Many conditions with which psychiatrists have to deal demand a certain broadening of the traditional conception of disease - that of some morbid material or influence engrafted upon the organism. Among such conditions are mental deficiency and constitutional psychopathic states. Among them also is hysteria, which, far from being a disease in the traditional sense, is essentially mere simulation or assumption of disease or disability without organic basis - a special type of anomalous behavior.
. The manifestations of hysteria are varied, the only limit to their variation being the limit of the ability to produce them by an effort of the will (conscious or unconscious). Accordingly such manifestations as elevation of temperature, muscular atrophy, abolition of knee jerks or pupillary reflexes, heart murmurs, etc., do not occur in uncomplicated hysteria.
It would, therefore, be to no purpose to describe the clinical manifestations of hysteria. Some may be mentioned, however, as being among the most common: convulsions, tremors, paralyses, contractures, areas of hypo-sesthesia or anaesthesia, mutism, aphonia, deafness, amaurosis, amnesia, psychotic episodes, etc.
In ordinary times hysteria is seen more frequently in women than in men; but during the World War of 1914-1918 a great many cases occurred in soldiers and there was an unprecedented opportunity of observing them under conditions which forced into view their underlying psychic mechanism. These cases correspond perhaps most closely to the traumatic hysteria of peace times; but it is probable that they do not differ essentially from ordinary hysteria occurring independently of trauma.
The following presentation is based mainly on war experiences. A brief restatement, however, of pre-war current conceptions will be given first.
Charcot's conception of hysteria was that of a disease entity. This led to a preoccupation with symptomatology, differential diagnosis, clinical definition, and largely remained on a descriptive level.
Mobius saw in hysteria not a disease entity, but a biological trait characterized by a special type of reaction. "For him every one was more or less hysterical. Every one has hysterical small coin in the bank of his personality." 1
Janet's contribution consists essentially in the theory of subconscious mental processes. An idea or a group of ideas may operate somewhere beneath the threshold of consciousness, i.e., without the subject being clearly or at all aware of them; and they may operate so effectively as to largely control the conduct of the subject.2
Further progress in the analysis of hysterical mechanisms is due to Freud.3 He attempts an explanation of the phenomenon of splitting or doubling of personality to which Janet had called attention. Ideas or complexes of ideas are lodged in the region of the subconscious not at random but by a purposeful functional process, which he terms repression, by reason of being charged with painful affect. The important part played by affect in the etiology of hysteria had long been sensed and had been in particular insisted on by Binswanger. Freud's experience has led him, moreover, to assume the universality of a sexual origin of the repressed complexes underlying hysterical manifestations.
1 Smith E. Jelliffe. Hysteria. In Modern Medicine. Edited by Osier and McCrae, Vol. V.
2 P. Janet. The Mental State of Hystericals. English translation by Caroline R. Corson. New York, 1901.
3 S. Freud. Selected Papers on Hysteria. English translation by A. A. Brill.
"The final principle of the Breuer-Freud hypothesis is the principle of conversion. The strangulated affect, the unreacted-to emotion, belonging to the disassociated state which has been repressed, finds its way into bodily innervation, thus producing the motor phenomena of hysteria. In this way the strong idea is weakened by being robbed of its affect - the real object of conversion." 1
In one respect Freud's conception is comparable to the older one of Mobius, for Freud, too, does not regard hysteria as a sharply defined disease entity, but rather as an exaggerated condition of a mechanism which in lesser degrees is operative in normal minds.
There remains to be mentioned the contribution of Babinski2 which has largely dominated the French and some other schools not only in pre-war years, but even through the war, having apparently survived the light of the great mass of, newly added experiences.
The essence of Babinski's contribution consists in an attempt to isolate from the heterogeneous material traditionally thrown together under the heading of hysteria the elements of which it is composed. An application of more careful diagnostic technique has enabled him to eliminate, to begin with, organic cases; further he would eliminate emotional disorders and reflex disorders, leaving a more restricted hysteria to which he has applied his newly coined term pithiatism. For him hysteria, in this restricted sense, consists in manifestations which are brought into existence by the influence of suggestion and the cure of which takes place by persuasion; the characteristic feature of the hysterical personality is abnormal suggestibility.
1 W. A. White. Current Conceptions of Hysteria. Interstate Med. Journ., Jan., 1910.
2Babinski. Demembrement de Vhysterie traditionelle. Pithiatism,e. Semaine medicale, Jan. 6, 1909. - Babinski and Froment. Hysierie, pithiatisme et troubles reflexes. Paris, 1916.
Perhaps the most significant point insisted on by Babin-ski is the necessity for distinguishing true hysteria from simulation, especially where the latter manifests itself in characteristically hysterical phenomena - paralyses, contractures, anaesthesia, etc. The result of treatment by persuasion here becomes the basis of the differentiation: if persuasion fails to cure the case is not hysteria but simulation.