On the acquisition of a gastroscope.

The authenticity of Charcot's original descriptions of hysteria has been questioned in the popular media. None the less, it is stili possible to encounter florid forms of hysteria in culturally deprived communities, and to answer Charcot's present day critics we present a selection of patients from Kentucky's Appalachian counties with hysterial neurological disease. Their case histories are contrasted with those Charcot himself described and thereby form a modern commentary on such conditions as la grande hysterie, hysteroepilepsy, hysterotraumatic monoplegia, and hysterical hemianaesthesia. Royal Preston Hospital, Preston, Lancashire PRI 6PS E M R CRITCHLEY, DM, FRCP, consultant neurologist Cardinal Glennon Memorial Hospital for Children, St Louis, Missouri 63104, USA H E CANTOR, MD, paediatric neurologist Correspondence to: Dr E M R Critchley. Introduction Hysteria is present when there is a disproportionate relation of symptoms to disability and a discrepancy between the manifestations and the anatomical and physiological arrangements of the body. ' Caution must be exercised in accepting even the most florid presentations, and hysteria presenting with neurological symptoms may be especially misleading.2 Furthermore, the physician has the added duty to understand why the patient has taken to express himself or herself subconsciously in this manner. The unexpectedly high incidence of hysterical disorders among the underprivileged white community of Kentucky's Appalachian counties is a matter of surprise, matched only by the similarities of these disorders to the original descriptions of Charcot in his clinical lectures on diseases of the nervous system.3 Clinical presentations One of the most startling forms of hysteria that Charcot demonstrated at the Salpetriere was la grande hysterie, otherwise called hysteria major or hysteroepilepsy with distinctive crises. Freud described la grande hysterie as consisting of four phases4: the epileptoid; violent movements; attitudes passionnelles (the hallucinatory phase); and the concluding delirium. According to