Labels and Origins: a Name Without a Disease?

In the beginning was Hippocrates, the Father of Medicine, who freed the emerging science from the chains of superstition, introduced empirical observation and the bedside manner, and both identified and named "hysteria." So runs the established wisdom on the Hippocratic origins of both medical science in general and of the diagnosis of hysteria in particular. Yet recent work on Hippocratic medicine has called into question much of this tradition. Once it was an acceptable scholarly pursuit to debate the inclusion of particular treatises in the canon of "The Genuine Works of Hippocrates": now it is widely accepted that not a single text of the Hippocratic corpus can be attributed with any certainty to the Father of Medicine.^[1] In place of a canon of "Genuine Works," we have a diverse set of multi-author texts. Once the Hippocratic doctor was seen as a model of medical etiquette and morality: now he can be restored to his own historical and cultural context, where he becomes only one of the numerous brands of healer competing for clients in the ancient world, unafraid to improve his chances of employment by the use of tactics questionable by later standards.^[2] With the improved visibility made possible by the new Hippocratic studies, the time has surely come to reexamine the texts so confidently labeled by the nineteenth-century Dr. Robb as "Hippocrates on Hysteria"^[3] and to review the relationship between the text of the Hippocratic corpus, its interpreters over time, and the discussions of hysteria.

Since the Hippocratic texts are so often quoted—and misquoted—in

contemporary debates on the status of the diagnosis hysteria, such a study will not only contribute to the growing body of work on Hippocratic medicine and its place in ancient society but also inevitably feed into these debates. Eliot Slater, questioning the value of the diagnosis in our own times, has argued that "the justification for accepting 'hysteria' as a syndrome is based entirely on tradition and lacks evidential support."^[4] This tradition goes back to the alleged origin of the diagnosis of hysteria in the Hippocratic corpus, and it is only by reclaiming the relevant texts from their use in the tradition that we can understand and question the diagnosis in later centuries. If a fresh reading of the ancient texts shows that their use by the tradition is unwarranted, this will have important implications for the history of hysteria in general.

Recent work on hysteria in the Hippocratic corpus by medical historians, psychologists, and physicians is, almost without exception, based on the history of hysteria published in 1965 by Ilza Veith. On the name itself she wrote,

In the Egyptian papyri the disturbances resulting from the movement of the womb were described, but had not yet been given a specific appellation. This step was taken in the Hippocratic writings where the connection of the uterus (hystera ) with the disease resulting from its disturbance is first expressed by the term "hysteria." It appears in the thirty-fifth aphorism, which reads: "When a woman suffers from hysteria . . ."^[5]

Since the publication of Veith's book, these points have achieved canonical status. For example, R. A. Woodruff states that "the name, hysteria, has been in use since the time of Hippocrates"; P. B. Bart and D. H. Scully refer back to "the time of Hippocrates, who coined the name"; and S. B. Guze cites Veith as his only source for the "information" that "disorders diagnosed as hysteria have been encountered for about 2,500 years" and furthermore that, "as everyone knows, the term hysteria originated in Greek antiquity."^[6] These apparently confident assertions cover not only the origin of the word "hysteria," but also the very essence of ancient Greek gynecology. R. Satow, a psychotherapist and sociologist, asserts that "'hysteria' has been a label used for a potpourri of female ailments and non-ailments alike since antiquity. . . . The Greeks and Romans called almost all female complaints hysteria and believed the cause of all these female maladies to be a wandering uterus. . . . In various Hippocratic texts the term hysteria is applied to a large variety of female complaints."^[7]

What "everyone knows" is, however, not necessarily true. The earth is not flat, although once "everyone knew" that it was. Even leaving aside

the attempt to use Egyptian evidence, which has already been widely questioned,^[8] Veith's claims for Greek medicine are seriously flawed. As only one recent writer on hysteria, E. Trillat,^[9] has recognized, the "various Hippocratic texts" applying the term "hysteria" to many different complaints simply do not exist; moreover, to suggest that Hippocratic gynecology is about calling almost everything "hysteria" is a gross over-simplification. A total revision of our understanding of the tradition is thus long overdue.

Let us return to the text claimed by Veith as the inaugural moment of hysteria, "the thirty-fifth aphorism." It is a significant choice, since the Aphorisms is one of the most widely translated and best-known works of the Hippocratic corpus, believed for many centuries to have been written by Hippocrates himself as a distillation of the wisdom of a lifetime's clinical experience, and thus taken to be one of the most genuine works.^[10] Immediately, however, we encounter a difficulty; there is no "thirty-fifth aphorism." A. Rousselle^[11] has criticized Veith for reading back contemporary ideas into antiquity, but the problem is greater than this would suggest; Veith puts too great a trust in poor secondary sources. What she is referring to here is, in fact, Aphorisms 5.35 (L4.544), which does not use the term "hysteria" at all; instead, using the plural form hysterika , it begins Gynaiki hypo hysterikon enochloumenei , and it may be translated as: "In a woman suffering from hysterika , or having a difficult labor, a sneeze is a good thing."

What are these hysterika , and what is so good about a sneeze? Such questions plunge us directly into the heart of the hysteria debate. It is tempting to translate hysterika as "hysterics," but an apparently familiar word does not necessarily convey the meaning we would most naturally expect. Galen of Pergamum noted the difficulties of translating this aphorism (K 17b.824-825). Hysterika , he wrote in his commentary on the Aphorisms , could refer to all diseases of the womb^[12] or to only a particular condition called hysterike pnix (best translated "suffocation of the womb"), described by a number of post-Hippocratic writers and which will be discussed at length below, or to problems with the afterbirth, also known as ta hystera . He favors setting the aphorism in the context of hysterike pnix , for the following reasons. First, hysterika cannot refer to the afterbirth, because hystera and hysterika are not the same word. Second, it cannot refer to all diseases of the womb, because Hippocrates says that it is helped by sneezing. Clearly, not all diseases of the womb are helped by sneezing and, since Hippocrates cannot be wrong, Galen concludes that the passage must refer to hysterike pnix .

There is, however, no reason why we must follow Galen's line of ar-

gument since, despite his objections, there is nothing to prevent translating the phrase as "When a woman suffers from diseases of the womb." The argument that not all such diseases are helped by sneezing does not necessarily apply to pre-Galenic medicine. A sneeze expels various kinds of matter that may cause disorders, and thus has value in many situations; in a specifically gynecological context, substances such as mustard, black or white hellebore, and castoreum were widely recommended in the ancient world to promote menstruation or the expulsion of the afterbirth.^[13] Since retained menses were thought to be the cause of many female disorders, the expulsive value of a sneeze could often be beneficial.

It is in a passage of Pliny the Elder, written a century before Galen, that the sternutatory powers of mustard appear in the narrower context of "suffocation of the womb." Mixed with vinegar, mustard was thought to rouse women suffering from an epileptic fit or "vulvarum conversione suffocatas,"^[14] translated in the Loeb edition as "fainting with prolapsus" but more literally meaning "suffocated by the turning of their wombs." This may suggest another value of the sneeze, which was seen as being of particular importance in "suffocation." Many ancient writers discuss the difficulty of knowing whether a sufferer from the condition they call "suffocation of the womb" is, in fact, alive or dead. Pliny himself gives the case of a woman who lay as if dead for seven days with "conversio vulvae," turning of the womb.^[15] In such cases, it was necessary to test for life by holding a feather or a piece of wool at the nostrils. A sneeze was welcomed as evidence of the presence of life.

Sneezing, due to its expulsive powers, can thus be "a good thing" for many disorders affecting women, but by the first century A.D ., when Pliny was writing, it had come to be seen as particularly valuable in "suffocation of the womb" because it could recall to life a patient lying as if dead. It is thus possible that it had the first meaning in Aphorisms , but that this had been overlaid with the second by the time of Pliny. Galen, writing a hundred years or so after Pliny, put together the broad context of the Aphorisms passage and the more specific context of Pliny; the example thus makes us aware of the possible changing interpretations of a text over time.

Regardless of how we choose to translate the passage, it should above all be noted that this is not what Veith called "a specific appellation": a disease label. Veith admits that the form hysterikos , "from the womb," "connected with the womb," or, when applied to a woman, "liable to disorders of the womb," is "more frequently used,"^[16] but she does not acknowledge that it is in fact used exclusively, and moreover that the Aphorisms example is only a further case of this general type.

It is not difficult to find the source for this particular misconception on the part of Veith. The idea that it is in the Hippocratic corpus that hysteria is not only described but also given its name can be traced back beyond her to the Emile Littré edition of 1839-61, the gynecological volumes of which—numbered 7 and 8—appeared in 1851-53. For the present purpose, a study of these must concentrate on the additional French material supplied by Littré. This appears in two forms. First, for many of the Hippocratic texts he provides section headings for each chapter; these have no analogue in the Greek manuscripts. This applies to the three volumes of the Gynaikeia , known in English as Diseases of Women ,^[17] where several passages are headed "Hystérie." Second, additional material appears in the translation itself, where Littré uses the medical categories of his own time. The misplaced confidence of the title used by Robb in his article "Hippocrates on Hysteria"^[18] is based on translating Littré into English while simultaneously incorporating distinctions made only in the headings.^[19] As Rousselle has recently suggested, these owe far more to nineteenth-century debates and theory than to the Hippocratic texts they are supposed to summarize.^[20] Just as Adams aimed to make the Hippocratic texts that he selected as "The Genuine Works of Hippocrates" intelligible to "any well-educated member of the [medical] profession at the present day,"^[21] so Littré "read Hippocrates in his own image and in the image of the medicine of his time,"^[22] with the explicit intention of using Hippocratic wisdom to improve the medical practice of his own day. "Until the nineteenth century, medicine nourished itself on Hippocrates—or at least on that which it believed it could find in Hippocrates."^[23]

The section headings written by Littré go further than merely labeling certain sections "Hystérie." In addition to this, Littré distinguishes between imagined movement of the womb, which he classifies as hysteria, and real movement, which he describes as displacement. He thus makes such comments as, "This section appears to be a confusion of imaginary with real movements of the womb"; "This appears to be some displacement of the womb rather than hysteria"; and "The fact remains that there is confusion between imaginary and real displacements."^[24] He believes that the Hippocratic texts do not make sufficiently clear the distinction he seeks, in contrast to Veith, who—again, wrongly—claims that "the Hippocratic physician was aware of the importance of a careful differentiation between hysterical symptoms and those of organic disease."^[25] The writers of these ancient texts make no such distinction. They describe what is, for them, a real and organic condition: the movement of the womb (hystera ) to other parts of the body. Since it is Littré, rather than any Hippocratic physician, who is interested in the distinc-

tion, it may be suspected that Veith is basing her remarks on the Littrean section headings rather than on the Greek text.

The origin and process of transmission of the error in translation should now be plain. Littré read the Hippocratic corpus in the context of the mid-nineteenth century, in which hysteria was a recognized condition of debated etiology; he expected to find hysteria in the text, duly found it, and drew it out in the headings he wrote for the various sections. Robb translated into English the passages headed by Littré as "Hysteria," and subsequent readers of the Hippocratic corpus have accepted the categories imposed by Littré on his material. Taking only the Aphorisms passage, Littré translates "Chez une femme attaquée d'hystérie. . ." while Francis Adams gives "Sneezing occurring in a woman with hysterics," and J. Chadwick and W. N. Mann have "When a woman is afflicted with hysteria." In giving "When a woman suffers from hysteria. . ." Veith is following the widely available Loeb translation.^[26]

Thus the diagnosis of hysteria is one made not by the ancient authors of the texts, but rather by the nineteenth-century translator of the Hippocratic corpus. At this point it would be possible to argue that this is of only minor importance; granted, the tradition is wrong to claim that the Greeks invented the name and thus the diagnostic category of hysteria, but if the Hippocratic texts nonetheless contain the first clinical descriptions of hysteria, should we much concern ourselves with the origin of the name? As a result it becomes necessary at this point to begin to consider what we are to understand by "hysteria." When a translator reads the diagnosis into a text, this would seem to suggest the belief that there is a fixed entity called hysteria, constant over time and place, so that we can say with Chariot that "L'hystérie a toujours existé, en tous lieux et en tous temps,"^[27] and with D. W. Abse that "in fact, east and west, hysteria continues unabated in various guises."^[28] If we believe this, it will be of relatively little significance that the name "hysteria" is not Hippocratic. A concept may exist even if it is not named; as G. Lewis points out, the ancient Hebrews had no word for what the Romans were to call lex talio , the law of retribution in kind, but they did say "An eye for an eye and a tooth for a tooth."^[29] Further general questions about hysteria will also need to be addressed. Is it a disease like any other, and thus a fit subject for medical study and treatment? Is it a disease at all?^[30]

If hysteria is constant, found throughout history, worldwide, we can begin to talk about whether or not Hippocratic medicine recognized it, regardless of whether the Hippocratics named it, just as we can talk about whether tuberculosis, epilepsy, and gonorrhea were recognized. Furthermore, if it is historically constant, a body of text of the length of

the Hippocratic medical corpus should, statistically, contain some cases of it. Any decision that it is constant therefore prejudges the question of whether or not it existed in Hippocratic times: by definition, it must have done, and our task is only to find the sections in the texts which provide a more or less accurate match with our chosen clinical picture. This task, however, is complicated by the belief that hysteria, like chlorosis, is a disorder that apparently disappeared in our own century; as Trillat says, "L'hystérie est morte, c'est entendu."^[31] This could lead us to apply more stringent criteria to the Hippocratic texts, to conclude that hysteria was not present in classical Greece, and thus to revise our views on the significance of its apparent disappearance from the medical scene.

There are however two main obstacles standing in the way of a decision to treat hysteria as a historical constant. The first is that, unlike tuberculosis, epilepsy, and gonorrhea, hysteria is in no way a clearly defined disease entity for which most medical practitioners in our society would draw up the same list of symptoms; the second, that an integral part of the definition of hysteria often consists in its supposed ability to mimic symptoms of other diseases.

Contemporary medical writers on hysteria fall into two main groups. One group accepts that hysteria is "a valid, independent syndrome"^[32] and, in applying this label, makes use of the Perley-Guze criteria, which list over fifty symptoms in ten areas; exhibiting twenty-five symptoms in nine out of ten areas qualifies as hysteria, in the absence of any other diagnosis.^[33] One area is entirely concerned with menstrual difficulties;^[34] since menstrual suppression is by far the most common symptom in Hippocratic gynecology—for reasons that relate to the belief that amenorrhea indicates the presence of a dangerous reservoir of unshed blood^[35] —it should not be surprising that retrospective diagnosis of hysteria in the Hippocratic texts is common. The second group's position is conveniently summarized by Slater's (1965) lecture "Diagnosis of 'hysteria.'"^[36] The single quotation marks around "hysteria" say it all. Slater picks up the Perley-Guze point that the label hysteria is applied "in the absence of any other diagnosis" and concludes that the diagnosis merely indicates the "absence of relevant physical findings"; it is "a disguise for ignorance and a fertile source of clinical error . . . not only a delusion but also a snare" and "a way of avoiding a confrontation with our own ignorance."^[37] Edward Shorter suggests that diagnoses such as hysteria have often covered an undetected uterine infection.^[38] C. D. Marsden, too, points out that a high percentage of patients diagnosed as having hysteria turn out to have an underlying organic disease and concludes

that "there can be little doubt that the term 'hysterical' is often applied as a diagnosis to something that the physician does not understand."^[39]

Slater therefore argues that "the justification for accepting 'hysteria' as a syndrome is based entirely on tradition and lacks evidential support."^[40] F. Walshe's response to Slater, significantly using the same title but omitting the quotation marks around the word "hysteria," defends "the concept of hysteria as a nosological entity in its own right."^[41] The debate in medical circles continues, and Slater's contribution is discussed at length in Alec Roy's (1982) collection of essays, Hysteria .^[42] R. Mayou gives a fair summary of the medical situation when he writes that there is at present "no agreement about diagnostic criteria" for hysteria.^[43]

The second difficulty encountered in regarding hysteria as something constant is that, if anything is a widely accepted part of the definition, it is the suggestion that it can mimic the symptoms of any other disease.^[44] In this case, how can hysteria itself be a disease, and what is to prevent it from taking such radically different forms in different epochs as to be almost unrecognizable as the same condition? The corollary is also true; as Shorter puts it, "every organic disease imaginable . . . has at one time or another been classified as hysteria."^[45] Does a condition with such indistinct and shifting borders exist in any meaningful sense? As Trillat puts it, hysteria is "une maladie qui n'en est pas une, tout en l'étant . . ."^[46]

Nineteenth-century medical literature suggests that hysteria can manifest itself in a highly dramatic form; in the ideal type of Charcot's "grande hystérie," violent muscular contractions culminating in the arched posture (arc-en-cercle ), paralysis, loss of voice, retention of urine, anesthesia, and blindness. In a recent study of admissions for hysteria to the Edinburgh Royal Infirmary in the late eighteenth century, however, G. B. Risse found that only a minority of alleged victims had fits of this kind; most women sufferers had loss of appetite or other digestive problems, menstrual difficulties, and fainting spells, symptoms suggestive of many organic diagnoses.^[47] Yet one relatively constant feature of the diagnosis of hysteria in modern times is that it implies that the physical symptoms so labeled, whether dramatic or not, have no recognized organic cause. It should now be clear why hysteria has been described as "that most unsatisfactory of psychiatric syndromes."^[48]

Marsden's recent discussion shows the widest possible extent of the definition of "hysteria." "Physicians use the term to describe the symptom (conversion disorder or disassociation state), the illness (somatization disorder or Briquet's syndrome), the personality (histrionic), a form of anxiety (phobic anxiety after Freud), an epidemic outbreak (mass hysteria) and irritating patients (if female they are hysterical; if male they

are psychopaths)."^[49] The irritation felt by doctors toward hysteria patients is eloquently expressed in the words of a doctor writing in 1908, a time when the contracture or "drawing up" of a limb was a common symptom: "As Vance cut off the plaster cast from a 14-year-old girl whose leg had 'drawn up' a year previously, she cried, 'It is going to draw up; it is going to draw up,' at which Vance said severely, 'If it does draw up, I will break your d____d little neck.'"^[50]

Other contemporary writers argue for a restriction of the definition of hysteria, excluding the syndrome and the personality type and using hysteria only for a universal human reaction, comparable to anxiety or depression.^[51] Shorter's suggestions may be helpful here, insofar as they permit a degree of universality, while incorporating variation among cultures. He accepts that "'hysteria,' it appears, is a real psychiatric disease, in addition to being an epithet with which men have stigmatized women across the ages." However, he goes on, "the presentation of 'hysterical' symptoms tends to be molded by the surrounding culture" to a greater degree than that of, for example, the symptoms of schizophrenia. A major question to ask therefore concerns the social construction of the disease: Why is it that, from a wide repertoire of the possible, "certain symptoms are selected in certain epochs"?^[52] I will return to this important question, in relation to the Hippocratic texts.