Chapter III: Part 3

If from any cause there occurs a failure to appreciate the stimuli clearly, if the emotional reactivity be disturbed, if the sense of value becomes biassed in one direction or another so that the response is recognized by the patient as abnormal there will result a disharmony and a feeling of ill-being of the organism. Under these conditions the processes of facilitation along certain definite lines and inhibition of all other lines--processes which are essential to clear consciousness--will become difficult or perhaps impossible and a mental illness will develop. In the slighter degrees the disharmony may be known to the patient without there being any outward manifestation to betray the conflict going on within. In the severe degrees the mental activity of the patient may be under the control of some dominant emotional state so that it may be impossible for him to adapt himself to his surroundings in a normal manner although his behavior may not appear so irrational when we know the stimuli affecting him. Within these extremes we discover all degrees of disturbance, and all varieties of signs and symptoms may be encountered.

But the signs which become obvious to superficial observation are, to a large extent, secondary products. The primary symptoms are felt by the patient as a disturbance of the capacity to perceive, to think, to feel, to judge, and to act, and with these disabilities there will be associated a certain degree of confusion and anxiety which cannot fail to appear as the result of such alterations of function.

The obvious signs may represent merely a more intense degree of the primary affection, disturbed capacity together with some confusion and anxiety; or they may represent efforts on the part of the patient to overcome or to escape from the disturbance or to explain it to himself. And now the total lack of knowledge of the processes on which mental activity depends, the altered standard of judgment due to some degree of dissociation, and the necessity of obtaining relief in some way or other will have much to do with determining the character of the symptoms with which we are all familiar. So many factors are concerned in the production of these secondary characters that it is difficult to assign to the symptoms their true value or to decide whether they possess much value at all with regard to the fundamental disturbance which constituted the primary illness. So often they appear to be mere rationalizations, mere false judgments on the part of the patient; they thus form subjects for investigation rather than fundamental constituents of the illness.

We, therefore, must not accept the outward and visible signs at their face value but attempt to discover what past experiences in the life of the patient have led to such disturbance of function, to such a change in his mental activity.

It will possibly be of some assistance to provide one or two examples in order to demonstrate the importance of the past experiences as agents capable of producing such alterations.

The first case will illustrate the results produced by the development of a dominant emotional tendency during early childhood. The patient up to the fifth year of her life had been an ordinary, normal child, attached to her mother, fond of her nurse, interested in her toys. During the next two years she endured much bad treatment at the hands of a new nurse which produced such an impression on her that she felt she was a changed child. This nurse, described to me by the patient as a handsome woman, having met the inevitable man, used frequently to meet him clandestinely. The child was neglected, was sometimes left alone, on one occasion in a graveyard, but she was forbidden to mention the subject to any one under threats of being carried away by a "bogey-man." The child became very frightened by this, to such an extent that one night she had a severe nightmare in which a "bogey-man" came to carry her away. At the end of two years a profound change had taken place in her which she now describes thus: "I was a changed child; I was separated from my mother and could no longer confide in her nor did I wish to do things for her as I had done before; I could not enjoy my toys; I had no confidence in myself; I was not like other children." And from that time on, as girl and as woman, she has never felt that she has been like others of her sex. Such a condition, being started and confined by repetition, interfered with her free development and it was remarkable how many incidents occurred in her life to confirm the disability, but the germ of her serious breakdown thirty years later was laid in her fifth and sixth years.

The second case is that of a patient who, as a child, had some convulsive attacks. She was therefore considered delicate and was thoroughly spoiled. When nearly thirty she lived through a sexual experience which caused extreme anxiety; she broke down and was admitted to an asylum. After admission she looked across the dormitory and saw a head appearing above the bed-clothes, the hair of which had been cut short for hygienic reasons. With a memory of her sexual indiscretion still vivid in her mind she jumped to the conclusion that she was in a place where men and women were crowded together in the same room. She got out of bed, refused to return to it, fought against the nurses and was transferred to a single room, with the mattress on the floor and the window shuttered. She wondered where she was and came to the conclusion that she was in a horse-box. Then arose a feeling of terror that she would be at the disposal of the grooms when they returned from work. The sound of heavy footsteps of the patients passing along the corridor to the tea-room suggested that the grooms were returning and that her room would soon be invaded. The feeling of terror increased and she tried to hide in the corner, drawing the mattress and clothes over her. And so on.

Months later when I had my first interview with her, her sole remark during the hour was "How can I speak in a place like this?" This was repeated almost without intermission throughout the hour. It formed a good example of the origin of the process of perseveration, a process frequently adopted by the patient to guard against the disclosure of a troublesome secret.

If we attempt to trace out some of the mechanisms employed in these two cases we shall see that in response to definite stimuli each reacted in a manner which cannot be considered abnormal in kind. It was normal reaction for the child to be distressed at being separated from her mother in such a way, to be frightened by being left in the graveyard alone, or at the threat of her being carried away by a "bogey-man" if she dared to mention anything of the clandestine meetings to her mother. It was not very abnormal that after her sexual experience the other patient while still in a confused state caused by the intense emotional condition of anxiety, should, on seeing a head with the hair cropped short, jump to the conclusion that there was a man in a bed in the same ward with herself, or that she should feel frightened and wish to leave the room.

The mental activity in each case depended on mental content, that is, memory of past experiences with their intense emotional states which acted as the driving force and also made the recall of the experience go extremely easy. The further developments after being placed in the single room with mattresses on the floor and the window shuttered were rationalizations also based on mental content, _i.e._, on the memory of rooms somewhat similar to that in which she found herself and of the use of such rooms. It is interesting to note also in the first case that in her wildest delirium during an acute attack she lived through episodes of her past life. One example may be given. In the course of her delirium she thought that a "blackbird" had flown to her, touched her left wrist and taken away all her vitality. This depended on an experience of her going to Germany when a girl and meeting a young German officer whom she did not like. A few years later she went to Germany and met the officer again. Without going into full details I may say that on one occasion when walking with him he seized her left wrist with his right hand and attempted to kiss her; she struggled fiercely and ran from him. Here we see that not only is her delirium based on a past experience, but that the whole memory is symbolized in the "blackbird" which was the emblem of the German nation in whose army the officer was then serving. Connected with this there was also another unpleasant episode which dated from her tenth year. Much of her delirium was worked out in such a way that most of the details could be traced back to experiences of her earlier life.

But however absurd her statement regarding her being touched by a "blackbird" and all her vitality removed might appear to superficial observation, it must be admitted that when we know the mental content of that patient, we cannot but see that at any rate it was not so irrational. And not only was this recognized by the doctor, but, and this is much more important, by the patient herself.

It is, therefore, the mental content which must be discovered before doctor or patient can understand the disability and before any common ground between the two can be found. And when the mental content is known it will be easy to recognize the affective condition of the patient to be a normal response. It will also be specific and if intense will dominate the patient. "Why is it I can never feel joy as I used to do?" was the pathetic inquiry of the patient dominated by a feeling of misery and fear. Was it not for the reason that being dominated by misery and fear, joy could find no place? The emotion of misery because of its intensity could more or less inhibit the feeling of joy, but joy could not inhibit the misery.

No repetition of the memory of the unpleasant experiences with their associated emotion of misery and fear led to the formation of a habit of mind and feeling. And when once such a habit of mind is established it is remarkable by what a host of stimuli received in ordinary daily life the cause of the disturbance can be recalled.

This question of stimuli deserves further notice. It is not so difficult to realize the mechanism by which a stimulus which clearly crosses the threshold of consciousness can lead to a given reaction. But it is perhaps difficult to imagine how so many stimuli which do not cross the threshold of consciousness or which, if they do, are not recognized by the patient at the time as having any reference whatever to the special memory can yet set the memory mechanism into action. The result may not be seen till after the relapse of some considerable period of time, as in the case of a man who for years had been disturbed by terrific nightmares, based on the idea of snakes coming out of the ground and attacking him. He complained one day that he was much worse, that three nights before he had had the worst nightmare of his life. On being questioned as to what could have suggested snakes to him he could not tell. A few minutes later he said: "I think I know the cause now. I spent the evening before I had that nightmare with a sergeant who had returned from the service in India." This friend amongst other things had mentioned that whenever they were about to bivouac they had to search every hole under a stone and every tuft of grass to see that there were no snakes there. This, which had been received as an ordinary item of information, had been the stimulus which had set his memory mechanism into action and the nightmare between two and three o'clock in the morning had been the result.

The result in many instances is evidenced by an emotional state alone and the actual memory of the original experience may not come into consciousness. Many examples of this might be given. The sound of a trolley wheel on a tram wire in one case gave rise to terror instead of its normal reaction, viz., that of satisfaction at getting to the destination quickly and without effort. This terror was produced because the sound on the wire resembled that of a shell which came over, blew in a dugout, killed three men, and buried the patient. No memory of this incident came into consciousness, only a terror similar to that experienced at the time of the original incident was experienced. Or, the time four o'clock in the afternoon could act as a stimulus to arouse an emotional state of misery similar to that experienced at the same time of day during an illness some years previously. Or, passing the house of a doctor when on a bus could produce a sudden outburst of anxiety, giddiness, and confusion; the patient had been taken into that house at the time of an epileptic attack. Or, showing photographs of the front could lead to an epileptic attack which was based on the memory of the time when the patient was wounded in the head; this has occurred on two separate occasions separated by an interval of some months. Or, noticing a familiar critical tone in a remark made at a dinner-table could lead to an acute change of feeling so that the subject who, before dinner, had felt she would like to play a new composition on the piano so as to obtain the opinion of the guest who had exhibited the critical tone, after dinner felt incapable of doing so. Her feelings had been hurt on many former occasions by critical remarks made by him in that tone. The critical remarks were not called to memory but there arose the feeling that under no circumstances could she play that piece to him.

Of special importance also are the experiences of childhood. An unhappy home or unjust treatment as a child may warp the development of the personality, lead to a lack of self-confidence, to the predominance of one emotional tendency, and so prevent that balanced equilibrium which will allow a rapid and suitable emotional reaction such as we may consider normal. This may lead to a failure of development or a loss of the sense of value, because the existence of one dominating emotional tendency so often produces a prejudiced view which may render a just appreciation of our general experience almost impossible and may seriously disturb our mental activity.

And if, as Bianchi suggests, all mental activity depends on a series of reflex actions, or, as Bechterew and Pavlov have insisted, a series of conditioned reflexes becomes established, it will assist us to understand how such stimuli can give rise to mental disturbances, to mental illnesses. We shall see that there may be something of real importance underlying such remarks as "I felt I was a changed child"; or "It is because of the treatment I received from my father that I have taken life so seriously." "I have never imagined that what I went through in my childhood could so influence me now"; or "I have never had confidence in myself and often when I have appeared vivacious and interested I have had an awful feeling of incapacity and dread within myself."

The outward and obvious manifestations, therefore, are not necessarily a true index of our mental and emotional conditions. This is true of all mental illnesses, even the most severe.

One patient who had been in an asylum more than ten years illustrated this in a most striking manner. His outward manifestations led one to feel that he thought he possessed the institution in which he was confined and also the surrounding property and that the authorities were a set of usurpers and thieves who kept him incarcerated in order that they might enjoy what was really his money and his property. On one occasion I said to him, "George, what is that incident in your life which you cannot forget and which has troubled you so seriously?" The reply was a flood of abuse. I put the question to him several times without getting any further answer, but when I came to leave the ward, George came up behind me and whispered over my shoulder, "Who told you about it?" No abuse, no shouting as usually occurred, but a whisper, "Who told you about it?" Was not George running away from a memory with its emotion which was unbearable to an idea which allowed him to be angry with others instead of with himself? Many examples of this might be given and really might be found by us in our own experience. It is the mental content which is important, a mental content which can be recalled by various stimuli, and which will be more persistently with us the more intense is the emotion associated with it.

But the basis of the condition is not completely understood when we have apparently arrived at the psychic cause of the disturbance.

It is recognized that the emotions are accompanied by physical changes, changes which are specific for each emotional state. The physical changes which normally are associated with fear differ from those of joy or anger. This has been appreciated for a long time but recent researches have recalled other reactions to us. Reactions in the internal glands which further knowledge will probably prove to be of great importance, in fact to form an integral part of the sum of activities, connect with mental processes. The secretions of the glands exert an influence on the sensibility and reaction of the organs connected with psychic phenomena and their functions themselves are affected by reactions occurring in the nervous system. Revival of a memory may thus affect the functions of these glands, and the changes produced in them may react on the sensibility and reactivity of the nervous mechanisms. If this be so, it will be evident that the organism works as a whole, that a disturbance of one organ may interfere with the function of another and that in the repetition of all these influences we may find an explanation of the chronicity of many of these illnesses. A study of the activities and interactivities of all the organs of the body is therefore essential and must be made before we shall understand the biological significance of mental illness.

FOOTNOTES:

[Footnote 13: See Appendix III, p. 200.]

ADDRESS BY DR. PIERRE JANET

_The Chairman_: Our country may be hesitating a little--I hope it will not be for long--in joining a league of nations to prevent war, but there can be no doubt of our immediate readiness to co-operate internationally to prevent and reduce disease. Our distinguished guest from gallant France, Dr. Pierre Janet, professor in the College of France, evidently feels confident of our sympathy and willingness to collaborate in this latter respect, for he has ventured across the ocean, with Madame Janet, in response to our urgent invitation. His introduction to an audience of American psychiatrists would be quite out of place. His fame as a pathological psychologist has circled the world. In the science of medicine he is a modern Titan. For to-day's address he has chosen as a subject, "THE RELATION OF THE NEUROSES TO THE PSYCHOSES."

DR. JANET

Mr. President, my dear colleagues, ladies, and gentlemen: The Americans and the French have met on the battle-fields and they have faced together the same sufferings for the defense of their common ideal of civilization and liberty; it is right that they should meet likewise where Science stands up for the protection of health and human reason, and that they should celebrate together the Festivals of Peace. The President and the organizers of this Congress have greatly honored me in asking me to represent France at the celebration of the centenary of the Bloomingdale Hospital; but above all they have procured me a great pleasure in offering me the opportunity of coming again to this beautiful land, of meeting once more friends who had welcomed us kindly in former days; our old friends of past happy days who have become still dearer to us since they have been tried during the bad days.

Allow me, in the first place, to present you with the best wishes of the French Government who have had the kindness to charge me to interpret the sentiments of sympathy which they feel for all manifestations tending to render the relations that unite our two countries closer and more fruitful. The Academy of Moral and Political Sciences has equally charged me to assure you that it is happy to be represented by one of its members at the commemoration of the centenary of Bloomingdale Hospital that has so brilliantly and generously continued the tradition of Pinel and Esquirol. The Academy takes a lively interest in the psychological and moral studies of this Congress that seek the cure of diseases of the mind and the lessening of mental disorders. The Medico-Psychological Society, the Society of Neurology, the Society of Psychology, the Society of Psychiatry of Paris are happy to take part in these festivals and are desirous of associating still more closely their work to that of the scientific societies of the United States.

The celebration of the centenary of a lunatic asylum gives birth to-day to a national festivity in which all civilized nations participate. This is a fact that would have well astonished the first founders of lunatic asylums, the Pinels, the Esquirols, the William Tukes, and the first organizers of Bloomingdale. The public opinion respecting the diseases of the mind, the care to be given to lunatics, is vastly different to what it was a century ago. This transformation of ideas has taken place, in a great measure, as a result of the studies devoted to neuroses and that is why it seems to me interesting to present you to-day with a few reflections on the connections which unite neuroses and psychoses; for it is the discovery of these connections that has shown to the man sound in mind, or who imagines himself to be so, how near he always was to being a lunatic and how wise it was always to consider the lunatic as a brother.

Formerly a lunatic was considered as a separate being, quite apart from other members of society. The old prejudices which banished the patient from the tribe as a useless and dangerous individual had diminished no doubt with respect to the diseases of the body, which were more and more regarded as frequent and natural things to which each of us might be exposed. But these prejudices persisted with respect to some sexual diseases that were still considered ignominious and chiefly with respect to diseases of the mind. No doubt some intelligent and charitable physicians took interest in the lunatic, endeavored to spare him many sufferings, to defend him, to take care of him. But the people feared the lunatic and despised him as if he had been struck by some malediction which excommunicated him. I have seen lately a patient's parents upset with emotion, as they had to cross the gardens of the asylum to visit their daughter, at the single thought that they might catch sight of a lunatic. This individual, in fact, had lost in the eyes of the public the particular quality of man, reason, which, it appears, distinguishes us from beasts; he seemed still living, but he was morally dead; he was no longer a man.

No doubt it was a dreadful misfortune when some member of a family became insane, but this terrible calamity, which nothing could make one anticipate or avoid, was happily exceptional, like thunderbolts. The other men and even the members of the family presented nothing similar and regarded themselves with pride as very different to this wretched being transformed into a beast. This victim of heavenly curse was pitied, settled comfortably in a nice pavilion at Bloomingdale and never more spoken of. People still preserve on this point ideas similar to those they had formerly about tuberculosis, known only under the form of terrible but exceptional pulmonary consumption. Now it has at last been understood that there are slight tuberculoses, curable, but tremendously frequent. It will be the same with mental disorders; one day it will be recognized that under diverse forms, more or less attenuated they exist to-day on all sides, among a crowd of individuals that one does not feel inclined to consider as insane.

Little by little, in fact, men have had to state with astonishment that all lunatics were not at Bloomingdale. Outside the hospital, in the family of the unfortunate lunatic, or even in other groups, one observed strange complaints, moanings relating to lesions which were not visible, inability to move notwithstanding the apparent integrity of the organs, contradictory and incomprehensible affirmations; in one word, abnormal behaviors, very different to normal behaviors, regularized by the laws and by reason.

What was the meaning of these queer behaviors? At first they were very badly understood; they were supposed to have some connection with being possessed (with the devil), with miasmata, vapors, unlikely perturbations of the body and animal spirits that circulated in the nerves. One spoke, as did still Prof. Pomme at the end of the eighteenth century, "of the shrivelling up of the nerves."[14] But above all, one preserved the conviction that these queer disorders were very different to the mental disorders of lunacy. These peculiar individuals had, it was said, all their reason; they remained capable of understanding their fellow creatures and of being understood by them; they were not to be expelled from society like the poor lunatics; therefore their illness should be anything but the mental disorders of lunacy.

Physicians, as it is just, watched their patients and only confirmed their opinion by fine scientific theories. They christened these new disorders by the name of neuroses, reserving the name of psychoses for the mental disorders of lunatics. During the whole of the nineteenth century the radical division of neuroses and psychoses was accepted as a dogma; on the one side, one described epilepsies, hysterias, neurasthenias; on the other, one studied manias, melancholias, paranoias, dementias, without preoccupying oneself in the least with the connections those very ill-defined disorders might have the ones with the others. This division was accentuated by the organization of the studies and the treatment of the patients. The houses that received the neurotic patients and the insane were absolutely distinct. The physicians who attended the ones and the others were different, and even supplied by different competitions. In France, even now, the recruiting of asylum house pupils and hospital house pupils, the recruiting of asylum doctors and that of hospital doctors, give an opportunity for different competitions. One might almost say that these two categories of house pupils and doctors have quite a different education. The result was that the examination of the patients, the study thereof, and even their treatment, were for the most part often conceived in quite a different manner. For example, neuroses were studied publicly; the examination was on elementary sensibilities, the movements of the limbs, and especially reflexes; the insane were more closely examined in the mental point of view, in conversations held with them by the physician alone. Their arguments, their ideas were noted more than their elementary movements. Strange to say, just when the psycho-therapeutic treatments by reasoning and moralizing with the patients were being developed, they stood out the contrary of what one might have supposed--that this treatment should be applied to neurotic patients alone. It was admitted that lunatics were probably not able to feel this moral and rational influence; they were treated by isolation, shower-baths, and purgatives.

This complete division did not fail to bring about singular and unfortunate consequences. In a hospital such as La Salpetriere the tic sufferers, the impulsive, those beset with obsessions, the hysterical with fits and delirium were placed near the organic hemiplegics and the tabetics who did not resemble them in the least, and completely separated from the melancholic, the confused, the systematical raving, notwithstanding evident analogies. If Charcot who, moreover, has brought about so much progress in these studies, committed some serious errors in the interpretation of certain phenomena of hysteria, is it not greatly due to his having studied these neurotic patients with the neurology methods without ever applying psychiatry methods? Is it not strange to refuse psychological treatment precisely to those who present psychological disorders to the highest degree, and to place the insane who thinks and suffers altogether outside of psychology?

In fine, this distinction between the neurotic sufferer and the mental sufferer was mostly arbitrary and depended more than was believed on the patient's social position and fortune. Important and rich families could not be resigned to see one of their members blemished by the name of lunatic, and the physician very often qualified him as neurasthenic to please the family. A few years ago this distinction of the patients and of the physicians gave rise to a very amusing controversy in the newspapers. The professor of the clinic for diseases of the nervous system asserted that neurotic sufferers should be patients set apart for neurologist physicians alone, whereas the alienist should content himself with real lunatics. The professor of the clinic for mental diseases protested with much wit and claimed the right of attending equally the neurotic patients. All this proved a great confusion in the ideas.

Notwithstanding these difficulties, Charcot's studies themselves on hysterical accidents began to make people's minds uneasy and to modify conceptions of neuroses. They showed that neurotic sufferers presented disorders in their thoughts, that many of their accidents, in all appearance physical, were in connection with ideas, with the _conviction_ of paralysis, of illness, with the remembrance of such or such an event which had determined some great emotion. Without doubt, this interpretation of hysteria, which I have myself contributed to extend, must never be exaggerated, and it must not be concluded from this that every neuropathic accident always and solely depends on some remembrance or some emotion. In my opinion, this is only exact in a very limited number of cases; and then it only explains the particular form of such or such an accident and not the entire disease. Without doubt it seems to me exaggerated to-day to see in neuroses those psychological disorders alone, whereas the disorders of the circulation, the disorders of internal secretions, the disorders of the functions of the sympathetic which will be spoken of just here must also have a great importance. But, however, this observation proved very useful at that moment. A remembrance, an emotion, are evidently psychological phenomena, and to connect neuropathic disorders with facts of the kind is to include the study thereof with that of mental disorders. At this time, in fact, they began to repeat on all sides a notion that had already been indicated in a more vague manner; it is that neuroses were at the root, were in reality diseases of the mind.

If such is the case, what becomes of the classical distinction between neuroses and psychoses? No one can deny that the latter are above all diseases of the mind and we have here to review the reasons which seem to justify their complete separation. Will it be said that with psychoses the disorders of the mind last very much longer? But some patients who enter the asylum with a certificate of insanity are very frequently cured in a few months and some neuropathic disorders may last years. I could name you patients who since thirty years keep the same obsessions, and who at the age of fifty still ask themselves questions upon their pact with heaven, as they did at the age of twenty. Shall we speak of the consciousness the patient has of his state? But this consciousness may be complete in certain melancholies and very incomplete in certain impulsions.

Is it necessary to insist on the presence or absence of anatomical lesions which one tries to ascertain at the post-mortem examination? Shall we say with Sandras, Axenfeld, Huchard, Hack, Tuke, that neuroses are diseases without lesions? One finds lesions in general paralysis which is ranged with insanity and we find some also in epilepsies which are considered as neuroses; one no more finds lesions in melancholic conditions than in conditions of obsessions. Besides, as I have often repeated, this absence of lesions is of no importance; it is quite in keeping with our ignorance. Every one admits that organic alterations more or less momentary, but actually not suspected, must exist in neuroses as in other diseases. Neuroses as well as psychoses are much more likely to be diseases with unknown lesions than diseases without lesions, and it is impossible to take this characteristic into account to distinguish the ones from the others.

In reality, the notion of lunatic has lost its former superstitious signification and it has taken no precise medical signification. That word is now the term of the police language. It indicates only an embarrassment felt by the police before certain persons' conduct. When an individual shows himself to be dangerous for others, the public administration has the habit of defending us against him by the system of threats and punishments. As a rule, in fact, when a normal mind is in question, threats can stop him before the execution of crime, and punishments, when crime has been committed, can prevent him from beginning again; that is the psychological fact which has given birth to the idea of responsibility. But in certain disorders it becomes evident that neither threats nor punishments have a favorable effect, for the individual seems to have lost the phenomenon of responsibility. When an individual shows himself to be dangerous for others or for himself, and that he has lost his responsibility, we can no longer employ the ordinary means of defense; we are obliged to defend ourselves against him, and defend him against himself by special means which it is useless to apply to other men; we are obliged to modify legal conduct toward him. All disorders of the mind oblige us to modify our social conduct toward the patient, but only in a few cases are we obliged to modify at the same time our legal conduct; and these are the sort of cases that constitute lunacy.

This important difference in the police point of view is of no great importance in the psychological point of view nor in the medical point of view, for the danger created by the patient is extremely varied. It is impossible to say that such or such a disorder defined by medicine leaves always the patient inoffensive and that such another always renders him dangerous. There are melancholies, general paralytics, insane who are inoffensive, and whom one should not call lunatics; there are impulsive psychasthenics who are dangerous and whom one shall have to call lunatics. The danger created by a patient depends a great deal more upon the social circumstances in which he lives than upon the nature of his psychological disorders. If he is rich, if he has no need to earn his living, if he is surrounded by devoted watchfulness, if he lives in the country, if his surroundings are simple, the very serious mental disorders he may have do not constitute a danger. If he is poor, if he has to earn his living, if he lives alone in a large town and his position is delicate and complex, the same mental disorders, exactly at the same degree, will soon constitute a danger, and the physician will be forced to place him in an asylum with a good certificate. This is a practical distinction, necessary for order in towns, which has no importance in the point of view of medical science.[15] If we put these accidental and slightly important differences on one side, we certainly see a common ground in neuroses and psychoses. The question is always an alteration in the conduct, and, above all, in the social conduct, an alteration which tends, if I am not mistaken, toward the same part of the conduct.

The conduct of living beings is a special form of reaction by which the living being adapts himself to the society to which he belongs. The primitive adaptations of life are characterized by the organization of internal physiological functions. Later on they consist in external reactions, in displacements, in uniform movements of the body which either keep him from or draw him near to the surrounding bodies. The first of these movements are the reflex movements, then are developed those combinations of movements which we called perceptive or suspensive actions in keeping with perceptions. Later came the social acts, the elementary intellectual acts which gave birth to language, the primitive voluntary acts, the immediate beliefs, then the reflected acts, the rational acts, experimental, etc. As I said formerly, there is, in each function, quite a superior part which consists in its adaptation to the particular circumstance existing at the present moment. The function of alimentation, for instance, has to exercise itself at this moment when I am to take aliments on this table in the midst of new people, that is to say, among whom I have not yet found myself in this circumstance, wearing a special dress and submitting my body and my mind to very particular social rites. In reality it is nevertheless the function of alimentation, but it must be noted that the act of dining, when wearing a dress suit and talking to a neighbor, is not quite the same physiological phenomenon as the simple secretion of the pancreas. Certain patients lose only the superior part of this function of alimentation which consists in eating in society, in eating in new and complex circumstances, in eating while being conscious of what one is doing, and in submitting to rules. Although the physiologist does not imagine that these functions are connected with the exercise of sexual functions in humanity, there is a pathology of the betrothal and of the wedding-tour.

It is just on this superior part of the functions, on their adaptation to present circumstances, that the disorders of conduct (self-government) which occupy us to-day bear. If one is willing to understand by the word "evolution" the fact that a living being is continually transforming himself to adapt himself to new circumstances, neuroses and psychoses are disorders or halts in the evolution of functions, in the development of their highest and latest part.[16]

This halt in evolution can be connected with different physiological causes, hereditary weaknesses of origin, infections, intoxications, disorders of internal secretions, disorders of the sympathetic system. These diverse etiologies will most likely be of use later to distinguish between forms of these diseases; but to-day the common character of neuroses and psychoses is that this diminution of vitality bears upon the highest functions of self-government.

Whatever be the disorders you may consider, aboulias, hysterical accidents, psychasthenic obsessions, periodical depressions, melancholics, systematized deliriums, asthenic insanity, you will always find a number of facts resulting from this general perturbation.

In plenty of cases, the acts, far from being diminished, appear exaggerated; the patient moves about a great deal, he accomplishes acts of defense, of escape, of attack, he speaks enormously, he seems to evoke many remembrances and combine all sorts of stories during interminable reveries. But pray examine the value and the level of all these acts; they are mere gestures, shocks of limbs, laughter, sobs, reactions simply reflex or perceptive, in connection with immediate stimulation, with inhibition, without choice, without adaptation by reflection. The thoughts that fill these ruminations are childish and stupid, just as the acts are vulgar and awkward; there is a manifest return to childhood and barbarism. The behavior of the agitated individual is well below that which he should show normally. It is easy to explain these facts in the language we have adopted. The agitation consists in an activity, more less complete, in inferior tendencies very much below those the subject should normally utilize.

It is that in reality the agitation never exists alone, it is accompanied by another very important phenomenon which it dissimulates sometimes, I mean the depression characterized by the diminution or the disappearance of superior actions, appertaining to the highest level of our hierarchy. It is always observed that with these patients certain actions have disappeared, that certain acts executed formerly with rapidity and facility can no longer be accomplished. The patients seem to have lost their delicacy of feeling, their altruism, their intelligent critique. The stopping of tendencies by stimulation, the transformation of tendencies into ideas, the deliberation, the endeavor, the reflection; in one word, both the moral effort and the call upon reserves for executing painful acts are suppressed. There exists visibly a lowering of level, and it is right to say that these patients are below themselves.

The two phenomena, agitation and depression, are almost always associated in neuroses as well as in psychoses. It is likely that their union depends upon some very general law, relating to the exhaustion of psychological forces. It is probable that the superior phenomena exact under a form of concentration, of particular tension, much more power than acts of an inferior order, although the latter seem more violent and more noisy. "When the force primitively destined to be spent for the production of a certain superior phenomenon has become impossible, derivations happen, that is to say, that this force is spent in producing other useless and especially inferior phenomena."[17]

A very great number of phenomena observed in neuroses and psychoses are in connection with depression and agitation. Convulsive attacks, diverse fits of agitation, prove to us that before the fit there existed disproportion between the quantity and the tension of the psychological forces, and that the spending of forces during the fit re-establishes the equilibrium. But at the same time, after this spending, one observes a notable lowering of the mental level, a real psycholepsy. It is very likely that studies of this kind will produce some day the key of the epilepsy problem, for vertigos and certain epileptic fits are certainly phenomena of relaxation, the meaning of which we do not comprehend because we do not study sufficiently the state of psychological tension before and after the accidents.

The difficulty of accomplishing superior acts, the exhaustion resulting from their accomplishment, renders them fearful to the patient who has the fear, the phobia of these acts, just as he has the terror of that depression which gives the feeling of the diminution of life. The shrinking of activity and conscience, phobias, negativisms, generally take their starting point in this fear of exhaustion caused by some difficult action. In other cases the patient feels incapable of accomplishing correctly the reflected acts necessary to social and moral life, and feeling no longer protected by reflection, he is afraid of willing or believing something, as one is afraid of walking in a dangerous path, when one cannot see. The vertigo of life produces itself like the vertigo of heights, when one is not sure of oneself.

Depressed patients have felt, wrongly or rightly, a certain excitation after a certain action. Through some curious mechanism, certain acts, instead of exhausting them, have raised their psychological tension. The need, the desire to raise themselves inspires them with the wish to renew such acts, and we behold the impulsions to absorb poisons, impulsions to command, to theft, to aggression, to extraordinary acts, varied impulsions which play a great part in psychoses as well as in neuroses.

I shall not insist any more on a very interesting phenomenon in connection with the oscillations of the mind and which still plays a great part in these diseases. I am speaking of the change of feeling which may accompany the same action in the course of the oscillations of the mind. At the level with the reflected action, more or less complete, the thought of an action which appears important and of which one often thinks, determines interrogations, doubts, scruples. If the individual descends one degree, if he becomes quite incapable of reflecting and therefore of doubting, the same action he continues to think about may present itself under the form of an impulsion more or less irresistible.

There are patients who in the first stage have the fear and horror of committing an act and who in the second stage are driven to accomplish it. In other cases a subject may make use of an action as a means of exciting and raising himself; he seeks it, and the thought of this action is accompanied by love and desire. Let him become depressed and he will no longer be able to accomplish this same action without exhausting himself; he is then reduced to dread it and take an aversion to it. That which was an object of love becomes an object of hatred. Thence these turnings of mind that are so often to be observed in the course of neuroses and psychoses. In a score of my observations the frenzy of persecution and hatred presents itself as an evolution of those obsessions of love and domination.

These are very curious facts that one observes in the oscillations of the mind, in particular when the psychasthenic depression becomes more serious and transforms itself in psychasthenic delirium, which is more frequent than one generally imagines. As a rule the properly so-called psychasthenic has only disorders of the reflection; he doubts but he does not rave. But under different influences, his depression may augment, and when he drops below reflection he has no longer the doubts, the hesitations, he no longer shows manias of love and of direction, he transforms his obsessions into deliriums and often his loves into hatreds.

These are a few examples of the perturbations of conduct common to neurotic sufferers and the diseased in mind. One perceives that the same laws relating to the diminution of force and the lowering of the psychological tension intervene in the same way with the one as with the others. The distinctions, which have been established for social reasons and practical conveniences, no longer exist when one tries to find, by analysis of the symptoms, the nature of neuroses and psychoses.

The latter reflection shows us, however, that in certain cases, at least, there is a certain difference in degree between neuroses and psychoses. The evolution of the human mind has been formed by degrees, by successive stages, and we possess in ourselves a series of superposed layers which correspond to diverse stages of the psychological development; when our forces diminish we lose successively these diverse layers commencing with the highest. It is the superior floors of the buildings that are reached first by the bombardments of the war and the cellars are not destroyed at first; they acquire even more importance, as people are beginning to inhabit them. Well, according as the depression descends more or less deeply, the disorders which result from the loss of the superior functions and the exaggerated action of the inferior ones become more and more serious and are appreciated differently. The superior psychological functions are, in my opinion, experimental tendencies and rational tendencies. They are tendencies to special actions in which man takes in account remembrances of former acts and of their results, in which he enforces on himself by a special effort obedience to logical and moral laws. A little fatigue and a slight degree of exhaustion are sufficient for such an action to become difficult and impossible to prolong for a long time. Furthermore, the disorders of the experimental conduct or of the rational conduct are very frequent. These disorders only reach the superior actions which are not absolutely necessary to the conservation of social order. They can be easily repaired by inferior acts: if the man does not obey pure moral principles, at least he can conduct himself in appearance in an analogous manner through fear of the prison. Also, these disorders of the superior functions are considered as slight; they are called errors, or faults, and it is admitted that the subjects remain normal beings.

At the other extremity of the hierarchical series of tendencies the acts are simply reflex. When the disease descends to this level, when the elementary acts can no longer be executed correctly, we do not hesitate either, and we consider these disorders (related with known lesions) as organic diseases of the nervous system. But between these two terms we note disorders in behavior which are more difficult to interpret. These disorders are too grave and too difficult to modify by our usual processes of education and punishment for us to consider them as mere errors or as moral faults; they are variable; they are not accompanied by actually visible lesions and we have trouble in classing them among the acknowledged deteriorations of the organism. There is the province of neuroses and psychoses, intermedium between that of rational errors and that of organic diseases of the nervous system. It corresponds to the disorders of medium psychological functions, to the group of these operations which establish a union more or less solid between the language and the movements of limbs and which give birth to our wills and beliefs.

Can one establish, in this group, a distinction between neuroses and psychoses that rests on some more precise notion and that is not limited to distinguishing them in a legal point of view? A more profound knowledge of the mechanisms of the will and belief would perhaps permit us to do so. We are capable of wills and beliefs of a superior order when we reach decision after reflection. The operation of reflection which hinders tendencies and maintains them in the shape of ideas, which compares ideas and which only decides after this deliberation, constitutes the highest form of the medium operations of the human mind. Lower, still, there exists will and belief, but they are formed without reflection, without stoppage of ideas, without deliberation; they are the result of an immediate assent which transforms verbal formulas into wills and beliefs as soon as they strike the attention, as soon as they are accompanied by a powerful sentiment. The immediate assent is the inferior form of these tendencies.

If one wished to establish a scientific distinction between neuroses and psychoses, I should say, in a summary fashion, that in neuroses the reflection alone is disturbed, that in psychoses the immediate assent itself is affected. The shrinkage of the conscience, doubts, aboulias, obsessions, scruples are always disorders of the reflected will and belief. On the contrary, irresistible impulsions, deliriums, indifferences which suppress desires and only allow elementary agitations to subsist, show alterations in the immediate assent, in the will, and the primitive belief and must be considered as psychoses. Below could be placed the disorders of elementary intelligence, the disorder of the perceptive and social functions which characterize the mental deficiencies of imbeciles and idiots. One might also distinguish these disorders according to the degree of depth the destruction of the edifice has reached, according to the more or less distant state of evolution to which the patient goes back. But these psychological classifications are purely theoretical, and in practice many other factors intervene which oblige us to consider such a patient as incapable of doing any harm and such another as dangerous; this is the only difference to-day between neuroses and psychoses. Later on, without doubt, we shall be able to substitute for these simply symptomatical and psychological diagnostics, some etiological and physiological diagnostics. We shall be able from the very outset to recognize that a disorder, in all appearance slight and which is not deeply set, presents a bad prognosis, and we shall be able to foresee a serious and deep psychosis in the future. To-day, without doubt, one can often distinguish from the outset the future general paralytic from the simple neurasthenic. But in the actual state of science this ability to distinguish is not frequent and the future evolution of a depressed state can scarcely be foreseen with precision.

Certain individuals pass in a few years from psychasthenic depression with doubts and obsessions to psychasthenic deliriums with stubbornness and negativism, then to asthenic insanity with irremediable and complete want of power. Is it necessary to say that we made a mistake in our diagnostic and that from the first demential psychosis should have been recognized? I am not convinced of this: these diseases, excepting a few cases with rapid evolution, are not characterized from the outset. Without doubt we must note that these depressions which disturb the reflective tendencies of young patients in full period of formation, are dangerous and can bring on still deeper depressions of the psychological tension. But that evolution is rarely fatal; it can very often be checked, and it seems to me fair to preserve the distinction between neuroses and psychoses considered as different degrees of psychological decadence.