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erotic nature and which may give rise to passionate attitudes and movements.
(6) 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. The only certain differential feature is intellectual enfeeblement, which is almost constant in catatonia and altogether exceptional in hysteria. Before its appearance the diagnosis remains doubtful, and can only be surmised from the following features: psychic disaggregation is more marked in catatonia, resulting in true incoherence; the symptoms in catatonia have a more stable character; stereotypy is more marked; emotional indifference is more pronounced; there is no subconscious fixed idea.
(6) Epilepsy.— Unconsciousness during the seizure, subsequent amnesia, which is more constant and more complete in epilepsy than it is in hysteria, and the nature of the convulsive seizures serve as a basis for the diagnosis, which is in some instances very difficult to establish. Moreover it seems that hysteria and epilepsy may exist together in the same subject.
( (c) Mania. — Here the excitement is usually more continuous and less affected by external influences, such as the presence of spectators, which always increases the excitement of hysteria; flight of ideas is much more distinct; hallucinations are more rarely seen.
(d) Melancholic depression. — The depression is continuous and durable and is independent of external influences, while in the hysterical patient a pleasantry or a word of encouragement often suffices to dissipate, at least momentarily, the melancholic phenomena. Manifestations of psychic automatism are much less marked in melancholic depression than in hysteria.
The prognosis of hysteria is grave. The episodic mental disorders usually subside, either spontaneously or under the influence of treatment; but the hysterical disposition remains and renders recurrency of attacks probable.
The treatment 1 consists in rest, isolation, hydrotherapy, and mental suggestion, which, with or without hypnosis, produces marvelous results; also attention to the somatic disturbances so frequent in hysteria is of importance.
Excitement is to be treated by the usual methods. Isolation often produces very happy results.
$ 2. CONSTITUTIONAL PSYCHOPATHS. There are some persons who present from childhood evident psychic anomalies which justify their being classed in a separate group, — the constitutional psychopaths.
From this group must be eliminated epileptics, hysterical subjects, paranoiacs, and the feebleminded, which, in spite of their close relationship to the psychopaths, really form independent categories. Such distinctions are necessary for the avoidance of confusion in the theory and practice of psychiatry.
We shall study first the habitual mental state of psychopaths, then the anomalies of sexual life, which on account of their importance merit a separate description, and finally obsessions.
Habitual mental state of psychopaths. — The principal anomalies are those of (a) judgment, (b) the character, and (c) conduct.
(a) Disorders of judgment. These constitute perhaps the most essential stigma of the psychopath as well as the most important one from the social standpoint. The psychopath does not see things in their proper light, hence his singular notions, his paradoxes, his ridiculous enterprises.
1 Sollier. L'hystérie et son traitement. Paris, F. Alcan.
Usually he presents a more or less pronounced state of feeble-mindedness, weakness of attention or of memory, sluggish formation of associations of ideas, and poverty of imagination. In some cases, however, some of the faculties are normal or even brilliant: memory, imagination, or artistic aptitudes. But these abilities cannot be turned to account by reason of the lack of judgment, for almost always, if he is not actually feeble-minded, the psychopath is at least mentally unbalanced.
(6) Anomalies of the character. — These are very
b varied. Sometimes they consist in a general pessimism: the patient sees only the dark side of life; all occurrences make a painful impression upon his mind.
Usually the dominant note in the character of the psychopath is extreme mobility of the emotions. The subject passes alternately from exuberant joy to boundless desolation, from feverish activity to profound discouragement, from affection to hatred, from the most complete egoism to the most exaggerated generosity and devotion. Thus the expression unbalanced is perfectly applicable to this class of patients.
(c) The conduct shows insufficiency of judgment and instability of the emotions. It is full of contradictions.
The psychopath is apt to pose as a champion of justice, as an avenger of humanity. He is given to
anarchistic ideas, seeks to interfere in public affairs, to become a leader of popular movements — and succeeds but too often. His conduct is often inconsistent with his ideas of justice and charity, though he fails to see it himself. Theoretically he strives for the good of the universe, practically for the satisfaction of his own egoistic tendencies.
He tries all sorts of occupations, but succeeds in none, and accuses his fate on the injustice of men. He is apt to pose as a victim, while in reality he is what is aptly designated by the popular expression
a ne’cr-do-well.”. If he has no personal resources and if he is not aided by his relatives or by public charity he becomes a vagabond.
The psychic anomalies are often associated with physical ones, which are spoken of as physical stigmata of degeneration. Most of these abnormalities may be encountered in normal individuals. Only the combination of many of them in the same subject renders them of importance; they are more numerous in the insane, constitutional psychopaths, epileptics, and hysterical individuals than they are in normal persons.
They possess some theoretical interest, but are not of great practical interest; therefore I shall limit myself to the mere mention of the principal ones.
Cranial malformations: macrocephaly, microcephaly, scaphocephaly, extreme brachycephaly, or dolichocephaly; cranio-facial asymmetry, harelip, malformations of the palate; dental anomalies: : congenital absence of one or several teeth, irregularities of implantation, malformations; anomalies