The duration of the affection is very variable, from several weeks to a few years.

Treatment.

The principal indications are:

To watch the patient with a view to the prevention of suicide;

To support his strength;

To calm agitation if there is any;

To pay special attention to the alimentation. The first three indications are admirably fulfilled by rest in bed.

Forced alimentation is often necessary to fulfill the fourth.

The psychic pain may be efficaciously combated by the administration of opium in increasing doses. One may start with 15 minims of the tincture per day, increase to 60 minims or more, and then gradually reduce the quantity to the initial dose before discontinuing the treatment.

Finally, continuous warm baths may be of service in the agitated forms.

HYSTERIA.

CHAPTER VII.

CONSTITUTIONAL PSYCHOPATHS.

MORAL INSANITY.

§ 1. HYSTERIA.

To make a complete study of the mental disorders of hysteria would mean to consider the entire clinical history of this neurosis, for hysteria is essentially a mental affection. It is, however, the custom to leave a considerable portion of this subject to neurology, reserving for psychiatry the phenomena belonging to its own sphere, not only by origin, but also by their aspect. The paralyses, contractures, anæsthesias, in a word all the somatic symptoms, will therefore be systematically omitted from the following description.

The mental disorders of hysteria are all dependent upon the predominance of the automatism over the voluntary and conscious psychic operations. These disorders are classified as permanent and paroxysmal.

Permanent mental disorders. These constitute the mental stigmata of Janet,1 and impart to the personality of the hysterical subject its peculiar clinical aspect. The following are the principal ones:

(a) Weakening and mobility of attention, which no longer directs the associations of ideas, thus leaving uncontrolled the mental automatism. In some cases the patient lives as in a dream in which images and 1 Pierre Janet. État mental des hystériques.

ideas follow each other without order or logical sequence. In other cases the automatism assumes the form of a fixed idea upon which the affective phenomena and the reactions are dependent. Almost always subconscious, the hysterical fixed idea requires a careful search for its discovery and often cannot be revealed except during hypnotic sleep.

(b) Disorders of memory; amnesia of reproduction: recollections cannot be evoked at will though they may still arise automatically; this amnesia of reproduction is often partial and in its course is subject to numerous remissions and exacerbations; its duration is very variable, from a few minutes to several years; illusions and hallucinations of memory form the basis of pseudo-reminiscences remarkable for their vividness, their wealth of detail, and their quite plausible character: they result from extreme suggestibility and often originate from a story the patient has read or from an event narrated in his presence.

(c) Changes of affectivity and of disposition: morbid indifference associated with great variability of moods, egoism, sensitiveness, and a morbid desire to attract attention. The hysterical subject thus resembles closely the constitutional psychopath.

The morality of hysterical subjects has been much discussed with special reference to their duplicity and tendency to prevarication. Some see in the falsehoods of the patients nothing but errors attributable to amnesia; others, less tolerant, consider these falsehoods as intentional, and see in them a sign of perversity.

Both opinions are partly true. It is certain that these patients often commit errors unconsciously, but it is equally certain that they also prevaricate knowingly. The common phrase hysterical lies is not an unjustified

one.

(d) Anomalies of sexual life: sometimes, much less frequently than is commonly claimed, hysterical subjects present erotic tendencies; much more often there is frigidity with or without sexual perversion.

(e) Weakening of the will: aboulia is a constant phenomenon and manifests itself in apathy and negligence. Though occasionally the patient gives evidence of feverish activity, the duration of this activity is but brief and the subsequent reaction is marked by an exaggeration of the aboulia.

Automatic reactions replace voluntary ones and are met with in the most varied forms: pathological suggestibility, catalepsy, passionate impulses, etc.

Episodic mental disorders. These may either accompany the hysterical attacks or occur independently of them.

(a) Mental disorders associated with the attacks. These are:

(1) Before the crisis: an accentuation of the ordinary anomalies of the character; sometimes appears a hallucination, a fixed idea.

(2) During the crisis: hallucinations, delusions, or motor excitement may partly or completely replace the ordinary hysterical phenomena (maniacal or ecstatic form of crisis).

(3) After the crisis: delusional states associated with multiple combined hallucinations which are often of an

erotic nature and which may give rise to passionate attitudes and movements.

(b) Among the mental disorders occurring independently of the attacks an important one is somnambulism, spontaneous or induced; it presents the most perfect form of psychic automatism.

Closely related to somnambulism are the hysterical states of obscuration, which present themselves in two different forms: (a) the stupid form, characterized by mental hebetude and absence of reactions; (B) the agitated form, characterized by violent reactions and excitement associated with confused delirium. Sometimes the excitement is so pronounced as to simulate epileptic delirium. The duration of the attack is scarcely ever more than a few days.

Hysterical subjects may also have acute attacks resembling manic depressive insanity, which are known as hysterical mania and melancholia. I shall return to this subject in connection with the differential diagnosis.

A positive diagnosis of hysterical mental disorders is chiefly to be based upon the existence of the psychic stigmata mentioned at the beginning of this chapter and of the physical stigmata which are described in all works on neurology: clavus or globus hystericus, ovaralgia, anæsthesia, monoplegia, visceral disorders such as obstinate vomiting, palpitation, etc.

The differential diagnosis from the following conditions is sometimes very difficult:

(a) Catatonia.

The problem is a complicated one, since most of the catatonic phenomena may be encountered in hysteria, also most of the hysterical symptoms, nervous and psychic, may occur in catatonia.