Hysteria revisited

Brian Inglis

A Leg to Stand On Oliver Sacks (Duckworth £8.95) Doctors Jonathan Gathorne-Hardy (Weidenfeld & Nicolson £10.95)

Oliver Sacks, neurologist extraordin- ary, panicked on a Norwegian moun- tainside, fell, and smashed up a leg. With a notable piece of carpentry, a London surgeon fitted everything together again. The only trouble was, Sacks found he could not move the leg. It was as if he had forgotten how. Alarmed, but intrigued, he looked forward to a discussion of this curious development when the surgeon came on his round. I don't seem to be able to contract the quadriceps', Sacks volunteered, doubtless assuming that he would be treated as an equal. To his chagrin, the surgeon told him hhe was talking nonsense. 'He held up his and, like a policeman halting traffic. You're completely mistaken", he said with finality. "There's nothing wrong with the leg. You understand that, don't you?" With a brusque and, it seemed to me, irritable movement, he made for the door, his Juniors parting deferentially before him., Sacks, the surgeon had evidently Wesulned, was being hysterical. Ironically he Was right, though not in the sense that — and perhaps Sacks, too — would

, used the term. A century ago, gists diagnosed hysteria when confronted

twihth cases such as Sacks's where, though a is nothing physically the matter with the it appears to be paralysed. But with a"se development of what was then known d; nrganicism the assumption that real disorders must be organic — the diagnosis

went out of favour, to the irritation of Sir James Paget, who used to warn his stu- dents that functional mimicry of paralysis was not found only 'in silly, selfish girls' they should expect to find it among 'the very good, the very wise and the most accomplished'.

Sacks's Awakenings surely put him in that august company; and A Leg to Stand On is a worthy successor. His case is that `severe disturbances of body-image and body-ego' (he does not care to use the term hysteria, understandably; and Paget's prof- fered alternative, neuromimesis, never really caught on), following some physical or emotional — both, in his case — shock, are very common. But physicians and surgeons have been conditioned to ignore such disturbances, or to brush them aside as hysterical in the colloquial sense, as even some leading psychiatrists do. Sacks was compelled to conduct his own therapy, to find how to put life back into his limb.

It is a heartening story, though the exuberance with which he tells it is a little overpowering at times. All that prevents it from being on a par with its predecessor is the .inadequacy of the last section, on 'understanding'. He cites the research of the Lurias and other Russian neurologists in this field, but makes no mention of Paget's or of the other researchers a century ago. He fails to make the distinc- tion which the unfairly neglected Emile Coue insisted upon between the will and the imagination, as the sponsors of regen- eration; and he says nothing about recent research into the use of biofeedback to stimulate the imagination — all the more surprising in that Sacks used it himself, notably when he discovered the beneficial effect of Mendelssohn's violin concerto. It would also have been interesting to find whether suggestion under hypnosis — a method the Victorians used to detect whether paralysis was organic or neuro- mimetic — would have worked in Sacks's case; though I suppose that if he had asked for it, he would have been transferred to a mental hospital, there to get shock treat- ment instead.

Still, Sacks makes an impressive and very readable case for the right, and indeed the duty, of patients to undertake their own treatment when orthodoxy simply declines to accept the imagination's role as both the maker and the breaker of disease.

A Leg to Stand On itself stands alongside Norman Cousins's Anatomy of an Illness, as a demonstration of the irrelevance of

outmoded organicism in such circumst- ances. But this prompts the question: why is neo-organicism still dominant in hospital medicine, and to a depressing extent throughout the National Health Service? Why is the imagination's power so rarely recognised, let alone exploited?

The reason can be gauged from Doctors. Jonathan Gathorne-Hardy took a tape

recorder round to a hundred or so GPs; and the chief lesson which emerged from the conversations was that their training as

medical students was crazily irrelevant to their work in general 'practice, largely because of its organicist bias, and its refusal to recognise that they would be dealing with people.

For a start, medical students are selected chiefly on the basis of exam results which would suggest they could become able research scientists: not for qualities which would help them as doctors, let alone as GPs. And if a medical student does happen to have those qualities, they are stamped upon. Research, Gathorne-Hardy shows, has revealed that at many medical schools, adverse attitudes are inculcated; a high proportion of students have left Edin- burgh, for one, 'with views that at least indicate insensitivity towards, and at worst a positive hatred of people and patients'.

Students who are going to be GPs, too, have to complete the full hospital training, which means that all they see as a rule are disorders of a kind (or at a stage) that as GPs they are not going to be able to treat — that, after all, is why the patients are in hospital. And they are given only perfunc- tory instruction about the stress and psychosocial disorders that they are going to be dealing with. `They don't teach you about people, and it's rotten for the patients', a woman GP told Gathorne-Hardy. 'It was bad train- ing.' Perhaps, she added, they are taught better now? They are not. A vocational GP training has been tacked on to the end of their training in hospital, but by then the damage has been done. And teaching hospitals, owing to the proliferation of specialities, are actually getting progres- sively more remote from the realities of life, health and illness outside.

Gathorne-Hardy is a concerned and sympathetic observer, and his recorder has picked up much that is valuable; but he has been unable to solve the ugly problem which confronts anybody who has to fashion a book out of yards of tape. It must have seemed sensible to divide it up into sections, but without cross-referencing this has bred confusion. If you want to check, say, who the doctor that is pontificating on sex education, or on group practice, you will go to the index to find the page on which Gathorne-Hardy .has intro- duced him, or her — often engagingly. You will then find that there is no index. There ought to be some appropriate punishment for publishers who commit such crimes. Something lingering, in boil- ing Valium?