A curious hysterical blindness

The New York Times has an extended book review that explores female hysteria in 19th Century Paris while demonstrating a curious hysterical blindness of its own.

The piece reviews a new and supposedly excellent book by Asti Hustvedt called ‘Medical Muses: Hysteria in Nineteenth-Century Paris’.

Hysteria is the presentation of seemingly neurological symptoms without any damage to the nervous system that could explain it. Although we can’t explain why many neurological disorders appear, neurological symptoms – almost by definition – are linked to clear and detectable damage.

Those that appear without the presence of such damage were traditionally labelled ‘hysteria’ although are now subsumed under various diagnoses such as conversion disorder or somatoform disorder.

Charcot was a highly influential 19th Century neurologist who essentially defined the shape of modern neurology and he was fascinated by hysteria. This is the subject of Asti Hustvedt’s new book.

I’ve not read the book but the review, and many pieces like it, focus on neurologist Jean-Martin Charcot’s interest in female hysteria as a demonstration of how the female body and sexuality were uniquely pathologised in 19th century medicine.

This would be interesting were it not for the fact that solely focusing on ‘female hysteria’ misrepresents what happened.

Not least because after more than two thousand years of hysteria being portrayed as being a uniquely feminine disorder, Charcot identified and campaigned for the existence of male hysteria.

This is from medical historian Mark Micale:

During the 1880s, Charcot published the case histories of more than 60 male “hysterics” and treated countless others in his daily hospital practice. Between a third and a quarter of the overall number of hysterical patients he presented in his printed works were men or children. In these writings, Charcot formulated an elaborate set of medical ideas about the disease in males, including a theory of aetiology, a model of symptomatology, and a programme of therapeutics.

Throughout this period, Charcot campaigned energetically for his theory of masculine hysteria, and by the time of his death, in 1893, the idea was widely accepted within mainstream European medical communities. Many of Charcot’s medical contemporaries judged his work on the topic to be among the most scientifically significant parts of his oeuvre, and the School of the Salpetriere, as it was called, was associated internationally with the theme of male hysteria.

It’s true to say that the female ‘hysterical patients’ gained much more attention (due to a combination of public fascination, Charcot’s love of showmanship and the recent invention of photography) but it’s interesting to note that this pattern has continued into the modern day.

This is despite the fact that’s the famous neurologist’s own interests were far more balanced. A curious historical parallel.
 

Link to review in the NYT.
Link details of ‘Medical Muses: Hysteria in Nineteenth-Century Paris’.

10 Comments

  1. Joss
    Posted June 20, 2011 at 4:14 pm | Permalink

    Indeed!

    And were she to have had a chat with her sister Siri I’m sure she could have easily discovered this.

    In The Shaking Woman Siri Hustvedt mentions the mysterious chaning of nomencleture for ‘hysteria’ when men present with such ‘conversion’ symptoms.

    I note that the piece in the NYT mentions Idiopathic Chronic Fatigue (a brillinatly accurate thing for them to say) and then links to a piece about Chronic Fatigue Syndrome which undoes that accuracy in a second and once agains places the CFS/ME in the realm of conversion.

    Ho hum.

  2. Kelly Latta
    Posted June 20, 2011 at 11:32 pm | Permalink

    Mind Hacks writes “…Hysteria is the presentation of seemingly neurological symptoms without any damage to the nervous system that could explain it. Although we can’t explain why many neurological disorders appear, neurological symptoms – almost by definition – are linked to clear and detectable damage.”

    Multiple Sclerosis was also considered “hysterical paralysis” at least until technological advances allowed objective documentation of the demyelination of the nerve sheaths – aka so-called clear and detectable damage.

    Does this mean there was no damage prior to these technological advances or that it was just not clear and detectable and therefore hysteria?

    Archaic concepts such as “hysteria” and “neurasthenia” are cultural memes that should probably be abandoned until there is objective scientific evidence that they exist rather than being predicated on a lack of knowledge.

  3. neuroguy
    Posted June 21, 2011 at 8:29 pm | Permalink

    You shouldn’t criticize a book you admit that you haven’t read! I just finished it and you should know that the author insists, early on, that Charcot was the first to claim that men could be hysterics. I have the book in front of me, and I quote: “One of Charcot’s great advancements in the field was his official and adamant rejection of the uterine theory. He repeatedly insisted that hysteria could be found in men just as it could be found in women and hoped to separate the word form its etymology, arguing that its Greek origin-uterus-should be abandoned. Hysteria was a disorder of the nervous system, not the womb. This point, which he frequently reiterated in his lectures and writings, represented a radical departure from previous medical theory.” Also, Charcot was the first to describe multiple sclerosis and he distinguished it from other neurological disorders–he never insisted that it was hysterical paralysis. His error was in insisting that hysteria was a neurological disorder with organic lesions. And, by the way, the author never claims that CFS/ME is conversion. Her only point is that illnesses classified as “syndromes” are not given the respect they deserve, and are too often dismissed as “not real”–a position that she criticizes, and points out that hysteria, during Charcot’s time, was taken seriously.

    • Kelly Latta
      Posted June 22, 2011 at 2:09 pm | Permalink

      Thanks for the clarification.

      I did not mean to imply that Charcot himself considered MS to be hysterical paralysis, although many did.

      My point was more that history and modern medicine make for an interesting juxtaposition.

  4. Sam
    Posted June 22, 2011 at 9:52 am | Permalink

    Some 40% of patients referred to a neurologist in the UK come out of the consult with a vague opinion of ‘somatoform disorder’, aka ‘hysteria’, which term some doctors still use in private.

    The actual incidence of this ‘disorder’ is something like 0.01-2% according to US figures.

    Most of the 40% go on to develop florid signs and sx of a physiological neurological disorder in following years.

    The medical literature abounds in such misdiagnoses, with sometimes fatal results. This supposed condition’s DSM4 symptomatology is vague and can be diagnosed at whim without any clinical or other tests/scans.

    ‘Conversion disorder’ is a very convenient, cost-saving dx in a health care system where neurologists are few and far between and where the unaccountable health care institution cuts budgets according to a deeply socialist agenda – or simply where neurologists arrogantly make blind assumptions. Statistically, the majority of these dxs go to women, ethnic minorities, people with lower educational achievement, people from rural communities. Dxs are made on the balance of statistical probability and opinion.

    There is no known mechanism for the assumed physical process of ‘converting’ presumed psychological states into long term physical conditions the like of which attract conversion disorder labels. However, sensitive fMRI and other advanced scanning techniques are beginning to pick up more and more subtle physical/neurological changes/abnormalities that show genuine physical causes for what doctors have ever been pleased to call hysterical/somatoform/functional/conversion disorders.

    No doubt, these will go the way of MS – that is, newer, more sensitive medical technology will show these DSM4 ‘disorders’ to be actually disorders of thinking which occur largely only in the minds of neurologists and psychiatrists!

    I won’t be reading this book. Although I wonder if the author has elaborated on Charcot’s ‘showmanship': has she detailed the fraudulent performances Charcot co-erced his hapless patients into for the benefit of his audiences and ego? The lucrative business he built on the back of his ‘research’? Has she detailed the hitherto impecunious Freud’s part in repackaging and popularising this ‘disorder’ (he spent all of 19 weeks as a student of Charcot and somehow emerged an expert)? His seminal cases (one of whom he never even met and the other gave him the boot after only 11 weeks because she saw quickly that he was simply wrong)? Is there any mention of his cocaine addiction which may or may not be incidental? (Who in their right minds would willingly consult, still less trust, a doctor who’s off his head on some narcotic or other?!)

    Modern day doctors are not taught that the C19th medical establishment was, in fact, deeply sceptical of and resistant to this alleged conversion disorder which was nothing more than the modernisation of a dx first formulated c.4,000 years ago to explain physical signs and sx that were beyond contemporaneous medical knowledge. Spin, PR and the prospect of big money won out. Plus ca change.

    The actual evidence and history of the uses and misuses of this ‘disorder’ are tragic, shocking, scandalous. Indeed, I’d go so far as to call it a medical holocaust: millions of people have died as a result, and many millions more have been forced to live painful, attenuated lives.

    I’ve engaged in enough academic research on the topic to be convinced that, as Kelly Latta (above) so accurately sums up, “Archaic concepts such as “hysteria” and “neurasthenia” are cultural memes that should probably be abandoned until there is objective scientific evidence that they exist rather than being predicated on a lack of knowledge.”

  5. Joss
    Posted June 22, 2011 at 11:42 am | Permalink

    I hope that those with knowledge of this area have taken the time to add to the current consultation on the new DSM and have contacted the APA with any concerns.

    The consultation period has been extended to 15th July.

    Current proposals for ‘Somatic Symptom Disorders’ are here:

    http://www.dsm5.org/ProposedRevision/Pages/SomaticSymptomDisorders.aspx

    I am aparticularly concerned with the new category of Complex Symptom Disorder that would seem to make every one a psychiatric patient at some point.

    ‘Hysteria’ seems to be being relabled ‘Functional Neurological Disorder’ – watch out for the term ‘functional’ to many neurologists it doesn’t simply mean ‘we don’t have the ability to discover what is wrong with you’ but ‘you are suffering from a psychiatric illness even if you show no other signs of it that physical symtoms’.

    Once in that basket it is very hard to get other medical help.

  6. neuroguy
    Posted June 22, 2011 at 12:42 pm | Permalink

    The book is historical, and focuses on hysteria in Paris during the Belle Epoque from the patient’s perspectives. Charcot’s showmanship is emphasized throughout. The author also mentions the high number (40%) of dx that are idiopathic today, but only briefly. The focus of the book is hysteria in the 19th century, specifically how it was produced in the Charcot’s clinic, not contemporary medicine.

  7. Sam
    Posted June 22, 2011 at 1:58 pm | Permalink

    @ Joss

    Many thanks for writing about the new DSM and the opportunity for all of us to comment on their unscientific presumptions (as I have done!)

    It’s very worrying that, as you say, the criteria are being widened so that just about any illness can be seen as psychosomatic.

    Also the ‘functional’ label. That really is a monumental sleight of doublespeak.

    In fact, I’d go so far as to say that the psychiatrists and neurologists themselves are caught up in some massive folie a beaucoups.

  8. neuroguy
    Posted June 22, 2011 at 3:21 pm | Permalink

    The history of the DSM is fascinating and reflects the culture. Daniel Carlat’s new book Unhinged is a great read and addresses the arbitrary nature of psychiatric dx. Brain scans show brain changes in conversion paralyses. Freud claimed that one day it would all be neurology. Functional has replaced hysterical, and the best neurologists are not dismissive simply because something is functional (or of unknown origin.)

  9. Sam
    Posted June 24, 2011 at 9:26 pm | Permalink

    Thanks for your additions, neuroguy.

    I shall have to read Unhinged.

    The problem is that the vast majority of px never get even a sniff of an MRI etc. Do you have ref for Freud’s prediction? I’m wondering if it’s in a useful paper I failed to read or read properly. Mea culpa, if so.

    Freud’s minimally promoted claim notwithstanding, his rather better known blunt-edged tools hold the floor and the reality out here on the ground for px is that there are very few good neurologists in ‘delivery’ and px care terms. And most of them, like the vast majority of GPs, treat ‘functional’ as ‘fruitloop’. Px continuously report encounters with dismissive neurologists.

    In a related discussion I was having with a GP the other day, he said he thought the problem was not only the dearth of neuros but also that, traditionally, they’re the brightest of the bright: commensurate arrogance often overrides.

    I think the comment of a London neuro, discovered in a ‘Brain’ paper, is very telling:
    “… I put them ['functional' px] in a different category because they are not … well, I suppose you have to use the word ‘troublesome’… It’s all about how they make me feel … http://brain.oxfordjournals.org/content/early/2009/04/16/brain.awp060.full?ck=nck

    The honesty and (hopefully) unconscious ignorance of the neurologists interviewed for this paper is illuminating.


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