Wandering Wombs, Wayward Women: Endometriosis and the Afterlife of the Hysteria Diagnosis

BY SAMANTHA LIU

Hysteria has always been a markedly female condition. Plato in Timaeus was first to suggest the female uterus would be “sad” when it is not joined by its male counterpart; Hippocrates later coined hysteria in his Hippocratic Corpus as “the wandering uterus,” from hysteron meaning “uterus” [1]. Such characterizations trace back to centuries-old conceptions that women are more “prone to emotions” than men, “feel[ing] under circumstances where [a man] thinks” [2]. Thus within the scientific imagination, presumed defects in women’s reproductive and emotional health converged into the hysteria diagnosis. By the 1800s, hysteria was considered a diagnosable illness, in which women’s sexual deficits resulted in symptoms of excessive emotionality. Against a shifting urban order, this association was codified into a patriarchal medical regimen, specifically used against women who violated their gender roles. As such, this paper will track the nineteenth-century origins and subsequent institutionalization of the hysteria diagnosis, borne out of the medical profession’s desire to control deviant women, arguing that such trends shape present-day medical discourse around endometriosis. 

1840-1930: Hysteria, institutionalized

In his 1840 Practical Treatise on Diseases Peculiar to Women and Girls, intended as a family medical manual, Buel Eastman defines hysterics as a nervous disease that “disarrange[d] the womb.” The Treatise details the disease’s symptoms, chiefly the convulsive hysteric fit: “a wild and furious expression of the countenance, raving, gnashing the teeth, tearing out the hair, beating the breast with the hands, biting” [3]. His contemporary New York physician E.H. Dixon also imagines the hysterical fit with a kind of morbid fascination: “the patient writing like a serpent upon the floor, rending her garments to tatters, plucking out handfuls of hair, and striking her person with violence” [4]. Eastman continues to describe the types of women hysterics affect: widows cut off from sexual activity, infertile women, wealthily pampered women, and women with excitable or nervous predispositions [3]. 

Two facts are striking here. The first is that early nineteenth-century American doctors did have a precise requirement for hysteria diagnosis: that the woman have at least one hysteric fit. This standard was usurped just one decade later, including by British physician Robert Brudenell Carter, who suggested that a fit may be so miniscule and subtle that it escapes notice by family and friends [2]. In Carter’s framework, any woman could be suffering from “hysteria,” regardless of whether or not they visibly presented with a hysteric episode. Thus with new and ambiguous leeway, by the 1850s, medical textbooks began broadening the symptoms associated with hysteria. Henceforth, the disease could affect organs of “expression, respiration, locomotion” and cause feelings of grief, anxiety, numbness, nausea. Displaced from the womb, hysteria now encompassed all of a woman’s physiological, psychological, and emotional abnormalities. 

The more crucial fact, against a Victorian backdrop of a changing family structure,  is that Eastman links hysteria to a woman’s inability to fulfill her gender role. By the mid-nineteenth century, advanced medicine drove lower mortality rates and lower birth rates. Urbanization also fueled economic mobility—and aspirations to social-climb. For many lower-class women, the goal was no longer to acquire security through marriage, but to acquire jobs as factory workers or domestic caretakers. Meanwhile, wealthy married women retreated further into idle domesticity, where servants, tutors, and housekeepers attended to their former duties [5]. If in the eighteenth century, the ideal woman was a loving wife who worked industriously and eagerly around the house, this paragon became rare and still diminishing by the 1850s. 

As such, the hysteria diagnosis became a catchall label for women who violated the expected roles of wife and mother. Eastman notes the disease’s prevalence in widows and infertile women, suggesting that it resulted from not having enough sex [2]. Another doctor suggested that “sexual emotions are the most concerned in the production of the disease,” and that “women of strong passions, who are separated from their husbands…are especially liable” [2]. Thus physicians began to link sexual function with bodily normalcy. But the idea ran beyond sex—hysteria was assigned to any women who violated social or gender norms. Poor women, immigrant women, sexually promiscuous women, career-oriented unmarried women, and pampered and idle Victorian housewives were all demographics targeted by nineteenth-century medical books as particularly hysteria-prone [2]. Thus the real reason for hysteria emerges: physicians, agonized over changing female roles, sought medical aberration in groups of women who threatened the nineteenth-century paradigmatic housewife.

The influence of male physicians’ biases extended past the diagnosis. It formed the basis of a tacit, standardized system of medical oppression against socially “deviant” women, shaming them into fulfilling their supposed duties. When white upper-class women came to doctors reporting paralysis, nausea, headaches, and extreme pain, physicians acted with a sense of “superiority and hostility,” blaming their suffering on their “vapid and unconstructive li[ves]” [2]. Meanwhile, for lower-class working women exhibiting similar symptoms, the problem was placed upon their uncontrolled pleasure-seeking. Medicine became a battleground upon which white male doctors could enact their Protestant-like nostalgia for moral control, while nationally the ethos of masculinity and hard work was on the decline. In this vein, their “prescriptions” were mostly interventions to compel wayward women to behave: moral training, charity work, and outdoor exercise, most commonly [5]. Prevention methods remained equally unhelpful, in which mothers were urged to instruct their daughters to stifle their female tendencies toward emotion and vanity, so as to train against possible hysterical upsurges. This supposed incompatibility of femininity and wellness is not novel to the nineteenth century—as early as classical antiquity, Aristotle’s Nicomachean Ethics posited that women’s menstruation made them unfit for politics and education [6]—but never before had it been institutionalized via medicine. By the antebellum period, however, it culminated into the construct of female hysteria: less and less a real disease, more and more a projection of doctors’ anxieties over a womanhood in flux. 

1931-Present: Endometriosis’s growing pains

By the twentieth century, hysteria’s legitimacy was waning. New psychologists gradually sorted the symptoms of hysteria into anxiety, schizophrenia, borderline personality disorder; one study records the number of French psychiatric theses on the disease peaking at 110 in the 1890s, then rapidly dropping below ten by the 1920s [7]. Still, while Micale is quick to note optimistically the “clinical deconstruction of a diagnosis,” if its full-on “disappearance,” hysteria’s shadow still looms long in modern medicine [7]. Many of its symptoms—and stigmas—transformed subtly into a somatic disease: endometriosis. In endometriosis, the uterine tissue (endometrium) grows and implants in other pelvic organs. While normally this lining is shed during menstruation, when displaced from the uterus, the tissue instead becomes trapped in its thickened state [8]. One 2012 gynecology went further to argue that almost all women diagnosed as hysterics were likely suffering from endometriosis, noting the similarity of both its physical causes (the coagulation of blood in the pelvis) and lifestyle detriments (insomnia, nervousness, irritability, depression, and lethargy) [10].

Whether or not historically hysterical women really did have endometriosis, present-day discourse around endometriosis reflects at least the continuation of hysteria’s worst social prejudices. Afflicted women report unbearable, life-altering, excruciating pain as their primary symptom. Yet, there exist few other outward indications. As such, the disease evades medical recognition: the diagnosis time for endometriosis ranges 7.5 years to 10 years after the onset of the first symptom [11]. As one woman recalled in an anonymous interview, after going to several doctors with complaints of abdominal pain, “the GPs [gave] you a pat on the head and off you go dear… you’ve just been anxious” [11]. In another unfortunately viral instance in 2014, on the national radio show Loveline, a man had called in about his fiancee with endometriosis. Host and doctor Drew Pinsky had interjected, asking, “Was she sexually abused growing up?… Everything you mentioned are things that actually aren’t discernibly pathological…they’re what we call ‘garbage bag diagnoses’” [12]. In both cases, the paternalistic tone, directed toward an “anxious” woman, is vividly reminiscent of hysteria. Pinsky’s description of a “garbage-bag diagnosis” harkens specifically back to hysteria as a catch-all disorder, wherein a pathology is chalked up to a patient’s inherent, irrational emotionality. A woman’s body is therefore reduced to its sexuality—and even its sexual trauma. As such, stigmas surrounding hysteria have therefore persisted in doctors’ present understanding of endometriosis. 

Moreover, the language of endometriosis is inextricably tied to womanhood, reproductive capacity, and respectability. As early as elementary school, girls learn to conceal their menstrual process, “socialized…to keep tidy and discreet” [13]. That women are taught to disconnect from their bodily experiences strips them of agency, allowing for what one writer called “medical gaslighting” in endometriosis diagnoses [14]. In 2018, linguistics lecturer Stella Bullo conducted 250 interviews and analyzed the language with which women discussed their endometriosis [11]. One woman described herself as feeling “different and a bit freakish and broken,” even “repulsed by myself.” Another called herself “damaged goods,” and that she no longer felt like “a proper woman.” Specifically, their rhetoric externalizes their body from their self—whether as a commodity of “damaged goods,” or as a “freakish” spectacle—reflecting the cognitive dissonance of women shamed into suppressing their bodily experience. 

Their language also positions them in relation to normative expectations of womanhood and valuation. Indeed, as with hysteria, the entanglement of womanhood and health returns specifically to reproduction Endometriosis is most commonly diagnosed when investigating infertility, with ultrasound revealing ovarian cysts [15]. Through this self-selecting linkage of endometriosis and infertility, a failure to bear children becomes doubly associated with disease and defect in itself. As early as the 1920s, endometriosis was called the “career-woman’s disease,” when it was thought to affect middle-aged, unmarried, working women. Even though this association has been widely disproven, adult women still face stigmas that “any deviation from these apparent norms will invariably jeopardise her health” [16]. Resultantly, endometriosis is still considered a punitive measure for those who delay childbearing in pursuit of educational or professional success. Like hysteria, endometriosis carries doubly misogynistic reverberations: for lower-class and minority women, their pain remains undiagnosed; for career-oriented women, their reproductive failure is diagnosed—and blamed on their professional aspirations. 

Currently, endometriosis treatment options are limited. In severe cases, the only solution may be removal of the ovaries and uterus [16]. Nonetheless, if looking to the past offered insight into construction of hysteria, it also yields insights into its solution. A 2001 book by Nancy M. Theriot posits the healing power of storytelling in medicine, where doctor and patient “negotiate” reasons for an illness—contingent on mutual trust and confidentiality [9]. Theriot considers a 1869 case study by Dr. Van Deusen, who observed how married wives of smaller farmers seemed prone to fatigue, irritability, and headache. Van Deusen sought to investigate why wives felt this way, noting their stories of “marital discord,” burdened by “too many children and household cares, of problems with alcoholic husbands, of interfering in-laws, and of husbands’ too-frequent sexual demands.” In letting these women tell their stories, Van Deusen legitimized their experiences and thrust into the clinical limelight their demanding family roles. Combined with his suggestions to rest, avoid chores, resist their husbands’ demands, wives made full recoveries in as short as two weeks.  Perhaps an empathetic, narrative-based treatment has always been best for “hysterical” women. Writer Jaipreet Virdi described how her endometriosis experience made her “exhausted from the anguish, the advocacy, and the gaslighting”—could a more empathetic doctor have reduced her suffering? [14] Could removal from the domestic sphere actually alleviate women’s troubles? Discourses around hysteria expose the harm of conflating social ills with physical ailment, but perhaps narrative medicine illuminates a path forward. 

In the wake of modern medicine, endometriosis nonetheless represents an afterlife of patriarchal, classist discourses in medical hysteria. Specifically, hysteria’s legacy is the pathologizing of women’s bodies based on their reproductive capacity, feminine sensuality, and psychological deficiencies. From the nineteenth-century diagnosis of hysteria to contemporary attitudes toward endometriosis, the medicalization of women’s health historically functioned as a means of controlling behavior and enforcing societal norms; today, the slow and ineffectual recognition of women with endometriosis reflects a kind of medical misogyny which trivializes and over-writes women’s pain. Taken together, disease diagnosis—or the lack thereof—becomes a legitimate structure which oppresses women in and beyond the hospital. It strips women of their bodily experience, and reifies self-sacrificing motherhood as a woman’s biological “normalcy.” Yet storytelling has historically offered a new way to center women’s experiences and turn scrutiny toward their lived context. Turning to such stories may help disentangle the historical biases which shape the medical treatment of women’s health, working toward a more just model of care.

Samantha Liu is a junior in Grace Hopper College.

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