HISTORICAL MILESTONES

The term hysteria comes from the Greek hystera (womb, uterus), and from this emerged the “gynecological” explanation for mood and behavioral abnormalities linked to an ample range of dysfunctions, including psychiatric and neurological ones, that endured for more than two thousand years¹.

Beginning in ancient Egypt and Greece, the idea of a womb wandering throughout the body, as the cause of hysteria, was in vogue¹. The charge was credited to semen or blood upholding in the uterus, given that the humors could decay and the resulting distended uterus would be injured by toxic products or by pressure². However, Claudius Galenus [Galen] (129-199/217), considered that this nomadism was unrealistic. Galen's views were held until the end of the Humor Theory: the disease was caused by the humoral imbalance of blood, phlegm, yellow bile, and black bile. During the Middle Ages hysteria was supposed to be due to diabolical possession and witchcraft. Edward Jorden (1603) regarded the women accused of witchcraft as having a medical condition called “suffocation of the mother” (mother as the uterus). He used the ancient doctrine of “sympathy” to suggest that the womb could affect organs such as the brain, heart and liver^1,3. The doctrine of sympathy was the earliest attempt to explain “action at distance” of humors or vapors. The nervous system, came to be acknowledged as the main mediator of the “action at distance”, by the end of the 17^th century³. At the time, one of the theories against Galen's views emerged, mainly based on those of Thomas Willis (1621-1675), the eminent theoretician, and Thomas Sydenham (1624-1689), the famous clinician. The proposed thesis was that the seat of hysteria would be the nervous system, where animal spirits were supposed to circulate¹. Sydenham reinforced the idea that hysteria was not a uterine disease, and could be seen as a frequent manifestation³. Concepts of nervous disorders came into regular use in Britain, after Cheyne's book, “The English Malady” or a “Treatise of Nervous Diseases” (1733), was published. In France and Britain, these ideas provided the basis for a whole “nervous culture” in a self ascribed “refined, sensitive, and civilized society”. Subsequently, William Cullen (1712-1790) coined the term “neurosis” or “nervous disease”, which included several disorders, among them the “Spasmi” (as epilepsy, chorea, hysteria)³. The 1800s brought an increase of theories about hysteria, including the “uterine neurosis”, with the organ indirectly linked to the central nervous system, or the “encephalopathic” hysteria, primarily starting in the brain⁴. Later, Moritz Romberg (1840-1946) explained hysteria as a reflex neurosis caused by the irritation of the genital organs that could promote convulsions, paralysis, and the hysterical bolus².

SALPÊTRIÈRE HYSTERIA ERA

The 19^th century gave rise to the French medical supremacy, with the study of hysteria in hospital setting, replacing the English one of the previous century. The French School detained the anatomical-clinical characterization of diseases, taking advantage of the rich experience acquired from the crowded Parisian hospitals.

Female patients with episodical behaviors, such as epileptics and hysterics, were gathered in the same building, in La Salpêtrière, what favored Jean-Martin Charcot (1825-1893) to develop his views about both disorders. However, hysteria continued to be a puzzle ready to unleash exhaustive studies led by Charcot, since his first insights on the theme, at the time he got his Service, until his death (1862-1893). As a precursor, Charcot had Pierre Briquet (1796-1881), who regarded hysteria as an encephalic neurosis caused by the action of a variety of unpleasant environmental events in the brain of susceptible and predisposed individuals^4,5,6. Besides Briquet, other predecessors in the study of this disorder, in the second half of the 19^th century, such as Charles Laségue and Russell Reynolds, should be mentioned. Charcot's main scientific interest was devoted to describing and understanding the mechanisms of hysteria, emphasizing a hereditary predisposition, and the presence of a provocative agent, besides the influence of strong moral feelings and psychological trauma^5,6,7. He also recognized a combination of organic and hysterical manifestations, and consequently brain pathologies could favor it⁶. Charcot's writings show an awareness of the relation between hysteria and emotional disorders, and a hereditary dynamic “physical lesion” confined in the brain, and precipitated by a trauma. Charcot would further boost his concept of hysteria as an organic brain disease due to a “functional” disorder of the cortex, as he was unable to find over there any microscopic abnormalities. He coined the term “dynamic lesions", a neurophysiologic alteration anatomically not discernible, which could produce a marked behavioral change⁶. Such belief, which could not be subjected to experimental evidence at his time, became apparent and possible with the advent of functional neuroimaging. Charcot emphasized also his discovery of “hysterogenic points”, zones of hypersensitivity, which, when fingered, could provoke an attack, and that could be reversed by ovary compression^5,6,7,8. Charcot created at the Salpêtrière (1890) a laboratory of clinical psychology. At this stage he believed that a nervous system lesion was responsible both for somatic and psychic hysteria components⁷. Charcot claimed to have isolated hysteria as a distinctive and universal disorder, and this assertion was partly based on the “grande attaque”⁹. It must be acknowledged that Charcot performed his work in the Parisian Belle Époque, prone to artistic revolutions and theatricality. Charcot's understanding hysteria as a neurological disease attracted criticisms, as well as the methodology he used was not accurate enough, at the time, to unveil the basis of hysteria. Nevertheless, this model was the first one used by him. Later, he adapted his research strategies for the production of hysterical symptoms by introducing a psychological explanation, as he assumed that the patient had forgotten a particular body function. This involves a modern conception that an idea of a movement precedes it, and in the same way, it might be a sort of “paralysis depending on an idea”, a Russell Reynolds's concept based on traumatic neurosis (1869)^6,7. Charcot understood that the paralysis was not imaginary (unreal), but due to the imagination (thoughts)⁷. Charcot accepted also hysteria in men, in the same way as Galen, Willis, Sydenham and Briquet, before him^5,6,7,8,9, and recognized that hysterical tremors were more common among them⁵. Paul Richer and Gilles de La Tourette were among Charcot's associates who most shared his ideas, as can be seen from the published works on this subject (Figures 1 and 2, Box 1 and 2). Finally, it is remarkable that Charcot's neurogenic conception on hysteria reappeared, conducting to a psychobiological model of this condition founded on varied types of neuroimaging studies.

Figure 1 (A) The 1887 famous painting by André Brouillet (1857-1914) (a detail) shows in the first plain, Charcot and Babinski (Chacot's chefe de clinique – 1885-1887), besides Blanche Wittman (the woman fainting in Babinski's arms during Charcot's lecture) and Marguerite Bottard (Charcot’s chief nurse)⁷. Charcot had as hysteria study's co-authors, besides his team (mainly Pitres, Richer, Gilles de la Tourette, Sollier, Babinski, and later, Janet), the active co-participation and collaboration of some patients. Babinski later denounced the theatrical and artificial spectacle that for him created a simulated Clinique⁷; (B) However, Paul Richer (Les démoniaques dans l'art )⁹; and (C) Gilles de la Tourette (Traité clinique et thérapeutique de l'hystérie d'après l'enseignement de la Salpêtrière)⁵ were faithful allies of Charcot's ideas on hysteria. 

Figure 2 The persons with epilepsy offered a profusion of artistic material for the Salpêtrière studies on hysteria, as can be seen in two publications with Charcot’s participation: the Iconographie Photographique de la Salpêtrière (1877)¹⁰ and Les Demoniaques dans L'Art (1887)⁹. The Iconographie Photographique de la Salpêtrière was a key element in the Parisian Hysteria approach^8,10. Charcot's disciples, mainly Bourneville, who arranged for the publication of Charcot's works, produced several of its volumes. In Les Demoniaques dans L'Art, Richer and Charcot pursuits all forms of works of art to exemplify the syndrome of hysteria and its various bodily expressions. The last chapter includes a detailed text description and pictorial representation of the four stages of hysteria of the great epileptic attack. The patients allegedly evolve through these stages, the second one includes the arc-en-cercle, the most well known⁹: 1^st epileptic period (“… it is necessary to divide it into three phases: the tonic phase, the clonic phase, and the resolution phase”); 2^nd clownistic period (“It consists of two distinct orders of phenomena: the great contortions and movements by different processes meet the same principle dominant throughout this period and seeking the same result, that an overstated amount of muscle strength”); 3^rd passionate attitude period (“Hallucination obviously chairs this third period”); 4^th terminal period (“After a period of passionate attitudes or plastic poses, one might say, strictly speaking, the attack is over. Knowledge is back, but only in part, and for a while the patient remains in the grip of a delusion whose character varies; it is intersected by hallucinations and sometimes accompanied by some movement disorders”).