A Psychiatric Milestone by Various

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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]

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