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]]