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 Salpetrière 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.