Book Review

Approaching Hysteria: Disease and its interpretations

N Engl J Med 1995; 332:1796June 29, 1995

Article

Approaching Hysteria: Disease and its interpretations
By Mark S. Micale. 327 pp. Princeton, N.J., Princeton University Press, 1995. $29.95. ISBN: 0-691-03717-5

Is hysteria a brute fact of nature or is it primarily a social construct? Does the fact that hysteria mainly afflicts women reflect women's biology, or is it a reaction to oppression or some interplay between culture and biology? Approaching Hysteria raises these questions by summarizing an impressive array of studies that place historical accounts of hysteria within social, political, legal, religious, and literary contexts. The book's strength lies in its being an interdisciplinary and comprehensive history that avoids singular or narrow interpretations. On the other hand, its admirable breadth and objectivity come at some cost to original insight.

Unlike traditional historical accounts of disease, Approaching Hysteria examines the history of hysteria from a variety of perspectives and disciplines outside of medicine. Micale first gives a rich and complex historical account of hysteria as a disease entity, including its many contextual influences. He then interprets this history in a way that varies with each contextual framework. Finally, he explores hysteria's cultural history, taking a fascinating look at literary, political, and theological influences at various times and in various cultures. This cross-sectional analysis broadens the relevance of the book to include more physicians than simply those interested in the history of medicine or the topic of hysteria. Approaching Hysteria shows how physicians' interpretations of the symptoms of hysteria inevitably reflect social values and mores. Indeed, it demonstrates that the way we understand and treat any illness — especially mental illness — will be partly a function of our cultural milieu.

The book raises several profound questions for doctors today. How much are physicians' attitudes and assumptions about female patients with ill-defined somatic symptoms shaped by our cultural beliefs? Do multiple personality disorder, chronic fatigue syndrome, and eating disorders represent 20th-century versions of the 19th century's hysteria? Are certain disease classifications, especially ones that are seen primarily in disadvantaged groups, social constructs? According to Kenneth Stampp (The Peculiar Institution: Slavery in the Ante-Bellum South. New York: Vintage Books, 1956), a doctor in antebellum America described a disease in slaves called “drapetomania: the disease causing negroes to run away.” The symptoms included a “sulky and dissatisfied attitude,” and the recommended treatment for patients with refractory disease was “whipping the devil out of them.” To what extent is hysteria, which developed in a sexist culture, analogous to drapetomania?

Micale does not explore these ideas in great depth, but one conclusion he does reach is that hysteria, once an epidemic, is now vanishing as a medical diagnosis. He points out that much of what used to be called hysteria has now been “depathologized,” reclassified, and subsumed in various psychiatric categories, so that earlier descriptions of hysteria are no longer recognizable. But his assertion overstates the case. Although the diagnosis has been subdivided into (among others) conversion disorder, dissociative disorder, somatization disorder, and histrionic personality disorder, it could be argued — especially in the case of conversion disorder — that some core syndrome of hysteria remains intact. Moreover, even though official classifications no longer use the term “hysteria,” doctors still refer to patients as being “hysterical,” or diagnose “conversion hysteria,” “hysterical paralysis,” and so on. More important, beyond hysteria's informal linguistic persistence there continue to be many patients with dramatic, nonepileptic convulsions, not unlike the grand hysterics of Charcot's time. Paralleling the increase in historical studies of hysteria since the 1980s is the increase in the number of hospital epilepsy-monitoring units, whose staffs are able to sort out true epilepsy from its imitators. About one third of the patients admitted to these units are ultimately given the diagnosis of “pseudoseizures” — or, to give them another name, hysteria. Psychiatrists and neurologists have shown renewed interest in studying the causes and treatment of “hysteroepilepsy,” which at present remains ill-defined.

Whether or not hysteria is a thing of the past, however, Approaching Hysteria is a worthwhile and enjoyable read for the present. It will have obvious appeal to anyone interested in the history of medicine and will fascinate those who want to add nuance and insight to their current understanding of hysteria.

Cynthia Stonnington, M.D.
St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013