Science, sexuality and sensationalism

How surprising that the "oldest and most important category of neurosis in recorded medical history" is also "an irresistible blend of science, sexuality, and sensationalism". In the first big historical overview for 30 years, Mark Micale focuses particularly on this paradoxical nature of hysteria.

First described by Hippocrates as a loose collection of physical symptoms related to the womb, it became common after 1800 as unexplained motor paralyses, but these began to disappear a century later, at least in more developed societies. Micale emphasises, though perhaps not quite enough, the difficulty of rediagnosing and counting cases from the past; many of those middle-class Victorian women who retired to the sick-room may in fact have suffered more from anaemia or chronic infections than from cultural oppression. Today, hysteria does not appear in either of the main diagnostic systems of psychiatry.

Gender has been an inescapable issue from the Greek beginnings, and some writings by male doctors about female patients with "hysteria" represent chauvinistic medicine at its worst. While acknowledging that the feminist interpretation has been highly influential, Micale finds its greatest weakness to have been an "uncritical centrality of gender reductionism", since the history of a disease has many components, including culture and social class. The "shell shock" of the first world war, for instance, was an epidemic of hysteria in men.

Part Two deals with hysteria as metaphor, the interaction between medicine and culture, and here the emphasis is overwhelmingly on France, with Jean-Martin Charcot representing one world and Gustave Flaubert the other. Micale argues that the characteristics of the fictional Madame Bovary became so embedded in French culture that doctors began to diagnose these as the "hysterical personality". Though bolstered, like the rest of the book, with impressive reading, this proposition fails to convince. Charcot, ironically, has achieved most posthumous fame as a teacher of Freud; Andre Brouillet's picture of him demonstrating a dramatic case of hysteria at the Salpetri re is one of the main cultural icons of medical history. France was also where scientific concepts prevailed increasingly over the religious, though Charcot's most difficult cases tended to be sent to Lourdes, which Micale sees as the setting for a form of mass group therapy.

If hysteria became "a supreme mode of expression" in France, that was certainly not the case in Britain, where thinking remained firmly neurological. But in Vienna psychoanalysis began as an approach to hysteria, so leading to "some of the most brilliant psychological theorising of modern times". Freud's greatest contributions were to redefine it causally, rather than as a series of symptom clusters, and to reject the deterministic doctrine of degeneration which had blighted 19th-century psychiatry. If Freud's cases now seem rather bizarre, this indicates how specific syndromes are socially and culturally determined, while the basic mechanism of converting anxiety into physical symptoms probably goes on for ever.

In that case, how does hysteria appear in this present fin de si cle? Micale's three candidates are eating disorders, multiple personality disorder, and chronic fatigue syndrome. Once again, hysteria seems to have accommodated itself to the prevailing medical paradigms, and done so more in women.

Micale has made an important contribution to the historical understanding of hysteria; his breadth of scholarship is remarkable and his open-minded approach a refreshing contrast to the many ideological axe-grinders. If he would only rid the text of "contextualist", "problematizes", "genderal" and similar infelicities, it would make for easier reading.

Hugh Freeman was editor of the British Journal of Psychiatry and is an honorary visiting fellow, Green College, Oxford.