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the stenosis. The typical mitral diastolic murmur waspresent in all patients save one, but its intensity was notrelated to valve size. The length of the murmur wasthought to be proportional to the severity of the stenosis.Apical systolic murmurs were louder in patients withsignificant incompetence than in those without; but softsystolic murmurs were heard in patients with purestenosis, if atrial fibrillation was present. When grossincompetence was present a loud systolic murmur washeard, and absence of such a murmur virtually excludedincompetence. In intermediate cases the intensity of thesystolic murmur did not indicate the degree of incom-petence. It is important to distinguish the pansystolicmurmur of mitral incompetence from that of tricuspidincompetence, and from the ejection murmur of aorticstenosis.Radiographic studies confirmed the clinical findings

of enlargement of the right ventricle in pure stenosis,and of the left in pure incompetence. Enlargement ofthe right ventricle was greatest in patients with thesmallest valves. Left ventricular enlargement usuallyindicated significant incompetence but was present in4 cases with pure stenosis, in the absence of any othercause. The right ventricle was enlarged in mitral

incompetence when the pulmonary resistance was

raised, and McDoNALD et al. point out that such

enlargement does not exclude the presence of severeincompetence. The size of the left atrium was not

helpful in assessing valve size; severe incompetence wasusually accompanied, by a large left atrium, but this wasoccasionally seen with pure stenosis, as others havefound.8 9 systolic expansion of the left atrium was of novalue in distinguishing incompetence from stenosis.Calcification of the mitral valve was common but wasnot specially associated with incompetence-a findingwhich differs from that of WYNN. 5 Little differential

diagnostic help was apparently gained from radiographicsigns of pulmonary venous and arterial hypertension 10 11 ;perhaps this is so because the lung changes correlatebest with increases in pulmonary vascular resistance,which can be present in both incompetence and stenosis.The electrocardiogram showed evidence of right

ventricular hypertrophy in pure severe stenosis when thepulmonary vascular resistance was appreciably raised,but of left ventricular hypertrophy in severe incom-petence. In intermediate cases there was evidence ofbiventricular hypertrophy or normal ventricular balance.Broad and notched " mitral " p waves due to left atrial

enlargement did not differentiate between incompetenceand stenosis, but atrial fibrillation was universal in thecases of frank incompetence, whereas many with purestenosis had sinus rhythm. Hasmodynamic studiesshowed that when mitral disease was severe thedominant lesion (stenosis or incompetence) was closelyrelated to forward mitral-valve area. Significantincompetence was exceptional with the smallest valves,7. Wells, B. ibid, 1954, 16, 261.8. Venner, A. Brit. med. J. 1954, i, 1359.9. Goodwin, J. F., Hunter, J.D., Cleland, W. P., Davies, L. G., Steiner, R. E.

ibid. 1955, ii, 573.10. Davies, L. G., Goodwin, J. F., Steiner, R. E., Van Leuven, B. D.

Brit. Heart J. 1953, 15, 393.11. Short, D. S. ibid. 1955, 17, 33.

while dominant incompetence was the rule with the

larger valves. Between the extremes was a wide

spectrum in which dominant stenosis shaded graduallyinto dominant incompetence. Pulmonary vascularresistance was highest in patients with pure stenosis,but considerable increases in resistance were also foundin incompetence. Like other workers,12 McDoNALDet al. obtained little diagnostic help from the form of thepulmonary capillary venous pulse, a large v wave oftenbeing found in both stenosis and incompetence. Theyhold that more information is needed about the estima-tion of the rate of descent of the y wave, expressed asthe Ry/v ratio " of OWEN and WooD.13 But a slow"

y " descent is helpful in suggesting mitral obstruction.This valuable contribution lends weight to the

accepted criteria for the diagnosis of mitral incom-

petence, and suggests that combined clinical, radio-

graphic, and electrocardiographic examination usuallyprovides the best estimate of the relative contributionsof stenosis and incompetence. But difficulty exists inmany cases, and the refinements in diagnostic methodstill needed may be provided by the dye-dilutiontechniques of KORNER and SHILLINGFORD.14 Other

techniques, involving puncture of the left atrium 15-17and consecutive measurements of left atrial and ventri-cular pressures, may yield useful information; butsimultaneous measurement of flow is necessary for

diagnostic certainty.

12. Wynn, A., Matthews, M. B., McMillan, K. R., Daley, R. Lancet, 1952,ii, 216.

13. Owen, S. G., Wood, P. Brit. Heart J. 1955, 17, 41.14. Korner P. I., Shillingford, J. P. Clin. Sci. 1955, 14, 553.15. Radner, S. Acta med. scand. 1955, 152, 1.16. Morrow, A. G., Braunwald, E., Haller, J. A., Sharp, E. H. Circulation,

1957, 16, 399.17. Bjork, V. O. Acta chir. scand. 1954, 107, 466.18. Charcot, J. M. Lectures on Diseases of the Nervous System. London,

1877.19. Babinski, J. Ma conception de l’hysterie. Chartres, 1906.20. Bumke, O. Handbuch der inneren Medizin. Berlin, 1926.21. Turner, W. A. Epilepsy. London, 1907.22. Krapf, E. E. Bull. Wld Hlth Org. 1957, 16, 749.

Epilepsy and HysteriaFASHIONS in disease are imposed not only by medical

opinion but also by the Zeitgeist. Few doctors now seela grande crise d’hysterie-the major hysterical fit whichused to be an important and sometimes difficultdifferential diagnosis from epilepsy. CHARCOT,18 in thedawn of modern clinical neurology, made the distinctionwith his usual clinical shrewdness, and the main differ-ences that he noted continue to guide us. There were

cases, however, in which he found it hard on semeio-logical (and, one suspects, on setiological) grounds toseparate the two. These he referred to as " hystero-epilepsy ". The term and the concept were not generallyaccepted by a later generation of French neurologists.BABINSKI,19 for instance, insisted that all cases could beput into one or other category. BUMKE 20 in Germanywas equally emphatic. ALDREN TURNER 21 in this countrywas less dogmatic: but in general hystero-epilepsy wasregarded with suspicion. The aetiological segregation ofthe two conditions-and this was the real point at

issue-was considered to be complete. The problemwas shelved rather than solved, and KRAPF 22 has latelyreviewed it.

Diagnosis has always been difficult in the cases with

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features of both epilepsy and hysteria; and it was usualto suggest that hysteria happened to coincide with

epilepsy, just as it might with any other organic condi-tion. In some cases the concept of " affective epilepsy "-a form of reflex epilepsy in which the afferent stimuluswas an emotional one-was a help, but many could notbe forced into this mould. With the advent of the

electroencephalogram (E.E.G.) the differentiation shouldhave become easier; for if epilepsy is a specific cerebraldysrhythmia this can surely be recognised on the E.E.G.,and if the dysrhythmia is not present the attacks cannotbe epileptic. Unfortunately, with growing knowledge ofthe E.E.G., this argument is not as convincing as it was.E.E.G. records are still useful diagnostically, but it hasbecome clear that some abnormalities are not a specificepileptic dysrhythmia but are somewhat similar to suchdysrhythmia ; and commonly these are found in justthose patients whose abnormal behaviour raises the

possibility of a psychiatric diagnosis. Thus aggressivepsychopaths, and indeed inadequate psychopaths too,in whom hysterical features are readily found, haveabnormal E.E.G.S which represent in part a defect of" maturation " of the electrical record. In aggregatethese can probably be distinguished from a group ofepileptic records, but distinction in individual cases maybe very hard.

Growing recognition and exploration of the temporal-lobe group of epilepsies further obscures the borderline.(CHARCOT’s own description of hystero-epilepsy readsvery like an example of temporal-lobe epilepsy.) Hereundoubted epilepsy occurs in a setting of behaviourdisorder and emotional abnormality, and individual fitssometimes appear to have a mental cause. Indeed, forepilepsy in general BARKER 23 and others have made thewider claim that with abreactive and suggestion tech-niques an appropriate psychological stimulus will

reproduce specific epileptic activity, both electro-

encephalographic and clinical. Conversely formalpsychotherapy, particularly where specific psychogenicfeatures can be uncovered, may very occasionally havea dramatic effect on epilepsy; and the psychotherapy ofenvironmental adjustment may be more often effectivethough less dramatic.

It seems that we must reconsider the concept of

hystero-epilepsy, not in the form that CHARCOT put itforward, but as a more fundamental problem in thephysical and mental genesis of epilepsy. The clinicalproblem may be small; but the idea behind it is

important. In these days of psychosomatic medicineit is as well to try and see the reality behind the

phrase.23. Barker, W. Res. Publ. Ass. nerv. ment. Dis. 1950, 29, 90.

Annotations

TRUANTS IN INDUSTRY

Shepherd and Walker 1 have studied the relation ofabsence from work and overtime working, on the onehand, to wage level and the number of dependants onthe other. Their investigation was made in 1952 in alarge iron and steel works where wage differences dependon promotion grades and do not sharply reflect differencesin skill or responsibility, and bonuses bear little relation toindividual productivity. The difference in gross annualwages between the highest and lowest paid groups was1300. The data were taken from absence records; nearlyequal numbers of men were selected in each of six wage-groups, matched for average age, income-tax code-number (as an index of the number of dependants),heaviness of work, and temperature of working conditions.The number of absences and total duration of absence

(as number of shifts lost) were calculated per 100 men ineach group, and divided into absence due to sickness, dueto injury, with permission, and without permission.

Certain trends were obvious. The absence-rate was

high in the lowest-paid group, mainly through moreabsences without permission and more long absences withpermission. In other groups the number of absences andof shifts lost increased with increasing wages. Absencewithout permission increased with increasing wages, butthis did not hold for the highest and lowest wage-groups.At higher wage levels the high total number of absenceswas caused by absences without permission, but the largenumber of shifts lost was caused mainly by more recordedsickness. There was no evident a-priori reason to expecta greater incidence of sickness in the higher-paid group(indeed, in an outbreak of influenza the previous year the

1. Shepherd, R. D., Walker, J. Brit. J. industr. Med. 1958, 15, 52.

incidence had been much higher in the lower-paidworkers). Shepherd and Walker believe that the differencewas caused by a greater tendency to go absent (for illnessor other reason) and a tendency to stay away longer fora given illness in the higher-wage group, and by differ-ences in reporting illness. At lower wage levels manyabsences of medium length were probably due to sickness,though not reported as such. Thus there were many moreabsences (recorded as " without permission ", not as" due to sickness ") of four to nine shifts’ duration thanof two or three shifts’ duration; this would accord withtheir being caused by sickness, because of the NationalInsurance sickness-benefit regulations.

Absence-rates also varied according to family responsi-bility : they were high for single men, lowest for thosewith two dependants, and higher again for those withmore; this was true for both the higher-paid and thelower-paid workers. The amount of overtime workedincreased with number of dependants in the case of thelower-paid workers, but there was no such relationshipamong the higher-paid workers-perhaps partly becauseof income-tax differentials. The lowest-paid group hadthe highest overtime figures as well as a high absence-rate.

Shepherd and Walker differentiate between an indivi.dual " absence threshold ", determined by long-termfactors, both personal and general, and the immediatefactors which raise the question of whether or not to goabsent and may be powerful enough to exceed thethreshold. One step towards " coping with absence ",they say, lies in discovering the associations betweenabsence and such factors as number of dependants, timeof day (e.g., single-shift absences without permissionhave been shown to be commonest in the morningshift 2), or day of the week. Their investigation indicatesthat wage-level is an important factor.

2. Shepherd, R. D., Walker, J. occup. Psychol. 1956, 30, 105.