On The "Disappearance" of Hysteria A Study in The Clinical Deconstruction of A Diagnosis

On the "Disappearance" of Hysteria: A Study in the Clinical Deconstruction of a Diagnosis
Author(s): Mark S. Micale

Source: Isis, Vol. 84, No. 3 (Sep., 1993), pp. 496-526
Published by: The University of Chicago Press on behalf of The History of Science Society
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On the "Disappearance"
of Hysteria
A Study in the Clinical Deconstruction

of a Diagnosis
By Mark S. Micale*
Rest assured, hysteria is coming along, and one day it will

occupy gloriously the important place it deserves in the
sun.-Jean-Martin Charcot to Sigmund Freud (23 January
1888)
In reality, the patients have not changed since Charcot; it

is the words to describe them that have changed. -Georges
Guillain, La semaine des hopitaux (1949)
We dissect nature along lines laid down by our native lan-

guage.. . . Language is not simply a reporting device for
experience but a defining framework of it.-Benjamin
Whorf, "Language, Mind, and Reality" (1941)
THE HISTORY OF PSYCHIATRY, more than any other branch of the medical
sciences, is marked by the phenomenon of "rising" and "falling" diseases. Bur-
tonian melancholia in seventeenth-century England, the "vapors" of eighteenth-cen-
tury Parisian society, Beardian neurastheniain late nineteenth-centuryAmerica, and,
during our own time, psychogenic eating disorders-all are forms of psychiatric
illness that appear to have increased dramatically, even epidemically, in particular
times and cultural settings. Perhaps the best-known example is hysteria. After a long
and convoluted evolution across two and a half millennia of medical history,
including an efflorescence at the turn of the nineteenth century, hysteria is widely
held nowadays to have dwindled greatly in its rate of occurrence, if not to have
disappeared altogether. In the past fifteen years the rise to prominence of many
* Department of History, Yale University, 320 York Street, New Haven, Connecticut 06520.
Earlier versions of this essay were delivered in lecture form at the Wellcome Institute for the History
of Medicine (London); the Sixteenth International Symposium on the Comparative History of Medi-
cine-East and West (Mt. Fuji, Japan); the Department of Psychiatry, Beth Israel Hospital (Boston);
the Beaumont Medical Club, Yale University; and the Institute for Health, Health Care Policy, and
Aging Research, Rutgers University. I thank the members of those audiences-as well as Bill Bynum,
Phillip Slavney, Nancy Tomes, and Elizabeth Whitcombe-for their critical commentary.
Isis, 1993, 84: 496-526

?C1993by The History of Science Society. All rights reserved.
0021-1753/93/8401-0001$01 .00
496

THE "DISAPPEARANCE" OF HYSTERIA 497
nervous and mental maladies, including hysteria, has received considerable scholar-
ly attention. The converse question, of their alleged decline, remains largely
unexplored.1
The view of hysteria as a classically Victorian neurosis inexplicably on the wane
in the twentieth century has been common among critics, historians, and physicians
alike. As early as 1907 Fulgence Raymond, the noted Parisian professor of neurol-
ogy, designated the late nineteenth century as "the heroic period"of hysteria. In 1928
the poets Louis Aragon and Andre Breton, in one of their surrealist manifestos,
decreed hysteria "the greatest poetic discovery of the late nineteenth century." And
in the early 1950s Jacques Chastenet, the prominent historian of the French Third
Republic, labeled hysteria one of the primary "nevroses fin de siecle." Similarly,
doctors during the latter half of the nineteenth century matter-of-factly considered
hysteria the most common of the functional nervous disorders among females. Nine-
teenth-century medical publications on hysteria constitute a library of books, mono-
graphs, and articles. And a comprehensive historical catalogue of French psychiatric
dissertations indicates that no fewer than 20.5 percent of all theses written during
the nineteenth century dealt with hysterical disorders of one sort or another, the
largest percentage devoted to a single subject during any period.2 In the popular
historical imagination today, the late nineteenth century is the age of hysteria, with
Jean-Martin Charcot and Sigmund Freud serving as its representative personalities
and Paris and Vienna its quintessential capitals.
The contrast between the late nineteenth and the late twentieth centuries could
scarcely be greater. To be sure, many physicians continue to use the concept of
hysteria in specialized diagnostic settings-in reference to a personality trait or type;
in reference to a symptom that is formed functionally but mimics those caused by
somatic, particularly neurological, disease; or in reference to a psychoneurotic dis-
order characterizedby the habitual formation of symptoms in this manner.3 Yet neu-
rologists, psychiatrists, psychoanalysts, and clinical psychologists remain extremely
reluctant to employ the term in its two major noun forms, as they did so lavishly in
1 For a wide-ranging and interpretive review of the secondary literature pertaining to hysteria, with
an emphasis on recent scholarship, see Mark S. Micale, "Hysteria and Its Historiography-A Review
of Past and Present Writings," History of Science, 1989, 27:223-261, 319-351; and Micale, "Hysteria
and Its Historiography: The Future Perspective," History of Psychiatry, 1990, 1:33-124. Studies that
do address the topic of disease "decline" include Eugene Stransky, "On the History of Chlorosis,"
Episteme, 1974, 8:26-45; Robert P. Hudson, "The Biography of a Disease: Lessons from Chlorosis,"
Bulletin of the History of Medicine, 1977, 51:448-463; Barbara Sicherman, "The Uses of a Diagnosis:
Doctors, Patients, and Neurasthenia," Journal of the History of Medicine and Allied Sciences, 1977,
32:33-54; Ian R. Dowbiggin, Inheriting Madness: Professionalization and Psychiatric Knowledge in
Nineteenth-Century France (Berkeley/Los Angeles: Univ. California Press, 1991), pp. 162-168; and
S. P. Fullinwider, Technicians of the Finite: The Rise and Decline of the Schizophrenic in American
Thought, 1840-1960 (Westport, Conn.: Greenwood, 1982).
2 Fulgence Raymond, in "Definition et nature de l'hysterie," in Comptes rendus de la Congres des
Medecins Alienistes et Neurologistes de France et des Pays de la Langue Francaise, Geneva and Lau-
sanne, 1-7 Aug. 1907, 2 vols. (Paris: Masson, 1907), Vol. 2, pp. 367-417, on p. 378; Louis Aragon
and Andre Breton, "Le cinquantenaire de l'hyst6rie (1878-1928)" (1928), rpt. conveniently in Histoire
du surrealisme: Documents surrealistes, ed. Maurice Nadeau (Paris: Seuil, 1948), p. 125; and Jacques
Chastenet, Histoire de la Troisieme Republique, 7 vols. (Paris: Hachette, 1955), Vol. 3: La Republique
triomphante, 1893-1906, Ch. 1. For the catalogue of dissertations see Arnaud Terrisse, "Une histoire
des theses de psychiatrie en France du d6but du XVIIe siecle a la veille de la Second Guerre mondiale,"
in Nouvelle histoire de la psychiatrie, ed. Jacques Postel and Claude Quetel (Toulouse: Privat, 1983),
p. 541.
3 On current-day diagnostic usages of the concept see Phillip R. Slavney, Perspectives on "Hysteria"
(Baltimore: Johns Hopkins Univ. Press, 1990).

498 MARK S. MICALE
the past, to designate either a primary diagnosis or a patient (i.e., "It's a case of
hysteria," or "She's a hysteric"). To be specific: the dramatic, convulsive, poly-
symptomatic forms of the disorder found in Charcot's writings of the 1870s and
1880s and the gross and florid motor and sensory conversions displayed in Freud's
and Josef Breuer's well-known Studies on Hysteria of 1895 are regarded today as
extreme rarities.
This impression is confirmed by a computer search of the Index Medicus for writ-
ings on hysteria published in the second half of the twentieth century. The search
produces titles such as "The End of Hysteria" in the Annales Medico-Psychologiques
of 1960 and "Eclipse of Hysteria" in the British Medical Journal of 1965. A state-
ment by the editors of the British Medical Journal that appeared in 1976 describes
hysterical neuroses as "a virtual historical curiosity in Britain." Since the 1950s,
major psychiatric textbooks in the Anglo-American world have noted the gradual
decline of classic conversion hysteria. And for decades the literature of psycho-
analysis has bemoaned the disappearance of the grand hysterical patients of Freud's
time. "Where has all the hysteria gone?" queried one author in the Psychoanalytic
Review in 1979. A few years later a perplexed Jacques Lacan likewise asked: "Where
are the hysterics of former times, those magnificent women, the Anna 0.s and Emmy
von N.s? . . . What today has replaced the hysterical symptoms of previous times?"
In 1990 Phillip Slavney, a professor of psychiatry at the Johns Hopkins University
School of Medicine who is sympathetic to retention of the hysteria concept, authored
a thorough and thoughtful book on the disorder in which the term appears in quo-
tation marks throughout the text. "This could well be the last book with 'hysteria'
in its title written by a psychiatrist," Slavney observes almost nostalgically.4
Perhaps more surprising than these remarks by physicians have been similar state-
ments by historians of the medical sciences. Ilza Veith, who produced the standard
intellectual history of hysteria in 1965, scrupulously charts the development of med-
ical thinking about hysteria from the ancient Egyptian papyri to early psychoana-
lytic theory; but she devotes only two closing paragraphsto the vexing question of
"the nearly total disappearance of the illness" today. Similarly, Etienne Trillat,
former editor of L'Evolution Psychiatrique, published a second major Histoire de
l'hyste'rie in 1986. He concludes his three-hundred-page study with four pages on
this subject, the final lines of which read like a historical epitaph: "And what is
left of hysteria today? Hysteria is of course dead, and it has taken its mysteries with
it to the grave."5
In recent decades two explanatory trends have developed in regard to the curious
clinical diminution of hysteria in the twentieth century. Customarily, if historians
address the "disappearance"of hysteria at all, they attributethe phenomenon to psy-
chological and sociocultural factors. Early in this century Freud, in a well-known
4A. Rouquier, "La fin de l'hysterie," Annales Medico-Psychologiques, 1960, 118(2):528; "Eclipse
of Hysteria," British Medical Journal, 29 May 1965, pp. 1389-1390; "The Search for a Psychiatric
Esperanto," ibid., 11 Sept. 1976, p. 601; Roberta Satow, "Where Has All the Hysteria Gone?" Psy-
choanalytic Review, 1979-1980, 66:463-477; Jacques Lacan, cited in Elisabeth Roudinesco, La bataille
de cent ans: Histoire de la psychanalyse en France, 2 vols. (Paris: Ramsay, 1982), Vol. 1, pp. 82-83
(here and elsewhere, translations into English are my own unless otherwise indicated); and Slavney,
Perspectives on "Hysteria," p. 190. For a textbook mention of the decline in hysteria see D. Wilfred
Abse, "Hysteria," in American Handbook of Psychiatry, ed. Silvano Arieti, 3 vols. (New York: Basic,
1959), Vol. 1, pp. 286-287.
5Ilza Veith, Hysteria: The History of a Disease (Chicago/London: Univ. Chicago Press, 1965), pp.
273-274; and Etienne Trillat, Histoire de l'hysterie (Paris: Seghers, 1986), p. 274.

essay, argued that the prevailing social and moral conditions of his age were exacting
an inordinately high degree of sexual repression and in the process were producing
a race of neurasthenic men and hysterical women. During the past twenty-five years
Freud's analysis has been picked up and embroidered by many historians, social
scientists, and cultural critics, particularlyin the English-speaking world. According
to their interpretation,hysteria is a kind of pathological by-product of the Victorian-
Wilhelminian bourgeois social system with its sexual confinement, emotional oppres-
sion, and social suffocation. What one commentator has called "the Victorian hys-
terical mode," illustrated equally in the novels and the medical texts of the day,
often appears in this scholarship.6 Conversely, the conspicuous decline in rates of
hysterical illness during the twentieth century has, in this view, attended the passing
of those pernicious social and psychological conditions that generated an increase in
nervous complaints during the nineteenth century. In short, the disappearance of
hysteria is the result of de-Victorianization.
During the past two decades medical authors have posited a second explanation,
which might be called the argument from psychological literacy. According to this
interpretation, people were relatively primitive in their psychological processes be-
fore the twentieth century and found it easy to "somaticize" their anxieties-that is,
to express acute emotional distress through the formation of psychogenic physical
symptoms. However, with the coming of our "psychological society," and the popu-
larization of such concepts as unconscious motivation and psychosomatic sickness,
laypersons began to comprehend the psychodynamics behind hysterical conversion
symptoms, which thereafterfailed to elicit the desired social response and subjective
gratification. For secondary gain to work, it must remain unconscious in the mind
of the patient. As a result, according to this argument, people have been forced to
develop subtler and more sophisticatedmental mechanisms for coping with the stresses
of life. Typically, these new strategies center on the internalization of anxieties. This
line of analysis is often coupled with cross-cultural epidemiological data demon-
strating that hysterical neuroses currently prevail only in rural, lower-class, or third-
world environments and that the decline of hysterical conversion reactions within
industrialized and Westernized populations has been accompanied by a rise in de-
pressive and narcissistic disorders. This explanation has been popular with social and
6 Sigmund Freud, "'Civilized' Sexual Morality and Modem Nervous Illness" (1908), in The Standard
Edition of the Complete Psychological Works of Sigmund Freud, trans. James Strachey with Anna Freud,
Alix Strachey, and Alan Tyson, 24 vols., Vol. 9 (London: Hogarth, 1959), pp. 177-204; and Alan
Krohn, Hysteria: The Elusive Neurosis (Psychological Issues, 45/46) (New York: International Univ.
Press, 1978), p. 189 (quotation).
7 The scholarly literature in this mold is large and diversified. A sampling includes Carroll Smith-
Rosenberg, "The Hysterical Woman: Sex Roles and Role Conflict in Nineteenth-Century America,"
Social Research, 1972, 39:652-678; Ann Douglas Wood. "'The Fashionable Diseases': Women's Com-
plaints and Their Treatment in Nineteenth-Century America," Journal of Interdisciplinary History, 1973,
4:25-52; John S. Haller, Jr., and Robin M. Haller, The Physician and Sexuality in Victorian America
(Urbana: Univ. Illinois Press, 1974), Ch. 1; Regina Schaps, Hysterie und Weiblichkeit: Wissenschafts-
mythen uber die Frau (Frankfurt:Campus, 1983), Ch. 9; Madeline L. Feingold, "Hysteria as a Modality
of Adjustment in Fin-de-Siecle Vienna" (Ph.D. diss., California School of Professional Psychology,
Berkeley, 1983); George Frederick Drinka, The Birth of Neurosis: Myth, Malady, and the Victorians
(New York: Simon & Schuster, 1984), Chs. 1-6; Wendy Mitchinson, "Hysteria and Insanity in Women:
A Nineteenth-CenturyCanadian Perspective," Journal of Canadian Studies, 1986, 21:87-105; and Elaine
Showalter, The Female Malady: Women, Madness, and English Culture, 1830-1980 (New York: Pan-
theon, 1985), Chs. 5, 6. For expressions of this view by psychologists see Marc H. Hollender, "Con-
version Hysteria: A Post-Freudian Reinterpretationof Nineteenth-Century Psychosocial Data," Archives
of General Psychiatry, 1972, 26:311-314; and Krohn, Hysteria, Ch. 4.

500 MARK S. MICALE
cultural critics, too, who have at times combined it with sharp critiques of the so-
cieties that generate these enculturated psychopathologies.8
Although not always well argued, the existing hypotheses for the disappearance
of hysteria--the arguments from sociosexual emancipation and psychological liter-
acy-assuredly contain elements of truth, and in the long run they will no doubt
contribute to a comprehensive understanding of the subject. My argument in this
article is offered as one factor in a larger, multicausal explanation. I believe, how-
ever, that the more we study the matter from a close and specifically medico-his-
torical perspective, the more we discover the insufficiency of the large and seductive
sociogenic interpretations posited thus far and the need to look elsewhere for an-
swers.
This need is apparenton a number of counts. For instance, both linear intellectual-
historical narratives of hysteria based on printed medical texts and specialized his-
torical studies derived from medical archival sources record the extensive existence
of hysterical disorders in pre-Victorian societies, including many societies that are
not noted for sexual and emotional repression.9 This suggests, if not the universal
existence of the malady, at least a considerable transculturalpresence. In the same
vein, recent scholarship has established that nineteenth-centurymedical professionals
widely applied the hysteria diagnosis to men, children, and working-class women-
in other words, to groups of individuals outside the putatively pathogenic social
milieu inhabited by middle-class Victorian women.'0 And the contention that people
8 Within the American psychiatric world, ideas related to the "argument from psychological literacy"
seem to have been enunciated first in Paul Chodoff, "A Re-examination of Some Aspects of Conversion
Hysteria," Psychiatry, 1954, 17:75-81. Subsequent writings include John L. Schimel et al., "Changing
Styles in Psychiatric Syndromes: A Symposium," American Journal of Psychiatry, 1973, 130:146-155;
J. G. Stefansson, J. A. Messina, and S. Meyerowitz, "Hysterical Neurosis, Conversion Type: Clinical
and Epidemiological Considerations," Acta Psychiatrica Scandinavica, 1976, 53:119-138; Krohn, Hys-
teria, esp. pp. 174-176; and Marvin Swartz et al., "Somatization Disorder in a Community Population,"
Amer. J. Psychiat., 1986, 143:1403-1408. For statements by a medical historian and a sociologist see
Veith, Hysteria (cit. n. 5), pp. 273-274; and Pauline B. Bart, "Social Structure and Vocabularies of
Discomfort: What Happened to Female Hysteria?" Journal of Health and Social Behavior, 1968, 9:188-
193. Among the cultural critics see Christopher Lasch, The Culture of Narcissism: American Life in an
Age of Diminishing Expectations (New York: Norton, 1978), Ch. 2, esp. pp. 41-43; and David Michael
Levin, ed., Pathologies of the Modern Self: Postmodern Studies on Narcissism, Schizophrenia, and
Depression (New York: New York Univ. Press, 1987).
9 Veith, Hysteria; Trillat, Histoire de l'hysterie (cit. n. 5); Sander Gilman, Helen King, Roy Porter,
George Rousseau, and Elaine Showalter, Hysteria beyond Freud (Los Angeles: Univ. California Press,
1993); Glafira Abricossoff, L'hysterie aux XVIIe et XVIIIe siecles (etude historique et bibliographique)
(Paris: G. Steinheil, 1897); Guenter Risse, "Hysteria at the Edinburgh Infirmary: The Construction and
Treatment of a Disease, 1770-1800," Medical History, 1988, 32:1-22; Katherine E. Williams, "Hys-
teria in Seventeenth-Century Case Records and Unpublished Manuscripts," Hist. Psychiat., 1990 1:383-
401; and Michael MacDonald, ed., Witchcraft and Hysteria in Elizabethan London: Edward Jorden and
the Mary Glover Case (Tavistock Classics in the History of Psychiatry) (New York: Routledge, 1991).
10On hysteria in men and children see Elisabeth Kloe, Hysterie im Kindesalter: Zur Entwicklung des
kindlichen Hysteriebegriffes (Freiburger Forschungen zur Medizingeschichte, 9) (Freiburg: Hans Fer-
dinand Schulz, 1979); K. Codell Carter, "Infantile Hysteria and Infantile Sexuality in Late Nineteenth-
Century German-LanguageMedical Literature,"Med. Hist., 1983, 27:186-196; Mark S. Micale, "Char-
cot and the Idea of Hysteria in the Male: Gender, Mental Science, and Medical Diagnosis in Late Nine-
teenth-CenturyFrance," ibid., 1990, 34:363-411; Micale, "Hysteria Male/Hysteria Female: Reflections
on Comparative Gender Construction in Nineteenth-Century France and Britain," in Science and Sen-
sibility: Gender and Scientific Enquiry, 1780-1945, ed. Marina Benjamin (London: Basil Blackwell,
1991), Ch. 7; and Janet Oppenheim, "ShatteredNerves": Doctors, Patients, and Depression in Victorian
England (New York/Oxford: Oxford Univ. Press, 1991), Chs. 5, 7.
For application of the hysteria diagnosis to members of the working classes see Sicherman, "Uses of
a Diagnosis" (cit. n. 1), pp. 44, 52; Jan Goldstein, "The Hysteria Diagnosis and the Politics of Anti-
clericalism in Late Nineteenth-Century France," Journal of Modern History, 1982, 54:213-214; Risse,

in our own time are worldlier and more self-aware psychologically than their pre-
decessors remains suspect on many grounds and is difficult to document. Above all,
there is the problem of chronology. If the principal causes of the decline of hysteria
were those cited to date, we should expect to find a steady but gradual decrease in
hysterical disorders in the twentieth century as sexual liberalization and psycholog-
ical popularization advanced. To the contrary, the decline of hysteria as a workaday
diagnosis within European and North American medicine occurred rapidly after the
turn of the century and was effectively complete by World War I.
The historical record establishes this point unmistakably. An analysis of the med-
ical bibliography on hysteria as recorded comprehensively in the Index-Catalogue of
the Library of the Surgeon-General's Office reveals that the flood of French- and
German-language writings from the 1870s, 1880s, and 1890s tapered off dramati-
cally in the late 1890s. By 1910 the flow was small, and, after a temporary surge
of publications on "hysterical disorders of war" between 1914 and 1918, it shrank
to a trickle during the 1920s, 1930s, and 1940s. Amaud Terrisse's study of psy-
chiatric dissertations quantifies theses about hysteria by decade: in the 1870s, 49
dissertations written at French medical schools dealt centrally with hysterical dis-
orders; in the 1880s, 65; in the 1890s, 111; in the first decade of the twentieth
century, 85; in the 1910s, 13; in the 1920s, 9; in the 1930s, 1; and the 1940s, 3.11
Furthermore, the four major theoreticians of hysteria, whose names are associated
inseparably with the famous fin-de-siecle phase of the disorder-Jean-Martin Char-
cot, Hippolyte Bernheim, Pierre Janet, and Sigmund Freud-had either died or aban-
doned research on the subject by 1910.
The disappearance of hysteria was also registered directly by early twentieth-cen-
tury physicians working in a variety of medical, institutional, and national settings.
To my knowledge, the first statement by a medical author regarding the decline of
hysteria appeared in 1904, only a decade after the death of Charcot (1893) and the
publication of Studies on Hysteria by Freud and Breuer. Four years later Armin
Steyerthal, the director of a private health spa near Halle, Germany, predicted in a
pamphlet entitled What Is Hysteria? that "within a few years the concept of hysteria
will belong to history. . . . There is no such disease and there never has been."
And in 1914 Paul Guiraud, an asylum doctor in Tours, France, commented in the
Annales Me'ico-Psychologiques that "for some time now one has no longer dared
to speak of hysteria. Multiple theories clash and typical cases-have become rarerand
rarer." To much the same end, doctors during the interwar period reflected on the
theory of hysteria as if it were the product of an exotic, bygone era. In 1931
S. A. Kinnier Wilson of the National Hospital in London, who had studied with
Pierre Marie in Paris before World War I, reflected upon his experiences as a medical
student:
"Hysteria at the Edinburgh Infirmary," pp. 1-18; Micale, "Charcot and the Idea of Hysteria in the
Male," pp. 377-380; Edward Shorter, "Paralysis: The Rise and Fall of a 'Hysterical' Symptom," Jour-
nal of Social History, 1986, 19:572-573; and Williams, "Hysteria in Seventeenth-Century Case Rec-
ords," pp. 383-401.
1 Index-Catalogue of the Library of the Surgeon-General's Office, 1st ser., 16 vols. (Washington,
D.C.: Government Printing Office, 1885), Vol. 6, pp. 750-767; 2nd ser., 21 vols. (1902), Vol. 7, pp.
772-804; 3rd ser., 10 vols. (1926), Vol. 6, pp. 936-951; 4th ser., 11 vols. (1942), Vol. 7, pp. 966-
972. See also Terrisse, "Histoire des theses de psychiatrie" (cit. n. 2), p. 541. Tabulations from the
1930s and 1940s are derived from Patrick Genvresse and Jean-Claude Meurisse, Index ge'neral des theses
de psychiatrie publiees en langue fran,aise de 1934 d 1954 (Paris: Laboratoires Specia, 1988).

502 MARKS. MICALE
No longer do the "circushorses"of the Salpetri&re performbefore visitors as in the

palmy days of Charcot.No more does their contortedmusculaturerespondto the ap-
plicationof diverse metallic rods, as Gilles de la Tourettewas wont to demonstrate:
seldomindeedis the clinicianwitnessto the elaborateandprotractedhystericalfits whose
theatrical features were drawn with artistic skill by Paul Richer. . . . The times have
changedand we, both physicianand hysterics,have changedwith them.12
How, the historian can only wonder, have we gotten from the famous belle epoque
of hysteria in the closing decades of the nineteenth century to the virtual disappear-
ance of the disorder two decades later?
In this essay I pursue a line of investigation thus far unexplored. Instead of em-
phasizing social, sexual, and psychological factors, I focus on the rather technical
realms of medical nomenclature, nosology, and nosography. Specifically, I argue
that from 1895 to 1910 the hysteria diagnosis in its various nineteenth-century for-
mulations underwent a process of radical nosological and nosographical refashion-
ing-that is, a rapid change in what physicians interpretedas the clinical content of
the diagnosis and where they placed the disorder in the overall scheme of medical
classification-and that this drastic redefinition of the concept is what has created
the illusion that the pathological entity itself has disappeared.13 The key causes of
this diagnostic reconceptualization, I propose further, were scientific factors involv-
ing biomedical discoveries in etiological theory and diagnostic technique. At the
same time, these causes were reinforced and accelerated by a series of historically
specific sociological factors. By examining closely the evolution of European med-
ical systems during these years, and in particularFrench and German psychiatric and
neurological nosologies in the immediate post-Charcotian period, it is possible to
reconstruct this process in detail. In the past decade and a half, historians of science
and medicine have provided interesting and important analyses of the social con-
struction of diagnostic categories. This inquiry offers a study in the clinical decon-
struction of a diagnosis.
THE HYSTERIA DIAGNOSIS OF THE LATE NINETEENTH CENTURY
To comprehend the "decline" of hysteria during the past hundred years requires a
preliminary understandingof the diagnosis as it existed at the end of the nineteenth
12
Willy Hellpach, Grundlinien einer Psychologie der Hysterie (Leipzig: Engelmann, 1904), pp. 483-
494; Armin Steyerthal, Was ist Hysterie? Eine nosologische Betrachtung (Halle: Marhold, 1908), p. 26.
Paul Guiraud, "L'hyst6rie et la folie hysterique," Ann, Mc'd.-Psychol., 10th ser., 1914, 5:678-689, on
p. 678; and S. A. Kinnier Wilson, "The Approach to the Study of Hysteria," Journal of Neurology and
Psychopathology, 1931, 11:193-206, on pp. 194-195. For other early twentieth-century statements of
this development see Robert Gaupp, "Uber den Begriff der Hysterie," Zeitschriftfur die Gesamte Neu-
rologie und Psychiatrie, 1911, 5:457-466; Joseph Babinski, "Hyst6rie-pithiatisme,"Bulletins et Memoires
de la Societe Me6dicaledes H6pitaux de Paris, 3rd ser., 1928, 52:1507-1521; Antoine Giraud, La l6gende
de l'hysterie (Paris: Ficker, [1922]), Chs. 1, 2; and P. Hartenberg, "Que reste-t-il de l'hyst6rie?" Cli-
nique: Journal Hebdomadaire de M&decineet de Chirurgie Pratiques (Paris), 1933, 28:315-317.
13 A note on usage: in the analysis that follows, the term nosography denotes the assembling and
ordering of symptoms into disease entities and the differentiation of one disease entity from another.
This definition is in accord with the classic study by Knud Faber, Nosography: The Evolution of Clinical
Medicine in Modern Times (1923), 2nd rev. ed. (New York: Paul B. Hoeber, 1930). Nosology is the
study of the classification of diseases within general medical systems. So defined, the significance of
both nosology and nosography for diagnostic practice is obviously fundamental.

century. A rich textual tradition representing something that may be interpreted as

hysteria stretches back to the Hippocratic canon of ancient Greece. Hysteria's long
and colorful heritage climaxed in the nineteenth century. The voluminous medical
literature of the time includes writings by neurologists, institutional psychiatrists,
and "nerve doctors," as well as gynecologists, surgeons, and general physicians. All
of the major previous paradigms of the disorder-gynecological, neurological, psy-
chological, and characterological-found expression. Although the literatureon hys-
teria spanned the century and was multinational in origin, physicians in France during
the final quarter of the century contributed the most commentary. Theorization on
the subject was dominated by Charcot, the celebrated Parisian neurologist who in
the 1870s and 1880s formed a coterie of young doctors and medical students around
him at the Salpetriere hospital to investigate in enormous and systematic detail what
he christened "the Great Neurosis." The disease picture of hysteria that has entered
the popular imagination today, and that is alleged to have disappeared, is primarily
the flamboyant version of the disorder that appeared in the writings of the Charcot
school. 14
The internal structure of the hysteria diagnosis as it existed a century ago was
distinctive in many ways. Two features deserve comment. First, it is important to
understand the relation between the causal and the symptomatological components
of the diagnosis in nineteenth-centuryEuropean medical thought. Charcot possessed
a clear etiological theory of hysteria. He believed that the disorder traced to a phys-
ical defect of the nervous system, such as a brain tumor or spinal lesion, that resulted
either from direct physical injury or defective neuropathic heredity. Such a defect,
or tare nerveuse, took the form of a "functional" lesion, by which he meant a path-
ophysiological alteration of unknown nature and location in the central nervous sys-
tem.
Nonetheless, nineteenth-centurytheories of hysteria remained wholly speculative.
Because of advances in pathology and bacteriology, doctors were achieving a new
level of etiological understandingfor many infectious and neurologicaldiseases. During
the late 1870s and 1880s laboratoryresearchers isolated specific microbial pathogens
for cholera, tuberculosis, gonorrhea, diphtheria, typhoid fever, and tetanus in dra-
matic succession. But precisely this sort of hard-and-fastinformation on the material
origins of the illness was lacking for hysteria. Nineteenth-century doctors hypothe-
sized about whether hysteria derived from an anatomical lesion, a molecular change,
a nutritional deficiency, or an electrophysiological irregularity in the brain, but in-
conclusively. Confronted, then, with the perpetual "problem of the missing lesion,"
as it was called, Charcot and his contemporaries had to "define" hysteria in a purely
symptomatological fashion, through the totality of its external clinical signs, which
they believed could be grouped into symptom clusters and then into discrete disease
categories. "What, then, is hysteria?" Charcot asked in his final publication on the
subject in 1892. "We do not know anything about its nature, nor about any lesions
producing it; we know it only through its manifestations and are therefore only able
14 See Veith, Hysteria (cit. n. 5): Trillat, Histoire de l'hyste'rie (cit. n. 5); George Wesley, A History
of Hysteria (Washington, D.C.: Univ. Press America, 1979); and Gilman et al., Hysteria beyond Freud
(cit. n. 9). No general history of hysteria in the nineteenth century exists. For the Salpetrian literature,
an extensive exposition may be found in Georges Gilles de la Tourette, Traite'clinique et therapeutique
de l'hyste'rie d'apres l'enseignement de la Salpetriere, 3 vols. (Paris: Plon, Nourrit, 1891-1895). See
also Georges Guillain, J. M. Charcot (1825-1893): Sa vie, son oeuvre (Paris: Masson, 1955), Chs. 13,
14; and Trillat, Histoire de l'hyste'rie, Ch. 6.

504 MARK S. MICALE
to characterize it by its symptoms.'"15 Given the great range, drama, and mutability
of the symptoms of hysteria, nineteenth-century physicians were able to de-empha-
size intractable questions of causation and therapeutics and to concentrate on the
clinical phenomenology of the disorder. But it was precisely the etiological elusive-
ness of these concepts of hysteria, the lack of a strong causal theory to hold them
together, that would allow for their swift symptomatological dissolution in the future.
A second cardinal feature of nineteenth-century models of hysteria is their ex-
tremely expansive symptomatology. Unique among disorders, hysteria assumes its
form by aping other diseases. Consequently, the scope of its projected symptom-
atology has grown and shrunk and grown again over the centuries. Between 1872
and 1878, when Charcot first formulated his theory of hysteria, it was tightly delim-
ited. In the 1870s the diagnosis centered on the hysterical attack and the motor and
sensory "stigmata"-paralyses, contractures, anesthesias, hyperesthesias, and dys-
functions of vision and hearing. Then, over the next fifteen years, the diagnosis
underwent a nosographical inflation whereby its clinical boundaries were progres-
sively broadened. To the well-known neurological somatizations were added clinical
subcategories such as traumatichysteria, hysterical catalepsy, hysterical fugue, hys-
tero-neurasthenia,toxic hysteria, hysterical heart, hysterical anorexia, hysterical tic,
hysterical fever, and hysterical gastralgia. In short, as hysteria became the object of
more medical investigation, the accumulation of observations led not to a more rig-
orously defined clinical category, but only to more encompassing descriptive defi-
nitions. As a result, by the end of the nineteenth century the diagnosis resembled
an oversized and slightly vulgar late Victorian edifice-highly articulated in detail
and impressive to contemplate from afar, but impractically large and with an ex-
tremely shaky etiological foundation. In the hands of a new and ambitious generation
of medical architects, the nosographical structure would prove remarkably easy to
dismantle.
ORGANIC MEDICINE: CHANGES IN ETIOLOGICAL THEORY

AND DIAGNOSTIC TECHNIQUE
By the middle of the 1890s physicians in Europe and North America began to ob-
serve and to criticize the clinical overinclusiveness of the hysteria diagnosis. 16 In the
wake, then, of Charcot's death in 1893, how did the "clinical delimitation" of hys-
teria take place? Who were the main figures involved in the nosographical deflation
of the diagnosis? And to what new areas of medical theory did the diagnosis con-
tribute? I believe that three major medical categories absorbed elements of the di-
agnosis in its nineteenth-century versions. The first of these concerns general neu-
rological medicine, and most apparent in this regard is epilepsy.
15J M. Charcot and Pierre Marie, "Hysteria Mainly Hystero-Epilepsy," in A Dictionary of Psycho-
logical Medicine, ed. D. Hack Tuke, 2 vols. (London: Churchill, 1892), Vol. 1, p. 628. Charcot excelled
at this procedure and utilized it in the construction of other disease pictures as well. In his obituary
notice about Charcot, Freud states that Charcot called the method of formulating symptomatological
syndromes "practicing nosography": Sigmund Freud, "Charcot" (1893), in Freud, Standard Edition,
trans. Strachey et al. (cit. n. 6), Vol. 3, p. 12.
16 See Pierre Janet, "Quelquesd6finitions r6centes de l'hysterie," Archives de Neurologie, 1892, 25:417-
438, 1893, 26:1-29, on pp. 17, 18; Smith Ely Jelliffe, cited in S. A. Kinnier Wilson, "Some Modem
French Conceptions of Hysteria," Brain, 1911, 33:292-338, on p. 308; and Meyer Solomon, "The
Clinical Delimitation of Hysteria," New York Medical Journal, 1915, 102:944, 945.

Owsei Temkin has stated that the medical conception of the relation between epi-
lepsy and many other convulsive disorders, including hysteria, remained hopelessly
confused before the middle of the nineteenth century. Nineteenth-century neurolo-
gists were keenly aware of the age-old confusion between epilepsy and hysteria, and
Charcot struggled all his life with the differential diagnosis of the two disorders. As
a part of this effort he formulated a set of criteria, based purely on clinical obser-
vation, that he believed distinguished the epileptic fit from the hysterical paroxysm.
But the imitative capabilities of the hysterical patient were formidable. In many Eu-
ropean hospitals hysterical and epileptic patients had been housed together in the
same wards for years. Charcot himself first became interested in hysterical disorders
at the Salpetriere in 1870 when he attempted to separate "non-insane hystero-epi-
leptic" patients from the genuine epileptics. In addition, his printed case presenta-
tions and unpublished clinical records show that a percentage of his hysterical pa-
tients during the 1880s came from households with epileptic family members. To
account for the clinical ambiguity between the two diseases, Charcot applied the
hybrid diagnostic label "hystero-epilepsy" to a large number of his patients-an
unsatisfactory term and concept that he abandoned in his later years. 17 In light of
these facts, it was almost inevitable that Charcot, like generations of physicians be-
fore him, would confound elements of the two disorders in formulating his theory
of hysteria.
During the second half of the nineteenth century the British neurological com-
munity conducted superb clinical work on epilepsy and began to seize the lead from
the French. In particular, Charcot and the English neurologist William Gowers dis-
agreed sharply over the concept of la grande attaque hyste'ro-e'pileptique.For Char-
cot, the hysterical attack was an elaborate four-part affair (see Figure 1). The first
stage took the form of an epileptoid seizure marked by tonic contractures and clonic
spasms. This was followed by a stage of "large movements" (grands mouvements),
in which the patient assumed striking contorted postures, including the arched-back,
or arc de cercle, position; a stage of attitudes passionnelles, characterized by the
hallucinatory reenactment of past emotional events; and a stage of delirious with-
drawal, which could last for hours or even days. Gowers, however, like most of his
colleagues in Britain, was skeptical of the work of the Paris school; he believed that
Charcot's first stage represented the essential pathological event, a true epileptic
seizure, with the subsequentphenomena-Charcot's second, third, and fourth stages-
forming an elaboratepsychological sequelae to the fit. In Epilepsy and Other Chronic
Convulsive Disorders (1881) Gowers discusses these cases at length, referring to
them as "epilepsy with coordinated hysteroid convulsions." 18 So far as I can deter-
mine, the two men observed the same clinical picture but interpretedit differently-
17
Owsei Temkin, The Falling Sickness: A History of Epilepsy from the Greeks to the Beginnings of
Modern Neurology, 2nd rev. ed. (Baltimore/London: Johns Hopkins Univ. Press, 1971), pp. 351-359.
See also Louis Paul Crouzet, "Les epileptiques a la Salpetriere, division des alienes: De l'application
de la loi sur les alienes" (M.D. thesis, Univ. Paris, 1871); J.-M. Charcot, "De l'hystero-epilepsie," in
Le!ons sur les maladies du systeme nerveux faites a la Salpetriere, comp. D. M. Bourneville (Paris:
Adrien Delahaye, 1872-1873), pp. 321-337; and Charcot, "Grande hysterie ou hystero-epilepsie," in
Le!ons du mardi d la Salpetriere: Professeur Charcot: Policliniques, 1887-1888 (Paris: Aux Bureaux
du Progres Medical, Delahaye & Lecrosnier, 1887 [sic]), pp. 173-179.
18 Desire-Magloire Bourneville and Paul Regnard, Iconographie photographique de la Salpetriere, 3
vols. (Paris: Delahaye & Lecrosnier, 1876-1880); Paul Richer, Etudes cliniques sur la grande hystirie
ou l'hystero-epilepsie, 2nd enlarged ed. (Paris: Delahaye & Lecrosnier, 1885); and W. R. Gowers,
Epilepsy and Other Chronic Convulsive Disorders (London: Churchill, 1881), Chs. 6, 7.

506 MARK S. MICALE
P-a- It Pifia& pibpa-d- 2! Pnrod. de ebwndgn. S!PM iXO& p> _ VPoe;0:iietti0i; .0
A B C D Cf - 7~ -0 H 3 K ? L :g;$: D
VL~~~~~~~~LV
.. ,
34..
tiS;~~ A.4, .^CE ~ ~~~~~~~~~~~
Figure 1. Bodilypositions in the four main stages of the classic Charcotianfit. (FromPaul
Richer,Etudes cliniquessur la grande hysterie ou l'hystero-epilepsie,2nd rev. and enlarged ed.
[Paris:Delahaye & Lecrosnier,1885], unnumberedpage.)
Charcot as epileptiform hysteria, Gowers as organic epilepsy with a long psycho-

logical aftermath in what today would be called the postictal period.
During the last three decades of the nineteenth century the French theory of epi-
lepsy predominated in medical thinking on the Continent. In the Salpetrian literature,
nearly a quarter of the cases carry the mixed diagnosis "hystero-epilepsy." In the
twenty years following Charcot's death, however, Gowers's interpretation was in-
creasingly adopted in Germany, France, and elsewhere. A sequence of texts on the
subject, including works by Charles Fere (1892), G. Bonjour (1907), G. Bouche
(1908), Paul Guichard(1908), and Theodore Diller (1910) and culminatingin Joachim
Caspari's Clinical Study of the DifferentialDiagnosis of Epilepsy and Hysteria (1916),
reveals a growing interest in the concept of "hysterical epilepsy" and "post-epileptic
hysteria" in preference to the earlier view of Charcot. What Gowers and his followers
surmised from observation at the bedside-namely, that many of the most dramatic
cases of hysteria involved an underlying organic element-was borne out in the late
1920s with the advent of electroencephalography, which eventually allowed for a
much finer differentiationbetween hysteria and the various epilepsies, including what
by the 1950s was termed temporal lobe epilepsy.19
'9 Charles Fere, Epilepsie (Paris: Gauthier-Villars/Masson, 1892), Chs. 6, 8, 12, 18; G. Bonjour,
"Diagnostic diffdrentiel des crises dpileptiques et des crises hysteriques: Un sympt6me nouveau,"
L'Encephale, 1907, 2:263-264; G. Bouche, "Diagnostic et prognostic de 1'epilepsie essentielle," Jour-

Additionally, the early twentieth century brought a new clinical and theoretical
interest in "the psychology of epilepsy." A majority of nineteenth-century physi-
cians, including Charcot and his circle, reacted against the former confusion between
hysteria and epilepsy by striving diagnostically to distinguish true epilepsy from its
hysterical counterfeits. In contrast, in a number of pioneering essays from the 1870s
and 1880s, the English neurologist J. Hughlings Jackson described the exceptional
mental states that may follow an epileptic discharge. During the first decade of the
twentieth century English and German physicians, following Jackson's lead, began
to explore the complex neuropsychiatric interactions that may develop between epi-
lepsy and hysteria within the same patient. An importantpart of this work involved
investigating the remarkable variety of behaviors-stupor, transient amnesia, sen-
sory hallucinations, confusional states-that may occur in the postconvulsive period
of epilepsy and that are today grouped under the heading "epileptic psychosis." (In
our own time, this line of research has produced the concepts of the "functional
overlay" and the "psychogenic pseudo-seizure.") In other words, the scope of clin-
ical phenomena classified as epileptic during the early twentieth century was en-
larging steadily, and this expansion almost certainly took place at the expense of the
hysteria diagnosis.20
The past connections between the diagnoses of hysteria and syphilis are no less
complex and significant. From the 1820s onward a debate raged in the European
medical community over the causal and clinical relations between syphilis and in-
sanity. Nineteenth-century physicians, including several who wrote about hysteria,
were well aware of many of the neural manifestations of syphilis that could develop
after a long period of latency. Charcot himself conducted importantresearch on optic
atrophy and on meningitis with convulsions of syphilitic origin. On this point, how-
ever, Charcot's celebrated clinical intuition failed him, and he proved unable to make
the etiological connection between syphilitic infection and either tabes dorsalis or
general paralysis of the insane. In 1876 the French venereologist Alfred Fournier
first proposed the syphilitic origins of tabes. He then turned to general paresis and
accumulated clinical data on the subject during the 1880s. In a historic statement to
the Paris Academy of Medicine in October 1894, and later that year in his book
Parasyphilitic Affections, Fournier announced the results of his study, which estab-
lished a strong statistical correlation between infection with syphilis and the subse-
quent development of general paralysis.21
nal Medical de Bruxelles, 1908, 13:601-607; Paul Guichard, "De l'hyst6rie a forme d'6pilepsie partielle
et 6pilepsie jacksonienne chez une hyst6rique, diagnostic diff6rentiel" (M.D. thesis, Univ. Montpellier,
1908); Theodore Diller, "Differential Diagnosis between Epilepsy and Hysteria and Their Mutual Rela-
tionship, " International Clinics, 20th ser., 1910, 4:177-188; Joachim Caspari, Klinische Beitrdge zur Dif-
ferentialdiagnose zwischen Epilepsie und Hysterie (Berlin: Ebering, 1916); and Hans Berger, "Uber das
Elektrenkephalogrammdes Menschen, " ArchivfiirPsychiatrie undNervenkrankheiten, 1929,87:527-570.
20 J. Hughlings Jackson, "On Temporary Mental Disorders after Epileptic Paroxysms" (1875), "On
Epilepsies and on the After-Effects of Epileptic Discharges" (1876), and "On Post-Epileptic States: A
Contribution to the Comparative Study of Insanities" (1889), all rpt. in Selected Writings of John Hugh-
lings Jackson, ed. James Taylor, 2 vols. (New York: Basic, 1958), Vol. 1, pp. 119-134, 135-161,
366-384. Pertinent to this point is Esther M. Thornton's Hypnotism, Hysteria, and Epilepsy: An His-
torical Synthesis (London: William Heinemann, 1976). Thornton advances the interesting thesis that the
most dramatic cases of grande hysterie in the nineteenth century were actually cases of temporal lobe
epilepsy in which attacks were elicited though the procedures employed by hypnotists in public dem-
onstrations.
21 Alfred Fournier, De l'ataxie locomotrice d'origine syphilitique (Paris: Masson, 1878); and Fournier,

508 MARK S. MICALE
During the same years that Fournier was conducting his research on the etiology
of syphilis, the Charcot school was deeply engaged in its hysteria studies. Charcot
dissented vehemently from Fournier's findings. Throughout his lifetime he insisted
that syphilis, tabes, and general paralysis, as well as other nervous and neurological
diseases including hysteria, were separate manifestations of a more basic neuropathic
heredity. Primary and secondary venereal infections might operate as agents pro-
vocateurs of these disorders, but they represented fundamentally different maladies
that were unrelatedcausally. As Fournierpointed out in two chapters of Parasyphili-
tic Affections, the result of this misconception was widespread diagnostic confusion
between certain cases of acute hysteria and advanced neurosyphilis.22Again, how-
ever, European medical thinking moved away from Charcot. As with Gowers and
epilepsy, what Fournier had sensed clinically in the 1870s was established conclu-
sively through technical advances in the following generation. In 1905 Fritz Schau-
dinn and Erich Hoffmann, in Berlin, observed microscopically the Spirochaeta pal-
lida, the actual syphilitic organism, in human tissue from a primary syphilitic lesion.
The following year August Wassermann, a serologist also situated in the German
capital, used the latest staining techniques to develop the first blood test for the
presence of syphilitic antibodies. And in 1913 Hideyo Noguchi and J. W. Moore,
working at the Rockefeller Institute in New York City, used the most recent histo-
pathological methods to isolate the spirochete in the brain tissue of a paretic patient.23
Epidemiologically, the connection between the diagnoses of syphilis and hysteria
was by no means as remote a hundred years ago as it appears today. In late nine-
teenth-century European medicine both disorders were seen as afflictions of the cen-
tral nervous system. Moreover, an unprecedented, epidemical rise in cases of syphilis
occurred in many urban areas in Europe during this period-that is, during the same
years as the upsurge in hysteria. In the 1850s Fournier had claimed that as much as
15 percent of the general adult population of Paris was infected with syphilis. To
the same effect, Claude Quetel, in a recent historical account of syphilis, cites a
rapport ge'ne'ralundertaken by the French Ministry of the Interior in 1874, which
found that 2,619 patients in municipal mental hospitals across the nation suffered
from general paralysis; this represents 6.2 percent of the population of French public
asylums. Quetel finds further, from archival medical records, that in certain Parisian
institutions specializing in the disease, such as the Charenton asylum, as many as
Les affections parasyphilitiques (Paris: Rueff, 1894). Tabes dorsalis, designated in nineteenth-century
French medicine as locomotor ataxia, refers to syphilis of the spine, whereas general paralysis of the
insane, also known as general paresis or dementia paralytica, signifies the meningoencephalitis of tertiary
neurosyphilis. Both are progressive neurodegenerative diseases. On the debate over the relations between
syphilis and insanity see Gregory Zilboorg with George W. Henry, A History of Medical Psychology
(New York: Norton, 1941), pp. 526-551.
22 For Charcot's view see Charcot, "Syphilis, ataxie locomotrice progressive, paralysie faciale," in
Lecons du mardi (cit. n. 17), pp. 1-11; Georges Gilles de la Tourette, "Hyst6rie et syphilis," Progres
Medical, 2nd ser., 1887, 6:511-512; and Jean-Martin Charcot to Sigmund Freud, 30 June 1892, in
"'Mon Cher Docteur Freud': Charcot's Unpublished Correspondence to Freud, 1888-1893," Bull. Hist.
Med., 1988, 62:572-575, 587-588. Cf. Fournier, Les affections parasyphilitiques, Chs. 16 and 17,
where he specifically dissents from the view of the Salpetriere school.
23 Fritz Schaudinn and Erich Hoffmann, "Vorlaufiger Bericht uber das Vorkommen von Spirochaeten
in syphilitischen Krankheitsproduktenund bei Papillomen," Arbeiten aus dem Kaiserlichen Gesundheit-
samte, 1905, 22:527-534; A. Wassermann, A. Neisser, and C. Bruck, "Eine serodiagnostische Reaktion
bei Syphilis," Deutsche Medizinische Wochenscrift, 1906, 32:745-746; and Hideyo Noguchi and
J. W. Moore, "A Demonstration of the Treponema Pallidum in the Brain in Cases of General Paralysis,"
Journal of Experimental Medicine, 1913, 17:232-238.

35 percent of the patients were so afflicted. In 1913-the year that Noguchi and
Moore announced their results-Emil Kraepelin observed similarly that paretics con-
stituted an average of 10 to 20 percent of all admissions to mental hospitals in Ger-
many.24 In short, during the final third of the nineteenth century patients with ad-
vanced syphilis were intermixed with general institutionalizedpsychiatric populations,
which also included many cases diagnosed as severely hysterical.
Equally relevant are the clinical similarities between the two maladies. In the nine-
teenth-century medical literatureon hysteria, acute paralytic disturbances are among
the most common symptoms. The onset of general paresis, like hysteria, may be
characterized by convulsive seizures, double vision, loss of pain sensation in scat-
tered areas of the body, and sensory ataxias, as well as exaggerated emotional be-
haviors. The situation was furthercomplicated by the fact that hysterical symptoms,
especially monoplegias, hemiplegias, and paraplegias, often appear in conjunction
with syphilis, especially at the outset of the secondary stage of infection. Fournier
speaks of these cases as "parasyphilitichysteria." One of his students believed that
the associations between the two ailments were so close and common that a special
mixed diagnosis was in order. Finally, it may be relevant to consider the patient
population from which the leading nineteenth-century theory of hysteria derived. In
Charcot's writings, roughly 40 percent of the case histories of hysteria concern adult
males from the working classes, a population in which the occurrence of syphilis
was exceptionally high at the time.25 Clearly, the medical historian can only spec-
ulate on this point; but it appears likely that a not-insignificant number of individuals
included a century ago in the French medical literature as hysterical were in fact
afflicted with "the great imitator" in its advanced stages. Once again, the technical
means for distinguishing definitively between neurosyphilis and other neurological
and psychiatric disorders, and therefore for recategorizing these cases, became avail-
able to the generation of practitioners following Charcot.26
It is impossible to review here every medical development of the late nineteenth
and early twentieth centuries that bore on the hysteria diagnosis; but in retrospect
we can see that the process occurred in many areas. In 1895 Karl Roentgen discov-
ered the X-ray. A major diagnostic tool for detecting structuraldamage to the body,
including cranial injury, was now at the disposal of doctors. The separation of the
numerous cases of "post-traumatichysteria" from those involving structuralphysical
injury was made much easier. In 1896 Joseph Babinski discovered the cutaneous
plantarreflex that still bears his name ("Babinski's sign" or "Babinski's toe reflex").
A simple but reliable procedure was now available for separating most hysterical
hemiplegias and paraplegias from paralyses of organic, especially cerebrovascular,
24 Alfred Fournier, cited in Roger L. Williams, The Horror of Life (Chicago: Univ. Chicago Press,
1980), p. 49; Claude Qu6tel, History of Syphilis, trans. Judith Braddock and Brian Pike (Baltimore:
Johns Hopkins Univ. Press, 1990), p. 161; and Emil Kraepelin, General Paresis, trans. J. W. Moore
(New York: Journal of Nervous and Mental Disease Publishing, 1913), pp. 138, 139.
25 Fournier, Les affections parasyphilitiques (cit. n. 2 1), pp. I 1- 118; M. Hudelo, "Hyst6ro-syphilis,"
Annales de Dermatologie et de Syphiligraphie, 3rd ser., 1892, 3:839-842; and Micale, "Charcot and
the Idea of Hysteria in the Male" (cit. n. 10), pp. 370-373, 377-380.
26 Psychiatric textbooks published after the work of Noguchi and Moore also registered the diagnostic
significance of these technical advances for psychological medicine. See William White, Outlines of
Psychiatry, 5th ed. (New York: Journal of Nervous and Mental Disease Publishing, 1915), p. 117;
Francis Dercum, A Clinical Manual of Mental Diseases, 2nd rev. ed. (Philadelphia: Saunders, 1918),
pp. 267-268; and Aaron Rosanoff, Manual of Psychiatry, 5th rev. ed. (New York: John Wiley, 1920),
pp. 395-396.

510 MARK S. MICALE
origin.27To cite one furtherexample, Charcot and his student Georges Guinon wrote
often during the 1880s about the concept of "toxic hysteria." The cases they pre-
sented under this rubric were produced by excessive exposure to lead, mercury, and
carbon disulfide in the environment. Over the next two decades many of the mental
and physical symptoms they discussed in these cases came to be understood as the
effects of chemical poisoning and were regrouped under the heading "toxic psy-
choses. ,28
Hysteria, it is often said today, is a "diagnosis of exclusion." By definition, it
can be applied only when all possible anatomical and physiological explanations for
the symptoms have been ruled out. As a consequence, the legitimate sphere of the
diagnosis (some critics would say of psychodynamic psychiatry as a whole) may be
fated continually to contract as the understanding of organic illness expands. In the
ongoing appropriationof the mental by the physical, the early twentieth century was
a highly active period. The most astute observers were aware of the change and its
implications. In 1914 Paul Guiraud of Tours wrote, "When we have completed the
clinical analysis of all the hysterical symptoms, when we have given to each malady
what belongs to it, who knows if anything will still remain of hysteria?"29
INSTITUTIONAL PSYCHIATRY AND THE RISE OF GERMAN-LANGUAGE THEORIES

OF THE PSYCHOSES
At the same time that the old "citadel of hysteria" was under attack from outside
the domain of psychological medicine, it was also being undermined by innovative
medical ideas within the psychiatric profession. If we inspect the tables of contents
of French and German psychiatric textbooks from around 1915 and contrast them
with their counterparts from a generation earlier, we find that the two sources are
remarkably dissimilar. A number of diagnostic categories from the earlier sources
are used much less frequently or have fallen away altogether, while new ones have
appeared in their place. Easily the largest new nosological unit in the later works is
formed by the psychoses, in the present-day sense of the word. These theories of
the psychoses make up the second major area of medicine that laid claim to the old
27 Babinski commented specifically on the implications of his discovery for hysteria in "Des signes
permettant le diagnostic differential entre les affections nerveuses hyst6riques et organiques," Clinique,
1911, 6:551-553.
28 From 1895 to 1905 a spate of medical dissertations-many of them from provincial medical fac-
ulties-probed the differential diagnosis of hysteria and other organic diseases too. See Maurice Pignet,
"Pseudo mal de Pott (mal de Pott hyst6rique)" (M.D. thesis, Univ. Lyon, 1895); Domitian Glinenau,
"Rapportsde 1'hyst6rie avec la tuberculose pulmonaire" (M.D. thesis, Univ. Paris, 1896); J. Nouaille,
"Contributiona l'tude de I'hysterie senile (hyst6rie chez les vieillards)"(M.D. thesis, Univ. Paris, 1899);
J. Combes, "Contribution au diagnostic de l'hyst6rie cofncidant avec le syndrome de la sclerose en
plaques ou l'hemiplegie" (M.D. thesis, Univ. Toulouse, 1901); Emile Fouquet, "Contributiona 1'etude
de la pseudo-scl6rose en plaques d'origine hyst6rique" (M.D. thesis, Univ. Lille, 1901); Pierre Aubry,
"Des rapports de la chor6e avec l'hysterie et en particulier de la choree rythmee cons6cutive a la chor6e
de Sydenham" (M.D. thesis, Univ. Toulouse, 1903); and Henri Bernadicou, "Contributiona l'etude des
rapports symptomatiques entre le tabes et l'hyst6rie" (M.D. thesis, Univ. Paris, 1904).
29 Guiraud, "L'hyst6rie et la folie hyst&rique"(cit. n. 12), p. 684. See also Thomas Buzzard, On the
Simulation of Hysteria by Organic Disease of the Nervous System (London: Churchill, 1891), pp. vii,
113; and Wilson, "Some Modem French Conceptions of Hysteria" (cit. n. 16), p. 337.

territoryof hysteria. They were almost entirely the product of the German-speaking
medical communities.30
During the first half of the nineteenth century the generic diagnostic categories
that had existed in Western psychiatric medicine since ancient times-mania, mel-
ancholia, delirium, and dementia-began to break down into more specialized cat-
egories. As part of this process, the notion of "hysterical insanity" and "hysterical
mania" (la folie hyste'rique, la manie hyste'rique,das hysterische Irresein) emerged
in French, German, and British medicine during the middle of the century. In works
by Wilhelm Griesinger(1845), B. A. Morel (1852-1853; 1860), L. V. Marce (1862),
and J. J. Moreau de Tours (1869), hysterical insanity represented a loose assortment
of behaviors-usually dramatic, erratic, or erotic in nature-that accompanied cer-
tain cases of nervous and mental illness in female patients. Among asylum physi-
cians, the concept of hysterical insanity proved serviceable, and later in the century
it cropped up in psychiatric treatises by Richard von Krafft-Ebing, H. Schiule, Jules
Falret, Henri Legrand du Saulle, Valentin Magnan, Henry Maudsley, and Thomas
Clouston.3'
Then, in 1874, Karl Ludwig Kahlbaum, the director of a private mental hospital
in Gorlitz, Silesia, published a short monograph entitled Catatonia, or Tension In-
sanity. In this study Kahlbaum described a clinical syndrome for which he coined
the term Katatonie. Kahlbaum's catatonia was in part a reformulation of the concept
of hysterical insanity from the preceding generation. In addition to the stuporous
states the word signifies today, the syndrome included high levels of anxiety, radical
mood shifts, and various thought disorders. Kahlbaum proposed a number of cata-
tonic phases, one of which he called the stage of "patheticism," or pathetic behav-
iors. The pathetic stage was marked by "theatricalpostures and gesticulations," "sen-
sual playfulness," "a tendency to clownishness," "expansive moods that permeate
speech, actions, and gestures," and "histrionic exaltation, sometimes in the form of
a tragic-religious ecstasy." A number of these features-notably, the "clownishness"
and quasi-religious behaviors-were at this same time being incorporatedby Charcot
into his new hysteria formulation. Kahlbaum also noted in his conspectus that several
of the mental phenomena he chose to classify as catatonic had been described a few
years earlier by one of his colleagues, Ewald Hecker, under the heading "hebe-
phrenia."32Interestingly, the ideas and terminology of Hecker and Kahlbaum went
almost entirely unnoticed during the 1870s and 1880s.
Twenty years later, however, their work was integrated into the new, more am-
bitious, and far more successful psychiatric system of Emil Kraepelin. Kraepelin,
"the Linnaeus of psychiatry," set himself the task of establishing a comprehensive
plan of classification for mental medicine. The psychiatric system that resulted from
30 To the best of my knowledge, the first person to perceive the clinical continuities between the
decline of hysteria and the rise of the psychoses was Henri Baruk, "L'hyst6rie et les fonctions psy-
chomotrices," in Comptes rendus de la Congres des Medecins Alie'nistes et Neurologistes de France et
des Pays de la Langue Francaise, Brussels (Paris: Masson, 1935), pp. 3-7, a source to which the
following several pages are much indebted. For the phrase "citadel of hysteria" see Paul Hartenberg,
"Les nouvelles idees sur l'hyst6rie," Presse Medicale, 1907, 15(2):468-469, on p. 469.
31 Paul Bercherie, "Le concept de folie hysterique avant Charcot," Revue Internationale d'Histoire
de la Psychiatrie, 1983, 1:47-58.

32 Karl Ludwig Kahlbaum, Die Katatonie; oder, das Spannungsirresein: Eine klinische Form psych-
ischer Krankheit (Berlin: August Hirschwald, 1874), descriptions on pp. 31-36; and Ewald Hecker,
"Die Hebephrenie: Ein Beitrag zur klinischen Psychiatrie," Archivfur Pathologische Anatomie und Phys-
iologie undfiir Klinische Medicin, 1871, 52:394-429.

512 MARK S. MICALE
his work was enormously influential, not least in American psychiatry, and to a large
extent is still with us today. The most importantof Kraepelin's diagnostic categories
were dementia praecox and manic-depressive psychosis.
Kraepelin presented his taxonomic plan in his famous Lehrbuch. His textbook ran
to eight editions between 1883 and 1915 and so provides an excellent overview of
the contemporary history of European psychiatric nosology. The most striking fea-
ture of the work is its expansion from edition to edition. The first edition of the
book, which was entitled Compendium of Psychiatry, had 384 pages. The second,
third, and fourth editions, published respectively in 1887, 1889, and 1893 as A Short
Textbook of Psychiatry for Students and Physicians, were 540, 584, and 702 pages
in length. In the fourth edition, which appeared the very year of Charcot's death,
Kraepelin formally introduced the term dementia praecox, which he borrowed from
Morel. He presented the concept in a 10-page discussion of the three subforms (the
others were catatonia and paranoia) of the "degenerative psychological processes."
In 1896 the fifth edition, an 825-page Textbook of Psychiatry for Students and Phy-
sicians, appeared; here dementia praecox ranked above catatonia and paranoia in a
15-page passage. In the well-known sixth edition of 1899, in two volumes, Kraepelin
included a 75-page description of dementia praecox and his first chapter-length dis-
cussion of the manic-depressive psychoses. Edition seven of the Lehrbuch, which
incorporated chapters of approximately 100 pages apiece on dementia praecox and
manic-depressive psychoses, was published in 1903-1904. The final edition ap-
peared between 1909 and 1915. It consisted of no fewer than four weighty volumes
totaling over 3,000 pages. The sections on dementia praecox and manic-depressive
psychoses had swollen to 301 and 212 pages, respectively; together, they were longer
than the entire first edition of the work.33Few works exhibit more clearly the strong
classificatory impulse that has animated the history of psychiatry.
As Kraepelin's textbook grew during the late nineteenth and early twentieth cen-
turies, and with it the concepts of dementia praecox and manic-depressive psychoses,
the historian may inquire: Where did Kraepelin find the building blocks for his vast
nosographical synthesis? Without doubt, the historical origins of Kraepelinian theory
are diverse; but I want to suggest that Kraepelin drew in part on the nineteenth-
century hysterias. Although French medicine boasted a rich, unbroken tradition of
commentary about hysteria from the preceding two hundred years, and the British
had produced a smattering of important texts from the time of Robert Burton and
Edward Jorden onward, the German-speakinglands possessed no indigenous national
discourse on hysteria until the end of the nineteenth century. The 1880s brought a
sudden increase of interest in the subject, and by the 1890s the German-language
literatureequaled the French in quantity. At first German and Austrian doctors were
inspired directly by Charcot's conception of the disorder, which they liked because
3 Emil Kraepelin, Compendium der Psychiatrie: Zum Gebrauche fur Studirende und Aerzte (Leipzig:
Abel, 1883); Kraepelin, Psychiatrie: Ein kurzes Lehrbuch fdr Studirende und Aerzte, 2nd ed. (Leipzig:
Abel, 1887); Kraepelin, Psychiatrie: Ein kurzes Lehrbuchfur Studirende und Aerzte, 3rd rev. ed. (Leip-
zig: Abel, 1889); Kraepelin, Psychiatrie: Ein kurzes Lehrbuch fur Studirende und Aerzte, 4th rev. ed.
(Leipzig: Abel, 1893), pp. 435-445; Kraepelin, Psychiatrie: Ein Lehrbuch fur Studirende und Aerzte,
5th rev. ed. (Leipzig: Johann Ambrosius Barth, 1896), pp. 426-441; Kraepelin, Psychiatrie: Ein Lehr-
buch far Studirende und Aerzte, 6th rev. ed., 2 vols. (Leipzig: Johann Ambrosius Barth, 1899), Vol.
2, pp. 137-214, 359-425; Kraepelin, Psychiatrie: Ein Lehrbuch fur Studirende und Aerzte, 7th rev.
ed., 2 vols. (Leipzig: Johann Ambrosius Barth, 1903-1904), Vol. 2, pp. 176-283, 496-589; and Krae-
pelin, Psychiatrie: Ein Lehrbuchfar Studirende und Aerzte, 8th rev. ed., 4 vols. (Leipzig: Johann Am-
brosius Barth, 1909-1915), Vol. 3, pp. 668-972, 1183-1395.

its neurocentricetiology and symptomatology accorded well with the organicist med-
ical philosophy prevailing in their profession. Then, during the 1890s a number of
researchers, including Adolph von Struimpell,Paul Mobius, Breuer, and Freud, grad-
ually broke with the Salpetrian model and advanced their own more psychologized
theories of the disorder.34
Kraepelin, in formulating his ideas about dementia praecox and manic-depressive
disorder, drew on both the mid-century medical writing about hysterical insanity
(especially that of Griesinger) and the recent French and German literature on hys-
teria. The evidence for this lineage is strongly suggestive. If we compare many of
the images in the Iconographie photographique de la Salpe?trie're,published in 1876-
1880, with those in the classic ninth chapter on dementia praecox in the sixth edition
of Kraepelin's textbook (1899), we find that the clinical descriptions and pictorial
representationsare much alike.35Kraepelin divided dementia praecox into three sub-
types: hebephrenic, catatonic, and paranoid. In the case-historical records of the
nineteenth century there is little indication of paranoid patterns of behavior among
patients diagnosed as hysterical; but the hebephrenic and catatonic forms of the dis-
ease have clear clinical parallels with hysteria. Kraepelin's hebephrenic state is char-
acterized by "various hyperesthesias," exaggerated sexual behaviors, and "expansive
mood shifts" including "uncontrollable laughing and sobbing." Catatonic dementia
praecox is marked by sensory, especially auditory, hallucinations, "great suscepti-
bility to suggestion," "impulsive actions," "religious delusions," and stereotyped
movements, mannerisms, and postures. At one point Kraepelin stated, with dubious
precision, that according to his data 18 percent of all cases of dementia praecox
involve hysteriform or apoplectiform attacks. These attacks, he added, occur twice
as frequently in female patients as in males. During the early twentieth century sev-
eral medical authors, two formerly Kraepelin's students, explored the diagnostic con-
tinuum between the older and newer syndromes.36
What scholars today can perceive only as rough descriptive congruences were for
some clinicians clearly overlapping medical conditions. In 1904 Charles Dana, the
noted New York neurologist, wrote a piece in the Boston Medical and Surgical Jour-
nal entitled "The Partial Passing of Neurasthenia." Dana observed much the same
"disappearance"of neurastheniathat we are finding for hysteria. In his article Dana
discussed a number of new categories and vocabularies that he believed should re-
place the neurasthenia concept. He went on to remark, "It is my contention that a
large number of these so-called neurastheniasand all the hysterias should be classed
as prodromal stages, abortive types, or shadowy imitations of the great psychoses. "
Other physicians reflected retrospectively on the change in diagnostic categorization.
34 The history of hysteria studies in central Europe before Freud remains to be written. The most
useful source thus far is Hannah S. Decker's Freud in Germany: Revolution and Reaction in Science,
1893-1907 (Psychological Issues, 41) (New York: International Univ. Press, 1977), Ch. 2.
3' From the three volumes of Bourneville and Regnard, Iconographie photographique de la Salpetriere
(cit. n. 18), compare in particular images of the hallucinatory and delirious stages of the grande attaque
hystero-epileptique (Vol. 1, plates 6, 9, 11, 17, 29, 30; Vol. 2, plates 9, 10, 15, 25, 35) with Kraepelin,
Psychiatrie: Ein Lehrbuch (1899), Vol. 2, plates 2, 6.
36 Kraepelin, Psychiatrie: Ein Lehrbuch (1899), Vol. 2, pp. 146, 149-182. See also 0. Kaiser, "Bei-
trage zur Differentialdiagnose der Hysterie und Katatonie," Allgemeine Zeitschriftfar Psychiatrie, 1901,
58:957-969; Michel Reyneau, "D6mence pr6coce et hyst6rie" (M.D. thesis, Univ. Bordeaux, 1904-
1905); Luickerath, "Zur Differentialdiagnose zwischen Dementia Praecox und Hysterie," Allg. Z. Psy-
chiat., 1911, 68:312-329; and Fritz Kreuser, "ZurDifferentialdiagnose zwischen Hebephrenie und Hys-
terie," ibid., 1913, 70:873-936.

514 MARK S. MICALE
Konrad Rieger, for instance, was a director of the Wurzburgpsychiatric clinic whose
career spanned the period 1870-1920 and who had personally observed Charcot's
demonstrations in the early 1880s. In his autobiography of 1929, Rieger stated that
certain cases that he had diagnosed as hysterical in the 1880s and 1890s would now
be diagnosed as dementia praecox.37
Other unequivocal statements were made at the Congres des Medecins Alienistes
et Neurologistes de France et des Pays de la Langue Fran?aise, the most important
yearly conference for French professionals in these fields. The 1907 meeting, held
conjointly in Lausanne and Geneva, included a special session devoted to "the def-
inition and nature of hysteria." The proceedings of the congress indicate that the
physicians in attendance observed with some alarm the recent eclipse of the hysteria
diagnosis. The session quickly became an animated discussion about the relation of
hysteria to the new theories of the psychoses emerging from Germany, Austria, and
Switzerland. One speaker after another acknowledged the clinical connections be-
tween the two. A strong undercurrentof scientific nationalism runs through the com-
ments of the conference participants,who seem to have sensed that la science francaise
was being supplanted by a foreign medical system. One member even ingeniously
attempted to combine theories-old and new, French and German-by proposing
such hybrid designations as "pseudo-hystericaldementia" and "hysteriformdementia
praecox."38
Once again, the strongest statement came from Guiraud, writing in 1914 when
the shift in diagnostic styles was nearly complete:
Certain symptoms previously labeled as hysterical-hallucinatory delirium, exalted

imagination,nervousattacks,and so on-belong to othermentaldiseasesand in partic-
ularto manic-depressive psychosesanddementiapraecox.How manycases of dementia
praecoxare takenat the beginningof their sickness for hysterics?Theirmanneredpo-
sition, theircatalepsy,theirhysteriformattacks,theirquasi-hypnoticdelirium. . . lead
to confusion.Manymedicalwritershave noticeda hysteroidsyndromeat the beginning
of hebephrenia,but this grouping[of symptomsas hebephrenia]now seems more sat-
isfactoryto us.
Whenwe readcases publishedby variousauthorsunderthe nameof folie hysterique,
prolongedcatalepsy,hysteriformdementiapraecox,etc., we are struckby the identity
of the symptoms. The patients are the same, and the clinical observation is equally
precise; only the nosological grouping is different.39
It would be difficult to find a more explicit statement.

All that remained was for Eugen Bleuler, working at the Burgholzli hospital in
Zurich, to publish his monograph Dementia Praecox, or the Group of the Schizo-
phrenias in 1911. Bleuler's classic work integrated the mid-century concept of hys-
terical insanity, Hecker's hebephrenia, Kahlbaum's catatonia, the most severe psy-
chopathological aspects of the Charcotian hysterical fit, and Kraepelin's dementia
praecox into the broadly applicable concept of schizophrenia. So defined, schizo-
3? Charles L. Dana, "The Partial Passing of Neurasthenia," Boston Medical and Surgical Journal,
1904, 150:339-344, on p. 339 (italics added); for the parallel historical story of neurasthenia see Sich-
erman, "Uses of a Diagnosis" (cit. n. 1), esp. pp. 35-37. Konrad Rieger, Die Medizin der Gegenwart
in Selbstdarstellungen, ed. L. R. Grote, 8 vols. (Leipzig: Felix Meiner, 1929), Vol. 8, pp. 135, 146,
158-159.
38 See "Definition et nature de l'hysterie" in Comptes rendus (1907) (cit. n. 2), B. Pailhas, Vol. 1,
p. 391.
39 Guiraud, "L'hyst6rie et la folie hysterique" (cit. n. 12), pp. 687-688 (italics added).

phrenia-"that new, expansive, and conquering entity"-began its own highly suc-
cessful career, incorporatinga number of clinical constituents of the former hysteria,
now disguised under new names and camouflaged in different theoretical surround-
ings.40
The German-languagecategories of the psychoses achieved prominence during the
first fifteen years of the twentieth century through the more or less direct translation
of old medical ideas and language into new ones. At the same time, a second and
more subtle reconceptualizationwas taking place. This involved retentionof the word
hysteria but its application is a new diagnostic context. From the turn of the century,
the hysteria concept was increasingly employed as a transient psychological reaction
or as a pattern of symptom formation that may appear in conjunction with other
more basic psychopathologies. This usage is still common in psychiatric practice
today. A single influential example will serve to illustrate the emerging trend. In
1916 Bleuler published the first edition of his own Textbook of Psychiatry. In con-
trast to nineteenth-century manuals, the editions of Bleuler's work appearing after
World War I contain no chapter on hysteria in any form. However, his index records
a dozen entries under "hysteria," all of them in the adjectival form: "hysterical con-
dition," "hysterical syndrome," "hysterical reactions," "hysterical associations,"
"hysterophilic disease," and so on.4'
In the writings of medical authors from preceding centuries, hysteria took the form
of a primary, unitary diagnosis. In Salpetrian theory, in particular, the disorder con-
stituted an independent disease entity with an indivisible clinical core-the hysterical
paroxysm and the neurological stigmata. For Bleuler's generation and after, how-
ever, hysteria as such ceased to exist. In his textbook Bleuler ranked hysteria as the
last of ten minor subtypes of "psychopathic forms of reaction." With some impa-
tience, he reviewed current definitions of the diagnosis, and in places he cited the
term ironically, as "'hysteria,"' "the so-called hysterias," or "the pseudo-hysterias."
In Bleulerian psychiatry, hysteria became a kind of free-floating symptomatological
reaction that could develop with almost any physical or mental disorder.42Of course,
the diagnostic implications of the new hysteria-only-a-symptom theory were enor-
mous. Latter-dayphysicians continued to see and to include in their clinical accounts
essentially what their earlier counterpartshad seen and included, but hysteria became
a far less frequent primary diagnosis. The shift from hysteria as a unitary disease
entity to hysteria as a secondary psychological reaction was easily as important to
its twentieth-centurydecline as the introductionof any new medical term or category.
THE NEW PSYCHONEUROSES
Between 1895 and 1910 the idea of neurosis as we understandit today also emerged.
This brings us to the third and final medical category that absorbed elements of the
former hysteria diagnosis. As J. M. Lopez Pifiero and J. M. Morales Meseguer have
shown, the term psycho-neurosis appeared during the 1890s and took on its current
meaning. It ceased to designate a generic, "functional" abnormality of the nervous
40 E. Bleuler, Dementia Praecox; oder, Gruppe der Schizophrenien (Leipzig/Vienna: Franz Deuticke,
1911); and Trillat, Histoire de l'hysterie (cit. n. 5), p. 262 (quotation).
41 E. Bleuler, Lehrbuch der Psychiatrie (1916), 4th ed. (Berlin: Springer, 1923), p. 540.
42
Ibid., pp. 412-423. For a second example of this usage of the hysteria concept refer to Karl Jaspers,
Allgemeine Psychopathologie (Berlin: Springer, 1913).

516 MARK S. MICALE
system-neurosis in the sense of Gowers, Charcot, and George Beard-but became

a purely psychological disorder of moderate severity located between the conditions
of health and psychosis. Charles Rosenberg and Bonnie Blustein, among others, have
pointed out that it was also during the final quarter of the nineteenth century that
neurology and private-practice psychiatry developed as organized and contiguous
medical specialties, competing at times for patients and for scientific authority over
certain subjects.43The fortunes of the hysteria diagnosis were intimately caught up
with both the psychologization of the neurosis concept and the territorial rivalries
among neurologists, institutional alienists, and private-practice psychiatrists. Sim-
plifying somewhat, we can say that those portions of the diagnosis that were not
claimed decisively at this time by specialists in organic medicine or institutional
alienism were up for grabs by a younger generation of independent psychiatrists
eager to theorize anew about the neuroses. If the establishment of categories of psy-
chosis was swift and relatively uncontested, the intellectual history of the neuroses
was a welter of competing terms and theories.
Three new theories will occupy our attention. First, Pierre Janet's "psychas-
thenia." Janet, a student of Charcot in the early 1890s and a founder of modern
depth psychology, completed a medical thesis in 1894 entitled The Mental State of
Hysterics. The year before, in a perceptive and wide-ranging article appearing in the
Archives de Neurologie, Janet had reviewed the latest medical literature on hysteria
from France, Germany, Switzerland, and North America. In both works he empha-
sized that a new type of thinking about hysteria offered important, purely psycho-
logical interpretationsof the disorder.44
Janet's review essay includes what is believed to be the first foreign-language
discussion of the work of Freud and Breuer (misspelled Brener), and historians often
cite the source for that reason. However, toward the close of the essay, as well as
in a number of places in the dissertation, Janet advanced his own ideas regarding
the psychogenesis of hysteria. Specifically, he proposed that the field of the less
acute psychopathologies be divided into two large categories, hysteria and psychas-
thenia. Janet created the idea of psychasthenia essentially by splitting off the mental
phenomena from the diagnoses of Beardian neurastheniaand Charcotianhysteria and
combining them, somewhat arbitrarily,into a single diagnostic entity. Under psych-
asthenia Janet grouped symptoms such as phobias, depressions, and obsessions, fixed
ideas and irrational fears, and impulsive and compulsive behaviors.45
In his writings during the mid 1890s Janet devoted considerable space to clarifying
the nosographical relation between psychasthenia and hysteria. Etiologically, he be-
lieved the two maladies were identical; but he thought that hysteria and psychasthenia
differed symptomatologically in several basic ways. Hysteria manifested the well-
known quasi-neurological signs that had been described by physicians since the sev-
enteenth century, whereas psychasthenia was characterizedby a series of purely psy-
43 Jose Maria L6pez Piniero and Jose Maria Morales Meseguer, Neurosis y psicoterapia: Un estudio
historico (Madrid: Espasa-Calpe, 1970), pp. 259-387; Charles E. Rosenberg, "The Place of George M.
Beard in Nineteenth-Century Psychiatry," Bull. Hist. Med., 1962, 36:245-259; and Bonnie Ellen Blu-
stein, "'A Hollow Square of Psychological Science': American Neurologists and Psychiatrists in Con-
flict," in Madhouses, Mad-Doctors, and Madmen: The Social History of Psychiatry in the Victorian
Era, ed. Andrew Scull (London: Athlone, 1981), pp. 241-270.
"4 Pierre Janet, Etat mental des hysteriques, 2 vols. (Paris: Rueff, 1893-1894), esp. Vol. 1, pp. 258-
301; and Janet, "Quelques definitions recentes de l'hysterie (cit. n. 16).
45 Janet, "Quelques definitions recentes de l'hysterie," pp. 23-29.

chological behaviors. But in clinical reality, Janet acknowledged, the two psycho-
neuroses often developed as parallel disorders: "There are, in my opinion, the closest
relations between the two groups. . . . It is impossible to deny that a very large
number of patients belong simultaneously to both classes." There exists "an essential
analogy" between the two maladies, and "certain symptoms . . . are always com-
mon to the two categories of patients." Thus, Janet creatively coupled the psycho-
logical and neurological symptoms of the two disorders. He paired hysterical attacks
with attacks of anxiety, hysterical anesthesias with episodes of depression, hysterical
paralyses with abulia or loss of will, hysterical contractureswith psychological idees
fixes, and so forth. Toward the close of the essay Janet conceded that in some cases
hysteria and psychasthenia are indistinguishable: "It appears to us impossible, then,
to separate these two disorders completely. We believe that they are very close one
to the other and both form part of a vast class of mental maladies that we propose
to call disorders of psychological dissociation."46
The notion of psychasthenia was short lived. Over the following fifteen years Janet
wrote often about the diagnosis, his most systematic exploration being the two-vol-
ume study Obsessions and Psychasthenia (1903). However, his last published ref-
erence to the idea dates from 1910, and by 1915 he had moved away from clinical
studies in general toward the synthetic philosophical psychology that preoccupied
him for the remainder of his life. After a brief spell of international popularity, the
diagnosis of psychasthenia fell out of favor and was itself absorbed into other di-
agnostic categories.4 For present purposes the psychasthenia concept is important
because it illustrates the fluid clinical and theoretical relations that existed between
the nineteenth-centurynervous disorders and the early twentieth-century psychoneu-
roses.
A second new psychodiagnostic category from this period is Joseph Babinski's
"pithiatism." Pithiatism represents another nosographical novelty that is unfamiliar
to most Anglo-American readers now but was highly influential in its day. During
the 1880s Babinski was one of Charcot's most loyal and brilliant students, and from
1885 to 1887 he served as chef de clinique at the Service Charcot. He was in many
ways a natural heir to the Salpetrian tradition. But Charcot's untimely demise in
1893, during a summer holiday in rural France, created a serious professional di-
lemma for many medical students and young doctors in Paris. The animosities that
had accumulated during Charcot's authoritarianthirty-year rule at the Salpetriere
came to the fore, and the academic and professional empire over which he had pre-
sided began to crumble. Because many former proteges now desired to distance
themselves from the Charcot legacy, the majority of Babinski's peers abandoned
their studies of hysteria and hypnosis after 1893 and turned to other purely somatic
topics of research.48Babinski, too, pursued this path-and others.
During the latter half of the 1890s Babinski wrote scattered and increasingly dis-
approving remarks about hysteria as a diagnosis. Then, in 1901, eight years after
Charcot's death, Babinski, now a neurologist of international eminence, made the
46
Janet, Etat mental des hyste'riques (cit. n. 44), Vol. 2, p. 293; and Janet, "Quelques definitions
recentes de l'hysterie," pp. 23-24, (24 quotation).
47 Pierre Janet, Les obsessions et la psychasthenie, 2 vols. (Paris: Felix Alcan, 1903). The term did
linger in certain French psychiatric texts. See, e.g., Henri Ey, P. Bernard, and C. Brisset, Manuel de
psychiatrie (Paris: Masson, 1960), pp. 419-421.
48 Christopher G. Goetz, "The Salpetriere in the Wake of Charcot's Death," Archives of Neurology,
1988, 45:444-447.

518 MARK S. MICALE
decisive break with his erstwhile mentor. In a short communication delivered to the
Paris Neurological Society in November of that year, Babinski, in the words of
Wilson, "set for himself the laudable aim of reorganizing an unwieldly nosological
conception and of limiting the sphere of its operation." Babinski sought to accom-
plish this by underscoring the diversity and ambiguity of existing meanings of hys-
teria, by narrowing drastically the definition of the disorder, and by renaming this
new, more restricted clinical syndrome pithiatism. He proposed to discard the term
hysteria altogether.49With Babinski, diagnostic delimitation became diagnostic elim-
ination.
Pithiatism, Babinski explained, is a derivative of the Greek words for persuasion
and curable. Babinski had been struck, in his years of hospital work, by the hy-
perimpressionability of the hysterical patient. He became convinced that the hyster-
ical stigmata described at length by Charcot were largely, if not entirely, the products
of self-suggestion, often mediated iatrogenically, and that the appropriatetreatment
was medical countersuggestion: "Hysteria is a psychic condition that renders the
afflicted subject susceptible to autosuggestion. . . . What characterizes the primary
disturbances [of hysteria] is that it is possible to reproduce them by means of sug-
gestion with rigorous exactitude in certain subjects and to make them disappearunder
the exclusive influence of persuasion."50Babinski, then, defined pithiatism as any
class of morbid phenomena that it was possible to reproduce or to cure by suggestion.
His is a psychologized-or perhaps more aptly, deneurologized-hysteria, which
takes a psychotherapeutic potential as its distinguishing feature.
The logical and clinical shortcomings of the theory of pithiatism are obvious to
us today, as indeed they were to many doctors at the time. The historical importance
of the episode rests in the reaction of Babinski's medical colleagues to his proposal.5'
At the 1901 meeting of the Paris Neurological Society Babinski's proposition was
received with the utmost interest and seriousness. Pierre Marie, the distinguished
president of the society, appointed a three-man commission to explore Babinski's
proposals in all their ramifications. The commission deliberated for no fewer than
six and a half years-the longest preparation for a report in the history of the so-
ciety-during which time it canvassed professional opinion across France and ex-
amined patients in hospitals and private practices in the Paris region.
The subject was finally taken up at the meetings of 9 April and 14 May 1908, in
two three-hour morning sessions. In fifty-four pages of small print the Revue Neu-
rologique, the official publication of the society, documented the full proceedings.
We learn from this source that the debate evolved quickly from an evaluation of
pithiatism to "a report on the current status of the hysteria question." A questionnaire
distributed to members of the organization posed eight questions on the existence,
origin, and nature of the major symptom categories that composed "traditionalhys-
teria." Babinski, Marie, Edouard Brissaud, A. J. Souques, Albert Pitres, Alexis
Joffroy, and Henri Meige, all of whom had once been prominent members of the
49 Wilson, "Some Modern French Conceptions of Hysteria" (cit. n. 16), p. 307; see also Joseph
Babinski, "Definition de l'hysterie," Revue Neurologique, 1901, 9:1074-1080. This and six subsequent
essays on pithiatism are conveniently reproduced in Babinski, Oeuvre scientifique (Paris: Masson, 1934),
pp. 455-546.
50
Babinski, "Definition de l'hysterie," 1079, n. 2, p. 1077.
5' This part of the story has been related in Trillat, Histoire de l'hysterie (cit. n. 5), pp. 199-204;
and Roudinesco, Bataille de cent ans (cit. n. 4), Vol. 1, pp. 59-76. See the critique of the concept of
pithiatism in Guillain, Charcot (cit. n. 14), Ch. 14.

Charcot school, were in attendance. Dominated by Babinski, one member of the

group after another took the floor and publicly denied that these classes of symptoms
could be hysterogenic. So-called hysterical convulsions, paralyses, contractures,
hemianesthesias, visual impairments, and all the rest, they claimed, were in fact the
results of organic disease, iatrogenesis, or simulation. Many membersconfessed openly
to what they now regarded as the misdiagnosis of many cases from their earlier
medical practice. The meeting on 14 May dealt with the eighth topic on the ques-
tionnaire: "Faut-il conserver le mot Hysterie?" Everyone present agreed that hysteria
had previously been defined much too elastically. Many found Babinski's theory of
pithiatism problematic, and no consensus was reached on usage of the term. None-
theless, the full membership of the organization, with one exception, agreed offi-
cially to discard hysteria in reference to each of the symptom categories and to re-
strict its application to the new concept of "the hysterical syndromes."52
It was a remarkable moment in the decline of the old diagnosis. Exactly fifteen
years after Charcot's death, the most prestigious professional organization in French
neurology dismantled the Salpetrian model of hysteria, symptom by symptom, in
two days, just as Charcot had constructed it with such care over two decades. In-
cluded in the audience on those spring mornings were many individuals who had
contributedenergetically to the initial fashioning of the diagnosis a generation earlier.
A year later Babinski celebrated his victory in an essay on pithiatism that was tell-
ingly titled "On the Dismemberment of Traditional Hysteria" (see Figure 2). Pre-
vious attacks on the hysteria diagnosis had originated outside of Paris, usually from
abroad. The final collapse of the Charcotian synthesis was engineered within the
Salpetriere itself.53
During the opening decade of this century, the controversy over the comparative
merits of pithiatism and hysteria was largely a French affair. At the same time that
Babinski and his colleagues were squabbling in Paris, a third new theory of hysterical
neurosis was emerging. This theory originated from a very different European capital
and eventually proved at least as controversial, and considerably more consequential,
than pithiatism or psychasthenia. The relationship of the work of Freud to the long
prepsychoanalytic history of hysteria as a whole and to the Salpetrian heritage in
particular is complicated and deserves a full study of its own. Suffice it to say that
in Studies on Hysteria and the "Dora" case (1901), Freud provided well-known clin-
ical representations of the fin-de-siecle hysteric. However, after cultivating the sub-
ject intensely during the first ten years of his psychoanalytic work, Freud abandoned
it after the turn of the century and thereafter returned to the topic only fleetingly.54
52 Proceedings of the Societe de Neurologie de Paris, meetings of 9 Apr. and 14 May 1908, in Rev.
Neurol., 1908, 16:375-404, 494-519, esp. pp. 375, 404, 510-519. The one outspoken opponent of
these decisions was Fulgence Raymond, the successor to Charcot in the Chaire des Maladies du Systeme
Nerveux and a longtime rival of Babinski's.
5 J. Babinski, "Demembrement de l'hysterie traditionnelle: Pithiatisme," Semaine Medicale, 1909,
29:3-8, rpt. in Babinski, Oeuvre scientifique (cit. n. 49), pp. 486-504. The historical irony of these
actions was not lost on everyone in the group. "Fait singulier, et qui ajoute a l'interet de ce debat, les
Neurologistes francais, ceux-la memes qui jadis, collaborateurs de Charcot, avaient edifie a l'Hysterie
un si vaste monument nosographique, ont entrepris spontanement la critique de leurs anciens travaux et
de leurs propres idWes":Henry Meige, "La revision de l'hysterie a la Societe de Neurologie de Paris,"
Pres. MWt., 1908, 54:425.
54 As Trillat writes, "toute la theorie psychanalytique est nee de l'hysterie. Seulement, la mere meurt
apres l'accouchement": Histoire de l'hyste'rie (cit. n. 5), p. 213. On the relationship of Freud's work to
the prepsychoanalytic history of hysteria and to Charcotian theory the best studies to date are, respec-
tively, Ola Andersson, Studies in the Prehistory of Psychoanalysis (Stockholm: Svenska Bokforlaget,
1962), Chs. 2-4; and Jean-Bertrand Pontalis, Entre Freud et Charcot (Paris: Gallimard, 1977).

520 MARK S. MICALE
UNIN NDIAL
Paraissant le Mereredi matiu
TRAVAUJX ORIGINAUJX tud ,n

ilts nunpo te0P oti ot
- t~~~~~~]onea
toutaunmoinssingulilreement exagi-ri paroivesculairedare uoi point proalable-
DAmembrnsmnent thAerts tr.dtlonnnstt cette tooolt6attribut!e0 I'hystlriedoerepro- mnettddtdrior6et coest ce que montre
de1hs
Penthsat.sms. duire les moaladies len plus diveroes, do l'obsorvationn Quaeot lh0nolmuanestho ie,
toutfaire.,ommenooolo edisait jadis.Cest 0t. Bernoieim aeu,ity alongtemopsle mO-
Avantfaitmesonpremiers pas,da~n Slauar- on point d6sormoisacquis, noos i1 me ritedeoutenio-quoelledtaitleplus souvent
IN
ritr;oneurologiqoe, PEcole do la Salpi- sneoble int rnsiant do rechercher les motlifs d'origine suggentive, et jocrois avoir fourni
tri!re, oh joeus lhonneourdOtre do 1W0 quiavaoeoctcondoit4I'ancienneconnoeptioncdo noouveaox argouments teI'ppuide cette
OP chef de cliniqoedeCharcot,je ton, ot doenettre en OC-idence
88te les raisons qui thee; j'ai noontrt- qoo, souivnt la mnoenlre
It nos dObuts,inipr6gno des dies surtIhys- l'ootfoit otbondonner. Soloi emni 1lento)sion doniton proneiditdannr'interrogetoire et
v
t6reoqu'on enseignait 0, cette Opoque'ot exoessiveo quo Phynt6rie
.
a nubieotient 0 trois lonexanon don sujets, on obtenait,on on qui
ces
qui,jusqueaans dorniersntemps, onot 01 cooauses Ioit
PCPl on a ommnnis does conoerne los pr6tendus stigmatets, des
presqueoununimtenoent adnoinen. erreored diagiostilloon consniddrantornnmo rtsoltats tout ddtOooentn ot je pole dire que
Je tes eceis doaborderoeptOresanunnr-hysttiriuentiesaftteotions orcaniquoon: Octo dopoisdoesnooies je rcontrouve plus coies
serror, noeis ultrieuremnoet,trurpp poe amC nouon t'ineportunce do to nupeocoherie,ton hysttdriquen qui n'otit pns 000 prOate-
certanuensconstetationsuaeoenlequet]osoelles ettoot dounesorveillaoresoffinanteno;u blenoonten contuoteavec dot personees ea-
noepaurrentdittlciles 0, conoilier, 0c ton ruttaothth Itll'ysrie donsplitinornonos qui publendo ten avoir nuggestlonnden. It est
amenO 0 dotter do leor enactitude et je noe roeuleaent do l sinuelnation, 30 on, a not- vrui quoon pent objector 0,cola quo t'hOmi-
prposani do nnonoettre dordonavant, snon fondo don SteIn norveun quil doinent lMe anesth6sie seonnitivo-neensorielle,quoellesoil
opottionpreconCue, n nIs in- dnicl e tn e ornt onloo l- oot 0 Io gention, dOnote ndai
reuse tots ten toils pouoontnoepernoettre do nonotrerte\aolitudodo nionopiniionpor noninstonisteice do thlystrie. Cole est
d'encontetterla valeur.Si tes enosutatodo ut-nao~lonenminutieune donfaitn, cll Con- exact, nuiaiit noenentrs noninsn-eelquono
rnes rechoerhesnmonntcondoit iuabatoln- nolountsooootnivernolnt lston ois ca0ses peutaiodniit fatireenaitrees ph6nottednes
tortea doctrinedenoon illuntrenoaltre, ic doerreoo-qoeojeoienndlinurnolroo. chez un trlg-egoednonobredenojets;qu'il
ienonsnnere-pesnooins-je tiennshtledio-e esl nornoeparfiouti\rernoent fecile de ten
- one adnoiratioeprofondopour to grand t- t0ourproucerque don o0oolinnnnoona- d6velopperchez den noeteden,cenqui an
nleurologinte dont tenneonaueo unrihlpntl-- niquennoitoi-Wsouvent connil-d6re oo
omm c omnprei,d doilleurstrdstien:quclonnputt
rio tort inoportants,daitllouos,noolgi-esion it(lnqo. 1 01 i opno or lonesbleauooupdo cas, associer artittciet-
orrcornquolS nysnottgissn-n, oneononitituonteoOenipleo'il-mnipil-cie Non seulemeont jotf- lenoent onie hnnoiannetilnisi nuggestive 06
quoune fbiblepartied'unecouvno inoposante. leome,snoo orlinto Ito conctredit,quo oniehl-noipdgicorgaunique: que cet10hdnoi-
MecsOtudonpoursuiviespendantOttodi- I'ono frl-toqoenonoct rapportl-0 ihyolrie onnetithsieo aordinairententpoursourceren
znoinodeaotnes aoutooirenit onit9ot o nun toooedesca oO~iptl,-fici oo,lcn e, noaisje intrreogatoin- no:lialnoddectueusenoent
conononicution devent taorinoSt do bornr- soulielisqnton d orretton (IC000genreOl-tOlht potq lu01 10n dhiftivei, on raison de
logle, o0 je soutins cetto th&no que hill autrefois in6vitatolles cae ion lotnait 00 tO trclquelloe dos assotniationt hys3 n
anoit rang' dunn iblynti-rie lien trotblesl qui dilutlsititol 00u0u1 n1o101 sf01,(l deisoclier orean iques, to prdsenoce doullo ttl-nianestt0-
iieluioapparteliaient pasetnolil'ndiquuiiles ,
codonc- d o del- prlyscc
spe 1Oil adint- sle dans 011 cue dhdnoipil(gic noen d6ain
biites qu'it fallait, seloi noi, unnigner 0 tait, OInef,tto quo FhiilO1iOOl hysOldbiquO nuleieOnlt le nature.
cette ndroser- Ale mnoti6re do voir a 010 pouvai0 reprotluiro trolliflIllr'ri le11fain010 Contrmirenoeitl 0 on qunouipensait autre-
udoptie pa0O INdM. Dtiloth 1 tubrv, ten en- do Fh(Oniiplt-gio tltbloooro-
norgaiueetqtl- fois, ion curaetbres intrinsbquen de t'hOmi-
tours do tuartiole tyolvbreo done to, tiresen crillooquos trlo quoe 1'i0 d110,0i0t, p10-dr peuv01n1 scum condolrer on din-
deucdnoe dWillon do TooiW Charoot-Btou- to prodneor nou Fatln0bl0 Wi011e Ofettlilil gIlostic prediledi on l'ignorait jadis c'ent
chaerd-Btrinsaud Jr I'ai d6vciopptic (le 000- oartliiqnqc conornitnolltl d'anedenlt% nV- quo, aigulilds nor one fausse vuin, los
ve dans 0~
uneconfdrelloe tailv- to noei'dId pIditiqoits, don preteoluslsbiO nllsnlolonli
le-nti, tee clollnstablcn dalls ttlesqullos
eurologiten 110000810tpats no tio-re
do 1Pilot don rdtfexes tendineux qui (taient
purti
(to l'internat den h6pitaun do tuarin en 11106.
Je aisounotellle encnore allCongr's te neu- io eeo avnitou prisenaisnolcee-taelltileg potlrtatl'onihet d'ulle exploration syst6-
roingle do 10110cr do tO9,. Enlot otto v10i0net o n e0 poerlnettaIt Iil-anlilr le 11i0- niltiquc 01 qittlsnWtcaient pan tolur din-
I,trte dtinoIlt6 eIl ovoil et inail do Fanto gortlosc OIr,000stol onotralie quies latooe- positioll certnins signes objectito que jeal
M50 A to SnolOldedneorologie do elrie, riti-. ico neOseras0pasonobarrase poliO,pr,- dkouverts depols. DIons on prenoier tee-
et j'a no to gloande satintaotion de oi se neter doessujots atteints dilW-noipIl-gioi0- vaultelr cc slIjet pauruen 1893, on uottrieure-
beauoou pdecnorncolldgucs,rentre autres nifetemntnornogaoniqueoqui,oceprndollt,nsottl eitnool inalintesnreprises,doinsndeseomn.
M101. Brinssaod, Duped, ltallet, Souqoen,s en, nnt001 lI d trioll nor- notnicantioIns 00 discussions Itla Socid-td do
hIcigo, panooger noon opinioni d'une noanice dqr,op-onctsopioiqoon,nont, neuologoic,j'ai eoutenu quo Ilivstdrie Otalt
conipt-e nou presque conoplite. Je ppu oo dorl oteS d tnetb sie 10 qll incapable (le noodifner ten rOexese tendi
nodnodirequo,nortenpollntsenseintiels,todla edlsrot oooo elno en cloez nounon quo,per-onnsdquent,'hOnoiplOgie
plupartdennoenbresdo ta Socidtdont 0006 lesqut Ibinoipltgiea 010connsrutive'_ hystdriquepure no s'aceompagnait janais
deccred avee nooi,et quo t'opposition qoli one o
n1t0; inceremenoot, j0a Yu tlOsrue dune oegao"ion don riiexes tendnoneux
i1i0 Wodftite poe certainn d'entre eon noa dItll--nip e hyotOrique oboezden individus Cetto opinion a M1A dnabord vivetnent
port6 que sue don qawtuestions seondaires; Ogootit
g utcin
t 'fetoi adate
udoo,ncc cnbntu, nouispetit 0Lpotlt sos adver-
peut-i-trenodnoe n'a-n-ottoOdquoto consO- nucuntroubledo Ia sensitdtitden tloit to saires snundevenus de noilns on seeing
quence d'un sinoplenoalentendu e1ta-telle panotosie ontavit pan Old pocOdde toe nonobreux e0 it ressort de Ia derni6redis-
tenu &ce quo noes dOes, brid-emnent
expo- quetl4uo l-nototln d'une
Incontestablernoent, cussion ato 0081t1 do neurologiequ'au-
ont dIe innutftononoent
teden, conopriesos poet. to ottedo 'Onoutiondans to genObse doe jourdbhuitons noon coltignen sent dar-
J'esp6requoentls pr6sentantsoonuneautre ancitlentshystdriqucsa00800 n'oios ono- crudavee montAinsi done, dane an eons
face elles 'inoponeront 04tesprit do noes gdredet,douitreport, on,noapan0enu suItl- dbhnoiptO-gie,1tenagdration unitat4rateden
contradictoeurs sammnont ceomplede tInfluence de cot r6ftenestendineus, nymptdnseautrefoin
agent sureid6veloppenoent den nffections gonnudOjO,maInm6cuenodanasa valnnr,
organiques.On aurait pu cependantdire, pernoetd'affiraserquo ruona affairshoune
Tous Insm6decinsreconneissentactuel- a prioni,quola perturbationdo Ia deirote- affection orgpniquedo systbate sermonx
Figure 2. Firstpage of an articleby Joseph Babinski,officiallyannouncingto the French medical

communitythat the traditionalhysteriadiagnosis had been redefined.(FromJoseph Babinski4
"D6membrement de l'hyst6rietraditionnelle:Fithiatisme," Semaine MWdicale,1909, 29:3-8.)
In a simultaneous development that has received much less attention -fromscholars,

the basic theories of psychoanalysis, formulated on the eve of the "disappearance"
of hysteria, introduced a number of theoretical innovations that contributed to the
waning of the diagnosis.
Lik0e Janetand Babinski,Freudcontributedto the progressiveclinical restriction
of the hysteria diagnosis by reordering particular groups of symptoms. During the
mid 1890s, a highly fertile period in his intellectual biography, Freud was investi-
gating the origin and mechanism of neurotic illnesses. In January 1895 he published
an article in the Neurologisches Centralblatt. The essay is rather technical and typ-
ically receives little discussion in standard intellectual histories of psychoanalysis,
but from our perspective here it is a choice document. The essay appeared under the
title "On the Grounds for Detaching a ParticularSyndrome from Neurasthenia under
the Description 'Anxiety Neurosis."'55 Freud argued in this context that the criteria
5 Sigmund Freud, "On the Grounds for Detaching a Particular Syndrome from Neurasthenia under

for the diagnosis of neurasthenia, which had been widely adopted in German and
Austrian medicine, were defined much too broadly. Within the composite province
of neurasthenia, he contended, existed a complex of neurotic symptoms with an
independent etiological determinant. These symptoms also occurred together clini-
cally, and the complex required its own type of treatment. Therefore, Freud sug-
gested, the symptoms should be labeled separately. Freud went on to name the syn-
drome Angstneurose, or "anxiety neurosis," because all of its elements arose from
the symptoms of anxiety. Freud proposed to categorize the anxiety neuroses-along
with neurastheniaand, later, hypochondria-among the "actual neuroses," as he was
soon to call them. He contrasted the anxiety neuroses with the "psychoneuroses of
defense," which included hysteria and obsessional neurosis.
In early Freudian theory the anxiety neuroses had a purely physical, specifically
chemical, etiology. Freud believed that they were the result of the undischarged
accumulation of sexual tension produced by abstinence or unconsummated sexual
excitation. Symptomatologically, Freud's new anxiety neuroses included several rec-
ognizably neurasthenic symptoms, such as irritability, sleeplessness, and gastric dis-
comfort. But to these signs he added a number of pathological phenomena that ac-
cording to the medical theories of the day would almost certainly have been labeled
hysterical. For example, in Freud's view two frequent manifestations of anxiety neu-
rosis were respiratory and cardiac distress. The dizziness, sweating, heart palpita-
tions, and "nervous dyspnea" characterizing an outbreak of anxiety-that is, an anx-
iety attack-read very much like the onset of a mild hysterical fit. In a number of
places Freud made the analogy himself: anxiety attacks, he commented, may cause
paresthesias that are "like the sensations of the hysterical aura." The tremors and
shivering that may accompany an outbreak of anxiety "are only too easily confused
with hysterical attacks."56
In the closing section of the essay Freud addressed the clinical relation of the
anxiety neuroses to their neighboring neurotic disorders. Like Janet, he insisted in
theory on the independence of his new nosographical concept, but he also hastened
to acknowledge the "intimate relations which anxiety neurosis has with hysteria."
In clinical reality, he observed, the two overlapped extensively:
The symptomatology of hysteria and anxiety neurosis show many points in common,
which have not yet been sufficiently considered. The appearance of symptoms either in
a chronic form or in attacks, the paresthesias, grouped like aurae, the hyperesthesias and
pressure-points which are found in certain surrogates of an anxiety attack . . . these and
other features which the two illnesses have in common even allow of a suspicion that
not a little of what is attributedto hysteria might with more justice be put to the account
of anxiety neurosis.
Freud commented further that pure forms of hysteria and anxiety neurosis are rather
rare. In truth, it is the combined forms of the neurosis-the "mixed neuroses," in
which symptoms and etiologies of both disorders are integrated-that are more com-
mon.57
the Description 'Anxiety Neurosis"' (1895), in Freud, Standard Edition, trans. Strachey et al. (cit. n.
6), Vol. 3, pp. 85-115.
56 Ibid., pp. 92-99.
57Ibid., pp. 114-115, 112-113.

522 MARK S. MICALE
The subject of anxiety occupied Freud throughout his life. "On the Grounds for
Detaching a ParticularSyndrome from Neurasthenia" was merely the starting point
for a complex evolution of his views on the origins and psychological functions of
anxiety that would culminate in Inhibitions, Symptoms, and Anxiety (1926) and con-
clude with Chapter 32 of The New Introductory Lectures on Psychoanalysis (1933).
In these later writings Freud abandoned the belief that anxiety is a form of trans-
formed libido and developed a different set of causal ideas. He always retained the
term anxiety neurosis, however, and his symptom picture of the syndrome remained
stable.58Moreover, the idea of the anxiety disorders, unlike the psychasthenic and
pithiatic concepts, thrived in twentieth-century European and American psychiatry.
Freud's modest essay of 1895 beautifully illustrates the process whereby particular
symptoms, or symptomatological subgroups, were peeled away or "detached-ab-
trennen"-from earlier diagnostic categories with little change in clinical content
and then used under different names in making twentieth-centurypsychological med-
icine.
The final step in the process occurred as a result of developments in the nonpsy-
choanalytic mental sciences. In 1915 the American physiologist Walter B. Cannon
published Bodily Changes in Pain, Hunger, Fear, and Rage. Derived from his pi-
oneering work on the physiology of the adrenal medulla, Cannon's book detailed
the direct and powerful influence of certain emotions on vital bodily functions, such
as respiration, digestion, blood circulation, and endocrinological activity.60 Subse-
quent research in the area established the effects of strong emotional states on the
thyroid, parathyroid, and pituitary glands and, through these agencies, on the sym-
pathetic nervous system and then the entire body.
Cannon refrained from applying his findings to psychological medicine, but the
implications of his work were immediately apparent.6' During the next two decades
psychologists, psychiatrists, and psychoanalysts in Germany and the United States
explored the potential long-term pathological effects of these psychophysiological
interactions. The ancient principle that mind and body are interactive was now placed
on a systematic, scientific foundation. By the late 1930s Georg Groddeck, Felix
Deutsch, K. Fahrenkamp, G. R. Heyer, Fritz Mohr, Viktor von Weizsacker, Kurt
Westphal, Franz Alexander, and Gustav von Bergmann, among others, demonstrated
the possible neurotic origins of asthma, dyspepsia, rheumatoid arthritis, abdominal
and duodenal ulcers, arterial hypertension, and certain dermatological maladies. As
a result of this new knowledge of the function of the glands of internal secretion,
many of the disturbances described by Charcot, especially those involving visceral
58 Moreover, Freud subsequently separated from the phobias and anxiety neuroses a further clinical
entity to which he gave the name "anxiety hysteria." Anxiety was its most obvious feature, but it had
a psychological mechanism resembling that of conversion hysteria. See the case history of "Little Hans"
(1909), in Freud, Standard Edition, trans. Strachey et al. (cit. n. 6), Vol. 10, pp. 1 15-117. An account
of Freud's evolving thinking on this subject is available in the editor's introduction to Inhibitions, Symp-
toms, and Anxiety, ibid., Vol. 20, pp. 77-86.
59 Other specialized diagnostic categories were also divorced from hysteria at this time and granted
independent nosological status. Two examples are hysterical anorexia and post-traumatic hysteria.
' Walter B. Cannon, Bodily Changes in Pain, Hunger, Fear, and Rage: An Account of Recent Re-
searches into the Function of Emotional Excitement (New York/London: Appleton, 1915); see also
Cannon, "The Emergency Function of the Adrenal Medulla in Pain and the Major Emotions," American
Journal of Physiology, 1914, 33:356-372.
61 Israel S. Wechsler, "The Psychoneuroses and the Internal Secretions," Neurological Bulletin, 1919,
2:199-208.

and vasomotor hysterical disorders, were explained differently. Similarly, psycho-

genic physical symptoms previously considered to be hysterical conversion symp-
toms that involved the internal vegetative organs under the control of basic biological
functions were now reclassified as psychosomatic reactions.62 In other words, with
the emergence of modern psychosomatic medicine during the second quarterof this
century, many of the common, nondramatic, often monosymptomatic hysterias were
redefined. The primary diagnostic redistribution of hysteria was complete.
ON DIAGNOSTIC DRIFT IN THE HISTORY OF PSYCHIATRY
In the foregoing discussion I have outlined the many ways in which, one after an-
other, elements of earlier hysteria diagnoses were reshuffled and fitted into a new
set of diagnostic pigeonholes in twentieth-century medicine. This is not to suggest,
however, that there exists a direct diagnostic equivalent for every past case labeled
hysterical or a single successor category for each component of the earlier diagnosis.
Rather, the relation between past and present diagnostic theories is complex, shifting,
and approximate, with a significant degree of nosographical slippage between sys-
tems. Furthermore,the diagnoses that have replaced hysteria involve a large number
of mixed and multiple labels-drawn from organic and psychological medicine and
combining neurotic and psychotic symptomatologies-as well as psychoanalytic and
nonpsychoanalytic vocabularies.63
Along similar lines, the intention of this essay is not to establish the scientific
error of past diagnostic practices or to prove the superiority of present-day diagnos-
tics; still less is it literally to rediagnose the historical record by attempting to de-
termine what patients previously diagnosed as hysterical "really had." Likewise, I
offer no argument about the actual rate of occurrence of hysteria in the past or pres-
ent. Whether hysterical disorders are more or less prevalent in our own time than
before is an interesting question for the psychiatric epidemiologist; but insuperable
methodological and epistemological obstacles exist to answering it with any degree
of accuracy and meaning. In contrast, the analytical focus of this essay is on past
medical practices, and especially on the diagnostic behavior of physicians at a par-
ticular historical moment. A century ago, I have tried to show, a unique confluence
of factors in European and North American medicine caused doctors to cease em-
ploying the hysteria diagnosis and to adopt instead a different set of diagnostic terms,
ideas, and practices, which they deemed to be more in accord with the medical
science of a new generation. Cumulatively, these changes produced a full-scale di-
agnostic paradigm exchange.
As stated earlier, I also do not seek to provide a unicausal explanation for the
history of hysteria during the past hundred years. With a phenomenon so complex
and multifaceted, a series of reinforcing factors have almost certainly been at work.
Some of these factors, such as changes in sociosexual mores and in popular psy-
62
Charles Brisset, "Hystdrie et pathologie psychosomatique," Revue du Practicien, 1964, 14:1459-
1470. On the initial separation of psychosomatic from hysterical conversion disorders, by two physicians
involved in the process, see Franz G. Alexander and Sheldon T. Selesnick, The History of Psychiatry:
An Evaluation of Psychiatric Thought and Practice from Prehistoric Times to the Present (New York:
Harper & Row, 1966), Ch. 24.
63 A useful illustration of the disjuncture between past and present diagnostic models may be found
in E. M. R. Critchley and H. E. Cantor, "Charcot'sHysteria Renaissant," Brit. Med. J., 1984, 289:1785-
1788.

524 MARK S. MICALE
chological literacy, have been studied previously. Others remain largely unex-
plored.64 Here I have focused on the intramedical arena, and specifically on the
relatively abstruse factors of nomenclature, nosology, and nosography. This is partly
because this dimension of the story has not been examined before and partly because
I believe that, of the range of factors in operation, this one is the most important in
explaining the pseudo-disappearanceof hysteria. First and foremost, I wish to argue,
the hysteria diagnosis was deconstructed from the inside out because of widespread
changes in the theory and practice of diagnosticians. In general, too little weight has
been given, I believe, to the processes of nosological shift and nosographical drift
as forces in the history of psychiatry and particularly as factors explaining the re-
currentphenomenon of rising and falling nervous disorders. As we have seen, these
processes can create the impression of an entire epidemiological trend. Indeed, they
have the power to hide certain diseases, to create new ones, and to consign existing
ones to oblivion. Nor, it should be added, are these processes limited to the sphere
of psychological medicine.65
Viewed broadly, the major nosographical categories of the mental sciences have
followed several historical patterns of development. Some clinical entities were first
described and labeled in ancient times. They retained a high degree of clinical co-
herence and consistency over the centuries and demonstrate clear continuities in the
diagnostic language used to denote them. This is the case with the melancholia of
classical times, the hypochondriacal melancholia of the early modern period, and
today's depressive disorders. A second clinical group was initially described at a
particularhistorical moment and then translated, although only roughly, into latter-
day diagnostic categories and language. This is probably the historical relation be-
tween eighteenth-century hypochondriasis, nineteenth-centuryneurasthenia, and cer-
tain twentieth-century categories of neurosis. A third pattern of evolution involves
the conversion of a diagnosis of a nervous or mental disorder into an organic model,
as with chlorosis, which is widely held nowadays to have been in most cases a form
of severe iron-deficiency anemia.66 In a fourth pattern, a cluster of physical and
behavioral phenomena that have been described loosely and sporadically receive a
diagnostic designation as a discrete and autonomous clinical syndrome. This applies
to the concepts of manic-depressive psychosis, the phobias, obsessive-compulsive
neuroses, and anorexia nervosa.67 And in a fifth pattern, an entirely new psycho-
Among the likely, less explored factors are the decline of French hereditarian degeneracy theory,
which provided the etiological context for most theories of hysteria during the age of Charcot; the dis-
crediting of the gynecological model within psychological medicine, including the rejection of hysteria
with its lingering etymological connections to female reproductive anatomy and physiology; the scientific
discrediting of hypnosis owing to the popular, sensationalistic excesses associated with hypnotic exper-
imentation on hysterical patients; and the widespread medicolegal abuse of the diagnosis of traumatic
hysteria in cases involving travel- and work-related accidents.
65 For an authoritative statement about their operation in organic medicine see Russell Baker, "Where
Have All the Ulcers Gone?" New York Times Magazine, 16 Aug. 1987, p. 14.
" Stanley W. Jackson, Melancholia and Depression: From Hippocratic Times to Modern Times (New
Haven, Conn./London: Yale Univ. Press, 1986), Pts. 2, 5; Esther Fischer-Homberger, Hypochondrie:
Melancholie bis Neurose: KrankheitenundZustandsbilder(Bern/Stuttgart:Hans Huber, 1970); and Hudson,
"Biography of a Disease" (cit. n. 1).
67 G. E. Berrios, "Obsessional Disorders during the Nineteenth Century: Terminological and Classi-
ficatory Issues," in The Anatomy of Madness: Essays in the History of Psychiatry, ed. W. F. Bynum,
Roy Porter, and Michael Shepherd, 3 vols. (London/New York: Tavistock, 1985), Vol. 1, pp. 166-
187; Paul Errera, "Some Historical Aspects of the Concept, Phobia," Psychiatric Quarterly, 1962, 36:325-

pathological entity, usually of toxic or infectious origin, appears suddenly on the

medical scene. Examples of this phenomenon are lethargic encephalitis in Europe
during and after World War I and the AIDS-related dementia and delirium of the
past fifteen years.
The disease entity hysteria experienced a still different, and considerably more
complex, evolution. "The term hysteria," the French psychiatrist Henri Ey once ob-
served, "is the prototype of a nosographical concept (ailment, syndrome, or symp-
ton) that is undermined in turns by inflation or an equally excessive restriction.,,68
During the final quarter of the nineteenth century the hysteria concept had grown
huge, the most expansive ever in its long, cyclical history. This was especially so
in France, which for a single, glorious generation became the internationalepicenter
of the hysteria industry. An immense structure of symptoms and syndromes, the
diagnosis in France was sustained less on scientific grounds than through the intel-
lectual and professional authority of one man. Almost immediately upon the death
of Charcot, the nineteenth-century pan-diagnosis of hysteria began to break apart
under its own weight, and the many clinical states that it had contained began to
scatter. This dissolution was partly due to physicians' clinical need to reduce the
scope of the diagnosis from its previous overloaded form. This "internal"reason was
powerfully bolstered by a number of "external," sociological forces-chiefly, the
generational drive of Charcot's students to assert their own ideas about the disorder;
the rivalry between French and German physicians to achieve intellectual dominance
within the mental sciences; and the growing competition among neurologists, insti-
tutional psychiatrists, and private-practice psychiatrists to claim explanatory author-
ity over the subject.
All diagnostic categories continually undergo change, but most diagnoses retain
their basic clinical unity or are divided into no more than two or three parts. But
hysteria, which lacked a strong etiological theory to hold it together, was effectively
broken down into its constituent symptomatological parts, which were then reassem-
bled in new combinations and distributed to many other medical categories. With
increases in general medical knowledge and advances in diagnostic techniques, many
cases of hysteria were now believed to involve physical diseases, such as epilepsy,
syphilis, multiple sclerosis, and cranial injury. At the same time that the diagnosis
was losing ground to ascertainably organic ailments, it was being redefined by new
and more nuanced psychiatric classifications. Most importantin this regard were the
psychoses described by Kahlbaum, Hecker, Kraepelin, and Bleuler and a series of
theories about the psychoneuroses, such as Janet's psychasthenia, Babinski's pithia-
tism, and Freud's anxiety neuroses. The large majority of these changes took place
during 1895-1910. Those bits and pieces of the historical hysterias that were not
gathered up and used in the construction of fresh categories were conveyed more or
less intact to the present, where they form the specialized and enormously reduced
usages of the hysteria concept in current-daypsychiatric medicine. In large measure,
it is the process of the atomization of the diagnosis of a century ago and its recon-
336; and P. Lasserre, "Le concept d'anorexie mentale et l'histoire de la pensee psychiatrique," Psy-
chologie Medicale, 1971, 3:607-640.
68 Henri Ey, "Introduction a 1'etude actuelle de 1'hyst6rie (historique et analyse du concept)," Rev.
Prat., 1964, 14:1417-1431, on p. 1417.

526 MARK S. MICALE
stitution in many new places and under a multitude of different names that has cre-
ated the historical illusion of a disappearance of the disorder itself. Yes, as Trillat
observed, the Great Neurosis is now gone; but it has vanished into a hundred places
in the medical textbooks, through a process that can be chronicled in detail with the
standard investigative techniques of the historian.


On The "Disappearance" of Hysteria A Study in The Clinical Deconstruction of A Diagnosis

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On the "Disappearance" of Hysteria: A Study in the Clinical Deconstruction of a Diagnosis

Author(s): Mark S. Micale

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A Study in the Clinical Deconstruction

Rest assured, hysteria is coming along, and one day it will

In reality, the patients have not changed since Charcot; it

We dissect nature along lines laid down by our native lan-

Isis, 1993, 84: 496-526

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(Baltimore: Johns Hopkins Univ. Press, 1990).

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This content downloaded from 195.34.78.244 on Wed, 18 Jun 2014 06:25:15 AM

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No longer do the "circushorses"of the Salpetri&re performbefore visitors as in the

THE HYSTERIA DIAGNOSIS OF THE LATE NINETEENTH CENTURY

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century. A rich textual tradition representing something that may be interpreted as

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ORGANIC MEDICINE: CHANGES IN ETIOLOGICAL THEORY

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P-a- It Pifia& pibpa-d- 2! Pnrod. de ebwndgn. S!PM iXO& p> _ VPoe;0:iietti0i; .0

Charcot as epileptiform hysteria, Gowers as organic epilepsy with a long psycho-

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INSTITUTIONAL PSYCHIATRY AND THE RISE OF GERMAN-LANGUAGE THEORIES

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de la Psychiatrie, 1983, 1:47-58.

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Certain symptoms previously labeled as hysterical-hallucinatory delirium, exalted

It would be difficult to find a more explicit statement.

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THE NEW PSYCHONEUROSES

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system-neurosis in the sense of Gowers, Charcot, and George Beard-but became

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Charcot school, were in attendance. Dominated by Babinski, one member of the

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TRAVAUJX ORIGINAUJX tud ,n

Figure 2. Firstpage of an articleby Joseph Babinski,officiallyannouncingto the French medical

In a simultaneous development that has received much less attention -fromscholars,

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57Ibid., pp. 114-115, 112-113.

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and vasomotor hysterical disorders, were explained differently. Similarly, psycho-

ON DIAGNOSTIC DRIFT IN THE HISTORY OF PSYCHIATRY

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pathological entity, usually of toxic or infectious origin, appears suddenly on the

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