Today symptoms of what Freud described as hysteria may manifest as or somatoform disorders

Hysteria is one of the oldest concepts in medicine, but since the 1950s it has become increasingly muddled, ambiguous, and discredited, and no longer appears in the nomenclatures of either the American Psychiatric Association's Diagnostic and Statistical Manual or the International Classification. The term hysteria comes from the Greek word hystera for womb, reflecting the belief of ancient Egyptian physicians that the phenomena of the disease were due to ‘wandering of the womb.’ Hippocrates and Galen both accepted this assumption and until the late nineteenth century hysteria remained a disease of women and of the body (generally the nervous system). The idea that it was a purely psychological disorder dates from Breuer and Freud's Studies on Hysteria in 1896, which led to the psychoanalytic concept of hysteria—the dominant explanatory theory for the next 60 years. The demise of hysteria was due primarily to the fact that the term came to be used in a variety of ways that were only tenuously related: (a) neurological conversion symptoms; (b) psychophysiological reactions—a wider concept of conversion including pain and visceral symptoms; (c) dissociative reactions—fugues and amnesic episodes assumed, after Janet, to be based on dissociation of consciousness; (d) outbreaks of mass, or epidemic, hysteria; (e) Briquet's syndrome—multiple, unexplained, somatic symptoms and persistent invalid behavior; (f) anxiety hysteria—an obsolete psychoanalytic term for phobic anxiety; and (g) a personality type assumed to be particularly susceptible to develop hysterical symptoms. Contemporary understanding of hysterical behavior has been influenced strongly by the sociological concepts of the ‘sick role’ and ‘illness behavior’ and by learning theory, and attempts to reduce both the attractions of the sick role and influences discouraging healthy behavior now have a central role in management. This conceptual model explains the distribution of hysterical behaviors in populations, including the predominance in young women, and many other clinical observations, but it fails to account either for neurological conversion symptoms or for fugues and other dissociative phenomena.

Current Concepts

In the 20th century, the number of classic cases of hysteria decreased dramatically and mysteriously. Technological advances in medicine may have partly contributed to their decline since many cases of hysteria were eventually explained by medical or neurological disorders. However, much remains to be understood. Recent decades have seen the rise of “fashionable diagnoses,” such as multiple chemical sensitivities, fibromyalgia, and chronic fatigue syndrome. Modern American psychiatric nosology no longer uses the term hysteria. Instead, the condition has evolved into several new categories representing a heterogeneous group of disorders. Hysteria was initially classified as conversion hysteria or dissociative hysteria in an attempt to separate its physical and mental manifestations. The first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-I), published in 1952, created the corresponding categories of conversion reaction and dissociative reaction. The latest edition, DSM-IV, recognizes two broad separate groups of disorders, somatoform disorders and dissociative disorders, even though the mechanism of dissociation may actually underlie the production of somatoform disorders as well.

The somatoform disorders are a group of heterogeneous disorders manifested by physical symptoms that are not intentionally produced and that suggest the presence of a underlying medical condition. However, the symptoms are not fully explained by such a condition or by the effects of a substance or another mental disorder. This group of disorders includes somatization disorder, hypochondriasis, and conversion disorder. Patients with somatization disorder have a chronic history of multiple medically unexplained symptoms, such as pain in various locations, nausea, diarrhea, weakness, and double vision. Patients with hypochondriasis are convinced they have or are terrified of developing a serious disease, such as cancer, despite normal results from medical evaluations and frequent reassurance. In conversion disorder, sensory or motor abnormalities do not follow the anatomical distribution of the nervous system and may be reinforced by attention received from others. However, it is important to keep in mind that a high percentage of patients initially diagnosed with conversion disorder go on to develop actual neurological disorders that were previously unrecognized. Of note, conversion symptoms also occur in persons with known neurological disorders, such as pseudoseizures in patients with epilepsy.

The dissociative disorders are a group of conditions that are produced by the mechanism of dissociation, or exclusion of mental contents from conscious awareness, and include disturbances of memory, consciousness, and personal identity. These pathological experiences go beyond what normal individuals may experience when distracted or when performing learned tasks in an automatic fashion, such as driving without paying focused attention to the familiar road. The dissociative disorders include dissociative amnesia, dissociative fugue, and dissociative identity disorder. Of note, the latest revision of the International Classification of Diseases (ICD-10) categorized conversion disorder as one of the dissociative disorders.

Another disorder that also derives from earlier descriptions of hysteria is histrionic personality disorder, formerly called hysterical personality, which is grouped under the separate category of personality disorders. Persons with histrionic personality disorder are dramatic and flamboyant, seek to be the center of attention, may be sexually seductive, and often express emotion with inappropriate exaggeration, at times appearing insincere. These shallow displays of emotion in fact hide an underlying difficulty in forming meaningful, lasting relationships. Histrionic personality disorder is also associated with somatization disorder and conversion disorder.

The somatoform disorders have a wide range of proposed etiological factors, including increased autonomic arousal under stress, abnormal relations between the brain hemispheres, possible genetic factors, coexisting depression or anxiety, emotional trauma in childhood or later in life, learned behavior from early exposure to parental illness behavior, unconscious conflict, sociocultural factors, and external reinforcers. The dissociative disorders may be caused by a combination of emotional trauma and a predisposition to dissociation. Clusters of cases of dissociative identity disorder, formerly called multiple personality disorder, may have been partly due to heightened publicity of the disorder. Histrionic personality disorder may result from constitutional makeup and possibly early experiences with caregivers.

Treatment of the somatoform disorders includes cognitive behavioral therapy, relaxation techniques, biofeedback, physical therapy, a steady relationship between the primary care physician and the patient that focuses on managing the symptoms instead of a total cure, regular follow-up visits with the physician to provide reassurance, avoidance of potentially harmful and unnecessary medical tests, and judicious use of antidepressant medications. Treatment of dissociative disorders and histrionic personality disorders generally involves extended psychotherapy.

Finally, the term hysteria has also been used to refer to epidemic or mass hysteria, currently termed mass psychogenic illness. This illness refers to a variety of symptoms that simulate physical illness but that occur in several persons at the same time. Symptoms may include headache, dizziness, fainting, and hyperventilation and usually occur in persons who believe that they were exposed to an environmental toxin in a particular place, such as a school or town, or who have witnessed symptoms in other people exposed to such a toxin. Epidemic hysteria appears to be a social phenomenon that occurs in psychologically healthy people. Symptoms are usually short lived, although in some cases they may become chronic.

Historical Changes in the Meaning of Hysteria

The word hysteria is familiar to most clinicians and lay people, but is elusive in definition. It is no longer used in psychiatric or psychological nomenclature, but, surprisingly, it was once the cornerstone of modern psychiatry. Several scholars of the history of psychiatry have proposed that the epidemic of hysteria afflicting American and British women in the late nineteenth and early twentieth centuries spawned the field of psychoanalysis. However, the disorder has now virtually disappeared. Furthermore, the term hysteria, once the focus of intensive treatment efforts and research, can scarcely be found in modern mainstream psychiatric literature.

The symptoms of hysteria can be found as early as 1900 BC in the Egyptian papyri (the actual word hysteria is derived from hystera, Greek for uterus). In both Egyptian and Greek writings, this multisymptom complex described in women was thought to be caused by a wandering uterus. Treatments were directed at coaxing the uterus to return to the pelvis and keeping it there once it returned. Assuming that sexual intercourse and childbirth would keep the uterus from moving, the most common prescription was for marriage and coitus.

Subsequent centuries brought changes in the definition and hypothesized etiology of hysteria. The definition became quite broad, referring to nearly any symptom of disease that was found more often in women than in men. Etiological explanations continued to focus on uterine pathology but also included causes such as satanic possession.

The nineteenth century brought a dramatic increase in the incidence of hysteria, although it is not clear why this happened. Treatments continued to focus on the uterus and newly discovered ovaries. The cauterization of the cervix, leeches applied to the cervix and vagina, and the removal of the ovaries were all common treatments that were only moderately successful. In the late nineteenth century, however, hypnosis was discovered to be useful for curing some symptoms of hysteria, such as the paralysis described earlier in S.M. Janet, Freud, and others believed that the mechanism of this cure was that hypnosis allowed the therapist, and then later the patient, to gain access to repressed feelings. In exploring these hidden feelings, buried conflicts could be resolved and the symptoms would disappear. The use of hypnosis diminished as Freud developed the technique of free association with interpretation by the analyst. This technique became the hallmark of psychoanalysis and was eventually used for many psychiatric disorders.

The Diagnostic and Statistical Manual 4th edn. (DSM-IV) has reclassified hysteria into two other disorders in the somatoform disorders category: conversion disorder (CD) and somatization disorder (SD). CD is a psychiatric syndrome characterized by disturbances of bodily functions (e.g., blindness, hearing loss, paralysis, and lack of sensation) that do not correspond to known pathophysiological mechanisms. SD is a psychiatric disorder in which the patient has many different somatic complaints but no underlying medical problem can be identified.

As with hysteria, these disorders are more common in women. However, we now know from clinical and research data on combat and natural disasters that men may also present with unusual physical symptoms that do not have medical explanations. The primary risk factor for both disorders in men and women is trauma or extremely stressful events over which the patient has no control. The trauma may be acute, as in the case of S.M. or exposure to battle, or chronic and repressed, as in the case of G.H., who had been the victim of repeated sexual abuse. She had remained asymptomatic until her first sexual relationship reawakened bodily sensations associated with a time of great stress earlier in her life.

Overwhelming stress in the context of helplessness seems to be the key feature of situations that produce SD or CD. However, studies of the function of either the sympathoadrenal or hypothalamic-pituitary-adrenal (HPA) axis components of the stress-response system have not demonstrated consistent abnormalities. It does appear that patient with SD are more subjectively sensitive to pain, with greater stress-response system reactivity. The multiple illnesses in SD may be due to a sensitization of the brain cytokine system by past adverse experiences such that it responds with a sickness pattern to a lower threshold of stress than is usually required in other people.

Hysteria and psychologic influences: the role of suggestion

To study hysteria in an experimental setting, Charcot invoked two previously highlighted observations: first, the close temporal link between hysteric signs and an event involving emotional stress or minor physical trauma; and, second, the facility by which physicians could hypnotize hysteric patients. Whereas the emotional stresses recounted by hysterics were of a wide variety and included fear, abandonment, and intense passion, cases involving minor trauma were more homogeneous and became a particularly rich resource for study. Charcot was a consulting physician for the national railroad company and hence evaluated a large number of patients who endured injuries in the context of their work. Though there were many serious injuries, Charcot was impressed with the number of neurologic cases seen after seemingly inconsequential physical trauma (Charcot, 1887c). The neurologic signs among these latter railway workers included weakness, anesthesia, or spasms that fit best into the category of hysteria (Micale, 1995). Charcot dispelled the historic bias that hysteria occurred only in women and effeminate young men. Discussing this point in his classroom of predominantly male doctors, he stated:

Male hysteria is not at all rare, and just among us, if I can judge from what I see each day, these cases are often unrecognized by even distinguished doctors. One can concede that a young and effeminate man might develop hysterical findings after experiencing significant stress, sorrow or deep emotions. But that a strong and vital workman, for instance, a railway engineer, fully integrated into the society and never prone to emotional instability before, should become hysteric – just as a woman might – this seems to be beyond imagination. And yet, it is a fact – one that we must get used to. Such was the case with so many other ideas today so universally accepted because they are founded on demonstrable evidence; but for so long, they met only skepticism and sarcasm – it is only a matter of time (Charcot, 1887d, French, p. 255; English, p. 222).

Basing his diagnosis on the criteria for hysteria outlined above, Charcot considered the medical literature from England where railway accidents were of particular public and medical concern. He discovered the writings of the Englishman, J. Russell Reynolds (1826–1896), specifically his 1869 article, titled, “Certain forms of paralysis depending on idea” (Reynolds, 1869). With this foundation, Charcot considered whether emotional stress or a minor traumatic event could provoke focal neurophysiologic alterations in the brain of predisposed hysterics, with resultant neurologic impairments. Repeated thoughts of the original inducing event could somehow unleash the same physiologic dysfunction that, repetitively, in Charcot's words, “for want of a better term, we designate dynamic or functional lesions (Charcot, 1887b, French, p. 319; English, p. 278).” Charcot's terminology for this latter construct was autosuggestion. Charcot's perspective, however, remained always founded in neuroanatomy:

I have lightly struck the man's shoulder. In his case, as with any particularly predisposed neurologic subject, this minor trauma, this focal jolt, is sufficient to induce throughout his entire arm, a feeling of numbness and heaviness, the essence of paralysis; by the means of autosuggestion, this trace paralysis rapidly becomes complete. It is within the center controlling psychological processes, by that I mean within the cerebral hemispheres, that the phenomenon clearly is taking place (Charcot, 1888d, no page numbering).

In parallel with these ideas of autosuggestion, Charcot had begun work on hypnotism at the Salpêtrière. He was impressed that hysterics were easily hypnotized and, during a trance, the physician could induce or dissipate hysteric signs by suggestion. This construct integrated well with the observations of autosuggestion and led Charcot to propose that suggestion, whether internally or externally generated, must play a pivotal role as an agent provocateur for the unleashing of the dynamic, physiologic lesions underlying typical hysteric symptoms. Whereas the original provoking forces may have been external in the form of stress or trauma, the physician-induced suggestion could rekindle the same neurologic events in the experimental setting of hypnosis. As such, autosuggestion accounted for the spontaneous and self-perpetuating spells that caused the patient's neurologic disability (Charcot, 1887e). In the view of the Salpêtrière school, hysteria and a proclivity to hypnosis thereby became interchangeable. The Charcot classroom and hospital ward served increasingly as an experimental human laboratory, where repeated hypnotic inductions allowed Charcot and his students to study the gamut of hysteric signs and their phases of development as well as resolution (Goetz et al., 1995).

Charcot's work with hypnotism brought him both fame and condemnation (Goetz, 2006). Many neurologists of the day dispelled these demonstrations as theatric maneuvers of no scientific value, and considered the exotic disorders seen at the Salpêtrière to be too frequent and too unusual to be independent of Charcot's own charisma. Disputes occurred over the requisite link between hysteria and hypnotism. Throughout this late period, covering the end of the 1880s up to his death in 1893, Charcot found his work on hysteria eroding on all fronts from the unquestioned acceptance of dynamic nervous system lesions to the categoric hereditary etiology of neurologic disorders, the role of autosuggestion to hysteria, and the pathognomonic hypnosis–hysteria link (Widlocher and Dantchev, 1994).

In the final years of Charcot's life, he produced very limited writing to clarify his final stand on hysteria as a neurologic entity, but the few documents that do exist suggest considerable self-questioning and the recognition of the need to reformulate his thinking (Goetz, 2003) After Charcot's death, his assistant Georges Guinon wrote a reflective essay, titled “Charcot intime,” describing his last meeting with Charcot (Guinon, 1925). Guinon recounted that Charcot specifically discussed hysteria and considered his original concept obsolete and in need of full revision. Guinon provided no indication of the type of revamping needed, but his text clearly indicates that the topic of hysteria remained of intense interest to Charcot and that new work was envisioned. The only comment directly written by Charcot comes from a very brief preface written to introduce a monograph by his colleague, Janet (Charcot, 1892). Here, Charcot alludes to a pivotally new idea, but he presents it casually, as if readers could find extensive documentation elsewhere in his writings:

These works confirm a point of view that I have oftentimes expressed – which is that hysteria is for the most part a mental illness. This particular aspect of the disorder should not be neglected, if one wants to understand and treat hysteria (Charcot, 1892, p. iii).

Within Charcot's extensive publications and formal texts on hysteria, no other statement ascribes a predominant role of mental or psychiatric causation to hysteria. Even though a number of Charcot's later lectures on hysteria approached topics that could be considered in the realm of mental disorders, double personalities, and very unusual forms of amnesias, he emphatically retained his neuroanatomic perspective (Gelfand, 1993). As a group, although the collective evidence suggests that Charcot may have been moving towards ideas that would today be considered closely linked to a true psychogenic cause of neurologic signs, his actual writings do not establish a solid argument for any fundamental change in Charcot's thinking on hysteria.

Conclusions

The history of hysteria is long, complicated, fluctuating, and central to the history of medicine and neuropsychiatry, especially epilepsy. Patients with medically unexplained syndromes have been recognized in many different cultures for up to 4000 years, and the term hysteria has been used with various meanings to describe many such patients for approximately 2500 years. In the last 500 years the focus has gradually shifted, firstly, from uterine theories in females to brain and mind explanations in males and females; and, more recently, from theoretic concepts to a greater emphasis on detailed clinical descriptions, especially neurologic and psychologic, as illustrated in this Handbook.

The history of hysteria provides a perspective of medical practice and social commentary over many centuries. It has appeal and relevance well beyond the field of clinical medicine to psychology, sociology, history, and literature. It is intimately linked to concepts of causality involving cerebral anatomy and physiology, personality, deception, unconscious forces, social influences, and continuing attempts to understand brain–mind relationships. No agreed definition of hysteria has ever been possible and its meaning has changed with historic epochs. It has probably always been with us. Some view it as a snare and a delusion (Slater, 1965). Others point out that it has always outlived its obituarists (Lewis, 1975). We can agree with Kinnier Wilson (1919), a century ago, that hysteria remains in a state of flux.

Introduction

Apparent similarities between hysteria and hypnosis have been noted from the 19th century onwards. In particular, the process of suggestion has been viewed as a potential explanation of hysteric symptoms, operating via effects on brain function (e.g., Charcot and Marie, 1892; Oakley, 1999a). This chapter considers the relationship between hypnosis and hysteria, now described as “functional neurologic symptoms.” Characteristics of hypnosis are outlined before considering ways in which hypnosis might act as a model for functional symptoms. This provides a basis for evaluating past and current attempts to explain functional symptoms by analogy with hypnosis.

Aetiology

Old ideas about hysteria refer to ‘migration’ of the uterus around the body. With increasing anatomical sophistication the cause was later thought to be disease of the brain, and in the late 1800s, when the brains of people with hysteria who died were found to be normal in structure, these gave way to ideas of altered brain functioning – functional brain disorders.

In the early 20th century Freud and the psychoanalysts developed the idea that hysterical phenomena were psychogenic. That is, that they were manifestations of unconscious mental phenomena, with the physical symptoms being a way of resolving a mental conflict – and indeed often symbolising it. Thus for example, someone who was conflicted about leaving home might find that they were unable to walk. Associated theoretical notions were the concept of primary gain and secondary gain. Primary gain was defined as the internal psychological benefit the person would obtain by resolving the conflict. Secondary gain has been used to refer to the practical advantages that may follow from being sick (for example receiving care and attention). Janet, also writing in the early 20th century, emphasised the splitting of mental functions (dissociation) and the importance of the person's idea of disease shaping the form of the symptom.

Modern ideas of the aetiology of dissociation continue to emphasise the role of psychological factors. Previous experience (such as childhood abuse) is a predisposing factor, psychological or physical trauma a precipitating factor, and special rewards for disability a perpetuating factor. There has also been increased interest in the neurobiology of dissociation, with preliminary work on functional brain imaging suggesting identifiable changes which are different from those of people feigning illness (Halligan et al 2000).

Introduction

In the long history of hysteria, its brief time as a psychiatric illness begins, and in a sense ends, with Freud. Though he, and his work, inevitably had antecedents and collaborators, his contribution was unrivaled in its novelty, scope, and impact. He made hysteria a psychiatric illness with a model that dominated psychiatry's thinking for over half a century, and rendered it seemingly inescapably different from the rest of medicine. Such was the grip of that model on generations of psychiatrists that even when his ideas were finally rejected, wholesale, by the Diagnostic and Statistical Manual of Mental Disorders (3rd edition) (DSM-III) in 1980 (APA, 1980) a special case for a Freudian hysteria was made for 30 years more. I shall outline that model and how it fared in the 20th century, charting the rise and fall of a “golden age” for hysteria, when it stood as a paragon of illness, instead of as a reproach.

How common are pediatric functional neurologic symptoms?

Taylor observed: “Hysteria, the laying claim to sickness for which there is no objective evidence, is a commonplace reaction, and those who become dignified by a formal diagnosis are a severe, extreme or fortuitous selection” (Taylor, 1986).

There have been two recent surveillance reports of the incidence of conversion disorder in childhood. In the study of Ani et al. (2013), over a 15-month surveillance period there were 204 confirmed cases in the UK and Ireland, giving an estimated 12-month incidence of 1.30/100 000. When looked at in terms of age, the incidence was 0.26/100 000 among children younger than 10 years and 3.04/100 000 for children 10–15 years old.

Koslowska et al. (2007), in a surveillance study of Australian children under 16 years of age, found an annual incidence of conversion disorder of 2.3/100 000. In children younger than 10 years of age, the incidence was 0.8/100 000. However, in New South Wales, the overall incidence was 4.2/100 000, perhaps due to more diligent reporting.

UK neurology before World War I

There were clearly many people working on hysteria, especially in France, Switzerland, and Germany at this time, including Sollier, Raymond, Binswanger, Oppenheim, Mills, Hellpach, Vogt, McDougall, Jules Dejerine, and Dubois. In 1911, Samuel Alexander Kinnier Wilson (1878–1937), who had trained with Babinski in Paris and later worked at Queen Square and Kings College in London, wrote a paper in Brain entitled “Some modern French conceptions of hysteria” (Kinnier Wilson, 1910) to discuss this material. Kinnier Wilson was an example of the neurologist at that time, like William Rivers, happy to cross over to psychiatry, at one stage being president of the psychiatry section of the Royal Society of Medicine. He commented that the “mere enumeration of these conflicting hypotheses may overwhelm the reader with a deep sense of despair at their hopeless dissimilarity, and he may reasonably fear that finality is as far off as ever.” But in typical ironic style, he points out that they all have one thing in common, the earnestness with which their views are held based on their personally determined treatment. Wilson selected Babinski and Janet (and not Freud) for special and prolonged discussion. Wilson came back to hysteria on many further occasions in his career, providing excellent summaries of knowledge at the time (Wilson, 1931). Oddly, his famous textbook, Neurology (Kinnier Wilson, 1940), did not include a chapter on the subject, probably due to his premature death (Reynolds, 2012b). He made several films of hysteria and other movement disorder in the mid-1920s supporting his interest in the topic (Reynolds et al., 2011; Sethi, 2011).

There had been some excellent work by British physicians. John Russell Reynolds’ paper on the importance of idea (Reynolds, 1869), and Robert Todd's observations on paralysis had been seminal (Todd, 1854). Paget (1814–1899) did not write extensively about hysteria but his key observation, “She says, as all such patients do, ‘I cannot’; it looks like ‘I will not’; but it is ‘I cannot will’,” remains as popular as ever (Paget, 1873). William Gowers’ (1845–1915) chapter on hysteria, from the heart of the National Hospital for Nervous Diseases in London, is especially rewarding and runs to 57 highly informative pages (Gowers, 1892). I discuss this chapter at some length here as an example of the sophistication of neurologic thinking at that time, reflected by many authors, which arguably became less rather than more over time.

Gowers’ description of hysteria is one that is echoed by others in this period who viewed the mechanism as a disturbance of the function of the nervous system which could affect men as well as women.

The conditions of hemianaesthesia, paralysis and contracture must be regarded as the expression of a condition of restrained function (inhibition) or unrestrained activity, of certain cerebral centres, sensory and motor.

Gowers went to a lot of effort to explain that he did not think the majority of his patients were simulating their symptoms.

It is now generally recognised that the malady is a real one, occasionally of great severity, and to a large extent beyond the direct influence of the patient's will.

This appreciation of mechanism (the “how”) was presented alongside a complex view of causation (the “why”). There was an appreciation of numerous potential predisposing, precipitating, and perpetuating factors, both mild and severe, which may be “either physical or mental influences.” His thoughts on the interplay between ideas, fear, and desire are particularly interesting.

The nervous system is dominated by idea and by fear, as well as by desire; the definite conception of a symptom may lead to its occurrence; and when idea and emotion are conjoined, and a symptom is not only conceived but either dreaded or desired, its occurrence is still more easy.

He also proposed a role for panic or depression in onset.

It may be a sudden alarm…it may be merely the depressing emotions from which no life is exempt, trifling in themselves, but potent because unresisted.

He was especially forthright about the danger of iatrogenesis and unhelpful beliefs in relatives:

When the disease has once developed, it is often greatly increased by injudicious management. The near relatives of the hysterical are often conspicuously deficient in judgement, and the little common sense they may possess is often rendered useless by their affection for the sufferers.

The importance of normal physiology was stressed in terms of how symptoms might develop.

Paraplegia is excited by emotion with especial frequency. Even in health a sensation of weakness in the legs may be caused by sudden alarm, and this, in hysteria, may be followed by a progressive loss of power. It is common for the onset of persistent weakness to be preceded by occasional momentary “giving way of the legs,” at once recovered from – a very characteristic feature.

He also appreciated the importance of pain in precipitating paralysis.

Spinal pain is very common in these cases, and being increased by standing, may distinctly excite the paralysis.

In comparison to other countries there was, however, a dearth of original research and writing on the subject in the British literature. Kinnier Wilson suggested that, “Here in England hysteria has never been cultivated.” He could only find 10 articles on it among the 350 in Brain published between its inception in 1877 and 1910, despite “seeing cases of functional disease in abundance.” He suggested this was down to a lack of a Maître figurehead in the British establishment.

One exception to this was Henry Bastian (1837–1915), one of the senior staff at Queen Square who published a whole book about hysteric paralysis (Bastian, 1893). It is however, difficult to comprehend and I cannot help feeling that it shows the first signs of that particular author's journey to some peculiar ideas about life being able to appear from inanimate matter (Jellinek, 2000).