Basic Organic Disabilities

Altogether 11 men and 13 women were given an organic diagnosis coupled with the diagnosis of "hysteria." In some of these cases there appears to have been at the time some hysterical exaggeration of organically determined symptoms. This overlay was of temporary duration, and in the long run the course of the illness was that of the basic organic process, so that at a later stage one finds the organic disability persisting, all hysterical quality to the picture having faded away long ago. Sometimes the diagnosis of "hysteria " was based on the disproportion between the degree of disability and the physical signs. In a number of these cases (57101, 31797, 39849, 18025) organic personality changes or oncoming dementia have contributed to this disproportion, or have provided the indications of an altered mental state, which came to be interpreted as "hysterical." In such cases one wonders what the clinician had in mind which led him to speak of "hysteria." The semantic difficulty is exemplified strikingly in the case of a patient (42239) who suffered from unsteadiness in walking, giddiness, and visual hallucinations ever since an attack of meningitis. The physician noted that there was a basis for the hallucinations, depersonalization, etc., in the old meningeal infection, but added: "It is however my view that her failure to accept any responsibility in rehabilitation with consequent dependence on doctors and institutions is hysterical."
    In this group other organic diagnoses which were missed on the first occasion include patients whose black-outs, fits, or post-ictal symptoms were thought to be hysterical, and who were later rediagnosed as epileptics ; patients whose "hysterical" symptoms were later shown to be associated with drug intoxication; and a woman with atypical migrainous headaches, later rediagnosed as a basilar vessel migraine. The next group of patients we have to discuss are those diagnosed simply as "hysteria," with no mention of any other factor, but who have eventually been found to have organic disease. Twelve men and 16 women fall into this group, which is a very mixed one. Two patients suffered from facial pain and were later rediagnosed as having trigeminal neuralgia and operated on with success, one at the National Hospital (32788) and one by Mr. Pennybacker at Oxford (48555). A girl (44595) with pain in the neck and paraesthesiae and weakness in the hands, diagnosed as hysterical in 1953, has recently been rediagnosed by Dr. Critchley as having a thoracic inlet syndrome. Patients whose fits were first thought to be hysterical have since been treated for epilepsy; an anomalous unsteadiness of gait has been diagnosed as the result of a vestibular lesion. As a rule the result of follow-up has been to change the interpretation of facts that have not changed; but there is also a small group of patients whose hysteria-like symptoms proved so deceptive that serious organic disease was entirely missed-an error not so much in interpretation as in observation.

    One may, for instance, mention the following cases. A woman (40838) with pain in the right shoulder and arm, numbness and paraesthesiae in the right arm and leg, and intermittent loss of consciousness, later proved to be a case of Takayasu's syndrome. A man of 65 (44098) with weakness of both legs and lack of normal sensation up to the waist, was later admitted to the Guy's-Maudsley Neurosurgical Unit, where they found upgoing toes and a sensory level at the fourth dorsal segment; there were positive myelographic findings, and a decompressive laminectomy was carried out; since then the patient has made steady if partial improvement. Two elderly men (46411, 42995) with unexplained neurological symptoms have steadily deteriorated into dementia; and a girl of 23 (43309) has subsequently developed the radiological picture of cortical atrophy.

    We are finally left with 9 men and 24 women, approximately 40% of the follow-up group with which we started, in whose cases no evidence for organic disease has yet been found. But even here the concept of " hysteria " fragments as we touch it. Among this group we find two schizophrenics (57425, 29010), a chronically anxious obsessional, and seven patients with recurrent endogenous depressions. Sift these out, and we are finally left, not with any single homogeneous group of nuclear hysterics, but with two groups of patients, each of them classifiable as suffering from hysterical conditions by current standards, but differing sharply from each other. We have in fact seven patients, mostly very young, who had acute psychogenic reactions in the form of a conversion syndrome conforming to the group of patients investigated by Carter; and 14 patients suffering from a lasting personality disorder who come somewhere near to satisfying the criteria proposed by Guze.