871

ROYAL SOCIETY OF MEDICINE.

SECTION OF MEDICINE.

ON Oct. 23rd, with the Vice-President, Dr. ROBERTHUTCHISON in the chair, this Section held a meeting(to which the Section of Psychiatry was invited) todiscuss the subject of

HYPOCHONDRIA.

Dr. R. D. GILLESPIE, in his opening paper, saidthat the condition was one of a distinct reactiontype, which was well worth isolating, because of itstherapeutic and prognostic aspects. It was not adisease. It had long been, and still was, identifiedand confused with melancholia, hysteria, neuras-

thenia, and certain other conditions. Some older

psychologists spoke of a " hypochondria cum

materia " when gross organic disease was found and" hypochondria sine materia" when no importantphysical disease was evident. It was a matter of con-troversy whether hypochondria existed per se, or

only as part of a larger symptom-complex. Hebelieved such a syndrome could usefully be distin-guished. It was a subject which at the present daysuffered from comparative neglect. He consideredhypochondria to be a persistent preoccupationconcerning the bodily health to a degree in excess ofwhat would be justified by any physical disturbancewhich happened to be present ; an emotional attitudewhich was best described as interest with conviction,anxiety (in the sense of a fearful apprehension ofdisease) being absent. In the patient’s mind thepresence of disease was a settled conviction. Thiscondition, Dr. Gillespie contended, was inaccessibleto psychotherapy, and ran a chronic course withoutintellectual or emotional deterioration. For a longtime hypochondria was considered to be a form ofneurasthenia ; Kraepelin, in fact, placed it amongthe neurasthenias. It should be differentiated fromanxious preoccupation. Depression or affectivesadness was no part of the concept. Whereas thehysterical patient was susceptible to reassurance,the hypochondriac was not. Hypochondria developedin the type of person who had led a subjective andsolitary life. The common-sense view of the con-dition was that it consisted not of the direct expressionof organic brain disease, but rather of a reaction toinfluences, either external or internal, as an excusefor voicing some trouble. The fixity of the symptomswas attributed to habitual self-centredness. The con-dition usually arose in later life, at which time therewas said to be an increasing tendency to becomelargely interested in the bodily health. The common-sense view left untouched, however, the reason whysuch self-centredness existed, and why there was thisfixity. The alleged preponderance of hypochondriain the male sex was explained by the fact that similarmanifestations in the female were designated hysteria,though the speaker contended that there a distinctdifference between the two conditions.The prognosis of hypochondria, Dr. Gillespie con-

tinued, must depend in part on the relative importanceof the exogenous and endogenous factors. The morethe condition seemed dependent on a physicalabnormality, the more likely were the symptoms tcdisappear when that had been dealt with ; but whenit was rather an outgrowth of the personality thEoutlook was more doubtful, as the personality wasso often suffused with unhealthy attitudes. Cases iryoung persons might be regarded as more favourabhthan cases in the old. By way of treatment an3organic disease present should be dealt with. Thes(people did not lend themselves to profound analysisbut common-sense measures, such as change o:

occupation and environment, should always be tried

Discussion.Dr. R. S. ALLISON agreed that hypochondria coul<

be regarded as a definite entity, and not merely aa variety of some other condition. Often the physician was confronted with a patient who showed n4

abnormality save an undue concentration on hisbodily sensations ; but hypochondria was more

than that. In fact, it did not differ greatly from theanxiety of neurasthenic states. He liked Dr. Gillespie’sdefinition that it was " an interest with conviction."A distinctive point was the patient’s persistent searchfor a cure, by means which even the sick man wouldnot resort to. When the symptoms were said by thepatient to centre around the alimentary tract, it wasimportant to search for any cause of real symptoms,though the hypochondriac was a difficult subject toinvestigate, and might be in such a hurry for resultsthat he was unwilling for a barium meal to passnaturally, but quickened it by taking purgatives.When a person had had an operation at some previoustime the possibility of there being adhesions shouldbe looked into. To try to remove the patient’s falseimpression was to embark on a forlorn hope. Iforganic disease contributed to the trouble, removalof this rendered the prognosis much more hopefulthan when there was no such disease. The inculca-tion of good daily habits, such as the regular use ofliquid paraffin, would do much. It was also rationalto give bromide in small regular doses.

Dr. W. R. REYNELL considered that Dr. Gillespiehad established his thesis that there was a definiteclinical entity such as he described, though-as sodelimited-it was rare. His remark that there wasa preoccupation in excess of what the physicalsymptoms justified presented a difficulty, Dr. Reyneltthought, as it was difficult to assess what degree ofpreoccupation was justified in a case of markedvisceroptosis. He did not agree that when diseasewas absent though the patient considered he had it thecase was inaccessible to psychotherapy. In a largenumber of cases this treatment was possible. He

thought it was often possible to tell, even in child-hood, what type of person was liable to become ahypochondriac. It was the person of low vitalityand low blood pressure, of the toxic, debilitated type-a type abnormally liable to feelings of illness-andvery hyperaesthetic. In a word, these patients wereprone to dysaesthesia, and it was possible to benefitthem greatly by rational psychotherapy. The bestdrug for them was the spoken word-spoken in theright way.

Dr. T. A. Ross thought it would be a great achieve-ment to be able to determine which psychoneuroticcases were likely to benefit from treatment andwhich were not, as treatment took a long time, andenergies could thereby be conserved for the hopefulcases. There was a type of old man in this categorywho was quite inaccessible to treatment ; the impor-tant thing for such a patient was to keep him out ofthe hands of quacks. He thought that Dr. Gillespie’sdescription was a description of a type of life ratherthan of a disease.

Dr. C. P. SYMONDS also thought that the openerhad established a very definite clinical picture, but hedid not feel so certain that he had shown it to be adefinite type of mental reaction separable from themanic-depressive and hysterical groups. The form

: associated with manic-depressive psychoses was the: one too often missed by the general practitioner andl the general physician; he referred to the mild. depressive psychotic whose symptoms were expressedrather in the way of bodily symptoms than as a frank mental disorder. Most of them were sent to the; neurologist with the diagnosis of neurasthenia, butl by that time they had usually been under one or more operations. Too often in these cases a history of somer previous nervous breakdown was not pointedly inquired for. Apart from such a history there were, associated symptoms and signs of value in diagnosis,f such as self-depreciation and self-reproach, with a. sluggishness of response, evident to the patient and

supported during the physician’s examination. Therewas also a tendency to a marked increase in the

1 symptoms in the early part of the day, with a distincts lifting of the cloud as the day advanced. The manic-- depressive group were relatively inaccessible to psycho-3 therapy, but not so the young people whose fear was

872

not based on a settled conviction of disease. Thisdifference might be one merely of degree, not aqualitative one. The schizophrenic with hypo-chondriacal symptoms might be difficult to diagnosein an early stage. He discouraged the idea of makinginaccessibility to therapy a criterion of diagnosis.

Dr. PARKES WEBER thought the term hypochondriashould be limited to the kind of case to which Dr. Rossreferred.

Dr. F. DILLON spoke of the sadism which was sooften expressed in the hypochondriacal state. It wasdifficult to conceive that a man who insisted onhalf a dozen abdominal operations was doing it fromany mere egoistic motive ; the most probable explana-tion, he thought, was that the man was identifyinghimself with someone else, and in that way wasderiving antagonistic satisfaction.

Dr. JOHN CARSWELL said his hope had been thatthe term hypochondria, if employed at all, would berestricted to the involutional case. lie had seenhypochondrial symptoms as the earliest manifestationsof general paralysis of the insane ; sometimes in earlyphases of dementia praecox. Even a patient withdelirium tremens might display, in the pre-deliriumstage, a restless anxious reference to bodily symptoms.He had never seen a hypochondriac who got the betterof the physical condition who did not carry out self-treatment in defiance of his medical man, and somesuch lived to a good age. He was always self-centred,bent upon giving himself a good time, and he rigorouslyshut out of his mind all other considerations.The CHAIR1>IAN said that he, in common with every

general physician, saw the hypochondriac as an

ordinary harmless person, and one who certainly wasnot insane. He agreed with the opener that thehypochondriac was usually an elderly gentleman whohad retired from business, and who collected symp-toms, very much as another old gentleman wouldcollect postage stamps or old china. His health had,in fact, become his hobby. True, most of the itemsin his collection were fakes, but every now and againhe came upon something which was real, and this wasapt to be overlooked by the physician, who hadarrived at the conclusion that it was all fake. Sucha man was harmless and incurable ; indeed, thespeaker did not want to cure him, for, from the pointof view of the patient, it would be unkind to do so.The hypochondriac was said to be egocentric, but hewas not always so, for one could recognise thevicarious hypochondriac. Numbers of parents- weredesperately hypochondriacal about their children,but not about themselves. The extravagantly fussytype of parent was well known. Even a whole nationcould become hypochondriacal. A case in point wasthe Jewish race. Ever since Moses was so ill-advisedas to lay down for the people’s observance a sanitarycode, they had been a nation which had devotedfar too much attention to ills and the discovery ofimaginary illnesses. Hysteria had always seemed toMm to be something different. The hysterical personseemed to have some definite purpose to serve in his.manifestations, whereas the hypochondriac’s collectionof symptoms seemed purposeless, being rather in thenature of some definite occupation. As Dr. Gillespiesaid, there was but a small literature on the subject,yet it would always remain for the physician one ofvery great interest.

Dr. GILLESPIE, in reply, said he did not includeamong hypochondriacs those who suffered fromvisceroptosis. Even among presumably educatedpeople physiological knowledge was still very inade--quate. Often the type of subjects under discussionsuffered from an ever-present consciousness of guilt.

LONDON FEVER HoSPITAL.-This institution, inLiverpool-road, Islington, which was founded in 1802, andhas 178 beds, is seeking to raise 50,000 by the first generalappeal it has ever made. A new isolation building is apressing necessity, the old one being out of date and beyondyepair. It is pointed out that this is the only voluntaryAever hospital in and around London.

Reviews and Notices of Books.STERILITY IN WOMEN.

Diagnosis and Treatment. By SIDNEY FORSDIKE,M.D., B.S. Lond., F.R.C.S. Eng. and Edin., Sur-geon to the Hospital for Women, Soho-square.London : H. K. Lewis and Co., Ltd. 1928. With25 illustrations and 17 plates. Pp. viii. + 133. 9s.

So many advances have been made in the diagnosisand treatment of sterility during the last ten yearsthat Dr. Forsdike has been tempted to give someaccount of these from his own wide experience. Themethod of investigating a case is well and clearlydescribed, and the case sheet devised by the authorwill prove useful to other workers. Stress is laid onthe importance of examining the husband who,according to Dr. Forsdike’s records, is responsible forsterile union in 25 per cent. of cases. " In ordinarycases the investigation of the woman ceases at thebimanual examination until a report has been obtainedof the man’s condition." The technique of tubalinflation as practised by the author is fully describe.No anaesthetic is used, and a pressure of 300 rmn. Hgis considered safe. Out of 100 cases in which thetubes were inflated 15 became pregnant withoutfurther treatment at periods varying from 1 to 12months. Later in the book it is stated that unlessthe pregnancy occurs within three months of theinflation it cannot be regarded as due to it; ifthis test is applied only 7 of the 15 can be regardedas possibly due to the inflation, and three of theseoccurred in patients married only two years. Evenwhen the strictest tests are applied, however, theauthor’s contention that inflation alone is responsiblefor the cure of sterility in certain cases is borne out.If pregnancy does not follow in three months afterinflation lipiodol is used and a hysterogram taken.This method of demonstrating the site of obstructionin closed tubes was described by Dr. Forsdike in 1925,and since then he has used it in a large number ofcases. His technique is clearly described, and excel-lent pictures illustrate X ray findings after injection.Of 67 cases in which lipiodol was used, the tubes werefound to be patent in 41 ; of these 41, pregnancyfollowed in 14 without any further treatment. Acritical examination of the details of these cases willperhaps carry less conviction than the cases ofpregnancy after inflation, but as to the value oflipiodol as a diagnostic agent there can be no doubt.The chapters on treatment leave nothing to bedesired. In tubal obstruction the author recommendsoperation only when the closure is situated at thefimbriated end ; even then, in 20 cases in which anopening was made at this end, 11 were found to beclosed again in three months, and only two of the 20became pregnant and bore living children. Excisionand anastomosis of the isthmus and implantation ofthe distal end of the tube in the uterine wall arecondemned. In none of ten operations of thiskind did air pass at the end of the operation. Dr.Forsdike concludes that " operations upon this partof the tube offer no prospect of relieving sterility."It is unfortunate that a book so excellent in substanceshould here and there be disfigured by sentencescarelessly constructed. On the first page, for example,sterility is defined as

" a woman who offers no evidence

of being fertilised." Moreover, though the causes ofsterility are thoroughly discussed, the classificationis confusing and does not seem to be adhered to evenby the author. Thus the Empress Josephine is classedas " relatively sterile," while at page 19 " relativesterility " is included as a variety of " congenital."Surely she was really an example of " secondarysterility " following infection after her second labour.The monograph shows in every page evidence of

rich personal experience, and will well repay themost careful study.