History of ideas Early ideas

The recognition of the relevance of emotion and motive to bodily and mental symptoms is as old as Hippocrates and Galen. (!> King(2) has pointed out that the actual Greek of the Hippocratic writings describes hysterical symptoms only adjectivally, an idea that some modern physicians have also favoured. (3f) The use of hysteria as a noun to label an illness is not apparently known before Cullen. (5) In the nineteenth century the term seems to have been encouraged by the inclusion of the word hysteria (l'hystérie) as a noun by Littré in his French translations of the Greek of Hippocrates. The actual hysterical symptom that is most prominent is hysterike pnix which has been translated as hysterical loss of breath. This loss of breath, sometimes historically called 'suffocation of the mother', reflects the recognition of breathing or choking difficulties in some patients, including the famous 'ball in the throat'. The pattern of symptoms most often recognized seems to have been an obstruction of respiration together with aphonia.(6)

These may be symptoms of anxiety rather than any motivated disorder, and breathing difficulties might also arise during late pregnancy with pressure of the uterus on the abdominal contents and the diaphragm. In early times the term hysteria seems to have been used more broadly than it is today to describe a variety of anxiety and depressive symptoms, mostly in women, that might occur under emotional stress, sometimes with fainting or loss of consciousness.

Later generations came to explain these symptoms as due to possession by demons, particularly if there was fainting. Indeed, by the early modern period rival churchmen vied with each other to show that their own faith could dismiss the evil spirits more effectively. (7) As late as 1603 it was determined by judicial process that witchcraft was the cause of certain physical complaints in young women.(8) In 1697 executions for witchcraft occurred in Salem, Massachusetts, in response to accusations arising from a group of young girls. The executions were performed only after 'spectral evidence', i.e. reports of visions, was accepted as valid in the trials, and hangings ceased only when such evidence was rejected.

It has long been recognized that symptoms like those mentioned can occur without physical cause and appear to be due to emotional problems. The accumulated knowledge was well encapsulated by Sydenham(9) in his 'Discourse on hysteria' when he described the effects of mental trauma on bodily function:

When the Mind is disturb'd by some grevious [sic] Accident, the animal Spirits run into disorderly motions; the Urine appears sometimes limpid, and in great quantity; the sick persons cast off all hope of recovery ... Whatsoever part of the body the disease doth affect (and it affecteth many) immediately, the symptoms that are proper to that part appear; in the Head, the Apoplexy, which ends in a Palsy of one half of the Body, comes presently after Child-bearing; sometimes they are seized with convulsions, that very much resemble the Epilepsy, and are commonly called the Suffocation of the Womb, in which the Belly and Entrails rise upwards towards the Throat; At other times they are miserably tormented with the Hysterical Clavus (nail), in which there is a most vehement pain in the Head, which you may cover with your Thumb, the sick person in the mean time vomiting up green Matter like to that sort of Choler that has its name from Leeks.

In other words if we suffer emotional disturbance as a result of some serious stress (such as personal injury or bereavement), this causes a change in the nervous system which leads in turn to symptoms in different parts of the body according to the underlying pathophysiology. This explanation is extended by Sydenham to the situation of the 'Suffocation of the Womb in which the Belly and Entrails rise upwards towards the throat'. With this firm psychogenesis of hysteria in women he recognized an equivalent illness in men to which he gave the label hypochondriasis.

At that point, near the beginning of the eighteenth century, the diagnosis of hysteria was clearly broad. It overlapped with and had to be separated from hypochondriasis, which was not done very successfully, it mistakenly involved physical conditions like jaundice and oedema, and it included a number of the features of depression and anxiety which we would now distinguish from a diagnosis of conversion or dissociative disorder.

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