"Hysteria 311" - The Thirty-Fifth Maudsley Lecture

Journal of Mental Science 107: 359-81 (1961)


   Permit me to begin by saying how pleased and proud I am to have received the invitation to deliver this year's Maudsley lecture. This is, I think, one of the highest honours that our psychiatric confraternity can confer on any of its members, and is something that the recipient will treasure as an enduring reward.

   Henry Maudsley, whom we commemorate today, advanced the psychiatry of his time by applying philosophical ways of thought to clinical observations on individ­ual patients. Experimental and statistical techniques in his day were little under­stood, and psychiatry itself was not yet ripe for their application. The situation is now a very different one; and we have reached the stage where work which does not rely on one or more of the powerful techniques now available is likely to be received both by editors and by the generality of readers in a spirit of no enthusiasm.

   It is, therefore, with some trepidation that I venture to offer you a discourse which is based on observational data of a solely clinical type. These data have, indeed, been accumulated on a genetical principle, the hypothesis that monozygotic twins offer a controlled experiment set up by nature. But the limitations which apply to all purely clinical studies still obtain. However, there are certain rather primitive questions for which clinical studies are still the appropriate instrument. Controlled experiment and delimited statistical survey are the methods needed for problems which can be isolated and precisely defined. Until we can say just what it is we want to know, exploration along a wide front is still the most promising approach. This is, I submit, still the case with the neuroses; and of all the neuroses perhaps to the greatest degree in hysteria. If I have to trouble you with case presen­tations, which will lend an anecdotal air to my remarks, I must ask for your indul­gence; I know no other way to make my points.


    The twins which are the subject of this report were collected, as part of a systematized unselected series of all twins with a neurotic or psychopathic diagnosis, from the in‑patient and out‑patient material of the Bethlem and Maudsley Hospitals between 1 March, 1948 and 31 December, 1958, and from Belmont Hospital between 1 November, 1950 and 30 June, 1953. The Bethlem‑Maudsley group in the present study includes all those and only those twins, with a twin partner of the same sex who had survived into adult life, who in the records were at any time allotted the diagnostic classification number 311 of the W.H.O. International List of Diseases (1957), "Hysterical reaction without mention of anxiety reaction", with one further case (DZ 5) who had been given the number 320.7, "Pathological personality NOS" and specified as "hysterical". The Belmont diagnoses which were accepted for inclusion were those of "hysteria" and "anxiety‑hysteria".

   I would like here to express the gratitude of our Unit to both of these hospitals, and to all the many colleagues whose ungrudging co‑operation has made this work possible. If at times I suggest corrections of their views, such as a revision of diag­nosis, it must be understood that all I claim is the easy advantage of the observer who can be wise after the event.

   The preliminary case‑work on these cases was largely carried out by Mr. James Shields, my colleague in the Genetics Unit at the Maudsley. But for the last three years Miss M. Malherbe has undertaken a complete review of all the data obtainable on the neurotic twins, filling in gaps in our information and securing interviews with the surviving patients and their twins. Diagnosis of zygosity has been made on the basis of history, physical comparison, bloodgroups, finger‑prints and the P.T.C. test. In the series reported there is only one case (DZ 5) in which there is any material doubt that this diagnosis might be incorrect.


    The most striking of our findings is that, in the 12 MZ and the 12 DZ pairs, there is no single twin partner of all the 24 probands who has at any time received a formal diagnosis of hysteria. [The author's diagnoses on follow‑up of probands and co‑twins are given in Table 1.1.] The nearest approach to such a diagnosis is found in one of the dizygotic pairs (DZ 9).

The family background of this pair was a curious one. The father was a manic‑depressive with several hospital admissions, and in addition a crank who ran an unsuccessful campaign for the revival of craftsmanship among country blacksmiths. The mother was his first cousin, with further manic‑depressive illness on her own side of the family, and must have been as cranky as he was. When the Proband was taken to the Child Guidance Clinic at the age of 11, the psychiatrist noted that the little girl prattled to him about coprophiia and of her twin sister's inferiority complex and infantile attachment to the father. She was regarded as an anxious self‑dramatizing girl, but was not then diagnosed as a hysteric. However, it was the Twin who was first taken to the C.G.C. some months before her sister at the age of 11, and again later between 13 and 16. She was then regarded as "an unstable adolescent with hysterical and depressive traits, reacting to an abnormal environment"; but the depressive aspect was thought more important than the hysterical one.

The Proband was diagnosed as a hysteric when she was treated in the Maudsley at the age of 18. She had become depressed and unable to go on with her studies at the university, and was self‑reproachful and agitated, picking her hands and biting her nails. Several suicidal attempts were thought to be histrionic. Her illness was put down to a romantic attachment to a psychopathic criminal, who was shortly expecting release from prison. She was treated with psychotherapy and improved, but two years later was back again, now four months pregnant by a Ghanaian student. There is a suggestion in the case record that the earlier depression had been succeeded by a mildly hypomanic state, involving the patient in her pregnancy. If that is so the whole cycle may have been a cyclothymic one.

    If we can accept this pair as a concordant one, we must calculate the concor­dance rate for hysteria as 0 per cent in the MZ pairs, 8 per cent in the DZ pairs, which is far from impressive evidence of any specific genetical causation. We may, however, cast our net somewhat wider, and consider whether there are further cases of neurosis among the twins. In fact, three of the MZ and one of the DZ twins have come under psychiatric observation for this cause (MZ 2, 10, 12, DZ 1). One of these (MZ 2) may he taken as an illustration.

This pair, also, comes from a family in which endogenous depressions have occurred. From the beginning the Proband was a little behind his twin in development and vigour, but they were both forward children. They won scholarships to grammar school and university, and were on the point of starting at their universities in 1939 when the war came. Both registered as conscientious objectors, and were assigned to such duties as land drainage and civil defence. This was too much for the Twin, who according to his mother, decided he must get out and organized himself a medical discharge on grounds of psychoneurosis. The patient might have had more cause for this. He had had a mild depression at the age of 16 after the death of his father, and another depression lasting three months in 1943. However, he stuck it out, and served his time.

   After the war both returned to their universities. The Twin completed his three years, got his B.A., and through a varied and adventurous career, till recently in the theatrical world, has never had any later neurotic episode. The Proband, however, got behindhand with his studies, and as the finals approached began to fear he would not even get a good pass and would be left without means or profession. He could not concentrate, had difficulty even in talking, and had symptoms of depersonalization such as the feeling he was doing everything "second‑hand." On the day of the finals he did not present himself, but had an amnesic fugue lasting six hours. A few days later he was admitted to the Maudsley, underweight and depressed, but without other abnormality. Psychotherapy and a modified insulin treatment brought improvement. After discharge he was recommended to come up for further psychotherapy, but did not, and improved to recovery without further aid. He went back to his studies for a time, but even­tually gave up without taking his finals. Ever since he has been perfectly well.

   In this case the hysterical dissociation seems to have occurred under psychogenic pressure, but also at a time when powers of adjustment were impaired by a state of depression. Dealing very briefly with the three remaining pairs in which there is technical concordance in respect of neurosis, we have (MZ 10) a pair of psychopaths with numerous hysterical personality features, of which the Proband has a long history of hospital attendances, the twin a single episode when he was invalided out of the Army for psychoneurosis, having lost his memory after a fall. The second (MZ 12) is a pair of boys, now 21, who from earliest years have been of dull intelligence, enuretic, truants, subject to a number of neurotic traits, and with long records of delinquency, and with hysterical symptoms such as faints, falls, and visual hallucina­tions. Characterologically they are almost mirror images of one another, but it is only one who achieved a psychiatric diagnosis of hysteria. The third case (DZ 1) is one in which the Proband is a severely psychopathic woman, her twin much more normal with a single illness, with symptoms of an anxious and depressive type, from which she recovered spontaneously in four months.

   So far, then, we have 3 MZ pairs and 2 DZ pairs concordant for neurosis, giving us concordance rates of 25 per cent and 17 per cent. Neurotic states, however, are not infrequently handled entirely by the family doctor, with or without referral to general hospitals, and never reach the psychiatrist at all. In this series there are four cases in which this has occurred (MZ 6, 8, DZ 2, 3). In the first of these the Proband is a higher civil servant who, after many years of work and war service in the Far East, found himself at the age of 38 reacting badly to the stresses of a very responsi­ble post. He complained of headaches, depression, inability to concentrate and a head that seemed full of cotton wool. He worried about a sister‑in‑law who had been under treatment for cerebral tumour, and the psychiatrist considered his illness hysterical, presumably on the basis that it was the product of suggestion. He ar­ranged, himself, to get psychotherapy, but despite it remained ill for four years, having to be off work for 6 months three years after the first onset. Eventually he made a fair recovery. His less brilliant twin found himself a much easier and less ambitious life, but also had an unexplained illness which started about a year later than that of his brother. The main symptom was lassitude, but after a time he also complained of an unpleasant smell in the nose. Moving in less sophisticated circles than the Proband, he was satisfied with treatment along ordinary medical lines; but he remained ill until an antropuncture a year after the onset put an end to the smell in his nose.

   The other monozygotic pair which falls into this group (MZ 8) is one in which the Proband had an industrial neurosis with difficulty in walking, which lasted about 2 years, and kept him off work for a year. His twin was a bus‑driver, who was unable to walk for a fortnight after a road accident in which a man was killed.

   If we are to include these cases also in our concordance figures, we have 5 concordant pairs among the MZ twins, and 4 concordant pairs among the DZ. The difference is still negligible, and again we are driven towards the conclusion that specific hereditary factors are not manifesting their presence. We have not entirely covered all the psychiatric abnormalities among the twins of our probands; the list is complete with mention of a schizophrenic (MZ 11), a mental defective (DZ 8), and a ne'er‑do‑well with a criminal record (DZ 11).


   Our effort, then, to track down one type of aetiological factor, the genetical one, through the aid of concordance figures, appears to have taken us very little distance. Similarities of personality are often far‑reaching, but are rather seldom brought to the fore in symptomatology. Furthermore, despite the totally different genetical situation in MZ and DZ twins, in this group there is little difference between the two kinds of twins, whatever the criteria we employ. There is one further step we can take along genetical lines, and that is an examination of the family history.

   In his valuable monograph on Hysteria, Ljungberg (1957) calculated that the incidence of hysteria in the fathers, brothers, and sons of hysterics was approxi­mately 2, 3, and 5 per cent and in their mothers, sisters, and daughters 7, 6, and 7 per cent. For the general population he gives a morbidity risk of 0.5 per cent. The findings, he thought, supported the view that polygenic factors were responsible.

   Ljungberg provides a life‑table showing the distribution of morbidity risk of hysteria with age. Using this, we can calculate that in the 23 fathers, 24 mothers, 43 brothers and 29 sisters of our probands we have observed the equivalent of 96.31 life‑times of risk. Among these first‑degree relatives there is no single individual who has ever been diagnosed as having a hysterical illness. However, two mothers can be written down as having abnormal personalities of a hysterical kind, and one brother is an abnormal socially poorly adjusted individual who, I think, would have been classified by Ljungberg as a hysteric. The incidence of hysteria, on these criteria, is then approximately 3 per cent. This fits in fairly well with Ljungberg's own figures. Another way of putting it is to calculate that, if the incidence of hysteria among the relatives of my probands had been the same as in Ljungberg's group, I could have expected to find 4.2 hysterics among them, with which the observed 3 agrees fairly well.

   Ljungberg found no significant increase in the incidence of other psychiatric disorders among the relatives of his propositi, but there was such an increase in the propositi themselves. Among his male hysterics he found 3 who were schizophrenic, and among the females 5. The incidence of schizophrenia in the propositi themselves was, therefore, 3.1 per cent. In addition there were 1 male and 4 female manic­depressives, i.e., 2.4 per cent; and 4 male and 8 female epileptics (3.3 per cent). All these figures are high, and although individually they are not very significant, to­gether they are impressive. Ljungberg states that the total incidence of psychoses among his propositi, that is including schizophrenia, manic‑depressive psychosis, presenile and senile psychoses, psychogenic psychosis and undiagnosed psychosis, is 9.9 per cent for men, 9.5 per cent for women, diverging significantly from the expectation for the general population of 3.1 and 3.2 per cent.

   Among the relatives of my probands I found no schizophrenics, and only two epileptics, a brother and a sister. There was, however, a noteworthy number of manic‑depressive and typically endogenous affective psychoses. There were no fewer than 5 well‑established cases, 3 fathers and 2 mothers; and in addition one mother and one brother are of cyclothymic personality, one sister possibly had a depressive illness, and one mother had a depression diagnosed as reactive, but quite probably predominantly endogenous. If we take the risk period as lying from 20 to 65 in the male and 20 to 60 in the female, we may calculate that 69.5 risk‑lifetimes have been observed, against which 5 sure cases represents an incidence of 7 per cent.

   Among his propositi Ljungberg found that nearly half of both the men and the women had shown abnormal personalities, hysterical, asthenic and psycho‑infantile types predominating. However, among the first‑degree relatives there was no great incidence of psychopathy, as judged by fairly strict criteria, 4.9 per cent among parents and 2.6 per cent in siblings against an expectation of approximately 3 per cent. Among the relatives of my probands 2 fathers, 4 mothers and 1 brother were personalities abnormal to the point of psychopathy; but 3 of these individuals have already been classified as hysterics, so that we are left with an approximately 4 per cent incidence of non‑hysterical psychopathy among the parents. In addition, one each of the fathers, brothers and sisters, and 3 of the mothers, could be regarded as showing hysterical traits of personality within normal limits.

   The findings are, therefore, largely what might have been expected on the basis of Ljungberg's work, with the single exception that in this series the cyclothymic constitution shows up in a remarkable way. There is no indication that hysteria (or 'hysteria 311') can claim the autonomy of a genetical syndrome.


   Let us then turn to the environmental determinants, beginning with those that arise in infancy. There are two findings here which are interesting. In the dizygotic pairs, in all 8 cases where a difference in birth weight is known, it was the proband who was the lighter; and of the 6 cases where there was a noteworthy difference in health in childhood, in 5 cases it was the proband who was at a disadvantage. No such systematic difference shows in the MZ pairs. Both these findings suggest the significance of physical factors operating in early life; but as the differences between proband and twin are confined to the DZ pairs, we cannot exclude the possibility that these physical factors may have a genetical basis. Finally, a striking finding is that where there was a difference in handedness, in 3 MZ and 3 DZ pairs, it was the proband who was left‑handed or ambidextrous. The probability of such a finding arising by chance is one in 64. This, too, is a feature which may be speculatively connected with an organic predisposition.

   Sometimes, in the individual case, it is possible to be a little more precise. Thus in one of the DZ pairs (DZ 6), the proband at the age of 13 was away from school for a year, and in hospital for 4 months, with an illness involving jerky movements, provisionally diagnosed as chorea and finally as habit spasm. Recovery was very gradual when she was taken to the seaside to live with an aunt. The mother does not remember nervous traits before this illness; but according to another source both twins had neurotic symptoms before this age. In the Proband anxiety attacks started at the age of 19. A feature of her illness was that whenever she became emotionally upset, numbers of jerky and tic‑like movements would appear. The development of the illness was most unfavourable, the patient ruthlessly exploiting her symptoms to dominate her environment, but it seems to me by no means out of the question that a post‑choreic personality change of an organic type partly laid the ground for her hysterical disposition.

   A diligent search for other factors which might have played a part, such as birth order, birth difficulties, differences in breast feeding, in early development, and in parental attitude, and twin leadership, etc., have brought no quantitative differences between proband and twin to light.


   We receive an indication that this may be of moment in the observation that in the MZ pairs 5 of the twins enjoyed rather better health than the proband, the opposite being seen only once. In the DZ pairs the difference is more striking; in 9 cases the twin had the generally better health, and there is no case where the proband had the advantage. One way in which physical illness may predispose to hysterical symptoms is illustrated by MZ 3. The only noteworthy difference between the twins in this case is the amount of illness suffered by the Proband, gastric and intestinal trouble, cystitis, etc., which seems to have had a genuine physical basis; when her physical health improved, the hysterical symptoms passed off. However, differences are more quantitative than qualitative, and there is only one case (DZ 8) in which a physical factor played a recognizably decisive role.

In this case the Twin, who is a mental defective, has stayed at home and has had no physical illness. The Proband had otitis media and later mastoid disease. She had in all six mastoid operations, then a labyrinthotomy, and finally in 1953 at the age of 35 an operation for drainage of a temp ero‑sphenoidal brain abscess. There was delay in healing, and she was suspected of interfering with the ear and stirring up infection whenever her work as a nursing sister got beyond her. Her matron regarded her as having exhibitionist tendencies. She did her work well, but had too much sick leave. On one occasion she was found to have "large quantities" of barbiturate drugs in her possession, and was thought to be taking them to excess. Her neurosurgeon referred her to a psychiatrist with a note that "although she recently had a brain infection with B. coil abscess in the brain, I think there is no doubt that many of her symptoms are not organic in origin." The psychiatrist thought she showed organic intellec­tual deterioration, with indications of a nominal dysphasia, also an absence of insight not wholly explained as a hysterical reaction. Psychometry confirmed impairment of memory, learning difficulties and some nominal dysphasia.

   She was admitted to hospital in an excitable, talkative, emotionally labile, and rather euphoric state. She felt that her condition had been neglected and was "selfrighteous and sanctimonious, naive, and exhibitionistic." She rejected any suggestion of self‑injury. The diagnosis was "Hysteria,? self‑injury." Two weeks after admission her ear began to discharge, and for an interim of a fortnight she was transferred to an E.N.T. hospital. After her return she continued to run an intermittent temperature. At times she seemed little bothered by her own illness, at other times she would complain of pain in the ear, and hint that more investigations should be done.

   Perhaps the poor girl was right. She went home in September 1953, and died a year later, the post‑mortem revealing that a large abscess in the left temporal lobe had ruptured into the ventricles. There was very little infection in the middle ear.

    In this tragic case there can now be little doubt that the whole of the illness was attributable to the chronic cerebral abscess, which was never effectively treated. The hysterical colouring to the case, which led to unworthy suspicions of the Proband's integrity both as a patient and as nurse, was presumably derived from the person­ality. Before her illness she was a rather over‑enthusiastic humourless person, at­tracted into nursing by a genuine idealism. Brain changes in the temporal lobe probably made her more labile, sensitive, and difficult. The bad relations which developed between the patient and her medical advisers seem a not unnatural result of pressure on her side to get more effective treatment, and despair on theirs about how that could be provided.


   Among his group of hysterics Ljungberg found 3 per cent were epileptic. The suspicion that epilepsy has provided the basis of a hysterical predisposition arises in a number of cases in the present material. One of the most interesting is MZ 7, in which the Proband suffered from faints from adolescence onwards. One is tempted to regard them as having been vaso‑vagal, since low blood‑pressure runs in the family, and the Proband's blood‑pressure has always been very low, when taken in hospital 80/50, as against her twin's 115/70. Her psychiatric history is long and complex, with hysterical symptoms such as aphonia, talking in sleep and a trance state at different times. However, at the age of 44 at last follow‑up, she was having attacks occurring almost entirely at night in her sleep, with bladder incontinence, and was being treated with epanutin.

   Two of our probands had epileptic siblings. In one of these (DZ 1) the patient suffered from attacks of giddiness and faintness, but showed nothing else to suggest epilepsy. In the other (DZ 7) the patient had atypical fits at the age of 11, leading to an examination at the National Hospital and the conclusion that they were not epileptic. At 25 she had a severe anorexia nervosa, so intractable that after 3 years she had an anterior leucotomy. After this the fits recurred and persisted despite anticonvulsants. EEGs showed numerous slow and fast waves, but nothing specific of epilepsy. Some attacks were observed, and regarded as tetanic and produced by over‑breathing. At the age of 31 she had a second leucotomy. At follow‑up this year, aged 38, she is once again having fits about once a month. She has a walking disability of the grossest hysterical kind, but also a mass of obsessional rituals. Her state suggests a progressive cerebral process.

   Apart from these cases, blackouts, attacks of going limp, dizzy attacks, faints, falling attacks, short lapses of memory, have been observed in 6 MZ cases (1, 4, 5, 8, 9, 12) and in 4 DZ cases (2, 4, 5, 10). In one of these (DZ 2), the patient was found to have a very unstable EEG, and metrazol produced a burst of typical spike and wave suggestive of epilepsy. In another case (DZ 10) the patient's illness, which was depressive in form, was preceded some months previously by the occurrence of two epileptiform attacks on the same night. The general practitioner was sent for, and found her semi‑conscious, having bitten her tongue.

   Not very many of these patients have had any EEG examination, and those that have showed only non‑specific anomalies. However, considering how atypical a temporal lobe attack can be, and how much EEG investigation is often required to demonstrate a temporal lobe focus, it seems to me far from improbable that more thorough and systematic examination would have brought to light some unmistaka­bly positive findings. One of the probands (DZ 12) was under my own care in the National Hospital with a state of agitation and depression, in which she complained of overwhelming sexual feelings and the continual recurrence of spontaneous orgasms. Though I was unaware of it at the time, the symptoms were very similar to those of the well‑known case of Erickson (1945) of angioma of the paracentral lobule; and the temporal lobe epileptics of Van Reeth et at. (1958) had comparable sexual experiences.


    Among his 381 propositi, Ljungberg found 3 males and 5 females who were schizophrenic. In the present material there is also a schizophrenic (MZ ii). These twins were dull and backward boys who became schizophrenic within a year of one another between the ages of 22 and 23, in 1957. They are now both chronic patients in mental hospitals. When the Proband was admitted to the Maudsley Hospital he had shown a personality change and catatonic symptoms for three months, and had had delusions, such as that the sound of passing cars was that of aerial activity indicating the imminence of war. However, such symptoms were to some extent in abeyance while he was in the Maudsley, and the foreground of the picture was taken up by a hysterical pseudodementia. Asked in digit retention to repeat 246, he gave 358. He said 2 + 3 = 6, 3 + 3 = 5, 4 + 2 = 7, that there were 13d. in Is. and 21s. in £1. On a later occasion he denied all knowledge of his home address, his brother and his previous career, and even said he did not know his own name; but he now said there were 12d. in is. and 20s. in £1. Asked why he had got the answers wrong before, he said "Joking, doctor, just for a joke." Asked why he had been walking round with an empty wheelbarrow, he said, "An empty wheelbarrow is easier than a full one; I don't like heavy work." In short, the picture, which was of very temporary duration, was that of a Ganser state or buffoonery syndrome. These states have attracted much psychiatric attention from time to time, and have been found to be of very various aetiology, schizophrenia accounting for a certain number.


   Ljungberg found 5 manic‑depressives in his group, and in the first two case histories I quoted there are grounds for thinking that hysterical symptoms arose in the course of an endogenous depression. These are not the only ones. The illness of the proband in MZ 6, already quoted, was depressive in symptomatology, and the principal justification for a diagnosis of hysteria was the belief that the patient's headaches were the product of suggestion. A fourth case is that of DZ 10, whose illness, depressive in form, came on in the puerperium shortly after a stillbirth. A fifth case is that of MZ 4.

In this case, the patient attended the Maudsley out‑patient department at the age of 34 with the complaint that every three or four months he would have 7 to 10 days in which he was dizzy, irritable and taciturn. The attacks came without precipitating cause, and between whiles he would be all right. His wife thought they had started after hearing that an acquaint­ance had been found to have cancer. Three weeks before attending, the patient had gone to work, had felt bad, and had collapsed at the First Aid post. He had had several slight turns of weakness almost daily since. He slept well, but woke tired, was constipated, got very de­pressed, and had fears of cancer. On examination, though he looked pale and ill, nothing abnormal was found but a numbness of the shoulder thought to be hysterical. He soon ceased to attend the out‑patient department, but follow‑up six years later shows that he made a spontaneous recovery and has remained well ever since; in the interview he showed nothing hysterical. The father of this man was admitted to Bexley Hospital with a depression at the age of 62, dying there five years later.


   In his study, Ljungberg assigns a principal aetiological role in hysteria to devia­tions of personality, and in this he follows excellent precedents. Nevertheless he found that more than half of his propositi had shown no marked deviation of the premorbid personality. The commonest deviant types were the hysterical 21 per cent, the psycho‑infantile 10 per cent, and the psychasthenic 8 per cent. Ljungberg further defines these types as follows. The hysterical type shows the suggestibility and distractibility postulated by Janet; he is quick to learn and to forget, with enthusiasm easily aroused but endurance limited; he has a pressing need of variety, and of being the centre of attention; he is subjective and egocentric.

   The psycho‑infantile type has a strong affective fixation and dependence on his relatives, and needs guidance and help; he shows traits of childishness, is credulous and easily led; under external pressures he is apt to react with a state of insuffi­ciency.

The psychasthenic type easily becomes tired and suffers from anxiety. In order to compensate for a reduced supply of energy, the psychasthenic tends to avoid surprises and choice situations, and often subjects himself to a routine. He is shy, withdrawn, meticulous, dutiful, irresolute and vacillating.

   In the present study, I have not subjected these cases to the same analysis. I have not attempted, in fact, to estimate any deviation from an imagined norm. Instead I have tried only to note the particular ways in which probands differed in personality from their twins. Nevertheless the results agree fairly well with those of Ljungberg, with the proviso that the main differences between proband and twin were along the psychasthenic and the psycho‑infantile dimensions rather than the hysterical dimen­sion.

   The commonest and most consistent difference was for the proband to be the more anxious, worrying and tense of the pair, this difference being shown in 9 pairs in the one direction. It may be quite marked, even in MZ pairs, and then of course is not genetically caused. In one pair (MZ 6) the difference arises as the result of a polar development of the twins; in the rivalry in which they were involved the one who excelled became increasingly ambitious, serious and tense, while his brother gave up all lofty ambition and relaxed into a humdrum career. The important role which tendencies to tension and anxiety have played, not only in the personalities but also in the illnesses of these patients, is illustrated by the fact that two of them have each been submitted not to one but to two leucotomy operations.

   Related to the anxiety tendencies, minor perfectionist and obsessional features were shown in 7 probands and in 2 twins; and there was greater social timidity and shyness in 11 probands to 1 twin. Differences in energy and initiative also showed a preponderance, the twin having the advantage over the proband in 11 cases to 4.

   Traits which I should call hysterical ‑ excitability, suggestibility, shallow affects, selfishness and self‑will, histrionic traits ‑ were about as common as in Ljungberg's material, and were more marked in the proband than the twin in a quarter of the cases (MZ 1, 10, 12; DZ 1, 6, 9). Some degree of hysterical disposition is, however, shown by 4 twins (MZ 2, 5; DZ 3, 10).

   From the historical point of view, it was as a rule the proband who was the more neurotic in childhood, and who had more changes of occupation. There were also striking features about their sex lives which to some extent support Ljungberg's emphasis of psycho‑infantile traits.

   Taking the probands, there are only 3 men and 1 woman who have had fairly normal lives, with marriage to normal partners. Two male and 6 female patients have probably never had any sex relationship at all. Two other women have had difficul­ties in marriage, one being separated from her husband for a time. All the remainder have chosen odd partners. Of the men, MZ 2 married a wife who had been hysterec­tomized; MZ 4 married a woman who was a chronic neurotic and hypochondriac; MZ 10 married a neurotic woman who later had a paranoid psychosis. Of the women, MZ 3 first got engaged to a Canadian soldier who proved to have a wife already, and later married a man who had been in hospital with a schizophrenic illness. MZ 5 married a man who later went to prison for car frauds. Since her divorce she has cohabited with a man she refuses to marry, though she has twice been pregnant by him. One of these pregnancies was aborted on psychiatric grounds; after the other she arranged to have the child adopted.

   In the dizygotic series, DZ 2 married a man who had been deaf since childhood, and who later left her perhaps owing to her illness; this woman was also sterilized; DZ 3 married a man with chronic nephritis who soon became impotent; DZ 7 found her husband through a marriage bureau, a shy and nervous man who dotes on her; DZ 9 fell in love with a criminal psychopath twenty years older than herself, and later had an illegitimate baby by a black man; and DZ 12 married an unsociable rigid man, who is both vegetarian and valetudinarian.

   The twins have been more fortunate, but in them too, sex interest which is late or feeble, and failure to marry is found in 10 cases; and two marriages have ended in divorce.


   It is not easy to exclude the operation of psychogenic factors in any of our cases; but in about half of them it is difficult to put one's finger on anything very particular. If the proband has come under one form or another of psychological stress, the same has been no less true of the twin, and a differential incidence cannot be discerned. In a further 5 cases (MZ 2, 4, 6; DZ 3, 12), we find psychogenic factors obtruding, but with some doubt about the extent to which they have been effective. These stresses are of a banal kind; examination anxiety, an extravagant wife, responsibilities of an exacting post, an impotent husband, a rather unimportant love affair. In two further cases the psychogenic factor exercised a decisive role, but one which would hardly have been effective save for the pre‑existing hysterical disposition. Thus the illness in MZ 8 was essentially in the nature of a compensation neurosis; and the repeated fugues of DZ 11 were precipitated by the most trivial embarrassments.

   In one case (MZ 5) there was a stress situation of a truly drastic kind. The patient married a man of whom her parents disapproved, and even after the marriage they waged a long, ruthless and eventually successful campaign to part her from him. When she was in the Maudsley, the patient complained she felt in the middle of a battle that was tearing her apart, and that she was being asked to make decisions which were too difficult for her. However, the case was an exceedingly complex one. Both the patient and her unstressed monozygotic twin developed Graves' disease and had to undergo thyroidectomies; the Proband showed an EEG abnormality not shown by her twin; and during her illness she exhibited a depression with diurnal variation of endogenous type, obsessional features and depersonalization. Her after­history was very psychopathic for years after the solution of the acute conflict by divorce.

   Four of the cases show a psychogenic situation of a particularly interesting kind, what one might call a form of folie a deux, since two people share the same delusion. We see, as it were, the sick patient on the obverse of a medal, on the reverse side of which is the face of a fellow‑conspirator. This figure is that of a member of the family who is busily employed in fostering the illness. Where the patient is female, this individual is commonly a father or husband. Thus in MZ 1 the hysterical development of the Proband's personality can be traced to the father, who preferred her to her twin and after an appendix operation gave orders she was to do no more heavy work. In DZ 4 we find a husband who is dominated by the Proband's complaints, has to come home to comfort her in the middle of the day and is never allowed out in the evening. In DZ 6 the Proband suffers from attacks of breathless­ness, and has had almost continuous psychotherapeutic support for 9 years; the situation is made almost unmanageable by the fact that her father panics if she has one of her attacks, and feels he must be able to give her, at once, all the sedative tablets she wants. In the fourth case (DZ 7) the husband not only works for a living but also runs the house for the patient, looking after her in every way. He is repeating the pattern of behaviour of the Proband's own parents, since her father also did all the work for his supposedly crippled wife.

   This situation is one which is commonly met in the cases one calls hysterical, though it is less frequently recognized. The supporting partner, when seen, makes a normal impression, and his attitude to the patient seems, at first glance, to be everything that is proper. The patient and her partner, however, make a closed circuit with one another, isolating them from other relationships, each supplying the other's needs. The effect tends to be very malign; the four cases quoted have periods of continuous and still continuing illness of 15 years, 7 years, 9 years and 11 years.


   Such long illnesses are seen in only a minority of cases, but they are not uncom­mon. Ljungberg regards hysteria as a relatively benign condition, and reports that after 1 year only 38 per cent of patients were still suffering from symptoms, after 5 years 23 per cent, and after 15 years 20 per cent. Looked at in another way, these results are not so encouraging: if 62 per cent of patients recover within the year, less than half the remainder can ever be expected to recover at all. The follow‑up results in the present series are a good deal worse. Five of the probands recovered within a year, and a further 7 in periods of 2 to 7 years. To the present time half the patients are still suffering from symptoms, at a mean duration of 51/2 years after the critical diagnosis was made.

   It is often made a subject for wonder that the psychiatrist does not frequently see patients in middle life who have had hysterical symptoms for many years; and the comforting conclusion has been proposed that this is because the youthful hysteric nearly always gets better. Both Ljungberg's material and the present series show that this is not so. If the psychiatrist does not see these patients in later life, it is because the patients themselves have found out the hollowness of the hopes that he can offer. They have given up attendance at psychiatric clinics, and have learned to rely on the medicines they can get from their family doctors.

   Perhaps the most surprising feature of the follow‑up statistics is their lack of uniformity. Some patients do well, others very badly indeed; and good or bad outcome bears little relation to the nature, the amount or the severity of the hysteri­cal symptoms. To get a clue to the prognosis, we have to look, not at the hysterical mechanisms exposed, but to their aetiological basis, whether this is a brain lesion, an endogenous psychosis, a deviation in personality development, a temporary stress situation, or a built‑in self‑perpetuating mechanism.


    We have now reached the position when we are compelled to ask, what is the justification for regarding hysteria as a syndrome? The aetiology appears to be very various; and the hypothesis of a genetical basis of a specific or indeed important kind has had to be discarded. Among the hysterics of the present series we have found patients suffering from a focal brain lesion, also probably from epilepsy, from schizophrenia, from endogenous depression, and from anxiety states falling more easily into the category of affective than hysterical illnesses. Comparative analysis of personalities shows the affected twin not so much more hysterical as more anxious than his partner. Both psychogenic and physical factors play a role in aetiology; but with some interesting exceptions they are of a varied and non‑specific kind. The clinical picture is equally various; and the hysterical symptoms which are relied on for diagnosis are always accompanied by others of a different nature. No particular method of treatment seems to be of more general application than any other. Drug therapy, psychotherapy, E.C.T. and leucotomy have been tried, none showing any sign of being a specific remedy; patients get well or remain ill for reasons which are individual and often far from clear.

   The one thing which is common to a large majority of the cases we have investi­gated is that they were very difficult problems clinically; even after prolonged follow‑up many remain complicated and obscure. It is certain that some clinicians make the diagnosis of hysteria more readily than others. In some sense it is true to say that "hysteria" is a label assigned to a particular relationship between observe and observed; it appears on the case‑sheet most readily if the doctor has foul], himself at a loss, if the case is obscure and if treatment has been unsuccessful. Of a! diagnoses it is that which is least likely to be made in a spirit of detachment. There a temptation to shelve further enquiry along aetiological lines, if the clinician sees thinks he can sec a histrionic quality in the patient's complaints, if some symptom. can be regarded as lacking genuineness, and if the patient demands rather thai: accepts treatment.

   To be sure, the dissociative mechanisms of hysteria are known of old, and can lead to symptoms which deserve no other name. But the diagnosis of an illness as hysterical goes much further than the recognition of a symptom. The unreliability of the diagnosis indicates the unsatisfactoriness of a psychopathology which is based solely on a mental mechanism. In the past, delimited studies of such conditions as Ganser states and anorexia nervosa have repeatedly shown their heterogeneous nature. It seems permissible to suggest that this principle might be of wider applica­tion. The mere manifestation of a mental mechanism within the range of normal potentialities tells us little of consequence. If in our patient we find the signs of hysteria and no more, then these are signs that we have not yet looked deeply enough.