Substantival and Adjectival Views

This brings me at last to my own contribution to this discussion. I shall endeavour to persuade you that, to use Brain's terminology, the adjectival view can be maintained with some qualifications, whereas the substantival view cannot. I think the designation of a patient as a " hysteric " should be avoided, as it implies a qualitative rather than a quantitative distinction for which there is no warrant. But it would be legitimate, I believe, in a given instance to say that a particular symptom was "hysterical "; and the case is also arguable that the so-called "hysterical" traits of personality are not misnamed. In either of these uses, however, one should be aware of the possibilities of error. There is no "hysterical" symptom which cannot be produced by well-defined non-hysterical causes. The patient who coughs but does not speak may be suffering from schizophrenia; and the patient with loss of memory may be a malingerer. With such a caveat, then, the adjectival use may be allowed to pass. However, to suppose that one is making a diagnosis when one says that a patient is suffering from "hysteria" is, as I believe, to delude oneself. The justification for accepting "hysteria" as a syndrome is based entirely on tradition and lacks evidential support. No clearly definable meaning can be attached to it; and as a diagnosis it is used at peril. Both on theoretical and on practical grounds it is a term to be avoided. Let us briefly consider the theoretical aspect first.

    All the signs of " hysteria " are the signs not of disease but of health. The patient who cannot speak can phonate; it can be shown that the anaesthetic patient does feel ; the patient with the hysterical amnesia can be brought to recall. "Hysteria," one might say, is not an illness, but health, even if from the doctor's point of view it is health in the wrong place. One cannot build up a picture of an illness out of elements which are severally the evidence of absence of illness. No unitary concept is to be reached this way.

    On the practical side we have to remember that the diagnosis of "hysteria" is in essence the assertion of a universal negative. If it is shown that one out of a group of symptoms is "hysterical," this is merely to demonstrate that in respect of this symptom the patient is showing a normal and not a pathological reaction. It raises no presumption that the other symptoms exhibited are hysterical likewise, any more than a normal test result in one aspect of bodily function is relevant to a question of malfunction in some other aspect. To maintain the contrary one would have to assert that there is some distinctive feature in which "hysterical" individuals differ from normal ones-for example, in the mechanisms by which symptoms are produced. No one has gone so far as to claim this. The mechanism of dissociation, which by many authors, including Brain, is believed to play a central part in the production of "hysterical" symptoms, is itself entirely normal. As Head pointed out, the neurologist dissociates every time he looks through the ophthalmoscope in order to get the monocular vision he needs for the task. So it is with all the other mechanisms and the physiological and psychological attributes which by various authorities have been associated with "hysteria"; they are all normal. In diagnosing "hysteria" in a given case one is asserting in fact that not one of the symptoms is caused by disease, and that the probability that the patient is suffering from any disease which might have caused one of the symptoms is negligibly small. The necessity then arises to do what Brain said could be done; one must find the cause of the " hysterical" reaction. Short of that, one has left the patient undiagnosed.