and 19th centuries and the first half of the 19th century were revolutionary times in medicine, particularly in Paris. In the field of psychiatry, Philippe Pinel (1745-1826) was a great pioneer [3, 7] and the first to distinguish insane/alienated patients from misfits, beggars, and other vagabonds. Pinel individualized four main nosological entities of mental diseases: mania, melancholia, dementia, and idiocy. While several contemporary physicians, notably Vincenzo Chiarugi (1759-1820) in Italy, proposed the moral care for patients with mental illnesses, Pinel offered detailed accounts of case histories and the full description of moral treatment [8, 9]. This was not only a matter of humanitarianism, but a process of gaining the confidence of patients and of providing them a stimulating and pleasing environment. The moral treatment was later expanded to describe mental and psychic therapies. Jean-Etienne Esquirol (1772-1840), a student of Pinel, also played a major role with his treatise on mental diseases and the 1838 law that led to the creation of asylums in all parts of France [3]. Pinel did not pay very much attention to hysteria. In the first edition of his nosographic book [10], he considered hysteria as an example of ‘névroses de la génération de la femme’, i.e. ‘female genital neurosis’ in English, among which nymphomania belonged to as well. Pinel believed as others that these neuroses originated from a dysfunction of the neural state of female organs, namely the uterus. He suspected that continence may be causal and thus suggested marriage as a preventive and curative therapy.

The Mid-19th Century and the Contributions of Briquet, Brachet and Landouzy

Early in the second half of the 19th century, a major work on hysteria was published in Paris by Paul Briquet (1796-1881), entitled Traité dinique et thérapeutique de l'hystérie (Clinical and Therapeutic Treatise on Hysteria) [11, 12].

Briquet presented a series of 430 patients, including 7 men, and thus provided evidence that hysteria was neither restricted to female patients nor related to the uterus, but rather to the brain. However, no brain lesions were found in the cases that came to autopsy. Factors found to be associated with hysteria were youth, female sex, ‘affective’ and ‘impressionable’ temperament, family history of the disorder, low social class, migration, sexual licentiousness, situational difficulties, and poor physical health. The damaging role of violence and sexual abuse in infancy was also depicted.

Briquet described the multiple clinical manifestations of this syndrome which were then classified into seven categories: hyperesthesia including pain, anesthesia, sensory hallucinations, spasms including of the abdomen, attacks (convulsions), palsies, and abnormal contractility.

Another important contribution of Briquet was his extensive review of the numerous therapies proposed for the care of hysterical patients, some employed in the past - even antique times - and others currently in use at the time of his publication. General care comprised the cure of the cause or associated pathologies (tumors, inflammation), along with the recommendation to keep away the family (husband, parents), hydrotherapy, fresh milk, and sometimes blood-letting, which a...