Diagnosis of "Hysteria"
Slightly abridged Shorvon Memorial Lecture delivered at the National Hospital, Queen Square, London, on 30 November, 1964.
British Medical Journal, May 1965, 1, 1395-1399
It is a unique honour to have been asked to give the first Shorvon Memorial Lecture; and I should like to give thanks to the Hospital and the School who have awarded the privilege to me, and to the family whose generous endowment has established it. At this moment I would not find it easy to embark on a formal biographical sketch of a man who was my close friend and colleague, whose death little more than three years ago left us all with a lasting regret. It is, however, proper to record essential facts. Hyam Joseph Shorvon was born on 16 June 1906. He joined the National Hospital as Clinical Assistant on 1 January 1947, and later became Assistant in the Department of Psychological Medicine, and finally Assistant Physician in Psychological Medicine in 1960. He died all too prematurely on 14 May 1961.
What I should like to express on this occasion is in the nature of a personal tribute, such as from personal knowledge only I can make. I first got to know Joe Shorvon twenty-five years ago, in 1939, at the beginning of the war, when we joined the same hospital of the Emergency Medical Service. He was working then as a general physician, but he soon became interested in the psychiatric work of the neurosis centre. With D-day and the opening of the western front in Normandy he joined us in an acute treatment unit, and began to show his great qualities as an observer and a therapist. These were the days when abreactive methods of treatment were being developed; and they were proving extremely successful in the hyperacute neurotic states we were seeing in men flown direct from the front. These methods depended on the application of Pavlovian principles, which at that time had only just begun to make an impact on psychiatric thought in Britain. When Shorvon eventually joined the psychiatric staff at the National Hospital he brought us the best help of all, that of the naturally gifted healer. As a colleague and a participator in our weekly teaching conference Shorvon made a unique contribution. There was nothing conventional in what he had to say, and his insights were very personally his own.
Joe Shorvon would, I believe, have greatly approved the choice of subject for address. The problems of hysteria are of great subtlety and complexity. He made a worthy contribution to our understanding of the mechanisms; and he was one of those rare therapists who, from the range of experience of a normal soundly constituted personality, can step out to handle with wisdom and decision the thorny and often intractable problems of treatment.
Neurological Diagnosis
It is generally agreed that no one has yet framed a satisfactory definition of " hysteria "; but it is usually claimed that it can be recognized when met with. However, the ease and reliability with which this is done is differently viewed by different authors. "Hysteria" has been called the "mocking-bird of nosology" (Johnson, 1849), and "that strange disease" (Gowers, 1885). "There is scarcely one [nervous disease] 'which may not be simulated by this Protean malady," observes Gowers (1888a). "There is ... no symptom-complex of somatic illness that may not have its hysterical 'double,'" says Walshe (1963a).
Hysteria to Gowers is a "morbid state of the nervous system," more common in women than in men, in which the "primary derangement is in the higher cerebral centres, but the functions of the lower centres in the brain, of the spinal cord and of the sympathetic system may be secondarily disordered." He thought the malady was " a real one, occasionally of great severity, and to a large extent beyond the direct influence of the patient's will." To a certain degree he distinguished between symptom and personality, noting that hysteria was "in its slighter forms . . . as much a temperament as a disease" (Gowers, 1888b).
Charlton Bastian, another National Hospital physician, seems to have been aware of the logical indefensibility of making diagnoses by exclusion, since he refers to the diagnosis of "hysterical paralysis" as "a negative verdict." "We merely imply," he says, "that we think we are warranted in saying that the case before us is not one which has been caused by any gross organic disease of the nervous system, and that no causative changes therein would be detectable, even with the aid of the microscope. We leave entirely unanswered the other ordinary problems which go to constitute a complete diagnosis; nothing is implied, that is, as to the part of the nervous system which is at fault, or as to the nature of the process by which its functional activity has been impaired." "To arrive at a thoroughly warranted positive diagnosis of 'functional paralysis' is often for a time impossible even to one who has a very extensive acquaintance with nervous diseases ; at the most such a diagnosis may be regarded as more or less probable." The diagnosis is, he says, "often a matter of the most extreme difficulty," and "only a half-diagnosis." Moreover, "the more slender and insecure is the practitioner's knowledge of nervous diseases the more prone is he to regard strange or puzzling cases as instances of 'hysterical paralysis'" (Bastian, 1893a). He notes that "cases of hysterical paraplegia, rightly so called, are only encountered with extreme rarity" (Bastian, 1886), whereas cases of organic diseases of the spinal cord associated with hysterical symptoms are not uncommon.
Bastian thought that the diagnosis should depend on considerations of two kinds, severally connected with the grouping of symptoms, and with the mode of onset and past history. This, he says, is "a complicated procedure, and not too calculated to land us in certainties" (Bastian, 1893b), but unfortunately the only safe method of saying whether we have to do with a malady due to a mere functional defect or to an organic lesion.
The distinction Bastian draws between functional and organic, or at least the use of these words to cover the distinction, he must himself have abandoned a little later. Kinnier Wilson(1930), in the Morison Lectures, notes that, since clinical symptoms are to be considered as representing either excitation or cessation of function, it is meaningless to distinguish "functional" from "organic." He said: "This, so far as I personally am concerned, is an ancient platitude; I date my awakening to a conversation with my old teacher, the late Dr. Charlton Bastian, who, when I told him a patient had been admitted under his care suffering from what I, with the dogmatism of the house-physician, described as 'functional fits,' replied: 'Did you ever see a fit that was not functional?'"
In 1922 Henry Head published his lecture on "The Diagnosis of Hysteria," with which the present lecture so rashly shares a title. He laid it down that " for the diagnosis of hysteria it is necessary, not only that there should be no demonstrable organic cause for the symptoms, but that the positive signs of hysteria should be present." What are the positive signs of "hysteria" ? Unfortunately Head could not describe any common characteristic by which these signs could be recognized, and he dealt with them by enumeration. What follows is three pages of the very best clinical observation, showing how one by one a visual defect, a sensory disturbance, a paresis or spasm or tremor or ataxia, are to be recognized as due or not due to an organic state. Hysterical aphonia, for instance, is to be distinguished from an organic state by the preservation of the ability to phonate on coughing. Similar principles apply to all the conditions discussed. No criterion is given for distinguishing the " hysteric " from the normal individual. What is given is a list, which might be enlarged without limit, of rules by which the "hysteric" can be distinguished from the patient with any single named organic impairment of function. What is common to all these rules is their usefulness for disclosing normally preserved functional capacities underlying the superficial appearance of incapacity.
Neurologists of the present day are somewhat reserved in their approach to the theoretical aspects of "hysteria," but two physicians of the National Hospitals are able to help us. Sir Francis Walshe (1963b) discusses the differential diagnosis under two heads-the relation of the symptom to the disability, and the discrepancy between symptoms and anatomical and physiologicalarrangements in the body. The hysterical patient is interested in his symptoms, while the organically ill patient merely feels that they are a hindrance. The "discrepancies" alluded to are the "positive signs" of Head under a less ambitious name. Walshe does not claim that the diagnosis of "hysteria" rests on positive criteria; but neither does he state explicitly, what is in fact his position, that the clinical differentiae are the coupling of a personality trait or an attitude within normal psychological limits, with the physical signs of physiologically normal function.
In his account of "hysteria" Lord Brain assigns a key position to dissociation in the production of symptoms, unlike Walshe, who considers that the central feature is a loss of bodily function. We owe to Brain (1963) a useful distinction between what he calls adjectival and substantival views of "hysteria." He writes:
"If hysteria is regarded as a disease it tends to encourage the belief that it is necessary to decide whether a patient is suffering from hysteria or from something else. But if the patient is regarded as a hysteric it allows for the possibility that he may have other things the matter with him as well. He may be reacting hysterically to mental subnormality or depression, or even to anxiety. He may have hysteria and epilepsy, or hysteria and some organic brain disease. On the other hand, the substantival idea of hysteria as a disorder leads to the inquiry as to what abnormality hysterics have in common which leads them to react characteristically. This can be expressed in psychological terms, or in terms of disordered neurophysiology. These two modes of explanation, of course, are complementary and not mutually exclusive."