Psychological Medicine, 1975, 5, 9-12
The survival of hysteria AUBREY LEWIS From the Institute of Psychiatry, The Maudsley Hospital, London SYNOPSIS There have been many battles in the last 100 years between those who consider hysteria to be a 'morbid entity' or 'disease' and those who would like to drop it once and for all. The controversy still goes on. It has not been settled by follow-up studies or by applying genetic considerations. Hysteria is a tough subject, unlikely to be killed so long as clinicians find it useful, if not indispensable. In psychiatry there are forms of illness, with names going back two and a half millennia, which have had sentence of death passed upon them more than once, yet they obstinately survive. Paranoia is one such condition and term, hysteria is another. Hysteria is indeed an extreme case. Built upon a false and absurd notion of pathology, it was inevitably the subject of controversy, ridicule, and denial. Funeral orations upon it have often been delivered in the last 100 years, in language appropriate to the state of psychiatric knowledge. Thus, of English writers on the subject, in 1874 W. B. Carpenter described it as 'a state of the nervous system which is characterized by its peculiar excitability, but in which there is no such fixed tendency to irregular action as would indicate any positive disease.'
These indictments, which have been reinforced by clinical and genetic evidence, are paralleled by similarly destructive arguments put forward by notable French, Swiss, and German psychiatrists. There is a long series of these, worth recalling. In 1902 Hoche said roundly, 'Hysteria is not a syndrome [Krankheitsbild] but a special form of mental disposition'. Dubois (1904) put it on record that 'il est inutile de s'efforcer de donner a l'hysterie le caractere d'une entite morbide'. Steyerthal (1908) predicted 'within a few years the concept of hysteria will belong to history . . . there is no such disease, and there never has been. What Charcot called hysteria is a tissue woven of a thousand threads, a cohort of the most varied diseases, with nothing in common but the so-called stigmata, which in fact may accompany any disease.'
A quarter of a century later Ormerod (1899) wrote that the objections to 'hysteria' are obvious:
Gaupp (1911) said
'not only that it has become etymologically meaningless but also that to many minds it has the disagreeable connotation of a certain moral feebleness in the patient, and of unreality in the symptoms.'
'Nowadays the cry is ever louder: away with the name and the concept of hysteria: there is no such thing, and what we call hysteria is either an artificial, iatrogenic product, or a melange of symptoms which can occur in all sorts of illnesses and are not pathognomonic of anything'.
In 1965 another English physician, Slater, expressed forcefully his contemporary objections. 'All the signs of "hysteria" are the signs not of disease but of health . . . there is nothing at all consistent in the medical condition of the patients who get diagnosed as "hysterics" . . . no evidence has yet been offered that the patients diagnosed as suffering from "hysteria" are in medically significant terms anything more than a random selection.'
Bumke (1925) reviewed the neuroses and declared 'There was once a disease hysteria, just as there was hypochondria, and neurasthenia. They have disappeared. The syndrome has replaced the disease entity.' Kraepelin (1927) said: 'Hysteria is not a sharply delimited syndrome but a special way of dealing with affective tensions; it can occur in very different morbid conditions in
10
Aubrey Lewis
which inner excitement is not adequately kept under control.' Moerchen (1929) simply entitled his diatribe 'Hysteria is not a disease'. Kranz (1953) concluded that
que, quelle que soit la facon dont on l'envisage, sous le jour ancien ou sous le jour nouveau, il y a une hysterie, et que cette hysterie, comme l'epilepsie . . . s'accompagne frequemment de troubles psychiques.'
'hysterical phenomena are only modes of reaction which fundamentally are available to everybody and are not in themselves abnormal, but become so in that they last unduly long, become fixed, or are excessive. . . . It is reasonable to ask that we should at least drop the word "hysteria" in favour of "hysterical reaction", and in the end give up this term too, loaded as it is with moral value-judgments: we can make ourselves understood by psychiatrists without it. But in spite of all that "hysteria" will not disappear altogether from psychiatric vocabulary for a long time to come.'
Much later (1941) one finds a prominent American psychiatrist, Stanley Cobb, declaring that 'hysteria, in the particular sense in which I believe it should be used, is a fairly clear-cut syndrome'.
Rouquier (1960) confidently wrote on 'la fin de Physterie'. And in the most recent French textbook (1964) Pierre Marchais adjures us 'si nous conservons le terme "hysterique", etant donne son caractere traditionnel, il faut bien reconnaitre qu'il meriterait d'etre abandonne pour deux raisons essentielles'. UPHOLDERS OF THE TERM
This is an imposing cloud of witnesses. Many more could be cited who testify similarly. But opposite this array there are the upholders of the term, who believe it to be a significant and justified designation of a diagnostic category that has equivalent title-deeds to that of obsessional neurosis and anxiety state. Charcot stated his position unequivocally: hysteria is a mental disorder par excellence. Before him Briquet (1859) had seized the bull similarly by the horns: Thysterie est loin d'etre une affection composee de phenomenes incoherents. . . . Je trouvais au contraire qu'elle constituait une affection dont il etat tres facile de comprendre la nature, dont tous les symptomes avaient leurs analogues dans l'etat physiologique et n'ayant de bizarre que l'apparence . . . dont le diagnostic pouvait se faire aussi surement et avec autant de precision que celui de tout autre maladie.' Regis (1914) avowed his faith with firm simplicity: 'on connait ces debats retentissants qui ont eu lieu en 1908 sur l'hysterie. . . . Nous croyons done, pour l'observer de pres et impartialement tous les jours
DEFINING DISEASE
From this welter of powerful opposing voices two main assertions can be picked out: that hysteria is not a disease; and that hysteria is not a syndrome. Obviously the meaning attached to these two terms 'disease' and 'syndrome' is a cardinal issue in the controversy. Those who refuse the name of 'disease' or 'morbid entity' to any condition that has not been demonstrated to have an anatomical or chemical pathology must clearly now refuse it to hysteria: even if we will not go so far as Hoche, who said that it does not have, and never will have, a basis in pathological anatomy, it is at present in that exposed state. It must, however, also be said that our present ignorance, or limited knowledge, of the somatic pathology of schizophrenia should lead to a similar refusal to call that a disease. This is, of course, not merely a semantic quibble, nor a modern difficulty. Although a few writers, like Szasz, insist that mental illness is a myth, and that the only real illness is bodily illness, the majority of psychiatrists have no desire to adopt this crude standpoint, or to differentiate psychoses from neuroses on the ground that the former have—or must be assumed to have—a somatic basis; they have, however, substituted 'reaction type' or 'syndrome' for 'disease'. Adolf Meyer was largely responsible for this change of language and approach in the English-speaking countries: the same movement occurred in France, as Henri Ey (1954) makes clear in his £tudes. Hysteria, then, in modern usage is not a disease; but neither is schizophrenia or melancholia. The hysterical reaction may be a manifestation of a somatic abnormality, as a paranoid psychosis or a manic excitement may likewise be, and in each such case multi-dimensional analysis will take into account constitutional predisposition as well as environmental and physical
The survival of hysteria
influences spread over the lifetime of the affected person. If by common consent the term 'reaction-type' or 'reaction' is applied to hysteria, the chief opportunity for divergent views will be afforded by the personality. Some will be reluctant, or wholly unwilling, to make the diagnosis of hysteria unless the patient's personality is of the supposedly hysterical pattern; while others—the majority, very likely—will be so familiar with the many varieties of personality that may be found in people with a full-blown hysterical reaction that they will refrain, as Kretschmer and many other psychiatrists have, from expecting or requiring a recognizable hysterical personality when diagnosing hysteria, though certain broad characteristics are remarkably frequent and conspicuous.
FOLLOW-UP STUDIES
If instead of hysterical reactions we speak of the hysterical syndrome, then the questions on which Slater and other writers have dwelt will be to the fore—namely, is the clinical picture uniform? And does the course of the disorder show that its pattern remains consistent? Having made two follow-up studies Slater concluded that there is very little consistency: thus when patients who had been diagnosed at a neurological hospital as having hysteria were followed up seven or more years later a few were found to have organic disease which had not been recognized, and those in whom no evidence of organic disease had been found included two now diagnosed as schizophrenics, an obsessional, and seven depressed patients. The remainder fell into two groups— one of mostly young people with acute psychogenie reactions of the conversion type, and the other composed of patients with a lasting personality disorder and a history of attentiongetting, manipulative behaviour, and excess of hospitalization. Slater had obtained somewhat similar results in a follow-up study of patients diagnosed as having 'hysteria' at a psychiatric hospital; and others who have conducted followup inquiries into hysteria have, as he indicates, made similar observations. He therefore concludes that there is nothing consistent in the medical condition of patients diagnosed as hysterics; they are medically a random selection
11
of patients, with many sorts of illness. He compares his findings with those of five other followup studies and accounts for their diversity by supposing that the later state of the patients depended not on the natural history of the condition but on the diverse operational definitions of it in accordance with which they had been selected as having hysteria. I made a comparable follow-up inquiry upon patients in whom the diagnosis of hysteria had been made at the Maudsley Hospital over a five-year period: the follow-up was carried out between seven and 12 years later. There were 73 women and 25 men who could be traced: information about their later condition was obtained by an interview with the patient and with a close relative, or in some cases by correspondence with them or their doctor. The relatively large number of patients traced and interviewed was wholly due to the skill and thoroughness of an experienced psychiatric social worker, Miss Margery Seward. The results were diverse, but not appreciably more so than when a group of schizophrenic or depressive patients is followed up. Seven of the women had died, three from conditions unconnected with their psychiatric affection, three from a probable affection of the central nervous system, and one by suicide. Forty were well and working, free from disabling or troublesome symptoms. A third of the remainder were consistently better than at the time of original admission, though still troubled; a fifth worse than at admission; the condition of the rest was much the same as it had been eight to 12 years before. In the majority of those who had not recovered their mental health, anomalies of personality and social adjustment had been conspicuous first to last, and the stresses to which they had been exposed during the interim period were steady and continuous or practically identical with those recognized at the initial consultations. Eight of the patients had a depressive syndrome, sufficiently accounted for by their situation and social or other environmental difficulties, and showing a strong tincture of hypochondriasis. In none of the patients did the retrospective diagnosis of schizophrenia seem to be justified. The male group was smaller, and slightly older: the average age on admission was 33,
12
Aubrey Lewis
whereas that of the women was 31. None of the men had died, and 14 of the 25 were well and working at the time of the follow-up. Of the remaining 11, two were improved, four were much as they had been when first seen, and five had become worse: two of these were in a mental hospital, with diagnoses of schizophrenia, and another, who had had a severe fall, had evidently passed into a state of dementia. In both the men and the women the residual psychiatric illness in those who had not recovered was remarkably close in its main features to the clinical picture presented at the time of original admission. The individual case histories show, of course, special factors and personal vicissitudes which coloured the illness, but in very few did this raise the question of an altered diagnosis; and in none besides those mentioned above did this amount to more than a switch from 'hysteria' to 'depressive hypochondriasis' or 'unstable, maladjusted personality'; in one patient euphoria and lability of mood, which had been present according to his wife for years, could be regarded as a mild hypomania. A diagnosis made eight or 12 years after an earlier psychiatric assessment is not necessarily more correct than the previous one. It is open to those who have made quite different follow-up observations on hysterics to dispute the diagnoses made here on the later occasion, and to suspect that schizophrenics and manic-depressives may have been overlooked. But the findings do not differ seriously from those arrived at by Ljungberg on a much larger sample. That they are not similar to the findings on patients diagnosed at a neurological hospital is not surprising. A TOUGH OLD WORD
The later state of these patients cannot be held to gainsay the acceptability of the diagnosis 'hysteria' so long as it is regarded as a reaction. There may be other grounds for annihilating the concept, and it is coming too close to the argumentum ad hominem to maintain, as Ajuriaguerra has, that 'tous les medecins ne reagiront pas d'une maniere egale devant l'hysterique. II est trop pres de nous pour que nous ne reagissions pas d'une maniere sentimentale ou aggressive. La forme aggressive consiste a nier l'hysterie en tant que maladie ayant
les caracteristiques determinees. L'accepter dans la nosographie serait revaloriser l'hysterie, faire rentrer les troubles des passions ou des anormalites proches du vice dans Ie cadre du pathologique et minimiser ainsi la valeur des vertus.' One need not impute to those prosecutors who ask for the death sentence on hysteria any but objective grounds for their plea: Slater, for example, has advanced genetic evidence in support of his negative contention. But the majority of psychiatrists would be hard put to it if they could no longer make a diagnosis of 'hysteria' or 'hysterical reaction'; and in any case a tough old word like hysteria dies very hard. It tends to outlive its obituarists. I am grateful to the editor and publishers of Evolution Psychiatrique for allowing this article to be published in English. REFERENCES Ajuriaguerra, J. (1951). Le probleme de l'hysterie. L'Ence'phale, 40, 50-87. Briquet, P. (1859). Traite Clinique et Therapeutique tie t'Hysterie. J. B. Bailliere: Paris. Humkc, O. (1925). Die Revision der Neurosenfrage. Zentralblatt fiir die gesamte Neurologic und Psychiatrie, 41, 669-677. Carpenter, W. B. (1874). Principles of Mental Physiology. King: London. Cobb, S. (1941). Foundations of Neuropsychiatry. 2nd edn. Williams and Wilkins: Baltimore. Dubois, P. (1904). Les Psychonevroses et leur Traitement Moral; Lecons Faites a I'Universite de Berne. Masson: Paris. Ey, H. (1954). £tudes Psychiatriques. Desclee de Brouwer: Paris. Gaupp, R. (1911). Ober den Begriffder Hysteric Zeitschrift fiir die gesamte Neurologic und Psychiatrie, 5, 457-466. Hoche, A. (1902). Die Differentia/diagnose zwischen Epilepsie und Hysterie. Hirschwald: Berlin. Kraepelin, E. (1927). Psychiatric. 5 Auflage. Barth: Leipzig. Kranz, H. (1953). Die Entwicklung des Hysterie-Begrifls. Fortschritte der Neurologie und Psychiatrie, 21, 223-238. Ljungberg, L. (1957). Hysteria. A clinical, prognostic and genetic study. Ada Psychiatrica et Neurologica Scandinavica, 32, Suppl. 112. Marchais, P. (1964). Psycho-pathologie en Pratique Medicate. Masson: Paris. Moerchen, F. (1929). 2. Hysterie ist keine Krankheit! Die Verwirrung des Neurosebegriffs. Zeitschrift fur arztliche Fortbildung, 26, 686-690. Ormerod, J. A. (1899). In A System of Medicine, Vol. 8, 88-127. Edited by T. C. Allbutt. Regis, E. (1914). Precis de Psychiatrie. 5th cdn. Doin: Paris. Rouquier, A. (1960). La fin de l'hysterie. Annales MedicoPsychologiques, 118, T.2, 528. Slater, E. (1961). "Hysteria 311." The thirty-fifth Maudsley Lecture. Journal of Mental Science, 107, 359-381. Steyerthal, A. (1908). Was ist Hysterie? Halle a. S.: Marhold. Szasz, T. S. (1961). The Myth of Mental Illness. Harper: New York.
The survival of hysteria AUBREY LEWIS From the Institute of Psychiatry, The Maudsley Hospital, London SYNOPSIS There have been many battles in the last 100 years between those who consider hysteria to be a 'morbid entity' or 'disease' and those who would like to drop it once and for all. The controversy still goes on. It has not been settled by follow-up studies or by applying genetic considerations. Hysteria is a tough subject, unlikely to be killed so long as clinicians find it useful, if not indispensable. In psychiatry there are forms of illness, with names going back two and a half millennia, which have had sentence of death passed upon them more than once, yet they obstinately survive. Paranoia is one such condition and term, hysteria is another. Hysteria is indeed an extreme case. Built upon a false and absurd notion of pathology, it was inevitably the subject of controversy, ridicule, and denial. Funeral orations upon it have often been delivered in the last 100 years, in language appropriate to the state of psychiatric knowledge. Thus, of English writers on the subject, in 1874 W. B. Carpenter described it as 'a state of the nervous system which is characterized by its peculiar excitability, but in which there is no such fixed tendency to irregular action as would indicate any positive disease.'
These indictments, which have been reinforced by clinical and genetic evidence, are paralleled by similarly destructive arguments put forward by notable French, Swiss, and German psychiatrists. There is a long series of these, worth recalling. In 1902 Hoche said roundly, 'Hysteria is not a syndrome [Krankheitsbild] but a special form of mental disposition'. Dubois (1904) put it on record that 'il est inutile de s'efforcer de donner a l'hysterie le caractere d'une entite morbide'. Steyerthal (1908) predicted 'within a few years the concept of hysteria will belong to history . . . there is no such disease, and there never has been. What Charcot called hysteria is a tissue woven of a thousand threads, a cohort of the most varied diseases, with nothing in common but the so-called stigmata, which in fact may accompany any disease.'
A quarter of a century later Ormerod (1899) wrote that the objections to 'hysteria' are obvious:
Gaupp (1911) said
'not only that it has become etymologically meaningless but also that to many minds it has the disagreeable connotation of a certain moral feebleness in the patient, and of unreality in the symptoms.'
'Nowadays the cry is ever louder: away with the name and the concept of hysteria: there is no such thing, and what we call hysteria is either an artificial, iatrogenic product, or a melange of symptoms which can occur in all sorts of illnesses and are not pathognomonic of anything'.
In 1965 another English physician, Slater, expressed forcefully his contemporary objections. 'All the signs of "hysteria" are the signs not of disease but of health . . . there is nothing at all consistent in the medical condition of the patients who get diagnosed as "hysterics" . . . no evidence has yet been offered that the patients diagnosed as suffering from "hysteria" are in medically significant terms anything more than a random selection.'
Bumke (1925) reviewed the neuroses and declared 'There was once a disease hysteria, just as there was hypochondria, and neurasthenia. They have disappeared. The syndrome has replaced the disease entity.' Kraepelin (1927) said: 'Hysteria is not a sharply delimited syndrome but a special way of dealing with affective tensions; it can occur in very different morbid conditions in
10
Aubrey Lewis
which inner excitement is not adequately kept under control.' Moerchen (1929) simply entitled his diatribe 'Hysteria is not a disease'. Kranz (1953) concluded that
que, quelle que soit la facon dont on l'envisage, sous le jour ancien ou sous le jour nouveau, il y a une hysterie, et que cette hysterie, comme l'epilepsie . . . s'accompagne frequemment de troubles psychiques.'
'hysterical phenomena are only modes of reaction which fundamentally are available to everybody and are not in themselves abnormal, but become so in that they last unduly long, become fixed, or are excessive. . . . It is reasonable to ask that we should at least drop the word "hysteria" in favour of "hysterical reaction", and in the end give up this term too, loaded as it is with moral value-judgments: we can make ourselves understood by psychiatrists without it. But in spite of all that "hysteria" will not disappear altogether from psychiatric vocabulary for a long time to come.'
Much later (1941) one finds a prominent American psychiatrist, Stanley Cobb, declaring that 'hysteria, in the particular sense in which I believe it should be used, is a fairly clear-cut syndrome'.
Rouquier (1960) confidently wrote on 'la fin de Physterie'. And in the most recent French textbook (1964) Pierre Marchais adjures us 'si nous conservons le terme "hysterique", etant donne son caractere traditionnel, il faut bien reconnaitre qu'il meriterait d'etre abandonne pour deux raisons essentielles'. UPHOLDERS OF THE TERM
This is an imposing cloud of witnesses. Many more could be cited who testify similarly. But opposite this array there are the upholders of the term, who believe it to be a significant and justified designation of a diagnostic category that has equivalent title-deeds to that of obsessional neurosis and anxiety state. Charcot stated his position unequivocally: hysteria is a mental disorder par excellence. Before him Briquet (1859) had seized the bull similarly by the horns: Thysterie est loin d'etre une affection composee de phenomenes incoherents. . . . Je trouvais au contraire qu'elle constituait une affection dont il etat tres facile de comprendre la nature, dont tous les symptomes avaient leurs analogues dans l'etat physiologique et n'ayant de bizarre que l'apparence . . . dont le diagnostic pouvait se faire aussi surement et avec autant de precision que celui de tout autre maladie.' Regis (1914) avowed his faith with firm simplicity: 'on connait ces debats retentissants qui ont eu lieu en 1908 sur l'hysterie. . . . Nous croyons done, pour l'observer de pres et impartialement tous les jours
DEFINING DISEASE
From this welter of powerful opposing voices two main assertions can be picked out: that hysteria is not a disease; and that hysteria is not a syndrome. Obviously the meaning attached to these two terms 'disease' and 'syndrome' is a cardinal issue in the controversy. Those who refuse the name of 'disease' or 'morbid entity' to any condition that has not been demonstrated to have an anatomical or chemical pathology must clearly now refuse it to hysteria: even if we will not go so far as Hoche, who said that it does not have, and never will have, a basis in pathological anatomy, it is at present in that exposed state. It must, however, also be said that our present ignorance, or limited knowledge, of the somatic pathology of schizophrenia should lead to a similar refusal to call that a disease. This is, of course, not merely a semantic quibble, nor a modern difficulty. Although a few writers, like Szasz, insist that mental illness is a myth, and that the only real illness is bodily illness, the majority of psychiatrists have no desire to adopt this crude standpoint, or to differentiate psychoses from neuroses on the ground that the former have—or must be assumed to have—a somatic basis; they have, however, substituted 'reaction type' or 'syndrome' for 'disease'. Adolf Meyer was largely responsible for this change of language and approach in the English-speaking countries: the same movement occurred in France, as Henri Ey (1954) makes clear in his £tudes. Hysteria, then, in modern usage is not a disease; but neither is schizophrenia or melancholia. The hysterical reaction may be a manifestation of a somatic abnormality, as a paranoid psychosis or a manic excitement may likewise be, and in each such case multi-dimensional analysis will take into account constitutional predisposition as well as environmental and physical
The survival of hysteria
influences spread over the lifetime of the affected person. If by common consent the term 'reaction-type' or 'reaction' is applied to hysteria, the chief opportunity for divergent views will be afforded by the personality. Some will be reluctant, or wholly unwilling, to make the diagnosis of hysteria unless the patient's personality is of the supposedly hysterical pattern; while others—the majority, very likely—will be so familiar with the many varieties of personality that may be found in people with a full-blown hysterical reaction that they will refrain, as Kretschmer and many other psychiatrists have, from expecting or requiring a recognizable hysterical personality when diagnosing hysteria, though certain broad characteristics are remarkably frequent and conspicuous.
FOLLOW-UP STUDIES
If instead of hysterical reactions we speak of the hysterical syndrome, then the questions on which Slater and other writers have dwelt will be to the fore—namely, is the clinical picture uniform? And does the course of the disorder show that its pattern remains consistent? Having made two follow-up studies Slater concluded that there is very little consistency: thus when patients who had been diagnosed at a neurological hospital as having hysteria were followed up seven or more years later a few were found to have organic disease which had not been recognized, and those in whom no evidence of organic disease had been found included two now diagnosed as schizophrenics, an obsessional, and seven depressed patients. The remainder fell into two groups— one of mostly young people with acute psychogenie reactions of the conversion type, and the other composed of patients with a lasting personality disorder and a history of attentiongetting, manipulative behaviour, and excess of hospitalization. Slater had obtained somewhat similar results in a follow-up study of patients diagnosed as having 'hysteria' at a psychiatric hospital; and others who have conducted followup inquiries into hysteria have, as he indicates, made similar observations. He therefore concludes that there is nothing consistent in the medical condition of patients diagnosed as hysterics; they are medically a random selection
11
of patients, with many sorts of illness. He compares his findings with those of five other followup studies and accounts for their diversity by supposing that the later state of the patients depended not on the natural history of the condition but on the diverse operational definitions of it in accordance with which they had been selected as having hysteria. I made a comparable follow-up inquiry upon patients in whom the diagnosis of hysteria had been made at the Maudsley Hospital over a five-year period: the follow-up was carried out between seven and 12 years later. There were 73 women and 25 men who could be traced: information about their later condition was obtained by an interview with the patient and with a close relative, or in some cases by correspondence with them or their doctor. The relatively large number of patients traced and interviewed was wholly due to the skill and thoroughness of an experienced psychiatric social worker, Miss Margery Seward. The results were diverse, but not appreciably more so than when a group of schizophrenic or depressive patients is followed up. Seven of the women had died, three from conditions unconnected with their psychiatric affection, three from a probable affection of the central nervous system, and one by suicide. Forty were well and working, free from disabling or troublesome symptoms. A third of the remainder were consistently better than at the time of original admission, though still troubled; a fifth worse than at admission; the condition of the rest was much the same as it had been eight to 12 years before. In the majority of those who had not recovered their mental health, anomalies of personality and social adjustment had been conspicuous first to last, and the stresses to which they had been exposed during the interim period were steady and continuous or practically identical with those recognized at the initial consultations. Eight of the patients had a depressive syndrome, sufficiently accounted for by their situation and social or other environmental difficulties, and showing a strong tincture of hypochondriasis. In none of the patients did the retrospective diagnosis of schizophrenia seem to be justified. The male group was smaller, and slightly older: the average age on admission was 33,
12
Aubrey Lewis
whereas that of the women was 31. None of the men had died, and 14 of the 25 were well and working at the time of the follow-up. Of the remaining 11, two were improved, four were much as they had been when first seen, and five had become worse: two of these were in a mental hospital, with diagnoses of schizophrenia, and another, who had had a severe fall, had evidently passed into a state of dementia. In both the men and the women the residual psychiatric illness in those who had not recovered was remarkably close in its main features to the clinical picture presented at the time of original admission. The individual case histories show, of course, special factors and personal vicissitudes which coloured the illness, but in very few did this raise the question of an altered diagnosis; and in none besides those mentioned above did this amount to more than a switch from 'hysteria' to 'depressive hypochondriasis' or 'unstable, maladjusted personality'; in one patient euphoria and lability of mood, which had been present according to his wife for years, could be regarded as a mild hypomania. A diagnosis made eight or 12 years after an earlier psychiatric assessment is not necessarily more correct than the previous one. It is open to those who have made quite different follow-up observations on hysterics to dispute the diagnoses made here on the later occasion, and to suspect that schizophrenics and manic-depressives may have been overlooked. But the findings do not differ seriously from those arrived at by Ljungberg on a much larger sample. That they are not similar to the findings on patients diagnosed at a neurological hospital is not surprising. A TOUGH OLD WORD
The later state of these patients cannot be held to gainsay the acceptability of the diagnosis 'hysteria' so long as it is regarded as a reaction. There may be other grounds for annihilating the concept, and it is coming too close to the argumentum ad hominem to maintain, as Ajuriaguerra has, that 'tous les medecins ne reagiront pas d'une maniere egale devant l'hysterique. II est trop pres de nous pour que nous ne reagissions pas d'une maniere sentimentale ou aggressive. La forme aggressive consiste a nier l'hysterie en tant que maladie ayant
les caracteristiques determinees. L'accepter dans la nosographie serait revaloriser l'hysterie, faire rentrer les troubles des passions ou des anormalites proches du vice dans Ie cadre du pathologique et minimiser ainsi la valeur des vertus.' One need not impute to those prosecutors who ask for the death sentence on hysteria any but objective grounds for their plea: Slater, for example, has advanced genetic evidence in support of his negative contention. But the majority of psychiatrists would be hard put to it if they could no longer make a diagnosis of 'hysteria' or 'hysterical reaction'; and in any case a tough old word like hysteria dies very hard. It tends to outlive its obituarists. I am grateful to the editor and publishers of Evolution Psychiatrique for allowing this article to be published in English. REFERENCES Ajuriaguerra, J. (1951). Le probleme de l'hysterie. L'Ence'phale, 40, 50-87. Briquet, P. (1859). Traite Clinique et Therapeutique tie t'Hysterie. J. B. Bailliere: Paris. Humkc, O. (1925). Die Revision der Neurosenfrage. Zentralblatt fiir die gesamte Neurologic und Psychiatrie, 41, 669-677. Carpenter, W. B. (1874). Principles of Mental Physiology. King: London. Cobb, S. (1941). Foundations of Neuropsychiatry. 2nd edn. Williams and Wilkins: Baltimore. Dubois, P. (1904). Les Psychonevroses et leur Traitement Moral; Lecons Faites a I'Universite de Berne. Masson: Paris. Ey, H. (1954). £tudes Psychiatriques. Desclee de Brouwer: Paris. Gaupp, R. (1911). Ober den Begriffder Hysteric Zeitschrift fiir die gesamte Neurologic und Psychiatrie, 5, 457-466. Hoche, A. (1902). Die Differentia/diagnose zwischen Epilepsie und Hysterie. Hirschwald: Berlin. Kraepelin, E. (1927). Psychiatric. 5 Auflage. Barth: Leipzig. Kranz, H. (1953). Die Entwicklung des Hysterie-Begrifls. Fortschritte der Neurologie und Psychiatrie, 21, 223-238. Ljungberg, L. (1957). Hysteria. A clinical, prognostic and genetic study. Ada Psychiatrica et Neurologica Scandinavica, 32, Suppl. 112. Marchais, P. (1964). Psycho-pathologie en Pratique Medicate. Masson: Paris. Moerchen, F. (1929). 2. Hysterie ist keine Krankheit! Die Verwirrung des Neurosebegriffs. Zeitschrift fur arztliche Fortbildung, 26, 686-690. Ormerod, J. A. (1899). In A System of Medicine, Vol. 8, 88-127. Edited by T. C. Allbutt. Regis, E. (1914). Precis de Psychiatrie. 5th cdn. Doin: Paris. Rouquier, A. (1960). La fin de l'hysterie. Annales MedicoPsychologiques, 118, T.2, 528. Slater, E. (1961). "Hysteria 311." The thirty-fifth Maudsley Lecture. Journal of Mental Science, 107, 359-381. Steyerthal, A. (1908). Was ist Hysterie? Halle a. S.: Marhold. Szasz, T. S. (1961). The Myth of Mental Illness. Harper: New York.
