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Page 27
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.
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