Anthology of French Language Psychiatric Texts

Anthology of French Language Psychiatric Texts Edited by Frangois-Rbgis Cousin, Jeun Gurrub6, Denis Morozov TransZated by john Crisp

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Anthology of French Language Psychiatric Texts Edited by Frangois-Rbgis Cousin, Jeun Gurrub6, Denis Morozov TransZated by john Crisp

Anthology of French Language Psychiatric Texts

CONTENTS

Preface

11

Norman Sartorius and Driss Moussaoui Presentation

15

Joseph Daquin (1732-1815)

19

Frangois-Rigis Cousin, Jean Garrabi, Denis Morozov The Philosophy of Madness Philippe Pinel (1745-1826)

33

Medico-Philosophical Treatise on Mental Alienation Third Section: Distinction of the Different Species of Alienation Pierre Cabanis (1757-1808)

45

Relations of the Physical and the Moral in Man Jean Etienne Dominique Esquirol (1772-1840)

On Mental Diseases

55

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Jean Itard (1774-1838)

91

The First developments of the Young Savage of the Aveyron Jean-Pierre Falret (1794-1870)

105

Of the Non-Existence of Monomania Pierre Briquet (1796-1881)

127

Clinical and Therapeutic Treatise on Hysteria Antoine Laurent Bayle (1799-1859) Researches on Chronic Arachnitis. Part I. Observations

145

of Chronic Arachnitis with Mental Alienation Jacques-Joseph Moreau called Moreau de Tours 159 (1804-1884) On Hashish and on Mental Alienation. Physiology.

Introduction BknCdict Augustin Morel (1809-1873) Treatise on Mental Diseases

173

Jules Baillarger (1809-1890)

181

Dual Form Insanity Charles Laskgue (1816-1883) and Jules Falret (1824-1902)

199

Shared Delusion Etienne Azam (1822-1899)

213

Periodic Amnesia or a Double L i f . 7%eHistory of Fe%da. First case observed in France Jean-Martin Charcot (1825-1893)

Eighteenth Lesson. Concerning Six Cases of Hysteria in Men

247

Contents

9

Valentin Magnan (1835-1916) Clinical Lessons on Mental Diseases

259

Valentin Magnan (1835-1916) and Paul Legrain (1860-1939)

267

The Immediate Delusions 285 Jules Cotard (1840-1889) Studies on Cerebral and Mental Diseases. On Nihilistic

Delusion Hippolyte Bernheim (1840-1919)

3 19

Hysteria Sigmund Freud (1856-1939)

335

Jules SCglas (1856-1939)

341

Language Disorders in the Insane 361 Gilles de La Tourette (1857-1904) Study on a Nervous Disorder Characterized by Lack of

Motor-Coordination Accompanied by Echolalia and Coprolalia. Observation 11 (Personal) Alfred Binet (1857-1911)

377

The Measurement of Intelligence Philippe Chaslin (1857-1923)

389

Elements of a Semiology and a Clinical Approach to Mental Disease Eugen Bleuler (1857-1939)

405

Schizophrenia Pierre Janet (1857-1949)

Doubling of the Personality Mental Accidents of Hysterics

427

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Paul Skrieux (1864-1947) and Joseph Capgras (1873-1950) l%e Reasoning Insanities. Delusion of Interpretation

447

Vladimir Serbsky (1858-1917) Contribution to the Study of Dementia Praecox

459

Gaetan Gatian de ClCrambault (1872-1934)

475

Passionate Delusions; Erotomania, Claiming, Jealousy. Patient Description Maurice Dide (1873-1944) and Paul Guiraud (1882-1974)

493

Clinical Psychiat ry. Hebephrenic Syndrome Eughne Minkowski (1885-1972) l%e Notion of Loss of Vital Contact with Reality and

507

its Applications in Psychopathology Henri Ey (1900-1977)

531

l%e Psycbopatbolgy of Pierre Janet and the Dynamic Conception of Psychiatry References

551

PREFACE

Norman Sartorius, President of the W A Driss Moussaoui, Secretary for Meetings of the W A The motto of the Xth World Congress of Psychiatry in Madrid One World, One Language was chosen in recognition of the need to bring together psychiatrists living in different countries and belonging to different schools of thought, and to facilitate their contacts and collaboration. The Congress was successful in that it provided opportunities to renew friendships, to learn from experience and research done elsewhere and to create bridges and collaborative arrangements where these never existed before. It also demonstrated that the improvement of communication among psychiatrists is a task of highest priority. This is so for various reasons-including economic pressures on health care systems, the rapid growth of knowledge, the increase of the numbers of mental health professionals-all of which require consensus within the profession and a common stance in promoting the care for people with mental illness and research in the field of mental health and disease. It thus became obvious that activities that promote communication among mental health professionals, and are

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likely to increase their respect for each other so that they can work together, will have to be among top priorities for the World Psychiatric Association in the ensuing years. This goal was then pursued through a variety of means: by increasing the numbers of Member Societies, now 114 in 96 countries, by developing educational programmes, by an extensive programme of publications now including seven international journals and other activities. The programme of scientific and professional psychiatric meetings and congresses was also significantly expanded-in the period 1996-1999, the WPA has organised or co-sponsored 50 international meetings and congresses varying in size from a few hundreds to several thousand participants. The scientific sections of the W A have also made a major contribution to this effort through the publication of newsletters, section meetings and joint development of educational programmes. In order to proceed in a more comprehensive and faster way in this work the WPA has established partnership with other NGO’s, with scientific institutions and with representatives of the health industries. In this respect, a particularly valuable contribution of WPA’s work have been donations notably from SynthClabo who supported W A ’ s project of strengthening psychiatric libraries in developing countries: with the help of this donation, libraries in 22 countries worldwide were equipped with computer facilities, access to Internet and subscriptions to technical journals. In the course of these activities, it became obvious that language barriers do not only represent difficulties in travel and daily living, but that they also affect the utilisation of knowledge published in only one language. The rich traditions of psychiatry and the wealth of ideas available to those conversant with the language of their producers remain hidden to others or, worse still, reach them distorted through incomplete or incorrect citation. It was therefore most encouraging to receive support from SynthClabo enabling the WPA to bring out the first of the series of

Prefdce

13

translations of major scientific texts-this time from French into English. Other translations will, we hope, follow, facilitating progress of science and practice in psychiatry, by pooling its knowledge and inspirations from different cultures and traditions. The texts presented here can all be found in the Henry Ey library at HBpital Sainte-Anne in Paris, a library aptly named after Henry Ey who not only made major contributions to world psychiatry but also served as WPA Secretary General for many years. We are confident that clinicians and researchers from all over the world will find great interest in reading the descriptions and pathogenetic hypotheses of French authors of the 18th, 19th century and the first half of the 20th century. Their observations are not only of interest from a historical perspective, but could be used to re-evaluate our way of thinking psychiatry today. We believe that such texts could be of help to modern psychiatry from the heuristic point of view. It is our pleasant duty to thank Doctors Garrabk, Cousin and Morozov who have been instrumental in choosing the original texts of this anthology. We would like to thank very much SynthClabo company and the printing house Les EmpGcheurs de penser en rond (especially Michhle Mazier and Philippe Pignarre) for their financial and technical support in the realization of this book, which we hope, is the first of a long series. We do hope that such collaboration between WPA and Synthklabo will continue in the future, with more activities to bring the psychiatric world to one language.

PRESENTATION

The World Psychiatry Association has decided to publish a collection of anthologies of the fundamental texts of international psychiatric literature. These selected extracts will be published in each country simultaneously in the language in which they were written and in English translation, so that readers around the world for whom the working language of the World Association is more familiar, will find them easily accessible, yet may refer where appropriate to the original version. It may even be hoped that these extracts will prompt many psychiatrists to read the works from which they were taken in full. This will enable them to rediscover forgotten authors who introduced into psychopathology concepts which we continue to use, without always knowing their precise origin. In the case of authors who are well-known or at least still quoted today, the reader will also be able to discover what exactly they wrote, for such quotations are often inaccurate, and it is a surprise to find, in referring to the actual text from which they were taken, that the author’s thinking is quite different from that attributed to him, particularly in quotations of quotations. Obviously, in a literature as rich as that of French psychiatry, the choice, for which we have accepted to take

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responsibility, of a limited number of texts-impossible as it is to include in a single volume all the pieces that deserve to be included-will necessarily appear arbitrary. Nonetheless, the rules that we set ourselves in making this choice should allow us, depending on reactions to this first volume, to add to this anthology by extending it to other texts. For the present, we have confined ourselves to extracts of works published between, let us say, the French Revolution and the Second World War, to indicate the historical limits to the period which we have, for the moment, chosen to cover. Of course, the medical literature on madness began much earlier, in the 16th century, either with French translations of works published in the language of science, Latin (the first edition of Jacques Grevin's translation of De praestigio duemonum et incantationibus ac venificis published by Jean Wier in 1564 dates from 1567), or with works written directly in French, the vernacular (Jacques Ferrand's Le Traite' de l'essence et de 1a gu&son de l'dmour ou de la mdancolie e'rotique, published in 1610, and republished in an expurgated edition in 1623, was translated into English in 1640). This literature has continued to be produced up to the present day, in modern times during a period when French was the language of many physicians, who employed it in their own writings. We will provide a number of eminent examples. Within the period to which we have restricted ourselves, there are certain recurrent subjects which are considered to constitute fundamental questions of psychopathology and which therefore provided us with a guiding theme to direct our choice. We began by selecting the names of several dozen authors who participated in the debates on these questions. Then we sought in their works passages in which they express their opinion as clearly and concisely as possible. This led us to select thirty authors born between 1732, for the oldest, and 1900 for the most recent, whose works contain passages which, in a dozen pages, express the essence of their ideas. We were obliged to eliminate authors of equal eminence but for whom, in order not to distort the meaning

Presentation

17

of their writings, we would have had to reproduce much longer texts, thereby reducing the total number of extracts which could be included in a volume of this size. For the same reason, although several passages from some of the selected authors would have deserved inclusion in the anthology, we have restricted ourselves to a single extract. In some cases, these psychiatrists have already appeared as authors of essential texts in Jacques Postel’s “Psychiatry” where, of the 66 authors of different nationalities, 35 published their texts in French. In order to avoid duplication, we have therefore chosen different passages. Finally, we had to take into account the imperatives of the English translation. Certain authors-and this is as true for psychiatric literature as for other literary texts-are untranslatable in the sense that a translation, however good it is, cannot render the style by which their thought is expressed. In attempting to transmit that thought, there would be a risk of betraying it. O u r thanks and congratulations are due to John Crisp who has ably performed this difficult task. We have revised the technical aspects of his translations, where custom has sometimes fixed upon terminology different-though not necessarily more apt-than that proposed by him. In conclusion, we have included a series of short introductions to the authors, their works and the extracts chosen, along with bibliographical references for each one. We also mention, where applicable, any recent editions of old works which can be somewhat inaccessible in editions of the time. Finally, we have attempted in these introductions to establish the genealogy of the ideas by noting master-pupil influences or breaks in the development of those ideas. We hope that this work has increased the accessibility of the psychiatric literature in French and will arouse in the reader a desire to study it in greater depth.

The editors

Joseph Daquin (1732-1815)

Joseph Daquin was from Savoie, and received his training in Turin. At the age of 56, he was appointed physician t o the hospice of his native city, ChambCry. After 3 years working with a number of patients described as incurable, in 1791 he published the first French work entirely dealing with insanity: ”The Philosophy of Madness”. Considered to be the first alienist to recommend moral treatment, he added to the second edition of his work (1804) an eloquent subtitle: “in which it is proved that this disease should rather be treated by moral means than by physical means and that those suffering from it are unequivocally affected by the influence of the moon.” It is the first manuscript which is best remembered, largely because the ideas in it are more clearly expressed. It is true that there are several reasons why the second edition-dedicated this time not to humanity but to Philippe Pinel* (the first edition of whose “Medico-Philosophical Treatise on Mental Alienation or Mania” had been published three years earlier, in 1801)-might be preferred. It includes a large number of clinical observations of the insane. It is known that Pinel, considered to be the founder of French psychiatry, never showed any gratitude towards Daquin, despite the latter, in the midst of

* The asterisks indicates authors also represented in this anthology.

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revolution, having dedicated the second edition of his book to citizen Pinel. The physician of the mad of ChambCry provides a truly personal eye-witness account of the daily life of the insane in his hospice: “these isolated, abandoned men of every kind, who are shunned, who are obliged to be confined in cells like ferocious beasts, and whom curiosity, despite the fear that they inspire, impels us to go to look upon like the beasts held in menageries. . .” The descriptions of the sad lot of these unfortunate patients are identical to those denounced a few years earlier in the report by Colombier and Doublet. In 1785, these two inspectors, following a general tour of the hospitals, had drawn up the founding memorandum of French psychiatry: KInstructionon the manner of governing the insane and on seeking to cure them in the asylums intended for them”. By way of anecdote, it is this memorandum which contains the first description of mental contagion affecting the carer: “most of the people who guard the mad have, after a certain time, their physionomy much disturbed.” It was thus no longer sufficiant to incarcerate the mad, whether raging or calm, as had been done throughout the 18th century. Once confined, they were to be treated, partly by physical means but also by moral means born of the philanthropic theories of the Age of Enlightenment. Hence Daquin’s declaration: “Finally, I wish the physician to come with that gentle and consoling philosophy which seems to do something without acting and which, rather than wishing first to consider disease as an enemy, instead seeks, so to speak, to embrace it like a friend and to discover whether the vital forces which precisely constitute that which we call nature are alone sufficient, with some slight assistance, to destroy the causes which appear to wish to extinguish the principle of life.” Joseph Daquin explains what he means by philosophy. For him, it means breaking free of all the “hotchpotch of drugs” and bringing the madman “moral assistance”, that is to say patience, gentleness, enlightened prudence, consoling words. Treatment was to be personalised for each case, with the physician seeking to understand and penetrate the patient’s internal “logic”. Undoubtedly, certain remnants of the old practices survived: raging madness was less extreme when the patient had diarrhoea, hence the advantage of purgatives, although emetics were rejected;

Joseph Daquin (1732-181>)

21

while the specific effects of hellebore were rejected, and while bleeding was discouraged in cases of inveterate madness, cold baths or ice placed on the head like a skullcap were recommended, as were camphor or opium. Some historians were to detect here the first experiments in the use of electricity which would lead a few years later to electric shock treatment: “Who knows whether electricity, given first through baths, then through sparks and finally through electric shocks, might not cause a jolt to that organ (the brain), capable of destroying the obstacle which holds the reasons and the senses enchained.” It was, above all, observation of the mad which governed the premises of moral treatment, in which the example of the physician, but also of the institution, became the chief therapeutic instruments. “It is everywhere the custom to keep the insane enclosed in cells, from which they are rarely permitted to depart. Experience obliges me to believe that this method, although sometimes-though more rarely than is thought-absolutely necessary, is moreover inimical to a cure. I have observed that, when they are not extremely furious (and it is far from the case that they are all, always, so), their attacks are less violent and less frequent when they are made to take effort: it would seem that the physical liberty that they are allowed to enjoy, in removing them from their cells, restores in part their liberty of soul; the imagination becomes calm and extends in proportion to the extension of the atmosphere in which they breathe; the majesty of nature distracts them, brings diversion to their extravagant ideas which seem then to become less impetuous, to acquire more logic, more connection, to manifest less incoherence.” Fransois-Rigis Cousin

Principal works

DAQUIN (J.), La Philosophie de la folie [The philosophy of madness], ChambCry, Gorrin, 1791, reprinted Paris 1792. DAQUIN (I.), La Philosophie de la folie, oh l’on prouve qae cette

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Texts

maladie doit plutdt &re traitie par les secours moraux que par Les secours physiques et que ceux qui en sont atteints $rouvent d’une manitre non iquivoque L’infuence de la Lune [The philosophy of madness, in which it is proved that this disease should rather be treated by moral means than by physical means and that those suffering from it are unequivocally affected by the influence of the moon], 2“ded., Chambiry, P. Cliaz, year XI1 Principal references

DAQUIN (J.), La Philosophie de la folie, presentation by Claude QuCtel, facsimile of the 1st edition, Paris, FrknCsie Cdition, 1987. MOREL (P.), QUETEL (C.), Les Midecines de La )%Lie [The medicines of madness], Paris, Hachette, Pluriel, 1985, 285 pages.

The Philosophy of Madness

In this work, it is solely my intention to touch lightly upon these different species of madness; I could not promise to analyse them in depth, it would require more talents than I possess, and more time than the practice of medicine permits me. One would also have need of a greater number of observations, the which would furnish data from which consequences might be drawn which could prove of advantage to these kinds of patients. There is a lack of anatomical details relative to the opening-up of the corpses of the deranged, and it might be said to the shame, not of the art, but indeed of the artists, that these details have been infinitely neglected. Few authors have interested themselves in the observation of the mad, even less so in their treatment; either by virtue of the fear that they inspire, or of the disgust occasioned by the treatments that they must be given, or perhaps of the dire prejudice wherein are the great number and the common of physicians who, considering this sickness as almost incurable, have thought that, no sooner has a man given signs of dementia, than he must immediately be enclosed for fear that he might injure his fellow men, or because he can be of no utility to them. There are even those who, in order to treat this sickness, have a routine

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which they employ in almost every case, and when they have exhausted all their science upon them, and have likewise repelled them by the quantity of their remedies, as by those which they have given to no purpose; wearied in the end as much as the patients, they abandon them to their sad destiny, until it pleases providence to unburden the globe of them; often even the multiplicity of the remedies, which does not give nature time to recognise herself and to unite her forces and to liberate herself, causes them to pass from one degree of this sickness to another much more unfortunate, in which, being no longer able to experience the action of the beneficial assistance which a wise, prudent and humane hand might administer, they are no longer susceptible of any species of cure. I have searched in several authors, in order to find out whether I might discover something analogous to my ideas on madness, and I have found there nothing that would give satisfaction. Even the literary societies and the academies have scarcely concerned themselves with this subject; several of them propose prizes each year; some have even been founded by virtuous citizens in different places for purposes of great utility to the truth; but none has considered these unfortunate individuals, and none of these societies has sought to obtain on this disease something satisfactory and advantageous to these patients. It is not my intention, as I have said, to give a complete treatise on madness. Several authors have spoken of it in a didactic manner, limiting themselves to the great division of madness into melancholy and into mania, and it is under these two denominations that they have understood all the different species of madness; they have assigned treatments solely for these two cases, and have proposed nothing for the others. My purpose is only to touch in general on the different branches of this unfortunate affliction of human kind, without entering into the details which could be of interest only to the school. I shall try to be, if possible, as intelligible to those who are not physicians, as to those who

7be Philosophy of Madness

25

are, and in this way to be above all of use to the houses in which patients of this sort are enclosed, and to the administrators of those same establishments. In order to be able to discover madness under all the aspects in which it shows itself and in all its nuances, for it has many, it is necessary to give of it a clear and precise idea, so that it can be recognised almost at first sight. Moreover, it is not always necessary to be absolutely a maniac, for it to be decided that one is mad; indeed, much prudence and precaution should be used before madness is asserted; and it would be appropriate to assign a line of demarcation, so to speak, between the final degree of reason and the first of madness. Physicians have not made sufficient efforts positively to define these two degrees, in order to present them clearly to the lawyers, when it comes to deciding the civil status of an individual in this respect and to appreciating whether his actions depart from the ordinary ways of good sense, both with respect to his family and to the rest of the society to which he belongs. What then is madness? Madness in general is that state in which the exercise of the operations of the soul or of the mind is incomplete, and not always in accordance with the laws of the natural order, that is to say, in which this exercise is contrary to reason, which herself must be considered as the result of all these different operations properly conducted. This definition will perhaps not be to the taste of all readers; however, on a little reflection, it will be seen that the disease called madness is not the same in all people, that it is not always constant, and that it does not always affect all the operations of the mind at the same time, and that consequently the definition which I give encompasses all its forms, in such a way that as soon as one observes a lunatic, speaks with him, and frequents his company, it is impossible not to decide, with assurance, that an individual is or is not mad. Thus, we will take it as true that a man shall be reputed mad, whenever he departs from the rules of reason, whether in his thoughts, or in his speech, or in

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the ordinary actions of his life, because madness, although it admits the exercise of all the operations of the soul, is exactly the contrary of reason. But in order properly to perceive the contrast that there is between madness and reason, should one not also define that which is understood by reason, so as justly to appreciate the state of the lunatic and that of the reasonable man? The philosophers and particularly the physicians have not yet examined this question in sufficient depth; each of them speaks of madness, each of them proffers the word reason, and the line of separation between these two states has perhaps not yet been exactly drawn. It may perhaps even arise that a person who is outside the limits of one or the other, will be, in the strict acceptance of the terms, neither mad, nor a reasonable being. Now reason, in my view, is that faculty with which nature has endowed man in order to understand the truth, insofar as it is necessary to him, either for his preservation, or for his happiness, or for the general good of society, and the objects of which are so evident as to strike his spirit and win him over; or rather, reason is the knowledge of the true, and madness is the absence of this knowledge. By these definitions I believe that while it is not such a simple thing to classify the mad, it will at least be more difficult not to recognise them and to confuse them with other individuals in society; it seems to me, indeed, that all the different alienations of mind can be circumscribed within the following enumeration: the raging mad and the quiet mad, the extravagant and the insensate, imbeciles and those who are simply demented. For, although there remain different degrees between these species of madness, nonetheless each of the unfortunates who are in this state, will not have the natural faculty to know the true, whether physical or moral, as is appropriate to his preservation, and in consequence to his happiness and to that of society. In the raging madman all the intellectual faculties are in an unnatural liveliness and activity; all is exaggerated in him, his physical

The Philosophy of Madness

27

and moral movements exceed the natural bounds; he has a surprising muscular strength, great enough to snap the chains which bind him, to break the walls which enclose him; even the individual who belongs to that amiable, frail and delicate sex, whose distinctive character is gentleness, then becomes, so to speak, a wild bear; the imagination sees nothing but enemies, and the thoughts know nothing but anger and rage; all the attitudes are forced, and nothing in such a person continues to resemble that which he was before the loss of his reason. In the quiet madman on the contrary, all is in contrast to the raging madman: he appears to be in continual reflection; he speaks little or not at all: one would say that he is absorbed in profound meditations; he remains constantly in the place which he has chosen, moves scarcely at all and repose seems to be the state in which he is most content. However, this gloomy tranquility should not be trusted; it is often insidious and treacherous, which makes it all the more dangerous: for at the moment when one thinks him the most calm, he seeks to do harm, to escape or sets wicked and crafty traps, which even by the greatest prudence one cannot avoid. If questioned, rarely does he reply; and if forced to reply, then it is easy to perceive that his reason is in default, that his words have no link and no relation between them, and that he is by consequence incapable of knowing the truth relatively to the common good of society. The extravagant madman observes and knows none of the rules of reason; he follows only his whims, he moves at each instant from one subject to another without tarrying on any: the volubility of his speech is astonishing, he gives you no time to interject a word; a host of singular and incoherent ideas follow each other with inconceivable rapidity and, so to speak, overleap one another. It is not possible to imagine how the brain can provide ideas with such precipitation and impetuosity, and the muscles of the tongue so many alternating and continual contractions

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and expansions as they are required to execute in order to move it. The extravagant madman is truly the opposite of the stupid madman; the latter comes and goes and is in a continual agitation of body; he pays no attention to what is said to him; he fears neither dangers or threats; however, he never offers harm to anyone or at the least very rarely. How then might this state be that of reason which is wise and moderate in all her operations, whose every word is appropriate to her subject and whose actions have all the morality required by circumstances? The insensate madman is lacking in spirit, is devoid of enlightenment and greatly limited as to his ideas; he would be an extravagant madman if his ideas, his actions and his words possessed the necessary vivacity and petulance; he holds the middle place between the extravagant and the imbecile. As he too knows neither fear nor danger, he has and indeed is incapable of having any kind of foresight, not even for that which might be of advantage to him; his reason thus being in default, he is susceptible of little reflection or of none, and all is virtually reduced in him to the satisfaction of the most ordinary needs of life. The insensate madman, according to this definition, would therefore be the very opposite of the prudent man. In the imbecile and the demented, the intellectual organs appear to be totally in default; he acts on the impulses of others with no form of discernment: imbeciles possess no ideas of their own devising; it seems that in them the functions of the brain also lack activity and, so to speak, movement; and it is no doubt thereby that they are deprived of reason. Were one to examine with close attention the different actions of imbeciles, one would undoubtedly discover to what point their imbecility derives from the absence or from the weakness of certain of the faculties of the mind, or from those two things at the same time. For if one of the faculties is lacking in us or becomes deranged, the

i%e Philosophy of Madness

29

human understanding constantly shows the effects of the defects produced by their absence or derangement. Finally, it appears that that which makes the difference between imbeciles and the other lunatics, is that the others join together poorly matched ideas and thus form extravagant propositions, concerning which nevertheless they sometimes reason correctly, while the imbeciles form very few propositions or none, conceive nothing of what is said to them or what is done to them, and reason almost not at all; it would appear even that there is but a nuance from the imbecile to the stupid, and if imbecility is the opposite of wit, it could be said that stupidity is the opposite of conception. The state of dementia is that where reason is so enfeebled that the sufferer knows not whether that which he does is good or bad. The words dementia, imbecility and madness are thus more or less synonymous, with nevertheless that difference between dementia and imbecility by which the former is an absolute deprivation of reason, while the latter is only an enfeeblement; and both differ from madness in that they indicate a habitual state of deprivation or weakening of good sense, while ordinary madness seems only to denote a violent derangement of the imagination which, ceasing by intervals, appears and disappears alternately. As the three great faculties of the soul are imagination, memory, and reason, the latter is, of them all, that which, so to speak, crowns the understanding; it is therefore nothing other than the knowledge of the manner in which we should regulate the operations of our soul. These three operations furnish to each other mutual assistance, and the reasoning which follows is no more than a progression of judgments which depend one on the other; once there ceases to be a link between these judgments, once the sequence is no longer pursued, there must necessarily occur a discord between the faculties of the soul, confusion is introduced into the ideas, and gives rise to that state which characterises madness. For, of two men in one of whom the ideas have

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never been able to connect and the other in whom they connect with such facility and strength that they can no longer be separated; the first would be without imagination, without memory and would consequently be unable to exercise any of the operations which these should produce; he would be absolutely incapable of reflection, he would be an imbecile. The other would have too much memory and too much imagination, and this excess would produce almost the same effect as a total want of both; he would scarcely be able to exercise his reflection, he would be mad. The most disparate ideas being strongly linked in his spirit, for the sole reason that they were presented together, he would consider them to be naturally linked and would place them one following the other, as if by cause and effect. Although madness admits the exercise of all the operations of the soul, it is a deranged imagination which guides them, and madness is unfortunately separated from strong imagination by nothing more than an imperceptible nuance. It might even be concluded that the mad do not even possess instinct which is not at all under our command, and which appears to exclude memory, reflection and the other operations of the soul: moreover, the mad are scarcely susceptible of reflection, this necessarily entrains attention which, itself necessitating the link of our ideas, produces memory; two operations of the soul which the mad possess little or not at all; for they pay little attention to what one says or what one does, and most do not remember the words they have spoken or the actions they have performed: blows and bad treatment are almost the only things to make an impression on them and which they recollect. However, memory is not in general as uncertain in the mad as one would be tempted to think; and I have several observations to the contrary. One of the lunatics in my charge who, at each visit I make to him, gives me letters or papers for different people, has never failed to ask me when I enter his room, even before I have spoken to him and without any cause which might recall the memory to him, whether

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I have given his letter or his paper to the person to whom it had been addressed. As our intellectual operations are excited by the sensations and the will is largely dependent upon these; as the link between the sensations and the will always operates by the intervention of the brain and of its functions, it can scarcely be doubted that the intellectual operations depend on certain movements and on the diverse modification of these movements in the brain itself. For, “in order that the exercise of our intellectual functions should take place properly,” says Cullen, “it is necessary that the excitation of the brain should be complete and equal in each part of that organ; and if some parts of the brain are more excited than others, or more capable of being so, the consequence will be false perceptions, false associations and false judgments”. There are mental distractions to which one would not think to give the name of madness; nonetheless all those which have their cause in the imagination should be placed in the same class. If madness were determined only by the consequence of errors, it would be difficult to fix the point where it begins; it would appear that any error which carries us along would be madness, a consequence often produced by our passions taken to the point of blindness: for moral blindness is the distinctive character of madness. For example, if a man commits a criminal act with full knowledge of his actions, he is a villain: if he commits it in the belief that it is right, he is a madman. One might further add that misanthropy should be regarded as a sad madness; anger and humour as an impetuous madness; vengeance, which has always before its eyes an imaginary or real offence, and envy, for which all the successes of another are a torment, are painful madnesses. Madness therefore consists in an imagination which, unremarked by ourselves, associates ideas in an entirely disordered manner and sometimes influences our judgement and our conduct. According to these considerations, it appears likely that few people are exempt. The wisest would thus differ from the most deranged simply

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because, by good fortune, the defects of their imagination have as their objects only things which play little part in the ordinary course of life and which place them less visibly in contradiction with the rest of men. And should a man be observed above all in his conduct, in his way of life? for it is here that lies the pitfall of reason for the majority of mankind.

Philippe Pinel (1745-1826)

Philippe Pinel is considered to be the founder of modern psychiatry. Born in southwest France, he pursued his medical studies in Toulouse where he presented his thesis in 1773, then completed them in Montpellier. In 1778 he settled in Paris, but being unable to practise medicine there due to the rules of the Ancien Rkgime which restricted such practice in a city to graduates of the local Faculty, he initially turned to medical journalism. In 1785 he translated Instructions in practical medicine by William Cullen (1710-1790), an illustrious representative of the Edinburgh school, then, in 1788, published an annotated edition of the “Medical Works” of Giorgio Baglioni (1669-1707), a representative of the so-called iatrometric school. In the midst of the French Revolution, Pinel was appointed physician to the Bicctre Hospice where, since what Michel Foucault called the “Great Confinement” (1656), the mad had been interned, and where he remained only from 11 September 1793 to 29 April 1795. There, he noted the good results obtained through more humane treatment of the raving mad by the warden JeanBaptiste Pussin (1746-1811). The latter succeeded in eradicating the use of chains in this exclusively male establishment on the 4 Prairial of year VI of the Republic (28 May 1798). As a result, Pinel requested that Pussin be relocated, together with his wife, to the Salp&ri&-ewhere he himself had become chief physician on 13 May 1795. When this request was finally granted in 1802,

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it resulted in the abandonment of the use of chains, this time in the female section, before Pussin’s death., Appointed in 1795 as Professor at the Ecole de sand in Paris, which had replaced the Royal Faculty of Medicine following the latter’s closure at the start of the Revolution, Pinel occupied the chair of internal pathology. It is through his theoretical work that he contributed to the liberation of the mad and to the birth of psychiatry. This work essentially consists of two texts: -the “Philosophical nosography or the Method of analysis applied to medicine”, first published in two volumes in year VI (1798), proposes a classification of all diseases based on the organs affected. The chapter dealing with one of the “classes” of disease thus defined, the class of ”neuroses” in Cullen’s sense, i.e. corresponding c o darnagc c o c h e ncrvous system, was co take on

grow-

ing importance from one edition to the next, to the point that it eventually filled the majority of a third volume. The “Philosophical nosography” would remain the standard text for the study of general pathology throughout most of the 19th century. -the “Medico-philosophical treatise on mental alienation or mania” inspired by the philosophical ideas of Cabanis*, first published in 1801 (year IX). The replacement of the notion of “madness”, “mania” in the Greek sense of the word, by that of alienation made it possible to study mental disorders according to a medico-philosophical method. Hegel (1770-1931) and Daquin* both acknowledged the revolutionary nature of this innovation. In the title of the second edition (1809), Pinel removed the reference to the old term mania, to indicate that his subject was alienation alone. By the analysis of the relation between the alienated individual and that part of himself which has become alien to him, Pinel introduces a differentiation between different kinds of alienation, from which his continuators would go on to define the clinical entities still recognised today. We have therefore selected the passage from the second edition of the “Treatise” where Pinel specifies the existence of several forms of alienation. Jean GarrabC

Philippe Pinel (1745-1826)

35

Principal works PINEL (Ph.), Nosographie philosophique ou la mkthode de l’analyse appliquke d la mkdecine [Philosophical nosography or the Method of analysis applied to medicine], Paris, Gravelet, year VI. PINEL (Ph.), Traitk mkdico-philosophique sur l’aliknation mentale ou la manie [Medico-philosophical treatise on mental alienation or mania], Paris, Richard, Caille and Ravier, year IX. Reprint facsimile, Paris, Cercle du livre prkcieux, 1965. PINEL (Ph.), Traitk mkdico-philosophique sur l’aliknation mentale [Medico-philosophical treatise on mental alienation], Paris, Brosson, 1809. Reprint facsimile, Paris, Clin Comar Byla, 1975. PINEL (Ph.), Nosographie philosophique ou la mkthode de l’analyse appliquke Li la mkdecine [Philosophical nosography or the Method of analysis applied to medicine], 5th edition (3 volumes), Paris, Brosson, 1813. Bibliographical references GARRABE 0.) dir., Philippe Pinel, Le Plessis-Robinson, Les Emp2cheurs de penser en rond, 1994.

u.),

GARRABE Philippe Pinel (Lesjournkes de Castred, Castres, kditions mCdicales Pierre Fabre, 1989.

u.),

Gen2se de la psychiatrie (Les premiers kcn‘ts de POSTEL Philippe Pinel) [Genesis of psychiatry (The first writings of Philippe Pinel)], Le Plessis-Robinson, Les Emp2cheurs de penser en rond, 1998. SEMELAIGNE (R.), Aliknistes et philanthropes (Le Pinel et les

Tuke) [Alienists and philanthropists], Paris, Streinheil, 1912. WEINER (D.R.), The Citizen Patient in Revolutionary and Imperial Paris, Baltimore and London, The John Hopkins University Press, 1993.

Medico-Philosophical Treatise on Mental Alienation (Second Edition)

THIRDSECTION. DISTINCTION OF THE DIFFERENT SPECIES OF ALIENATION.

135. Does not the advantage of fixing an object well in the memory, and of giving of it an exact idea, come from the desire to circumscribe it within certain limits, and to avoid disparate considerations? How is one to determine what is properly to be understood by mental alienation and avoid confusion, if one includes in it, as certain Nosologists have done, the various lesions of the functions of the senses, of sight, of hearing, of taste, of touch and of smell, which are related to other diseases? Hypochondria can, by its successive advances, degenerate into mania; but considered in itself it differs greatly from it, forms a very extended type, and may give rise to very singular errors of the imagination. The same is true of several primitive nervous conditions known by the name of somnambulism, vertigo, strangeness, antipathy, nostalgia, nocturnal panic, and unrestrained desires for the pleasures of love which, depending on the sex, are called satyriasis or nymphomania. 136. The favorable influence exercised in recent times on medicine by the study of the other sciences, make it impossible any longer to give to alienation the general name of madness, which can have an indeterminate latitude and extend to all the errors and failings of which the human

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species is susceptible, the which, in view of the weakness and depravity of man, would be without limits. Would it not then be necessary to include in this division all the false and inexact ideas which are formed of objects, all the outstanding errors of the imagination and of the judgement, all that irritates or provokes fantastic desires? One would then set himself up as the supreme censor of the private and public life of men, encompass within his vision history, morality, politics and even the physical sciences, the domain of which has so often been infected by brilliant subtleties and by reveries. 137. An English Nosologist (Cullen) has made judicious remarks on the distinctive character of manic delirium which he judges to consist in errors of judgement, false perceptions of external objects, a strange association of ideas, and causeless moral affections of varying intensity; but are not the vain explanations and the gratuitous theories which he subsequently gives of the facts observed, as if to unveil their mechanism, in opposition with the grave and circumspect approach which a faithful historian of the symptoms of diseases should impose upon himself? How could he believe that a few subtle opinions on the movement of blood in the brain, and on the different degrees of a pretended excitement and of a collapsus of that organ, would be sufficient to plumb the profound mystery of the seat of thought, and of the disturbances of which it is susceptible? I have no wish to lose myself in those unknown regions, and I confine myself to the simple description of the results of the most constant and most repeated observation. 138. Is the distinction between the three species of mania accepted by Cullen, one mental, one corporeal, the third obscure, founded on essential differences, and are their external signs well characterised? Do the symptoms of each of them have marked dissimilarities, or do they not rather differ by their greater or lesser intensity, their duration or other accessory variations? One cannot but pity the fate of

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the human species, to be often the victim of the superficial studies which are conducted in medicine, and of the negligence with which the methods of division adopted by the Naturalists are taken as guides. In order to establish these distinctions on solid foundations, should not one first consider with the closest attention the specific objects, then collect a large number of observed facts and divide them into several groups on the basis of their multiple points of similarity and of striking analogies? It is by following a different route that so many arbitrary classifications have been established in medicine which have ended by placing doctors in contradiction with each other, and by leaving public opinion in a state of fluctuation with regard to their principles. 139. Another medical author famous in England, and fertile in ingenious ideas, has founded the classification of diseases on the most bizarre principles, and considers mania purely in terms of the moral disorders that it can cause; he distinguishes the type which is associated with agreeable ideas, with neither agitation nor development of the muscular forces, from the form which induces the lunatic to make the most violent efforts to obtain an object he desires, or to repel that which he detests; finally, he recognizes another sort of mania associated with a state of torpor and an irresistible tendency to despair. It was easy for this author to collect in society or in works of medicine, diverse entertaining anecdotes on the exclusive delirium of the melancholics,' and in this way to amuse the reader by sacrificing accuracy to pleasure, and to ignore the fundamental characters of mania and its true distinction into species. He even treats as alienation simple vices and failings which are 1. Darwin (Zoonomia, or the laws of organic Life.London, 1796.) designates as a species of mania pauperpatis amor [love of poverty], and he quotes as an example a very avaricious and very parsimonious surgeon who, having inherited a private income or almost IOO,OOO pounds, fell into mania out of fear of poverty. Each day he bemoaned the state of misery which would compel him to die in a prison or in a workhouse.

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constantly observed in society, sentimental love, excessive self-regard, snobbery, a great desire for fame, the habit of being occupied with sad thoughts, the sharp regrets of women over the loss of their beauty, the fear of death, etc. Is this not to convert into madhouses our most flourishing cities? 140. Amidst this fluctuation of opinions on the fundamental characters of alienation, and its division into species, is found a general conformity which is the result of the most repeated observations on the true notions of alienation, and the distinction of mania with faror, from tranquil mania and from melancholic delirium with extreme despondency and a tendency to despair. Thus has D r Chrigton established three species of mania belonging to the first type of insanities; but he considers to be a second type of insanities the illusions (hallucinationes) which consist in false perceptions of external objects, with no other derangement of the mental faculties, as in hypochondria; in the same rank he places demonomania or the conviction of direct communication with evil spirits, vertigo and somnambulism; finally, he forms a third type under the name amentia, in which he includes specific lesions of the diverse functions of the understanding. This author has come the closest in recent times to an exact division of the insanities; but he introduces into them several disparate objects, and even specific symptoms of mania and of melancholy, such as vertigo and the belief in communication with the Demon. The specific lesions of the mental faculties are also symptoms of the diverse species of alienation considered in accordance with their varieties and their diverse periods, and Z have looked at them (section 11) as distinctive characters, by which they may be known and by which their history may faithfully be traced. 141. The diversity of the names established by the doctors of Ancient Greece to express the nuances and the diverse 1. An Inquiry into the Nature and Origin of Mental Derangement, etc. By Chrigton. London, 1798.

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degrees of febrile delirium is testament to the depth of the study they had made of that condition of the brain; but may they be applied with the same success to the diverse species of alienation, and are their varied meanings known with sufficient precision to assist in the progress of this part of medicine? With what mistrust must one regard vague and uncertain methods applied to the manner of observing the insane! And has medicine not suffered until now of the natural tendency there is to draw amusement from the extravagant conceptions of these unfortunates and to make of them, in place of a serious study, a sort of comic spectacle? Attention has therefore been given above all to the strangeness of their speech and to their outbursts of somber or jovial humor, to make them an object of jest, rather than successively directing the regard to the divergences of their perception, the mobility of their ideas, the disorders of their recollection, the phantoms of their errant imagination, the unbridled heat of their passions. Moreover the deranged, unless the reason is entirely overthrown, seek to thwart those who wish to examine them too closely. They possess a profound capacity for dissimulation or a cold reserve which cannot be penetrated, and it is often difficult to form a precise idea of their true position and of the distinctive characters of their delusion. It is by many attempts, and in diverse skillfully conducted interviews, and above all by adopting with them a cordial manner and a tone of extreme frankness, that one can penetrate their most secret thoughts, clarify one’s doubts and, by means of comparison, eradicate apparent contradictions. The principles followed in public or private establishments in the manner of directing them can also produce in them ideas or emotions which are alien to them. Be they treated with haughtiness or with misplaced harshness, they become quick-tempered, hateful and full of violence. They may be restored to their proper affections only by gentle and benevolent means, and it is only then that the history of their distractions considered as a disease may be faithfully traced. It is likewise in this way that mania

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41

and melancholy may be followed in their diverse regular periods as in their unexpected changes, that being the only means properly to ascertain their characteristic signs. Is it then a matter for astonishment that the observations made until recent times on the deranged have in general been incomplete, and have had little worth as a fundamental basis for a regular classification of mental alienation in its diverse forms? 142. A general reform introduced into public or private establishments for the insane, the simplicity of the means and the regular order which has been established in their regime, now make it possible to embrace the entire course of mania through numerous examples, to contemplate it in the three successive periods of the symptoms at their most extreme intensity, in decline and during convalescence, without their progress being disturbed or inverted; we now have the advantage of multiplying the points of contact and the conformities existing between analogous facts, and this process of comparison gives rise to abstract ideas and general terms capable of expressing the diverse species of mental alienation. Moreover, every vain theory is excluded from these particular cases, and only symptoms that are manifest to the senses through external signs, such as the speech, strange gestures, the expression of certain bizarre and uncontrolled emotions, and diverse changes occurring in the physical state, are taken into the account. Why not, therefore, bring into this part of medicine, as into its other parts, the method used in all the branches of natural history? Are not the distinctive traits of mental alienation, apart from certain accessory varieties, the same in all the exact observations collected in diverse epochs? And should it not be concluded from this that all the other facts that may be collected will naturally fall into their place in the divisions that have been adopted? That is, indeed, what is confirmed each day by the deranged of either sex admitted into the hospices. 143. It is easy to acknowledge that the division of

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alienation into its diverse species has until now been established on arbitrary comparisons of a very small number of often incomplete and imprecise observations, rather than being founded on the counting of a great number of facts, collected with method,over a long period of years, in public and private establishments set aside for the deranged of either sex. The most strict and most unvarying order in the service and the direction of these patients is required to guarantee that the progress of the symptoms has not been disturbed nor inverted during their course, and that it has been possible to observe with care all the graduated stages of the alienation, from its extreme intensity and its decline until convalescence. The historical exposition of these facts must have been subject to a sure and constant method, and the observer must have given particular attention to the distinctive characters of the alienation, separated from the diverse lesions of the understanding and the will (section 11). H e must be aware that the accessory varieties of this condition which result from the diversity of the causes, from the greater or lesser intensity of the symptoms, from the difference of the objects of the delusion, or from the particular nature of the moral affections, can in no way furnish specific characters, since those very ones which seem the most opposed can exist within the same lunatic in different circumstances and at different epochs of mental alienation: this suffices to indicate the principles I have followed in this classification in order to render it exact and complete. 144. I had formerly communicated, to the Society of Medicine, the result of my research on alienation conducted in a private establishment; but I was too aware of the inadequacy of those observations to progress to general considerations on its division into species: the same views were taken up with more continuity and more extensive resources, in the first year of the revolution, following my appointment to the position of Doctor of the Bic&re Hospice, where I had continually under my eyes the spectacle of more than two hundred lunatics entrusted to my care.

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Several years later I set down the result of my multitudinous observations, and I felt it possible to establish a solid division of alienation into its diverse species, by comparing all my particular histories with those of the other authors, and by distributing them into separate collections, following the order of their affinities. In this way, a more or less marked general delirium, with a variable degree of agitation, irascibility or tendency to fury, has been designated by the name periodic or continuous mania. I have kept the name melancholic delirium for that which is directed exclusively toward an object or a particular series of objects, with despondency, dejection, and a greater or lesser tendency to despair, especially when it is taken to the point of becoming incompatible with the duties of society. A particular debility of the operations of the understanding and of the acts of the will, which presents all the characteristics of senile daydreaming, has been indicated by the name dementia; finally, a species of more or less pronounced stupidity, a very restricted circle of ideas and a nullity of character forms the condition that I call idiocy.

1. A collection of almost eight hundred lunatics, undergoing treatment or regarded as incurable, whom I have always under my eyes at the Salpb trikre, have further tested the method of classification that I have adopted, and I have not seen, since the first edition of my work on Mania, any case of alienation which cannot be naturally related to one of the species which I have just indicated. I have solely recognised that mania without delirium is not a species but a variety, since these lunatics, in the moment when they are reasoning correctly, give other signs of derangement in their actions and present other characters proper to the maniacs.

Pierre Cabanis (1757-1808)

The treatment that Cabanis has received at the hands of historians of psychiatry is peculiar. Some purely and simply ignore him and fail even to mention his name in indexes and biographical lists. Others speak, and speak highly, of his role in the birth of modern psychiatry, but emphasise only his importance as a philosopher and forget his primary role as a doctor, although it was precisely his medical practice which formed the basis of his philosophical thinking. After spending his adolescence in Paris, interrupted by a trip to Poland, Cabanis was initially attracted by the humanities, translating the Iliad into French verse and in 1797 publishing translations of German poetic texts. In the meantime, he had completed his medical studies in Paris between 1777 and 1783, although remarkably it was in Reims, in 1784, that he obtained the title of doctor. It was following the condemnation, in that same year, of Mesmer’s (1734-1815) doctrine on animal magnetism, and the prohibition against doctors in the Paris Faculty supporting it, that Cabanis, fascinated by mesmerism, chose to obtain his physician’s title from the faculty of a different city. As a member of the “Ideologists”, as Napoleon I(l769-1821) described the group which he considered to be his political enemies, Cabanis frequented the Auteuil salon of Madame Helvetius, to whom another regular, Benjamin Franklin (1706-1790), would propose marriage on the death of her husband in 1771. (It

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was to her that Cabanis had dedicated his collection of poetic texts translated from German.) Ideology was, according to the 1801 definition given in the eponymous work of Destutt de Tracy (1754-1836), “the science which has as its object the study of ideas (in the general sense of facts of consciousness), of their characteristics, of their laws, of their relation with the signs which represent them, and above all of their origin.” Cabanis, influenced by Franklin, in his turn influenced the ideas of Philippe Pinel“. He was physician to two celebrated aristocrats: the Marquis de Mirabeau (1715-1789) and the Marquis de Condorcet (1743-1794), notably under the Terror when the latter chose to take his own life in order to escape the guillotine. Cabanis married Condorcet’s sister-in-law, Mademoiselle de Grouchy. 19 1797, he was appointed Professor of clinical medicine at the Ecole de sand created to replace the abolished Royal Faculty. The subject of his principal work is “Relations of the physical and the moral in man”. This was a collection, published in 1802, of twelve papers, six of which had previously been given at the Institute. In 1823, two were published in four volumes, the “Works” of Cabanis; in 1825, a fifth volume, containing amongst other papers the “Notice on Benjamin Franklin” and the fragments of the verse translation of the Iliad, was published under the title “Posthumous Works”. In the “Relations”, Cabanis declares the need to associate the study of psychical facts with physiology, and assigns to instinct the linking role between the organic world and the intellectual world. For Whyte, Cabanis’ thinking “provided [. . .] a very lively stimulus for a certain number of 19th-century thinkers who hold an essential position in the history of thought on the unconscious, such as Schopenhauer, Maine de Biran and von Hartman.” Given the influence that the latter would, in his turn, have on Freud‘, it is understandable why the physician-philosopher Cabanis deserves his place in the present anthology and why he has given his name to the Paris street which leads to France’s most prestigious psychiatric institution. We have chosen passages from the second essay, “Physiological History of the Sensations”, where Cabanis describes the forrnation of ideas and the deciding processes of instinct, taken from

Pierre Cabanis (17S7-1808)

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the new edition of the “Relations”, published in 1843 by Laurent Cerisi, known as Cerise (1807-1869). Jean Garrabk

Principal works CABANIS (P.), Rapports du physique et du moral [Relations of the physical and the moral], Paris, 1802. CABANIS (P.), CEuvres works], Paris, Didot et Bossange, 1823-1824. CABANIS (P.), CEuvres posthumes [Posthumous Works], Paris, Didot et Bossange, 1825. CABANIS (P.), Rapports du physique et du moral [Relations of the physical and the moral], new edition by Dr Cerise, Paris, Fortin, Masson et Cie, 1843.

Principal references BESANGON (S.), La Philosophie de Cabanis. Une rgorme de la psychiatrie. [The philosophy of Cabanis. A Reformation in psychiatry], Le Plessis-Robinson, Les Empkheurs de penser en rond, 1996.

CERISE (L.), “Notice biographique sur Cabanis” [Biographical notice on Cabanis], in Nouvelle Cdition des Rapports [New edition of the “Relations”], 1843. WHYTE (L.), The Unconscious b e f r e Freud, New York, Basic Books, 1960.

Relations of the Physical and the Moral in Man

You therefore see, citizens, that the determinations which together are designated under the name instinct, together with the ideas which depend on it, must be related to these interior impressions, the necessary continuation to the diverse vital functions. And since Locke and his disciples have proved that reasoned judgments are formed on the distinct impressions which come to us from external objects through the intermediary of the senses, since they have even, in the accordance with the method of the chemist, decomposed the ideas and reduced them to their primitive elements; that they are then re-composed in every part, in such a way as to leave no doubt on the evidence of their results, it would seem that the division between these two species of causes has been made of itself. Instinct belongs to one; reasoning to the other. And this very well explains why instinct is more extended, more powerful, more enlightened even, if that expression may be used, in animals than in man; and why in the latter, the greater the exercise of his intellectual forces, the weaker is the part played by instinct. For you know that each organ has, in the natural order, a limited and circumscribed faculty of feeling; that however continual excitations can greatly push back the

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limits of this faculty, but that this is always at the expense of the other organs: the sensitive being having the capability of only a certain sum of attention, which ceases to be directed to one side when it is absorbed on the other. You are aware also, without my saying it, that in the most ordinary state of human nature, the results of instinct mix with those of reasoning, in order to produce man’s moral system. When all his organs enjoy a modest, and in some sort proportional, activity, no order of impressions dominates; all are balanced and combined. These circumstances which, moreover, conform most closely, I believe, to its real destination, are by consequence those where the analysis we have just reported is most difficult. But just as certain phenomena of health can only be properly understood by consideration of sickness; so even that which seems confused and indiscernible in the most natural moral state, can be distinguished and classified clearly as soon as the equilibrium between the feeling organs is broken and, as a result, certain operations or certain qualities become dominant. I use here the word instinct, not because I consider the idea attached to it in vulgar language to be sufficiently determined; indeed, I believe it indispensable that this matter should be discussed in greater depth, and I propose to return to it in a specific essay: but the word exists; it, or its equivalent, is employed in all languages; and since the preceding observations oppose a view which seeks to have it perceived as empty of meaning, or as representative of a vague and false idea, it was impossible to substitute for it another word, which would necessarily have seemed to misrepresent the question. I observe moreover that it seems to have been made exactly in the spirit of the rigorous meaning that I give it: indeed, it is formed of the two radicals EV, in, inside, and the Greek verb onC,~tv,meaning prick, goad. Instinct is therefore, according to the etymological meaning, the product of excitations the stimuli of which are applied within, that is to say, precisely in accordance with the meaning

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we give it here, the results of the impressions received by the internal organs. Thus, in animals in general and in man in particular, there are two quite distinct types of impressions, which are the source of their ideas and of their moral determinations; and these two types are found, but in different relations, in all species. For man, placed, by some circumstance of his organization, at the head of the animals, partakes of their instinctive faculties; as they, in their turn, although deprived to a large degree of the art of signs, which is the true means of comparing sensations and of transforming them into thoughts, partake to a certain degree of his intellectual faculties. And perhaps, by looking closely, it might be found that the distance which separates him, in this latter respect, from certain species is small relatively to that which separates several of these same species from one another; and that the superiority of instinct which most have over him, in conjunction above all with their almost absolute absence of imagination, compensates, to their real good fortune, the advantages which he has been granted, which they do not enjoy. It is much to have established clearly that all ideas and all moral determinations are the result of the impressions received by the different organs: it is, I believe, a further step to have shown that these impressions offer quite obvious general differences, and that they may be distinguished by their seat and by the nature of their products, although, once again, they nevertheless act ceaselessly upon each other, on account of the rapid and continual communications between the different parts of the sensitive organ. For, according to the expression of Hippocrates, all converges, all conspires, all consents. It is perhaps also something to have attached the embarrassing observations concerning instinct to philosophical analysis, which, finding no origin for them in sensations as such, had excluded them as erroneous, or dangerous in their consequences, and capable of returning all to confusion.

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But there remains one further great lacuna between internal or external impressions, on one hand, and moral determinations, or ideas, on the other. Rational philosophy has despaired of filling it; anatomy and physiology have not yet addressed this goal. Let us see if it is indeed impossible to travel there by sure roads. However, I believe it necessary to tarry a moment on a few circumstances which may improve our understanding of the manner in which operations of the sensibility are executed. [. * .I §VII.-For there to be integrity in all the functions, it must exist in all the organs; in particular, the cerebral system and all its dependencies must have experienced no lesion, neither in their primitive formation itself, nor subsequently and by the effect of diseases. For example, in order to think, the brain must be healthy. Hydrocephalics, in whom its substance is destroyed and disappears by degrees, become stupid. Nonetheless, the existence of the spinal chord is sufficient to sustain the life of the viscera of the chest and abdomen, and even, when this chord has suffered the same lot as the brain, the large nervous trunks maintain a residue of life for some time. Some children are born without a head:' these die immediately after birth, because the nutrition which took place by means of the umbilical chord can no longer continue in this manner, nor in any other that be sufficient to maintain life. However, they may often be large and fat; their limbs are well formed: they have every sign of strength. In other children, the state of the brain entirely prevents thought. They nonetheless live as healthy and vigorous beings: they digest well; all their other organs develop; and the instinctive determinations which form part of general human nature, are manifested in them at more or less the ordinary periods and according to the customary laws. Not 1. That is to say it without a brain; and very often in this case there is no mouth, and its opening is obliterated.

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long since I had the occasion to observe one of these automats. His stupidity was a consequence of the extreme smallness and misshapenness of his head, in which there had never been sutures. He was born deaf. Although his eyes were in a fairly good state, and he appeared to receive some impressions of light, he had no idea of distances. However, he was otherwise very healthy and very strong; he ate with avidity. When he did not receive the next morsel with sufficient speed, he was seized by violent agitations. He liked to grip whatever came to hand, particularly animated bodies, whose gentle warmth, and, I believe, whose emanations also, seemed agreeable to him. The organs of generation were in him in precocious activity; and there were frequent proofs that they greatly excited his attention. Finally, fleshy masses may be seen to form in the womb and in the ovaries, or bony parts, such as for example jaws, which grow teeth, and experience genuine life; for they are animated by nerves, the influence of which governs in them the same movements as in those which form part of a complete and regular body. There exist those anomalous productions such as headless monsters of whom we spoke previously: life is preserved in them only insofar as they remain attached to the organs which gave them birth; nature forms them and nourishes them there by a particular artifice. Those which can be expelled in a kind of childbirth, wither and die as soon as they are left to their own devices, because they cease then to pump the nourishing juices analogous to their nature. But it may be seen that they had a life of their own, of greater or lesser duration, in accordance with that of their nerves, which evidently form a system, as does every sensitive organ in a properly formed child. 1. Observers of vegetal physics have often observed in the truncated parts of plants certain develo ments which did not extend to the entire plant. A bud may vegetate and ower, while the branch and the tree to which it is

K

attached are no longer alive; it may become the seat of regular albeit partial vegetation. But the phenomenon is much more striking when it is encountered in the animal system.

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Thus, I repeat, the action and reaction of the nervous system, which constitute the different vital functions, can be exercised on isolated parts of that system. The further the circle, or the influence of these parts, is extended, the further the functions are multiplied or complicated. The development of the viscera of the thorax and of the stomach can take place through the sole influence of the spinal chord. But thought, which is produced in the brain, could not exist when that organ is absent: it deteriorates to a greater or lesser degree when it is ill-formed or diseased: and it is of no surprise, since the nerves of sight, of hearing, of taste and of smell depart directly from it, and the brachial nerves, on which depend the most delicate operations of touch, are closely attached to it, being formed, in large part, of the cervical pairs. To achieve a just idea of the operations from which thought proceeds, the brain must be considered as a particular organ, especially destined to produce it; just as the stomach and intestines to operate the digestion, the liver to filter bile, the parotid, maxillary and sublingual glands to prepare the salivary juices. Impressions, arriving in the brain, cause it to enter into activity, just as food, falling into the stomach, excites it into a more abundant secretion of gastric juices, and into the movements which favor its own dissolution. The proper function of the one is to perceive each particular impression, to attach to it signs, to combine the different impressions, to compare them between themselves, to draw judgments and determinations from them, just as the function of the other is to act on the nutritive substances, the presence of which stimulates it, to dissolve them, to assimilate their juices into our nature. Do I hear it said that the organic movements by which the functions of the brain are executed are unknown to us? But the action by which the nerves of the stomach determine the different operations which constitute digestion, the manner by which they impregnate the gastric juices with the most active dissolutory power, are no less hidden

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from our researches. We see foods fall into this organ, with the new qualities: and we conclude that it has truly brought about this alteration. Likewise, we see impressions arriving at the brain, through the intermediary of the nerves: they are at this time isolated and without coherence. The organ enters into action; it acts on them: and soon it sends them back metamorphosed into ideas, which the language of physiognomy and of gesture, or the signs of speech and of writing, manifest without. We conclude, with the same certainty, that the brain in some way digests impressions, that it organically effects the secretion of thought.

Jean Etienne Dominique Esquirol (1772-1840)

Esquirol, who studied directly under Pinel“, continued the latter’s work in the emergence and the first developments of alienism. Born in Toulouse, he was initially destined for an ecclesiastical career before revolutionary upheaval took him into the army as a medical officer. Arriving in Paris in 1799 to begin his medical studies, he attended Pinel’s department at the Salp8tri;re and in 1805 presented his thesis on “The passions considered as causes, symptoms and curative methods in alienation”. At the death of Pussin he was appointed “physician-supervisor” of the section of the female insane where chains had just been removed, then an ordinary doctor in that hospital. The experience he acquired in these functions enabled him, in 1819, to produce a report for the Ministry of the Interior: “On the establishments provided for the insane in France and on means of improving them”. He set up and developed a private mental asylum where he implemented the methods he recommended. Appointed chief physician to the Maison royale de Charenton (today the Esquirol Hospital) in 1826, he continued the teaching on mental pathology he had begun in 1817 at the Salpetrihre. The historic building where today we are able to admire Esquir01’s statue was reconstructed after the alienist’s death in accordance with his ideas on hospital hygiene. Esquirol took part, along with his students, notably J.T. Falret,* in the preparation of the law of 30 June 1838, which would

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serve as a model for similar laws in many countries and which for a century and a half governed the operation of asylums in France. Its effect was to oblige every department to create a specialist public establishment for the insane. Was it the ecclesiastical vocation of his youth which prompted Esquirol to choose for these institutions a name which recalled the outlaw’s right to of church asylum, rather than the term hospital which at that time had negative connotations? In the same year 1838 Esquirol published “On mental diseases considered in medical, hygienic and medico-legal terms”, a collection of essays he wrote throughout his career on insanity from those three points of view. It includes the articles written by Esquirol between 1821 and 1826 for Panckoucke’s “Dictionary of medical sciences” where he gives definitions of a certain number of psychopathological phenomenaidiocy, dementia, hallucinations, etc.-in terms virtually the same as those used today, thereby distinguishing several varieties of insanity. In particular, he contrasts mania defined as a general delusion with the extensive group of partial delusions or monomanias, a concept which represents the most original aspect of his theoretical work. These monomanias are themselves subdivided into intellectual, affective and instinctive monomanias. In the first group is lypemania which, as a partial sad delusion ( h u q meaning sad in Greek), replaces melancholia with suicidal tendency, a condition in which Esquirol was particularly interested. The existence of instinctive monomanias and in particular of homicidal monomanias would be the subject of violent debate, on account of the important consequences their acknowledgement would have in the medico-legal field. Although, soon after Esquirol’s death, his pupil Jean-Pierre Falret was to pronounce the final word on the non-existence of the monomanias, the idea that it might be possible to analyse madness-previously conceived as a global phenomenon-by breaking it down into primary elements, greatly altered the way in which doctors and the public had previously looked at mental pathology. This is demonstrated by the survival into modern day vocabulary of words based on the monomania model, with a prefix referring to the nature of the partial insanity and the ending “mania”. “On mental diseases.. .” is illustrated with 26 engravings by Ambroise Tardieu, often reproduced for their aesthetic qualities, based on drawings of the physionornies of insane patients which

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Esquirol had commissioned from Georges Gabriel (Plate 17 shows the layout of Charenton with commentary explaining the urgency of the additional buildings constructed after Esquir01’s death). This was one of the first attempts to give a visual representation of the clinical approach to mental alienation. Jean Garrabk Principal works I

ESQUIROL (E,), Des passions considirkes comme causes, symptSmes et moyens curatifs de l’aliination mentale [On the passions considered as causes, symptoms and curative methods in mental alienation] (1805). Reprint Paris, Librairie des Deux Mondes, 1980. ESQUIROL (E.), D e la lypbmanie ou mdancolie (1820) [On lypemania o r melancholia]. Reprint Toulouse, Privat, 1976 (Presentation P. Fedida and J. Postel). ESQUIROL (E.), Des maladies mentales cons&6es sous les r a p ports midical, bygiinque et midico-ligal [On mental diseases considered in medical, hygienic and medico-legal terms], Paris, Bailli&re, 1838. Reprint Paris, FrCnCsie, 1989. Bibliographical references GAUCHET (M.) and SWAIN (G.), La Pratique de 1’espr.t humain [The practice of the human mind], Paris, Gallimard, 1980. GOLDSTEIN (J.), Console and Classzh. The French Psychiatric Profission in the Nineteenth Century, Cambridge University Press, 1987. SANCHEZ-CARDENAS (M.) and ZINS-RITTER (M.), Une m&e ttre son enfint [A mother kills her child], Le Plessis-Robinson, Les Emptcheurs de penser en rond, 1997.

On Mental Diseases (1838) O N HALLUCINATIONS.

A man who has the intimate conviction of a sensation actually perceived, while no external object capable of exciting that sensation is accessible to his senses, is in a state of hallucination: he is u visionary. Sauvages has given the name of hallucination to the errors of a man who, having a lesion of the senses, no longer perceives sensations as he perceived them before that lesion. Seeing things, feeling things, hearing things, are classified by this nosologist amongst the first order of the class of insanities; but the other senses, together with reasoning, being able to rectify these illusions, these errors, the phenomena in question should not be confused with delusion. Sagar calls hallucinations false perceptions which form the first order of insanities in his Nosology. Linnaeus places them in the order of the diseases of the imagination (irnaginarii). Cullen classifies them amongst the local maladies. Darwin, and the English doctors since, have given the name of hallucination to the partial delusion which only affects one sense, and they nevertheless employ it indiscriminately as a synonym for delusion. This symptom of delusion has been confused by all the authors with lccal lesions of the senses, with the perverse

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association of ideas, finally with the effects of imagination. It has been studied only when its object is the ideas which seemed to be associated with sight, and never when it reproduces ideas associated with the other senses. Nonetheless, considered in all its varieties, with whichever sense it is seen to be associated, this symptom is very frequent; it is one of the elements of derangement and may be encountered in all the varieties of that sickness. The ascetic books of all peoples, the history of magic, of sorcery of all ages, the annals of mental medicine provide numerous cases of hallucination; I myself have collected and published a large number. The observations that follow show the hallucinations as far as possible in isolation from the other symptoms of madness. M. N., aged 51 years, of a bilious-sanguine temperament, having a large head, a short neck and highly coloured face, was prefect, in 1812, of a large town in Germany, which rose against the rearguard of the retreating French army. The disorder which resulted from these events, the responsibility which weighed on the prefect, turned the latter’s head; he believed himself accused of high treason, and, by consequence, dishonoured. In this state, he cut his throat with a razor; on returning to his senses, he heard voices accusing him; cured of his injury, he heard the same voices, became persuaded that he was surrounded by spies, believed himself denounced by his servants. These voices would repeat night and day that he had betrayed his duty, that he was dishonoured, that there was nothing better for him to do than to kill himself: they employed by turn ail the languages of Europe which were familiar to the patient: one only of these voices was heard less distinctly, because it employed the Russian tongue, which M. N. spoke less easily than the others. Amongst these different voices, the patient very clearly distinguished that of a lady who repeatedly told him to take courage and to have confidence. Often M. N. would stand aside in order to listen and to hear better; he would question, reply, provoke, defy, become angry,

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addressing himself to the persons he believed to be speaking to him: he was convinced that his enemies, by diverse means, could divine his most intimate thoughts, and reach him with the reproaches, the threats, the sinister opinions which they heaped on him; otherwise, he reasoned perfectly correctly, all his intellectual faculties were of a perfect integrity. He would follow conversation on diverse subjects with the same wit, the same learning, the same facility as before his illness. Returning to his country, M. N. spent the summer of 1812 in a castle, where he received many visitors; if the conversation interested him, he would no longer hear the voices; if it languished, he would hear them imperfectly, and quit the company, standing aside the better to hear what these perfidious voices were saying; he would then become anxious and preoccupied. The following autumn, he came to Paris. The same symptoms obsessed him along his route, and became exacerbated after his arrival. The voices would repeat: “Kill yourself, you cannot outlive your dishonour.. .No, no! the patient would reply, I will be able to end my existence when I have been justified; I will not bequeath a dishonoured memory to my daughter.” He went to the minister of the police (Rial), who received him kindly, and attempted to reassure him; but no sooner was he in the street, than he was again obsessed by the voices. I was invited to attend the patient: I found him walking in the courtyard of the mansion where he lodged with his only daughter. His face was highly coloured, the complexion yellow, the expression anxious, the eyes wild. I was received with politeness; to all my questions I received no other reply than this: “I am not sick.” The next day, same reception.. .He told me: “I need neither physician nor spy.” Agitation for the rest of the day. M. N. conducted his daughter, aged 15 years, to one of her friends; in the evening, increased disquiet, exasperation, insomnia, thirst, constipation. The following day, M. N. went early to the prefecture of police, where he declared that he has just placed his

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daughter in a boarding school, that he would not yield to the relentless enemies who were inciting him to kill himself until he had fully justified himself, that he had come to give himself up for immediate judgement. O n the same day, the patient was entrusted to my care. For more than a month, M. N. remained in his apartment without going out, not sleeping, eating very little, wishing to see no one, and pacing about in long strides, like a man who is anxious, worried. If offered remedies, he would reply with an ironic smile. Otherwise, his politeness was complete, his conversation logical, very witty and sometimes gay; but he never betrayed his secret, appeared very preoccupied, and above all very defiant of the people who waited upon him. During conversation, he would be distracted, sometimes stopping to listen and replying tersely, angrily and sometimes with outrage to the supposed voices. After some two months, he appeared to desire me to prolong my visits; I resolved to give the voices which pursued him the name gossi&; this word was successful, and, in the future, he employed it to express their horrible importunacy. I ventured to speak to him of his illness and of the reasons for his sojourn; he gave me many details on all that he had experienced for so long; he lent himself a little better to my reasoning, he discussed my objections; he refuted my opinion on the causes of his voices, he reminded me that they were showing, in Paris, a so-called invisible woman, who would reply at a distance when spoken to. “Physics, he would say, has made such progress that with the help of machines, she can transmit her voice a great distance. -You travelled one hundred leagues by carriage and on paved roads, the noise of the vehicle would have prevented your gossips being heard.. . -Yes, no doubt, but with their machines, I could hear them very distinctly.” The new policies, the approach of the foreign armies towards Paris, appeared to him fables invented in order to discover his opinions; all of a sudden, in the midst of one

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of our conversations, he said to me, raising his voice and in a solemn tone: “Since you wish to have it, here is my profession of faith. The Emperor showered me with benefits, I served him with zeal and devotion, I failed in neither duty nor honour, I swear it; let them do with me what they will.” Towards the end of March 1814, after a long conversation, I asked M. N. to pay me a visit, in order to convince himself, by the inspection of my library, whether I was a physician; he refused; but three days later, expecting to catch me unawares, he proposed to come immediately to my cabinet. I accepted. After long perusal of my books, he said: “If these books have not been placed here expressly for me, this library is indeed that of a physician.” A few days later, the siege of Paris began, but the patient remained convinced that this was not a battle, but a shooting drill. The king was proclaimed, I showed M. N. newspapers with the arms of France, he read them and returned them to me, adding: “These newspapers were printed for me.” I objected that this would not only be a very costly, but very dangerous, measure; this argument did not convince him. I suggested that he should take a walk around Paris to convince himself but he refused. O n 15 April, he said to me suddenly and spontaneously: “Shall we go out?”; the instant we arrived at the Jardin des Plantes, we came upon a great number of soldiers, wearing the uniforms of every nation. Hardly had we gone a hundred paces when M. N. squeezed my arm and said to me: “Let us return, I have seen enough, you did not deceive me; I was sick, I am cured.” From that moment, the gossips fell silent, or no longer made themselves heard, until the morning, on rising. My convalescent would distract himself from them by the briefest of conversations, by reading, by walking; but he now judged this symptom as I judged it myself. He regarded it as a nervous phenomenon, and expressed his surprise at having been duped by it for so long. He agreed to the application of a few leeches, to take some foot baths, to drink a few glasses of purgative mineral waters. In the month of May, he moved to the

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country home, where he enjoyed perfect health, despite the sorrows he experienced and although he had the misfortune to lose his only daughter there. M. N. returned to his country in 1815, where he was called to the government service. This case offers the most simple example of an hallucination of the hearing that I have observed. The hallucination alone characterised the brain disorder of this patient; his anxieties, his mistrust, his fears were nothing but the consequence of that phenomenon, which lasted more than two months; although the convalescent had entirely recovered the free exercise of his understanding. Could it be that habit was the cause of this persistence? M.P ..., aged 60 years, from a family distinguished in the sciences, was a very remarkable officer of marines, of average height, with a protuberant forehead and developed occipital bone, brown hair, dark eyes, pale complexion, highly cultivated intelligence, and very gentle character. He indulged in onanism in his youth. One of his brothers took his own life. At the age of 30 years, M.P.. .took part in the 1807 campaign in Prussia as an officer of marines. He was billeted for a long time in very damp quarters and was taken by intermittent fever with delirium. At the age of 31, during convalescent leave, M.P. . .married a charming woman, and entered a family which treated him as their own son; shortly afterwards, delusion, attempted suicide. The patient, entrusted to my care, recovered in three months. Restored to his family, he was the happiest of men. He returned to the army with the rank of lieutenant of the marine of the guard, and took part in the campaigns of 1810 to 1811. In July of the latter year, at the age of 34, following a setback which was taken for an injustice, the delirium returned but ceased at the end of the year. In the 1814 campaign, M.P.. .was appointed squadron chief of the marines of the guard; shortly afterwards, a new attack brought about by the abdication of Bonaparte. In 1815, at the age of 38, he returned to the service for the hundred days, against the

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advice of his wife’s family. After the second abdication,

M.P.. ., struck down once again, conceived for his wife and

for her family, whom he had so greatly cherished before, a violent aversion which nothing could destroy. H e deserted his adoptive family, and set out alone on foot to Rome, under the dominance of religious ideas. Scarcely had he set foot on the soil of Italy, when one day, overtaken by fatigue, he sat down on a rock, and experienced something extraordinary: God appeared to him, he had his first vision. From that time, throughout the whole journey, he believed himself followed by his father-in-law who constantly placed every possible obstacle in the way of his accomplishing his journey; he saw him, he heard him, he fought with him, yet nevertheless he finished his journey. Returning to France, he was placed in the hospice of Avignon where he allowed his beard to grow, neglected the most ordinary measures of cleanliness, undertook fasts, spoke rarely, was interested in nothing, indulged in no distraction. I visited this hospice in 1821; M.P.. .recognised me, greeted me kindly and asked me several questions regarding my health, regarding certain people whom he had known when he was in my care, eleven years earlier. Being brought back to Paris, M.P.. .entered Charenton in 1825. His delusion was religious and mystical. A thousand hallucinations, a thousand illusions of the senses deceived his reason. M.P.. .believed himself to have immediate communication with God. The Son of God appeared to him sometimes, he saw him borne upon clouds, surrounded by his angels, a cross in his hand; be intimates his orders to his humble servant I? . ., not through words, but through signs which appear in the air. M.P.. .would not perform the simplest act without consulting Gad in heaven. He repeated passages of the Bible, of the Gospels, with which he would contradict the observations made to him regarding his reports of his hallucinations and his illusions; God expresses himselfthus in Holy Scripture; and he would quote the verse. Having fasted excessively during Lent 1827,

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M.P.. .fell sick; I ordered him to take food, he obeyed only following contemplation in order to consult God and to receive the order from on high. He would repeat often, in our discussions: formerly I did not believe in God, I was in

darkness; but since I have hadfdith, God has given me light. M.P.. .was always in the gardens, contemplating the sky, the clouds, a notebook and pencil in his hand; he would draw the symbolic figures which he saw in the air: these were sometimes geometric figures, sometimes animals, household utensils, flowers, instruments of music, of agriculture; sometimes bizarre figures which resembled nothing; all these were signs for the instruction of men,for as it is said in Scripture: there shall be signs in the sky; he had seen all created, he understood the creation and the signs that he saw, he wished to explain them, and in his explanations religion and poiitics were constantly mixed; he drew all his visions and wrote down the explanations. In ordinary life, M.P.. .was calm, polite, amiable; if he spoke of his visions, it was with a smile upon his lips, in soft language. H e would express himself without exaltation, with very well chosen words; if contradicted, his eyes would become animated, his gaze would lift and be fixed upon the clouds, his face would colour, but there would be no signs of fury. M.P.. .removed from the best society, became stout, his hair became grey, his appetite was good, as was his sleep. He lived apart and habitually remained in the open air; he spoke little, and never entered into dispute; I often spoke to him of his wife and his family, in order to restore him to his former affections; they wished, he would say, to make me deny the faith, they are the enemies of God, I reject them; his dress was bizarre in its assortment of colours. The strange hallucinations of a highly distinguished officer of marines, who has been at Charenton for 11 to 12 years, will not be read without interest. His religious monomania was carried to excess. At the age of 50, this patient was almost always dominated by ideas of mysticism

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and of penance. He would fast, go barefoot, remove his clothes and stretch naked on the floor of his room. Habitually calm, he had several attacks of fury, caused by the refusal to allow him to go to Brest in order to resume his service. In the spring of that year, 1836, M. H.. .handed me several loose sheets, on which he had written down his hallucinations: here are a few passages from them: First sheet. “In the name of the Father, of the Son and of the Holy-Spirit; “Signs and visions which foretell the reign of God and the coming of 0. L. J. C. “In the latter years, there have been very extraordinary occurrences in heaven and on earth. The reign of God and the coming of 0. L. J. C. are near. God has favoured me with several visions which prove it. It is particularly in the last few years that I have had the happiness to see God, and that I have seen several dwelling places in the heavens. How many things I know! “In the East, in October 1821, towards midnight, I heard a very loud voice coming from the sky, which pronounced words which I cannot repeat; for I did not understand them. A little later, I heard great cries, and I saw demons being punished by God. At this sound, I arose hastily and prayed. On the next day, I gave my money to the poor. A few days later, before sunrise, I saw in the East the triangle, emblem of its divinities. I spoke of it to several people, but my conduct then was not sufficiently religious for me to be believed. I should have prayed, done penance, but I did not. It was only a few years later that I began again to instruct myself in religion; I went little to mass, out of shame. I have conquered this shame, I have done penance.

“T. H.” Second sheet. “In the name of the Father, etk. “Signs and visions, etc. in 1829. “At the end of June, during the night, a man appeared above France: the presence of God was very strong, and I

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heard it said: is it the end of the world? it seems it is the end of the world. Men were full of fear and many were troubled. At daylight, the most perfect calm reigned. A few days later, I saw these men crossing a part of the sky, with armed men. Their movement was hasty, and this patrol seemed to be intended to warn men in heaven and on earth; for I saw them in different regions and in many places. Throughout the whole summer, I saw angels and saints in several parts of heavens. “Several times I saw God the Father, who had the goodness to speak to me. The first time, he was surrounded in great power, the sky was blazing. I saw him surrounded with light globes which, before, had appeared dark; then, he went into different hells, where he killed several monstrous beasts, and he caused to be filled the holes from which I believed false oracles were being given. His power was everywhere and the heavens were overwhelmed by it. “I saw several times, in the sky, St. John the Baptist, in a cart drawn by seven horses, from which, I believe, he was making ready with the angels the events which must proceed the coming of Christ. “I beg you to believe that my visions are genuine.

“Signed, T. H.”

I have suppressed the other sheets, for sometimes the ideas are no longer coherent and no longer reasonable in the system of ideas which dominates the patient. Thus, he ends a sheet with this reflection: “I believe that Jesus Christ will come, because he has gone astray several times. I pray all believers to intercede for me.” Madame de S.. ., aged 47 years, of average height, generally thin of body, brown hair, blue eyes, endowed with great sensitivity, of lively and very gentle character, began menses at the age of 14. Mme S. was always of delicate health, but exempt from serious maladies; married at the age of 21, she became pregnant at 23, and gave birth successfully. She did not nurse;

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three months after her confinement, she had an intestinal disorder, which persisted despite the discharge of the haemorrhoids. At the age of 31, second pregnancy, during which the character of Mme S. became difficult and capricious; she was delivered at the due time and without incident; nursed her infant and returned to her original sweetness of nature. Mme S. was fatigued by nursing, and the abdominal disorder grew in severity. At the age of 38, she became excessively devout, she had mystical ideas, persuaded herself that she should live with her husband solely for the purpose of conceiving children according to God’s word, accusing her husband of being too earthly in his ideas. Nonetheless, she became pregnant for the third time; the delivery was successful. The child died after a few months, and Mme S. had lavished on him care of an excessive tenderness, because, she said, the child had been born in accordance with holy visions. The greatest pain was succeeded by calm and tranquillity; the mystical ideas dissipated, and from the age of 40 years, Mme S. enjoyed perfect health until, at the age of 46, she lost her eldest daughter, recently married. Although in despair at this loss, she affected great resignation in order to sustain the courage of her husband, who was overwhelmed. She returned to her religious reading with greater ardour than ever; she read several of those pretended political prophecies which were to be found everywhere; this diverse reading greatly preoccupied her. She lost sleep and appetite, and from the month of January 1817, she spoke often of the events predicted for France. Finally, at the beginning of the following March, she attended the service for the anniversary of her daughter’s death: she remained sad, morose, silent, without appetite, sleepless. All of a sudden, on 5 March, cries, complaints, convulsions, loquacity, Mme S . spoke incessantly of God, who had announced to her great events. The sky had opened, she had seen her daughter there, who had said to her that France was going to pass into the reign of grace and justice; that a messiah would appear, to place himself at the head of the

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new Church and of the government; that in the future all would be happy. This state lasted seven hours, and when Mme S. was restored to herself, it was suggested that she come to Paris for reasons of health; she obstinately refused. As soon as she was told that God had commanded it, she immediately descended from her apartment; the horses were at her carriage, she entered it without difficulty, and on the 6 arrived in Paris. On 7 March, another crisis, convulsions, cries, hallucinations, attempts to rid herself of her husband and her chambermaid. She repelled them by her threats and by her words, struck them both, taking them for devils. With isolation she became more tranquil, but not more reasonable. Mme S . . .despaired that the devil had taken on the face of her husband, who was the person she loved the most in the world. She went easily to see M. Pinel, because she believed that celebrated man to be as knowledgeable as herself on all that was to come. She was entrusted to my care. From the first day, the new habitation, the strange persons around the patient affected her to such a point that she never betrayed the thoughts which filled her mind. She manifested no concern at the absence of her husband, nor any disquiet to find herself with strangers. This change of situation was the accomplishment of God’s commands. The following day, the 8 March, Mme S.. .exhibited some trust in my regard; I attempted to make her understand how her convictions were contrary to the truth, and to make clear to her the true reasons for her presence in Paris. She laughed at my error, invited me with benevolence to prepare myself for great events; otherwise, she was calm, spoke little, was never unreasonable, sometimes laughed for no reason and in the evening played a game of cards. She refused all medicines. March 10, after a long conversation, in which Mme S.. . recounted, for the first time, everything she had seen, everything she had heard, everything she had discovered in holy books; after a long discussion, she agreed to make the

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following treaty with me, which I wrote down, and which we both signed. According to this treaty, it was agreed that if the messiah had not arrived on the 25 March, if great events had not taken place by that time, the patient would consent to be declared mad, and would submit to the treatment prescribed for her. From that day on, she was not only calm, but she was gay, conversed freely, spoke to no one of what was in her mind, sustained conversation with wit and on all sorts of subjects. Only with me did Mme S.. .hazard a few words on her prophecies, and solely out of concern for my future happiness. The 25 March passed; the following day, I demanded execution of the treaty. Mme S.. .yielded with good grace, and manifested a great desire to see her husband again. She saw him the following day, and seemed to all of us so reasonable that, that very day, she departed for her province. The convictions of this lady were not entirely destroyed, but they were greatly weakened. Having returned home, she resumed her former manner of living, whether within her own circle, or in society. No one suspected that she had been sick, and in a very short time the final traces of her illness were entirely erased. Mme R., seamstress, aged 44 years, tall, generally thin of body, brown hair, eyes brown and lively, face of high colour, sanguine temperament, enjoying very good health, of gay character, but obstinate and choleric. Age 19: menses, preceded by atrocious colics. Age 22, married, seven pregnancies, three stillbirths. Age 30: when nursing, Mme R. entered into dispute, had a fit of anger, the milk dried up, tranquil delirium which persisted for 18 months; good health since. Age 41: walking in the street, Mme R. was drenched by a pot of tepid wash-water, during the period of menses. Menstruation ceased and did not return. Since then, headache, excessive spending, purchase of things unnecessary to the household, disputes and quarrels on politics, more difficult and more irascible character.

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Age 44: dispute, fit of anger; in the evening, agitation, stet. Mme R. broke the windows of her neighbours, was arrested, sent to the police, where she was condemned to pay for the broken windows. New fit of anger, violent delirium, extreme agitation, loquacity, cries, songs, dances, etc. Taken to Charenton, the patient remained there 5 months, in an acute state of mania. Transferred to the Salpttrihre, on 19 November 1816, the patient was not habitually unreasonable, but was in a state of continuous agitation, talked incessantly, tore her clothes, tormented her companions; usually gay, she sometimes wept; she had insomnia, constipation; she dressed in a bizarre manner, and recounted to anyone ready to listen, with the utmost coolness and a tone of the most profound conviction, that there was in Charenton a female inmate who had been visited by Jesus Christ and for whom he paid 3,000 francs in board. While our patient was in that house, she also saw Jesus Christ: he was tall, and his hair was dark, which, she would add, was astonishing, since Jesus Christ is depicted as fairhaired, but perhaps he had been fair-haired in his childhood. Jesus Christ had a handsome face, a pretty mouth, fine teeth, his voice was gentle, as was his speech; he had announced to our hallucinated patient that the winter would not be cold; that he would punish the Jacobins by flooding their houses; he appeared to her in spirit so that the others would not see him, he took her by the arm and conducted her into a yellow chapel which then existed in the garden. He had told her several times that there would be no more wars nor misfortune, since the people had been converted. Since she had been at the Salpttrihre, Jesus Christ had visited Mme R. every evening; he had promised that there would be a swift and abundant harvest, he would give her money regularly; he had sent her several letters (she had the letters in her possession, but did not wish to show them to anyone); he would send into her cell the sweetest odours of jasmine and orange, he had painted landscapes and views on the walls of the cell, and he would light it each evening

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with the brightest stars; our patient alone had the right to see o r to hear these beautiful things. Miss C. . ,,tall, generally spindly of form, black hair, large black eyes, skin brown and grey, temperament biliousnervous, delicate chest, of lively character, with a keen imagination. At the age of one year, Miss C.. .had smallpox; at the age of 12, menses, preceded by chlorosis for three months; since then, irregular and scanty menses; at the age of 14, Miss C. . .fell in love with a young man with whom she had been brought up, he died; Miss C.. .was 16 years old, she fell into melancholy, refused to eat and passed several days, at various intervals, without taking the slightest nourishment. Following this, she became subject to headache, stomach aches, would sleep little and would often be awakened by nightmares. She would experience convulsions and fainting at the slightest vexation, especially after meals. At the age of 17, a new inclination, the melancholy and all the nervous manifestations disappeared, health appeared very good. At the age of 18, Miss C.. .lost her parents, was left without resources and guidance: lack of appetite, more irregular menses; melancholy, desire for death, joy at the idea that she would soon rejoin her parents. Finally delirium for five to seven hours every day; in the intervals of calm, refusal to eat; loss of weight, pulmonary catarrh, leukorrhoea, intermittent fever initially tertian, then quartan, then daily with delirium between the attacks. The patient would see her dead parents by her side, which would cast her into the most profound despair. Certain friends, in the hope of consoling her, gave Miss C. . .advice drawn from religion, which she began to practice. But at the age of 21, thwarted in her inclinations, she lapsed again into sadness and discouragement, felt overwhelmed by the loss of her parents and by her great poverty. It was then that, in church, the Holy Virgin appeared to our patient, seated next to God, consoling her and assuring her that she would take her under her

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protection; the same apparition occurred every day during the delirium of the intermittent fever which lasted more than a year. At the age of 23, her lover having compromised her, Miss C.. .overtaken by sorrow, wished to die and refused food. After fifteen days of abstinence, she fell into a state which she could not express; nonetheless she dragged herself to church, and while she was praying, despite her physical weakness, despite the tumult of her passions and her ideas, God appeared to her, and asked her, in a tone of voice which penetrated her, the reasons which led her to destroy herself: Because I have been hurt, she replied. After a longer discussion, God commanded her to live, despite all the sufferings that still awaited her. He demanded an oath that she would do nothing to destroy herself: Miss C...took this oath; it should be remarked that having experienced many reversals since then, many sorrows, and two attacks of lypemania with impulsion to suicide, our patient has always been held back by this oath. At the age of 25 and a half years, Miss C.. .left her region, came to Paris, and there indulged in dissolute living with all the excess of a fiery temperament and imagination. Soon after, she became pregnant and was much distressed; during the pregnancy, she had several fainting fits each day, she became hydropic; nonetheless, the delivery was successful. After that, she was in miserable health, and believed herself about to die; moreover, desire for death which would put an end to her sufferings. At the age of 29, a second very stormy pregnancy, atrocious colics, successful delivery; Miss C.. .left the Maternity ten days after labour; returning home, alone, abandoned, without resource, plunged in the most profound misery, in pain, overwhelmed with sorrow, she worked night and day to feed herself; her state of weakness and suffering did not permit her to earn enough to live on. She went to church, prayed to God for three hours, promised to go to confession and to convert. She left with more courage and resolution, returned to work with

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renewed ardour. After a few days, she caught a fever and passed several days without eating. As the first time, she again saw God who appeared to her at eight o’clock in the morning; she was transported to the sixth heaven, saw things too beautiful to recount, the memory of which ravished her still; this state of ecstasy lasted more than nine hours. God appeared to her several more times, Jesus Christ came to visit her more often, gave her advice, commanded her to speak to the people; she passed several days without eating, as being in communication with God she believed she could do without it; she wished to work, but was unable to do so despite her great need. Miss C...had the same visions for three weeks; on 28 April, she was very agitated; on 30, she sang from her chamber casement, in the evening she declaimed, announcing great misfortunes for the people, speaking by turns of the disorder of her conduct, of her virtue, of her penitence; she armed herself with that which came to hand, threatening to exterminate any who approached and calling them profane; revolting against the persons of her acquaintance who approached to care for her, she drove them away with horror; even her sister was sent away with contempt and fury. O n 1st May, a physician having come to visit the patient, she commanded him to announce in the name of God the evils which threatened France.. .etc.. .The agitation and perversion of the ideas were at their height. O n 3 May, Miss C.. .was sent to the Hatel-Dieu, whence she was transferred to the Salp&ri&e; on arrival, on 5 May, she sang, talked incessantly, held a religious discourse mixed with obscenities; she was thin, of yellow complexion, with burning skin and a red tongue; she wished to do miracles and to cure all our patients; warm baths, calming drinks, foot baths, etc. O n the 15, general delirium, agitation, loquacity, cries, singing; on the 17, aggravation of all the symptoms, start of abundant menstrual flow; on 30 May, alternating calm and agitation: God had commanded her to warn the emperor,

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she knew those who were betraying him, she would denounce them, she also knew the spending of the State and those who were ruining it; she spoke haughtily, proudly and threateningly; she was very red, very agitated, walked with great strides, spat often, constipation, insomnia; end of June, return of menses; July, idem. Continuation of the warm baths, the cold head lotions, the refreshing drinks; August: calm, the patient would respond correctly to the questions addressed to her; September: sleep, return to reason, convalescence, headache; December: perfect health, Miss C.. .recognised her delusion: God had appeared to her very often during this last attack, had spoken to her, had revealed the future; he came in the form of a venerable old man, dressed in a long white cloak. During the following winter, her health remained perfect; Miss C.. .left the hospice of 13 April 1815. Hardly had she left the hospice, finding herself in the same state of abandonment and destitution, the same troubles returned, together with the same ideas. Our patient was possessed of the desire to announce to Napoleon the things which God had commanded her to say; she tried frequently to penetrate into the interior of the Tuileries; unable to do so, she wrote a letter addressed to the emperor, a second to the arch-chancellor, to ask him how Napoleon could be reached. I still have in my possession the reply sent by the archchancellor, but the patient dared not carry out the instructions contained in that reply. At the review prior to the departure for Waterloo, she forced her way through the ranks, and dramatically placed in the hands of an officer a packet of letters addressed to Bonaparte. Hoping that her advice had finally been received, Miss C. . .believed herself to have saved France. She was calm for a certain time, but poverty pursued her ceaselessly; finding no employment, she again lapsed into lypemania. She wished to destroy herself, and went several times to the river; but she was held back by the memory of the oath she had taken at the age

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of 23. She returned to the Salp&ri&e, on 21 June 1815, in the most deplorable state, particularly in her physical condition. Milk, sufficient nourishment, warm baths, refreshing drinks, mild laxatives quickly restored her strength. In the month of August, the patient was better and began to work; in the month of September, the menses were reestablished, the delusion had ceased, her gaiety returned: during the winter, headache, scurvy. For the last year, this young woman, aged 33, has been employed in the service of the division of the insane; she is in full possession of her reason; but her character is very difficult, she is capricious and erotic. She remains so convinced of the truth of what has been announced to her that she said to me one day (1817): “I shall be mad for another two years, until time has proved to me that all that was predicted to me is nothing but folly and error.” In 1819, Miss C.. .herself wrote the long history of the physical, intellectual and moral infirmities of which I have just given an extract. M. D., a doctor of medicine, tall, of strong constitution, of sanguine temperament, with a large head, a very exposed forehead, more protuberant on one side than the other, blue eyes, high facial colour, possessing a violent and stubborn character, was an extreme partisan of the so-called physiological doctrine; he was not content to spread this doctrine through his advice and his writings, but also by his example. He would bleed himself from time to time, submit himself to a severe diet, and bathe frequently. He had been known to provoke into a duel his colleagues who, in a consultation, did not share his medical opinions. Age 36 (August 1822): paralysis of one eye and of the commissures of the lips, with temporary delusion. Age 38 (September 1824): after a violent argument which took place in a consultation, suddenly delusion, agitation. Returning home, M. D. wished to bleed his wife, his children and his servants, and bled himself of several pounds of blood. Subsequently insomnia, loss of appetite, extreme turbulence, complete incoherence of ideas, hallucinations.

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Eight days later, M. D. was conducted to Charenton. On his arrival, his agitation was very great, his loquacity continual; the patient claimed to recognise everyone; he treated the service staff with haughtiness and impatience; he experienced hallucinations of hearing and sight; he was conscious of his state and his reasoning was correct. Towards the end of the month, he became furious and threatened to kill anyone who came near. Age 40 (October 1826): M. D. believed he had seen a patient of the institution insult and violate his wife; furious, he rushed upon him and injured him grievously. Age 41 (April 1827): he had several attacks of intermittent fever, which seemed to calm him without diminishing his delusion. When I was charged with the medical service of the royal house of Charenton, the state of M. D. had not changed. His physical exterior was in very good state. Seeing me for the first time, he appeared content and showed great confidence in me; but although he always expressed the same sentiments towards me and claimed to feel great deference, I was unable to persuade him to follow a regime and to take a few remedies appropriate to his state. I was strongly desirous to contribute to his cure, and I paid him particular attention. Nothing could make him recover from his hallucinations, nothing could overcome his medical exaggerations. He often asked me to bleed him; my refusals, the reasons for which I attempted to explain, did not discourage him. His insistence became stronger during the summer of 1827; finally, after several evasive answers, I yielded, hoping to reinforce the patient’s trust in me and thus to become master of his reason. It was agreed between us that a small exploratory bleeding would be performed. The bleeding was done one day in October; scarcely had the student who had performed the operation withdrawn, than our enthusiast removed the apparatus and filled with blood a chamber pot, a pewter bowl, spread a large quantity on the floor of his chamber; feeling himself weaken, he lay

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down on his bed, onto which the blood continued to flow. Attracted by a few sounds of complaint, the nurse came running and found the patient almost lifeless, lying on his bed. The students, alerted in turn, found the patient without pulse, without respiration, his face without colour, his eyes dull, his limbs flaccid, and thought him dead. Nevertheless, they performed frictions, first dry, then aromatic and alcoholic, and irritant frictions were practised on the different parts of his body; the patient was wrapped in wool. After long and painful efforts, the respiration and pulse became perceptible, a few drops of liquid reached the stomach. After several hours of care, the patient seemed to revive, pronounced a few words, but could not speak; gradually his strength returned, he recovered his voice, his senses recovered their functions, except for the eyes: the patient remained blind. As soon as M. D. was aware of his sensations (this required several days), he declared himself to be feeling quite well, apart from a certain weakness. He expressed no regret for his loss of sight, being sure that it would return. Despite the state of anaemia which persisted for several months, despite the loss of sight, the delusion was in no way altered. The hallucinations had the same energy, the same continuity, the same character, and M. D. continued to be excited by these hallucinations of sight and hearing. The patient was perpetually in conversation with persons whom he could see and hear; habitually content and happy, he often laughed out loud, applauded by clapping his hands.. .etc.. .He never complained of his situation. He remained very irritable, ready to lose his temper at the slightest vexation; all the functions of nutrition worked well; nevertheless he slept little, and did little exercise, no doubt because of his new infirmity; this state lasted with very little variation for seven years. Age 42 (1828): intestinal catarrh; very abundant evacuation of mucus which greatly weakened the patient. Age 49 (June 1835): during the night cerebral congestion;

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at the consultation on the morrow, the lips were deviated to the left, sensibility was reduced; it was necessary to pinch the skin hard in order to cause pain, the hearing was greatly impaired; a number of lacunae could be observed in the pronunciation of the words; the face was without colour, the eyes watery; the pulse strong, frequent and regular; the skin was hot; the patient was somnolent; he produced abundant phlegm; he had constipation: this state did not last long. From that time, the intelligence was weakened, the patient was less gay, his gaiety was less loud; he heard and understood with more difficulty; he less easily recognised people approaching by their voice; he remained almost constantly lying on his bed, and took no care for his cleanliness. He had little appetite, sometimes refused food, experienced difficulty in digestion; the patient grew thinner, there was diarrhoea, but the hallucinations and delusion persisted. Age 50 (16 March 1836): after several days of prostration, of diarrhoea, the dejections became involuntary. M. D. remained confined to his bed, he was no longer heard to speak alone, aphonia, death. (17 March 1836): post-mortem examination, diploic skull, flow of serosity after opening of the arachnoid. A few lines from the aphophysis of the crista galli there was a bone formation of conic, oval form, two lines thick, an inch and a half in circumference, adhering by its base to the dura mater which forms the fold of thefdlx cerebelli. Arachnoid infiltrated, thick, opaque at certain points, attachments between the pia mater and the cortical substance. These attachments, very numerous at the base of the brain, were more extensive in the upper region of the hemispheres, especially at the front; when these attachments were removed, the cortical substance was ulcerated in appearance; this substance was red. In the portions where there were no attachments on the dura muter, the cortical substance had a silver grey appearance; when scraped with the back of the scalpel, it came away in numerous fragments, and the

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portion of substance which remained attached to the grey substance seemed to be ulcerated, as I mentioned earlier. There was nothing remarkable to report on the origin of the seventh pair of nerves. The optic nerves, greyish, exhibited the colour and transparency of wet parchment, they were flattened and atrophied; devoid of neurilemma, they were firm, consistent and greyish; this colour, this consistency continued until their entry into the optic layers; about the latter, which were incised, there was nothing worthy of remark. The white substance of the brain showed a large quantity of vessels from which small drops of serous blood escaped. The colour of this organ was dull, slightly nuanced, violaceous in certain places, its consistency was generally firmer than in the normal state. The grey matter of the interior of the brain was pink. The cerebellum, the pedunculi cerebri, the pons varolii, the medulla oblongata and spinal cord seemed normal. From these facts, from all those that may be accumulated in the annals of the infirmities and maladies of the human mind, it may be concluded that there exists a certain form of delusion in which individuals believe, sometimes through one sense, sometimes through another, sometimes through several at a time, that they perceive sensations, while no exterior object is present to excite any sensation. Thus a man in delusion hears voices, asks questions, replies, holds a coherent conversation, clearly distinguishes the reproaches, insults, threats, commands addressed to him; discusses, becomes angry; hears celestial harmonies, the singing of birds, a concert, yet no one is speaking to him, there is no voice within reach, around him is the most profound silence. Another sees the most varied, the most animated images, the heavens open; he contemplates God face-to-face, takes part in the sabbath, rejoices at the view of a beautiful painting, of a fine spectacle, at the presence of a friend; he takes fright at the view of a precipice, of flames ready to consume him, of enemies armed to assassinate him, of

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snakes preparing to devour him; this unfortunate is in the deepest obscurity; he is deprived of sight. One lunatic believed that he could see a luminous chariot preparing to bear him into the sky; he opened his casement, advanced gravely to enter the chariot and fell. Darwin recounts that a student in Berlin, who previously had enjoyed good health, returned home in great fear, pale of face, wild of look, assuring his comrades that he would die within 36 hours. He lay down, called for a minister that he might make his peace with God, made his will; his comrades were alarmed by the apparent gravity of his symptoms. Hufeland was with the patient, but his counsels failed to convince. This celebrated physician prescribed a dose of opium, which induced a long and deep sleep that continued well beyond the thirty-six hours. O n his awakening, it was proved to the patient that he had been the plaything of his imagination; once convinced, his mind became calm again, his fears were entirely dissipated, his ordinary gaiety returned, and the young man confessed that having gone out the day before at nightfall, he had seen a death’s head and heard a voice saying to him: “You will die in thirty-six hours.” One hallucinated person asks for troublesome odours to be removed, or else experiences the sweetest aromas, and yet there is no odiferous object within reach; before becoming sick he had been devoid of the sense of smell. Another believes he is chewing raw flesh, or arsenic, or eating earth; sulphur, flames are burning his mouth; he is swallowing nectar and ambrosia. One melancholic continually saw bees emerging from his mouth. One maniac, hearing the growl of thunder, would say: “lightning has struck my head without injuring me;” he believed himself to be lying with several women one after the other, spoke as if they were present, praising one for her willingness, another for her reluctance, speaking to each one the language he believed suitable to her character: sometimes he would be gay, often jealous, sometimes angry. Walking in the garden, this same patient believed himself to be partaking of a meal, and went

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into raptures at the originality and variety of the dishes he was savouring, etc. There are hallucinated patients who feel themselves wounded and torn by rough instruments, by points, by weapons, all the time lying on a soft surface. They are transported far away, believe they hold in their hands objects which do not exist. Some monomaniacs, some epileptics at the beginning of the fit, believe they are being struck, being beaten; they show their body, which they claim to be bruised by the blows which have been rained upon them. One general believed that he had caught a thief, and shook his arms violently, as if holding someone who wished to strike him down. In sum, these individuals believe in the presence of persons or of things which can have no real existence, except in themselves, at least for them; the senses, the feeling extremities play no part in this delusion; these patients have no interest in the outside world; they are in a state of hallucination: they are hallucinated. The phenomenon of hallucination in no way resembles that which occurs when a man, in delusion, does not perceive sensations as he perceived them before his sickness, and as other men perceive them. The notions relative to the properties and the qualities of things and people are ill perceived, and in consequence ill judged; the lunatic mistakes a windmill for a man, a hole for a precipice, the clouds for a troop of cavalry. In this latter case, the perceptions are incomplete; it is a matter of error; ideas, existing sensations are not correctly linked one to the other. In hallucinations, there is neither sensation nor perception, any more than in dreams and somnambulism, since no exterior objects are acting on the senses. A thousand hallucinations mock human reason and lead it astray. Indeed, the hallucination is a cerebral or psychical phenomenon, which takes place independently of the senses. It persists even when delusion has ceased, and vice versa. The history of certain celebrated men confirms this

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independence of hallucinations, and proves that it is possible to be hallucinated and not deluded. The first observation provides a quite remarkable example of this. The most reasonable man, if he observes himself carefully, will sometimes perceive in his mind the most extravagant images, ideas, or the most bizarre associations. The ordinary occupations of life, the efforts of the mind, reason, all distract from these ideas, from these images, from these phantoms. However, the man in delusion, the dreamer, being unable to control his attention, cannot direct it or divert it from these fantastic objects; he is delivered over to his hallucinations, to his dreams. The habit of always making the association between the sensation and the external object which ordinarily arouses and provokes it, lends reality to the products of the imagination or of the memory, and persuades the hallucinated individual that what he is feeling could not take place without the presence of external objects. The apparent sensations of the hallucinated are images, ideas, reproduced by the memory, associated by the imagination, and personified by habit. The man then gives body to the products of his understanding; he dreams while waking. In the dreamer, the ideas of the day before subsist during sleep; while he who is in delusion experiences, so to speak, his dream while awake. Dreams, like hallucinations, always reproduce former sensations and ideas. As in dreams, the series of images and ideas is sometimes regular, but more often the images and the ideas are reproduced in the greatest confusion, and offer associations of the greatest oddity. As in dreams, those who have hallucinations are sometimes conscious that they are in delusion, without being able to disengage their mind. The dreamer, the hallucinated, is never astonished nor surprised by the ideas, the images which preoccupy him, while they would have excited all his astonishment, had he been awake or not deluded. This phenomenon, in both circumstances, is caused by the absence of any accessory idea, of any external image with which the dreamer or the hallucinated individual might compare the

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objects of his dream or of his delusion. The thinking faculty is entirely absorbed by these objects. The hallucinated differ from somnambulists in that, in the majority of cases, the hallucinated recall all which preoccupied or troubled their mind, while the somnambulist remembers nothing. Hallucinations differ from ecstasy only in that the latter state is always produced by a very great effort of the attention fixed on a single object towards which the imagination of the ecstatic constantly strives. In ecstasy, the concentration of the innervation is so strong that it absorbs all the powers of life; the exercise of all the functions is suspended, except that of the imagination; while in hallucinations, an increase in the action of the centre of sensibility is sufficient, and a violent effort of attention is not absolutely necessary. All the functions take place more or less freely, the man lives with his hallucinations, as he would live were he not deluded. The conviction of the hallucinated is so complete, so frank, that they reason, judge and decide in consequence of their hallucinations; they co-ordinate with this prime psychological phenomenon their thoughts, their desires, their will, their actions. In the days when witches and the possessed were burned, there were those who would cast themselves into the fire rather than deny that they had taken part in the sabbath. I have known hallucinated patients who, after their illness, would say to me: “I saw, I heard as distinctly as I see and hear you.” Many describe their vision with a sangfroid which characterises only the most intimate conviction. Whence the most singular actions and language, for hallucinations like real sensations induce, in the insane, pleasure or pain, love or hate. Thus, one rejoices, laughs out loud and feels himself the happiest of men, cradled by the dream of a happiness which is all the stronger, all the purer that, being unable to have any external thought, he sees no limits to his felicity, and thinks not that it may ever end. Another

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is sad, afflicted, in despair, overwhelmed by the weight of the frightful hallucinations which obsess him; his despair is all the more profound that, being unable to link the frightful state with anything nor to find any distraction, he can glimpse no compensation to his pain, nor suppose that it will ever end. Thus lypemaniacs believe that nothing could change their situation, nor deprive them of the happiness which intoxicates them, nor remove them from the frightful state in which they suffer night and day; many believe that they will never die. We have a woman at the Salpttriire who begs to be cut into pieces, because she does not know what will become of her when, everyone being dead, she will remain alone on earth. But hallucinations are not always characterised by this fixed idea or dominant passion; sometimes they are extended successively to the memories of the objects which have made an impression on the senses, and they impress on the delusion a versatility which may be observed in the speech and the actions. It is this that occurs in certain manias and in febrile delirium. Thus, there are patients whose hallucinations, from time to time, change their object. Hallucinations, therefore, are neither false sensations, nor illusions of the senses, nor erroneous perceptions, nor errors of the organic sensibility, as is the case in hypochondria. Can hallucinations be compared with the illusions of the senses or the false perceptions of hypochondriacs? These suppose the presence of external objects, or a lesion of the feeling extremities, while in hallucinations, not only are there no external objects truly acting on the senses, but sometimes the senses no longer function. I treated a former merchant who, after a very active life, became affected by gout around the age of forty-one years. A few years later, he became maniac; he was greatly agitated, spoke aloud with persons he believed he could see and hear; he saw the most singular things; often his visions threw him into the most lively enchantment. There was at the Salp&riire, in 1816, a Jewess, aged thirty-eight years; she was blind and a maniac;

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nevertheless she saw the strangest things; she died suddenly.

I found both optic nerves to be atrophied from their crossing point through to their entrance into the eyeball. There was no doubt, in this case, that the transmission of impressions was impossible. Likewise, there are deaf persons who believe they hear voices. At this moment, we have at the Salpgtri6re two absolutely deaf women whose only delusion is that they can hear a number of people with whom they dispute day and night; indeed, often they become furious. This is what occurs during sleep, with the difference that, during sleep, the senses are closed and do not lend themselves to the impression of external objects; while in delusion the senses, although open, are not attentive and are therefore inaccessible to external impressions, and even to some degree repel them. But in both cases, the effects are the same. The seat of hallucinations being not in the extremities of the sensitive organ, it must be in the centre of sensibility; indeed, it is possible to conceive the existence of this symptom only by supposing that the brain is put into action by some cause. The brain can be put into action by a sudden and violent commotion, by a strong contention of the mind, by a vehement passion; the brain is put into action sympathetically by the particular state of certain more or less distant organs, as occurs in sympathetic insanity, in fevers, in phlegmasia, or by the ingestion of certain poisons into the stomach. Darwin says that hallucinations probably originate at the root of the nerve of sensation, which is more susceptible to attack by inflammation. The brain is brought into action by a violent impression which strongly disturbs it. This disturbance may induce in that organ either an ecstatic state which produces the fixity of the ideas, or a convulsive state, which engenders an incoherence of ideas, and the most varied and most fugitive determinations. Hallucinations ordinarily relate to the activities of body

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and mind in which the hallucinated person indulged, or else they are linked to the nature of the actual cause which produced the disturbance of the brain. A woman has read stories about witches, she is preoccupied with the sabbath in which she must take part, she sees herself transported there, she sees all the practices by which her mind was fascinated. A lady reads, in a newspaper, about the condemnation of a criminal; everywhere she sees a bloody head, separated from the trunk, covered in black crepe. This head is projected above the patient’s left eye, inspires in her an inexpressible horror, which causes her to make several attempts to destroy herself. Hallucinations can also be effects of the voluntary or forced repetition of the same movements of the brain, repeated often and necessarily in order to acquire some knowledge or closely to examine some subject, as we find in many examples of the lives of contemplative men. Habit renders these movements easy and even involuntary, just as it renders more easy and sometimes involuntary the action of certain organs; the action of the brain prevails over that of the external senses, destroys the effect of real impressions, and causes the hallucinated person to mistake the effects of memory for real sensations. Once the normal state is perverted, delusion occurs. One observes in the hallucinated a sort of distance, as in the most reasonable men who are greatly absorbed by some profound meditation. The man whose delusion has for its principle an exalted passion, no longer feels anything; he sees, he hears, but these impressions do not reach the centre of sensibility; the mind fails to react on them; the passionate man is entirely given over to the passion which absorbs it, carries it, takes it outside itself. All that does not belong to the series of ideas, of affections which characterise his passion, is nothing to him; while everything which concerns him is constantly present to his mind. Here, it is passion which dominates reason, which modifies the ideas and controls the determinations. And, since of all the passions love and religion are

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those which have the most absolute and most general empire over man, because they act both on his mind and on his heart, it is not surprising that religious and erotic monomanias are characterised by the most bizarre and most frequent hallucinations. Hallucinations take place in men who have never experienced delusion, but they are one of the elements of delusion which are most frequently encountered in mania, lypemania, monomania, ecstasy, catalepsy, hysteria, febrile delirium. Out of a hundred lunatics, eighty, at least, have hallucinations. Sometimes this symptom occurs a long time before the delusion is obvious to those who live with the sufferers. Often the latter struggle against the hallucinations before expressing them and complaining, before they have committed any disorder of speech or act. Sometimes, early in the sickness, the hallucinations are fleeting and confused; as the illness progresses, they become as distinct, as complete as real sensations, and they are continuous and permanent. It is not rare for them to persist even when the delusion has ceased. During the most general delusion, during a very animated conversation, the deranged person suddenly stops to contemplate the object which he believes to be before his eyes, or to listen to and answer the people he believes himself to hear. This symptom can be observed in almost all those who are suffering delusion; nonetheless, individuals who, before being sick, were dominated by a passion, or subject to strong contentions of mind, are exposed to them more than the others, especially if they had applied themselves to abstract and speculative studies. Although, ordinarily, hallucinations are the lot of weak minds, men who are most remarkable for the capacity of their intelligence, for the profundity of their reason and the strength of their minds, are not always exempt from this symptom. Sometimes the hallucinations seem to depend on a lesion to the function of one sense alone, for example the hallucinated hear things; sometimes, they seem to proceed from

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lesion to the function of two or even three senses, and the hallucinated may hear, see and touch things. Finally, sometimes all the senses seem to work together simultaneously and successively to produce and to maintain the delusion. Certain cases suggest that hallucinations alone characterise a particular state of delusion, which has caused certain hallucinated persons to be taken as inspired; but observed closely, these individuals soon betray the veritable cause of their state. In Germany, there are still lunatics who are called seers. In the East, in India, one encounters pretended prophets who are simply hallucinated. Hallucinations which depend on the impressions received through the senses of taste and smell, are reproduced particularly in the early stages of madness. But those attached to sight and hearing are more frequent at all periods of the condition. Hallucinations of sight, which reproduce objects of more general interest and which make more impression on the multitude, have been called visions; this name is only appropriate to one mode of hallucination. Who would dare to speak of visions of the hearing, visions of taste, visions of smell?and yet the images, the ideas, the notions which seem to characterise the functional deterioration of these three senses, are presented to the mind with the same aspects, they have the same seat, i.e. the brain, they are provoked by the same causes, are manifested in the same diseases as hallucinations of sight, as visions. A generic term was needed. I have proposed the word hallucination as having no established meaning, and therefore as being appropriate to all varieties of delusion, which suppose the presence of an object able to excite one of the senses, although those objects are not within reach of the senses. Hallucinations are a sign not greatly favourable for cure in insanity. Being only a symptom of the delusion, which may be applicable to several maladies of the understanding, either acute, or chronic, they do not require a particular treatment. They should nevertheless enter greatly into consideration in the intellectual and moral direction of the insane, and in the therapeutic views adopted by the physician.

Jean Itard (1774-1838)

The son of a master baker, hard was born on 25 April 1774 in Oraison, in the Alps of Haute-Provence. His education was entrusted to an uncle in the church who, as was often the case at the time with gifted children, had him educated at a seminary, apparently with the intention of training him to manage the family fortune rather than to enter the church. However, the French Revolution of 1789 and the raising in 1793 of an army to defend the Republic against the monarchist forces, were to show him a different destiny. Like many former seminarists, he joined this national army as a medical officer and became a surgeon third-class at the military hospital of Toulon, evacuated from the city which was under siege by the English fleet and troops. O n the lifting of the siege, thanks in particular to the action of the French artillery commanded by a young captain of whom much would later be heard, Napoleon Bonaparte (1769-1821), Itard returned to service at the military hospital of Toulon. In 1798, still as a surgeon third-class, he joined the Val de GrSce military hospital in Paris, the city where the majority of his career and of his life would be spent. There he trained under Pinel*. At the end of 1800, while retaining his functions at Val de GrBce, Itard became physician t o the National Deaf-Mute Institute, founded before the Reyolution by the inventor of sign language, Abbot Charles de 1’EpCe (1712-1789). This establishment was close to the Val de GrBce hospital, in a street now named

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after the AbbC de I’EpCe. In 1803, Itard presented his thesis “Dissertation on pneumo-thorax or gaseous congestions which form in the chest”, one of the first studies on this subject. However, it was in a quite different field of pathology that hard was to become famous and take his place in the history of psychiatry. For it was he who undertook to treat Victor, the wild boy of the Aveyron, a child of some ten years found leading a virtually animal life in the woods where he had apparently been abandoned at birth. O n the orders of Lucien Bonaparte (1777-1840), brother to Napoleon and Minister of the Interior, Victor had been brought t o Paris to the Deaf-Mute Institute to receive the care required to make him into a human being. In an initial “Report to the Minister of the Interior” (1801), Itard describes the method, inspired by the moral treatment of his teacher Pinel-himself somewhat sceptical as to its efficacy in what he considered to be a case of “idiocy”-and by the ideas of J.-J. Rousseau on education and the state of nature, used to restore the use of speech to this wild child. Itard continued the treatment for several years, without in truth obtaining any convincing results, as expressed in his “Second Report to the Minister” (1806), which led him to wonder about the reasons for his failure to relieve this “mutism”. The story of the wild child inspired writers and articles, even if Victor, unlike the wolf-children of India, failed to find his Rudyard Kipling (1865-1936). hard had more luck, since the “new wave” director Fransois Truffaut (1932-1984) himself took on the doctor’s role in his film L’Enfant sauvage [The wild child] (1970). hard himself resigned from the army health service in 1805 in order to pursue his research in Paris and no doubt also to avoid having to rejoin his regiment, where he had been promoted to the rank of deputy surgeon major. Nonetheless, he was awarded the Lkgion d’honneur in 1814, the year of Napoleon 1’s abdication. In 1821 he published his “Treatise on the diseases of the ear and of hearing”, the fruit of his work at the Deaf-Mute Institute. In 1822, he was elected as one of the first members of the new Royal Academy of Medicine. With his friend Esquirol“, another student of Pinel, he prepared an annotated translation of Hoffbauer’s Legal medicine relating to the insane and to the deaf-mute or Laws applied to the disorders of the intelligence, which would be

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published in 1828 at a time when there as yet existed no writings in France on this new problem of medico-legal psychiatry. Itard differentiated clinically between deaf-muteness associated with an impairment of the auditory functions and “mutisrn produced by a lesion of the intellectual functions” (1828). This description prefigures the one which Kanner would make a century later of the syndromes to which he would give the name autistic (1943). In the same year, he published a case of what would become Tourette’s disease. Itard may thus be considered to be one of the fathers of psychiatric psycho-pedagogy in Europe, and one of its grandfathers for America. Edouard Seguin (1812-1880), who in 1837 had treated an idiot child in Paris under the joint supervision of Itard and Esquirol, emigrated to the United States in 1850, after taking part in another revolution, the one of 1848. From 1854, he contributed to the setting up of special classes in several States and, in 1876, was one of the founders and the first president of the Association of Medical Officers of American Institutions for Idiotic and Feeble-Minded Children. Denis Morozov

Principal works ITARD (J.), De L’kducation d’un homme sauvage, O M despremiers dkveloppementsphysiques et moraux du jeune sauvage de I’Aveyron [On the education of a wild man, or on the first physical and moral developments of the young savage of the Aveyron], Paris, Gouson Fils, VendCmiaire, year IX (1801). ITARD (J.), An historical account of the discovery and education of a savage man; or the first developments, physical and moral of the young savage caught in the woods near Aveyron, in 1798, London, printed for Richard Philippo, 1802. ITARD (J.), Rapportfait 2 S.E. le ministre de I’Inthieur sur les nouveaux dheloppements et L’eht actuel du sauvdge de L’Aveyron [Report to S.E. the Minister of the Interior on the new

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developments and the current state of the savage of the Aveyron], Paris, Imprirnerie imphriale, 1807.

u.),

ITARD Trait; des maladies de l’oreille et de l’audition [Treatise on the diseases of the ear and hearing], Paris, MkquignonMarvis, 1821. Second edition (posthumous), 1842. ITARD (J.), Die Krankheiten des Ohrs und des Gehors, Weimar, im. Corn. 1822. HOFFBAUER (J.C.),Mdecine 1;gule relative aux uliknnb et aux sourds-muets, ou les Lois appliquies aux dksordres de l’intelligence [Legal medicine relating to the insane and to the deaf-mute or laws applied to the disorders of the intelligence], Paris, Baillikre, 1827.

u.),

Victor de 1’Aveyron (De l’iducation.. .et Rapport 2 ITARD S.E.. .), Paris, Allia, 1994. Bibliographical references MALSON (L.), Les Enfants sauvages [The wild children], Paris,

UGE, 1964. LANE (H.), The Wild Boy of Aveyron, Cambridge, Harvard University Press, 1976. Trad. frans., Paris, Payot, 1979. GINESTE (T.), Victor de I’Aveyron, dernier enfant sauvage, premier enfant fou [Victor of the Aveyron, last wild child, first mad child] (revised and extended edition), Paris, Hachette, 1993 (large bibliography). DAGOGNET (F.), Le Docteur Itard entre l’knigme et l’icbec [Dr Itard between enigma and failure], in ITARD (J.), Victor de 1’A veyron.

The First Developments of the Young Savage of the Aveyron

A child of eleven or twelve years, who had been glimpsed a few years previously in the woods of the Caune, entirely naked, looking for acorns and roots with which he nourished himself, was, in the same place, and towards the end of year VII, encountered by three hunters who captured him as he was climbing a tree to evade their pursuit. Taken to a nearby hamlet, and entrusted to the keeping of a widow, he escaped after a week and took to the mountains, where he wandered during the hardest colds of winter, arrayed in rather than covered by a tattered shirt, withdrawing at night into solitary places, in daytime approaching the local villages, leading the life of a vagabond, until the day when of his own volition he entered an inhabited house in the canton of Saint-Sernin. There he was held, watched and cared for for two or three days, and thence transferred to the hospice of Saint-Affrique, then to Rodez, where he was kept for several months. During his stay in these different places, he remained wild, impatient and restless, continually seeking to escape, and provided material for the most interesting observations, collected by reliable witnesses, which I shall not fail to report in the course of this essay, where they will stand

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out to better advantage.’ A minister, a patron of the sciences, believed that the science of moral man could obtain some insight from this event. Orders were given for this child to be brought to Paris. He arrived there near the end of year VIII, under the guidance of a poor and respectable old man, who, obliged to separate from him a short time after, promised to take him back and act as his father if ever Society should abandon him. The most splendid and unreasoned hopes were entertained in Paris before the arrival of the Savage of the A v q ron. Many were the curious who took pleasure in imagining his astonishment at the sight of all the beauties of the capital. O n the other hand, many people, in other respects to be recommended for their enlightenment, forgetting that the organs are less flexible and imitation more difficult when a man lives from earliest youth apart from society and from his epoch, believed that the education of this individual would be a matter of no more than a few months, and that he would soon be heard to give the most fascinating account of his former life. Instead of this, what did they see? A child of disgusting filthiness, affected with spasmodic and often convulsive movements, ceaselessly rocking like certain menagerie animals, biting and scratching those who angered him, manifesting no form of affection for those who served him; finally, indifferent to everything and attentive to nothing. 1. Everything I have just said, and that I shall subsequently say, on the history of this child before his arrival in Paris is guaranteed by the official reports of citizens Guiraud and Constant of Saint-Estkve, Government commissars, the first near the canton of Saint-Affrique, the second near that of Saint-Sernin, and by the observations of citizen Nonnaterre, teacher of natural history at the central school of the department of the Aveyron, reported in great detail in his Notice historique sur le Sauvage de L’Aveyron, Paris, year VIII. 2. Although the word savage has until now designated the man of little civilization, it will be agreed that he who is wholly without civilization even better deserves this description. I will therefore conserve for this man the name by which he has always been called, until I have explained the reasons which led me to give him another one.

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It will easily be understood that a being of this nature could excite only a momentary curiosity. Crowds rushed to see him, saw without observing, judged without knowing, and had nothing more to say. Amidst this general indifference, the administrators of the National Institution of the Deaf-Mute and its famous director did not forget that society, by taking in this unfortunate youth, had contracted indispensable obligations towards him which it was incumbent on them to fulfil. Sharing my hopes in a medical approach, they decided that the child should be entrusted to my care. However, before presenting the details and the results of this measure, it is necessary to specify our starting point, to recall and describe that first period, so that that which we have achieved may be better understood, and by thus comparing the past with the present we may determine what is to be expected of the future. Obliged as I am, therefore, to return to facts already known, I shall expose them quickly; and so that I may not be suspected of having exaggerated in order that the contrast may stand out by comparison, I shall take the liberty here of reporting in a very analytical manner the account given of them to a learned society, in a session at which I had the honor to be present, by a doctor known equally advantageously for his genius in observation as for his profound knowledge of the diseases of the intellect. Proceeding first by an account of the young savage’s sensory functions, citizen Pine1 described his senses as reduced to such a state of inertia that this unfortunate was, in this respect, inferior to certain of our domestic animals; his eyes without fixity, without expression, wandering vaguely from one object to the next, resting on none; so little taught moreover, and so little exercised by touch, that they were unable to distinguish an object in relief from a painted body; the organ of hearing insensible to the loudest noises as to the most affecting music; that of the voice reduced to a complete state of muteness, and uttering nothing but a

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guttural and uniform sound; the sense of smell so little cultivated that he responded with the same indifference to the aroma of perfumes as to the fetid odor of the ordure which filled his napkin; finally, the organ of touch restricted to the mechanical functions of the apprehension of objects. Passing on to the state of this child’s intellectual functions, the author of the report showed him to be incapable of attention (unless for the objects of his needs), and consequently of all the operations of the spirit which the former entails, bereft of memory, of judgement, and the capacity for imitation, and so restricted in ideas even with respect to his needs, that he had as yet proved unable even to open a door or to climb onto a chair in order to obtain food placed beyond his reach; finally, devoid of any means of communication, attaching neither expression nor intention to the gestures and movements of his body, passing rapidly and without apparent motive from apathetic sadness to the most immoderate laughter; insensible to any kind of moral affection; his discernment was but a calculation of gluttony, his pleasure an agreeable sensation of the taste organs, his intelligence the capacity to produce a few incoherent ideas relating to his needs; his whole existence, in a word, purely that of an animal. Going on to report several cases, observed at Bidtre, of children suffering irrevocably from idiocy, citizen Pinel drew between the state of those unfortunates and that presented by the child who concerns us, the strictest comparisons, which necessarily resulted in a perfect identity between those young idiots and the Savage of the Aveyron. This identity led necessarily to the conclusion that, suffering from a disease considered until today incurable, he was incapable of any form of sociability and instruction. This was also the conclusion drawn by citizen Pinel, which he nevertheless accompanied by that philosophical doubt present in all his writings, which acts as a warning to he who is capable of appreciating the science of prognosis and of

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perceiving it as but a more or less uncertain calculation of probabilities and conjectures. I in no way shared this unfavorable opinion; and despite the accuracy of the picture and the justice of the comparisons, I dared to entertain some hopes. I founded them on the dual consideration of the cause and the curability of this apparent idiocy. I cannot continue without dwelling for a moment on these two considerations. They continue to apply to the present moment; they are based on a series of facts which I must recount, to which I shall be obliged more than once to add my own reflections. Were we asked to resolve this problem of metaphysics:

to determine what would be the degree of intelligence and the nature of the ideas of an adolescent who, deprivedfiom childhood of any education, had lived entirely separate from individuals of his species; unless I am grossly mistaken, the solution to the problem would be to give to this individual no more than an intelligence proportional to the small number of his needs and unadorned, by abstraction, with all the simple and complex ideas which we receive through education, and which combine in our mind in so many ways by means of our knowledge of signs alone. Well then! The moral picture of this adolescent would be that of the Savage of the Aveyron; and the solution to the problem would provide the measure and the cause of the former’s intellectual state. But to admit with greater reason the existence of this cause, one must prove that it has acted over a number of years, and answer the objection that might be made and that has indeed been made, that the so-called savage was nothing but a poor imbecile whom his parents, in disgust, had recently abandoned at the entrance to some wood. Those who entertained such a supposition failed to observe this child a short time after his arrival in Paris. They would have seen that all his habits bore the stamp of a wandering and solitary life: the insurmountable aversion for society

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and its customs, our clothing, our furnishings, our drawing-rooms, the preparation of our food; profound indifference to the objects of our pleasures and our factitious needs; a passionate taste for the freedom of the fields, still so strong in his current state, despite his new needs and his emerging affections, that during a short stay that he made at Montmorency, he would have unquestionably escaped into the forest without the most severe precautions, and that twice he escaped from the house of the Deaf-Mute, despite the surveillance of his governess; the extraordinary locomotion, heavy in truth since he has worn shoes, but always remarkable by the difficulty of matching our steady and measured gait, and by the continual tendency to adopt a trot or a gallop; the unvarying habit of sniffing each thing presented to him, even objects which we regard as inodorous; no less remarkable mastication, executed by the rapid action of the incisor teeth, suggesting somewhat, by its analogy with that of certain rodents, that like these animals our Savage most generally lived on vegetable products alone: I say most generally, as it would seem from the following trait, that in certain circumstances he might have consumed certain dead small animals. He was presented a dead canary, and within a moment the bird was stripped of its feathers, large and small, cut open with a fingernail, sniffed and rejected. Other indications of an entirely isolated, precarious and wandering life may be deduced from the nature and the number of the scars with which the body of this child is covered. Apart from that one visible to the front of the neck which I shall mention elsewhere as ensuing from another cause and meriting particular attention, there are four on the face, six along the left arm, three some distance from the right shoulder, four around the pubis, one on the left buttock, three on one leg and two on the other; this makes in total twenty-three scars, some of which appear to result from animal bites and the others from scratches and grazes of variable extent and depth; numerous and permanent evidence of this unfortunate’s long and total

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abandonment, and which, considered from a more general and more philosophical point of view, bear witness to the weakness and inadequacy of man left alone to his own resources, as to the bounty of nature, who, according to apparently contradictory laws, works openly to repair and preserve that which it seeks covertly to damage and destroy. If we add to all these facts deduced from observation, those no less authentic reported by the inhabitants of the countryside near the wood where this child was found, it will be apparent that in the first days that followed his entry into society, he ate only raw acorns, potatoes and chestnuts; that he made no kind of sound; that despite the most active surveillance, he succeeded several times in escaping; that he initially showed the greatest reluctance to lie in a bed, etc.: it will be known above all that he had been seen more than five years earlier entirely naked and fleeing at the approach of men;' which supposes that he was already, at his first appearance, accustomed to this kind of life; a custom which could only be the consequence of at least two years passed in uninhabited places. Thus this child has passed in absolute solitude some seven years out of twelve, which was the age he seemed to have attained when he was taken in the Caune wood. It is therefore probable and almost proven that he was abandoned there at the age of four or five years, and that if, at that time, he had already a few ideas and a few words of the beginning of an education, all would have been erased from his memory as a result of his isolation. That is what seemed to me to be the cause of his current state. It explains why I entertained a favorable expectation for the success of my care. Indeed, in relation to the little time he had spent amongst men, the Savage of the Aveyron was much less an imbecilic adolescent than a child of ten or twelve months, and a child against whom stood antisocial habits, an obstinate lack of attention, inflexible organs and 1. Letter of citizen N... published in the Journal des Dkbats, 5 pluvi8se, year VIII.

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an accidentally blunted sensibility. From this latter point of view, his situation became a purely medical case, the treatment of which was a matter of moral medicine, that sublime art created in England by Willis and Crichton, and recently spread to France through the successes and writings of Professor Pinel. Guided by the spirit of their doctrine, much less by their precepts which could not be adapted to this unusual case, I reduced the moral treatment or the education of the Savage of the Aveyron to five principal views. FIRST VIEW: T o form an attachment in him to social life, by rendering it more gentle for him than the one he was then leading, and notably more similar to the life he had just left. SECOND VIEW: To awaken his nervous sensibility by the most energetic stimuli, and sometimes by the lively affections of the soul. THIRD VIEW: To extend the sphere of his ideas by giving him new needs, and by multiplying his relations with the surrounding beings. FOURTH VIEW: T o lead him to the use of speech, by inculcating the exercise of imitation through the imperious law of necessity. FIFTH VIEW: To exercise for some time on the objects of his physical needs the simplest operations of the mind, and subsequently to determine their application to objects of instruction.

[. * .I Such is, Sir, the history of the changes effected in the system of affective faculties of the Savage of the Aveyron. This section necessarily brings to an end all the facts relating to the development of my pupil over the space of four years. A large number of these facts bear witness to his perfectibility, while others seem to deny it. I have made it my duty to present both without distinction, and to recount my reverses and my successes with equal truth. This astonishing variety in the results in some way renders uncertain

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the opinion that may be formed of this young man, and casts a sort of contradiction into the consequences that arise out of the facts described in this essay. Thus, by bringing together those disseminated in paragraphs VI, VII, XVIII, XX, XLI, LIII and LIV, one cannot prevent oneself from concluding, 1. that, as a result of the almost absolute nullity of the organs of hearing and speech, the education of this young man is still and must for ever be incomplete; 2. that, following long inaction, the intellectual faculties are developing slowly and painfully; and that this development, which, in children raised in civilization, is the natural fruit of time and circumstances, is here the slow and laborious outcome of the most active education, the most powerful resources of which are employed to obtain the smallest of effects; 3. that the affective faculties, emerging with the same slowness from their long sleep, are subordinate in their application to a profound sentiment of egoism, and that puberty, instead of having elicited a great movement of expansion, seems to have announced itself strongly only to prove that, if there exists in man a relation between the needs of his senses and the affections of his heart, this sympathetic accord is, like most great and generous passions, the happy fruit of his education. But if we recapitulate the favorable changes effected in the state of this young man, and particularly the facts recorded in paragraphs IX, X, XI, XII, XIV, XXI, XXV, XXVIII,

xxx, XXXI, XXXII, XXXIII, XXXIV, xxxv, XXXVII, XXXVIII, X L N , XLV, XLVI, XLVII and XLIX, one cannot fail to perceive his education in a more favorable light, and to accept as strictly accurate the conclusions, 1. that the improvement of sight and touch, and the new pleasures of taste, by multiplying the sensations and the ideas of our Savage, have contributed powerfully to the development of the intellectual faculties; 2. that, in considering this development in all its extension, we find, amongst other desirable changes, the knowledge of the conventional value of the signs of thought, the application of this knowledge to the designation of objects and

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to the enunciation of their qualities and actions, and hence the extension of the pupil’s relations with the people around him, the ability to express his needs to them, to receive orders from them and to maintain with them a free and continuing exchange of thoughts; 3. that, despite his immoderate taste for the freedom of the fields and his indifference to most of the pleasures of social life, Victor shows himself grateful for the care afforded him, capable of affectionate friendship, sensitive to the pleasure of doing right, ashamed of his mistakes, and repentant of his fits of anger; 4. and that finally, Sir, from whatsoever point of view this long experiment is envisaged, whether it is considered as the methodical education of a savage being, or whether it is simply perceived as the physical and moral treatment of one of those creatures ill-favored by nature, rejected by society, and abandoned by medicine, the care that has been afforded him, that which is still owing to him, the changes which have occurred, those which may be hoped for, the voice of humanity, the interest inspired by so absolute an abandonment and so bizarre a destiny, all these recommend this extraordinary young man to the attention of the learned, to the solicitude of our administrators, and to the protection of the Government.

Jean-Pierre Falret (1794-1870)

Born in the South of France, J.-P. Falret began his medical studies in Montpellier and completed them in Paris where he presented his doctoral thesis in 1819. At the Salp&rikre, he studied under the ageing Pinel”, then under Esquirol*. For eight years he worked in the private sanatorium which the latter had set up near the hospice in order to put into practice his therapeutic ideas. In 1822, J.-P. Falret in his turn set up a private sanatorium at Vanves, which for more than a century admitted numerous celebrated patients. Appointed physician at the Salp&riki-e in 1822, initially in charge of the idiots section, in 1841 he took over responsibility for the insane section, a position he maintained until 1867. Immediately upon his appointment, he opened a school for idiots in the institution, thereby beginning the education of the retlarded, a task which would be carried on by, amongst others, Edouard Seguin (18 12-1880)and Dksirk Magloire Bourneville (1840-1909). After a study trip to England, Scotland and Ireland to visit the institutions for the insane, J.-P. Falret contributed with his teacher Esquirol to the preparation of the law of 30 June 1838 which created new specialist institutions, the asylums. In 1843 J.-P. Falret completed his institutional achievements by what he himself considered to be his life’s work: the foundation of a Patronage Society and a convalescent home for the insane, “a half-way house between the hospice and society”, the forerunner of our contemporary intermediate structures.

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Finally, Falret made a further journey to the Grand Duchy of Baden to visit Europe’s most modern insane asylum of the time, at Illenau, which with Schule, then Krafft-Ebing (1840-1902) would develop into one of the most prestigious German schools. In parallel with this intense activity in assistance to the mentally ill, J.-P. Falret made a significant contribution to the study of mental diseases. He himself divided his work into three sections, three different periods: -during the first, like many physicians of his time, he was interested in pathological anatomy. However, realising that the anatamo-clinical method alone could not enable mental medicine to progress like organic medicine, he turned to the psychological approach to mental disorders; -during the second, he became interested in the work of the Scottish and German schools of psychology, turning for translation of their works to B.A. Morel* to whom he had been introduced by his intern Claude Bernard (1813-1878),the future author of “Introduction to experimental medicine” (1865); -finally, it was during the last period, the period of clinicai analysis, that J.-P. Falret’s ideas were to reach their full realisation. He established that mental medicine needs to be based above all on the rigorous clinical observation of morbid phenomena and especially of their development: “The progress of the mental diseases is undoubtedly the most important part of their histor y . . .That which it would be most useful to know, is the different progress of each of the particular species of madness.” This knowledge alone would be sufficient for a clinical definition of the mental diseases. The use of the evolutive criterion enabled him to describe one of these diseases, the one which in 1854 he had named “circular madness”, the future manic-depressive psychosis of Emil Kraepelin (1856-1926)who himself based his taxonomical system on this criterion of natural progress. It was also in 1854 that Falret published his essay “Of the non-existence of monomania”, refuting the concept introduced by Esquirol despite the veneration in which he held his teacher. In 1841, a year after Esquirol’s death, J.T.Falret began a course of teaching at the Salp6trii.re which would continue for more than fifteen years. The ”Clinical lessons in mental medicine given at the Salp?tri&rehospice” were published in 1854.

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Finally, in 1864, a collection “On the mental diseases and insane asylums” brought together all the works published by J.-P. Falret throughout his career. It begins with an extensive introduction which constitutes a work in its own right, since in it Falret took the opportunity, in summarising his thought, of explaining the origins of the clinical psychiatry which was to develop in the late 19th and early 20th centuries. For art lovers, Falret’s department at the Salpttrikre inspired severalpaintings by Armand Gautier, a friend of one of his students, himself an amateur painter, Paul Gachet (1828-1909).The latter was the model for two “Portraits of Doctor Gachet” painted by Vincent Van Gogh (1853-1890)in Auvers-sur-Oise, in the year of his suicide. Jean Garrabk

Principal works FALRET 0.-P.), LeCons cliniques de mkdecine mentale faites h l’bospice de la Salp$tri&e [Clinical lessons on mental medicine given at the Salpktrikre hospice], Paris, J.B. Baillikre, 1854.

FALRET 0.-P.), Des maladies mentales et des asiles d’aliknks [On the mental diseases and insane asylums], Paris, J.B. Baillikre, 1864. Reprint Chilly-Mazarin, Sciences en situation, 1994. FALRET 0.-P.), De la folie circulaire [On circular madness] (1854), in POSTEL (J.), La Psychiatrie (Textes essentiels), Paris, Larousse, 1994. Bibliographical references

SEDLER (M.J.), “Falret’s Discovery: The Origin of the Concept of Bipolar Affective Illness”, Amer. J. of Psychiatry (1983), 140, 9, p. 1127-1133.

ODIER (B.), Les Sociktks de patronage d’aliknks gukris et convalescents au XIF siicle [The patronage societies of the cured and convalescent insane in the 19th century], medical thesis, PitiCSdp;tri&e, Paris, 1982.

Of the Non-Existence of Monomania (1854)

The question of the existence or of the non-existence of monomania, under the appearances of a mere word, encompasses an entire doctrine. O u r opinion on this important and controversial subject is formal; we do not accept the unity of delusion in mental alienation. This conviction, the outcome of our first studies, fortified by repeated observation in the most favourable conditions and by the adherence of our students, has been upheld in all the courses of our teaching at the Salpttrih-e hospice. It is not our claim to undertake here a complete demonstration of our point of view; that task would require a volume the adequate completion of. Our intention is simply to show, without entering into a discussion of the particular facts opposed to us, under what influences the doctrine of the monomanias was introduced into science, and to indicate the principal causes of error which would tend to perpetuate it, if no effort were made to combat the very principles which serve as its basis. We will attempt to indicate, in general terms, how observation should be directed in order to acquire the clinical evidence of the multiplicity of delusions in all the deranged; finally, we propose briefly to describe the numerous and

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significant consequences brought about in the different branches of mental medicine by the doctrine that we defend. 1’ Critical examination of the authors.-The mad have always been divided into two principal classes: those who are deluded in all matters, and those who, being deluded on only a small number of subjects, or even on a single point, seem otherwise to have maintained the integrity of their reason. Pinel, by the authority of his name, did no more than consecrate and propagate that ancient division between general and partial insanity. His most illustrious student, Esquirol, by giving the name of monomanias to those insanities limited to a small number or a single series of subject, or even to a single subject, more clearly formulated the opinion of Pinel and of his predecessors, and by this means enhanced the credibility of the doctrine which has since spread to physicians of all countries. Does monomania understood in this way exist? Is it truly possible to see lunatics whose delusion is restricted to a single object? The authors who accept monomania are in disagreement in several respects. Some believe it to be very common; others admit that it is rare, but claim that incontestable examples of it are to be found: some claim, contrary to the most explicit texts, that Pinel and Esquirol did not 1. We read in Esquirol, des Maladies mentales, vol. 1, p. 405: “Pinel characterises melancholy by sadness, fear with partial delusion concentrated on a single object or on a particular series of objects.”-On page 406, we find that, “according to Professor FodCrC, melancholy consists in the permanent and exclusive intuition of some ohect pursued with ardour and almost always accom anied by fears, mistrust.” Esquirol’s opinion is in perfect conformity with t at of Pinel, of Fodkrk, and of his most illustrious predecessors; he utters it fre uently and with a great energy of expressions; he makes unity of delusion t e essential characteristic of lypemania and monomania (vol. 1, p. 98). O n page 9 of the same volume, Esquirol states the following: “The attention is exclusive on a single obect, nothing can distract it. All reasoning, all determinations, derive from this fixed idea; monomania offers a thousand

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examples of this delusion.” O n pages 22 and 98, the same opinion is expressed in the same terms.-On page 411, we read: “ B e unity of affection and of thought makes the actions of melancholics uniform and slow.”-On page 414, same doctrine, same

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intend the word monomania to refer to a single delusion, but a restricted delusion, and that in consequence the question we have raised is purely about words; finally, others maintain that no monomanias of ideas exist, but that there exist monomanias of tendencies or of feelings. This is not the place to enter into a detailed examination of these different variations on a single opinion; it is enough for us that these authors accept the existence of monomania, of one kind or another, rare or frequent, restricted or not to an order of faculties or of tendencies, for us to combat them all, since, in our view, no kind of monomania exists. ' We will say only say that these divergences between the partisans of monomania give rise to a presumption in favour of the thesis we support; indeed, they prove that this doctrine has already lost much ground, in the past thirty years, since its partisans defend it only weakly and have even abandoned it on several important points. The authors who still persist in this opinion (and their numbers diminish day by day) base themselves on a small number of facts which they repeat constantly, no doubt because nature is niggardly with them, and on philosophical principles, which are the veritable basis of the doctrine, and which for this reason merit longer examination. We therefore propose to examine successively the value of the facts and principles invoked by the partisans of the doctrine of monomania. It is impossible completely to refute, by a retrospective expression: "Their minds are applied to one single subject,n and this opinion is repeated twice on page 419. Being obliged to restrict ourselves to narrow limits, we will confine our quotations to the following passage, extracted from pages 421 and 422 of volume 1: "Lypemaniacs depart from afalse principle; but all their reasoning, all their deductions, conform to the strictest logic... Melancholics, having only one single though, ceaselessly repeat the same words." I. This opinion has already been defended by several of our students, amongst whom we would cite Dr. Jvlorel, who has sup orted it with talent in his remarkable work, entitled Etudes cliniques sur es maladies mentales (vol. 2, ir1-8~;Nancy, 1852, 1853), and in his Trait6 des maladies mentales, Paris, 1860.

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analysis, facts recorded in the annals of science, when one is deprived of verification by direct observation. If one were to undertake a detailed criticism of the principal facts cited in support of the doctrine of the monomanias, it would be easy to point out contradictions, manifest errors, to weaken its value and to arouse doubt; but it would not be possible to bring about total conviction. ' It is later observation, carried out in more favourable conditions and under the influence of truer and more fruitful guiding principles, which is required to verify and rectify previous observation. As a result, the earlier facts will be deprived of all value, in the presence of more complete and more cogent observations; such is the march of progress in all the sciences. We will nevertheless make a few general remarks with regard to the few cases of supposed monomania which are constantly cited in opposition to those who deny the existence of so restricted a delusion. These observations are divided, in our view, into three categories: the first, and most numerous, in reality offer no guarantee of authenticity or present no scientific value; they are extracted from various periodical reviews, from newspapers, for example from the Gazette des tribunaux, taken from people strange to the study of medicine or at least to the knowledge of mental illnesses: now, without contesting the reality of the details contained in these observations, the question, in the matter which concerns us, is to know whether anything has been omitted, and whether the delusion was restricted to the facts related by the observer. The facts of the second category are reported by specialist authors, offering all the necessary scientific guarantees, but they present, unknown to the author who cites them as examples of pure monomanias, clear evidence of multiple delusions: a certain number of cases of this kind are to be found in the work of Esquirol. These observations, far from providing appropriate material

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1. O n e of our pupils, Dr. Bariod, has nevertheless successfully attem ted this critical examination, regarding instinctive monomania, in his t esis (Paris, 25 June 1852).

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for our opponents, thus come in support of our way of seeing. There remains the third category of facts, considerably less numerous, which might seem to contradict our opinion: these are cases cited by competent authors, and which contain descriptions of single delusions. As regards these facts, we will confine ourselves to the following remarks: they are generally greatly lacking in detail, and usually show clear signs of incomplete observation; moreover, as we remarked previously, it is not a matter of contesting the truth of what is described, but of knowing whether anything has been omitted; often, however, the author does not even take the trouble to indicate this important negative factor on which, in reality, the entire discussion rests; finally, if one wishes to observe a fact, one must have the firm intention to research it; yet, the authors of whom we speak, far from having their attention fixed on the multiplicity of the delusions, were, on the contrary, guided by philosophical and clinical principles which must have induced them to consider exclusively the predominant delusion, and have diverted their attention from the examination of the other phenomena of the disease. This quite naturally leads us to indicate the causes of error and to examine the principles which guided the authors. These principles, which serve as a point of departure and a basis for the doctrine of the monomanias, we summarise as follows: the excessivelyphysiological direction of science, the exclttsive observation of predominant ideas. Let us enter into a few details in this regard, which are essential to the understanding of how these scientific principles inevitably led to the doctrine of monomania, and how it may be overturned by a contrary approach. The authors who have the greatest tendency to acknowledge the rarity of monomania in practice, are far from having the same dispositions when they remain in the sphere of theory. This is due, in our opinion, to the wholly physiological direction of current mental medicine. Indeed, whether one follows the philosophers in starting from the division

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of the human faculties accepted in psychology, or follows the people of society, the novelists and poets, in being guided, in the study of madness, by the comparison with the errors and passions of the normal state, in both these different but ultimately very analogous directions of science, one arrives naturally and almost inevitably at the belief in monomania. What, in fact, is agreed in most psychological schools? It is agreed that the mind of man is made up of distinct faculties, of separate forces, which often need to cooperate in order to achieve a result, but which are able to act in isolation, having their special laws and their particular mode of action. Now, the alienists, taking their inspiration from these psychological doctrines, have been led to say: Since the faculties act in isolation in the normal state, why should they not be separately injured by disease? Since man can manifest intelligence without will, sensibility without intelligence, why should there not exist diseases of the sensibility or of the will without disorder of the intelligence, and vice versa? Hence the division of the insanities, adopted by Heinroth, into insanities of the intelligence, insanities of the sensibility, and insanities of the will; hence too the division of the monomanias, proposed by Esquirol, into intellectual, affective and instinctive monomanias. It is in fact on the supposed isolation of these three orders of faculties that our illustrious master based himself in order to gain acceptance for the instinctive monomanias, and in particular homicidal monomania. These examples show how the fragmentation of our faculties, acknowledged by psychologists, naturally leads to recognising monomanias which correspond to the isolated lesions of each of those faculties. However, in our opinion, nothing could be more false and more contrary to observation, in both the normal and the diseased state, than this fragmentation of the human soul into a certain number of distinct forces, able to act in isolation, and therefore to be separately injured; all things in the action of the faculties of

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man hold and act together, and it is only by an abstraction intended to facilitate study, that the diverse modes of human activity can be considered as special forces, when they are but diverse aspects of a single principle, indivisible in its unity. According to us, therefore, both theory and observation condemn the philosophical principle on which the existence of the monomanias is based. However, that foundation which certain partisans of this opinion have sought in the separation of the faculties of the soul, others have thought to find in the comparison of madness with the errors and passions of the normal state. The reasonable man, they say, is subject to error; often he harbours illusions and nourishes bizarre or unrealisable ideas: sometimes these ideas remain isolated in his intelligence, sometimes they react to a greater or lesser degree on all his faculties and even on his conduct; but, so long as his ideas, although false and unrealisable, are not overtly absurd; so long as the man is not exclusively preoccupied by them, to the point of neglecting his most cherished interests, his most imperious duties; as long as they do not influence his conduct, to the point of making him commit unreasonable, absurd, ruinous, violent, or even criminal acts, he is not considered to be insane; he is simply strange or in error; however, in their eyes, once this limit is passed, he becomes a monomaniac, because he is dominated by a false idea, he is no longer able to curb or to elude it, and commits acts that are dangerous to himself or to society. Thus by imperceptible transitions does the passage take place from normal error to monomania. However, it is clear that the characteristics which distinguish error from monomania are difficult to grasp and inadequate, since they consist simply in the intensity of the error, the degree of the preoccupation, and its influence on the conduct of life. And yet did not Mr Leuret himself confess that he sought long and vainly a means to distinguish mad ideas from the absurd ideas which exist in the reasonable man, by considering only

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the idea in itself? Should not this confession of impotence, made by a physician who could so easily separate the normal from the diseased state, open the eyes of those who continue to assimilate the fixed idea of the monomaniac to the error of the man of sound mind. With this direction of science, indeed, we come to create as many monomanias as there exist possible false ideas in the human head, and to confuse madness with the errors of the human mind! This comparison, or rather this assimilation, which is established between the error of the reasonable man and the fixed idea of the monomaniac, is also established between passion and other monomanias with lesion of the sentiments. For example, it has always been said: I m furor brevis, which means literally that maniac fury differs from anger only by its longer duration or its greater violence. Indeed, the same reasoning is applied to ambition, religion, love, sentiments which one is content to exaggerate, in order to create the ambitious, religious or erotic monomanias. Ambition, it is said, is a passion natural to man; as long as it is applied to aims which are not outside the sphere of the individual who experiences it, beyond the point which he can legitimately attain; as long as this ambition, although relating to doubtless illusory aims, is not overtly absurd; as long as this passion, although intense, does not tyrannise the individual to the point that he forgets all the other demands of his life, he may be considered as simply possessed of a passion. However, if he extends his desires and his hopes beyond realisable limits, or even beyond the possible, into the domain of the marvellous; if his desires no longer recognise obstacles, cease to be justifiable, etc.; then, it is said, the ambition, having been simply passionate, becomes diseased, both by its very exaggeration, and by the absurd or unrealisable nature of its object, and the consequence is ambitious monomania. The passage from religious sentiments or from the sentiment of love to the corresponding monomanias is envisaged

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in the same way, and by this process are created imaginary lunatics, religious or erotic, similar to the solitaries of the Thebaid, or the heroes of novels. We cannot pursue any further here this natural tendency of the human mind which has led most observers, often unknowingly, to deduce from the idea or the passion of the normal man the existence of a corresponding monomania. Our purpose has been simply to indicate this tendency in the science, which we will seek to refute clinically later on, in order to show clearly on what basis the doctrine of monomania in reality rests, why it still gains credence in many minds, despite the evidence to the contrary from daily observation, and finally in order to convey the real significance of a question which at first sight seems simply to consist in a discussion about words. We now arrive at the second cause of error which has given rise to the belief in monomania; we mean the exclusive observation of the predominant idea in partial alienations. Certainly there exist, in madmen suffering from partial delusion, one or more ideas which immediately concentrate the attention and which at first sight seem to constitute the whole disease. Indeed, question the servants, the relations, the friends of the deranged; they will tell you: This is a madman who believes himself to be king, emperor, prophet; there is another whom religion has made mad, and who can think of nothing but religion; there is a third who became insane after being disappointed in love, and who believes he sees the object of his love everywhere. Question the patient himself: he too has his ready-made system; he has tried to group all his preoccupations around a single centre, from which he seeks, often with considerable skill, to derive all the consequences, by a series of logical deductions. Indeed, observers have generally followed this guidance, which is generally imposed on them, unknown to them, by the persons around the patient or by the patient himself. Usually, they have noticed only these salient ideas, which

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stand out at first sight and seem to encompass the entire disease; they have not noticed all the morbid phenomena, the general state of the patient, that which we call the ground of the illness, in which germinate and grow the predominant ideas or feelings, which are simply its projection. They have, in a sense, made their observations under the dictation of the deranged or of those who care for them, and they have thus neglected to study the most important part of their disorder. It is this incomplete observation, which we do not need to emphasise here; it is this tendency, we say, which has powerfully contributed, and which continues to contribute, to maintaining the belief in the doctrine of monomania; it is this which seems to add to the a priori deductions drawn from psychology, the apparent verification of direct observation, and it is due to the combination of these two powerful causes of error that this doctrine continues to be perpetuated in the science, despite the contradictory evidence continually provided by attentive and serious observation from day to day. 2 O Clinical examination of the patients.-The question of monomania is essentially clinical; this is the terrain on which partisans and adversaries need to meet. For our part, far from fearing such a trial, we encourage it, and the conviction we have had, since the beginning of our medical studies, of the non-existence of monomania, has been continually corroborated by long experience. We can affirm that we had never encountered, in our public and private practice, a single genuine monomania. But how can we pass on this conviction? To cite a few particular facts would be entirely insufficient; we can only choose types, and indicate in a general manner the means of discovering, by clinical observation, the multiplicity of delusions. Let us take as an example a lunatic preoccupied by religious ideas who would be classified amongst the religious monomanias. He says that he is inspired by God, charged with a divine mission; he is bringing to the world a new religion, of which he describes the singular dogmas, and

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performs a few bizarre practices. This idea, you will say, is completely mad; but, apart from this series of religious ideas, he reasons like other men. Well, examine him in greater depth, and you will see how incomplete is this first impression. And first, in the very sphere of predominant ideas, do you think that he explains his religious mission properly; that he seeks to support it with extensive evidence, as would a reasonable man; that he logically deduces all the consequences of his premises, and above all that he always ensures that he acts in accordance with his words? Certainly, there is an attempt to coordinate his delusion, which may be more or less advanced depending on the period of his disease; but there is a host of lacunae, of inconsistencies, of contradictions, which would revolt a man of sound mind. Moreover, he is far from being truly religious, as his words and some of his acts would seem to indicate; but that is not all; question him with more care, and you will quickly discover other diseased ideas: you will find, for example, in parallel with the religious ideas, a tendency to pride. He will believe himself called not only to reform religion, but to reform society; perhaps too he will imagine himself destined for the highest achievements; in his delusion of ambition, he will believe himself a great figure, a prince or a monarch. Here then is a delusion which initially appeared religious, and which is at the same time proud or political. Let us suppose that having sought tendencies to pride in this patient, you failed to find them; instead you will observe ideas of humility or fearful tendencies. The patient, preoccupied with religious ideas, will believe himself lost, incapable of anything, destined to perish, to go to the scaffold or to be poisoned; he will imagine himself pursued by enemies; perhaps he may even seek to destroy himself in order to elude the misfortune he fears. Often indeed, you observe in the same lunatic hypochondriac symptoms, fear of death, refusal of food through delusion of poisoning, and at the same time attempts at suicide by other means. Finally,

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the same patient will believe himself ruined, along with his family, condemned for imaginary crimes, for a bad communion, etc., or else, he will be convinced that his parents are dead, and neither their letters nor their presence will remove this conviction. Of course, all these delusions are not generally found together in a single patient; but I have grouped them here into a single picture, because they are those which are most frequently observed in practice, and in order to prove that by looking carefully one will always find several in a single patient, in diverse or parallel directions, with no necessary link between them. Moreover, these predominant delusions, which vary according to patients and social periods, also vary at the different stages of the disease, and it is common to see several predominant delusions succeed each other in the same patient in the course of his disease. Independently of this multiplicity of delusions, which an attentive examination will reveal in all the partially insane, there also exists in them a general state which we call the ground of the disease, which becomes more marked at certain moments, in veritable paroxysms, but several features of which persist in the habitual state, and even during significant remissions. These paroxysms have not been remarked in the partially insane, although they recur far more frequently than is believed, and may be characterised by a state of confusion and disorder close to that of general alienation, and this lacuna in observation is one of the causes which most contribute to reinforcing the belief in monomania. However, outside these exacerbations, during which the extent of the delusion becomes obvious to all, there exists, in all the partially insane, a diseased ground, on which the predominant ideas grow and are perpetuated, and which survives with unchanged characteristics, despite the diversity of the delusional ideas. This general state can be summed up by the two terms state of expansion and state of depression, on which the most scientific division of partial insanities today is based.

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In the first state, all the faculties are overexcited; the intelligence is more active, the ideas are numerous and follow each other rapidly; the sentiments and tendencies are violent and altered; the will is energetic and disordered, movements rapid and incessant, and all the physical functions partake in this exaggerated activity. The state of depression presents precisely inverted symptoms; the course of the ideas is slowed; they are few in number, vague, and follow each other slowly. The sentiments are weakened, painful, misanthropic; the will is indecisive, inert, inactive; the movements slow or almost absent. The patient habitually remains silent, seeks solitude and immobility; finally, there will often be heaviness of the head, rejection of food, pain in the epigastrium, loss of appetite and constipation. Obviously, the general symptoms, both physical and moral, are more or less marked depending on the patient; however, they exist in all to differing degrees, and it is important to be attentive to them in order to arrive at an exact and complete description of the diseased state, rather than confining it to the study of a single idea or sentiment. These different indications, drawn from the clinical observation of the deranged with partial delusion, although brief, should already make it clear how these patients should be observed in order to discover in them the multiplicity of the delusions, all the morbid symptoms, physical and moral, and in order to be convinced of the non-existence of monomania; we will add to these, two orders of considerations, deduced from the manner in which the madness develops and from the evolution of the delusional ideas. In the physiological approach of which we spoke earlier, it is accepted that there exists a sort of natural relation between the cause which gives rise to a mental illness, the first phenomena observed, and the symptoms of the declared illness. Thus, for example, it is supposed that the loss of a loved one, by plunging an individual into legitimate and justifiable sadness, must result in a melancholic mental illness, in which the preoccupations regarding the loved one

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will be the dominant subject of the delusion; it is also supposed that disappointed ambition or love give rise to a madness characterised by the belief in the imaginary possession of the objects, the fruitless pursuit of which caused the disease; finally, it is imagined that an exaggerated and ill-understood religion must engender a mental disorder consisting in scruples of conscience and fears of eternal damnation. This genealogy of delusion might seem seductive; but it is, in the generality of cases, contrary to observation. Things do not occur in this way in nature, and the passage from reason to madness does not ordinarily take place through imperceptible and reasoned transitions. And first of all, it is almost never the action of a single cause which engenders madness; not to speak of the very considerable influence of the predisposing causes, its appearance may almost always be attributed to the simultaneous and combined effect of several physical and moral causes. In addition, the relation supposedly established between the nature of the cause and the character of the confirmed illness, far from being habitual, is exceptional; moreover, when it exists, it explains only the predominance of the delusion and not the production of the disease itself. In fact, this passage from reason to madness may take two principal forms. In one of these, the impression stamped on the premonitory signs by the principal cause continues with the invasion of the disease; but then the latter, far from consisting solely in the idea in relation to the cause, is precisely characterised by the appearance of a collection of new phenomena, both physical and moral, which bring about a great change in the personality as a whole. In the second case, which is much more frequent than is generally thought, the initial preoccupations totally disappear, and the individual is transformed, on the invasion of the mental illness. The predominant delusions have no connection with the former ideas or with the cause of the disease, or, even, the latter may operate a total metamorphosis: that is why, for example, erotic ideas

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very often seem to occur in formerly very pious individuals, and vice versa. This result of clinical observation, so contrary to the predictions of theory, is a very powerful argument against the doctrine of the gradual and imperceptible transformation of passion into monomania. Another argument against that doctrine lies in the study of the evolution of delusional ideas. In the doctrine which assimilates madness to error or to a passion taken to the extreme, delusional ideas are conceived as generating each other by a series of logical deductions. Supposing, for example, a painful idea is established in the mind, the sadness which affects the patient is seen as deriving from it, just as the general satisfaction of another lunatic is attributed to his domination by a gay passion. Likewise, a supposedly original hallucination is thought to give rise to a whole delusion of persecution or religious vocation, which seems the natural consequence of a voice heard by the madman. Undoubtedly, delusions often engender each other by a series of deductions; secondary or tertiary delusions proceed from the original delusions; and in this we have an important observation which we have already particularly emphasised. Thus, for example, a voice which commands a madman to kill, might become the occasion of a violent act, of a murder. But it should not be concluded from this that delusions, and especially predominant ideas, are consistently generated in this way; instead of being the causes and departure point of the general state, they are most commonly a result of it. The madman, at the beginning of his illness, is in a vague and confused general state, of expansion or more often of depression and anxiety, which becomes the real ground on which the diseased ideas and feelings emerge and disappear, germinate and grow, as the product of this morbid soil, rather than being responsible for its formation. It is only little by little, and after having long hesitated between these different ideas, which he selects and abandons in turn, without choosing any, that

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the madman’s mind finally attaches itself to some of them, and slowly, often after a very long time, arrives at a more or less complete systematisation of his delusion, although nevertheless without ever achieving unity. This is not the place to describe in detail that interesting fashion in which delusional ideas, and in particular predominant ideas, develop. If we have mentioned it in passing to prove that, by consulting clinical observation, delusional ideas are found to have a mode of production quite different from that imagined a priori, it is in order to draw from this observation new evidence against the doctrine of monomania, since the general state pre-exists the delusional ideas and engenders them, rather than being engendered by them. There is one final consequence that we should draw from this fact. It has been claimed that though monomania is rare in the asylums, it must be frequent at the beginning of the illness, when the mad are still in society: in fact, the genealogy of delusions which we have just established demonstrates, on the contrary, that if monomania could exist, it would be in the later periods, and not in the initial period, that examples should be sought. 3 O Consequences of the doctrine of the non-existence of monomania.-We will have little to add to show the numerous consequences brought about, in the different branches of mental medicine, by the doctrine of the nonexistence of monomania. In aetiology and pathogenesis, instead of looking for a natural relation between symptoms in the passage from reason to madness, it is the combined action of the causes, together with the morbid element, which powerfully alters the close relation which it is vainly sought to establish between the cause and the symptoms of the disease, which will be taken into account. Another scientific object worthy of interest which might be studied, is that succession of circumstances which combine in the development of madness; this study might even prove of genuine use in the prophylaxis of mental disorders; but it will no longer be seen as a rational

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explanation of the production of the sickness, and more attention will be given to the multiple phenomena which appear with the invasion, and which make it possible to establish a precise demarcation line between reason and madness. As for the observation and description of mental diseases, there is no need to stress the important differences which are the consequence of our principles. These differences emerge naturally from the clinical examination done previously. In the current state of the science, it is believed that the clear and detailed recording of the predominant ideas is all that needs to be done: observations done in this way not only contain numerous lacunae, but are fundamentally flawed; they describe only the secondary phenomena, and omit the general dispositions of the mind, which give rise to the dominant ideas, which might not occur, although the illness were the same. In our manner of seeing, on the contrary, instead of observing only the predominant delusion, we concentrate on the ground of the disease, on the combination of physical and moral symptoms, the study of which is too generally neglected. This new approach to observation will therefore powerfully influence the description of the partial insanities. The same will be true of the nosology of mental diseases, which will necessarily be greatly affected by the profound modification in the study and description of the partial insanities. Today, physicians, seeing in these kinds of patients only predominant, or even single, ideas and sentiments, can only base their classifications on those subjects of the delusions; they therefore divide monomanias artificially, on the basis of the damaged faculties, or of the ideas and sentiments which they consider alone to constitute the entire disease. In contrast, by describing in these patients a combination of symptoms, in which the predominant subjects of the delusion are only a secondary projection, the way is being prepared for a more natural classification,

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which will take account of the totality of the morbid phenomena and of the progress of the disease. Finally, the treatment of mental illnesses will itself be favourably influenced by this alteration to the study of the characteristics and mode of development of madness. It will no longer be attempted to combat delusional ideas by reasoning, by intimidation, or by other processes intended to destroy error or to tame the passions of the sane individual; it will be known that these delusional ideas are only an accessory phenomenon of the disease, and that even in the most favourable cases, all that may be achieved by means of these procedures would be the replacement of one idea by another or the substitution of one sentiment for another. Efforts will therefore be made to discover, in other directions, general methods directed against the disease itself, against the general tendencies, and not against a secondary symptom; methods energetic enough to fight successfully against the persistent tenacity of these diseased dispositions. In conclusion, it remained for us to say a few words about the most immediate consequence of the doctrine of the nonexistence of monomania; we refer to the beneficial influence which it will exercise on the legal treatment of the insane. We are accused, in denying monomania, of providing weapons for the courts, and thus of exposing monomania sufferers to condemnation as being responsible for their actions. But this accusation arises out of a misunderstanding, and should instead be directed at our opponents. For what is the effect of maintaining the doctrine of monomania? It renders impossible any strict line of demarcation between passion and madness; as a result, the judgement of so difficult a question is abandoned to all the risks of error of an individual assessment, based not on medical experience of similar cases, but on proofs taken from the action itself, submitted to examination by the medical expert. The latter, instead of remaining within the sphere of his profession, is obliged to have recourse to legal discussion. He is forced to establish, as do Esquirol and Marc for example, that a criminal act was

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committed by a madman, when it cannot be explained by any plausible motive, when it affects persons who are indifferent, or even dear, to the one who committed it; finally, when the latter, instead of seeking to escape by all means from the rigour of the law, has delivered himself spontaneously into the hands of justice, will admit his crime and will not even seek to attenuate or to explain it. Undoubtedly these considerations, drawn from the details of the act itself, are not to be neglected in so difficult a judgement; but it can be seen how inadequate they are in distinguishing passion from madness. It can be understood how, in the hypothesis of an idea or a single act, the boundaries between crime and mental alienation become blurred, and how little enlightenment the partisans of monomania afford the judges in the solution of this question. As a result, the magistrates, who are reluctant to accept such a restricted lesion of the human mind, generally condemn the unfortunate madman whom doctors depict as a monomaniac. By contrast, in the doctrine that we defend, how many more elements of conviction does science offer justice! No longer is a false idea represented as the sole cause of a violent act, a passion supposedly exaggerated to the point of becoming a disease, a violent tendency held to be irresistible; it is the complete picture of the disease which the physician goes through before the magistrate’s eyes; it is from his medical experience that he draws the criterion which allows him to distinguish passion from madness. He knows that if the accused individual is insane, he will be able, however restricted the delusion, to reveal a diseased condition extending to several points, beyond the criminal act. The physician then becomes, by his special knowledge, the natural and necessary auxiliary of the courts, and is easily able to ensure that the madman is absolved, since instead of seeking proofs in the sole details of the criminal act, he bases them on all the symptoms, and on the progress of the disease!

Pierre Briquet (1796-1881)

Curiously, although Briquet’s career was above all an interlude, it is because of the work he did in his maturity on hysterical neurosis that his name has survived in the history of psychiatry. For this anthology, we have chosen an extract of the work where he expounds the conception which marks the break in the historical epistemology of hysteria which occurred in the second half of the 19th century, by contrast with the conception accepted for several millennia. Briquet did his medical studies at the Paris Faculty, and the thesis he presented in 1824 was the start of a faultless career: he was appointed ugr@ in 1827 then hospital physician first at Cochin in 1836, then at the Charitk in 1846, when he was already fifty years old. The CharitC hospital, built near SaintGermain-des-PrCs through the good offices of Queen Marie de MCdicis (1573-1642) and entrusted to the Saint-Jean de Dieu (1495-1550) order of friars, had been renovated at the Revolution, when admission became open to women (the CharitC hospital was destroyed to give way to the Faculty of Medicine, called the Saints-P&resafter the street in which it is located; only the historic chapel has survived, now the church of Saint-Vladimir-the Great in the Ukrainian Catholic denomination). As Briquet himself wrote: “Placed by accident of circumstance at the head of a service where it had long been the custom to send patients suffering from hysterical disorders,” he

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was obliged, “for reasons of conscience, to apply all his attention to patients of this sort towards whom his taste for the study of the positive sciences did not attract him.” He therefore set to work, collected four hundred and thirty observations of hysterical patients and drew from them innovative conclusions which he expounded in a “Clinical and Therapeutic Treatise on Hysteria” (1859). Although these cases concern only women, as his department at the Charitk dealt exclusively with female patients, he rejected the theory of the “uterine” cause, accepted since the time of Egyptian and Ancient Greek medicine. Briquet therefore assumes the existence of “male hysteria” since for him, it was a “neurosis of the part of the encephalon which receives affective impressions and sensations.” Only the involvement of the encephalon could explain the fact that the symptoms occur in all parts of the body in the manner of somatic conditions. As regards the existence of hysteria in men, Briquet, who himself had precursors in this respect, anticipated Charcot“. In order to explain the much greater frequency of hysteria in women than in men-twenty times, according to him-he adduces the fact that young women are more exposed to violent emotions and sorrows, and that they demonstrate a particular susceptibility to those affective disturbances which in his view were the cause of the neurosis. He did not attribute a particular role to disorders of sexuality in the genesis of hysteria. Briquet considered that the name of this neurosis should be changed-although he offered no suggestion himself-but thought that doctors were too attached to the traditional names of diseases to accept such a change. The year after the publication of his “Clinical and Therapeutic Treatise on Hysteria”, Briquet was elected to the Academy of Medicine, strangely in the medical physics and chemistry section. Freud* does not seem to have been aware of Briquet’s work, or at least does not mention it in his Studies on Hysteria (1895), while Charcot spoke in glowing terms of his predecessor. His suggestion that the term conversion neurosis be used was only partially adopted. The name Briquet, often with the first name Paul, appears in the writings of recent historians of hysteria. In 1980, the third edition of the APA’s D.S.M. removed the

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term “Hysterical neurosis” and replaced it in part with “Somatoform disorders”. Somatization Disorder 300.8 1 was given as an equivalent of “Briquet’s Syndrome” and contrasted with Conversion Disorder 300.11. D.S.M. IV (1994) specifies: “The criteria for Somatization Disorder in this manual are rightly more restrictive than the original criteria for Briquet’s syndrome.” However, the final word goes, for the moment, to the 10th edition of the WHO’S International Classification of Mental Disorders (1992) which states under the heading: “F.48.8 Other specified neurotic disorders”: “This classification should include mixed behavioural, emotional and belief disorders, frequently observed in certain cultures, the aetiology and nosological position of which remain uncertain.. .As these symptoms are closely linked to beliefs and modes of behaviour specific to certain cultures, they should not be considered as delusional.” The work gives, amongst others, the example of Briquet’s Syndrome. Jean GarrabC

Principal works BRIQUET (P.), Trait6 historique et thhapeutique de l’hyst6rie [Historical and therapeutic treatise on hysteria], Paris, J.B. Bailli&e, 1859.

Bibliographical references VEITH (I.), Hysteria, B e History of a Disease, University of Chicago, 1963. TRILLAT (E.), Histoire de l’hyst6rie [History of Hysteria], Paris, Seghers, 1986. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Washington, 1980.

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American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Washington, 1992. World Health Organization, The I.C.D. 10 Classlfication ofMental and Bebavioural Disorders, 1992.

Clinical and Therapeutic Treatise on Hysteria (1859)

DEFINITION

Hysteria has been known since civilization has existed; according to Galien, the women who, in ancient times, were responsible for the treatment of the diseases of persons of their sex, had long been familiar with this malady, to which they gave the name hystericul disorder, because, according to them, it came from the uterus. Moreover, there is reason to believe, according to a few passages from the treatises Of the Nature of Women,and Of the Diseuses of Women,published under the name of Hippocrates, that these matrons had imagined, on the nature of this disease, the theory professed by the princes of medicine who came later. It is likewise certain, according to the writings of Galien, that it is to them that we owe the practice employed to stop hysterical attacks, which has been designated under the name confrication of the vulva. Thus, hysteria was known before the existence of a medical corpus: it bore the name which it bears today, the theory employed to explain these phenomena was that which has been in force since, and one of the means of treatment most favored by the authors had long entered into practice. Philosophy, which most often is nothing other than the

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establishment in scientific form of the reigning traditions and ideas of the age, adopted these doctrines, which consisted in viewing the woman as a secondary being, destined solely to serve the sexual pleasures of the man and to supervise the raising of children. True love, that which was called celestial, existed only between men. Woman excited only a coarse, terrestrial love, the sole love for which it was supposed that her constitution was organized. Pythagoras, according to those of his opinions which have been handed down, considered the uterus as a separate being, possessed of those faculties which characterize the animal, that is to say of spontaneous sensation and movement, lodged in another being. Such was also the opinion of Empedocles, of whom Hippocrates was the disciple. Plato, in his Tirnaeus, after having in his own way explained the origin of man, the first and superior creature, passes to that of woman, and says: “Cowardly men who have often been unjust are, in all likelihood, transformed into women in a second life. At the same time the gods created the desire for cohabitation; for this purpose they placed in us a living animal, and placed another in women.” After a few words on the animal in men, which is untamed, capricious, etc., he moves on to that in women. “The womb,” he says, “is an animal which ardently desires to engender children. When it remains for a long time sterile after puberty, it can with difficulty tolerate its condition, it becomes angry, it runs throughout the whole body, blocking the air passages, stopping the respiration, casting the body into extreme dangers and occasioning diverse diseases, until desire and love unite the man and the woman, give birth to a fruit and pluck it as from a tree, sowing in the womb, as in a field, animals invisible by their extreme smallness, then nourishing them after separation, developing them within, and then bringing them to light, completes the act of generation of animals. “Thus are made women and all females.”

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Such were the opinions of philosophy. Nothing could be more natural than that, in their turn, the doctors educated in such doctrines should make the uterus play a principal role in certain nervous diseases, and that all ancient medicine should have regarded hysteria as a disease produced by disorders of that organ. Although religion, civilization and morality have long attributed to woman a mission more noble than that assigned to her by pagan philosophy, although the first presents her as man’s companion, and the second, in the Institutes of Justinian, has described her duties, amongst which is that of being the solatiurn vitue [life’s solace], and the third perceives her as destined to supervise and shape childhood, to surround the adult with all her solicitude, and to relieve the aged in their infirmities, attributes which are far from being those of the uterus, the majority of doctors of all ages have nevertheless remains faithful to the doctrines of the ancients, and certain of the most modern works which have been published on hysteria, such as that of Louyer-Villermay, and that of M. Landouzy, still present the uterus, either sick or unsatisfied in its genital needs, as the point of departure and as the source of all the phenomena of hysteria. I consider the facts from another point of view, and for me hysteria is a neurosis of the encephalon, of which the apparent phenomena consist principally in the disturbance of the vital acts which are employed in the manifestation of the affective sensations and of the passions. T: :s definition needs certain explanations to be understood, and in order to give them in a satisfactory manner I will pursue the matter a little further. The power which created the creatures, has surrounded them with all the means of protection necessary to their preservation and their well-being. The animals, which alone possess the faculty of movement, employ this faculty either to move towards one another in order to share their pleasures or to relieve their sufferings, or to flee when one of

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them becomes disagreeable or dangerous to the others. But, in order to obey this law of nature, it was necessary that very apparent signs, intelligible to all, should make known these needs and these dangers. These signs are the visible changes by which sensations, passions and needs are manifested; from the glow worm which lights its fires when it desires the approach of its fellows, to man, who expresses the movements of his soul and his needs by his gestures, by his voice and by the expression of his face, there exists a chain which in its links contains the whole series of intermediate beings. It is these changes particular to each affective sensation and to each passion which, in the human species, constitute the field of hysteria; every hysterical phenomenon has its specific type in the diverse vital actions by which the affective sensations and the passions are manifested externally, as will be observed on the occasion of each of these phenomena. All these hysterical disorders which seem so strange and which for so long have led doctors astray, are nothing other than the pure and simple repetition of those acts, augmented, enfeebled or perverted; if we consider any one symptom of hysteria, its model will always be found in one of the acts which constitute the manifestations of the passions. I will choose as an example that which befalls a woman of impressionable nature who experiences a sudden and lively emotion: immediately, this woman has constriction of the epigastrium, she feels oppression, her heart beats, something sticks in her throat and strangles her, finally she feels in her limbs a discomfort which makes them somehow fail her, or else she encounters an agitation, a need for movement, which makes her contract her muscles. Here indeed is the exact model of the most ordinary, the most common, hysterical attack. Observation of the facts shows that most usually, indeed almost always, hysterical phenomena are the more or less troubled repetition, not of all these acts, but only of those through which painful sensations, sad or violent affections and passions, are manifested. Finally

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these manifestations, by frequent repetition, come to produce lesions, either dynamic or material, in the organs by means of which they operate, and thus add a new series of accidents which complete the picture of which hysteria is composed. These ideas are, it is true, a long way from those theories which see in hysteria only unsatisfied appetites, or merely genital parts affected with inflammation, suppuration, cancers. But while they depart from those coarse antique theories which it was later sought to revive from the Greeks, they come infinitely closer to other more philosophical opinions; to those of Raulin, of Sydenham, who had clearly recognized that there was in the hysterical woman an assembly of sufferings, or at least a general disposition to suffering, which resides in her whole being and which they expressed by the words mobility,susceptibility, nervous weakness; they are in a way simply the consequence of those ancient corollaries which made of the brain, that is to say of the center of sensibility, the seat which receives those sensations that are the productive causes of hysteria, and a point of departure of the phenomena of this disease, corollaries we owe to Ch. Lepis, to Willis and to Georget; they are finally simply the complement of the ideas of M. H. Girard, who considers hysteria to be the result of vicious alterations of the organism localized in the brain, and of those of Professor Forget and of M. Gendrin, who advance that hysteria is only the expression of a special susceptibility of the nervous system. I will stop here, my intention for the moment being merely to describe the form of the morbid phenomena by which hysteria appears to our senses. Later, as the facts are exposed, I will show in what manner the causes of hysteria act on the economy, and to what type of neurosis they give rise. Accustomed to the mathematical progress of the physical sciences, I will only draw my conclusions once the facts have been developed. Galien had said of hysteria: “Passio hysterica unum

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nomen est, varia tamen et innumera accidentia sub se comprendit” [the hysterical passion is one name, under which however are subsumed various and innumerable accidents]. R i d r e was of the same opinion, for he wrote that hysteria was not morbus simplex, sed morborum iliada [a simple disease, but an Iliad of diseases]. According to Sydenham, the shapes of Proteus and the colors of the chameleon are not more numerous than the diverse aspects in which hysteria appears. F. Hoffman defined this disorder in the following terms: Morbus ille, aut potius morborum cohors [that disease, or rather cohort of diseases], etc. The accidents which hysteria can produce are, in truth, diverse in nature; however, they are much less numerous, and above all, they are more consistent than is thought. There are those which form the basis of the disease, which are rarely absent; these are small in number. There are others, which are very common and more numerous than the first, but which are also restricted to a fairly narrow circle; finally, there are in addition certain phenomena which seem bizarre, but of which the cause is found either in the constitution of the sufferers or in the circumstances which surround them. The principal symptoms of hysteria are: an extreme sensitivity of the nervous system; diverse hyperesthesias, the most dominant of which are pains in the epigastric region, on the left side of the thorax, and along the left vertebral groove; anesthesias principally affecting the skin, the muscles and the sense organs; spasms of which the most common are oppression in the epigastrium, the sensation of a globe rising from the stomach to the throat, and strangulation; finally convulsions which begin with epigastric constriction, which are ordinarily accompanied by loss of consciousness, and which culminate in tears and sobbing; symptoms which are all under the direct influence of the moral affections. The names under which this disorder has been known are very numerous; they can be divided into two kinds: the

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first kind, which refer to the womb, the presumed cause of the disease, such as mt4, strangulatus, suffocatio, praefocatio uteri, womb’s ill, mother’s ill, metronervia, etioangiovaric neuropallia, are, to my thinking, the result of an error. The others, employed by the authors who place the disease either in the economy as a whole, or in the nervous system, such as vapors, bad nerves, Georget’s spasmodic encephalitis, Brachet’s nurospasmia, M. Girard’s acute cerebropneumogastric neuropathy, are too general and do not characterize hysteria. These names are therefore incorrect; but should we seek to find a better one? The answer to this question is to be found in Galien. That author says precisely on the subject of hysteria: “Little importance should be attached to these debates, for doctors have quite enough to do in occupying themselves with the circumstances relating to hysteria, without wasting their time in disputes about words.” It should be known that before this author, there had been long discussion on the question of whether the parts of generation should be called the womb or vulva, and whether they should be described in the singular, as certain doctors believed, or in the plural, as other authors had done. Moreover, the attempts at naming so far tried do not appear, as we have seen, to have succeeded sufficiently for new attempts to be made. I will therefore adopt the term hysteria, because it was the first to be employed, because it is the one most generally used, because it is known to all, and finally because I hope that with time it will have lost its etymological value and will become simply a proper noun, like gold, iron, lead.

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First part. Etiology generalities concerning etiology Etiology seems to have been considered by certain authors as simply a question of pure curiosity and as the, somehow necessary, complement of the history of diseases; they therefore appear to have concerned themselves with it merely out of a sort of prudence, and with the sole purpose of completing the frame which they had to fill. These doctors are evidently committing a grave error; for etiological data constitute, in many cases, the branch of nosology which casts the most illumination on the nature of diseases; it is from this that prophylaxis is directly derived. The ancients had so well understood this truth that, under the name of proximal causes or of related causes, they included in etiology the quest for the intimate nature of morbid disorders. Hysteria is undoubtedly one of the pathological states to which the preceding reflections can best be applied. It will be seen, through the details which follow, to what degree etiology can serve to illuminate the little understood nature of that disease. But in order for the study of the causes of hysteria to give all that it is capable of producing, it must be correctly guided; if, after the example of that which was done until recent times, this study is content to take into consideration only those facts which are in accord with received theories, and to neglect the others; if it takes into account only the salient points which present certain interesting particularities, leaving aside those which seem too simple, and if, above all, this study is effected solely with the purpose of confirming an hypothesis, there is every probability that it will lead to false consequences. If, on the contrary, etiological research is done by means of a large number of facts collected as they appear and

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without preconceived ideas, if all those which belong to the same disease are recorded without regard to their final signification; and if, finally, they are attentively perused, the result will be a whole by means of which etiology cannot fail to cast light on the questions which it serves to elucidate. From the most distant epoch of antiquity until our day, doctors have followed the first of these two methods in their study of hysteria, and they arrived at the conclusion that this disease depended directly on the genital organs, the needs of which, according to some, had not received the satisfaction desired by nature, and the vital activity of which, according to others, was elevated above its normal type. The former, that is to say the large majority of writers,

from Hippocrates until

Louyer-villermay,found in their

etiological research that the conditions favorable to the development of hysteria were all related, either with the exuberance of a pretended female spermatic liquor, or with that of the menstrual blood, or with a defect in the flow of one or other of these two fluids. The latter, on the other hand, who date from the doctrine of Broussais, deduced from their work that these conditions were ail circumstances which would augment the physiological or pathological activity of the genital organs. These two results are, as one may see, far from running parallel one to the other. The second view has so far been followed, with respect to hysterical disorders, by only two authors, Georget and M. Beau. Placed in favorable circumstances, I continued in the same spirit as my two forerunners the researches which they had commenced. Georget and M. Beau had insufficient materials at their disposal to induce conviction, and the results of their investigations, although taken from nature, acted the part of toothing stones in science. More fortunate, I was able to collect four hundred and thirty observations of

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hysteria from patients admitted into my service at the hospital of the CharitC, over a period of ten years. The reader will see that this assembly of facts collected at very different epochs, and by observers who had no relation between them, agree very exactly. There exists in pathology a division of the causes of diseases, which is very ancient, but which has nonetheless continued to receive almost general acceptance, it is that which consists in distinguishing the conditions under the influence of which diseases occur, into predisposing causes and determining causes. As it appears to be the method best able to reveal the facts associated with the production of hysteria, I believed it necessary to adopt it, while recognizing that this division is arbitrary, and that in certain circumstances the two orders of causes merge into one; the predisposing cause being well able, by its duration, to become a determining cause and directly provoke hysteria, without the intervention of any new circumstance capable of playing the role of a determining cause. In the etiological review which I propose to record, I will commence, in treating each subject, by describing the opinions expressed by the authors and recognized in the science, then I will contrast with them the results of the new research; I will thus present successively, on each matter, the opinions and the facts; in this way the reader will be in a position to judge on which side the truth is to be found.

c. .I *

As we glance t h r o u ~ hthese different orders of agents of hysteria, we wonder with astonishment how it was possible, for centuries, to attribute to the genital organs so important a role in the production of this disease. It is easy to see, in examining the facts, that hysterical neurosis ordinarily results from three different orders of modifiers: moral suffering, physical suffering, and the enfeeblement of the organism. One becomes hysterical only having suffered, or

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having experienced hard blows; happiness, contentment, joy and pleasure in moderation, never occasion hysteria. Agreeable sensations produce this effect only when, coming with too much suddenness or vivacity, they become a cause of disturbance, and of derangement in the nervous system. Hysteria is incontestably the result of suffering or discomfort, and of moral suffering much more than of physical suffering. Moral suffering which is of slow progression, which is long-lasting, inevitably has its culmination in the affective part of the encephalon; indeed, it is sufficient for an impressionable woman to experience for a certain time one of the sad moral impressions which have just been mentioned, for her to be infallibly seized by hysteria. All the determining causes thus act either directly or indirectly on the portion of the encephalon which is given ovee to the affective sensations, and which is related with all that determines the passions. This portion of the encephalon then becomes a center of painful sensations. It is, in consequence, painfully impressed. From the outset, it reacts regularly and gives rise to the manifestations proper to the type of suffering it experiences, that is to say it governs the appearance of the exterior signs which distinguish each passion. But since the action of determining causes ordinarily lasts a certain time, the effects which they produce are prolonged, and instead of being a simple momentary manifestation of passion, they constitute a permanent manifestation; moreover, as these determining causes are generally agents in the nature of sad sentiments, the result is that the reactions which they provoke are customarily those excited by the sad passions; never, in hysteria, does one experience that sentiment of well-being, of expansion, of free play of the faculties, to which agreeable impressions give rise; on the contrary, it is always this feeling of discomfort, of suffering, of oppression, of constriction which are produced by disagreeable impressions. It may be easily understood how, when the affective

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portion of the encephalon has long been the center of painful and incessant sensations, it finishes by falling into a sort of pathological state; in their turn, the reactions born of it lose their regularity; the organic actions which they bring about may be exalted, diminished or distorted; the encephalon being no longer capable of governing them, they will take place, in some sort, automatically and without conscious volition; and ic will result from this defect of governance, that the combinations of actions or of movements the most ordinary to each of the subjects, by reason of their susceptibility, of their ordinary passions and of their customary actions, will be those which occur, and that it will be, according to the individuals, the head, the heart, the stomach, the uterus or the muscles which will be employed for these manifestations. Thus perverted, these manifestations may give rise to a disruption and to a mixing of the passional expressions, which will be precisely all that which appears bizarre and incoherent in certain cases of hysteria. Such a disorder cannot, it is clear, exist with impunity; the diverse organs become in this fashion the almost continual seat of painful sensations, become affected in their turn and, by dint of suffering, enter into a pathological state which is a veritable disease; each of them becomes a center of sympathetic irradiation; hence the multiplicity of the sufferings of hysteria, hence all those spontaneous centers of sufferings by which hysterics are incessantly tormented. This study of the determining causes of hysteria can be summed up in the following terms: 1. In five sixths of hysterics, the disease has followed the action of a determining cause. 2. In one seventh, it has developed under the influence of predisposition alone. 3. In one fiftieth, it has occurred without appreciable causes. 4.More than one half of these causes had acted directly on the encephalon. One fifth had acted by debilitating the economy and by producing the nervous predominance.

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One sixth had made its primitive action felt on the stomach. One eighth had first acted on the uterus and its dependencies; finally, causes of which the proportion is difficult to determine had acted on the exterior integument, but in sum all had acted on the encephalon. 5. The importance that has been assigned to the influence of the genital organs, either in the physiological state, or in the pathological state, has been excessively exaggerated. 6. The causes which produce the hysteria beginning with an attack are ordinarily instantaneous and powerful. 7. Those which produce gradual hysteria are, by contrast, slow, of little intensity and of a nature to change the constitution. 8. The causes of hysteria, studied in accordance with age, show the small influence of the genital organs and the profound influence of the parts which compose the encephalon. It might be supposed that there exists a difference between the causes which give rise to hysteria in the poorer classes and those which produce the same effect in the wealthy classes. A priori, the supposition appears correct: the two classes live in conditions sufficiently dissimilar for one to expect to find some difference in the action of each of them. But experience shows that the difference is not as great as might be thought. All the great observers, Primerose, Ettmuller, Lorry, Sydenham, Raulin, Whytt, Cheyne, recognize that the passions of the soul, and above all sad passions, are the most usual causes of hysteria. One can see, in the work on the vapors by Comparetti, a doctor who practiced in Venice in the last century, amongst the superior classes and the rich merchants, that sad passions and painful emotions are found to be indicated as the principle causes in the diverse observations of hysterical illnesses reported by that author. We have seen that, in the work of M. Landouzy, in which are assembled all the scattered facts published by Galien, Forestus, Sennert, Fernel, Baillou, Rivikre, Hoffman, Frank, Louyer-Villermay, men who practiced their care only amongst people of quality and the

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superior classes; we have seen, I say, that out of some sixty cases where the determining cause is found to be indicated, fear is noted in 15 hysterics; disputes and moral emotions in 21, family sorrows in 10; harassments and vexations in 6; total, 52. Doctors of more recent times, Messrs Dubois (of Amiens), Monneret, Copland, Conolly, also accept that moral affections play the greatest part in the production of hysteria in women of all classes. A moralist has said that the causes of nervous diseases would never remain unknown were it possible to search the depths of the human heart. The only difference that can be found between the diverse classes of women, consists solely in the degree of sensibility and in the degree of power of the modifiers. Acting on women of the lower classes, whose natures are little susceptible to impression, the moral influences needs to be powerful, but God knows how profuse they are amongst the common people. O n the infinitely more sensitive organisms of society women, these influences do not need to be energetic in order to produce great effects. Doctor Gendrin, to whom one cannot deny the merit of having observed hysteria well and of being familiar with it, attributes this illness to moral affections and physical sufferings; he does not believe, any more than M. LClut of the Salpitrikre, that unsatisfied uterine desires frequently produce it. He considers that suffering perturbs the nervous system and augments its excitability.

Antoine Laurent Bayle (1799-1859)

Originally from Provence, like many others he studied medicine in Paris. He worked under the aegis of his uncle-a doctor who had made his reputation in the study of tuberculosis-and early on became one of the protCg4s of Laennec. Becoming an intern in medicine at the Charenton Royal Asylum, unlike the others he did not become a pupil of Esquirol. Bayle was essentially interested in general medicine and studied the intercurrent disorders of the insane from an anatomo-pathological point of view. Uniquely in the history of psychiatry, it was at the age of 23, in the presentation of his inaugural thesis on 21 November 1822, that he put forward the principal clinical ideas which made him famous. His thesis, entitled “Researches on mental diseases”, successively studied chronic arachnitis, chronic gastritis or gastroenteritis, and finally gout, three diseases which could cause mental alienation. Mental disorders (acute or chronic phrenesias) are seen as secondary to the organic condition. The organic origin of mental diseases was born. It is particularly the first part of his work which is known. Bayle proposed the existence of a symptomatic mental alienation in general paralysis, rather than an essential mental alienation. He considered that multiple factors caused an influx of blood into the vessels of the brain, and that this slow or sudden congestion of the meninges was the necessary and an immediate cause

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of arachnitis and hence of general paralysis. The clinical cases described are submitted to precise semiological observation and to an anatomo-pathological study of the brain. Describing a motor disorder with disruption of the intellectual faculties, he declared: “Thus these two symptoms, the alienation and the disorders of movemeit, begin and proceed together at an equal and proportional pace throughout the course of the illness.” He subdivided the disease into three stages: the first, described as monomania, combined disorders of speech and of movement, intellectual enfeeblement and monomaniac delusion; the second stage of mania combined movements of the tongue and lips and general delusion with the dominant idea; finally, the third, socalled dementialphase, combined dementia with increased general and partial paralysis, with the further addition of fits of an apoplectic or epileptic nature. Although he had noted it in the majority of his 1,822 clinical observations, it was not until three years later that Bayle would assign all its importance to ambitious delusion, making delusional megalomania virtually the identifying symptom of chronic arachnitis known by the name of progressive general paralysis. “In April 1818, he suddenly lost consciousness, recovering it a short time afterwards. This attack was followed by a hemiplegia of the right side, which gradually disappeared. From that time on his intellectual faculties became disturbed; the patient fell constantly under the domination of a delusion of ambition, which gradually increased. In the month of October, he was the Emperor Napoleon; he was possessed of immense riches, forty thousand barrels filled with gold ...” Antoine-Laurent Bayle’s theory was to revolutionise the ideas of the alienists of the time, although it would be a long time before he received due credit for this revolution. For this was the first description of a so-called anatomoclinical disease, the syphilitic nature and the specific treatment of which would be not be discovered until a long time after (Alfred Fournier, 1879; Noguchi and Moore, 1913). It was subsequent to the work of Antoine Laurent Bayle that French psychiatry would, for several decades, pursue an organicist direction, in an attempt to apply the anatomoclinical model of general paralysis to the whole spectrum of nosographic entities. Thus, according to Bayle’s ideas, general paralysis is a sequential

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morbid entity which, in the course of its development, will present several clinical pictures simultaneously combining neurological and psychical signs, but which nevertheless is a single entity in its anatomo-pathology. Franiois-Rigis Cousin

Principal works BAYLE (A. L.), Recherches sur les maladies mentales [Researches on mental diseases], thesis, Paris, 21 November 1822. BAYLE (A. L.), Nouvelle doctrine des maladies mentales [New doctrine of mental diseases], Paris, Gabon, 1825, p. 169. BAYLE (A. L.), Trait6 des maladies du cerveau et de ses membranes [Treatise on diseases of the brain and of its membranes], Paris, Gabon, 1826. BAYLE (A. L.), “De la cause organique de 1’aliCnationmentale accompagnie de paralysie gknirale [On the organic cause of mental alienation accompanied by general paralysis]”, Annales mkdico-psychologiques, 1855, I, p. 409.

Principal references “La dkcouverte de Bayle”, [Discovering Bayle], in BERCHERIE (P.), Les Fondements de la clinique, Histoire et structure du savoir psycbiatrique [The foundations of clinical practice, History and structure of psychiatric knowledge], Paris, Seuil, La Biblioth2que d’ornicar, 1980, Chap. 13, p. 71-79 “L;a paralysie gknkrale” [General paralysis], in POSTEL (J.), QUETEL (C.), Nouvelle histoive de la psychiatrie [New history of psychiatry], Paris, Dunod, 1994, p. 203-214.

Researches on Chronic Arachnitis (1822)

PARTI: OBSERVATIONS OF CHRONIC ARACHNITIS WITH MENTALALIENATION

1st observation. Chronic arachnitis. (Monomania, dementia) Claude-Fransois L‘$’c’c,a man of somewhat robust temperament, aged forty-eight years, cafi owner, had committed many excesses of drink, and had indulged immoderately in the pleasures of the flesh. He had experienced losses which had caused him the keenest of sorrows. In April 1818, he suddenly lost consciousness, recovering it a short time afterwards. This attack was followed by a hemiplegia of the right side, which gradually disappeared. From that time on his intellectual faculties became disturbed; the patient fell constantly under the domination of a delusion of ambition, which gradually increased. In the month of October, he was the Emperor Napoleon; he was possessed of immense riches, forty thousand barrels filled with gold; on any other subject, his ideas maintained a certain coherence. Generally calm, he was sometimes greatly agitated, and even violent when contradicted; he spoke with great difficulty, and was unsteady in his gait; he did not sleep, but ate well; his legs were slightly swollen. O n 27th October, he was conducted to the royal house

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of Charenton. State of dementia, dominant ambitious ideas, more advanced incomplete paralysis. For the first two months, little change in his state. O n 4th January 1819, general pallor and flaccidity, dulled sensations, absence of attention to surrounding objects, in which he manifested no interest. He heard with difficulty the questions asked him; in order for him to understand and answer them, they had to be repeated several times and presented in different ways. He maintained only a small number of incoherent ambitious ideas which he expressed when spoken to, whatever question was asked of him: he was an emperor; his two sons were emperors, and resided at the Tuileries; he possessed millions and then further millions; his wife had three medals of honour. On any other matter, he was incapable of associating even the most simple ideas. If asked of what country he was emperor, he would reply Besanson, to which he attached Germany and France. He was scarcely able to remain on his feet: he walked slowly, swayed at each step and dragged his feet. He was calm, apathetic, silent, and generally remained seated on a chair, to which he was bound to prevent him falling; at other times, he would walk in the courtyard or the corridor. At times he would speak in a low voice, constantly repeating the words emperor, millions, diamonds, etc. His voice was hoarse, trembling, his pronunciation very difficult. He was unable to control his excrements and urine. He was of good appetite, asked often for food, and was very thin. O n 14th January, he was no longer able to remain upright; his appearance was much impaired, his faculties further obliterated; he had grazes on various parts. O n 30th January, debility, thinness, swollen legs, continual silence, no answer to questions asked him, unless they related to his ambitious delusion. In this case, he would reply solely, emperor, I am emperor. O n 8th February, complete moral and physical prostration. He was entirely incapable of uttering a word, and made no movement which suggested he understood what

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was said to him: his face was agitated by slight convulsive movements; his eyes were fixed and without expression. All parts which were exposed to any degree of pressure or rubbing, such as the sacrum, the trochanters, the elbows, etc., were marked by livid grazes and gangrenous wounds; the pulse was weak and slow; these symptoms increased. O n the 9th, death pangs lasting a few hours, and death. Opening of the corpse. Corpse extremely thin, legs and feet infiltrated, bedsores on various parts of the body. Skull. A degree of serosity between the two layers of the arachnoidea; four to six ounces of the same liquid collected at the base of the skull. The arachnoidean layer of the dura mater highly injected. The two hemispheres of the brain adhered in the fissura magna. The cerebral arachnoidea of the base of the encephalon, healthy; that of the convexity and of the internal side of the hemispheres, opaque, whitish at various points, maintaining part of its transparency at other points, thickened, very hard and easy to detach from the surface of the brain, to which it adhered at a few small points. The pia mater very red, injected, and infiltrated by a large quantity of serosity. The lateral and middle ventricles, distended by the same fluid: the membrane which covers them, together with the ventricle of the cerebellum, much thickened, able to be separated from the surface of the brain, sprinkled with granulations perceptible to the touch, which rendered it rough and coarse. The cerebral substance soft; the medullaria much firmer. norax. All the pectoral organs, healthy. Abdominal cavity. The gastric mucose membrane, thickened, rough and audible under the instrument. The other organs healthy. Does not this observation prove that the disorder of the intellectual faculties arising in L.. .was the symptom of a chronic arachnitis, and not an essential delusion? It is a conclusion which cannot but be accepted, by a comparison of the organic lesions with the symptoms presented by the illness at the different stages of its progress. It is not

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necessary to prove that the opacity of the arachnoidea, its thickening, its increased hardness in the upper region of the brain, together with the serous infiltration of the pia mater and the collection of a large amount of serosity, either at the base of the brain, or in its cavities, are the anatomical characteristics of chronic phrenesia. It is a fact that no one will contest, and which is put beyond doubt by all the knowledge we possess with regard to chronic phlegmasia of the serous membranes, and in particular of the arachnoidea. This having been established, let us see what must have been the action of the organic impairments of the latter membrane in determining the phenomena of the disease. 1. At the beginning, sudden loss of consciousness, hemiplegia; a few moments after, return of feeling and movement in the side paralysed, but significant problems for the whole muscular system; from this time, disorder of the faculties, monomania. Some of these symptoms belong to apoplexy; but the absence of collection of blood, of cavities or of cysts in the ventricles or the brain substance show that no cerebral haemorrhage had occurred. The seizure experienced by the patient was therefore what Mr Rochoux (Researches on apoplexy) calls a blood stroke, that is to say, a sudden seizure of that fluid in the vessels of the pia mater and of the brain: however, there exists here a symptom which is not seen in simple brain congestions: delusion. I attribute this symptom to the irritation of the arachnoidea, which secondarily irritates the brain: for while it does not exist in cerebral congestion, neither is that disorder accompanied by impairment of the arachnoidea. Thus, this first period of the disease presents us on the one hand with a congestion of the blood in the tissue of the pia mater and of the brain, plus a slight irritation of the arachnoidea, and, on the other hand, the symptoms of each of these disorders. 2. In the second period, speech difficulties, unsteady gait, occasional agitation, and sometimes violence, much weakened faculties, same dominant ideas. If it is recalled that, in blood strokes, the paralysis diminishes gradually instead of

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increasing, when it is properly treated, these phenomena will be attributed to the increase in the phlegmasia of the arachnoidea and of the serous emission, disorders which act on the brain in two ways, loby irritating it, 2O by compressing it. 3. In the last period, movement trembling and almost impossible, paralysis of the sphincters, complete dementia with collapse of the intellect, which is reduced to a few dominant and incoherent ideas; no agitation. There occurs, at this stage of the disease, that which takes place in most chronic phlegmasias of the serous membranes. The slight irritation which had accompanied the arachnitis, disappears; the tissue of the cerebral serous membrane becomes opaque and thickened; it emits a large quantity of serous fluid; the brain is no longer excited, but is overwhelmed by the quantity of serosity in which it is plunged. The following observations will confirm these ideas, which might otherwise be considered somewhat rash at this juncture.

2nd observation. Chronic arachnitis. (Monomania,

mania) Mr Edme-Charles A . . ., aged forty-five years, of a sanguine temperament, of strong constitution, clerk to a justice of the peace, had experienced a great deal of fatigue and deprivation during a voyage he had made to the GreatIndies; he had indulged in excesses of the flesh and suffered several syphilitic diseases. In March 18 17, a haemorrhoidal flow, of long date, ceased and did not return. Around the same time, he was a prey to lively sorrows with regard to the destiny of his numerous family, which he feared to be unable to support in view of the misery of the times. At the beginning of May, he experienced frequent absences, and, a short time afterwards, was overtaken by an ambitious delusion, characterised by ideas of wealth, of grandeur, of honours, and by a cerebral congestion marked

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by difficulties in pronunciation and in walking. He manifested a very great penchant for drink and for the pleasures of love, and he was subject to attacks of exaltation, during which he would speak much of the objects of his delusion. He slept very little and ate a great deal. (Bleeding of two basins from the arm.) O n 27 June, he was conducted to the Royal House of Charenton: predominant ambitious ideas; he was extremely rich and powerful; considerable exaltation, occasional furor, in which he would tear his clothes, as being unworthy of a man of his rank; difficulty in pronouncing certain words, quite assured gait, incoherence in his speech; ravenous hunger: he would steal everything he came upon, either to satisfy this hunger, or because all belonged to him. Throughout the month of July, same state. In the three following months, intellectual faculties more profoundly impaired, attention completely lacking; he would sometimes answer the questions asked to him, after they were repeated several times; but always in monosyllables, or else with words entirely unrelated to the question; memory abolished, extremely restricted ideas, confined to matters of fortune, grandeur, etc., which would come into his mind without connection and without order; no sign of judgement, calm at times, agitation at others. (Use of the straitjacket and overall to prevent him tearing his clothes.) Dragging, interrupted, trembling speech; very unsteady gait, lack of cleanliness. Towards the end of November, marked improvement in symptoms, diminution of agitation and partial paralysis, understanding much less impaired. In the month of December, return of reason; mind weakened, without marked delusion; however, he retained certain ambitious ideas which were quite well coordinated; first, he wished to study pharmacy, then medicine, to support his children; he would always answer that he was in perfect health; he was content with himself, wished to return to his family and resume, if possible, his occupations. Slight problems of the tongue, which occasioned a certain

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slowness in pronunciation, and stammering in certain words; some trembling of the hands. In January 1818, diminution of these symptoms. Same state until May. In the first days of that month, he spoke more than ordinarily; there was exaltation in his ideas and actions; self-content; face red and animated, some extravagant speech for which he was obliged to be confined again. A short time afterwards, complete collapse of the faculties of the understanding: general delirium, accompanied by a continuous, and extremely violent, agitation. The straitjacket and basket ' were used to restrain him; he continued every moment, night and day, to utter confused, ill-articulated and incoherent shouts, and vociferations; his voice was muffled; one could understand nothing of the words he pronounced; his face was dull, contorted, its movements highly disordered; he would make a thousand efforts, twist and turn incessantly in every direction; his limbs and head were agitated by spasms almost too violent for the strong ties by which he was bound. Despite all this disorder of the related functions, his appetite was voracious; the pulse and the other nutritive functions were unimpaired. This state lasted approximately four months, in a continuous manner, with slight remissions of very short duration. Towards the middle of November, the agitation diminished, the excretions became involuntary, the legs swollen, the faculties obliterated. O n 6 December, loss of consciousness, deep breathing, weak pulse. Death two hours after midday. Opening of the corpse.-Skull. Some six ounces of serosity had collected at the base of the skull; a great quantity was leaking from the vertebral canal. The cerebral arachnoidea, on the whole surface of the hemispheres, but principally towards the middle part of their external part, was opaque, greyish, much thickened, and hard, such that it was easy to 1. This is a kind of covered box the length of the body, made of wicker like an ordinary basket, of which one of the ends is cut open to allow a space for the head.

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separate it from the brain without breaking it; it was intimately adherent to itself in thefissura magna, its internal side adhering to the cerebral parenchyma in the thickened portions, and it was covered with a light and soft layer of the latter, when detached from the encephalon. Its external surface, slightly injected, presented a few very small granulations, perceptible only to sight. The arachnoid layer of the dura mater manifested a slight redness at various places. The pia mater was red, and slightly infiltrated by serosity. The lateral ventricles were full of the same fluid; their surface was covered with granulations. The whole cerebral vascular system was hugely injected. Cerebral substance healthy. n o r a x . Half pint of serosity in each of the pectoral cavities. Left lung adhering to the pleura costalis. Three ounces of serosity collected in the pericardium; the layer of this membrane, which covers the heart, infiltrated with that fluid which gave it a gelatinous appearance. Abdominal cavity. Small quantity of serous fluid in the peritoneum. Gastric mucus membrane of brownish red colour, slightly thickened, and covered with a layer of extensive mucus. The capsule of the spleen, adhering to the diaphragm, hard, whitish, audible under the instrument, and presenting a cartilaginous structure. The other organs, healthy. The history of the disease we have just described offers such a striking relation between the symptoms and the physical impairment in the corpse that, given the latter, it would be possible, so to speak, to deduce the former. In order to show more clearly the coordination and the intimate link between causes and effects, we will begin these reflections with a concise picture of the organic lesions: opaque, greyish, much thickened and very hard arachnoidea, adhering to the grey matter of the brain over a large part of the convexity and of the internal side of the hemispheres, six ounces of serosity at the base of the skull, ventricles full of the same fluid, a few granulations on their

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surface. What was the action of these deteriorations such that they produced the physical and intellectual disorders evident to us by observation? At the origin of the disease, a sanguine temperament, excesses of all kinds, the suppression of a habitual haemorrhoidal flow, keen sorrows, were the cause of a cerebral congestion manifested by an impairment in pronunciation and walking; at the same time, the arachnoidea became irritated and gave rise to the monomaniac delusion and to the agitation which sometimes accompanied it. This latter fact, of which we have already spoken, is of the greatest importance and requires a number of new considerations in order to remove all doubt as to its existence. The examples of sudden congestions of blood without cerebral haemorrhage are very numerous, and form the largest number of cases of apoplexy encountered each day. The symptoms of this condition are limited to a more or less profound impairment in feeling and movement, which never extends so far as an absolute loss of feeling, nor to the complete resolution of one side of the body; they subsequently disappear over a varying period, and during their existence never manifest either delirium or agitation. O n the other hand, the many observations published by Messrs Parent and Martinet, and those that may be read in numerous dissertations, constantly show us these two phenomena, but at infinitely varied degrees, dependent on a host of circumstances. In the observation that we are considering, the disturbance of the faculties and the disorder of the movements must be attributed to the inflammation of the arachnoidea. But this phlegmasia never has the characteristics of acute frenzy: quite mild at every stage of its progress, it increases gradually, slowly but progressively degrading the tissue of the arachnoidea. Throughout its whole duration, its advance is chronic; it is determined by causes which are specific to it, and never gives way to acute arachnitis. It is this latter circumstance which has led the two authors whom we have just cited to propose that chronic arachnitis does not exist, or at least that it must be

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excessively rare. For the same reason, Dr Montfalcon casts doubt on its existence. (Dictionary of medical sciences, phrenesia article.) After the early stages of the disease of Mr A*"*, the inflammation of the arachnoidea increased; the serosity was emitted more abundantly than in the natural state; the brain was more irritated and more compressed that it had been at the invasion: thus the impairment in the movements, the temporary and mild agitation, the limited and exclusive delusion observed at that time, were succeeded by a maniac agitation subject to frequent paroxysms of furor, a general disorder of the understanding, and an incomplete and general paralysis which rendered pronunciation very difficult and the gait unsteady. Five to six months after, the inflammation diminished, part of the serosity was probably absorbed: calm and reason were then gradually re-established; however, the faculties remained weakened: the movements recovered only a part of their original freedom, phenomena which are probably associated with a certain thickening of the arachnoidea, and with a certain quantity of serosity, which persisted beyond the inflammatory irritation and the congestion of the blood by which it is always accompanied. But it is easy to see that, in such a state, the patient must be disposed to a relapse, even for the slightest reasons. This relapse took place; a further cerebral congestion occurred; the inflammation of the arachnoidea resumed: this membrane, more violently irritated than ever before, became further thickened, and began to adhere to the external surface of the brain, over the whole extent of its upper region, in conjunction with the pid mater, which was strongly injected. From this there inevitably resulted the most violent irritation of the encephalon, and, as an equally necessary consequence, a corresponding disorder in its own functions and in that of the locomotive apparatus over which it presides, an extreme disorder, manifested by the complete destruction of the understanding, the confused, inarticulate and continuous cries, the constant, violent and

~

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spasmodic agitation of the head and limbs. These symptoms differ from those which accompany acute arachnitis only in their duration. In the latter disease, they are soon followed by the period of coZlapsus, while, in the patient who is the subject of these reflections, they lasted for four months. This period of prostration finally arrived for Mr A’C’b’b one month before his death; calm was re-established, the faculties remained obliterated; the paralysis was considerable. In these symptoms one recognises a more abundant emission of serosity. In the observation of L.. ., where we found no adherence of the meninges to the brain, the agitation only occurred in the second period of the disease, and was never continuous nor very intense. What was the influence of the chronic gastritis revealed by the autopsy on the mental alienation suffered by the patient? It is difficult to reply to this question. However, it is certain that it was not the cause of the delirium, since there existed no symptom of gastric disorder when the latter appeared, and it was only after the invasion that the patient took to drink with passion.

Jacques-Joseph Moreau, called Moreau de Tours (1804-1884)

A student of Bretonneau in Tours, an intern and pupil of Esquirol at Charenton, Moreau de Tours began his career accompanying wealthy patients on their travels, thus conforming to 18th-century educational principles but also to the treatment of alienation as propounded by Leuret (“Moral treatment of madness”, 1840). The same Leuret who was to be his rival at Bicgtre, since Moreau de Tours rejected the principles of moral treatment, denigrating the role of the physician alone, of giving the insane work and of the architectural arrangement of the asylum. During a “therapeutic” journey in the Orient, he discovered hashish, which led to his interest in natural substances like belladonna and datura, as well as the effects of other narcotic substances such as ether or chloroform. “Anyone who has visited the Orient knows how widespread is the use of hashish, especially amongst the Arabs, for whom it has become a need no less imperious than opium for the Turks and Chinese, and alcoholic liquors for the peoples of Europe.” From that time on, he became convinced that hashish and other dysleptic substances produce phenomena identical to dreaming, and required experimental study in order to discover the source of delusion and hence how it could be treated medically. “I had seen in hashish, or rather in its action on the moral faculties, a powerful, unique means of exploration in the field of mental pathogenesis; I was persuaded that, through this substance,

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it should be possible to be initiated into the mysteries of alienation, to return to the hidden source of those disorders so numerous, so varied, so strange that they are habitually referred to by the collective name of insanity. “In this way, and guided exclusively by observation, but by that kind of observation which comes solely from the consciousness or the inner sense, I believed it was possible to find the primitive source of every fundamental phenomenon of delusion.” Moreau de Tours organisedfantasia sessions at the Hachischins Club in a Parisian hotel. “In 1841, when I published my essay on hallucinations, I had only been able to study the effects of hashish in an imperfect manner. Since then, I have conducted a large number of experiments on myself and on a number of people (including several doctors) whom I succeeded-which is not always easy-in persuading to partake of some.” He eventually came round to treating the insane with dawamesc, an Arabic word which refers to an oily extract of hashish perfumed with essence of rose or jasmin. “D... (Louis). Aged 33, born in Soissons, hairdresser residing in Paris ... “D... becomes of an extravagant gaiety; his head becomes exalted; his hopes, his pretensions, his vanity, know no bounds. H e believes himself rich, or at least certain to become so; he buys luxurious objects, hunting dogs, guns, etc. He believes himself a genius, a poet of the first order; he describes himself as the hairdresser-poet. ‘Fear not, he repeats often to his wife, I will make a name for myself‘. He covers the walls of his room with words, broken, incoherent sentences, which he claims to be poetry that, in his own words, would make Racine and Corneille die of envy, were they still of this world. D... was taken to Bicgtre on 16 February 1842. “On 5 June, I administered to D... some thirty grams of dawamesc. “It was not until an hour and a quarter had passed that the effects made themselves apparent. Excessive gaiety, immoderate laughter. D... clearly appeared to be under the influence of illusions and hallucinations the nature of which it is impossible for us to know, since the patient paid no attention to what we said to him, being completely absorbed by the ideas which

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preoccupied him. I had him conducted to the music room. The sounds of an expressive organ and other instruments exercised an immense influence on him. D... moved, danced, stamped, or else stopped short, lay down, knelt, his hands clasped and eyes turned towards heaven, shed tears, groaned, according to whether the music, by which he was entirely penetrated and controlled, became by turns serious, joyful, religious or melancholic. With the music, all agitation ceased. “By evening, no trace of the symptoms we have just described remained. D... dined with the same appetite as usual. Until the time he went to bed, he remained perfectly calm, no longer chattering as before, but still speaking nonsense, and not wishing to describe what he had experienced after eating the jams which I had given him. He claimed to remember nothing, except having experienced great contentment and having laughed a great deal. The night was calm, almost entirely dreamless. O n the next day, the patient’s general state had quite clearly improved. There were fewer inconsistencies in his speech; the nights were generally calmer. Pride and vanity are still behind everything he says; however, he shows more restraint, less assurance, and no longer becomes irritated when contradicted. A few days later, he was sent to the Sainte-Anne farm, where manual tasks quickly contributed to his recovery.” Frangois-RCgis Cousin

Principal works MOREAU de TOURS U.), Du hachisch et de l’ali6nation mentale, Etudes psychologiques [On hashish and on Mental Alienation, Psychological Studies], Paris, 1845, Fortin et Masson, 431 pages. Principal references

BOLLOTTE (G.), “Moreau de Tours”, Confrontationspsycbiatriques [Psychiatric comparisons], 1973, 11, p. 9-26.

O n Hashish and on Mental Alienation (1845)

PHYSIOLOGY

Introduction

It was curiosity alone which initially impelled me to experience for myself the effects of hashish. A little later, I have no hesitation in confessing, I found it hard to protect myself from the irritating recollection of the sensations which it had led me to experience; however, may I be permitted to add that, from the start, I was further motivated by reasons of another order. These are those reasons: I had seen in hashish, or rather in its action on the moral faculties, a powerful, unique means of exploration in the field of mental pathogenesis; I was persuaded that through this substance, it should be possible to be initiated into the mysteries of alienation, to return to the hidden source of those disorders so numerous, so varied, so strange that they are habitually referred to by the collective name of insanity. Perhaps it will be found presumptuous and rash in me to express myself with such assurance on a subject which, in general, so-called positive men are unwilling even to consider, consigning it to the province of a cloudy metaphysics. I hope that this audacity, which I acknowledge, will be legitimatised by the conscientious researches to which this

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work is dedicated, for it will be seen that it is founded, not on reasoning, on inductions which are always legitimately open to doubt, but on facts which no doubt, no uncertainty could affect, on simple and obvious truths of interior observation. Thus, as will be seen, all I needed to do, so to speak, was to transfer the principal phenomena of delusion ' onto those brought about by hashish, applying to the former the mode of explanation which the examination of that which took place in me provided for the latter. In this way, and guided exclusively by observation, but by that kind of observation which comes solely from the consciousness or the intimate sense, I believed it was possible to find the primitive source of every fundamental phenomenon of delusion. There is one which seems to me to be the primitivefact which generates all the others: I have called it the PRIMARY FACT. Secondly, I was obliged to acknowledge, for delusion in general, a psychological nature not only analogous, but absoLately identical to that of the dream state. This identity of nature which escapes external observation, that is to say, which is exercised solely on others, is clearly apparent, I may say, is perceived through intimate observation. We hope to avoid in the researches we propose to undertake the dryness and sterility which might, perhaps, be feared, the subject being psychology. Serious and numerous lacunae still exist in the history of the symptoms of mental alienation. 1. I employ the words delusion, insanity, mental alienation without distinction to designate disorders of the mind. I am fully aware of the many differences which, from the symptomatological and therapeutic point of view, distinguish delusion as such from insanity; however, from the psychical point of view, it must be recognised that these differences do not exist. The causes, the symptoms or external signs can vary; the intrinsic psychical nature is essentially the same, whatever the form, acute or chronic, partial or general, in which the disorders of the spirit occur.

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Many alienists have, with their investigative scalpel, searched for the material causes of folly, sou-ght to find in the depths of the organs the grain of sand which has jammed the intellectual machine, sought in the arrangement of the molecules of the brain the explanation of the disorders of thought. Most have carefully described the infinitely varied symptoms offered to them by the many patients amongst whom they had long dwelled; but I know of none, speaking of madness, who has passed on to us the result of his personal experience, has described it in the light of his own perceptions and sensations. There perhaps remained something, therefore, to be done in this respect. Moreover, the uncertainty which reigns in the treatment of mental illnesses is well-known. By unveiling the primitive fact, the primordial functional lesion from which flow, like streams from a single source, all the forms of madness, I hope to propose some useful ideas with regard to the best method of treating this disorder. I will finish this paper by reporting a number of therapeutic attempts conducted by means of hashish.

General physiological points.

S I.

Among the intellectual faculties, there is one by means of which we are able to study in ourselves the mechanism of those faculties in the physiological state; that faculty is reflection, the power which the mind has to, so to speak, fold back upon itself, the species of mirror in which it can contemplate itself at will, and which provides it with a faithful image of its most intimate motions. This power is lacking in us when our faculties are disturbed, when there is anarchy within them, when, in a word, there is madness. We know that some exceptions to this rule can be found; however, those of the insane who

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are able to reflect on that which is taking place in their innermost being are rare, and are found, moreover, only in certain particular cases of madness. In addition, is it entirely certain that we are in a position to understand these patients when they describe their observations to us? Is not, on the contrary, the language in which they speak necessarily foreign to us? How might they pour into our breast the feelings that agitate them? What do we learn when they tell us that they are borne away by an irresistible instinct, that they are dominated by some extravagant idea which they are unable to express, and whatever they do to free themselves, their thoughts succeed each other, mix and come together with uncontrollable rapidity, that they see objects, hear sounds, voices, which exist, as we commonly say, only in their imagination?. . .Obviously, all we see here is the surface of things; there is no way by which we could penetrate further, probe the causes, the sequence of the mental anomalies of which they speak. Is this not the case for the acts of understanding of the affections, especially, as for sensations which it is impossible to know and to judge other than from oneself? In order to understand any kind of pain, it must have been experienced; in order to know how a madman is mad, one must have been mad oneself; but mad without becoming unaware of one’s delusion, without ceasing to be able to judge the psychical alterations which have taken place in our faculties

S 11. By the way it acts upon the mental faculties, hashish allows he who submits to its strange influence the power to study in himself the moral disorders which characterise madness, or at least the principal intellectual changes which are the starting point of all kinds of mental alienation. For in striking, in disorganising the various intellectual powers, there is one which it does not reach, which it allows to subsist in the midst of the most alarming disorders: that is the consciousness of self, the intimate feeling of individuality. However incoherent are your ideas, subject

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to the most bizarre, the strangest associations, however profoundly altered are your emotions, your instincts, led astray as you are by illusions and hallucinations of every kind in the midst of a world of fantasy, like to the world into which you are sometimes borne in your most disordered dreams.. .you remain master of yourself. Positioned outside its impairments, the ego dominates and judges the disorders which the disruptive agent brings about in the lower regions of the intelligence.

$ 111. There is no fact elementary to or constitutive of madness which is not encountered in the intellectual alterations effected by hashish, from the simplest maniac excitation to the most furious delirium, from the mildest morbid impulse, the least complicated fixed idea, the most limited lesion of the sensations, through to the most irresistible compulsion, the most extensive partial delirium, the most varied disorders of sensibility. As we successively consider these diverse phenomena, we will examine their origin, we will study their progression, their connections; then, comparing them with those observed in the insane, we will consider to what point external observation and in particular the declarations of patients are in accord with our own remarks. By these combined modes of exploration we will be led to the following conclusions: 1.Every form, every accident of delirium or of madness as such, fixed ideas, hallucinations, irresistible impulses, etc., draw their origin from an initial intellectual alteration, always identical to itself, which is evidently the essential condition of their existence. This is maniac excitation. We employ this expression solely for reasons of conformity with the received terminology, for otherwise it provides a far from accurate rendering of our thought. How can one correctly describe that simultaneously simple and complex state, made up of flux, uncertainty, oscillation and mobil-

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ity of the ideas, which is often reflected in a profound incoherence? It is a disaggregation, a veritable dissolution of the intellectual compound which we call the moral faculties; for one feels, in this state, that there occurs in the mind something analogous to that which happens when some body undergoes the dissolving action of another body. The result is the same in the spiritual order as in the material order: the separation, the isolation of the ideas and of the molecules whose union had formed an harmonious and complete whole. Nothing is comparable with the almost infinite variety of the nuances of delusion, unless it be the activity of thought itself. Whence the reluctance showed by most authors to connect it with an organic lesion, regardless moreover of their idea of the nature of this lesion. By relating all these nuances to a primitive, original form, to intellectual excitation, which adapts itself, so to speak, so easily to the exaggerated molecular movement which we can readily conceive in nervous irritation, do we not remove any excuse for such reluctance? 2.As the psychic process to which I have just referred develops under the influence of hashish, a profound alteration takes place in the whole thinking being. There arises, imperceptibly, unknown to you and despite all your efforts not to be taken by surprise, there arises, I say, a veritable dreaming state, but dreaming without sleep! For sleep and waking are now so confused, if I may use that word, merged into one, that the most enlightened, the most clear-seeing consciousness, can make no distinction between the two states, any more than between the diverse operations of the mind which are exclusively associated with one or with the other. From this fact, the importance of which is clear to all, and the proofs of which are set down on every page of this book, we have deduced the real nature of madness, of which it encompasses and explains all the phenomena, without exception.

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Whatever view one holds on the nature of dreams, on the physiological causes which produce them, if we examine the role played by the intelligence in the dreaming state, we find that it is present in them, so to speak, in its entirety; that not one single of its faculties is unable to be exercised, precisely as in the waking state, although in different conditions. In dreams, we experience the same sensations as while awake; we perceive, we judge, we have convictions, we feel desires, we are shaken by passions, etc. It was erroneously that that which occurs in dreams was attributed solely to the imagination. It acts in them on its own behalf, and that is all; but it is not the imagination which reasons, perceives, touches, feels, acts, converses, holds discussions, becomes passionate, etc. Indeed, its action seems to us infinitely more restricted than in waking, for one imagines little while dreaming, and the world of sensations, of memories, within which the soul becomes agitated and which is absolutely foreign to the imagination as such, almost entirely absorbs its activity. No doubt, the existence constituted by the dreaming state is a purely ideal one. However, this is only true in a relative sense, since for the dreamer, it is entirely real; what we see, what we hear, what we feel in dreams, we see, we hear, we feel really, as really as if we were awake; the only difference is in the origin of the impressicns which the understanding perceives and develops. This does not mean that we consider ourselves entitled to conclude, with one of the most eminent psychologists of our time,2 that l;fe may be no more than an illmion. Functions, of whatever order, suppose organs; outside the organism I cannot conceive of that 1. Imagining necessarily implies an effort of the mind, of the will. How then may one attribute to the faculty of imagining the production of those images, of those pictures, which, in dreams, appear unexpectedly, pass and are layed out before our eyes, form and vanish without any intervention o f t e will? Let one only try, while awake, to imagine the thousandth part of these fantastic dream productions, and see if one succeeds! 2. J.J. Virey, De la pbysiologie danr ses rapports avec la philosophie. @lienJoseph Virey, French doctor and naturalist, 1775-1846.)

K

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which we call life; if sensations occur during sleep, it is because they first occurred during waking, and it is impossible to believe that a brain which had been closed to every external impression could create them in their entirety, could dream, which comes to the same thing.. .We would not go so far, but I am happy to repeat Dr Virey’s remark, because it depicts marvellously the mode of action of the moral faculties in the dreaming state. Most often, an extreme disorder, a strange confusion which encompasses equally things, people, time, place, governs the association of ideas during dreams, and thus give rise to the most bizarre productions, to the most monstrous combinations. “The dream,” as the previously cited author puts it, with his customary elegance of style, “can be defined: a defective drama without unity of time and place, comparable to those plays described by Horace as velut aegri somnia [like the dreams of a sick man].” However, this is not always the case: sometimes the associations of ideas are perfectly regular, our reasoning follows a strict logic, however false, however impossible the point of departure; some object has engaged our passions, aroused our anger, excited our compassion, struck us with fear, and we obey the impulse that these different passions communicate and seek the means to satisfy them. Furthermore, and this fact is of great importance with regard to the subject that concerns us, the operations of the soul sometimes present, in dreams, a regularity which is not encountered while awake. “It might seem extraordinary,” says Nodier, “but it is certain that sleep is not only the most powerful, but also the most lucid state of thought, if not in the fleeting illusions with which it envelopes it, at least in the perceptions which derive from it, and which it brings forth at will from the confused web of dreams. The ancients, who had, I believe, little to envy us for in experimental philosophy, depicted this mystery cleverly through the emblem of the transparent door which allows entry to the dreams of morning, and the unanimous wisdom of the

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peoples has expressed it in an even more vivid manner through significant expressions in every language: let them sleep on it; he has dreamed up d new idea. It would seem that the mind, clouded by the shadows of external life, never more easily becomes free of them than under the gentle reign of this intermittent death, where it is permitted to repose in its own essence, sheltered from the influences of the personality of convention which society has made for us. The first perception which comes into being through the inexplicable vagueness of the dream is as limpid as the first ray of sunlight which strikes through a cloud, and the mind, suspended for a moment between the two states which share our life, lights up suddenly like the flash of lightning in its dazzling passage from the storms of heaven to the storms of earth. It is here that Hesiod awakens, on his lips the taste of the nectar of the Muses; Homer, his eyes unsealed by the nymphs of the Meles; and Milton, his heart ravished by the last glimpse of a beauty never to be recovered. Alas! Where will one recover again the loves and beauties of sleep?-Deprive the genius of his visions of the world of marvels, and you deprive him of his wings. The map of the imaginable universe is drawn only in dreams; the visible universe is infinitely small.” It would seem therefore that two modes of moral existence, two lives, have been allotted to man. The first of these two existences results from our relations with the outside world, from that great whole which we call the universe; we share it with the beings that resemble us. The second is but the reflection of the first, is in a sense made up of the materials which the latter provides, but is nevertheless perfectly distinct from it. Sleep is like a barrier which stands between the two. The physiological point where external life finishes, and where the internal life begins. While things are in this state, there is perfect moral health, that is to say, regularity of the intellectual functions within the limits set for each of us. However, it may happen that

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under the influence of various causes, physical and moral, these two lives begin to merge, the phenomena specific to each begin to come together, to unite in the simple and indivisible act of intimate consciousness or of the ego. An imperfect fusion takes place, and the individual, without having completely departed real life, belongs, in several respects, through various intellectual points, through false sensations, through erroneous beliefs, etc., to the ideal world. This individual is the madman, especially the monomaniac, who presents such a strange amalgam of madness and reason, and who, as is so often said, lives in a waking dream, a commonplace expression which, in our eyes, nevertheless reflects with absolute accuracy the fundamental psychological nature of mental alienation.

Bkn6dict Augustin Morel (1809-1873)

Benedict Augustin Morel was born in Vienna of an unknown mother and to a father who, as a supplier to Napoleon 1’s armies, followed them in their campaigns across Europe. The child was entrusted to a priest who continued to look after him after his father’s death. This difficult start to life gave him a perfect grasp of the German language. After tasting the seminary and then, in order to survive, a number of professions (journalist, tutor in an American family), around 1851 Morel began medical studies in Paris. There, he made friends with other students as povertystricken as himself, Philippe Buchez (1796-1869, the future philosopher and politician, Las&gue’kand Claude Bernard, sharing with them the Bohemian life later described by Henri Murger. It was Claude Bernard who introduced Morel to J.P. Falret“, who was looking for a qualified person to translate the works of the German psychological school. Having presented his thesis in 1839, Morel began to contribute, from the start of their publication, to the Annales m~dico-psycbologiquesthrough articles marked by the influence of Falret and de Stahl (1660-1774). In 1844, required to accompany a patient on a journey across Europe, Morel took the opportunity to record his observations on mental pathology in Belgium, Holland, Germany, Italy and Switzerland. He was particularly impressed by his visit to the Abendberg

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establishment (Berne), which specialised in the treatment of cretinism. After the 1848 revolution, thanks to the support of his friend Buchez, he was appointed physician to the Mariville asylum (Lorraine), one of those set up by the law of 30 June 1838. There, in 1851, he began a theoretical and clinical course on mental diseases, the contents of which were published in Nancy in two volumes of “Clinical Studies” (1851-1852). It is in this work that Morel describes a clinical picture which he calls “premature dementia” or “juvenile dementia” without, however, drawing the theoretical consequence of this description, as would Emil Kraepelin in 1899, in his application of this term to the disease he then defined. Appointed chief physician to the Saint-Yon asylum, in Normandy, in 1856, it was there that Morel ended a career spent entirely outside Paris. He was one of the pioneers of legal mental medicine in France. Although, like Falret, he rejected the Esquirolian concept of homicidal monomania, he defended the notion of “insidious epilepsy’’ behind certain criminal acts. Called to Munich in 1868 as an expert witness in the trial for the murder of Count Chomsky, he managed to avert the death penalty for the accused, who was interned soon after the verdict, due to the emergence of clear signs of madness. These were the circumstances in which Morel, having met the future Louis I1 of Bavaria (1845-1864-1886), of whom his grandfather Louis I of Wittelsbach (1786-1868), king from 1825 to 1848, said that he had “the passionate eyes of Adonis,” is supposed to have declared that “these eyes showed the presence of madness.” Morel published two “Treatises” which should not be confused. The first is the “Treatise on degenerations” where he expounds a theory of degeneration as a “morbid deviation of an ideal primitive type of human being”. This deviation is likely to occur under the influence of environmental factors which can “create in children a specific organic or definitively transmissible state with the potential to lead to the extinction of the race.” This view of degeneration, borrowed from the Christian socialist philosophical ideas of Buchez, differs from that of Valentin Magnan“ to which they are sometimes assimilated. In the second, “Treatise on mental diseases”, Morel proposes that these should be classified on the basis of their aetiology. H e

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thus distinguishes: lo Insanities by intoxication, headed by chronic alcoholism. 2O Insanities due to fundamental neuroses (in the 19th-century sense): hysteria, hypochondria, epilepsy. 3 O Sympathetic insanities, i.e. those where the brain is affected secondarily, and idiopathic insanities where it is fundamentally damaged in its substance. “It is in this last category that the progressive paralysis of the insane is classified (paralytic madness, the modern diffuse chronic periencephalitis).” 4 O The specific state designated by the name dementia, “a terminal form of the different mental disorders”. This classification marks the direction in which late 19th-century alienism was moving, with the significant role attributed to heredity in the aetiology of the mental diseases and the inevitability of the dementia1 prognosis. Jean GarrabC

Principal works MOREL (B.A.), Etudes cliniques sur les maladies mentales [Clinical studies on mental diseases] 2 vol., Nancy, Paris, 1851-1852. MOREL (B.A.), Trait; des dkglnirescencesphysique, intellectuelle et morale de l’espke humaine [Treatise on the physical, intellectual, and moral degenerations of the human species], Paris, Baillikre, 1857. Reprint in Classics in psychiatry, New York, 1976. MOREL (B.A.), Trait; des maladies mentales [Treatise on mental diseases], Paris, Victor Masson, 1860.

Bibliographical references CONSTANT (F.), Introduction 2 la vie et 2 1’m.m-e de B.A. Morel [Introduction to the life and work of B. A. Morel], medical thesis, Paris, 1970.

Treatise on Mental Diseases

((Madness is one of those diseases which was the last to be studied, being one of those which was the most difficult to study. But now that physiology, now that philosophy, have made so much progress, is not the application of this progress to the study of madness, a study so interesting and so sad, one of the first needs of science and one of the first duties of hurnanity? * (Flourens, Examen de la phr6noZogie.)

If we now move away for a moment from the observation of facts in the individual, and study the successive evolution of pathological facts at the level of the species, we will be permitted to observe a similar phenomenon, that is the successive and progressive evolution of hereditarily transmitted pathological phenomena following and influencing each other over a series of generations. In the first generation, I assume, one will observe only the predominance of the nervous temperament, the tendency to cerebral congestion, with its natural consequences: irritability, violence, excesses of character. In the second generation, a recrudescence of these pathological disposi-

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tions of the nervous system will be observed. One will encounter cerebral haemorrhages, idiopathic brain disorders, or at the least some of those capital neuroses which are associated, much more often than is thought, with prior hereditary dispositions: epilepsy, hysteria, hypochondria. Let us pursue this progression, on the assumption that nothing has been attempted to halt the successive and irresistible sequence of phenomena. In the generation that follows, the dispositions to insanity will be, so to speak, innate; the tendencies will be instinctive and of an unfavourable nature. They will be reflected in eccentric, disordered, dangerous acts. They will have that special character by which it is possible for us to establish these unfortunate beings in their proper place in the hierarchy of intelligences brought down by means of hereditary predispositions of an unfavourable kind. Finally, as the progression continues, it will be possible to follow the succession and sequence of the consequences of hereditary transmission through to their final pathological ramifications, with regard both to degeneration of an intellectual and moral character and to degeneration of a physiological character: deaf-muteness, congenital weakness of the faculties, dementia praecox; or limited intellectual life, sterility, or at the least reduced infant viability, imbecility, idiocy and finally cretinous degeneration. Such is, as a rule, the pathological progression of phenomena in hereditary disorders, where nothing has been attempted to halt the process. However, this latter observation itself tells us that medical intervention can play a positive part in altering the, so to speak, fatal progress of pathological hereditary conditions; that it is sometimes possible for us, in circumstances more common that might at first sight be thought, to break the sequence. Indeed, quite apart from medical action, we have already seen that nature, left to her own devices, can by crossing individuals, find elements capable of regenerating the family and the species; it will then be possible to follow the upward

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process of phenomena of renewal, just as we have followed the progressive downward evolution of degenerative phenomena.

THIRD CLASS Hereditary madness characterised by limited intellectual existence. In this third class, as I have said previously, * the signs of unfavourable hereditary transmission appear at a very early age in these patients, in the form of intellectual inertia and extreme depravation of the moral tendencies. Zhey learn with d$jjculty and forget quickly. I have already shown in my Dbgbnkrescences that individuals who fall into this category of hereditary alienation had a limited intellectual existence and quickly lapsed into dementia. Sometimes however, one observes in them special dispositions for the arts, but they lack all ability to coordinate their ideas. Their innate tendency to wrong has led me to describe them, from a medico-legal point of view, by the name instinctive

maniacs. I have also written:’ These sorts of lunatics constitute a dangerous and little-understood class; they are the pathological representatives of the worst dispositions of the spirit, of the most deplorable aberrations of the human heart. They are degenerate natures, to use an expression which I was the first to employ with regard to them, whose place has not as yet been clearly marked, neither in the domain of science, nor in that of criminal justice. Arson, theft, vagrancy, early propensities for debauchery of all kinds, constitute the sad summary of their moral existence. These unfortunates who, as a rule, have been imbued -

1. Classification des maladies mentales; alidnation hhbditaire, 2. Tendances au vol considhkes comme maladie; perversion es 280. instincts genbiques, p. 442.

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neither with any sense of moral good, nor with any sense of physical good in humanity, and who are the most direct representatives of unfavourable hereditary transmission, form a large proportion of the populations of the prisons and penal institutions for children. The signs of physical degeneration, such as deformation of the head, small stature, sterility, or at the least, in almost all cases, difficulty in propagating their race, in giving birth to well-formed and viable children, occur much more markedly in individuals of this category that in those of the previous class. I do not propose to dwell on the innate tendencies to evil which exist in lunatics of this class; this would be simply to repeat the same facts which I have already quoted with regard to patients of the previous category, who bear a great similarity to this present one. However, there is a valuable distinctive sign which may be equally useful to parents, to the institutions and to the magistrates responsible for assessing responsibility for the acts committed by these unfortunates: I refer to that pathological phenomenon which is distinguished by the cessation of the intellectual faculties, and even, in certain cases, by the almost sudden transition to the most irremediable idiocy. It is at the critical periods of existence, or else under the influence of the slightest determining cause, that this fatal transition occurs. The following example, taken from my Trait; des dkgknkrescences, will shed full light on this truth. It is in this connection that my thoughts return with sadness to a hereditary condition which occurred in a progressive form in a family with whose members I had been educated as a child. An unfortunate father consulted me one day on the mental state of his son of some thirteen or fourteen years, in whom a violent hatred for his begetter had suddenly replaced the most tender sentiments. This child, whose head was perfectly well-formed and whose intellectual faculties were well in advance of those of his fellow students, initially struck me by an apparent interruption in his

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growth. His first sorrows were connected with this seemingly futile cause, which was far from being the starting point of the strange anomalies of his feelings. H e was in despair at being the smallest in his class, although he was always first in his compositions, and moreover without effort and almost without work. It was, so to speak, by intuition that he understood things and that all was ordered in his memory and intelligence. Imperceptibly, he lost his gaiety, became sombre, taciturn, and showed a tendency to isolation. It was at first thought that he harboured masturbatory tendencies, but this was not the case. The child’s state of melancholy depression, his hatred for his father, which extended to the idea of killing him, had another cause. His mother was deranged, his grandmother eccentric in the extreme. I ordered that this child’s studies should be interrupted and that he be isolated in an institution of hydrotherapy. Gymnastic exercises, bathing, manual work, were to form part of the new hygienic conditions of his existence. These methods were pursued regularly and intelligently under the guidance of a wise and enlightened physician, D r Gillebert d’Hercourt, and a most positive alteration was effected in the child’s organic state. He grew considerably, but another phenomenon as disquieting as those of which I have spoken came to dominate the situation. The young patient gradually forgot everything he had learned; all his brilliant intellectual faculties underwent a very worrying period of cessation. A sort of torpor, similar to stupor, replaced the initial activity, and when I saw him again, I concluded that the fatal transition to the state of dementia praecox was in the course of taking place. This desperate prognosis is generally a long way from the ideas of parents and even of the physicians who care for such children. Such is, nevertheless, in many cases the sad conclusion of hereditary madness. A sudden immobilisation of all the faculties, early dementia indicate that the young subject has reached the limit of the intellectual life allotted to him. The term then used to refer to such unfortunates is imbecile,idiot.

Jules Baillarger (1809-1890)

Jules Baillarger studied medicine in Paris, was presented to Esquirol and obtained a position as an intern at the Charenton asylum. H e very quickly became the great Esquirol’s student and then friend. His role was that of a secretary and he was virtually a daily visitor to the Ivry sanatorium. He was also a member of the inner circle who joined the master for family lunch every Sunday. In 1840, he was appointed to the Salpetrihre, and headed the section next to that of another of Esquirol’s pupils, Jean-Pierre Falret, with whom he maintained a fierce rivalry. In fact history records their disagreement regarding the first paper on the subject of a unique form of melancholia and mania. It was in 1854 at a lecture at the Academie de midecine de Paris, that Jules Baillarger expounded his theory on “Dual form insanity”. For him, this was a form of alienation consisting of regularly alternating periods of excitation and depression. He wrote: “All the writers on mania have considered the transformation of mania into melancholia or vice versa to be fairly common. They have also all perceived these facts to be two different disorders, two distinct attacks, which succeed each other more or less within a single patient. This is an opinion that I have sought to combat. Indeed, I would like to demonstrate that we

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have here not two diseases, but a single one; that the two supposed attacks are nothing but two stages of a single attack.” In this way he identified a new morbid entity, forming a specific clinical class alongside mania and melancholia. Jean-Pierre Falret claimed to have identified this dual form insanity himself several years before, giving it the name circular insanity, a form of maniac and depressive alienation, and even to have described in it the period of lucidity which would later become known as the free interval. 19th-century alienists flocked to the clinical lectures of Jules Baillarger, who was considered to be a brilliant speaker, possessed of a capacity for the most refined clinical observation. It was he who in 1843, with Cerise (1807-1869) and Longet, founded the review les Annales mkdico-psychologiques, a journal “intended in particular to assemble all the documents relating to the science of the relations between the physical and the moral, to mental pathology, to the legal medicine of the insane, and to the clinical study of the neuroses.” Nine years later, in 1852, the Sociktk mkdico-psychologique came into being, the first scientific association of physician alienists in France. Jules Baillarger chaired the first session. Another significant position he held was as chairman of the committee on goitre and cretinism, which reported following a long survey conducted mainly in the Alpine regions of France. It was Jules Baillarger who introduced the standard distinction between psychical hallucinations (perceptions of non-existent objects with no sensory content) and psycho-sensory hallucinations (involving the sense organs). “The most frequent and complicated hallucinations affect hearing; invisible interlocutors address the patient in the third person, so that he is the passive listener in a conversation; the number of voices varies, they come from all directions, and may even be heard only in one ear. Sometimes the voice is heard in the head, or throat, or chest; the insane-deaf are more prone to hear voices.” His interest in hallucinations began early, in his 1842 study of the connections between hypnagogic states and hallucinations. It was he who first used the term “thought echo”: “We know that the insane often talk to themselves; instead of hearing their thoughts expressed aloud, it may be that they hear their words

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repeated. These lunatics explain this fact by saying that there is a sort of echo around them.” His clinical views were also developed in his work on general paralysis. Despite the anatomo-clinical unity proposed by Bayle, he was to revert to a sort of dualistic theory which sought to describe a particular form occurring in the paralytic demented. In his view, this clinical form, which he would successively call mania with ambitious delusion, congestive mania and finally paralytic insanity, was distinct from dementia1 states in general paralysis. O n the creation of the Chair of Mental Diseases and Diseases of the Encephalon, Jules Baillarger disclaimed competence and gave way to Benjamin Ball. Frangois-Regis Cousin

Principal works O n hallucinations: BAILLARGER (J.), “Des hallucinations” [On hallucinations], Mkmoires de L’Acadkrnie royale de mbdecine, Paris, 1846, 12, p. 273475. BAILLARGER (J.), “Physiologie des hallucinations: les deux thkories” [Physiology of hallucinations: the two theories], Annales rnbdico-psychologiques, 1886, 4, p. 19-39. O n dual form insanity: BAILLARGER (J.), “Notes sur un genre de folie dont les accks sont caracterisks par deux piriodes rigulikres, l’une de depression, l’autre d’excitation” [Notes on a type of insanity in which attacks are characterised by two regular periods, one of depression, the other of excitation]. -AcadCmie de mCdecine, 30January 1854,Bulletin, 19, p. 340. -Amales rnkdico-psychologiques, 1854, 6, p. 369. -Gazette hebdomadaire, 3 February 1854. O n general paralysis: BAILLARGER (J.), “De la demence paralytique et de la manie avec dklire ambitieux” [On paralytic dementia and on mania with

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ambitious delusion], Annales mbdzco-psycbologiques, 1858, 3, p. 368. BAILLARGER (J.), “De la folie avec prkdominance du dklire des grandeurs dans ses rapports avec la paralysie gknkrale”[On insanity with predominance of delusion of grandeur in its relations with general paralysis], A n n d e smbdico-psycbologiques, 1866,8, p. 1. BAILLARGER (J.), “Manie congestive” [Congestive mania], Annales mldico-psycbologiques, 1879, 1, p. 243. O n the theory of general paralysis: “De la folie paralytique et de la dkmence BAILLARGER paralytique considkrkes comme deux maladies distinctes” [On paralytic insanity and paralytic dementia considered as two distinct conditions], Annales rnbdico-psycbologiques, 1883,9, p. 19 and p. 191, and 10, p. 18.

o.),

BAILLARGER (J.), “De la gukrison de la paralysie gknCrale et de la thkorie des pseudo-folies paralytiques” [On the cure of general paralysis and on the theory of pseudo-paralytic insanities], Annales rnbdico-psycbologiques, 1887. BAILLARGER (J.), “Doit-on dans la classification des maladies mentales assigner une place h part cette pseudo-paralysie gknkrale ?”, [In the classification of mental diseases, should a separate place be assigned to this pseudo-general paralysis], Annales mkdico-psycbologiques, 1889, 9, p. 196. The complete works of Jules Baillarger were published in a two volume edition in the year of his death: BAILLARGER (J.), Recbercbes sur les maladies mentales [Researches on mental diseases], two volumes, Paris 1890.

Principal references

COUSIN (F.-R.), “Des sympt8mes thymiques dans les schizophrknies aux troubles psychoaffectifs”, [Thymic symptoms in

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schizophrenias with psychoaffective disorders], L ’Ence‘phale, April 1999. “L,a paralysie gkdrale” [General paralysis], in POSTEL (j.), QUETEL (C.),Nouvelle histoire de la psychiatrze [New history of psychiatry], Paris, Dunod, 1994, p. 203-214.

Dual Form Insanity (1854)

There are no states which show more marked differences the one from the other and more striking contrasts than melancholia and mania. The melancholic is weak, timid and irresolute; his life is spent in in inertia and mutism; his conceptions are slow and confused. The maniac, by contrast, is full of confidence, of energy and audacity; he deploys the greatest activity, and his loquacity has no limits. It would therefore seem, in theory, that two states so opposed must be foreign one to another, and that a great distance must separate them. This is not, however, that which is demonstrated by observation. Indeed we see, in many cases, melancholia succeed mania, and vice versa, as if a secret bond united these two diseases. These singular transformations have been often reported. Pine1 speaks of attacks of melancholia which degenerate into mania. According to Esquirol, it is not unusual to see mania alternate, and in a very regular manner, with pulmonary phthisis, hypochondria and lypemania.

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These alternations of melancholia and mania have also been observed by Mr Guislain, and I might add by almost all the authors; but although the fact is well-established, it seemed to me that it had not sufficiently been studied. By bringing together and comparing a certain number of observations, it becomes clear that there exist quite numerous cases in which it is impossible to consider in isolation and as two distinct disorders the excitation and the depression which succeed each other in a single patient. This succession, indeed, is not a matter of chance, and I have been able to confirm that there exist connections between the duration and the intensity of the two states, which are clearly nothing other than two periods of a single attack. The consequence of this view is that these attacks properly belong neither to melancholia nor to mania, but that they constitute a special kind of mental alienation, characterised by the regular existence of two periods: one of excitation and the other of depression. It is of this kind of madness which I shall try here to indicate the principal characteristics. I shall refer to it provisionally by the name dual form madness. I believe I can do no better, in order to give an exact idea of the attacks, than to cite a few observations, restricting myself, moreover, to the details which shall seem to me the most important. Observation 1-Miss X.. ., today aged twenty-eight years, had several attacks of mania from the age of sixteen to eighteen. After remaining in good health for three years, she experienced a relapse, and since then her illness has not ceased. This condition returns by attacks, of a duration of approximately one month. During the first fifteen days, one observes all the symptoms of a profound melancholia; then all of a sudden the mania breaks forth and lasts for the same time. When the period of depression begins, Miss X...feels herself prey to a sadness which she cannot overcome. A sort of a numbness little by little invades her entire being.

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Her physionomy takes on an expression of suffering, her voice is weak, her movements of extreme slowness; Soon the symptoms become worse, the patient remains immobile and mute on her chair; all effort becomes impossible, the slightest stimulation is painful, the light of day fatigues her. Miss X.. .is very well aware of what is happening around her; she understands the questions addressed to her, but replies slowly, in monosyllables, and in such a low voice that her words may be heard but incompletely. Together with all the symptoms above, there is insomnia, loss of appetite, constant constipation; the pulse is weak and slow. After three or four days, the physionomy is already profoundly affected; the eyes are shadowed, sunken and without expression, the complexion pale and yellow. When this state has endured fifteen days, it suddenly ceases during the night, and the general torpor is replaced by an exaltation of the greatest liveliness. The following day, the patient is seen to be animated in her features, bright in her gaze, lively in her speech, her movements sudden and rapid; she is unable to remain one moment in the same place, and runs back and forth as if pulled by an irresistible force. Having been confused, her intelligence acquires vivacity. Miss X.. .would grasp with remarkable sagacity everything which, in t h e persons around her, might lend itself to ridicule. Her eloqlwnce would be inexhaustible and express itself through continual epigrams. In this new state the insomnia would continue, but the appetite was restored. After fifteen days, calm would return almost suddenly. Miss X., who recalled everything she had said during the second period of her attack, would appear a little sad and confused; but soon she resumed her ordinary habits. Unfortunatety, the intermission would be of short duration; rarely has it lasted two or three months; usually, it is after fifteen or twenty days that a new attack breaks out. The patient, who during the period of depression had taken only a wholly insufficient quantity of nourishment,

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would lose weight very rapidly. O n one occasion, the loss was 12 pounds in fifteen days. In the period of reaction and during the intermission, the appetite would be very great, and the increase in weight would also take place with great rapidity. As for the moral and intellectual state of the patient during the two periods of the attack, I can give no better idea than by citing the following observation, in which the patient himself describes what he experienced. Observation II.-This madman, cured by Willis, had attacks similar in almost every way to those I have just described; only each period lasted ten days instead of fifteen. “I would always await with impatience, says the patient, the attack of agitation which would last ten to twelve days, more or less, because I enjoyed throughout it a sort of beatitude: everything seemed easy to me; no obstacle could stop me in theory, nor even in reality; my memory suddenly acquired a singular perfection; I could remember long passages from the Latin authors. Ordinarily, I have difficulty in finding two rhymes at once, and yet at this time I would write in verse as rapidly as in prose; I was crafty and full of all kinds of expedients. “The indulgence of those who, in order not to push me too far, allowed me to give free rein to all my fantasies, reinforced in my mind the conviction of my superior powers and reinforced my audacity. My insensitivity to cold, to heat, to all the small inconveniences of life, further justified it. Finally, a profound and concentrated egoism made me relate everything to my person. “However, he adds, if this first kind of illusion made me happy, I was only the more to be pitied in the state of despondency which always followed it, and which would last approximately as long. I regretted all my past actions, and even my very ideas. I was timid, ashamed, pusillanimous, incapable of action, whether physical, or moral. The change from one of these states to the other took place

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suddenly, with no transition, and almost always during sleep.” I could simply repeat the details above for the intellectual and moral state of the female patient whose observation I read earlier. In this case, I have preferred to report the words of the patient cured by Willis. I have borrowed the third observation from Esquirol. In this case, each attack, instead of twenty days or one month, lasted three or four months. Observation 111.-The patient, having had a very short attack of melancholia at the age of twenty-eight, had remained in good health until her thirty-sixth year. She then became deranged with no established cause. This is how Esquirol describes the attacks. “At the beginning, he says, sadness, gnawing, langour of the stomach, moral discouragement, inability to perform the slightest exercise, the slightest occupation. After six weeks, suddenly general excitation, insomnia; agitation, disordered movements, excessive desire t o drink wine, confused ideas, perversion of the affections, etc. After two months, the symptoms disappear, and the patient recovers, with her reason, calm and sobriety. “Every year, the attacks recur with the same symptoms.” Dual form madness is well described here: the periods succeed each other regularly, and each intermission is of some eight months. In the fourth observation, which was communicated to me a few days ago, and which I will quote word for word, the attacks last six months. Observation IV.-“M. X.. .has been subject for twenty years to alternations of excitation and depression. When he falls into that which he himself calls his spleen, he becomes indifferent to everything. His eye is dull, his gait slow and heavy. Although very hard-working, he can no longer work, and even feels no taste for work. This state lasts several months. M. X.. .then gradually recovers his animation, and he passes through a very short interval of what

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might be called perfect reason; soon, however, the activity increases to such a point that it is impossible not to recognise a veritable febrile excitation. The patient ceases almost to sleep, he reads and composes enormously, but with much disorder. Although very old, he is at times affected by attacks of priapism, and goes as far as to run around his garden, prey to a lascivious fury. This period also lasts some three months, and M. X...gradually lapses back into his spleen.” I have come to the attacks which continue for a year. These cases are perhaps the most numerous. The patients spend almost six months in the melancholic period and almost six months in the maniac period. Here is an example observed in a young girl who today is still in my service, at the Salpttrikre. Observation V.-Miss M.. ., aged twenty-four years, had her mother and her grandmother insane; she herself became melancholic four years ago. At the beginning, sadness, world-weariness, idleness, ideas of suicide. These symptoms, which began to be observed in the month of May, gradually grew worse, and the patient soon became entirely inert. She spent her days on her chair, in immobility and mutism. Her eyes would be wide open and her physionomy would express stupor. Her complexion was pale, the extremities cold, the appetite almost absent; the urine flowed involuntarily. This state only began to improve in the month of October. The progress was very slow; it was only after six weeks that the young Miss M.. .seemed to enter convalescence. Scarcely had fifteen days passed, than symptoms of excitation arose. Soon the patient was completely agitated. Her speech became obscene, she uttered constant oaths, and sometimes committed acts of violence, etc. This new phase of her illness lasted, approximately, as long as the first. Since then, three similar attacks have taken place. The only difference to be noted, for these last attacks, is that the periods, while remaining of the same duration, were characterised by symptoms of less intensity.

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I ask leave to quote a final observation taken from Esquir-

01. Observation Irl.-‘‘A young man from the Midi, aged twenty-five years, of an eminently nervous temperament, at the approach of winter, for the last three years, has been seized by great excitation. He becomes very active, ever in motion, speaks a great deal, believes himself a distinguished figure; makes a thousand plans, spends much money, buys, borrows, without being greatly concerned as to payment; highly irritable, everything wounds him, excites his temper and his anger; he is no longer sensible of the friendship of his parents, is unable even to recognise the voice of his father. As soon as spring makes its influence felt, this young man becomes calmer; little by little he becomes less active, less talkative, less sensitive; as the temperature rises, the physical and intellectual strength seem to abandon him; he falls into inaction, into apathy, reproaching himself for all his extravagances during the period of excitation; he ends with lypemania, with the desire to kill himself, and finally with attempts at suicide.” The cases described above seem to be sufficient for an understanding of the characters of dual form madness. I must nevertheless add that attacks much shorter than those which I have described have been observed. Dubuisson speaks of a lady for whom he cared for four years, who showed alternately, every two days, one of the signs of melancholia and of mania. “The patient, he says, presents one day the symptoms of a melancholic delusion, characterised by the most sordid avarice and by the greatest mistrust, being otherwise of a gentle, tranquil and taciturn nature. The day after, this partial and exclusive delusion changes nature, and becomes general; the patient then becomes agitated, tormented; she shouts, becomes angry, becomes quarrelsome and intolerable in her incessant demands, and through her loud and continual loquacity: it is this that often makes it necessary to remove her from society, and to keep her confined on those days.”

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There exist other observations in which the attacks would last six and eight days, each period being of equal duration. It should be noted, indeed, that the shorter the duration of the attacks, the more equal is that of the two periods. In these attacks, the transition from one period to the other occurs suddenly and usually during sleep. The patient goes to bed melancholic and wakes up maniac. This is no longer the case when the periods last five to six months; here, the transition takes place very slowly and by imperceptible degrees. A moment even occurs when a sort of equilibrium is established, and the patient, who no longer shows signs of delusion, appears to be entering convalescence. In the case of a first attack, one may be led to believe in a cure. I have committed this error twice. Hardly had the patients, who seemed to me to be convalescent, left the hospice, than symptoms of excitation were observed in them. Soon they were brought back, a prey to the most lively maniac agitation. It was the second period of the attack which I had failed to foresee. Similar errors have often occurred. In one case even, a young woman, who was believed cured of an attack of melancholia, was allowed to leave a great institution, and yet she was already showing obvious signs of excitation. It was the start of the maniac period. Indeed, the patient soon indulged in the most regrettable acts, and was brought back furious to the asylum which she should never have left. I know that the interpretation given to this latter order of facts may be contested. It arouses objections the value of which I do not deny, but which I will nevertheless attempt to answer. When the duration of the attacks is at the most a few months and the transition from one period to the other takes place in a sudden and rapid manner, it will generally be acknowledged that these attacks constitute a special variety of mental alienation; but when after five or six months

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of melancholia a patient remains thirty or forty days without giving any sign of delusion, and then falls into a maniac state, why, it will be said, not follow the opinion of Pine1 and of Esquirol, and see in this two distinct diseases which succeed each other? Is there not here, in fact, an intermission? and is this intermission not sufficient for one to admit two attacks and not one alone? In order to resolve this difficulty and to establish whether or not there is a veritable intermission, I believe that it is necessary to specify what is to be understood by the word madness, and I ask permission to make a short digression in this regard. It was, in my opinion, wrong to have been content to say that madness is characterised by disorders of the sensibility, of the intelligence and of the will. There are in this condition two very distinct elements: 1. Lesions of the intelligence; 2. The loss of awareness of these lesions. The second of these elements is that which essentially characterises madness. One is not necessarily insane because he has hallucinations, still less because he experiences a certain degree of depression or excitation in the exercise of the intellectual faculties. In order for these lesions to constitute madness, the patient must cease to judge them for that which they are, or else allow himself to be led by them into acts which his will is impotent to prevent. This having been established, I return to the supposed intermission which is said to separate the period of depression from the period of excitation, when the attacks of dual form madness are of long duration. If one observes the patients with care, one will notice, it is true, that they would cease to present signs of delusion for fifteen days, one month, even six weeks. However, if the madness has disappeared, does this mean that the return to former habits is complete? This question can only be answered by comparing the

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patients with themselves before the invasion of the delusion. It is understandable that the physician here may easily fail to recognise nuances which would not escape relatives. It is therefore on the family that one must call in order to avoid simple errors in this respect. In this way, one can discover whether these short intermissions, very real if one looks only for the offence in the strict sense, are, on the contrary, incomplete in other respects. Thus, one of the patients whom I allowed to leave the Salp&ri&e, thinking her cured, still retained a slight tendency to isolation, and a little taciturnity which, as I have learned since, was not natural to her, yet which did not prevent her having excellent manners, being very hardworking and seeming in every way reasonable. The response to the principal argument which might be advanced in order to transform the two periods into two distinct attacks, is thus observation, which demonstrates that the equilibrium of the faculties is not entirely restored. Apart from this question of fact on the non-reality of the intermission, one may also advance the relations of intensity and duration which exist between the two periods. In bringing together and comparing the facts, it is clear that the greater is the depth of the melancholic depression, the more violent is the maniac excitation. In very long attacks this relation, it is true, is not so precise, but the differences are so slight that it is impossible not to acknowledge it. Here is a further example demonstrating this regularity, even for very long attacks,. It was published by Dr Des Etangs, in the report of a visit to the Salp&tri&re. It concerns a woman suffering from imbecility, but who had in addition attacks of dual form madness. This woman, having passed the winter mute, immobile and crouched in a corner, would suddenly be reborn in spring and during summer. An uncontrollable loquacity and violent signs of nymphomania would announce the end of her immobility and her mutism.

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I must also point out here that the principal element of diagnosis for dual form madness is precisely this regularity in the succession of the periods. It is therefore irrelevant to advance as an objection the numerous cases in which symptoms of agitation occur at the beginning, at the end, or even in the course of the melancholia. The fact is, these symptoms appear in an irregular fashion, and they are, in general, of short duration. Do I need to add that, in admitting the existence of dual form madness as a special variety, I nonetheless acknowledge cases in which, after a very clear intermissions, the melancholia is seen to follow the mania or vice versa. I have indicated the manner in which the transition from the first to the second period takes place, and it now remains to me to say a few words on the type of the attacks. In this respect, the observations can be classified into several categories. loThe patient may have only one attack. In these cases, the maniac period has often been seen as a crisis which brought about the cure of the melancholia, that is to say of the first period. Pinel included several cases of this type in his writings under the title: “Idiotism, a species of alienation frequent in the hospices, sometimes cured by an attack of mania.” By the word idiotism, Pinel here includes many cases of what has been called acute dementia, stupidity, melancholia with stupor. 2 O The attacks recur three, four, six, ten times at intervals of two, four, six years. 3 O They can affect the intermittent type, and sometimes the intermissions are very regular. 4 O In certain cases, the attacks follow each other without interruption and there is no intermission. The disease, which usually lasts for several years, can thus be compared to a long chain in which each attack is one of the links. This continuous succession is also observed for very short or very long attacks; only in the first case, the

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transition is sudden; in the second, it is slow and gradual. In such cases, the patient, as can be seen, spends his life in an alternation of excitation and depression, of gaiety and sadness, without ever stopping at the state of equilibrium which constitutes health. There is, in the symptoms of the period of excitation, one particularity which seems to me worthy of further mention, which is that the delusion is much more often characterised by instinctive impulses than by delusional conceptions in the strict sense. Nymphomania and satyriasis are observed in many cases, and it would seem that there is in this respect a sort of reaction after a long period of numbness of the genital organs. The impulse to drink strong liquor was the dominant symptom in one of the patients cited by Esquirol. Finally, a continual tendency to acts of spite is often observed. As regards treatment, I have seen only one case which seems to me to require mention. Having for three years combatted without success, by means of various medicines, the attacks of one patient, I performed each month a bleeding in the midst of the interval between menstrual periods. This treatment, sustained over eight months, achieved a favourable, but incomplete, result. The second period, that of maniac excitation, was suppressed. It has not recurred in the last two years. The condition has now been reduced to the melancholic period alone, which continues to recur as if by periodic attacks. These are the considerations which I felt it necessary to develop on dual form madness, a madness the existence of which as a specific variety seems to me to have been placed beyond doubt. The necessity now is to seek clinical elements which would make it possible, in the case of a first attack, to recognise its nature in the first period. It would then perhaps be possible, in some cases, to prevent the development of the second phase of the condition.

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Conclusion. loOutside monomania, melancholia and mania, there exists a special type of madness characterised by two regular periods, one of depression and the other of excitation. 2 O This type of madness occurs: 1. in the form of isolated attacks; 2. recurs in an intermittent fashion; 3. the attacks can follow each other without interruption. 3 O The duration of the attacks varies from two days to one year. 40 When the attacks are short, the transition from the first to the second period takes place in a sudden manner and ordinarily during sleep. By contrast, when the attacks are prolonged, it takes place very slowly and by degrees. In the latter case, patients appear to enter convalescence at the end of the first period; but if the return to health is not complete after fifteen days, six weeks at the most, the second period breaks out.

Charles Lashgue (1816-1883) and Jules Falret (1824-1902)

Laskgue was one of the last physicians to possess a broad general education. With degrees in literature and philosophy, he became a teacher at the Louis-le-Grand lycCe, and it was through his friends Claude Bernard (1813-1878) and BCnCdict Morel (18091873) that he met Jean-Pierre Falret (1794-1870) at the Salp&rikre and came to his vocation as a neurologist and alienist. The subject of his first publication was the moral treatment propounded by Fransois Leuret (1797-1851). In it, he wrote that the purpose of treatment is “to impose on the madman the will of a reasonable man, to suppress his individuality by replacing it with another, to substitute the personality of the patient with that of the physician”. After a journey to Russia to study the cholera epidemic, Ladgue was appointed deputy Inspector General of the insane asylums. A few years later, he notably became physician to the special central police station. It was here that he was to acquire his remarkable clinical experience through the close analysis of the symptoms presented by the insane. Hisfirstmonographdealtwiththedelusionofpersecution,which he isolated before the systematic study of 1871 by Legrand du Saulle(1830-1886):“There exists aform ofpartial delusion, to which, in the absence of a better term, I give the name delusion of persecution, which recurs with sufficiently consistent characteristics to constitute a pathological species among the mental alienations.”

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One of his aphorisms is is well-known: “Alcoholic delusion is not a delusion, but a dream”. In this 1881 article, Laskgue concentrates on the visual hallucinations of alcoholic delusion, identical to those of dreams. He stresses the antecedents of sleep disorders and the importance of anamnesis: “Long before becoming delusional in the day, the alcoholic was delusional at night, as I have shown, and the fit can exhaust itself in a few weeks of dreaming, without ever attaining sufficient intensity to become diurnal. Moreover, the attacks recur at variable intervals, the proverb: Once a drunk, always a drunk, being only too true. It is therefore easy to question the mother, and especially the wife of the alcoholic ... “The highly intelligent wife of a wine merchant, a remittent drinker, whom I questioned, made the remark to me herself. My husband, she said, now that he spouts while awake what he used to spout when he was asleep, and I understand him better, looks as if he was waking up from time to time, the way he used to at night when I shook him and shouted in his ear, because shouting at him would not have been enough and yet he no longer sleeps.” Laskgue was also famous for his judgments and masterly clinical descriptions in legal medicine. H e was particularly interested in female shoplifters, being the first to describe the temptation created by the growth of the department stores: “Finally, the big retail houses, as they increased in size, have become enormous showcases, both inside and outside. The buyer has free access to them, can wander at will, with no need to explain her presence. She is encouraged to look, in the justified hope that her curiosity will result in a purchase.” For Ladgue, the sight of the objects arouses the temptation to steal, and the impulse, where it exists, is only fleeting. The personality of such thieves intrigued the clinician: “The woman arrested, in possession of goods of various values, belongs to a family of undoubted respectability. Both her past and her present are beyond reproach; her needs, her fantasies, do not exceed her means and even remain within the most modest limits. “The criminal act is surprising because it is without purpose or precedent.. . ”... the theft was quite simply brutal, absurd, totally lacking in calculation, like those committed by general paralytics and epileptics.” Laskgue had little belief in invincible passions, and gave his

Charles Las2gue (1816-1883) and Jules Fulret (1824-1902) 201 opinion on many subjects in legal psychiatry, such as exhibitionism and onanism: “An individual, almost always, if not always a man (I have seen only one woman involved), is arrested for public outrage to morality. He has exposed his genital organs, not arbitrarily, to passers-by whoever they may be, but in the same places and to the same people, for generally the exhibition is repeated several times before a complaint is made, followed by surveillance and arrest; it is a private scandal rather than a public outrage.” And on the subject of masturbation: “It is generally thought that these individuals (energetic masturbators) are men in whom the genital sense is highly developed. There is a very great tendency to consider this vice as the result of exuberant ardour, which is unable to be satisfied by normal processes. That is a mistake: the multiplication of the genital act is in no way proof of exaggerated genital aptitude. A man who urinates every five minutes is not a man who urinates well; a man who eats often is not a man who eats well.” He was the first to describe shared delusion or communicated madness, a term which would be retained in Anglo-Saxon classification. He writes: “There is the incubus and the succubus, the active and the passive, a special receptiveness in one receiving the influence ofthe other.” This is not a splitting of the insanity, but the influence of a patient on another person suggestible to the propagation of the delusional ideas. Laskgue was also known as a teacher without equal, possessed of an incisive style and a strong sense of aphorism. His classes at the Pitik, his clinical courses on mental disease at the Paris Faculty of Medicine, but also in different hospitals, led to his appointment as Professor of clinical medicine at the PitiC. H e was one of the rare alienists to preach against the separation of general medicine and mental medicine. FranGois-Rkgis Cousin

Principal works LAShGUE (C.), “La folie deux” [Shared delusion] (with Jules Falret), Archivesgknbrales de rnkdecine, 1877,2, p. 257, and Annales rnkdico-psychologiques,1877, 18, p. 231.

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LAShGUE (C.), “Le vol aux ktalages. Esquisses mkdico-1Cgales” [Shoplifting. Medico-legal sketches], Archives gknlrales de mkdecine, fkvrier 1880. LASEGUE (C.), “Le dklire alcoolique n’est pas un dklire mais un r&ve” [Alcoholic delusion is not a delusion but a dream], Archives gknkrales de mldecine, 1881, 2, p. 573. LASEGUE (C.), Etudes mkdicales [Medical studies], 2 volumes of 926 pages and 1,179 pages, Paris, Asselin, 1884.

Principal references

Ecrits psychiutriques, Lasigue C., Textes choisis et prlsentks par

1. Corraze [Psychiatric writings, Las2gue C., T$xts chosen and presented by J. Corraze1, Rhadamanthe, Privat Editeur, 1971. COUSIN (F.-R.), TREMINE (T.), “Folie A deux: trajet historique, naissance d’un doute” [Shared delusion: historical course, birth of a doubt], L’Information psychiatrique, 1987, 63.7, p. 859868.

Shared Delusion

It is a matter of principle that the madman, whatever the form of his illness, resists with an obstinacy itself pathological all arguments that may be advanced against his delusion. Contradiction silences him or leaves him indifferent, but in no way changes his fundamental ideas. If intimidated or already on the road to cure, he will at most consent to be silent, but his intelligence does not benefit from this calculated reticence. He may, in this respect, in some degree be likened to children who, when threatened, refrain from the expression of their feelings, while still contriving to show that they make no undertaking beyond an apparent concession. If madness were not impervious to persuasion, it would simply be error rather than a sickness. In compensation, the madman influences the sound of mind no more than they influence him. It has been said that madness is contagious, and that the frequenting of the mad may not be considered as exempt from danger for those who live in contact with them. This may be true for the predisposed in search of an opportunity, it is absolutely false for the immense majority of reasonable men. Nurses in asylums are no more exposed than those in hospitals, and cohabitation with patients represents, for the family,

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no greater danger. Just as they cannot be convinced, so are they themselves unable to convince; for this to be possible, they would need to have at their disposal moral and intellectual resources incompatible with their pathological state; proselytism, in respect of strange ideas repugnant to reason, is no easy task, and would have a chance of success only were it to be exercised in indefatigable struggle. However, the madman lives alienated from the opinion of others; he is sufficient to himself and little cares, so irresistible is the authority of his belief, whether or not one follows him onto the terrain which he will not relinquish. In this way, an absolute line of demarcation is established which allows no compromise. If life in the community of the mad is harmful, and it often is, it is not on account of a contagion of delusion. However, it may be that the companion does not immediately resign himself to acceptance of the fait accompli; he hopes that some lifting of the veil will permit reason to recapture its power and, armed with this belief, he attempts to educate the patient. He becomes irritated or discouraged by lack of success: he exceeds his power of resistance and exhausts it. When this series of attempts is prolonged with the perplexities that it entails, only the most steely of characters are able to resist the damaging influence, The tighter the bonds that attach the companion to the madman, the more ardent his zeal and the greater the fatigue. By contrast, the indifferent escape both this needlessly painful work and its consequences. This is how matters occur where an absolute delusion is confronted by by a healthy intelligence. Fortunately, this is the most frequent situation, but there exist cases where the scission between the madman and those who live in his proximity is not so complete, and it is these exceptional cases which are the subject of our study. Here the problem contains two terms between which an equation is to be established: on the one hand, the active

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madman: on the other, the receptive individual who, under diverse forms and to different degrees, is influenced by him. Alone, free to give rein to his pathological instincts, the madman is relatively easy to examine; he has the taste, even the appetite, to express the ideas that obsess him, or he resolves on a relentless mutism which is no less significant. Once entered, the courtyard is easier to explore if it is less open to the outside world. For his involuntary and unconscious accomplice matters are altogether different. Half rational, much reasoning, ready to make temporary sacrifices to objections, able to anchor himself outside the delusional concepts which he has not created, which he has often resisted over quite a long period of time, he escapes. His half-morbid, half-motivated convictions are far from possessed of the unshakable certainty of delusional beliefs. It requires a complete psychological inquiry to discern, amidst these somewhat confused elements, which are the product of contagion and which arise out of the mental nature of the confidant. From another point of view, the madman is subject to the pressure of the companion of his ravings, who encourages them, coordinates and imparts to them a degree of plausibility. For this solidarity, of which neither one nor the other is conscious, to be established, there must be a combination of circumstances which is not impossible of definition. Complete insanity, quite divorced from probability, does not invite and will never obtain the adherence of assistants; on the other hand, delusions which come close to the truth have a greater chance of acquiescence in so far as they are more easily accommodated to a feeling, or, as the theologians, those masters of moral casuistry, would have said, in so far as they do more to flatter some human concupiscence. The madman who asserts what is clearly false is instantly unmasked for his imposture. The object he sees is invisible to those whom he is unable to drag into the sphere of his hallucination; the voice that he hears cannot be heard; the

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organized persecution, proclaimed by the newspapers or by books, has to its credit neither books, nor periodicals. Nor should it be said that another lunatic could be seduced, for the confirmed insane never possess such docility and remain absolute masters of their delusions. If, on the other hand, the sufferer confines himself to the world of conjecture and interpretation, if the facts he invokes belong to the past or are merely apprehensions for the future, direct verification becomes impossible. How can one prove to another and to oneself that the event, the details of which the madman recounts with convincing prolixity, did not take place? The lesson he has taught himself allows no variants, no gaps; his memory is accurate because it excludes everything, except the pathological ideas. He is never caught in a mistake, however long ago the adventure occurred, and his conviction, by dint of its monotony and its narrowness, becomes communicative. Nonetheless, the companion will not allow himself to be convinced unless the story concerns him personally, and the two sentiments which best lend themselves to this form of attraction are undoubtedly fear and hope. Both of these take from existing realities only their point of departure; their true domain is in the future, in the direction of the unknown. While it is easy for a man to acquire the certainty that you are not rich, it is difficult for him to guarantee that you will not become rich. Lawmakers, in defining fraud, impose a penalty on “anyone who, through the use of false names or false qualities, or by employing fraudulent methods to persuade of the existence of false enterprises, of imaginary authority or credit, to induce the hope or fear of a success, of an accident or any other chimerical event,. . .has defrauded or attempted to defraud all or part of another’s fortune.” If one removes all the epithets which imply responsibility on the criminal’s part, this describes thp -3ecies of delusions which attract adherents. iformity of ideas corresponds to a conformity of sens, as long as the thing is possible and not repugnant

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to reason. The insane, whose delusional notions express themselves through disquieting or consoling predictions are, all in all, those who come closest to the physiological state. It would be possible, by unnoticeable steps, to mark the passage from simple character disposition to madness, beginning with people who are timid, or inclined to indefatigable hopes, and culminating with terrified lunatics, with melancholics absorbed by eternal apprehension, or with the ambitious for whom success is always imminent. This form of delusional aspiration thus does not arouse repulsion, and, in its moderate forms, invites doubt rather than rejection. How many times does the doctor, however experienced, ask himself whether the origin of the matter was not a genuine accident, rather than a chimerical event, and hesitate between an exaggeration and a sentimental aberration. In the shared delusion the madman, the agent provocateur, does indeed correspond to the type whose principal traits we have just outlined. His associate is more difficult to define, but by patient research it is possible to grasp the laws that this second factor in communicated insanity obeys. The first condition is that he should be of low intelligence, more disposed to passive docility than emancipation; the second is that he should live in constant contact with the patient; the third is that he should be attracted by the bait of personal interest. One only succumbs to the swindler through the seduction of the possibility of reward; one yields to the pressure of madness only if it affords a glimpse of the fulfillment of a cherished dream. We will examine each of these data successively on the basis of information obtained from observation. 1O Children, with their apprehensive nature, their restricted environment, are the most disposed to become the echoes of a shared delusion. Indecisive as it is, their reason has no power to resist, and as long as the madman has made them an interested party, they hope or they fear on their own behalf with the egoism inherent to their age. Their

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belief, in some cases, goes so far that the madman himself hesitates to follow and one would at first sight think that the children had themselves created the delusions of which they are the reflection. In general, save in very rare cases, the notions transmitted in this way are more often frightening than agreeable. It is known that children predisposed to cerebral disorders are greatly susceptible to fear. Spontaneous manifestations consist of night terrors, fear of the dark, nightmares, imaginary dangers or menacing individuals; artificially produced manifestations are of a similar nature. The joys of the future affect them little; it is only later, as reason becomes stronger and the capacity to look forward greater, that the envious aspirations towards pleasure, fortune, etc. arise, beginning to develop only several years after puberty, when the child approaches manhood. Two old maids take in, as the sole inheritance from one of their sisters, a little orphan girl of 8 years, frail and pale. Life is difficult and resources unequal to needs. One of the sisters dies and in the absence of her contribution existence becomes even harder: the other sister is overcome by an ordinary delusion of persecution, of senile form. The neighbours are in league against her; voices are cursing her; she hears sounds to which she attributes a menacing significance. Her insanity advances progressively; after four years, it has reached such proportions that the residents of the house are worried. The child, who goes out rarely and only for urgent tasks, while her aunt locks herself in her room and refuses to leave, is questioned. She recounts that bad people have tried to poison her and her aunt; both have suffered serious accidents; enemies have entered during the night to remove her from the protection of her relative; to all questions she replies with the lucidity of children whom the society of the old has made mature before their time. Her assertions are all the more plausible in that they represent the derangement of the absent madwoman, attenuated, trimmed by the niece who is not insane.

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There occurs here a curious fact which we have seen reproduced many times. Delusional notions, reduced to their weakest expression in passing through the channel of a half-sound intelligence, are closer to reason than any idea engendered in the brain of a lunatic. Listeners are less unwilling to accept them. The objections they advance are accepted; the child renounces certain details, which are shown to be impossible; in consequence, those that remain gained further credence. The experience is in accordance with the rule already expressed: the less outlandish the delusion, the more communicable it becomes. The neighbours take up the child’s cause; they appeal to authority, inventing a romantic tale that would justify these claims of persecution. The inquiry and examination carried out by one of us leave no doubt. The lunatic is placed in an asylum, and the child in an orphanage, where she recovers from this, so to speak, parasitic disease; nevertheless the people of the district still harbour suspicions and declare themselves not satisfied In other cases, the participation of the entourage is more active; it not only receives, but provokes confidences, and, by word of mouth, the story is altered or amplified. The child then finds itself between two currents. One, that of the lunatic, who was the promoter of these notions, the other that of the listeners, who attenuate the improbabilities and add to the acceptable aspects as their fancy takes them. Led astray by the one, put right by the others, the child comes to believe her second-hand inventions and finally to make others believe them. This dual culture is very marked in a case which we will mention, without entering into details that are interesting but would take too long to recount. Once again, it concerns a young girl brought up this time by her mother, whom her father had abandoned in misery before disappearing. The mother suffers from persecution, but her delusion, without complications of senility (she was aged 40), takes a specific form. It is the priests, and one priest in particular,

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who are against her and prevent her finding work. The girl is 16 years of age, scrofulous, chlorotic, of average height and stature, of low intelligence. She has learned to read only with difficulty, has frequented school little, has received no proper education. Mother and daughter live in a small community on the small allowance paid to them by a wealthier relative; they live in the same room, sleep in the same bed and are never apart. The child repeats her mother’s delusional stories to the neighbours; she confirms her claim that a priest visit her from time to time, in the evening when she was in bed and the lights were extinguished, and threatens them. Her mother hears him, although he speaks in a low voice, and the girl too hears, though confusedly. In the morning, her mother repeats everything to her and she clearly remembers having heard his words. The listeners discuss the details of this strange adventure and add their own comments. They choose to discover that this imaginary priest is seeking the girl’s virtue and she too is easily persuaded of this. The consequence is an official complaint, medical examination and identification of the mother’s characterized madness. In the two cases, as in all the others that we have been able to observe (and they are numerous), the madness came into being in the adult and spilled over onto the child; it was a fully apprehensive delusion of persecution. r

i

L- * *I

The facts we have just described cannot be summarized. Like all psychological investigations, their value lies in the details and no brief conclusions can be drawn from them. To condense these stories would be to commit the error of an observer who believes that the adventures of an exploration pursued in unknown lands could be described by stating the points of departure and arrival and the intermediate stages. Nevertheless, we believe we can end our study with the following conclusions: lo In ordinary conditions, there is no contagion of

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madness between a lunatic and an individual of sound mind, just as contagion of delusional ideas is very rare from one madman to another. 2 O The communication of madness is possible only in exceptional conditions which we have just examined under the name shared delusion. 3 O These special conditions can be summed up as follows: a. In shared delusion, one of the two individuals is the

active element; the more intelligent of the two, he creates the delu,sion and gradually imposes it on the other, who constitutes the passive element. The latter first of all resists, then little by little yields to his companion’s pressure, while in turn reacting on him, in some measure, to rectify, amend and coordinate the delusion, which then becomes shared and which is repeated to all comers, in the same terms and in an almost identical manner. b. For this intellectual process to be accomplished in parallel in two different minds, these two individuals must live a life absolutely in common over a long period, in the same milieu, sharing the same mode of existence, the same feelings, the same interests, the same fears and the same hopes, and away from any other exterior influence. c. The third condition, for contagion of delusion to be possible, is that this delusion should have a degree of plausibility; that it should remain within the limits of the possible; that it should be founded on real events in the past, or on fears and hopes imagined for the future. This condition of plausibility alone renders it communicable from one individual to another and allows one person’s conviction to be implanted in the mind of another. 4 O Shared delusion always occurs in the conditions cited above. All the observations present characteristics which are very similar, if not almost identical, in men and in women, and likewise in children, adults and the aged.

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5 O This variety of madness is more frequent in women, but is also observed in men.

Heredity might be invoked as the predisposing cause in its production when it concerns two people belonging to the same family, such as mother and daughter, two sisters, brother and sister, aunt and niece, etc. But this cause can no longer be invoked in cases where there exists no family link between the two patients, for example when the illness occurs between husband and wife. 6O

7 O The principal therapeutic indication is to separate the two sufferers. It may happen then that one of the two is cured, especially the second, when he is deprived of the support of the one who communicated the delusion.

8 O In most cases, the second sufferer is less strongly affected than the first. Sometimes, he may even be considered to have simply undergone a temporary moral pressure, and not as insane, in the social and legal sense of the word. In this case, confinement is not necessary, as it is for his companion. 9 O In a few rare cases, the moral pressure exercised by a madman on another individual weaker than himself may extend to a third person, or even, to a lesser degree, to a number of people around him. However, in this case it is almost always sufficient to remove the active lunatic from this milieu which to various degrees he has influenced, for his entourage gradually to abandon the false ideas which had been implanted in them.

Etienne Azam (1822-1899)

The presence of this surgeon in an anthology of French psychiatric literature is due to the fact that his work on a question essential to 19th-century mental medicine-the question of hypnotism-led to his discovery, through that method of exploring the psyche, of the phenomenon which he named “dual consciousness” or “split personality”. The son of a Bordeaux surgeon, Azam completed his medical studies in Paris, where he presented his thesis in 1848, before returning to practise surgery in his native city. There he would be appointed both Professor of clinical surgery and deputy physician to the female insane asylum. His reading of the book published in 1843 by James Braid (1795-1860) Neuypnologyor the rationale of nervous sleep considered in relation with animal magnetism, led him to the discovery of what the Scottish physician called “hypnotism”. Following the visit to Manchester, where he practised, of a French hypnotist, Charles Lafontaine (1803-1888?),himself a student of the Marquis de PuysCgur (1751-1825), Braid had begun to study mesmerism and had reached the conclusion that the so-called fluid of animal magnetism did not exist and that the state into which the “magnetised subjects” were plunged was in fact a nervous sleep. Azam, who initially took an interest in hypnotism as a method of anaesthesia, brought Braid’s discovery to the attention of the Parisian medical community-notably Broca, Velpeau and Trousseau-although it had gone largely unnoticed in Great Britain, especially as its

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inventor persisted in using it for therapeutic ends. Azam and Braid began a correspondence which was interrupted by the death of the latter, whose book would finally be translated by Jules Simon and published in France. Azam, who quickly recognised the superiority over hypnosis of the then quite new chloroform, sought to verify Braid’s hypothesis on nervous sleep. As Jean-Martin Charcot would declare, “luck was with him, in placing in his hands experimental subjects who spontaneously presented some of the phenomena which Braid had described”. Of these subjects, the best known is FClida whom Azam followed from 1858, when she was aged 15, for a period of several decades. Throughout this observation, he published different articles in which he described the phenomenon which he first called “periodic amnesia”: at certain periods of her life FClida appeared to forget who she was, and her forgotten identity was then replaced by another, this “secondary state” in its turn vanishing from her mind when she recovered the memory of her initial state. Azam would subsequently refer to this phenomenon, similar to that observed in hypnotism, as “dual consciousness” and then as “split personality”. It was this latter term which long survived, passing into everyday language, until-themselves forgetting by a sort of periodic amnesia the work of Azam and his successors, whether American like Morton Prince (1854-1929) and William James (1842-1910), or French like Pierre JameP (1859-1947)-therapists using methods of hypnosis discovered or thought themselves to have discovered the phenomenon in the 1970s. It would be categorised in the D.S.M. III in 1980 under the term Multiple Personality Disorder 300-14. The disorder is considered there to be apparently extremely rare. D.S.M. IV (1994), which gives this diagnostic category the name Dissociative Identity Disorder points out that a certain number of clinicians think that the epidemic which struck the United States was due to the media interest in this disorder and to the suggestibility of the subjects in whom it was observed. The CLM. 10, while retaining the description “Multiple Personality F 44-8I”, classified this category among the ”Other dissociative disorders” (of conversion) and considered it to be a “rare and controversial disorder”; in particular, it was uncertain to what degree it is “iatrogenic or specific to a given culture”.

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This shows the relevance of Azam’s historic publications, which precisely raise these questions. At the end of the nineteenth century, they were brought together in a number of collections. Jean GarrabC Principal works AZAM (E.), Hypnotisrne, double conscience et alte‘ration de la personnalite‘ [Hypnotism, dual consciousness and personality change], Paris, Baillikre, 1887. AZAM (E), Hypnotisme et double conscience [Hypnotism and dual consciousness], Paris, FClix Alcan, 1893. BRAID (J.), Neuypnology or the rationale of nervous sleep considered in relation with animal magnetism, London, 1843. PRINCE (M.), La Dissociation d’une personnalite‘ [The dissociation of a personality], Paris, Alcan, 1911. Bibliographical references GARRABE (J.) “D’Azam au D.S.M. IV, ou de la double conscience au trouble dissociatif de la personnalitC” [From Azam to the D.S.M. IV,or f;om split consciousness to dissociative personality disorder], L ’Evolutionpsychiatrique, 1996, April-June (61), p. 295-308.

Periodic Amnesia or a Double Life The History of Fklida First Case Observed in France (Minutes of the Academy of Moral Sciences and Scientific Review, 1876.)

I propose to recount the history of a young woman whose existence is tormented by a disorder of the memory which offers no analogy in science; this disorder is such that it is permissible to wonder if the young woman in question does not have two lives. Whatever the nature of the phenomena I am going to describe, they merit the interest of psychologists, for just as physiology cannot do without the study of diseases, likewise may not the study of the faculties of the mind, which is none other than the physiology of the functions of the higher order, be conducted without the analysis of the lesions of those functions. Confronted by a subject that is almost or entirely new, and somewhat embarrassed as to the choice of a title, I have preferred to leave the choice to the reader; having finished his reading, he will decide which name he favours. I beg his indulgence together with his closest attention, for the terms, the words I am obliged to use are the ordinary terms diverted from their common acceptance and could give rise to some obscurity. Moreover, I ask that it be not forgotten that, doctor as I am, I recount as best I can an observation which is more

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the province of psychology than of medicine, and that, as the mere narrator of a fact, it is not for me to choose in favour or against any subtle solution which may arise out of its analysis. The reflections which follow my account are intended rather to complete it than to take sides in a debate; by describing this case sincerely and clearly, I have no greater ambition than to make my modest contribution to the understanding of man.

FClida X...was born in 1843, in Bordeaux, of healthy parents; her father, a captain in the merchant marine, perished when she was but a small child, and her mother, left in a precarious situation, was obliged to work in order to bring up her children. Fklida’s early years were difficult; nonetheless, her development followed a regular course. Around her thirteenth year, a little after puberty, she began to show symptoms suggestive of the beginnings of hysteria: various nervous accidents, vague pains, pulmonary haemorrhages which the state of her respiratory organs could not explain. A good worker and of developed intelligence, she was employed in day work as a seamstress. Around the age of fourteen and a half years the phenomena which form the subject of this account were revealed. For no known reason, sometimes under the influence of an emotion, FClida X.. .would experience a sharp pain in both temples and would fall into a profound faint, similar to sleep. This state would last approximately ten minutes: after this time she would spontaneously open her eyes, seeming to awaken, and there would commence the second state which I shall call the second condition and which I shall describe later; this would persist for one or two hours, then the faint and the sleep would recur and Fklida would return to her ordinary state. This sort of fit would recur every five or six days or more infrequently, and her family

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and the people around her, in view of her change in behaviour during this sort of second life and her forgetfulness on awakening, considered her mad. Soon the accidents associated in the strict sense with hysteria grew worse. FClida would experience convulsions, and the phenomena of seeming madness became more disquieting; it was then that I was called upon to take her into my care, for, being at the time the physician to the public asylum for deranged women, it was natural that I should be asked to treat an illness which was considered mental in nature. Here is what I noted in October 1858: FClida X.. .is dark-haired, of average size, quite strong and of ordinary weight; she is subject to frequent haemoptysis probably of a supplementary nature. Very intelligent and quite well educated for her social condition, she is of a sad, even morose, character, her conversation is serious and she speaks little, she is very strong-willed and very keen in her work. Her affective sentiments seem little developed. She reflects ceaselessly upon her morbid state which causes her serious concern and suffers from sharp pains in several points of the body, particularly in the head; the symptom named claws hystericus is highly developed in her. Particularly striking is her sombre air and her lack of desire to talk; she replies to questions, but that is all.. . After careful examination from the intellectual point of view, I find her actions, her ideas and her conversation perfectly reasonable. Almost daily, for no known cause or in the grip of an emotion, she is seized by what she calls herfit; in fact, she enters her second state; having witnessed this phenomenon hundreds of times, I am able to describe it with exactitude. Above, I spoke of it in accordance with what I had been told; now I am describing it according to what I saw. FClida is seated, some sewing task on her knees; all of a sudden, with no warning and after a pain in the temples of greater violence than usual, her head falls onto her chest,

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her hands become idle and hang slackly along her body, she sleeps or seems asleep, but it is a special sleep, for neither noise nor any stimulus, pinching or pricking, suffice to wake her; moreover, this type of sleep comes with absolute suddenness. It lasts two or three minutes; formerly, its duration was much longer. After this time, FClida awakens, but her intellectual state is no longer what it was when she fell asleep. Everything appears different. She raises her head and, opening her eyes, greets newcomers with a smile, her physiognomy becomes lighter and expressive of gaiety, her speech brief, and she hums as she continues the sewing task that she had begun in her previous state; she stands up, she moved with agility and scarcely refers to the thousand aches from which she had been suffering a few minutes earlier; she attends to the ordinary household tasks, goes out, walks around town, makes visits, undertakes this or that activity, and her behaviour and gaiety are that of a healthy young woman of her age. Her character is completely changed: instead of sad she has become gay, and her vivacity is almost turbulent, her imagination is more exalted; her emotions are transported to sadness or to joy at the slightest reason; having been indifferent to everything, she becomes sensitive to excess. In this state, she perfectly remembers everything which has occurred: both during other previous similar states and also during her normal life. I will add that she has always maintained that the state, whichever it is, in which she is at the time she is spoken to, is the normal state which she calls her reason, as opposed to the other state which she calls herfit. In this life as in the other, her intellectual and moral faculties, albeit different, are incontestably whole: no delusional idea, no false judgement, no hallucination, I would even say that in this second state, in this second condition, all her faculties appear more developed and more complete. This second life from which physical pain is absent is greatly superior to the other; this is, above all, for the significant

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reason to which we have already referred, that during it Fklida remembers not only what happened during the previous fits, but also all her normal life, while, as I will later recount, during her normal life she has no memory of what took place during her fits. After a period which, in 1858, would last for three or four hours almost every day, all of a sudden Fklida’s gaiety would vanish, her head drop on her chest, and she would fall back into the state of torpor which we have described.-Three to four minutes would elapse and she would open her eyes to return to her ordinary existence.-This is scarcely apparent, for she would continue her work with determination, almost with fury; usually, it would be a sewing task begun in the preceding period. She would not recognise it and it would require a mental effort to understand it. Nevertheless, she would pursue it as best she could while bemoaning her unfortunate situation; her family, being familiar with this state, would explain what had occurred. A few minutes earlier she would have been crooning some sentimental ballad: if asked to sing it again, she would have absolutely no idea what was meant; if spoken to of a visit she had just received, she would have no recollection of having seen anyone. I think that I should specify the limits of this amnesia.-The forgetfulness would apply only to what took place during the second condition, no previously acquired general idea being affected; she would be perfectly able to read, to write, to count, to cut, to sew, etc., and a thousand other things which she knew before becoming ill or which she had learned in her previous periods of normality. This observation was noted in 1858, and I have verified it recently, at the invitation of Messrs Liard and Marion, professors of philosophy. These psychologists, who were kind enough to give me the benefit of their advice, impressed upon me the importance of this aspect, for in certain celebrated cases of double life, the forgetfulness had

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applied to the whole past life, including general ideas.-This was true of MacNish’s American lady. Physically, FClida is a highly characterised hysteric; she suffers from dyspbagia globosa, her tactile sensitivity is reduced; her sense of taste, in the normal state, is wholly lacking, for I was able to make her chew pills of a revolting flavour in which she detected no taste; her sense of smell is diminished, and she has no feeling in many parts of her body; finally, at the slightest emotion she has convulsions without total loss of consciousness. I will not spend too much time on this very familiar picture; suffice it to say that Fdida is undoubtedly a hysteric, and that the singular characteristics that she presents must be under the dependence of that general condition. At that time, a third state appeared, which is simply an epiphenomenon of the attack. I witnessed this state only two or three times, and over sixteen years her husband observed it only some thirty times; being in her second condition, she would fall asleep in the manner described and, instead of awakening in the normal state as usual, she would find herself in a special state characterised by unspeakable terror; her first words are: “I’m frightened.. .I’m frightened.. .’,; she would recognise no one but the young man who became her husband.-This near delirious state does not last long, and is the only time that I was able to perceive in her any false conceptions. I might have mistaken certain hyperaesthetic states of hearing or of smell for sensory hallucinations, but an attentive study showed me that a simple exaltation of those senses enabled her to hear conversations or noises or to smell odours which nobody around her could perceive. The history of hysteria is full of similar examples; nothing more needs to be said on this subject. If I had had any doubts regarding the complete separation of these two existences, they would have been removed by that which I shall now describe. 1. MacNish, PhiLosophy of Sleep, p. 215.

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A young man aged between eighteen and twenty years had known FClida X...since childhood and was used to come to the house; these young people, between whom there was great affection, were promised to each other in marriage. One day, FClida, being more sad than was usual, told me with tears in her eyes: “My illness is becoming worse, my belly is swelling and I feel sick each morning;” in short, the complete picture of early pregnancy.-From the concerned faces of those around her, I had suspicions which were soon to be lifted. For indeed, in the attack which soon followed, FClida said to me before the same people: “I perfectly remember what I have just said to you, and you must have understood me without difficulty: I admit it without hesitation.. ., I believe I am with child.” In this second life, her pregnancy did not worry her, and she accepted it quite happily. Thus, having become pregnant during her second condition, she was unaware of it in her normal state and knew it only during her other similar states. But this ignorance could not endure: following the attack a neighbour, before whom she had expressed herself very clearly and who, more sceptical than was warranted, believed that FClida was dissimulating, reminded her frankly of her admission. This discovery made such a strong impression on the young woman that she experienced hysterical convulsions of great violence, which obliged me to give her my attention for a period of two or three hours. The child conceived during the attack is today sixteen years old, but of that later. At that time (1859), I recounted this case to several colleagues, most of whom believed that I had been the victim of illusion or trickery. Only three eminent men, having seen Fklida X...with me, encouraged me to pursue my study: Parchappe, the celebrated alienist; Bazin, chief physician of the public asylum for deranged women and professor at the Bordeaux Faculty of Sciences, and Gintrac senior,

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director of the School of Medicine and correspondent of the Institute.-For all the others, it was as though science is a thing complete, and all that lies outside the familiar framework could only be trickery. However, for those three elite minds, scientific understanding with regard to the difficult study of the functions of the brain remains incomplete, and no fact should be neglected.-Monsieur Bazin placed in my hands a book almost unknown in France, Neurypneumology or nermous sleep, by Braid, in which hypnotism is described; it was the reading of this book which was at the origin of the researches which occupied the scientific world at the end of 1859 and which I summarised in 1860 in the Archives de midecine et de chirurgie and in the Annales midico-psychologiques de Paris. These researches, described by Velpeau at the Institute, were confirmed by Messrs Broca, Follin, Verneuil, Alfred Maury, Baillarger, Lashgue, etc., and fell into a sort of neglect only as a result of their unfortunate analogy with the justly decried practices of animal magnetism. It is upon Fklida X.. .and in particular upon one of her friends, Maria X.. ., that I conducted the experiments which were the basis of that study, which, after Braid and a number of ancient authors, established the action of convergent strabismus on the cerebral functions, both in man and in animals. In order not to stray from my subject, I shall describe only that which I observed in Fklida X...with regard to hypnotism: Fklida being in one of her two states and being seated opposite me, I would ask her to look attentively at some object placed 15 o r 20 centimetres above her eyes; after eight to ten seconds, she would blink and her eyes would close. For a few moments she would not answer any questions, the sleep in which she appeared to be dividing her completely from the outside world; in addition she would be impervious to touch. After this very brief period, she would reply to questions and would manifest the particular characteristic that, in her induced somnambulism

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and whatever her state at the time she fell asleep, she would always be in her normal state. Otherwise she would exhibit the normal phenomena of this somnambulism: catalepsy, anaesthesia, hyperaesthesia of the skin, exaggerated development of the sense of smell, of touch, exaltation of the muscular sense, all phenomena that are very easily produced by the process in question, even on animals (hens, cats) and which I do not need to emphasise here. Re-awakening would be induced with the same ease by the well-known means: rubbing or blowing on the eyelids. Although I had little faith in the numerous cures reported in the book by Braid, I must confess nevertheless that I induced artificial sleep in my patient by the means he recommends, in the hope of effecting a cure. That hope was disappointed, for I produced no alteration in her. The existence in our patient of a spontaneous phenomenon-the transition from one state to another-had naturally made me think of hypnotism, which just as somnambulism, as is commonly known, can occur spontaneously. Examples of this are not rare; of the many that are known, I will quote only a few: Early in 1875, Monsieur Bouchut observed in his service a young woman who would fall into somnambulism with catalepsy each time she worked with buttonholes, a difficult task which requires a certain attention and a great fixity of gaze. This person was a hysteric who hypnotised herself. Monsieur Baillarger referred in my presence, at the Soci6t6 mkdico-psychologique de Paris, to a young woman who would fall into catalepsy by regarding herself in the looking-glass. I could name an eminent pastor in the Reformed Church who can fall asleep at will for a half hour, by closing his eyes and turning his eyeballs inwards and upwards. Here the phenomenon is entirely at the discretion of the person. Finally, nine or ten years ago, a young woman, admitted

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to my clinical service for a tumour of the breast, would fall asleep in the middle of the day for three hours, and nothing could awaken her. When questioned, she explained that at a certain time of the month she was subject to such bouts, during which she was impervious to touch, but not somnambulistic. I shall draw no conclusions from these cases. Formerly, they appeared marvellous. Today, all have entered into science. I have just described Filida’s state in 1858 and 1859. At the end of the latter year, the phenomena appeared to improve, at least from what I was told; the birth was successful, and she nursed her child. At that time, diverted by other subjects of study, I completely lost sight of her; she had married the young man of whom we have spoken. However, this very intelligent young man closely observed his wife’s state from 1859 to 1876. His information fills the gap of sixteen years in my direct observation. Here is the summary of what occurred during those sixteen years. Towards the age of seventeen and a half, Fklida gave birth to her first child, and during the two years that followed, her health was excellent, and no particular phenomenon was observed. Around the age of nineteen and a half, the phenomena already described reappeared with moderate intensity. One year later, there was a second very difficult pregnancy, considerable spitting of blood and various nervous disorders associated with hysteria, such as attacks of lethargy lasting three or four hours. At this time and up to the age of twenty-four, the fits became more frequent, and their duration, which initially had been equal to the periods of 1. I requested my intern of the time, today a distinguished Bergerac physician and a Deputy for the Dordogne, to put her to sleep by artificial means. H e effected this over a period of fifteen or twenty days, and the young woman never again experienced this strange condition. After six years, I was able to observe that these spontaneous sleeps had never recurred.

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normal state, began to exceed them. The pulmonary haemorrhages, which have continued until recent times, became more frequent and more copious; Fklida experienced partial paralysis, attacks of lethargy, ecstasies, etc., phenomena which are all due, as is well known, to the hysteria which governs her temperament. From twenty-four to twenty-seven, our patient had three full years of normality. From this time and until 1875, that is to say during the last six years, the illness has reappeared in the form which I will soon describe. I would add that over these sixteen years FClida had eleven pregnancies or miscarriages (including the birth of 1859), of which two children survive. In addition, I must report one significant particularity. The second condition, the period of fits, which in 1858 and 1859 occupied only some one-tenth of her existence, gradually increased in duration, and became equal to normal life, then exceeded it, finally attaining the present state where, as we will see, it fills almost her entire existence. In the early months of 1875, the Academy of Medicine of Belgium, called upon to examine the Louise Lateuu question, asked M. Warlomont to prepare a report on the subject. This excellent study stresses the scientific reality of the phenomenon described as double l$, double consciousness, second condition, states which may occur spontaneously or be induced. M. Warlomont refers to cases which are wellknown but somewhat rare, in which I recognised similarities to my observation of 1858. Although I had realised its importance at the time, I had not published it, considering it to be too isolated in science, or too much outside the ambit of the surgery which I practise in Bordeaux. I therefore sought out FClida X . . .again and found her to manifest the same phenomena as before, but in a more aggravated form. Today Fklida X.. .is thirty-two years old, the mother of a family and in charge of a grocery store. She has but two living children; the elder, conceived, as

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we have discussed, during a period of fit, has his mother’s nervous temperament, is very intelligent, an excellent musician. He has attacks of nerves, without complete loss of consciousness, and after these nervous attacks, inexplicable terrors which recall the third state that we have described. Obviously this child, who is now sixteen years of age, is subject to the influence of his morbid heredity. In physique, Fklida X.. .has become thinner, but is not of sickly appearance. As soon as she recognised me on my arrival, she quickly consulted me as to the means to escape from her unfortunate situation. This is what she told me: She was still sick, that is to say she still had losses of memory which she incorrectly called her fits. Only these supposed attacks, which are, after all, simply the periods of normal state, had become much less frequent; the last had been three months before. However, the loss of memory which characterises them had made her commit such blunders in her relations with her neighbours that Fklida had preserved the most painful memories of them, and feared being considered mad. I examined her as to the integrity of her intellectual functions, and encountered no deterioration in that respect. However, in what she had just told me I easily deduced that her memory of what had taken place during what she called her last fit was perfectly clear, and this integrity of the memory gave me food for thought. I was right, as the next day I received a visit from her husband, who told me that the state in which Fklida was at that time and had been for more than three months was the state of fit or second condition, although she believed and maintained the contrary. Indeed, for her, today as in the past, whatever state in which she finds herself is always the state of reason, a fact of which my recollection of the past had already reminded me. Only, in the time during which I had not been studying her, the periods of normal state had become increasingly

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rare and increasingly short, to the point that the second condition occupied almost her entire existence. From that time on, recognising the remarkable nature of a state which, for sixteen years, had so completely altered the manner of being, the personality of my young patient, I studied her almost every day, with the intention of publishing her story. For reasons of brevity, I will only recount the principal facts of my study, or at least those which are characteristic. O n 21 June, FClida, who was evidently in the second condition state, told me that four or five days previously she had experienced three or four small fits in a single day, each lasting one or two hours; during that time, she had completely lost the memory of her ordinary existence, and during these moments, she was so unhappy at that singular state that she had contemplated suicide. She was then, she said, undoubtedly mad, for she was unaware that I had seen her again. She even begged me, in the event that chance should bring me before her at a similar moment, to act as if I were seeing her for the first time; further proof of her infirmity would increase her sorrow. She recognised that, at these moments, her character changed a great deal; she would, she said, become spiteful and would initiate violent scenes in her household. Warned by my recollection of the past and by her husband’s great familiarity with these variations, it was very easy for me to recognise that Fklida was in the state of second condition, although she pretended the contrary. Indeed, as before, her speech was brief, her character decided, her behaviour relatively gay and light-hearted; it was indeed the same gaiety as sixteen years before, but tempered by the sobriety of a wife and mother. I believe that I should report here certain episodes in the existence of our patient, as recounted by her. They will give an excellent and complete idea of her state. During the summer of 1874, following a violent emotion, she was seized by what she wrongly calls a fit, which lasted

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several months without interruption, and during which, as usual, she lost her memory. Indeed, the husband had told me that she had at that time experienced a period of normal state so complete and of such long duration that he had hoped she was cured. Two years earlier, being in what she considered her ordinary state (that is to say, the second state), she was returning in a carriage from the funeral of a lady of her acquaintance; on her return, she felt the onset of the period which she calls her fit (normal state), fainted for a few seconds, without the ladies who were with her in the carriage being aware of it, and awakened in the other state, with absolutely no knowledge of why she was in a mourning carriage, with people who, as is customary, were praising the qualities of a deceased person whose name she did not know. Being accustomed to these situations, she waited; by adroit questions she was able to elucidate the situation, and nobody had any idea of what had occurred. A month previously, she had lost her sister-in-law following a long illness. However, during the few hours of normal state of which I have just spoken, she had the pain of being totally ignorant of all the circumstances of that death; it was only by her mourning garments that she realised that her sister-in-law, whom she knew to be ill, must have died. Her children had taken their first communion while she was in her second condition; she also experienced the pain of being unaware of this during her periods of normal state. I should note that there was between the former situation of our patient and her current situation a certain difference; formerly Fklida would entirely lose consciousness during the short periods of transition; this loss was even so complete that one day, in 1859, she fell down in the street and was assisted by passers-by. Having awoken in her other state, she laughingly thanked them, and they were naturally unable to make head or tail of this strange gaiety. Today this is no longer the case, and the period of

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transition has gradually diminished in length, and although the loss of consciousness is just as complete, it is of so short a duration that FClida is able to conceal it wherever she is. This period bears the greatest similarity to the condition called in medicine petit mal, which is the smallest of the epileptic fits, however with the difference that petit ma1 generally occurs with absolute suddenness, while certain signs, known to her, such as pressure in the temples, warn FClida of her attacks. This is what happens. As soon as she feels them coming, she brings her hand to her head, complains of dizziness, and after an imperceptible period of time, passes into the other state. In this way, she is able to conceal what she describes as an infirmity. And indeed, this concealment is so complete that, of the people around her, only her husband is aware of her current state. Her entourage perceives only the variations of character which, I must say, are very marked. We will stress the variations which Fklida describes herself with the greatest sincerity. In the period of attack or second condition, she is more proud, more light-hearted, more interested in her toilette; moreover, she is less hard-working but much more sensitive; it appears that in this state she feels a more lively affection for those around her. Could it be that these differences from the normal state are due to the fact that, in this latter state, she feels a more lively affection for those around her? Could it be that these differences from the normal state are due to the fact that, in this latter state, she loses her memory, while in the second condition she retains it? This is likely, and is a question to which we shall later return. A few days later, on the 5 July, arriving at FClida’s dwelling, I was struck by her sad manner; she greeted me ceremoniously and seemed surprised by my visit. Her appearance struck me, and I felt that she was in a period of normal

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state; in order to make certain, I asked her if she remembered the last time we had seen each other. “Perfectly” she replied. “About a year ago, I saw you entering a cab on the Place de la ComCdie; I do not think you noticed me. I have seen you at other times, but rarely, since the time that you used to come to treat me before my marriage.” There was no doubt. Fklida was in the normal state, for she was unaware of my last visit which, it will be recalled, had taken place during the second state. I asked her questions, and I learned that she had been in her right mind (today she says right) since eight o’clock in the morning. It was approximately 3 o’clock in the afternoon. I took advantage of the occasion, which might perhaps not easily be repeated, to study her with care. Here is what I observed: Fklida was in a mood of sadness close to despair, and gave me the reasons in eloquent terms. Her situation was, indeed, very sad, and every one of us, looking into himself, can easily understand what his life would be like today, if the memory of the three or four preceding months were to be erased. Everything is forgotten, or rather nothing exists: business, important events, new acquaintances, information given-it is a leaf, a chapter of a book, violently torn out, a space which can never be filled. FClida’s memory exists, as we know, solely for events which took place during similar conditions, for example the eleven births. I shall make an observation here. FClida has given birth eleven times. In every case this primary physiological act, whether completed or not, has taken place during the normal state. I asked her point-blank what date it was. Her answer was mistaken by almost a month. I asked her where her husband was; she did not know, had no idea at what time he left her, nor what he said to her when he went out. Indeed, the change to the normal

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state had occurred at eight o’clock, and he had gone out a quarter of an hour earlier. By her side was a little dog; she did not recognise it and had seen it that morning for the first time. However, the animal’s behaviour indicated that it had been in the house for a long time. I could cite many circumstances of a similar kind, but the preceding examples are, I think, sufficient. Apart from these alterations which result directly from the loss of memory, I noted other differences between the normal state and the period of attack. The affective sentiments were no longer of the same nature. Filida was indifferent and exhibited little affection for those around her; she rebelled against the natural authority which her husband has over her. “He says: I want, all the time,” she complained, “and I do not like it; I must have allowed him to take up this habit in my other state. What distresses me,” she added, “is that it is impossible for me to hide anything from him, although in fact I have nothing to conceal in my life. But if I wished to, I could not. It is quite certain that in my other life, I tell him everything I think.” Moreover, her character was more haughty, more unyielding. What affected her particularly was the relative incapacity brought about by her losses of memory, above all with regard to her business. “I give the wrong prices for goods because I do not hnow how much they cost, and I am compelled into a thousand subterfuges through fear of appearing an idiot.” Three days later, her husband told me that the state of full reason of which I have just spoken lasted from eight o’clock in the morning until five o’clock in the afternoon; from that time, she had been in the second condition and would remain so for a period which he could not predict. H e added an interesting detail: It had happened several times that, falling asleep in the evening in her normal state, she would wake in the morning

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in the other state, without either her or her husband being aware of it; the transition had thus taken place during sleep. It is known that certain fits of epilepsy also take place during sleep, and that both the patients and the doctor are only able to deduce it from the extreme weakness experienced by the patient upon awakening. There are even epileptics who have never had an attack while awake and who, in consequence, could not possibly be aware of their situation. At the time of publication of this study, the state of our patient has changed little. The periods of normal state last no more than two or three hours and recur every two to three months.

I believe that I should add to the description of this case a few reflections which will perhaps assist in its interpretation. How should the state of FClida X...be characterised? Does she have a double personality, a double life? Is it a case of double consciousness?or does she present an impairment of the memory which, affecting only the memory, leaves intact the other faculties of the mind? If, in whatever state she is, FClida is asked what she thinks of herself, she does not think and at no moment of her life has thought that she is another person; she is perfectly conscious of always being herself; she does not, therefore, match the definition of M. LittrC who says: “Double consciousness is a state in which the patient either has the sensation that he is double, or without being conscious of his duality, has two existences which have no memory one of the other and are mutually unknown.” FClida does not have this sensation, and in one of her existences she has perfect recollection of her two lives. Nor does she think that she is another person, like the lady referred to by Carpentier in his Mental Pbysiolop?; who,

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believing herself to have become an elderly clergyman, found it ridiculous that this doctor should suggest that she marry. N o r does she resemble the pastor cited by Forbes-Winslow who felt in himself two selves, one good, one evil; nor MacNish’s American lady who, at a given moment, following a spontaneous sleep, would forget her whole previous existence, even what she had learned during that existence, reading, writing, music, and who was obliged to recommence her education until, reverting to her normal state, these notions had returned to her. We have seen that Fklidaysamnesia never affected the domain of general ideas or of previously acquired notions. Fklida represents none of these three types, who correspond fairly well to the descriptions of the double personality, double life or double consciousness, these being the terms until now used by the authors, notably in recent times by Messrs Warlomont and Littrk. It is likely that a precise analysis of the facts would show that these terms are interchangeable. However, this is not the place to debate that point of doctrine. In summary, therefore, what is the situation of this young woman? I acknowledge that she seems to have two lives; but is that not only apparent, an illusion given to the observer by the absence of recollection which characterises her periods of normal state? Let us look for analogies. Persons who are subject to fits of natural somnambulism do not recall on awakening what occurred during their fits. The same is true for Fklida. But such perfect somnambulism has never been seen, for in the state which corresponds to the state of somnambulism she is not asleep, she is entirely alive and thinking, and her life in this state is even superior to her normal life, for it is only during this period that she is able to have a complete notion of her existence. I would say the same for somnambulism caused by

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strabismus whether convergent or not; this somnambulism is also, in the strict sense, a second condition, like natural somnambulism; in respect to amnesia, it resembles FClida’s state, but does not reproduce it exactly. Persons subject to it are without spontaneity; moreover, they exhibit anaesthesias, hyperaesthesias and other impairments or imbalances in the sensory functions or in the muscular sense which have nothing in common with the functional integrity manifested by Fklida in the corresponding condition. There are other artificial or morbid second conditions which deserve mention. Alcohol, hashish, belladonna, opium, all produce states in which those under their subjection think and act without retaining any recollection once the action of those substances has been extinguished. Persons suffering from delusions through madness, epilepsy or temporary illness, seem to have two existences, of which one is reasonable, in which they are generally unaware of what occurred in the other.-But here the analogy ceases, for in these states, the ideas expressed or the acts performed are unreasonable, not because they are expressed or performed outside that which we call reason, but because in themselves they are not the result of logically consistent conceptions.-Properly speaking, these states are patches in life, morbid manifestations, absences. In FClida by contrast, we cannot stress it too strongly, the state of fit, of second condition, is a complete existence, perfectly reasonable and so perfect that nobody, even forewarned, unless guided by her husband or by myself, would be able to discern which of the two states is the additional state. In case a further argument were required to corroborate these differences, let us compare Fdida’s two conditions from the point of view of legal responsibility. We do not think that any enlightened judge could pronounce criminal an act committed in one of the second conditions which we have just described. The sick, the insane, the epileptic, the sleep-walker are not responsible

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for their acts, nor to a certain degree are the inebriated. Would it be the same for Fklida, if she were to commit a reprehensible act in one of her two states? The question needs to be asked, debated, but it must be recognised that it is not easy to resolve. If it were said that she is not responsible, it could be replied that a person who for months at a time is in the same intellectual state, and is moreover perfectly sane, must be conscious of and therefore responsible for her acts, although it may happen that at the time of the accusation or the judgement she has no memory of them. Were it said that she is responsible, it could be said with equal reason that it would be impossible to condemn a person whose intellectual functions are so greatly impaired. Indeed, the unity of the self being admitted, the consciousness of such a person might not be entirely whole, especially if we recall the third state, the rare but unquestionable occurrences of which we have already indicated. Moreover, a person who is unable to remember performing an act, however recent, could not be compos rnentis [of sound mind] as understood in law. While, therefore, for the other second conditions the lack of responsibility is not in doubt, it is, with regard to our patient, entirely debatable.

We believe we have established that the second condition which concerns us is not of the same nature as the similar states already observed, or rather already published; it now remains to us to consider whether amnesia is not the sole cause of the differences that the two states present, and whether, as we suggested earlier, it is not that condition which is the origin of the appearance of a double life. It is certain that FClida’s character and emotional responses are not the same in the two states.

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In the light of what we knew about her manner of being, what is the value of these differences? Let us not forget that before the illness and during the periods of normal state which exactly reproduce her previous state, FClida was and is naturally serious and solemn. Yet in her second condition, she is gay, frivolous and more preoccupied by her toilette and a thousand other trifles. But are not this gaiety, this change of character, something natural?. ..Indeed, in this state her memory is intact, it encompasses her entire life. FClida well knows that she will lose her memory, that she will have gaps, but this thought is nothing in comparison with the painful situation in which she is placed by an overwhelming amnesia which erases whole months of her life and undermines her selfrespect, by exposing her as apparently insane or as an imbecile. In her second state, her emotions seem more developed; but is that not once again a direct consequence of her greater freedom of mind? She is less preoccupied with herself, and therefore more interested in her surroundings. When she is in her normal state, aware of her sad situation, she can think, so to speak, of nothing but herself. Everybody knows of the egoism of the old and the sick; it is caused solely by their sensation of weakness. When she is strong and relatively healthy, FClida’s sentiments are those of the strong-love of others, devotion, generosity. In this state her character is more flexible and she complains less of her husband’s legitimate authority over her; is that not too a natural thing? Where there is greater love, there is greater tolerance. As for her greater frivolity, her increased interest in her appearance, they derive directly from her greater freedom of mind and from the fact already reported that in these periods her physical pains apparently no longer exist.-People who are in pain do not consider their looks and often find relief from their suffering through hard work.-At these times, FClida has no need to look for such relief. Finally, although in these second states FClida is more

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gay, more frivolous and less hard-working-seems more attached to those around her-this is only in comparison with her behaviour in her normal states, for, I must stress, nothing which one may observe in her is out of the ordinary; she is, at these times, similar to many women or girls who would pass entirely unnoticed. It could therefore be maintained that in Fdida X.. ., the memory alone is impaired and that the differences in character or affective sentiments are simply the consequences of the impairment of that faculty. I would add that this impairment of the memory, this amnesia, is as if periodical. In the normal state, the memory overlaps, jumps over the second condition states, linking together all the periods of the normal state, however far apart they are; the diagram below will, I believe, clearly explain my meaning. If it is right to claim that in Filida memory alone is affected, and everything points to that conclusion, is it not possible to argue from this in favour of that faculty being localised in some part of the brain? We have no preconceived idea with regard to the localisation of the intellectual faculties, and we consider as daydreams most of the attempts which have been made to that end. However, it must be recognised that the preceding fact is at least a presumption. Indeed, impairment of the memory alone, the other faculties remaining intact, leads us towards that conclusion in the same way as the impairment of the faculty of articulated language, the other faculties remaining intact, gradually led M. Broca and other observers to localise that function in the third frontal convolution of the left frontal lobe. To reach that conclusion regarding localisation, the following elements of knowledge were available: 1. Impairment of that faculty, with all the others remaining intact; hence the probability that its instrument is an isolated, special point in the brain;

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2. Concomitunt impairments to one point in the brain, limited and always the same. As regards memory, today we only know the first of these terms; might it not lead us to the other? Let us look for cases which resemble the one above and miss no opportunity to carry out necroscopic studies. There is one point in this story which I believe I should stress, as it is of general import. I refer to the striking way in which it demonstrates the importance of memory. Theoretically, everyone is aware of this importance, but it has perhaps never received a more striking practical dernonstration, and nobody by examining himself could more clearly reach that conclusion than by studying this young woman. For it is impossible to imagine the singular impression obtained by observing a person who, like Fklida, is unaware of everything that has happened, everything she has seen, everything she has said, everything she has been told during the preceding three or four months. She has not emerged from a dream, for a dream, however incoherent it may be, is still something. She has emerged from nothing, and if, like most sufferers from delusion, she had not lived intellectually during that period, the gap would be of little importance. However, during that time, her intelligence, her acts were complete and reasonable; time has moved on and her life has moved on with it, and also everything around her. Earlier, I compared this existence with a book from which pages had been torn here and there. That is not an adequate analogy, for an intelligent reader, imbued with the general spirit of the work, would be able to reconstitute the these gaps, while it is absolutely impossible for FClida X. ..to have any idea of any event that occurs during her second condition. How, for example, will she know that during this time she has contracted a debt, received a payment, or that an accident, a sudden disaster, has deprived her of her

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husband or her children? She will not find them by her side, she will await their return. The traveller who sojourns for three or four months far from his native land, without letters or news, has the notion of time passing; he may be surprised at what has occurred during this period, but he knows that something must have occurred. He expects to find out; for him time has moved on. However, when after four months in her second state, Fklida has a day of normal state, she has, during that day, no knowledge of the preceding months, she knows not how long that period lasted: one hour or four months are as one to her. Thus, in her appreciation of time, she makes the most singular errors, suppressing entire months; she is always behind. In a word, if I may put it in this way, her appreciation runs late. Even the almanac is of no use to her, for she has no basis from which to start. Her husband, or her sales ledger, by going back day by day to some sale she remembers, may enlighten her as to what the date is and when her period of amnesia began. I have left it to the reader to imagine the thousand consequences, the thousand incidents, that may arise in an existence divided in this way. It is not my role to envisage stories to excite the imagination, but simply to recount the truth. We believe at this point that we should counter a possible objection: reading this description, or studying FClida only today, one might be tempted to think that I have misjudged our patient’s situation, and that the state of wholeness, of reason, is that in which memory is complete, that in which she is in perfect possession of herself, and that the morbid state is the one characterised by amnesia. One would be wrong; this is why: First of all, having seen the fits begin and grow, I can affirm the identity between the former accidental state, which would last one hour in a day, and the almost constant

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state of fit of today which lasts four months as against one day. Moreover, the absence of memory is a minor criterion of the integrity of the intellectual function; for forgetfulness is not necessarily caused by an incomplete or impaired intellectual state at the moment when one is seeking to remember. Usually, amnesia is caused by the lack of impression made on the brain by an event at the time it took place. One does not forget because one cannot remember; one forgets because the forgotten event made an insufficient impression. The man who, after a delirium lasting several days, is unable, once cured, to remember what he did during the delirium, is nonetheless in perfect health. He was incomplete and sick only during the delirium, and it is because of the delirium that his memory is lost, since his brain did not receive a durable or sufficient impression. We would like once again to stress a particular circumstance. Today the second condition has grown so much to the detriment of normal life, that the roles between the two periods have been reversed. Sixteen years ago, the attacks lasted only a few hours out of several days, they were an accident, a stain in life; today, the second condition is, so to speak, ordinary life, since it lasts for three and four months at a time, compared with the periods of normal life which last only three or four hours: today, these are the stain, the accident, it is to these that FClida owes the trouble of her existence. The characteristics specific to these two states have in no way altered; only their duration has changed: one has simply grown to the detriment of the other. This alteration, brought about over sixteen years, raises a possibility: does not the increasing diminution in the duration of the periods of normal state and the ever greater rarity of their incidence suggest that they will disappear completely within a few years? That is certainly not impossible, it is even probable. But what will happen then? The

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second condition will become the whole life. Fklida X. ..will have a complete personality: intelligence, full memory of the past, everything will be there; but she will no longer have the same personality as formerly: she will be another person. She will be none the worse for it; she will even be better off, as she will have no more amnesia; but, in fact, she will be other. Her existence, seen from above, will have manifested the singular phenomenon of having contained three successive personalities: the first, normal, which, so to speak, she brought into the world at birth; the second, divided in two by amnesia; the third, new and different by its integrity. In this way, good would arise out of the excess of evil; for it would, in reality, be a sort of cure. I would not dare hope for any other. If this alteration were to occur, it would be in twelve or fifteen years, at the so-called critical age, the usual time at which hysteria ends. If I am spared, it is something I shall be able to observe in the future.

What hypothesis can we advance on the proximate cause of the amnesia we have just described? Let us see whether what we know may not put us on the track of that which we have yet to learn. The fine work of Messrs Claude Bernard and Luys has firmly established the influence of the circulation on the cerebral functions. An excessive supply of blood excites these functions; its reduction induces calm, repose. Sleep is caused by this diminution (ischaemia), which itself is brought about by the momentary shrinking of the vessels that supply blood to the brain. Let us reason by analogy and take as our example a function the seat of which seems certain, the function of articulated language. There it is! If the vessels which conduct blood to the third convolution of the left frontal lobe are reduced in diameter, that function will be impaired, the others will remain intact. Likewise if the memory is erased,

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one is perfectly justified in thinking that this impairment is due to a diminution in the supply of blood to the as yet unknown part of the brain where that function is situated. Now, FClida’s sick condition perfectly explains, by the action of hysteria on the contractile elements of the vessels, the reduction in their diameter. That is, at least, my personal conviction, which it is not my intention to develop here. What takes place when sleep is induced in man or in animals by obliging them to squint upwards or inwards, is one further proof. In the absence of the kind of necroscopic study which still remains to be done, it can be understood from the analysis of this manoeuvre: when a person or an animal is placed in these conditions, the prolonged contraction of the muscles of the eye which convulse it inwards and upwards compresses the vessels of the eyeball, alters their circulation, and consequently affects the brain circulation which is closely connected with that of the eyeball. Is it not likely that the sleep and the somnambulism which follow it are brought about by this action?. . . The manner of waking such sleepers easily proves it. M. Puel demonstrated a long time ago, in an essay crowned by the Academy of Medicine, that spontaneous catalepsy yields to gentle rubbing of the contracted muscles. After him, Braid and general experience taught that one awakens these sleepers by friction on the eyelids; this friction clearly acts on the contracted muscles and brings the contraction to an end, just as it does elsewhere; subsequently, the blood vessels are relieved of all compression, the brain circulation is no longer inhibited and the animal or the person return to their ordinary state. In summary, we think that the proximate cause of the amnesia, in this young woman, is a momentary and periodic diminution in the blood supply to the part of the brain which governs the memory. Moreover, we consider that this momentary shrinking of the 1. This study can be performed on animals by a method that I have devised in concert with Professor Verneuil, and which it is my intention to apply.

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vessels is due to our patient’s state of hysteria, a state which influences the contractile elements of those channels. This conception, in which hysteria plays a new role, would lead us to considerations too specific to medicine and physiology, which have their place in a different context.

CONCLUSIONS I.-FClida X.. .has for sixteen years suffered from an impairment of the memory which has all the appearances of a double life. 11.-This impairment is an amnesia which applies to periods of time of varying duration, which, having greatly grown longer, today occupy almost the entire existence. 111.-The memory, spanning these states of second condition, links together all the periods of normal state, to the point that it is as if FClida X...has two existences: one ordinary, made up of all the periods of normal state linked by memory; the other second, comprising all the periods of both states, in other words her whole life. IV.-The loss of memory is complete, absolute, but applies solely to what happened during the second condition. It affects neither prior notions nor general ideas. V.-Apart from the amnesia, which is a phenomenon of the normal state, during the periods of attack FClida shows modifications in character and affective sentiments which are not the consequence of it. V1.-This impairment of the memory and the phenomena which accompany it are caused by a reduction in the supply of blood to the as yet unknown part of the brain where memory must be localised. VI1.-The momentary shrinking of the vessels, which is the cause of this reduction, is brought about by the state of hysteria of FClida X. .

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I stated above that after the publication of the history of FClida, numerous papers had appeared in the scientific press. I will cite only the following letter from D r Dufay (of Blois), today a senator for Loir-et-Cher, addressed to the Director of the Revue scientifique This important letter, which discusses the notion ofpersonality, was published in July 1876.

"SIR,

When I read, in the edition of 20 May last of your Revue scientifique, the observation of periodic amnesia or double Z$e presented to the Academy of Moral and Political Sciences by M. Azam, I seemed to recognise the history of one of my former female patients, so great is the similarity between the nervous disorder described by my honourable colleague from Bordeaux and the one I myself observed."

Jean-Martin Charcot (1825-1893)

’

It is possible to distinguish in the vast breadth of Charcot’s work three parts which correspond, as we will see, to three periods-each lasting some ten years-in his professional life. Jean-Martin Charcot was born in Paris of socially modest background. As a child, he received a basic education from a primary school teacher who, in her youth, had been magnetised by the Abbot of Faria (1756-1819), although this circumstance should doubtless be seen as no more than a coincidence. He did his medical studies at the Paris Faculty, entered into hospital service as an intern in 1848 and presented his doctoral thesis in 1853. In 1856, he was appointed as a hospital physician, became ugrkgk in 1860, heading a department first in Lourcine then, from 1862, at the Salpetrikre. It was here, after an initial period of hospital practice, that began the second, neuro-anatomo-pathological, part of his work. In line with the anatamo-clinical method which was behind the Paris School’s triumph in the mid-19th century, Charcot described amyotrophic lateral sclerosis, or Charcot’s disease (1865), multiple sclerosis (1868), tabetic arthropathies (1868 and 1869), medullary localisations (1875), etc., in a single decade creating a new science, the science of neurology. Once these diseases were removed from the family of the neuroses as defined by Cullen and Pinel*, there remained in the latter group only diseases where no anatomical impairment to the nervous system could be identified, thus essentially turning upside down the

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original etymological definition of the word “neurosis” and giving it its 20th-century meaning. In 1872, Charcot succeeded Vulpian, who had collaborated in his research into neuropathology, as Professor of pathological anatomy and was elected to the Academy of Medicine. Finally, in 1882, the government of President Gambetta (18381882), eager to promote national glory, created for Charcot the world’s first clinical Chair of nervous diseases. The Salp&ri;re, which had become the Mecca of neurology, having been that of alienism under Pinel, saw an influx of French and foreign physicians in search of training. However, from 1878, Charcot was, as he wrote himself, “by force of circumstance. . .plunged into the midst of hysteria,’’when his department was joined to the “simple epileptics section,” which at the time indiscriminately included both patients experiencing genuine epileptic fits and those suffering from convulsive hysterical attacks. Taking his inspiration from the ideas of Briquet*-although he seems to have had little respect for those of Laskguepk-Charcot would devote the final part of his life to the scientific study of that neurosis, carrying with him his neurology students, some of whom would regret the change and disavow this research after the master’s death. Intrigued by the early work of Janet*, Charcot encouraged him to study medicine and set up for him at the Salpihrikre a laboratory of physiological psychology. He was interested in the problem of hysterical paralyses and in the differential diagnosis between these and organic paralysis. These paralyses sometimes occur after trauma, and in subjects of both sexes, an argument in favour of the existence of male hysteria. O n the basis of the hypothesis of a trauma which might be of either physical or psychological character, and which the subject was unable to describe in the waking state, Charcot resorted to hypnosis, which he apparently did not practise in person, in order to explore the psyche of hysterics. AndrC Brouillet’s famous picture, “A clinical lesson at the Salpetrihre in the department of Professor Charcot” (1887), currently in the Museum of the History of Medicine in Paris, is an example of the almost official iconography which grew up around these sessions of the theatre of hysteria. However, it dates from a time when the early successes were beginning to be called into doubt. In 1882, Charcot

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delivered an initial paper, this time to the Academy of Sciences to which he was elected in 1883. However, in Nancy, Bernheim” delivered his reply the following year. During his stay in Paris, in 1885-86,Freud was dazzled not just by the prestige of Charcot the scientist, but also by that of Charcot the man of the world, admired both by intellectuals and high society; he would name his eldest child, born in 1889, Jean-Martin. However, the sudden death of Charcot triggered a war of succession at the Clinic of Diseases of the Nervous System, where Raymond pursued Charcot’s neurological work without taking a personal interest in hysteria, the study of which he left to Pierre Janet”. Amongst his neurologist followers, only Gilles de La Tourette’fiwould remain loyal to the master’s ideas, publishing his “Clinical and therapeutic treatise on hysteria according to the teaching of the Salpttrikre” in 1895, two years after Charcot’s death. By contrast, Babinski (1857-1932) proposed on 7 January 1901, at a memorable session of the Society of Neurology, founded in 1899, that the word hysteria be replaced with the term : and ~ C X I X K O cur~: pithiatism (from the Greek ~ ~ 1 6I0persuade able). He believed that these neurotic disorders were characterised by the fact that “it is possible to reproduce them with rigorous exactitude in certain subjects and to make them disappear under the exclusive influence of persuasion.” This is what has been called the first dismemberment of hysteria, the second taking place in 1980, when the American Psychiatric Association proposed removing the term “hysterical neurosis” from the third edition of its Diagnostic and Statistical Manual of Mental Disorders and replacing it with “somatoform disorders” and “dissociative disorders”. Several physicians turned writers gave picturesque descriptions of sessions of hypnosis as practised at the Salpttrihe and the games supposedly played by the so-called hysterics and the sorcerer’s apprentices, working in cahoots to deceive the gullible. In Les Morticoles [The Sawbones] (1894), Lion Daudet (18671942) paints a ferocious caricature of the “Napoleon of neurosis” under the pseudonym “Foudange” [Insangel], one year after his state funeral. In his turn, the Swede Axel Munthe (1857-1949), in 7%eStoy of San Michele (1929), wrote such a description of hysteria at the Salpttrihe under the reign of Charcot that the

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publisher of French translation of this doctor’s memoirs felt obliged to withdraw the chapters “La Salp&ri&-e”and “Hypnotism” for reasons of 12se-majestb. The causes of the falling out between Charcot and his Swedish disciple in 1883 have not been established. Paradoxically, it was the surrealists, in the article by Louis Aragon (1897-1982) and Andrk Breton (1896-1966), themselves doctors turned writers, with its provocative proposal to commemorate “The 50th anniversary of hysteria” (1878-1928) who once again in the “crazy years” revived the interest of historians of psychiatry in this part of Charcot’s work.. Contemporary biographers again seem to be attaching an important role in the work of Charcot to his “Lessons on hysteria’’. Denis P. Morozov

Principal works CHARCOT U.-M.), CEuvres complt2es (.I Lecons sur les mu/d i e s du syst2me nerveux) [Complete works (Vol. I11 Lessons on the diseases of the nervous system)], Paris, Progrks mkdical, 1887. CHARCOT 0.-M.), L’Hysthie. Textes choisis et prisentks p u ~ E. Trillat [Hysteria. Texts chosen and presented by E. Trillat], Toulouse, Privat, 1971. Republished Paris, L’Harmattan, 1998.

Bibliographical references DAUDET (L.)yLes Morticoles, Paris, Charpentier, 1894. ARAGON (L.) and BRETON (A.), “Le cinquantenaire de I’hystkrie (1878-1928)” [The 50th anniversary of hysteria (18781928)], La R h o l u t i o n surrbaliste, 11 March 1928, p. 20-22. MUNTHE (A.), The Story of San Michele, New York, Duffin, 1929.

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GUILLAIN (G.), “I1 est injustifik et erronk d’oublier l’czuvre de J.-M. Charcot sur les nkvroses” [It is unjustified and mistaken

to forget the work of J.-M. Charcot on the neuroses], Sem. H+., Paris, 1949 (25), p. 147-160. OWEN (A.R.G.), Hysteria, Hpnosis and Healing: the Work of Jean-Martin Charcot, New York, Garrett, 1971. PEREZ PINCON (H.), El teatro de Zas histericas, Mexico, F.CE., 1998.

Eighteenth Lesson

Concerning Six Cases of Hysteria in Men.

Abstract.-Hysteria in the male is not as rare as is thought.-Role of trauma in the development of this disorder: Railway-spine.-Tenacity of hysterical stigmata in major sufferers of both sexes. Description of three typical cases of full hystero-epilepsy in males.-Striking resemblance between these three cases and to the corresponding cases observed in women. Gentlemen, Today we will be considering hysteria in men, and in order to circumscribe the subject more effectively, we shall consider male hysteria more particularly in subjects who are adolescent or fully mature and in the prime of life, in other words men between the ages of 20 and 40, and, in addition, we will examine in particular the intense, very accentuated form, the form which corresponds to that which is called, in women, major hysteria or hystero-epilepsy with mixed fits. The reason why I have decided to discuss this subject, which I have already covered many times, is that we currently possess within the clinic a truly

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remarkable assembly of patients, whom I will be able to present and study with you. My goal is, above all, to enable you to recognize and, so to speak, put your finger on, the identical nature of the full neurosis in both sexes. For, in the comparison which we will make, as we proceed, of the symptoms of major hysteria in women and in men, we will everywhere be able to observe the most striking similarities, and here and there only a few differences which, you will see, are of an entirely secondary nature. Moreover, this question of male hysteria is, in a sense, the order of the day. In France, in recent years, it has greatly preoccupied doctors. Between 1875 and 1880, at the Paris Faculty, five inaugural dissertations were presented on male hysteria, and Mr Klein, the author of one of these theses under the supervision of D r Olivier, recorded 80 cases of this disorder. Since then, there have been significant publications by Mr Bourneville and his students; by Messrs Debove, Raymond, Dreyfus and a number of others; and all these works suggest, amongst other things, that cases of male hysteria are to be encountered with relative frequency in everyday practice. Just recently, male hysteria has been the object of investigation, in America, by Messrs Putnam and Walton, * principally subsequent to traumas and more specifically to railway accidents. They have recognized, together with Mr Page, who has also examined this question in England, that many of these nervous accidents referred to by the name Railway-spineand which, according to them, would more accurately be designated Railway-brain, are, in sum, whether arising in men or women, simply hysterical manifestations. The interest that such a question arouses in the practical minds of our American colleagues is therefore easy to understand. The victims of railway accidents naturally demand damages from the Railway Companies. 1. I. Putnarn, Am. lourn. of Neurology, 1884, p . 507.-Walton., Arch. Ofi Med., 1883, v. X. 2. Page, Injuries of the spine and spinal cord without apparent mechanical lesion, and nervous shock, London, 1885.

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Claims are made; thousands of dollars are at stake. Yet, I repeat, often it is hysteria which is in question. These nervous states, serious and persistent as they are, which occur subsequent to “co1lisions”of this kind and which make it impossible for the victims to work or to pursue their occupations for periods of months or even of years, are often simply hysteria, nothing but hysteria. Male hysteria therefore deserves to be studied and to be understood by court medical experts, since significant legal interests are at stake, and these may perhaps be affected-a circumstance which will render the task more difficult-by the disfavor which still today, on account of deep-rooted prejudices, attaches to the word hysteria. The increased knowledge not only of the disease, but also of the conditions under which it occurs will, under such circumstances, be all the more useful in that nervous disorders often arise quite apart from any traumatic lesion and simply subsequent to the psychic nervous disturbance which results from the accident and in that, frequently, they do not commence immediately after it; that is to say that, at a time when one victim of the collision, who may, for example, have suffered a broken leg, is already cured, having been unable to work for three or four months, another might be suffering nervous consequences which might perhaps prevent him working for six months, a year or more, but which might perhaps have not yet reached their full intensity. It is clear, in this case, how difficult is the task of the court medical expert and it is this medico-legal aspect of the question which seems to have revived, amongst our American colleagues, the hitherto somewhat neglected study of hysterical neurosis. As the condition has thus come to be better studied and better understood, as generally occurs in such circumstances, cases appear to become increasingly frequent, and at the same time easier to analyze. A moment ago I told you that four or five years ago Mr Klein, in his thesis, had assembled 80 cases of male hysteria; today Mr Batault, who is preparing, in our department, a special study of the

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subject, has been able to collect 218 cases of the same kind, of which 9 belong to our clinic. ’ Male hysteria is therefore not very rare-quite the contrary. However, Gentlemen, to judge from what I see each day amongst us, such cases very often go unrecognized, even by physicians of great distinction. It is admitted that an effeminate young man may, after excesses, sorrows, profound emotions, present a number of hysteriform phenomena; but that a strong, robust worker, not overstimulated by education, a locomotive driver for example, previously in no way emotional, at least in appearance, could, following a train accident, a collision, a derailment, become hysterical, in the same way as a woman, that is something, it would seem, which defies imagination. Nonetheless, the evidence is indisputable, and it is an idea with which we shall have to come to terms. It will come, as for so many other propositions which today are established in every mind as undisputed truths, having long been met with scepticism and often irony. There is a prejudice which, undoubtedly, contributes greatly to placing obstacles to the acceptance of disorders relating to hysteria in men: it is the somewhat false idea generally held regarding the clinical picture of that neurosis in women. In males, the condition is often remarkable in the permanence and tenacity of the symptoms which characterize it. In females, by contrast-and it is undoubtedly this which would seem to mark the crucial difference between the two sexes, for those who do not have a full understanding of the illness in women,-what is believed to be the characteristic trait of hysteria, is the instability, the mobility of the symptoms. In hysteria it is therefore said, naturally on the basis of observations made with women, the phenomena are mobile, fleeting and the capricious progress of the condition is frequently interrupted by the most unexpected coups de tb&tre. Well, gentlemen, this mobility, 1. E. Batault, Contribution 2 l’ktude de l’hyst&ie chez I’homme.

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this fugacity is not, is very far from, as I have shown you by numerous examples, an unequivocal characteristic of hysterical illness, even in women. Yes, even in women, there are hysterias with durable, permanent phenomena, which are extremely difficult to change and sometimes resist all medical intervention. And cases of this kind are numerous, very numerous, even though they do not constitute the majority. This is a point to which I will return. But, for the moment, I will simply draw your attention to the fact that the permanence of the hysterical symptoms in men, their tenacity, often prevents their being recognized for what they are. Some, in the presence of phenomena which resist every therapeutic intervention, will conclude, I imagine, in the event of sensory disorders with nervous attacks similar in many respects to an epileptic fit, that there is a lesion of organic origin, an intracranial neoplasm or, if paraplegia is involved, an organic spinal lesion. Others will be happy to recognize and will even insist that there can be no question, in these cases, of an organic impairment, but simply a dynamic lesion; but in the presence of symptoms the tenacity of which does not accord with the pattern, which they have in their minds, of hysteria, they will think that they have encountered a special illness, not yet described, which merits a separate category. An error of this kind seems to me to have been committed by Messrs Oppenheim and Thomsen (of Berlin),' in a paper which otherwise contains a great number of facts which are interesting and well observed, if not always well interpreted, at least in my opinion. These gentlemen observed sensitive and sensory hemianaesthesia, similar in every respect to that of Messrs Putnam and Walton. Here, the cases concerned drivers, railway inspectors, workers, victims of train or other kinds of accidents who had suffered a blow to the head, or a commotion or general disturbance. 1. Arch. de Westpbal., Bd. XV, Heft 2 and 3.

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Alcoholism or lead poisoning are not involved in these cases, and it is recognized that, in all likelihood, these subjects are not suffering any organic lesion. Here, therefore, are patients altogether similar to those of Messrs Putnam and Walton; but unlike the latter, the German authors do not wish to acknowledge that the condition is indeed hysteria. For them, it is something special, some hitherto undescribed pathological state, which requires t o be allocated some as yet unoccupied place in the nosological classification. The principal arguments deployed by Messrs Oppenheim and Thomsen in support of their thesis are as follows: lothe anesthesia is tenacious; it does not present those capricious changes which are characteristic (?) of hysteria. It remains unchanged for months and years; 2' another reason is that the psychic state of the patients is not that of hysterics. The disorders of that kind, in these patients, do not have the changeable, mobile nature of those of hysteria. The patients exhibit a tendency to depression, to permanent melancholy, without significant variations for better or for worse. It is impossible for me, Gentlemen, to be won over to the conclusions of Messrs Oppenheim and Thomsen, and I hope to demonstrate: lo that hysterical sensory disorders can, in women themselves, present a remarkable tenacity, and that, in men, this is very often the case; 2 O that in men, in particular, depression and a tendency to melancholy are most frequently observed in the most obvious, least contestable cases of hysteria. In men, one does not generally observe-it is true, but it should certainly not be seen as a distinctive primary characteristic-those caprices, those changes of character and of mood which more commonly, though nonetheless not necessarily, characterize female hysteria. But it is time, Gentlemen, to end these preliminaries and to come to the principal purpose of our lesson today. We are going to proceed by clinical demonstration, by studying together, with a few details, a certain number of perfectly

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characterized cases of male hysteria. In the process, we will identify the similarities and the differences which exist between the hysterical phenomena observed in men and those which we recognize each day in the corresponding form of the illness in women. Finally, I intend to present to you, by way of summary, a number of general considerations regarding major hysteria considered in the male sex.

c. .I

Gentlemen, in studying with you, in these two lessons, the six highly significant cases which chance has placed beneath my hand, I have sought above all to convince you that hysteria, even severe hysteria, is not, at least here, in France, a rare condition; that it can, in consequence, occur, here and there, in ordinary clinical practice where only the prejudices of another age might cause it to go unrecognized. I dare to hope that after the very many proofs that have accumulated in recent times, this notion is destined henceforth to occupy, in your minds, the place that it deserves to hold.

Valentin Magnan (1835-1916)

Valentin Magnan is one of the great names which have punctuated the history of the Sainte-Anne asylum. Born in Perpignan, he was successively a medical resident at the hospitals of Lyon and Paris. H e worked in Lenticaille, at Bickre with Louis Marck (1828-1864), the man who was to describe puerperal madness, and above all at the Salp6triGre with his two masters Jules Baillarger (1809-1890) and Jean-Pierre Falret (1794-1870). His abilities were recognised very early on, and with his friend Gustave Bouchereau (1835-1900) he was in charge of the SainteAnne admission’s office, roughly the contemporary equivalent of the psychiatric emergency department. His principal publications dealt with the effects of toxic agents, absinthe, but also morphine, cocaine and above all alcohol. In 1874, he published a treatise on alcoholism and the different forms of alcoholic delusion. “The poison attacks not only the individual, but also exercises a powerful action on his descendants, to the extent that alcoholism is becoming the most actite procurer for the hospitals and asylums and a serious social threat which will in the end, if nothing is done, bring about the intellectual, physical and moral degradation of the race.’’ Magnan thus attributed a significant role to what at the time was commonly defined as insanity. Moreover, he envisaged the construction of special areas dealing with alcoholics, and even asylums set aside for this purpose.

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He charged his student Maurice Legrain (1860-1939, physician at the Ville-Evrard asylum) with leading an anti-alcohol crusade and together they published numerous texts on the evils of intemperance. Known for his clinical classes, he taught mainly on acute and chronic alcoholism and general paralysis, but also on his master MarcC’s puerperal madness. From this point of view, Valentin Magnan became the leader of the school which instituted the teaching of psychiatry at the Sainte-Anne hospital. His medico-legal work was obviously marked by his ideas on the responsibility to be attributed to alcoholics, but also by certain studies on onomatomania (with Jean-Martin Charcot, 18251893), kleptomania and sexual perversions. H e was the first alienist to describe the compulsion of dipsomaniacs as a “morbid, irresistible need, independent of the will”. His classes on dipsomania form the second part of his work: “Clinical lessons on mental diseases given at the clinical asylum (Sainte-Anne)”. Magnan defined dipsomania as a syndrome, a short fit of impulsive melancholia, an irresistible attraction which at intervals impels the individual to drink excessive quantities of intoxicating liquors. “The principal characteristic of dipsomania, we have said, is found in essentially intermittent and paroxystic fits which leave behind them a cerebral discomfort which gradually lessens, and patients revert to their sober habits, regretting the abuses in which they have momentarily indulged.” Magnan takes up Morel’s doctrine of degeneration and applies it to the clinical study of alcoholics. Thus, while the need to drink is the most obvious symptom, Magnan shows that these fits of intemperance occur against the background of a pathological heredity. This special terrain of morbid predisposition is graded from the merely predisposed to the degenerate. He describes dipsomania as: “an episodic symptom of a more profound mental state which is dependent on heredity.” Valentin Magnan sought to group the mental stigmata of degenerates (obsessions, impulses, retardation phenomena) into intermittent fits typical of the insanity of these individuals with their imbalance of intelligence or of emotion, victims of their irresistible drives. The class of hereditary degenerates produces four types of mental manifestations: the first group includes idiocy, imbecility ant

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26 1

mental deficiency; the second, cerebral abnormalities; the third, episodic syndromes; and the final group, delusion proper. It was with Maurice Legrain that Magnan would study delusion in degenerates, creating the famous acutefit of delusion. Strangely, this entity, which still survives in French classification and in daily psychiatric practice, was never described at length by Magnan: “a primary, multiple, polymorphous delusion, sometimes of short duration, but with no established course of development .” The thesis by his pupil Legrain alone contains the most famous aphorisms of classical French psychiatry:

“clap of thunder in a cloudless sky” to mark the suddenness of the onset; “equipped from head to foot” for the clinical picture immediately established; “without consequence, ;f not without future” for the rapid cure with a return to normality; “ephemeral budsappearing on a single trunk” for the possible evolution in the form of acute repeated fits of delusion. Magnan was also interested in chronic delusion with four-phase systematised evolution: incubation (exogenous interpretations of suffering experienced), persecution (psychosensory hallucinations which systematise the delusion), ambition (emergence of ideas of grandeur) and dementia (encystment of delusion, indifference and impoverishment). He completed Laskgue’s work with an ultimate systematisation of the structure of chronic delusions. Fransois-RCgis Cousin

Principal works MAGNAN (V.), De l’alcoolisme [On alcoholism], Paris, 1874. MAGNAN (V.), Legons cliniques sur les maladies mentales [Clinical lessons on mental diseases], Paris, Publications du Progrks mkdical, 1891, 2nd Cdition 1893, collected and published by M. Briand, M. Legrain, Journiac, and P. SCrieux.

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MAGNAN (V.), SERIEUX (P.), Ddire cbroniqtre d kvoltrtion systhnatiqtre [Chronic delusion with systematic evolution], Paris 1891. MAGNAN (V.), LEGRAIN (M.), Les Dlglnirks [The Degenerates], Paris, 1895. Principal references

“Magnan”, in BERCHERIE (P.), Les Fondements de Za clinique. Histoire et strtrcttrre dtr savoir psycbiatrique [The foundations of the Clinic. History and Structure of Psychiatric Knowledge], Paris, Seuil-La Bibliothkque d’Ornicar, 1980, Chap. 13, p. 129138. MAGNAN (V.), Le Ddire cbronique h kvolution systlmatique [Chronic delusion with systematic evolution]. Preface by J. Chazaud, Paris, L’Harmattan, 1998. COUSIN (F.-R.), VANELLE (J.-M.). “Dkfense et illustration du concept de bouffies dklirantes aigues” [Defence and illustration of the concept of acute fits of delusion], L’Information psychiatrique, 1987, 63, p. 315-321. GARRABE (J.), COUSIN (F.-R.), “Acute and transient psychotic disorders”, in New Oxford Textbook of Psychiatry, to be published 1999.

Clinical Lessons on Mental Diseases Delivered at the Clinical Asylum (Sainte-Anne)

[. . .] Hereditary madness therefore forms an absolutely distinct group. The characteristics we assigned to it above and the numerous facts which we have, at many times, had the occasion to make known, have, we believe, sufficiently demonstrated this. We can further add clinical proofs drawn from delusion in the degenerates, from their sexual perversions and from their physical stigmata. The deranged by heredity are deluded in a manner which is specific to them, and their delusion possesses typical characteristics which are perfectly recognisable. The chief one consists in the sudden appearance of the delusional ideas; in a few hours, in a few days, at most in a few weeks, a very intense delusion may be seen to develop which can adopt all the forms (maniac, mystical, erotic, ambitious, etc.). The delusion evolves rapidly, it may be simple, that is to say constituted of only a single form, but frequently one sees several forms succeed each other, and the patient who yesterday was ambitious, today is persecuted; in a few days he will be hypochondriac. This is a manner of delusion which is specific to those whose condition is hereditary. This it is which constitutes immediate delusion (primary delusion of Krafft-Ebing and of Schule). It does not present a regular

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development like chronic delusion, for example, and it usually ends suddenly, as it came, having occupied the stage for a brief period of time. Here is an example of immediate delusion, of ambitious form, in a defective degenerate:

Observation V1.-Feeble-mindedness. -Ambitious delusion. N.. ., aged 45 years, was admitted on 17 September 1886, having created a public disturbance in the street by representing warlike scenes after his own fashion. He was a natural child, but his father, he says, must have been a man of importance, for he had been used to come to see him as an infant in a carriage drawn by two horses. Brought up in an hospice, he had been apprenticed in the clog-maker’s trade, and had then departed for his craftsman’s Tour of France. He lived in this way, travelling a great deal, something of a vagabond, incapable of sustaining continuous employment and of establishing himself in a particular locality. He learned in some degree to read and write. Some five years ago, he had remained for a certain time in a large shoe factory, where his fellow workers took advantage of his simple-mindedness. They advised him one day to go to Lourdes to drink the miraculous water, adding: “It would not be surprising if it did you good.” Not understanding that he was being mocked, he took an opportunity to go to Lourdes, visited the grotto, and, trembling with emotion, swallowed, one after another, several cups of water. The next day, the holy water had its effect; he felt that he had become an artist and began to compose poetry. Full of himself, he resumed his former vagabond’s life and became very poor. As he was refused assistance, the idea came to him to put to profit the artistic talent which had been revealed to him at Lourdes. He requested permission to sing in the village cafes; he was granted a permit to sing

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in the streets for two hours; he earned 6 francs. That was the beginning. Immediately, he composed a show programme, mixed and combined fragments of operas, of melodramas, which he had had the occasion to see performed, and travelled around France, managing to live in this manner. He would imitate the wild man of the woods and the diverse grimaces of the monkeys, or else sing popular or warlike refrains; a remarkable and convincing actor, his voice would be tender in songs of love or harsh in acts of tragedy; pathetic or playful, he was able to make people weep or laugh, but he excelled above all in representing battles: he would fall while running like a soldier struck down during an attack. His delivery was remarkably realistic and his attitude entirely grotesque. H e would stop in the villages and first put himself in order with the municipal authority, then he would travel the streets shaking his castanets and bells on the end of a stick. As the passers-by gathered, he would announce his show. In his gestures and shouts, he would imitate the din of battle. He would mime the battles of the Revolution, personify the generals Marceau, Desaix, etc., represent alone the crossing of the bridge at Arcole, the clamour of the soldiers, the noise of the cannon, and when, in the midst of the streets, he ran, fell, stood up, fell backwards, uttering loud cries, imitating, he said, Marceau struck in the heart, dying for his country, so patriotic was the scene that the applauding public would reward him by throwing coins. So great was his gusto that he would quickly be covered in sweat. To fortify himself, he took to alcoholic drinks. In a page covered in strange drawings, N.. .described part of his existence and the capital fact that he became an artist after drinking the water of Lourdes. That is why, he said, there was a similarity between his story and that of Joan of Arc, who was the daughter of peasants and who, as she prayed by a fountain, had drunk water as he had. His speech was very remarkable in the disconnectedness of the ideas. His story was

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interspersed with strange quotations, with couplets, with songs. He gave a representation of himself fighting a duel. Since his admission into the asylum, he has filled numerous sheets of paper with his drawings, his poems or his writings. He intends soon to become a painter. H e has written a letter in which he complains that the administration has not yet had the wisdom to employ his talents. H e would have entertained the patients of the Asylum, and the receipts from the paying public would have earned it a considerable sum. At times, he claims to be a prophet, but this new ambitious idea is fleeting. An instant later, he loses interest in his prophecies. He is employed in the shoemaking workshop, and with the pieces of leather he picks up, he claims he is constructing a cathedral. He always carries a pencil and paper. He composes, studies types, and takes notes for his future representations as he goes about his business.

Valentin Magnan (1835-1916) and Paul Legrain (1860-1939) Delusion in Degenerates The Immediate Delusions

Clinical practice teaches that a considerable number of delusions have as their essential characteristic the remarkable suddenness of their appearance, the absence of forewarning. In a few days, in a few hours, sometimes from one minute to the next, delusional ideas arise, sometimes for no apparent reason whatsoever. In the midst of the most complete calm, there suddenly occurs an outburst of delusional ideas. In certain cases, epileptic delusion is the only condition whose sudden appearance can be compared to this explosion of intellectual disorders. Every kind of delusional idea may be observed in these cases. Sometimes it may be a delusion of persecution; patients suddenly believe themselves to be under special surveillance, to be the object of espionage by imaginary enemies, or by the people who are ordinarily around them; or else, they are being persecuted by the priests, the Jesuits, and are subject to some secret machination. Very often, it is an outburst of ambitious delusion; they have a divine mission, believe themselves to be God or Jesus Christ; they have an exalted destiny; they will be kings, emperors, prophets; they are possessed of an immense fortune. All these delusions are expressed sometimes with a calm and

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coolness which clearly demonstrate the patient’s certainty; sometimes with an enthusiastic exaltation, in the case of ambitious delusions, sometimes with inexpressible terror, in the case of ideas of persecution. At other times, in the midst of daily activities, an attack of mania may suddenly occur with complete disorder of speech and action, and multiple hallucinations. At yet other times, the delusion takes a mystical form. O r else, the delusions may be of other types impossible to define, which are specific to degenerates. Suddenly, they become unable to recognise the people around them; are astonished when they are addressed by their name, and maintain with conviction that they no longer exist. In general, the delusional ideas quite closely reflect the habitual mental state of the patient; the defective does not have the same delusion as the intelligent degenerate; their attitude is generally recognisable. Whatever the evolution and the outcome of these different delusions, that which characterises them above all is their mode of appearance; only the degenerates, as the many observations published here will show, are predisposed to this form of immediate delusion. For a significant inteliectual disorder to occur and reveal itself in so little time, a prepared terrain is required, a brain which can easily be unbalanced. Moreover, it is a simple functional problem with no impact on the general health of the patient; the temperature remains normal and the major functions perform regularly throughout the whole period of the attack. This characteristic of sudden appearance has enormous importance for diagnosis and for prognosis alike, as becomes clearly apparent from reading our observations. The immediate delusions are the most common, as episodes during the lives of degenerates. The latter may, it is true, experience delusions of other kinds, but it is much less frequent. We will also see them experience delusions of essentially chronic evolution, just as as we have sometimes seen delusion follow a long period of preparation (Chapter I: On tendencies to

delusion).

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How greatly, however, these latter cases differ from immediate delusion! Instead of seeing the disorders arise unexpectedly in the midst of complete intellectual health, like some kind of sea squall, there is a gradual modification of the ideas; these are transformed little by little in the direction of the future delusion, and the beginnings of that delusion may be of very long date. The emergence of the delusion is expected, while here, there is no warning. The observation that follows is that of a defective, who, suddenly, during the day, as he was performing his functions as an omnibus driver, was seized by an attack of mania, as a result of which he passed several months at Sainte-Anne. During this time, the attack of mania, having attained its peak immediately, gradually diminished until completely cured. The patient gradually reconstructed his memories, as his agitation diminished, and wrote down a large part of his story which he completed verbally. The cure has been maintained for a year.

Observation XVI.

Maniac delnsion occurring suddenly in a degenerate by heredity. Complete cure. N.. .Etienne, aged 21 years, was admitted to Sainte-Anne on 9 December 1884. HEREDITARY

ANTECEDENTS.--Pdternal

side.-Father.

Severely alcoholic, sad, melancholic, violent headaches, “loses his head”. Maternal side.-Mother. Extremely limited intelligence. No intellectual education. Lively, sometimes loses her temper. Brother. Deceased aged 25, alcoholic. Four brothers or sisters dead around the age of 2. Two brothers (aged 20 and 23) alcoholic. Sister, aged 35, “fell down every month as if dead.” Her arms shook with convulsions. Brother, aged 28, fell

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unconscious twice during his military service. Two cousins received treatment in an asylum for the insane. PATIENT’S HISTORY .-Personal antecedents.-College pupil until age 17, he then entered the seminary. He was destined for the priesthood, somewhat against his will. Mysticism is very widespread in the family. He remained a short time at the seminary and, around the age of 18, came to Paris, where he took employment as an omnibus driver. Character entirely gentle, very regular habits; has always been sober. No excess of drink, no sexual excess. No absences, 120biting of the tongue, no sudden paleness. In the three years he has spent in the same lodging and in the same employment, neither the landlord, nor the depot chief have noticed fainting, or nervous attacks. His childhood was also devoid of any convulsive problem. Maniac delusion. Sudden onset as in epileptics.-Suddenly, on 8 December 1885, while the omnibus was in motion, having received his usual fare, he began to argue with the passengers and claimed double what he was owed. He removed his cap, his jacket and his bag, grasped hold of the coachman saying: “I am stronger than you, stronger than anyone.” He claimed he was Victor Hugo. He was taken to a pharmacist, and from there to the Prefecture, in a state of furious maniac agitation. Later, we will report the patient’s own words, in which he recounts the various details regarding the beginning of his illness, as he gradually recovers the integrity of his memories. For the moment, let us follow the development of his delusion during his period at Sainte-Anne. State of the patient on his arrival.-Furious delusion, very violent agitation, disordered movements, shouting, sudden impulses; he attempts to fling himself on the people around him. Visual hallucinations.-10 December. Same excitation, incessant loquacity, incoherent, mystical and ambitious speech. Constant spitting. Refusal of food. Temperature 38O.--11 December. Insomnia. Speaks of the devil, mistakes various people for his father, whom he sees covered with

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stains which he wishes to remove. Incoherent speech: “If you come here, you are lost.-No, I do not want to drink.-I have no money.-I do not want to take anything for anything.-I want to earn it, etc.” Temperature 37.4’. Clings to clothes, kicks at the empty air, but does not attack directly.-I2 December. Night of insomnia: singing, shouting. Bed smeared with faecal matter. Hands covered in it, he wipes them in his hair.-I4 December. Same state. Speech in which God and the devil are mixed.-I5 December. Obscene language; still the same incoherence: “Victor Hugo, my father, etc.” Temperature 37.4O. The same state continues, without alteration, until the beginning of January.-January 1885. Towards the 6, the agitation diminishes considerably in intensity, the patient speaks little. He sometimes remains for hours lying on a bench.-On the 10, he enters a depressive phase with cooling of the extremities. Sad, hunched position, sometimes weeps and complains.-I5 January. He is again talkative and incoherent, speaks half Breton, half French; God, the Virgin, his cousin constantly recur in his speech. He does not answer questions and adopts an air of inspiration. He sometimes adopts the posture of a priest saying mass and murmurs prayers: “Forgive me, 0 Lord; when you laugh, I weep.” His delusion has become entirely mystical, but the maniac form persists. The nights are good.-I9 Jantlary. Same posture, same delusion; lamentations, prayers, tears; suppliant attitude. “God, the Angels, Paradise, Hell, etc.” His delusion is sometimes interspersed with attacks of violence, but always directed against imaginary beings. The same state continues with the same characteristics, without further alteration throughout the end of January and over the month of February. Towards the end of this month N.. .becomes less incoherent; sometimes during the day he has moments of complete lucidity, when he attempts to remember who he is and to reconstitute his memories. Then the delusion returns, but without great intensity. One feels that it is gradually easing. The general

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state is still excellent. The nights are good and the patient eats well. March 1885.-From the beginning of March, the recovery is almost complete. N.. .continues sometimes to have that mobility of mind which characterises the maniac, but it is now possible to fix his attention; the delusion has completely disappeared. His memories are becoming increasingly precise, and he is gradually managing to reconstruct his entire history. The first thing he remembers is the start of the attack. He was leaving Grenelle with his coach at 2.10 in the afternoon. Arriving at the bottom of the boulevard de Vaugirard, he rang for a passenger who has just mounted; he “experienced, he says, a rising at the level of the stomach, rising to [his] head” and he sank onto his left side without completely losing consciousness, then felt a trembling in his limbs; having now been overtaken by his maniac delusion, he was taken to a pharmacy. He very well recollects the moment when he entered this place. What took place next is still hidden behind a veil. Nor does he remember what he said to the travellers.--16 March. He has recovered all his lucidity of mind, and he remembers the whole delusion, as is proven by the following extracts from a letter which he sent to his brother-in-law on that date. “. . .I ask you to make my excuses to all my friends who had the kindness to visit me, for I confess that I blame myself for my manner towards them, as also for the words which I had the effrontery to pronounce before them. O n the day of my release, if my health continues to improve, which I sincerely hope, I shall repair all my offences.. .To judge by the manner of behaviour of the inhabitants of this place, and recalling my past conduct, I would imagine myself to be in an insane asylum. (He believed himself in a hospital, and this reflection proves to what extent his judgement had been restored.). ..It would appear that I am destined to suffer every possible disease on earth, though finally, madness, if mad I am, is the most cruel.” O n 23 M a d , he completed his recollections with an account. Here are extracts from it, which are of considerable

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value. “...Here are a few details on the events of 9 December 1884, at about 2.20 in the afternoon: All of a sudden, I felt myself seized by nervous trembling. My coachman was obliged to call a policeman, who accompanied me to a pharmacy in the rue Lecourbe. Here, the pharmacist attempted to make me drink a certain potion which I rejected with anger. I pushed away the people whose physionomy displeased me, expecting at any moment to yield my last breath. The policeman took me in my omnibus to the Grenelle station. I was searched, a statement was taken, and I was then placed in a cab and conducted, accompanied by two policemen, to Mr Fuccioni. At the moment I was preparing to seat myself in the cab, I seemed to see flying above my omnibus, which was preceding the cab, a snow-white dove. The first person I saw before me was a girl whom I pushed away with disdain.. . “On my arrival at the commissary, vain attempts were made to question me, for I was incapable of pronouncing a single word; I became angry on hearing the clerk described himself as God; it even became necessary to tie my hands, following which I was conducted to Necker, where they did not wish to admit me. Before leaving the hospital, I was presented to a nun whom I was unable to see before my eyes. The sight of a workman brought some relief to my sufferings. It was raining, nevertheless I was taken to the Prefecture. I was asked further questions which I was unable to answer. I was placed in a cell and held in a straitjacket, then brought here.” Finally, on 24 March, he added a further account to his previous information, with some reflections on his period at the asylum, which very clearly show the accuracy of his recollections.-Having definitively embarked on convalescence, he was released on 11 April 1885. Not one single sign suggesting the existence of epileptic neurosis was identified. This observation is instructive in more than one respect. First, in part heredity, in part the patient’s mental state,

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clearly establish the nature of the terrain on which the delusion grows. The sudden onset of the attack and its description offer a clear idea of immediate delusion. This suddenness was such that, initially, the diagnosis wavered between an attack of epileptic delusion, and an attack of mania. The diagnosis was clarified by the development of the condition; its duration is incompatible with the idea of epilepsy; the absence of the other signs of epileptic illness, together with a reconstruction of the facts, which the patient drew from his own memories, rules out the idea of fainting followed by delusion. Finally, the cure, which was rapid and complete, shows us yet another of the main characteristics of delusion in degenerates, one which we will discuss later: in the vast majority of cases, immediate delusions are cured; the suddenness of the onset, once the idea of epilepsy has been ruled out, allows the clinician to form a favourable prognosis. Moreover, an exact knowledge of the terrain on which the delusion develops will put him on the path to a diagnosis. Immediate delusion is entirely specific to degenerates. It is also very common. It is even so frequent that, on occasion, it may occur as a supplementary syndrome in the course of a delusion of chronic development, which, it should be recalled, is often observed in the same patients. A patient, for example, may already have been in delusion for several months; his delusion is of a chronic type and, as such, the prognosis is already somewhat unfavourable, when suddenly, breaking the monotony, there takes place an outburst of delusion which markedly interrupts the first one, just as we earlier saw the immediate delusion contrast, in so singular a manner, with the calm of mind a few days or a few hours before. This outburst is no more than an incident, and a very fleeting one, which disappears as it arrived, and the initial delusion resumes its course as if nothing had happened; it is a storm of short duration which has no logical connection with chronically evolving delusion and which is entirely isolated. Thus, in the course of

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a persecutory delusion of slow and gradual evolution, like those we shall see later, there arises a delusion of grandeur which passes like lightning, enters the patient’s mind like a fixed idea for a few hours or a few days, during which the patient becomes so attached to it that one might believe that a sudden transformation of the pre-existing delusion has taken place; however, this is not the case; calm is restored, and the original delusion, which seemed to have disappeared, continues its course. In this way, several successive outbursts can take place, each time in a different form, throughout the illness; they leave no trace behind. Under no circumstances should it be imagined that several delusions coexist; all these delusional flashes are like so many ephemeral buds belonging to the same trunk. [. * .I Immediate delusion is thus quite different again from chronic delusion, that major form of insanity with its four distinct periods, its essentially systematised delusion, grafted onto hallucinatory disorders. The mechanism by which the hallucinations occur differs in the two cases. In chronic delusion, they are essentially primitive. The whole delusion is constructed on them; if they did not exist, the subsequent delusion would not exist. In the delusional degenerate, when hallucinations exist, they form quite differently. They are contingent symptoms of the disease, but they do not constitute its immutable basis; indeed, many delusions in degenerates evolve without hallucinations; when hallucinations are seen to complicate the disease picture, they are usually caused by the delusion itself, through the following mechanism: all the brain centres are in a state of complete erethism; the anterior brain creates the delusional ideas and evokes the images in the posterior centres. These images are then represented in the anterior centres, with such vividness, that they are interpreted as realities. Thus, the hallucination has its direct cause in a series of delusional ideas which brings it into being, and it arises like a form of reflex.

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The centripetal route begins from the anterior centres, where the delusional idea is produced, attains the posterior regions of the cortex where the image is created, then returns to the anterior centres, bringing back the image thus created, which then intermingles with the delusion to form an apparent reality. Let us take an example! A very devout female defective patient, much weakened by voluntary fasting for the purpose of penance, has for some time been taken up with exaggerated religious practices. All of a sudden, her mind becomes exalted and she constructs a delusion of mystical form, with hallucinations. She recalls passages from holy books where God spoke to the prophets, unconsciously evokes them, and hears God speaking to her; her attitude is that of the hallucinated; in her excess of delusional excitation, God appears to her as she has seen him represented in sacred images, etc. Here is an example of immediate delusion with hallucination such as is often observed. Quite different is the hallucination in chronic delusion, where it is the primary element. It comes into being in situ, in the posterior regions of the cortex, without being provoked. It is caused by a gradually developing local lesion, and it is the functional expression of an anatomical lesion. Starting from this point, it reaches the anterior regions, taking them by surprise. The front brain, in full possession of its equilibrium, of its judgement, interprets it as a real fact, and draws from it logical conclusions which are the initial delusional ideas. A wholly systematised delusion then develops, which brings disorder to an intact, well balanced, intelligence which reacts with all the force of its energy. In the degenerate, the subject participates fully and wholly in his delusion from the start; in the subject with chronic delusion, this participation is slow, progressive; the systematisation evolves little by little, due to the persistence of the hallucinatory problems. Its physionomy is very clear and quite different from that of immediate delusion.

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How do the immediate delusions evolve? They are essentially temporary; they do not occupy the pathological scene for very long; they are not consistent. Occurring suddenly, they often disappear in the same way, in a few hours or a few days. Internment generally elicits a beneficial response; the patient, usually a defective, renounces his delusional ideas of his own accord, when they are shown to have little foundation; it does not generally require much effort to obtain this result. After a few days, the patient asks to be released and acknowledges his error.

r. .I

Immediate delusion does not always take so elementary a form, and a clinical aspect which is often observed is as follows: A patient enters the asylum with a delusional idea; a few days later another appears, erasing the first, with which it is in no way linked; a little later a third delusional idea, then a fourth follow, etc.; and so on for an indeterminate period. What has occurred here, therefore, is a series of delusional outbursts, all of them immediate delusions, all different one from another, without any cohesion. These variations which the delusional ideas undergo within a very short period are another of the major characteristics of delusion in degenerates. This delusion is essentially changeable in form; this is further proof of the absence of foundations on which the intellectual disorders rest. Profoundly unbalanced, degenerates bring this aspect of their mental state to the manner of their delusion; they are unbalanced, illogical, in their delusion as they are normally. The observation which follows is a type of multi-form delusion. The patient, feeble-minded, presents one after the other ideas of persecution, ideas of grandeur, melancholic ideas, hypochondriac ideas, intellectual disorders which follow each other at short but very variable intervals which sometimes overlap and which, all in all, constitute a wholly inextricable polymorphous delusion.

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ObservationXIX

Mental defectiveness. Very rapid succession of a large number of delusional ideas, without cohesion between them. HEREDITARY ANTECEDENTS-Mother, alcoholic. The other antecedents are unknown to us; the patient, claiming to be the son of Mac-Mahon, was unwilling to provide us with the means to obtain information on his heredity. The day of his admission, he stated he was the son of an unnamed father. PATIENT’SHISTORY.-very low intelligence, rudimentary instruction; is able simply to read and write; his mental state seems always to have been that of the discontented defective, interpreting the slightest fact to his disadvantage, considering himself something of a victim. At the same time, arrogant, somewhat enamoured of himself. His state of intellectual defectiveness may be better judged from the few extracts of letters which we give below. The delusion for which he was admitted to Sainte-Anne seems to have begun some three months previously and its onset does not seem to have been sudden. However, its development has always been devoid of rules, presenting the greatest mobility, implanted to no great depth on illogical and unbalanced terrain. Every kind of delusional idea is represented in this delusion, the patient successively adopts every possible attitude; today, excited; tomorrow, depressed, hypochondriac. However, in the midst of all this jumble of delusional ideas, two forms dominate and recur at every instant: the ambitious form, the persecuted form. Delusion. The first delusional idea occurred three months ago. At that time, he suspected that he belonged to a great family. Little by little, he had become accustomed to this idea which had become systematic three weeks previously, at which time he became the son of Marshal Mac-Mahon. Also at this time, his sister, a certain lady H.. .begins to

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persecute him, makes him lose his employment and has him followed in the street; she makes him put drugs in his food, and has him insulted. For fifteen days, he has been sending her foolish letters. He hears himself called an old woman, and also interprets in accordance with his delusion every word he hears and everything he sees. In restaurants, poison is mixed with his food. Hypochondriac preoccupations further contribute to his torment; he believes himself suffering from a disease of the heart. Since he stopped working, he sometimes occupies himself by writing verses and sends love letters to his cousin. Finally, recently, apart from his family connection with Mac-Mahon, he has further claimed close links with Admiral Courbet. Such was the state of B.. .when he entered Sainte-Anne. He expresses all his delusional ideas with the greatest coolness. He is totally convinced, and has the most sincere faith in his hallucinations.. .

c. .I *

It is clear from this observation that the beginning of the delusional period does not have the suddenness that we have noted in the other cases. That is because, under the name immediate delusion, we include delusions with a rapid onset, as is the case here, i.e. delusions without prodromes. The delusional forms which we will study in the next chapter have a similar onset, but their course and their evolution are different from those of immediate delusion. Observation XJX is a natural transition between the sudden temporary delusions and the delusions of chronic evolution. It finds its place here because of the successive outbursts of delusional ideas which make it resemble the previous cases. This observation of polymorphous delusion encompasses in a single delusional period the life of certain degenerates. Indeed, this observation can be dissociated and broken down into a certain number of cases of immediate delusion; instead of these cases succeeding each other very rapidly, following without transition, without a return to sanity,

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they can be conceived as separated one from the other by periods of calm of varying duration. The patient will then experience delusions several times in his life, and each time his delusion will make the same sudden eruption amidst the habitual calm of the intellectual life; only one difference needs to be noted: this is that the colour of the delusion will vary in each attack. This dissociation is very common in the life of degenerates. One patient, interned for the first time for an attack of mania which is cured, will later be interned for an attack of melancholia; another, interned for the first time for persecutory delusion, will appear a few years later with a new delusional outburst, this time ambitious in form. And thus, throughout the whole course of his life, the degenerate, because of his predisposition, will present a continuing disposition to delusion. It should be added, however, that a good number of patients never go beyond their first attack. This incidence of delusions with varied forms, at different periods in the life of a single patient, is only observed in degenerates. When the physician find himself in the presence of a second or third attack of delusion occurring in a single patient, especially if these attacks take a different form each time, he may conclude that a powerful hereditary predisposition governs the eruption of the delusion. Immediate delusion, therefore, assumes four different aspects from the point of view of observation: lo Simple, single, sudden, arriving like a squall and disappearing in the same way (Observation XVIII). 2 O Successive delusional outbursts, of varying forms, with or without remittences (Observation XIX). 3 O Delusional outbursts occurring at different times of life, separated by intervals of complete calm. 4 O Immediate delusions occurring in the course of a delusion of chronic evolution (Observation XVII). Whichever the case, it is always the sign of a state of degeneration. Fundamentally, all these cases are the same, and the same reflections apply. By definition, immediate

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delusion is a fleeting delusion. If we analyse the duration of the delusion in the few observations published here, we find that it does not exceed a few months. In observation XVI, where we saw a fine example of a cure, the fit of mania lasted two months and a half, including the acute period and the period of convalescence. In the vast majority of cases, the end of the attack is thus the expected outcome. We say end of the attack advisedly, because it is quite obvious that once the attack has ended, the terrain remains what it was before; in other words, the likelihood of a second or third delusion will always remain. It is here that we observe the third case described above: attack of delusion separated by intervals of calm. A practical conclusion must be derived from these considerations: in the presence of an immediate delusion, the clinician will form a favourable prognosis with regard to the attack, and will be quick to reassure the family; however, he will state his reservations as regards the likelihood of subsequent attacks, especially if, having precise information on the patient’s hereditary antecedents, he finds a very strong predisposition. His principal efforts should be applied to delaying any future intellectual disorder for as long as possible, through prescriptions of hygiene and practical counsel with the purpose of removing all potential moral causes, emotions, business worries, etc. It is not an absolute rule that rapid onset delusion culminates in recovery. Indeed, we sometimes see the intellectual disorders exceed the short time limit which is habitual to them, and the immediate delusion followed by a delusion of chronic evolution, for which the prognosis is quite different (this is one of the cases which we will examine in the next chapter). In order to explain this anomaly of development, one needs to take into account the nature of the predispositions, the degree of feeble-mindedness, and by consequence the age of the patient. The outcome of a delusion with slow evolution is, in fact, generally observed in older patients, without any delusional disorder, or else, in

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another order of ideas, in subjects who have experienced numerous attacks, or who have already experienced delusion at previous times. Feeble-mindedness is the inevitable consequence of all these causes, and it is logical that a cure is much more difficult to achieve than in the other cases. The diagnosis of immediate delusion presents no complication. It is sometimes difficult, in the absence of information, to be sure of the suddenness of the onset; in these cases, a careful analysis must be made of the terrain on which the delusion was established. The state of mental defectiveness, the state of imbecility, the degree of imbalance of the intellectual faculties, provide a guide to diagnosis. Is it possible, in these cases too, to derive information from the actual form of the delusion? When it is a mystical delusion or an ambitious delusion, this provides a valuable indication, especially when it shows clear evidence of incoherence or of absurdity. As regards persecutory delusion, it is less easy to decide. However, absurdity, the absence of cohesion and of logic rule out chronic delusion, and this information alone, combined with the analysis of the mental state, makes it possible to decide in favour of o r against immediate delusion. The maniac or melancholic forms can form part of the varieties of intermittent insanities; in this case, information on the previous history of the patient is required in order to make a diagnosis. In any case, the progress of the attack will clarify the case. Once in possession of the information, all that remains is to elucidate the nature of the delusion. It should be recalled that we consider immediate delusions to be pathognomic of an hereditary state. In addition, one should remember to consider the epileptic delusions and the hysterical delusions, which can dominate to a certain point. However, in epileptic delusion, which is anyway in general much briefer than the immediate delusion of degenerates, patients have absolutely no recollection of the whole period of the delusion, and we know that the degenerate with immediate delusion is able to reconstruct his own story as

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soon as the attack ends; moreover, it is almost always possible to find traces of epilepsy in the antecedents of the patients. As regards hysteria, a search for the many manifestations of the neurosis will suffice for diagnosis. Nevertheless, we would point out that an error of diagnosis, in this latter case, would have no great importance; hysterics are degenerates and, as such, are not unlikely to experience immediate delusion.

Jules Cotard (1840-1889)

As a medical resident in Paris in 1863,Jules Cotard was a fellow student of Valentin Magnan (1835-1916), and a pupil of JeanMartin Charcot (1825-1893). He is known above all for his friendships and long collaboration with Jules Falret (1824-1902), son of Jean-Pierre Falret (17941870), at the Vanves asylum, where he died of diphtheria contracted from a patient. His name has come down to prosterity in the form of a syndrome (Cotard’s syndrome) which he expounded for the first time to the Sociktk mkdico-psychologique in 1880. There he described the clinical case of a 43 year-old female patient, suffering from anxious melancholia with hypochondriac delusion, who had been interned for several years at the Vanves asylum. At the same time she presented ideas of damnation or possession, of negation and of immortality with a propensity to suicide. “She believed that she had no brain, nerves, chest, or entrails, and was just skin and bone; she believed also that neither God nor the devil existed, that she was eternal and would live for ever.” Jules Cotard returned to the theme two years later in the Archives de neurologie with the publication of an article on delusion of negation which he described as “a negative disposition.. .taken to the highest degree.. .applied either to their personality or to the outside world.”

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When the personality is affected “patients have no stomach, no brain, no head, they do not eat, they do not digest, they do not go to the cloakroom, and in fact they energetically refuse food and often retain faecal matter.” When the delusion of negation applies to the outside world, they imagine themselves dead, that the universe no longer exists, that they are damned; these patients suffer particularly from anxiety and have a tendency to suicide and self-mutilation. “I would like to venture the term dklire de nkggtion to refer to those cases.. .in which patients show a marked tendency to deny everything. He was to establish the essential clinical differences between delusions of persecution characterised by mistrust, poisoning persecution, delusion of grandeur, acoustic-verbal and sometimes homicidal hallucination, and delusions of negation which often comprise anxious monologue, profound depression of a melancholic type, a refusal to eat, visual hallucinations and often culminate in suicide. Finally, Jules Cotard described delusion of enormity, pseudomegalomania in melancholics (1888). “The patient believes himself to be the cause of all the evil in the world: he is Satan, he is the Antichrist. Some imagine that their slightest acts have disproportionate effects: if they eat, the whole world is lost; if they urinate, the earth will be drowned by a new flood. Are these ideas of grandeur? Is it an ambitious delusion to believe oneself the most infamous man who has ever existed and who will ever exist? “Although essentially melancholic, these conceptions in certain ways resemble true megalomania. Patients believe themselves to be exceptional beings, unique in the world, and attribute to themselves a sort of omnipotence, but an omnipotence for evil.. . “If we look more closely at the immortals, we notice that some of them are not only infinite in time, but also in space. They are immense, of gigantic size, their heads reach up to the stars. One female patient with a delusion of demonopathic immortality imagines that her head has taken on such monstrous proportions that it extends beyond the walls of the asylum and travels to the village to demolish, like a ram, the walls of the church. Sometimes, the body has no limits, it extends to infinity and merges

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with the universe. These patients who begin as nothing, come to be everything.. . “They expand like paralytics or megalomaniacs”, but they expand in the direction of melancholic delusion.” After his death, a work was published containing his principal articles on anxious melancholia, delusion of negation or delusion of enormity. Prefaced by his friend Jules Falret, this book presents clinical cases which are still valid in their descriptions. Fransois-Rkgis Cousin

Principal works

u.),

COTARD Etude sur les maladies ckrkbrales et mentales [Study on cerebral and mental diseases], Preface by Jules Falret, Paris, Bailli6re ex fils, 1891.

Principal references

u.),

COTARD (J.), CAMUSET SEGLAS (J.), Du dklire des nkgations aux idies d’knormitk [From delusion of negations to ideas of enormity], preface by J.-P. Tachon, Paris, L’Harmattan, 1997. BOURGEOIS (M.), “Le syndrome de Cotard aujourd’hui” [Cotard’s syndrome today], Annales mkdico-psychologiques,1969, 4, p. 534-544. CZERMAK (M.), “Signification psychanalytique du syndrome de Cotard” [Psychoanalytical significance of Cotard’s syndrome], in Passions de E’objet, Paris, TREMINE (T.), “1880-1890: centenaire dy syndrome de Cotard” [Centenary of Cotard’s syndrome], L ’Evolution psychiutrique, 1982, 47, p. 1021-1032.

Studies on Cerebral and Mental Diseases

VI.-ON NIHILISTIC DELUSION 1882

The important paper in which Lasi.gue, in 1852, separated

persecutory delusion from the diverse forms of melancholia, was a point of departure for complementary works which made this form of derangement one of those best known in its symptoms, in its progression and in its outcome. We need do no more than recall the names of Lashgue, of Morel, of Foville and Legrand de Saulle, and in particular that of M. J. Falret who presented to the SociktC midico-psychologique the fullest possible picture of the successive phases and of the evolution of that disease. As regards the other varieties of melancholic delusion, our knowledge falls far short of this relative perfection.

Simple melancholia, melancholia with stupor, anxious melancholia have been described with care; it is known that these forms are often intermittent, that they sometimes become continuous and finally chronic, but the characteristics and the successive phases of the delusion which culminate in this chronicity have not, to my knowledge, formed the subject of any study equivalent to that which has been done for persecutory delusion. I propose, in this paper, to describe a particular delusional evolution, which seems to me to be characteristic of a considerable number of these non-persecuted melancholics,

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more particularly those who are anxious, and to be based above all on negative dispositions which are very habitual in these patients. Generally, the deranged are negators: the clearest of demonstrations, the most authoritative of affirmations, the most affectionate of assurances, leave them incredulous or ironic. Reality has become to them foreign or hostile. But this negative disposition is particularly marked in certain melancholics, as has been remarked by Grieseinger. “Under the influence of the profound moral malaise which constitutes the essential psychic problem of melancholia, writes this author, the humour takes on an entirely negative character.. .That confusion, he later writes, which the patient experiences between the subjective change in external things which occurs in himself, and their objective or real change, is the start of a dream state in which, when it reaches a very high degree, it seems to the patient that the real world has completely vanished, has disappeared or is dead and that there remains nothing more than an imaginary world in the midst of which he exists in torment.” I propose the name nihilistic delusion to designate the state of those patients to whom Griesinger alludes in these lines and in whom the negative disposition is carried to the highest degree. Ask them their name? they have no name; their age? they have no age; where they were born? they were not born; their father and their mother? they have neither father, nor mother, nor wife, nor children; whether they have a headache, a stomach ache, pain at some point in their body? they have no head, no stomach, some even have no body; show them some object, a flower, a rose, they reply: that is not a flower, that is not a rose. In some, the negation is universal, everything has ceased to exist, they themselves have ceased to exist. These same patients who deny everything, also oppose everything, resist everything that they are called upon to do. Certain madmen, says Guislain, present an opposition which it is impossible to conceive when one has not seen

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them closely. It requires the greatest efforts to persuade them to change their linen, they refuse to go to bed, refuse again to rise, are opposed to everything they are asked. This is the madness of opposition. In this madness of opposition, Guislain includes mutism, the refusal to eat and that singular disposition of certain deranged persons who force themselves to retain their urines and their excrement. However, he does not refer to nihilistic delusion, of which the madness of opposition is, so to speak, simply the moral aspect. The same is true of most of the authors and it seems strange that so marked an intellectual lesion has not attracted more attention. Even the cases where the fact is simply described, are rare. Only the hypochondriac form of the nihilistic delusion has been commonly observed since the work of M. Baillarger. It is in Leuret that I find the most characteristic observation. Below is a summary of the questioning process. -How are you, mistress? -The person of myself is not married, call me Miss, please. -1 do not know your name, would you tell me? -The person of myself has no name: she wishes you not to write it. -1 would nevertheless like to know what you are called, or rather what you were formerly called. -1 understand what you mean. It was Catherine X..., we must no longer speak of what took place. The person of myself has lost her name, she gave it away on entering the Salpgtriire. -How old are you? -The person of myself has no age. -Are your parents still living? -The person of myself is alone, very alone, she has no parents, nor ever had. -What have you done and what has happened to you since you have been the person of yourself? -The person of myself lived in the asylum of.. .Physical

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and metaphysical experiments were performed on her and continue to be performed. This work was not known to her before 1827. There is an invisible being descending, she has come to unite her voice with mine. Leuret’s patient presented, in addition to the most marked nihilistic delusion, numerous hallucinations: she was tormented by invisible beings, by physics and metapbysics, in short, she manifested symptoms of persecutory delusion. Complex cases where, as here, the two delusions coexist, are not rare; I will provide examples of them later. Usually, however, these two forms of delusion are observed in isolation in different patients. The true persecuted individual passes through all the phases of his delusion, from the hypochondria of the beginning to megalomania, without his negative dispositions exceeding that which is commonly observed in the deranged; he denies out of mistrust, out of fear of being deceived, or else because he is entirely dominated by his delusional conceptions and his hallucinations, and has therefore come to live in an imaginary world, but his negative dispositions are quite different from the systematised nihilism of which I wish to speak here. In general, the persecuted present neither the profound depression, nor the groaning anxiety of the true melancholics; there does not seem to be in them that profound disorder of the moral sensibility which Griesinger considers to be the fundamental element of melancholia. It is on this terrain, however, after a variable period and following a particular delusional process, that systematised nihilism seems to develop. However, it is not unusual, in states of advanced chronicity, for the nihilistic delusion to continue, so to speak, beyond the general early disorders, and for patients, like that of Leuret, no longer to present either apparent depression or anxious agitation. I have just identified the dual origin of nihilistic delusion as melancholia with depression or stupor, and agitated or anxious melancholia. However different these two forms of

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melancholia may be in their external manifestations, one cannot but recognise their delusional similarities, similarities which are particularly striking in cases where the depression and the anxious agitation succeed each other or alternate in a single patient, without significant alteration to the delusion. These forms are dominated by anxiety (according to Griesinger, a frightful internal anxiety constitutes the fundamental state of melancholia with stupor), fears, imaginary terrors, delusions of guilt, of perdition and of damnation; patients blame themselves, they are incapable, unworthy, they bring misfortune and shame on their families; they will be arrested, condemned to death; they are to be burnt or cut into pieces. These fears of imprisonment, of condemnation and of torture should not, as M. J. Falret has often remarked, be confused with true persecutory delusion which is relatively rare in patients of this type. Quite other than the persecuted, they blame themselves; if they are to undergo the ultimate penalty, that is only just, they deserve no less for their crimes. From this point of view, two main classes of melancholics can be distinguished: those who blame themselves and those who blame the outside world and above all their social sphere. The latter are the persecuted, previously described by Guislain as the accusatory insune. This division of the melancholics largely corresponds to the division into melancholiu with general disorder of the intelligence and into sad monomania (Baillarger), and to the division into general Zypemaniu and partidl Ipemania (Foville); it can be said, very generally, that the true melancholics blame themselves, while the sad monomaniacs blame others. However, it is not unusual to see, on the one hand, the persecuted adopt, during a paroxysm, the characteristics of general, depressed or anxious melancholia; and on the other hand, the melancholics with delusions of guilt, having reached a fairly advanced period of their disease, adopt the physiognomy of the sad monomaniacs.

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No doubt, behind these external manifestations, which vary from stupor to anxious, quasi-maniac agitation, there exist more profound morbid dispositions in which resides the essential difference between the persecuted and the other melancholics. Perhaps it is in the tendencies of patients, which I mentioned earlier, either to blame themselves, or to blame others, that we should seek the most immediate manifestation of those intimate dispositions which constitute the true ground of the disease. These tendencies often exist many years before the obvious emergence of the delusion; to a very attenuated degree they are encountered in many men of sound mind, amongst whom they form two quite distinct categories. Long before they become truly deranged, the persecuted are suspicious and distrustful, more severe with regard to others than to themselves; likewise, certain anxious persons, long before they experience a clear attack of insanity, are scrupulous, diffident, self-effacing, more severe in their own regard than in that of others. I stress this division of the melancholic delusions, which have been confused by most authors. Marc6 seems implicitly to acknowledge it; he describes, in true melancholia, only the delusions of ruin, of guilt, etc., indicates the subsequent hypochondriac delusion and assigns the persecutory delusions to monomania; however, he does not otherwise emphasise this distinction, which anyway appears too absolute, since certain persecuted individuals present the characteristics of true melancholia and other patients with delusions of ruin and guilt resemble the monomaniacs. Let us now examine by what evolution of delusion the self-accusing melancholics arrive at nihilistic delusion; let us first sum up the main characteristics of their mental state. In their most attenuated form, these characteristics are those of the variety of melancholia described by the names simple melancholia or melancholia without delusion and, more exactly, by the name moral hypochondria, by M. J. Falret, who has described it with meticulous precision.

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The so-called melancholics without delusion in fact suffer from a sad delusion affecting the state of their moral and intellectual faculties, and which already exhibits a marked negative form. “They feel shame or even horror at their own person and despair at the thought that they will never be able to recover their lost faculties.. .They regret their vanished intelligence, their extinguished feelings, their faded energy.. .They claim to have no heart, no affection for their relatives and their friends, nor even for their children.’’ Delusions of ruin appear often, and seem to be negative delusions of the same nature: at the same time as his moral and intellectual riches, the patient believes himself to have lost his material fortune; he has nothing which constitutes human pride, neither intelligence, nor energy, nor fortune. It is the opposite of the delusion of grandeur where the patient claims immense riches together with every talent and every ability. This moral hypochondria is based in the common ground of melancholia and in a state of vague and indeterminate anxiety; “patients feel that all has changed both within them and outside, and are distressed no longer to perceive things through the same prism as formerly.” (J. Falret .) In these mild cases, it is already as if there existed a veil through which the patients perceive reality only in a confused manner; everything seems transformed. As the morbid state becomes more intense, this veil becomes thicker and, in cases of stupor, comes completely to mask the real world. The patient is then, as M. Baillarger has justly pointed out, close to the dream state. Not only from this point of view, but in every respect, there seems to be nothing but a difference of degree between these states of moral hypochondria and melancholic disorders with delusions of guilt, ruin, damnation and systematised negation. Moral hypochondria is a sketch; by simply accentuating the outlines and deepening the shadows, the picture of these latter forms of melancholia can be completed.

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Self-disgust culminates in the delusion of guilt and damnation, fears become terrors; external reality, transformed and confusedly perceived, is finally denied. Certain forms of nihilism may even appear very early in the moral hypochondriacs; they deny the possibility of cure, of any relief for their suffering; this is one of the first negations of these patients, some of whom will later go so far as to deny the external world and their own existence. It is important to make a clear distinction between this state of moral hypochondria and ordinary hypochondria. Although cases of melancholia without delusion must, according to M. Baillarger, be acknowledged, it is nevertheless important to be on one’s guard with regard to certain hypochondriacs who, in appearance, exhibit a close resemblance to the melancholics in question here. The true melancholic is in a state of general depression. ..Nothing similar occurs in the hypochondriac, who may at any time be drawn out of his supposed prostration, his nullity, his impotence, etc. by a simple disposition. Ordinary hypochondria, of which M. Baillarger is speaking here, is comparable in several respects to persecutory delusion, of which it is often simply the first stage, and it is above all the diverse evolution of the two hypochondrias which justifies M. Baillarger’s distinction. In general, it may be said that moral hypochondria is to the delusion of ruin, of guilt, of perdition and of negation, that which ordinary hypochondria is to the persecutory delusion. When nihilistic delusion is established, it applies either to the actual personality of the patient, or to the outside world. In the first case, it takes a hypochondriac form similar to the particular delusion reported by M. Baillarger in paralytics: patients have no entrails, no brain, no head, they no longer eat, no longer digest, no longer dress, and in fact they resolutely refuse food and often retain their faecal matter. Some, as I have indicated in a note presented to the Sociktk mkdico-psychologique, imagine that they will never die. This idea of immortality is found above all in cases

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where anxious agitation is predominant; in stupor, the patients are more likely to imagine that they have died. There are even those who alternately experience the delusion of having died and of being unable to die, depending on the alternation of their states of anxious agitation or stuporous depression. Hypochondriac delusion, largely moral at the outset, becomes, at a more advanced stage and especially when the disease attains the chronic state, both moral and physical. Patients who initially have lost both heart and intelligence, end by having no body. Some, like Leuret's female patient, speak of themselves only in the third person. In the persecuted patient, the contrary takes place. The hypochondria of the outset is above all physical; but at a more advanced phase, patients are preoccupied with their intellectual faculties; they are being transformed into half-wits, prevented from thinking, being told nonsense, having their intelligence removed, etc. These two hypochondrias differ not only in their progress; the hypochondria of the anxious bears the stamp of humility; they have nothing and are worth nothing; they are rotten; su$fering from ignoble diseases; some believe they have syphilis, a delusion which FodCrd had already noted to be connected with the delusion he calls damnoma-

nia. The persecuted hypochondriacs are entirely different. They in general have a very good opinion of themselves and of the strength of their constitution in sustaining so many ills; they blame external influences, the air, the humidity, the cold, the heat, food and especially medicines. If they have syphilis, it is not the syphilis, but the mercury which is the cause of all their suffering. They finish by b1av:- ' doctor and enter a state of confirmed persecu-

eh

,ersecuted individual feels himself exposed to s influences, which converge on his person he anxious individual by contrast believes he

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is the source of them, and that it is he who is responsible for spreading them all around; he imagines that he brings misfortune on those who approach him, on the doctor who treats him, on the servants who attend him; he will infect them with fatal diseases, compromise them or dishonour them; the house in which he lives will be cursed; walking in the garden, he causes the trees and the flowers to perish. Hypochondriac nihilistic delusion is often linked with alteration of the sensibility. Anaesthesia is frequent in stupor, and has been reported by all the authors; it is also encountered in certain anxious melancholics; in others, by contrast, it appears that there is an hyperaesthesia, patients do not permit themselves be approached; they cry out as soon as they are touched and constantly repeat: “Do not hurt me!” In what measure do these alterations of the sensibility contribute to the development of hypochondriac nihilistic delusion? That is a question of pathogenesis which I do not propose to try to elucidate. I shall confine myself to reporting them as a differential characteristic of the two hypochondriac delusions; common in the negators, they are very rare in the persecuted. When the delusion relates to the outside world, patients imagine that they have no family, no country, that Paris has been destroyed, that the world no longer exists, etc. Religious beliefs, and in particular belief in God, often disappear, sometimes very early. Griesinger has reported the lugubrious, negative ideas, by which the patients feel themselves invaded, their anxious agitation rendering them incapable of meditation and of prayer. A rapid description of the nihilistic delusion and of its diverse forms would not be sufficient to prove that this delusion is a particular species of melancholia. I wish to show that, in conjunction with this delusion, there exist numerous symptoms, closely associated in such a way as to constitute a veritable disease, distinct in its characteristics and its evolution.

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We can employ the persecutory delusion as our type. It is above all by identifying the differences and contrasts between him and the persecuted type, that I seek to depict the negator. I have already begun this parallel by marking the difference between moral hypochondria and ordinary hypochondria, between the anxious melancholic who blames himself and the persecuted who blames the outside world. When the disease becomes more intense, or takes a more severe form from the start, there occur, in addition to the symptoms indicated in moral hypochondria and to ordinary delusion of ruin and of guilt, new phenomena which merit attention due to their special characteristics: these are the hallucinations. These hallucinations are especially frequent in states of stupor, but they are also observed in the anxious form. Patients believe themselves to be surrounded by flames, they see precipices at their feet, they imagine that the earth is about to swallow them up or that the house is about to collapse, they see the walls waver and believe that the house has been undermined; they hear preparations for their punishment, the guillotine being prepared; they hear the roll of drums, explosions of firearms, they are about to be shot; they see the rope intended for their hanging, they hear voices accusing them of their crimes, announcing their death sentence or repeating that they are damned. Some have hallucinations of taste and smell and imagine that they have become rotten, that their food has been transformed, that they are consuming garbage, faecal matter, human flesh, etc. In general, hallucinations in patients with ideas of guilt belong to that category of hallucinations, established by M. Baillarger, which reproduce the existing preoccupations of the patients. A melancholic, this author states, who blamed herself for imaginary crimes, was obsessed night and day by a voice which announced her sentence of death and described the punishments reserved for her. Another

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patient, whose history is reported by Michka, believed herself guilty, pursued by the police and under sentence of death. She was placed in an asylum and a few days after, the lypemania being at its height, she saw almost constantly before her eyes the rope which would strangle her and the coffin prepared to receive her corpse. Patients believe themselves damned and see the fires of hell, they hear gun shots and believe that they are going to be shot. Guislain has pointed out the close connection between demonophobia, suicide and the type of hallucination where patients see flames, fires all around. The hallucinatory state of anxious, stuporous or agitated melancholics is totally distinct from that of the persecuted, first because of the visual hallucinations which are rare in the persecuted, and second by the character of the auditory hallucinations. Like the visual hallucinations, the latter simply reflect the delusions and it is sometimes difficult to distinguish one from the other; in the anxious, the hallucinatory phenomenon does not have this independence which, in the persecuted, lends it such distinctness together with a very particular evolution. The persecuted individual gradually arrives at a dialogue, he can be seen to listen, to answer his imaginary interlocutors with impatience or anger. Nothing similar in the anxious patient; if he speaks, he constantly repeats the same words, the same phrases, the same groans, his loquacity takes the form of a monologue, of a litany, while that of the persecuted is a dialogue. Nor is there observed in the anxious patient the repercussion of thought, the echo, nor that special vocabulary by which the chronic persecuted can be recognised after a few moments of conversation. I stated, at the beginning of this paper, the systematic opposition and resistance of individuals suffering from nihilistic delusion; they often exhibit a muscular rigidity and tension which reveals that their inertia is only apparent and that their resistance is not simply passive. As soon as one

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attempts to change their position, to bring some motion to their limbs, they powerfully contract their muscles in order to resist and to maintain their habitual position. I do not wish to linger on the trembling reported in some anxious subjects, on the cataleptiform accidents in stupor cases, but I cannot omit the suicidal impulses and mutilation so common in anxious patients, especially when they are dominated by religious ideas, which establish yet one more difference from the persecuted in whom suicide is much less frequent, and mutilation very rare. Anxious patients with ideas of damnation are those most disposed to suicide; even though they may believe themselves dead, or in the impossibility of ever dying, they nonetheless seek to destroy themselves; some desire to burn themselves, fire being the only solution, others wish to be cut into pieces and seek by every means possible to satisfy this morbid need for mutilation, for destruction and for total annihilation. Some show themselves violent towards the people around them; it appears that they wish to demonstrate that they are the most vicious beings, wholly devoid of moral sentiments; often they curse, blaspheme; for the damned and devils cannot do otherwise. The rejection of food, so closely linked with madness of opposition, also possesses certain special characteristics in negators. In general it is total and applies without distinction to all food; patients refuse to eat because they have no entrails, because “meat and other nourishment falls into the skin of their belly,” because the damned do not eat, because they cannot afford to pay. Some, however, dominated by a less intense delusion of guilt or of ruin, select their food: out of penance, they eat only dry bread or eschew dessert. The persecuted patient, on the other hand, carefully examines his food, seeks out what appears good, rejects what appears suspect; when by chance he encounters food which he supposes free of any poison, he eats voraciously. In general, the rejection of food is partial in the persecuted. To end this parallel, I will look at the course of the disease.

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The persecutory delusion is essentially remittent or, if one prefers, continuous, with paroxysms; the disease generally begins early, develops in a slow and progressive manner and lasts throughout life. This remittent course is already apparent in the hypochondria of the beginning; it is equally so where the sickness does not seem to evolve beyond that embryonic form. The condition has a quite different appearance in the negators: it strikes suddenly, often around the middle period of life, in people whose moral health had previously seemed good; when there is a cure, it is sudden, like the onset; the veil is torn and the patient awakens as if from a dream. The mildest forms, it goes without saying, are also the most curable. So-called melancholia without delusion, moral hypochondria, anxious states with delusions of ruin are usually cured. But the condition is subject to relapses at varying intervals, and takes on the character of the intermittent insanities. This intermittent character is sometimes revealed, even in incurable cases, by awakenings of short duration in which it seems that the patient has entirely recovered his lucidity. I once saw, says Griesinger, in a patient suffering from profound melancholia (she imagined herself to have completely lost her fortune and believed herself destined to die of hunger) a perfectly lucid interval, of approximately one quarter of an hour, which occurred for no obvious reason and likewise suddenly disappeared. In the forms where stupor is predominant from the beginning, a cure is often observed despite the intensity of the delusion and its absurdity. However, it is not unusual, after intense and prolonged anxious agitation, with hallucinations, panophobic delusion, etc., for patients to fall into a kind of stupidity which is too often mistaken for dementia and which continues indefinitely. These patients often show madness of opposition to the highest degree, they are mute, some repeating over and over again nothing but the word

“NO,,.

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The prognosis is also unfavourable when the intensity of the general melancholic disorder is seen to diminish, while the delusional ideas and the negations persist to the same degree. Patients arrive at a state of systematised nihilistic delusion which is rarely curable; in most cases they too exhibit madness of opposition, the unfavourable prognosis of which has been reported by Guislain. By its course, by its onset, by its sudden termination, when it is cured, nihilistic delusion belongs to the group of fitful or intermittent insanities and to cyclical derangement. Even if the name nihilistic delusion is reserved for cases where this delusion has attained the degree to which I referred at the beginning of this study, it can be said that nihilistic delusion is a state of chronicity specific to certain intermittent melancholics whose disease has become continuous. I wish only to state a point which seems to me to establish a difference between the negators and other intermittent conditions which are close to cyclical states. When the antecedents, the character of the patients, are examined, one often learns that they have always been a little melancholic, taciturn, scrupulous, devout, charitable, always ready to perform a service; some are endowed with the most distinguished moral qualities. Their diseased state, their delusion of humility are not in complete contrast with their former manner of being and are simply a morbid exaggeration of it. In short, these patients are not entirely in alternation, in the way of cyclical and certain intermittent patients, whose healthy state is in absolute contrast with the fits of melancholia. This characteristic in the negators also makes it possible to separate them distinctly from most hereditary patients, amongst whom they form a special category; this is because they are distinguished by an exaggerated development, if one may call it so, of those same moral qualities, the absence of which in other hereditary patients explains their

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disordered life, their profound egoism, their pride, their undisciplined character, their offences and their crimes.

If the nihilistic delusion seems to belong, in many cases, among the intermittent delusions, I must add that it is not unusual to see it develop on a ground of hysteria; nor is it unusual to encounter it as a symptom of diffuse periencephalitis. The delusion of smallness, reported in this condition by D r Materne, seems very close to nihilistic delusion and can coexist with it; we will see an example of it in the observations which follow. I have divided these observations into three categories: in the first, I place the cases where the nihilistic delusion occurs in simple form; in the second, a case where it is symptomatic of general paralysis of the insane; in the third, cases where, associated with the persecutory delusion, it constitutes those complex forms of alienation which explain why almost all the authors have confused, within the single description of melancholic delusion, delusions of ruin, of guilt, of mistrust and of persecution. These mixed cases would merit a special study; apart from the two orders of symptoms they show, I believe, certain particular characteristics. Patients believe themselves to be possessed rather than damned and imagine that they have beasts or devils in their body. Esquirol has reported cases of this type; FodkrC made the distinction between delusion of guilt and damnation, or damnomania, on the one hand, and, on the other, demonomania or demoniac possession. This latter form seems to me to establish a sort of transition between delusion of guilt and persecutory delusion. First category.-Nihilistic deltision in simple form. OBS.I.-Mme E.. ., aged fifty-four years, married with children, was committed on 15 June 1863 to the asylum of Vanves, having made several suicide attempts. Mme E.. .was in a state of anxious agitation with ideas

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of guilt and hypochondriac delusion; she imagined that her throat had narrowed and that her heart had been displaced. During the paroxysms of agitation, she would utter cries and would lament in a loud voice, constantly repeating the same words. All her organs were displaced, she could do nothing, she was lost, she was damned. 1864.-Same delusion, same anxious paroxysms with continuous repetition of the same stereotyped sentences. Mme E.. .was lost, had no head, no body; she was dead. Mme E.. .would utter piercing cries, repeat the same words with rage and herself say that she was enraged; she would grasp the objects around with her hands, as if convulsively, and once held, would no longer let them go. Mme E.. .saw phantoms in the walls, resisted her natural needs, on the pretext that it would kill her to satisfy them, uttered cries and indulged in violent acts in order to resist the fatality of the situation from which no one could save her; the ideas of suicide persisted. The nihilistic delusion became increasingly accentuated. Mme E...had neither arms nor legs, all the parts of her body were metamorphosed; she would repeat that everything was lost, that she could not move without the risk of falling into pieces and she would become convulsively rigid in the seated position which she habitually adopted. The madness of opposition reached its height, Mme E.. . would refuse to eat because she could not swallow, to walk, because she had no legs; she wished neither to stand up, nor to lie down, nor to dress, nor to eat, nor to walk, nor to relieve herself; she would become as rigid as a bar of iron in order to resist every act she was asked to accomplish, she would shout at any attempt to touch her and claim that she would break like glass. The years passed without bringing any change in this delusion. Mme E. . .reached a state of dementia characterised by grunts, inarticulate shouts and paroxysms of agitation; she continued to maintain the same muscular rigidity and

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to offer the same resistance to everything she was asked to do. Mme E.. .experienced a collapse of the uterus and of the rectum which could not be maintained because of the violent efforts of expulsion which she would make as soon as reduction was attempted. She died in 1878 in a state of general cachexia.

OBS.11.-Mme E.. ., aged sixty-three years, committed to Vanves in May 1868, was in a state of great anxious agitation; she imagined that she had nothing, that she had ruined her family and that she would be sent to prison. Mme E.. .was in constant motion, could not remain still; she groaned incessantly, complaining that she was lost, ruined, that it was through her fault that her children would die of hunger. She refused nourishment on the pretext that she could not pay for it; she believed herself to be suffering from a contagious disease and imagined that she exuded a revolting odour; she would allow no one to approach and believed that contact with her was fatal: she imagined too that there was poison and dirt in her food. Mme E.. said that she could neither eat nor walk, that she was absolutely incurable; she resisted all the ordinary cares that she should take of her person, it required a struggle to dress her, to make her rise from her bed, to make her walk, to feed her. Mme E.. .remained habitually huddled in a corner, sometimes mute, sometimes uttering a monotonous groaning and repeating that she was a monster. O u t of humility, Mme E.. .would consent to eat only at the servants’ table. She died in 1879, the delusion having undergone not the slightest alteration. OBS.II1.-Mme S.. ., aged fifty-three years, had already experienced an attack of depressive melancholia which did not necessitate a committal. The melancholic delusion

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recurred and she was brought to Vanves at the end of the year 1876. Mme S.. .was in a state of extreme anxious agitation; she considered herself guilty and lost; she would be sent to prison and she sought every means possible to attempt suicide. Mme S...would hear voices telling her that she was guilty, that she would be condemned and taken to prison; she believed she could hear the voice of her husband and of her daughter who were in prison because of her; she would utter incessant lamentations and refuse food. 1880. Mme S...continued to be dominated by the same melancholic ideas; she generally remained mute and immobile, and would not answer when addressed; at times she would express negative conceptions of an entirely absurd nature. Mme S.. .claimed that no one died any more, that no one married, that no one was born. There were no more doctors, no more prefects, no more notaries, no more tribunals; formerly Mme S.. .had been used to pray, but now this was useless, since God did not exist. Mme S.. .resisted all the ordinary cares that she should take of her person, continued to refuse nourishment and claimed that there was lime, potash in everything she was offered. Mme S.. .passes all her days in mutism and immobility. Today (May 1882) her state remains absolutely unchanged.

OBS.1V.-Mme M.. ., aged fifty-one years, married with children, seems to have been in good health until the year 1878. She then suffered a fit of anxiety with terrors; Mme M.. .saw flames, fires, believed herself ruined and imagined that she was going to be tortured. After two months, she was suddenly cured but after a few weeks she experienced the same condition and was brought to Vanves in a state of intense anxious agitation with moaning and continual terrors, in particular relating to fire. Mme M.. .imagined that she was ruined, that she was to be tortured, that her food was poisoned, that she was bewitched. She appeared to have hallucinations of hearing

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and of sight, claimed that frightfuI things took place each night in her room, that persons unknown to her came there. Mme M. . .refused to recognise her husband and her children when they came to visit her; she claimed that she had never been married, that she had neither father, nor mother, nor husband, nor children. A..., her native town, no longer existed, Paris no longer existed, nothing existed, her daughter was a devil in disguise. Mme M.. .allowed no one to approach, drew back in terror when anyone attempted to touch her or take her hand, and repeated incessantly: “Do not hurt me.” She denied everything and resisted everything; it was a struggle to dress her, undress her, feed her, etc., and Mme M.. .would exhibit an astonishing power of resistance. In August 1881, Mme M.. .was suddenly struck by hemiplegia of the left side; the delusion was in no way altered. The lower limb recovered its functions incompletely, but the upper limb became cramped. Mme M...continues to repeat the same denials, continued to say constantly: “Do not hurt me,” and stubbornly resisted everything she was asked to do. Today (May 1882) the situation remains the same in every respect.

OBS.V.-Mme J.. ., aged fifty-eight years, placed in Vanves in August 1879, was in a state of anxious melancholia which had already endured several months. Mme J...imagined that people were going to cut her nerves, render her deaf, mute and blind and subject her to tortures of all kinds; she would spend entire days in groaning and in calling upon the Virgin and all the saints. Paroxysms of very intense agitation with suicide attempts. Mme J.. .refused food; she was lost, damned; she was “stuffed with oil”, she was about to be subjected to the most frightful tortures and yet she would never be able to die. Frequent paroxysms during which Mme J.. .would roll

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on the ground and exhibit of grimaces and contortions of every kind, M i n e J.. .would constantly repeat the same sentences, often entirely absurd and unintelligible, but relating to ideas of transformation and of annihilation of her person and of everything around her. Mme J...would repeat: “There is nothing left, nothing more exists, everything is made of iron, etc.;” she herself was transformed, she was a little chicken, a ily, a talking woollen rag, she was no longer anything, she never ate, she no longer had a body; the people around her were nothing but shadows. Mme J.. .would resist everything, retained her faecal matter and her urine; it was a struggle to dress her, to undress her, etc., and in these struggles Mme J. ..would exhibit incredible energy and muscular vigour. Currently, in May 1882, the situation of Mme J.. .remains the same, her delusion has not altered in any way.

OBS. V1.-Mme C. . .,aged forty-three years, married with children, entered the Vanves asylum in November 1880. In 1875, following the sudden death of her father and the surgery for strabismus performed on her son, this lady had already experienced a slight attack of anxiety with insomnia and continual yawning, obsessed by the fear that her father had been buried alive and that her son might become blind following the surgery for strabismus. This anxious state went away after a month. At the end of March 1880, new attack, fairly rapid onset, preoccupations relative to questions of money, continual perplexity and indecision, insomnia. Mme C.. .blamed herself and believed herself guilty. After a few months, hypochondriac delusion. Mme C.. .believed that she no longer had entrails, that her organs had been destroyed and she attributed this destruction to an emetic which had indeed been administered to her. O n her arrival in the asylum, Mme C.. .was in a state of anxious melancholia with paroxysms of maniac agitation

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during which she would perform contortions, grimaces, roll on the ground and utter groans. These paroxysms would alternate with periods of immobility and mutism. Mme C.. .claimed that her gullet had been removed, that she no longer had entrails, that she had no more blood; she would never die, she was neither dead nor alive, she was a supernatural person, her place was neither with the living, nor with the dead; she was no longer anything, she begged people to open her veins, to cut off her arms and legs, to open up her body in order to make certain that she had no more blood and that her organs no longer existed. This patient left the asylum uncured after a stay of two months; I do not know what became of her.

OBS.VI1.-Mr A.. ., aged fifty-three years, placed in the asylum of Vanves in July 1877, was struck with melancholia after having experienced great moral suffering; he lost his wife and a son at almost the same time. Mr A.. .blamed himself for the death of his wife and of his son; he was rotten, he had syphilis, he was lost, he was damned, he was the greatest criminal who had ever existed, he was the Antichrist, he should be burned in the public square; Mr A.. .was plunged in the deepest sadness, he wept and groaned; he wished to be dead and made suicide attempts. 1880. Mr A.. .continued to express the same melancholic ideas of guilt, he was damned and destined to burn eternally. Mr A.. .would say that his whole body was rotten, that he had no blood, that he had no pulse, that his heart no longer beat, that his head was empty, that he had no human face. He was awaiting the end of the world, which was near. Currently, in May 1882, the situation is still the same, the delusion has in no way altered. OBS.VII1.-Mr A.. ., aged forty-eight years, placed in the Vanves asylum in March 1879, following a suicide attempt, was in a state of intense anxious agitation. He would seek

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every means to damage himself, to mutilate himself, to put out his eyes, to kill himself; he wished neither to eat, nor to take medicines, nor to receive any kind of care, considering himself unworthy. H e thought only of expiating his imaginary crimes; that is the reason why he wished to damage and to kill himself; he said that he had fallen into an abyss of infamy and that every day he fell deeper; he begged to be given a rope in order to hang himself, or a strong dose of poison. Mr A . . .did not seem to have auditory hallucinations, but he had numerous illusions of sight; he would attribute a mystical meaning to the shapes of external objects, he believed he could see figures of animals in the shapes of trees, etc. 1880. Mr A...imagined that he was to be tortured, plunged into icy water, fed on garbage and excrement, he begged to be given prussic acid in order to end his days. His brain had been softened, his head was like a hollow nut, he had no sex, no testicles, he had nothing left, he himself was nothing but “carrion” and asked for a hole to be dug so that he could be buried like a dog; he had no soul, God did not exist; at times Mr A . . .would say that he had neither wife nor children; at other moments, he would ask to see them and to return to them. Mr A...would constantly repeat the same phrases and the same supplications: Kill me, kill me; do not give me a cold bath, do not give me a cold bath, etc., which he would repeat for hours on end. H e would seek every means possible to kill and mutilate himself; he wished to put out his eyes, to tear off his testicles, etc. H e would show himself equally violent and injurious towards the people around him. At times, Mr A . . .could speak with lucidity; he was happy to recount different events from his former life. In May 1882, the situation is still the same, Mr A . . .constantly repeats that he is unworthy, ignoble, he wants to become a boot black, he has no testicles, he should be killed.

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Second catego?. -Nihilistic delusion symptomatic of general paralysis of the insane. OBS.1X.-Mr C.. ., aged forty-eight years, of robust constitution, married with children, having always led a regular and hard-working existence, had committed no excesses, it is said, other than excess of work. He would remain each day in his office until two o’clock in the morning and would rise at seven. For several years he suffered violent migraines with vomiting. In 1879, he complained of visual problems, of mists before his eyes; he consulted an oculist, who having examined the back of the eye, asked Mr C.. .to balance on one foot, which he was unable to do. Around that time Mr C...began to have frequent falls; often he returned home saying to his wife that he had almost been killed, that he had fallen and that he had been helped to rise. At the same time, his character began to alter, he became sombre, irritable, and appeared to be plunged into a profound sadness. He expressed mournful sentiments, gave advice to his wife and offered her meticulous recommendations on the subject of their children, as if he felt threatened by an imminent death. At the beginning of December 1879, he had another fall in the street, returned home frozen and was seized by intense trembling and chattering of the teeth. The doctor was called and reported, it is said, no onset of fever following this shivering. Similar shivering apparently occurred irregularly every day for five or six hours. Mr C.. .remained constantly in bed, under enormous covers, and, as soon as he was uncovered slightly, would again be overtaken by trembling and chattering of the teeth; he was completely unable to sleep. After a few weeks, Mr C.. .left his bed, but it was impossible for him to resume his occupations. He remained constantly in his office, mute, unoccupied, immobile, receiving no one and sending his wife away roughly when she came

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to see him. At times, he would repeat: “I am a cretin,” would say to his wife: “Will you not then restore to me my former life?” or else: ”I should shoot myself. I would ask God to make me die, but God does not exist.” One night, he repeated for hours on end a single series of incomprehensible syllables. Towards the month of March 1880, he began to express negative ideas of a wholly absurd nature; he would say that there was no more night and would refuse to go to bed; he would spend entire nights in his office and would reply to his wife that he could not go to bed since it was still day. He said that he was not eating, and however copious were the meals, he would fly into a fury, saying that there was nothing on the table. Committed to Vanves in the month of April 1880, Mr C.. .was observed to have a profound mental disorder. Mr C...was aware neither of the place where he found himself, nor of the time that had passed since he had quit his home. He was ordinarily calm, silent; at times he would claim that the people around him were assassins who would cut his throat and he would be seized by paroxysms of anxiety during which he would continually repeat the same words in a tone of lamentation. Mr C...declared that he knew neither where he was, nor who he was; he insisted that he was not married, that he did not have children, that he had neither father, nor mother, that he had no name. He would claim that he never ate and yet would eat hugely. He was in a desert where there was nobody, and from which escape was impossible, since there were neither cars nor horses. If shown a horse, he would say: “That is not a horse, it is nothing at all.” Mr C. . .would resist all the cares that should be taken of his person; he would refuse to be clothed because his whole body was no bigger than a nut; he would refuse to eat, because he had no mouth, to walk, because he had no legs. Mr C.. .would pull his ears and say that he had no ears, would pull his nose and say that he had no

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nose. Often Mr C.. .would say that he was dead, but during paroxysms of anxiety, Mr C.. .would say that he was half dead, and that he would never succeed in dying; he would take his arm, his leg, his calf and say: “This will never be detached.” At times, Mr C...appeared to have hallucinations of sight; he would see people, women dressed in white, descend from the ceiling of his room; at other times, he would see small horsemen a few centimetres high crossing his room in regiments. Confusion in speech, uncertain gait, unequal pupils. These symptoms of general paralysis became increasingly marked in the course of the year 1881. They were accompanied by ideas of grandeur which the patient referred back to the past. Mr C...would recount that he had formerly been immensely rich, that he had been the foremost lawyer in Paris, that he was a member of the French Academy, president of the Republic; today, he was nothing but a little cretin and anyway was going to die. In May 1882, Mr C.. .is reduced to a state of paralytic dementia; he can scarcely walk, his speech is almost unintelligible.

Third catego y.-Nihilistic delusion associated with delusion of persecution. OBS.X.-Mme G., aged forty-two years, married with children, several years ago experienced violent fits of hysteria. Placed for the first time at Vanves, at the end of the year 1875, she was at that time suffering from melancholic delusion with ideas of guilt, mystical ideas and paroxysms of furious agitation. Mme G.. .believed herself possessed by the devil, damned; she believed that she had been made pregnant by her maidservant, whom she took to be a man in disguise. Mme G.. .imagined that she had been transformed into

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a foul beast, into a scorpion and, in her paroxysms, would crawl on her belly, indulge in all sorts of contortions in order to imitate the movements of the scorpion. Mme G.. .refused food, performed all sorts of disordered acts and violences towards herself and the persons around her; she would hear the devil speak to her and was obliged to obey him. In the course of the year 1876, a significant improvement took place. Mme G. ..was calm, occupied herself with needlework, conversed readily; but she continued to be dominated by ideas of guilt, to believe herself adulterous, unworthy to return to her husband and children, and wished to make a public confession of her sins. She left in this state of remission at the end of 1876. The following year it became necessary once again to commit Mme G.. ., who insisted absolutely on making a public confession of her sins and of her crimes, in the streets and in the churches; Mme G.. .still believed herself to be guilty, unworthy; she wished to enter into domestic service and to earn her living, for she did not deserve to have money expended on her; however, new delusional ideas came to complicate this delusion of guilt. Mme G.. .believed herself to be magnetised, imagined that people could read her thoughts and that her thoughts could be the cause of the greatest misfortunes; she attributed supernatural power to her maidservant: this girl, by means of magic and evil procedures, would cause her son to be committed to the asylum where he would be subjected to torture and genital mutilation. Mme G.. .left the asylum for a second time in June 1879, and was returned there in August 1880; she imagined that she was being persecuted by people who had the power to read her thoughts, whom she called carigrafiers; these people were hounding herself and her children, and would constantly repeat the most frightful calumnies. They went so far as to make her utter, herself, foolish remarks which were then repeated all over

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Paris and throughout the world, and which might do the greatest injury to her family. At the same time as she blamed her persecutors and the people around her, Mme G.. .would blame herself; she was a monster, she was damned; she had three earwigs in her body and would finally be changed into a scorpion; already there was nothing human about her and she was like a foul beast. Mme G.. .wished to be dead, she moaned and made suicide attempts, but it was too late: already she was immortal, she could be cut into small pieces without dying. In May 1882, the situation is still the same; however, the ideas of persecution appear increasingly to predominate; Mme G. . .accuses the servants of constant gossip and slander in regard to her; she is damned, it is true, but it is the fault of the doctors.

OBS.XI.-Mme H.. ., aged fifty-one years, was committed in the month of August 1880. Approximately fifteen years ago, following severe dysentery, Mme H...experienced a cracking sensation in her back, “her back was detached.” Since that time, at least four or five times, Mme H.. .had remained in bed for nine to ten months, once for more than a year. Mme H.. .claimed that she was unable to rise, that her back had descended into her belly. Towards the beginning of the year 1880, Mme H.. .began to complain that everyone was against her, and her ideas of persecution were concentrated on the person of her son-in-law; she would repeat for hours on end: “Why then did my daughter marry X.. .?”Placed at Vanves in August 1880, Mme H. . .claimed that a spell had been cast upon her; she was damned, she had animals in her belly, monkeys, dogs, etc., she heard voices which drove her despite herself to acts of violence; she sought death, and yet she knew that she could never die. In September of the same year, Mme H.. .left the asylum in the same state of chronic alienation, to be transferred to another asylum. I could have quoted, in addition to these few cases, at

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second hand, a considerable number of observations scattered here and there in which nihilistic delusion is reported, at least in its hypochondriac form. I shall confine myself to giving the following bibliographical indications: LEURET. Fragments psychologiques, Paris, 1831, p. 121, 407 and following.-Traitement moral de la folie, Paris, 1840, p. 274, 281. ESQUIROL. Des maladies mentales, chap. “Dkmonomanie”, Pal;is, ,l838. FODERE. Trait; de dilire, vol. I, p. 345. MOREL. Etudes cliniques sur les maladies mentales, vol. 11, p. 37 and 118. MACARIO. Annales midico-psychologiques, vol. I. BAILLARGER. De l’ktat dksignk sous le nom de stupiditk, 1843.-“La thCorie de l’automatisme” (Ann. mid.-psych., 1855).-“Note sur le dClire hypocondriaque” (Acadkmie des sciences, 1860). ARCHAMBAULT. Annales mkdico-psychologiques,1852, vol. IV, p. 146. PETIT., Archives cliniques, p. 59. MICHEA. “Du dClire hypochondriaque”, (Ann. mid.-psych., 1864). MATERNE. 7%. de Paris, 1869. KRAFFT-EBING. Lehrbuch der Psychiatrie, OBS. I1 and VII. COTARD. “Du dClire hypochondriaque dans une forme grave de la mllancolie anxieuse” (Ann.mid.-psych., 1880 and above, p. 314).

I end this study with a synoptic table summing up the parallel between nihilistic delusion and delusion of persecution.

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NIHILISTIC DELUSION

Anxiety, groaning, precordial pain, etc.; patients are types of anxious melancholia. Others lapse into stupor. Some present alternating stupor and melancholic agitation. Hypochondria largely physical at onset. Hypochondria largely moral at onset. The patient blames himself: he is incapaThe patient blames the outside world, harmful influences originating in diverse ble, unworthy, guilty, damned. If the spheres and particularly the social sphere. police come to arrest him and take him to the scaffold, it is only what he deserves He does not blame himself; instead, he boasts of his physical and moral strength for his crimes. and of the excellenceof his constitution which allows him to sustain so many ills. Suicide and mutilation very frequent. Suicide relatively rare.

The patient does not ordinarily present the melancholic fancies.

Homicide more frequent.

Homicide more rare.

Disorders of the sensibility. Anaesthesia. Hallucinationsoften absent. When they exist, they simply confirm the delusional ideas. In consequence, no antagonism between the atient and the voices he hears, no d i a k y e . When patients talk to themselves, they repeat the same words or the same phrases in the form of litanies, addressed to the real people around them. Fairly frequent visual hallucinations. Visual hallucinations very rare. Subsequent physical hypochondria. Subsequent moral hypochondria; the persecutors are attacking the moral facul- Patients have no brain, no entrails, no ties, patients say that they are being made heart, etc. They are dead or else will never die. Transformation of the personality. stupid. Some speak of themselves in the third person. Nihilistic delusion and delusion of anniDelusion of grandeur. hilation. Patients deny everything; they have neither parents, nor family; everything is destroyed, nothing any longer exists, they have become nothing, they have no soul, God no longer exists. Madness of opposition. Total refusal of food. The negators refuse Partid refusal of food, through fear of because they are unworthy, because they poison. The patients choose their foods cannot pay, because they have no and eat with voracity those which they entrails, etc. believe not to be poisoned. Course of the disease, remittent, or con- Course, first clearly intermittent, then continuous. tinuous with paroxysms.

Disorders of the sensibility very rare. Constant auditory hallucinations presentingthe familiar particular development.

Hippolyte Bernheim (1840-1919)

Bernheim’s contribution to the birth of psychotherapy was considerable. Born in Alsace, he gave up his university and hospital post in Strasbourg when that French province was annexed by the German Empire in 1871. In 1879, he was appointed titular Professor of internal medicine in Nancy in Lorraine, where a University created in 1872 took in many Alsatian refugees. In 1882, he tried and adopted the method of hypnosis developed by Auguste-Ambroise LiCbault (1823-1903). Likbault, founder of what was to become the Nancy school, was a country doctor who had revived the use of Mesmer’s magnetism. Rejecting the fluid theory, to which-curiously-he would revert at the end of his life, he propounded his own view in a work entitled “On sleep and similar states considered above all from the point of view of the action of the moral on the physical” (1866). For LiCbault, hypnotic sleep differs from normal sleep only by the fact that it is brought about by suggestion, by concentration on the idea of sleep and by the “relationship” established between the hypnotic subject and the hypnotist. For almost twenty years Likbault, who successfully used hypnosis to treat every condition his patients suffered from, remained at best unknown, at worst considered as a charlatan. When he visited him in 1882 and tried, then adopted, his method, Bernheim brought LiCbault unexpected international fame. He brought the work of the obscure Lorrainian doctor to the attention of the scientific world in a work,

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“On suggestion in the hypnotic state and in the waking state”, published in 1884 shortly after Charcot himself had presented his paper on hypnotism to the Academy of Sciences. This almost simultaneous double publication marked the beginning of the quarrel between the Nancy school, with Bernheim at its head, and the Salpttrikre school. For Bernheim, hypnosis was a state of imposed suggestibility, suggestibility being “the ability to transform an idea into an act,” an ability shared by all human beings. As a result, the phenomena in hysterics under hypnosis described at the Salpkrih-e were no more than artificial productions brought about by suggestion and not authentic manifestations of neurosis. Subsequently, Bernheim abandoned hypnotism, believing that the effects achieved by this method could equally well be obtained by suggestion alone in the waking state, a method which he named “psychotherapy”. (Alexander notes that it was also Bernheim who was the first to use the term “psychobiology”, but that this word is used in the English-speaking countries to refer to the philosophical orientation of Adolphe Meyer). A certain number of psychiatrists around the world adopted Bernheim’s principles and methods, the best known being Albert Moll in Germany, Krafft-Ebing (1840-1902) in Austria, Betcheroff (1857-1927) in Russia and, in the USA, Morton Prince, whose work we mentioned in connection with that of Azam“. In Holland, the psychotherapy clinic founded in Amsterdam in 1887was named the LiCbault Institute. In that same year, Auguste Fore1 (1848-1931) travelled from Zurich to visit Bernheim. Finally, Sigmund Freud, having spent a few weeks in 1889 with Likbault and Bernheim, translated two of the latter’s writings, including the work where the word “psychotherapy” features in the title. For G. Zilboorg, Bernheim was the link in the chain which connected Mesmer-Charcot-Likbault to Freud. However, although at the end of the 19th century, he appeared to be the uncontested master of the emerging science of psychotherapy, his works were to be quickly forgotten or eclipsed in the 20th century by those of his translator. Jean GarrabC

Hippolyte Bernheim (1840-1919)

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Principal works BERNHEIM (H.), De la suggestion dans l’e’tat hypnotiqueet dans l’ktat de veille [On suggestion in the hypnotic state and in the waking state], Paris, Doin, 1884. BERNHEIM (H.), De la suggestion et de ses applications 2 la thlrapeutique [On suggestion and its application to therapy], Paris, Doin, 1886. BERNHEIM (H.), Hypnotisme, suggestion, psychothh-apie. Etudes nouvelles [Hypnotism, suggestion, psychotherapy. New studies], Paris, Doin, 1891. BERNHEIM (H.), Die Suggestion und ihre Heilwirkung. Ubersertzung von Sigmund Freud, Leipzig and Vienna, Deuticke, 1889. BERNHEIM (H.), Neue Studien iiber Hypnotismes, Suggestion und Psychothwapie. Ubersertzung von Sigmund Freud, Leipzig and Vienna, Deuticke, 1892.

Principal references LIEBAULT (A.), Du sommeil et des ltats analogues considh-ls surtout au point de vue de l’dction du moral sur le physique [On sleep and similar states considered above all from the point of view of the action of the moral on the physical], Paris, Masson, 1866.

ELLENBERGER (H.F.), The Discovery of the Unconscious. The History and Evolution of Dynamic Psychiatry, Harper Collins, 1970.

Hysteria

Amongst these psychoneuroses, there is one that I must mention especially, because its history, at the Salpi?tri&-e, has been confused with that of hypnotism, and because it is the condition which has provided suggestive therapy with its finest successes. I refer to hysteria. It is thanks to the doctrine of suggestion that I have, I believe, been able to cast light on this syndrome, whose pathogenic mechanism has been misuderstood until this day. The word hysteria was formerly applied to violent attacks of nerves (different from epilepsy). As they affected almost exclusively the female sex and were accompanied by a sensation of a ball rising from the hypogastrium (spheraesthesia), the lower part of the abdomen, into the neck, and sometimes by a forward projection of the belly, these attacks were attributed to the womb. It was said to move around the body or to send subtle vapours into the brain, which convulsed the whole organism. These simplistic ideas changed with notions of anatomy and of physiology, and the uterine doctrine was improved. The hysteria attack continued to be attributed to the uterus and the ovaries, but it was through the intermediary of the nervous system that these organs were thought to create

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the convulsions; the condition was a reflex neurosis of uteroovarian origin; and this doctrine still exists. However, in the seventeenth century, Lepois, Willis and Sydenham expressed the opinion that hysteria was a cerebral or general disorder which, apart from the attacks, gave rise to a host of symptoms affecting all the functions; sensory nervous disorders, anaesthesia, hyperaesthesia, perversion of sensibility, sensory disorders, amblyopia, deafness, illusions, motor disorders, paralyses, contractions, spasms, stammering, respiratory and digestive problems, even haemorrhage, skin disease, oedema, fever, etc.; and this symptomatology expanded every day; the Salpetri6re school in particular added numerous contributions. The field of hysteria thus grew singularly by all the concomitant signs being associated with the attack, and hysteria, instead of a simple attack, has today become a mysterious, polymorphous, inde-

finable dzsease, which does everything, which simulates everything. The Salpetri6i-eschool, which thought to introduce order into this chaos, to establish rules regarding the evolution of the attacks, to establish the constant stigmata which characterised the disease hysteria, produced an artificial result which increased the confusion. We need to return to the ancient conception of the word hysteria and restrict that word solely to the attacks of nerves which, falsely attributed to the uterus, were originally called by that name. Attacks of nerves are simply a psychodynamic reaction of emotional origin, a psychoneurosis. All of us, when seized by a violent emotion, experience certain nervous problems which I call psychodynamic. One person will experience a violent constriction of the thorax and larynx: he imagines he is going to suffocate, he turns blue, or is stifled by anger, by anxiety; this lasts a moment, then balance is restored. Another will remain as if transfixed, rigid with stupor, teeth and fists clenched, speechless and motionless.

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A third may be gripped by spasms or trembling of varying intensity which shake the whole body. Yet a fourth will have a feeling of weakness, as if he were without heart, without arms, without legs; he will have to sit down in order not to fall. Others shout, weep, ramble, experience violent and terrifying pains, etc. All these manifestations, which vary depending on individuals and on the nature of the emotion, last only a moment; the cerebral pendulum, disturbed for a moment by the emotional shock, recovers its regularity; order is restored. These are the early outlines of attacks which are not completed, hysteria attacks in miniature. When these phenomena are exaggerated and last a certain time, when this psychodynamic reaction persists for some time and the cerebral psyche, unbalanced or influenced by this reaction, is unable quickly to reconstruct the functional harmony, this is an hysteria attack. It is, as can be seen, the exaggeration of a normal phenomenon, of an emotive reaction. That having been established, in what conditions do these fits occur? A woman, more rarely a man, subsequent to an emotion, particular to each person, which particularly affects his or her impressionability-anger, fright, sorrow, pain-has an attack of nerves. This attack is made up of a very broad range of symptoms, which are in no way consistent. It may be a sensation of a ball or a foreign body which rises from the abdomen or the epigastric hollow into the neck (spheraesthesia), with thoracic constriction, laryngeal pains, anguish, convulsions, big furious disordered movements alternating with contractions; this is a convulsive hysteria attack, considered to be the standard attack. In others, the limbs and the body will contract and become motionless, with trismus, apparent loss of consciousness, closed eyes-the hysterical contraction attack wrongly called catalepsy. At other times, there is complete physical and mental inertia, without contraction, the appearance of sleep, with

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o r without unconsciousness: the sleep or hysterical collapse, wrongly called lethargy. In other cases, all these symptoms will be mixed, alternate, with no regular evolution, or else other bizarre manifestations take place: illusion, hallucinations, waking dreams, anxiety, pains, shouting, grinding of the teeth; or else respiratory anxiety or accelerated breathing may constitute the main or only symptoms; these are delusional hysteria, hallucinatory hysteria, dyspnoeic hysteria, etc. These diverse symptoms which erupt suddenly or after a few prodromes last from a few seconds to several hours; they exist in every degree from the reaction which can be called physiological and quasi-normal, to that which constitutes a major attack. O u r patient may have had such onsets of attack several times. This time, either the emotion may have been stronger, or the nervous impressionability greater, for example during the menstrual period, o r during a condition of anxiety, and the reaction is amplified and prolonged, taking on the proportions and duration of a true fit. This over, everything returns to normal, with no other sign. There is no further attack. It was an accidental attack, emotive and without repercussions. In others, the attack recurs with relativefrequency, through the influence of an emotion similar to the one which caused the first attack, or by the psychological evocation of that attack, by auto-suggestive memory alone. Such as the young woman whose observation I published, who had an attack of emotional hysteria at table between the first and second course and who since then, at each meal, at the same psychological moment, has unconsciously evoked the same attack in her mind by autosuggestion. Like all the nervous processes, like all the reflexes to which the nervous system becomes accustomed and which become automatic-tics, nervous cough, etc.-in the same way, the ability of the organism to produce fits, the hysterability, improves with repetition; and certain people

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develop a genuine hysterical diathesis which can be considered as an illness. In some, the fit is triggered by all emotions. In others, it requires an additional cause which increases the subject’s hysterogenic impressionability, for example menstruation or an illness of some kind. In some, the apparatus which I call hysterogenic reacts only to a particular emotion. A person may very well tolerate, for example, a violent fright, or anger, but will react to the sight of a snake which particularly affects his emotional idiosyncrasy. Each individual has his special emotivities, his particular impressionabilities which leave him defenceless, unless they have been controlled by education.

Hysterical aptitude otherwise bears no relution to general neruous impressionability. Certain very nervous subjects never experience attacks of hysteria; under the influence of emotion, they experience accelerated heartbeat, anxiety, diarrhoea, headache. Others who may be less nervous in general terms, easily give way to fits of nerves. You now understand what I mean when I say: In order to have an attack of nerves, one must be hysterisable, one must have a (symptomatic) hysterogenic apparatus, just as in order to have, for example, nervous eructations, one must have an eructatory apparatus. Those subjects who have frequent nervous attacks, can be exempt from any other manifestation during the interval between them; they have no stigma. In others, the repetition and the fear of the attacks produces certain persistent symptoms; or else the emotion which gives rise to the attack may at the same time develop the following symptoms: anxiety, insomnia, nightmares, dyspepsia, pain, lassitude, the persistent sensation of a ball or of retrosternal constriction maintained by auto-suggestion. However, these symptoms, and others of an emotional type or subsequent to the attack, have been wrongly considered as manifestations of the supposed morbid entity hysteria itself. They are, I repeat,

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concomitant symptoms also caused by the emotiveness which engenders the attacks or which follows them. We will see that these attacks of nerves and hysterical diathesis can easily be inhibited by suggestive education, which proves that it is purely a matter of nervous dynamism. Finally, hysteria attacks can be grafted onto all the diseases wbich give rise to emotion, anxiety, pain. Whether the emotion is due to an exterior factor, or due to an illness, it can always be hysterogenic in hysterisable subjects. Such diseases are: anxious neurasthenia, hypochondria, melancholia, phobias, obsessions, alcoholic or other hallucinations, saturnine pains, painful dysmenorrhoea, headache, ophthalmic migraine, neuralgias, hepatic, nephretic and appendicular colics, pelvic peritonitis, precardiac and respiratory anxiety, feverish anxiety with its anxious goosebumps, traumatisms with their emotional shock, all these conditions have the potential to cause psychoneuroses, including hysteria attacks. In these cases, the attacks are simply an epiphenomenon, a reaction not by the disease, but by the emotiveness created by the disease. And the best proof of this is that, by means of psychotherapy, as I will show, I can always eliminate this epiphenomenon, teach the patient to inhibit it; while the attacks of hysteria cease to exist, the disease still persists, but without the hysteria which the emotive psyche had added. The neurasthenia, phobias, melancholia, saturnism, utero-ovarian disorders, fever, etc., continue their evolution, thus demonstrating their organic or toxic nature, and the purely dynamic nature of the added hysteria. However, the authors, deceived by the impressive apparatus of the attacks, considering it to be a morbid entity which affects all the organs and all the functions, have been ready to burden hysteria with all this concomitant symptomatology and all the diseases to which it attaches itself. According to them, neurasthenia, melancholia, obsessions, fever, paralysis, colics, cardiac pain, etc., are all caused by hysteria;

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there have been accounts of hysterical fever, of alcoholic and saturnine hysteria, of hysterical skin disorders, muscular atrophies and jaundice! All of which explains why hysteria has been called the disease which simulates everything. What has further contributed to this confusion, is that other psychoneuroses can combine with hysteria; this happens in autosuggestible subjects possessed of easy mental representation and exaggerated ideodynamism. Other emotional autosuggestions can occur at the same time as the attack: the persistent spheraesthesia, anaesthesia, hyperaesthesia, headache, contractions, partial paralyses, vomiting, hallucinations, somnambulism, etc., all these psychoneuroses, and others, can combine together and also combine with the fundamental, hysterogenic conditions which may also be more generally psychoneurogenic. At other times, it is a single psychoneurosis, such as nervous vomiting, aphonia, sharp pain, functional impotence, etc., which is grafted by autosuggestion onto the d’isease. All these psychoneuroses, which are also subject to suggestion, should not be termed hysteria. To do so would be to divert the word from its original sense and apply it to thousands of totally disparate functional disorders, to all the dynamic nervous manifestations. There have been descriptions of the stigmata of hysteria, largely purported to be ovarian pain, the shrinking of the visual field, and sensitivo-sensory hemianaesthesia. I have demonstrated, and Babinski confirmed it long after me, that these symptoms do not arise spontaneously, but can be created by medical exploration in many impressionable subjects who are by no means hysterics. There are also references to mental stigmata, simulation, lying, eroticism: all these vices are imputed to these unfortunate women, to the point that even in the absence of the attacks, women who lie or are erotic are often accused of hysteria. In reality, hysterics have no specific mentality;

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many are honest, even naive, without cunning; they may be sensual or devoid of sensuality. The psychologists have come up with an obscure theory which I have not understood and which many doctors accept without understanding. According to them, hysteria is characterised by the disintegration of mental synthesis, aboulia, doubling of the personality, the shrinking of the field of consciousness, by a defect of regulation in the elementary reflex processes, either psychic or organic! To this conception, against which elementary observation protests, I will respond with one that seems to me simply the expression of clinical truth. Hysteria is a psycho-

neurosis of emotional origin characterised by attacks which have been given the name hysterical attacks; and nothing else. If I have somewhat dwelled upon the general history of the psychoneuroses, including hysteria, it is because they constitute the terrain upon which psychotherapy must act, on which it exercises its salutary influence, because the doctrine of suggestion clarifies their pathogenesis and justifies their treatment, because the phenomena produced by experimental suggestion, by what was formerly called hypnotism, are in reality nothing, I repeat, but artificial psychoneuroses. Not all functional disorders of emotional origin are psychoneuroses. When an emotion gives rise to a gastric problem, to diarrhoea, to urticaria, to jaundice, to migraine, the symptoms are due to gastritis, enteritis, to an infection of the hepatic ducts, to a general toxic state; they are not purely dynamic reactions. An emotion can act upon the vasomotor processes, the secretions, the peristalsis of the digestive tube, on the chemistry of the stomach and intestines, it can disturb the digestion and cause nutritive dyscrasia, it can arouse the virulence of the organism’s latent microbes and cause infectious diseases. Suggestion does not act directly on these symptoms as it does on mental representations. However, by repressing the emotiveness which creates them and can sustain them, it is capable of exercising a favourable

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influence. I know a young woman who at each emotion suffers from enteritis of the mucus membrane and urticaria with other symptoms. By teaching her to control her emotiveness, and to have confidence in herself, despite her nervous impressionability, I have almost completely cured her of these disorders of emotional, although not psychonervous origin.

[-I Specific psychotherapy of hysteria One further word on the specific psychotherapy of the hysterical attack and of hysterical diathesis. To begin with, in the great majority of cases, the hysteria attack can be halted in mid-course. Here is a patient whom I do not know: he is in an attack. Whether he is rolling on the ground, experiencing violent disordered convulsions with strangulation, is simply in contraction, with clenched teeth, whether he is asleep with apparent unconsciousness, I can break the attack by verbal suggestion. If it is a case of hysterical sleep, I tell the patient he is going to wake up, if necessary I open his eyes, telling him he is awake. If he is in contraction, I gently separate the clenched jaws, saying: “Look, you can open and close your mouth.” I restore the flexibility of the limbs by gently bending the elbow, the knees, the wrists, while saying to the patient: “Look, you can bend your elbow, your leg, your hand.” I add that he can open his eyes, make any movement, stand up. By proceeding in this way by gentle insinuation, rather than by command, in a very short time, varying from half an hour to a few minutes, the situation is resolved, and the normal state restored. If it is a major attack, I suggest that the oppression and the large movements should disappear, sometimes I simply suggest sleep, calm, and once this is achieved, I wake the subject. I do not rush the patient, I state gently that he is going to recover his calm and that all this nervous agitation

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is going to disappear. Usually, within a short time, this verbal suggestion is effective. Some subjects are more resistant. There are types of hysterical sleep which do not respond to the injunction to wake up. There are irresistible convulsions to which subjects abandon themselves with a kind of frenzy; the hysterical autosuggestion seems stronger than any counter-suggestion. Nonetheless, the latter is successful if one does not demand immediate success. Like a child with inconsolable weeping, which the parents would be wrong to repress immediately by strict admonition. A gentle suggestion will halt such tearful emotiveness once the necessary psychological period has passed. The same is sometimes true of attacks of hysteria. When they seem to resist suggestion, either because the subject has a strong will and will not accept it, or because the storm let loose is too violent, I do not insist, I say to the patient: “Your attack cannot stop immediately. But do not worry, do not make any effort; it will stop spontaneously.” By leaving the patient to himself, with the confidence I give him, the attack diminishes in intensity and shortly fades away. Just as the attack can be broken, in the large majority of cases it can also be induced; and this fact itself, the possibility of inducing attack, points to the diagnosis of hysteria; the epileptic attack cannot be induced by suggestion. For patients who have abdominal aura, or spheraesthesia, it is sufficient to touch the epigastrium or any region of the abdomen for it to become sensitive and hysterogenic by declaration. You say: “Here is the pain; the ball is rising to the neck; the attack is coming,” and it erupts. In some, a simple announcement of the attack is sufficient to produce it. If the aura or sensation which precedes the attack begins in another area, for example the thorax or head, if it is a respiratory anxiety or a dizzy headache, I touch these areas while suggesting the aura in the thorax or head, and the attack begins. It may be incomplete, or complete; it

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improves with suggestive training. Once the attack has been induced, I can check it at will like a spontaneous attack. When I am treating a hysteric, I generally begin by saying: “I am going to give you an attack, to make sure that it is a nervous attack. Do not worry, because I will stop it immediately.” I then induce the attack and check it as it develops, by suggestion. Having done that, I say to the patient with a smile: “You see that I can induce and stop an attack. Now, I can no longer give you one. You will no longer allow it to come. Look, I am again pressing the area I pressed earlier in order to give you one; you may well feel a pain, a ball trying to rise; but it will not rise now, is no longer stifles you; it no longer comes.” As I say this, I press lightly on the hysterogenic area; the subject feels a little pain, slight anxiety, as if the attack were trying to break out. But I reassure him with a smile, repeating: “It will not come; you are in charge; no attack can happen.” Almost alvrays, reassured by this calming suggestion, and dominated by my confidence, he learns to control it. I make him laugh, I train him to dominate the emotion of an imminent sensation of attack. Having done this, I pretend to suggest an attack. Again pressing on the area which was hysterogenic, I say: “Here comes the attack; the ball is rising, your throat is tightening.” And I add quietly: “But it can no longer come.” The subject, impressed for a moment by the hysterogenic suggestion, regains his self-control; he returns my smile and does not allow the attack to come. That is the first lesson in suggestion, and it is often enough to cure an inveterate hysterical diathesis. I repeat this lesson every day, I teach the patient to confront all the premonitory symptoms, the spheraesthesia, the pain, the oppression, or dizziness if the aura is cerebral, to tolerate pressure on the hysterogenic areas, to withstand all the emotions, without a psychodynamic reaction; he learns to be in control of himself. It is rare for three days to go by without a definitive cure;

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it is exceptional for it to take more than ten days to complete this education. It is truly surprising to see how easily this inveterate psychoneurotic habit is lost; and it can be said that of all the psychoneuroses, it is hysteria which is the easiest to cure. There nonetheless exist cases which initially seem resistant to direct suggestion. They are exceptional. Here, for example, is a young girl in my hospital practice, who for years suffered major convulsive attacks linked to nervous anxiety, which recurred one or more times a day. I tried in vain to check them by suggestion, or to prevent them. When I tried to check them, I succeeded only in aggravating them. My inhibitory suggestion aroused hysterogenic counter-suggestion. The girl was so impressionable that the slightest touch, even approaching her bed, induced an attack. It would have been a mistake, in such a case, to continue to use direct suggestion which inevitably remained ineffective, as it did not have the time to act, because it instinctively aroused provocative autosuggestion. Even if the patient was willing, the efforts she made to prevent the attack had the effect of causing it. What can you do in such a case? Nothing! I reassured the girl, told her: “It is not your fault, I know that you are trying, but it is too much for you. Nonetheless, my suggestion will still have its effect. We will not bother you any more, we will not touch you any more; and you will succeed yourself, without effort, in dominating these attacks which are of no importance. In a short time, it will all be finished.” I advised the people around to take no further interest in the patient and to pay no attention to her attacks. Every day, I went past her bed without stopping, saying simply: “It is going well,” avoiding touching her, impressing her: after three days, she had no more attacks. I was able to accustom her to being touched, to abdominal pressure, to emotions, without ill effects, and though she remained anxious, she has had no more attacks of nerves for several years.

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This form of indirect suggestion which consists in keeping subjects away from any strong impression, any direct intervention, in not touching them, either physically or morally, in influencing them by gentle insinuation, without seeming to, is also often effective with the other psychoneuroses. For almost twenty years, I have been curing all my hysterics by the method I have just expounded, without hypnotism; I educate the patients, I teach them to control their attacks, I give them confidence in themselves; I also vary the procedures slightly in order to adapt them to the individuality of each subject in all the psychoneuroses. I have not found a single hysteric resistant to psychotherapy. The word hysteria, of course, does not simply apply to the attacks. The diseases on which hysteria can be grafted, if they are toxic or organic, are not amenable to psychological treatment alone. These are the indications, these are the procedures of psychotherapy. I wished to establish, in the light of the facts and of a theory, that there is nothing mysterious about it, that it is rational and scientific; for the human organism does not consist solely of physical, chemical, physiological and biological properties. Doctors have sought to treat the diseased body as one treats a sick animal or plant, for example the vine infected with phylloxera. They purge, they bleed, they stimulate, they combat pain, they improve circulation, they disinfect, they kill microbes, they perform operations, as if with a damaged machine. Medical and surgical therapy has made great progress. All that is very fine. However, it is sometimes forgotten that the mind is also something in our organism, that it is not a negligible quantity in our physiological and pathological life. There is such a thing as psychobiology, such a thing as psychotherapy. That is what I wished to establish.

Sigmund Freud (1856-1939)

That Freud features as one of the authors chosen for this anthology of psychiatric literature in French, is because, although he wrote and published almost all his work (twenty-four books and one hundred and twenty-three articles) in German, several of the texts which stand at a watershed of his life and work are translations from French or articles he published directly in that language. The publication of what might be called Freud’s French writings covers a period of some ten years. Not all of them have been included in editions of the Complete Works,which contain only those considered as psychoanalytical and-with one exception, as we will see-those published after 1895. Nevertheless, these Freudian pre-psychoanalytical texts correspond to the period of the genesis of psychoanalysis, to that decade when, moving successively away from Charcot’s ideas on hysteria and Bernheim’s on psychotherapy, Freud began to develop his own theory of the neuroses. O n his return from his study trip to Paris between 20 October 1885 and 23 February 1886, Freud translated and published a volume of Charcot’s “Clinical Lessons” with a preface dated 18 July of the same year 1886. We have referred to the translations of two of the works of Bernheim* on hypnotism, suggestion and psychotherapy published in 1889 and 1892, after the trip to Nancy. Also in 1892 Freud published the translation of another volume

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of Charcot’s “Clinical Lessons”, this time accompanied by numerous notes in which he expounds his own conception of hysteria and criticises that of his Viennese teacher Meynest (18331892). Finally, in August 1893, immediately after Charcot’s death, Freud published his obituary, which opens the Complete Psychoanalytical Works. Reading this text enlightens us on the meaning behind this apparently paradoxical choice. Freud expresses the strong impression he had received from Charcot’s clinical teaching, recording in the original French the famous aphorism of the master of the Salp&trikre,which he was often to quote: “Theory is fine but it does not alter facts.” He recalled that the lecture hall where Charcot gave his lessons was decorated with the painting by Tony Robert Fleury (1837-1912) in which Pinel‘ is represented watching Pussin release the madwomen of the Salp&ri&refrom their chains. This painting made such an impression on Freud that he had an engraving of it hung in his consulting room. Freud compares Charcot’s restoration of the dignity of hysterics with Pinel who did the same for the madwomen: “as soon as Charcot, with all his authority,” had pronounced himself in favour of the authenticity and the objectivity of hysterical phenomena, they could no longer, as had previously been thought, be a matter of simulation. Freud considers that Charcot made a step forward in the study of hysteria which would forever ensure his reputation as the first to have elucidated the mystery of that disease: “While studying posttraumatic hysterical paralyses he had the idea of artificially reproducing these paralyses, which he had previously differentiated meticulously from organic paralyses, a process achieved by means of hysterical patients placed, through hypnosis, into a somnambulistic state. In this way he succeeded in demonstrating, by a strict chain of deductive reasoning, that such paralyses were the consequence of dominant representations in the brain of the patient at times when he is in a particular state, thereby for the first time explaining an hysterical phenomenon.” Freud associates what he considers to be the incomparable result of clinical research with the work of pupils of Charcot, including Pierre Janet‘ whom he cites here by name although, after their quarrel, he was to pretend never to have heard of him. It is true that the compliment addressed to the Salpttrikre school

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was double-edged, since for Freud the school had developed “a theory of neurosis in conformity with the medieval conception of that disorder, with the sole difference that the ’devil’ was replaced by a psychological formula,” a difference which seems to us far from negligible. Freud specifies that the work of Charcot and his students lost its interest for contemporaries uwhen Bernheim,‘k the pupil of Likbault,” began to erect the theory of hypnotism on a broader psychological base by making suggestion the central point of hypnosis. Only the adversaries of hypnotism, who hid their lack of experience in this field by relying on the opinion of some authority, remained loyal to Charcot’s theory and liked to repeat one of the declarations of his later years, in which he denied the utility of hypnosis as a therapeutic method. Finally, Freud announces that his followers will soon learn of significant changes and corrections to the aetiological hypotheses expounded by Charcot in his theory of the “neuropathic family” (in French in the original) which the master had made the basis of his general conception of nervous diseases, leaving only a very modest role (in French in the original) to the organic nervous diseases and the neuroses, which he did not differentiate from the point of view of their aetiology, considering both to be hereditary. One can understand why this surprising obituary, in which Freud scatters among the flowers of the traditional panegyric of the work of Charcot a few thorns in highlighting its limitations, was chosen to stand at the head of his own Complete Works. It was in fact the announcement of the work to come, which justified his claim to be the heir most worthy to write such an obituary. The.two texts published by Freud soon afterwards in French in the Revtre neurologique, Charcot’s review, in fact deal with the nosological differentiation of the neuroses, with their nosography based on the highlighting of mechanisms specific to each of them and finally with their sexual aetiology. In this way, they provide the foundation for the psychoanalytical theory of the neuroses which, as Bleuler put it, constitutes the essence of psychoanalysis. In “Obsessions and phobias. Their psychical mechanism and their aetiology” (1899, Freud establishes that obsessions and phobias are not a part of neurasthenia and that there was no justification in seeing them as aspects of mental

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degeneration. For him, they were neuroses in their own right, the principle difference between them being that “there is in any obsession two things: lo an idea which takes hold of the patient; 2 O an associated emotional state. Now in the phobias, this emotional state is always anxiety, while in true obsessions, in addition to anxiety, there may be another emotional state such as doubt, remorse, anger.” “A scrupulous psychological analysis of these cases [of true obsessions] shows that the emotional state, as such, is always justified.. .Only, and it is these two characteristics which comprise the pathological aspect: 1) the emotional state has become permanent; 2) the associated idea is no longer the correct idea, the original

idea, related to the aetiology of the obsessiwa, it is a replacement, a strbstitution.”

“The mechanism of the phobias is quite different from that of the obsessions. We are no longer in the realm of substitution. Here, psychical analysis no longer reveals an irreconcilable, substituted idea. All that is ever found is the emotional, anxious state, which by a sort of choice has brought out all the ideas capable of becoming subjects of a phobia. In the case of agoraphobia. . .we often find the memory of a f i t of anxiety and, in truth, what the patient fears is the occurrence of such a fit in the particular conditions when he believes himself unable to escape it.” Freud says that he hopes to be able to demonstrate that there is cause for establishing a specific neurosis, anxiety neurosis, to be differentiated from neurasthenia (a differentiation he makes in an article published in German in the same year 1895). However, already he claims that “anxiety neurosis is of sexual origin.. .but it does not apply to ideas taken from the sexual life: it has no psychical mechanism in the strict sense. Its specific aetiology is the accumulation of genesic tension, provoked by abstinence or frustrated generic irritation.” In “The heredity and aetiology of the neuroses” (l896), Freud addresses the disciples of J.-M. Charcot, notably Gilles de La Tourette“ and Janet“, presenting the arguments against the role attributed to nervous heredity in the aetiology of the neuroses. Above all, he describes the results of his own research on the aetiology of the neuroses. Having recalled the nosography of the neuroses (hysteria, obsessive neurosis or Zwangneurose, neurasthenia and anxiety neurosis or Angtsnetrrose), Freud

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maintains “that these functional pathological changes have as their common source the sexual l$e of the individual, either disorder in the current sexual L$e, or a significant past event.” He owed his results to the use of a new method of psychoanalysis (it was in this article that the word appears for the first time, referring to the description of the method given in “Studies on hysteria” published in the same year 1895 with Joseph Breuer. The origin of hysterical symptoms is an event of which the subject has retained an unconscious memory and which “is an early experience of sexual relations with actual irritation of the genital parts following sexual abase practised by another person and the period of life in which this disastrous event took place is early youth. . .Experience of sexual passivity before puberty: that then is the specific aetiology of hysteria.” As for obsessive neurosis (Zwangneurose), it “is associated with a specific cause very similar to that of hysteria. Here again, there is an early sexual event, occurring before puberty, the memory of which becomes active during or after that period. There is only one difference which seems crucial. Behind the aetiology of hysteria we find an event of sexual passivity, an experience undergone with indifference or with a slight degree of resentment or fear. In obsessive neurosis, by contrast, the event is one which caused pleasure, a sexual aggression inspired by desire (in the case of a boy) or participation with enjoyment in sexual relations (in the case of a girl). The obsessive ideas recognised by analysis (the word reappears) in their intimate meaning.. .are nothing other than self-reproaches by the subject on account of this early sexual enjoyment, but reproaches distorted by an unconscious psychical process of transformation and substitution.” The birth of psychoanalysis undoubtedly dates back to these texts. Jean GarrabC

Principal texts

FREUD (S.), “Charcot (1893)”, a Gesammelte Schrijien, Vienna, Internationales Psychoanalytischer Verlag.

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FREUD (S.), “Uber die Bereditigung von der Neurasthenie einen bertimunten Symptomenkomplex als ‘Angstneurose’ abzutrenuen (1895)”, ibidem. FREUD (S.), “Obsessions et phobies. Leur rnkcanisme psychique et leur Ctiologie” [Obsessions and phobias. Their psychical mechanism and their aetiology] (1899, Paris, Revue neurologique, 111, 2. FREUD (S.), “L’hkrCditC et 1’Ctiologie des nkvroses” [The heredity and aetiology of the neuroses] (1896), Paris, Revue neurologique, IV, 6.

-printed in French in Gesammelte Werke (G.W.), London, Imago Publishing Company, 1940-1952. -English translation in The Standard Edition of the Complete Psychological Works of Sigmund Freud, London, Hogarth Press, 1953-1974.

Jules Siglas (1856-1939)

As an alienist to the Hospitals of Paris, Jules Sdglas spent his entire hospital career at Bic2tre and the Salp&ri&e. A friend of Chaslin, he is one of France’s most brilliant late 19th-and early 20th-century clinicians. Were it not for his natural modesty, his fame as a semiologist would have extended beyond his native land. Soon after his appointment in 1886, Jules Skglas began to give clinical lectures at the Salp&rikre, lectures which achieved growing success due to the speaker’s clarity and semiological refinement. It was his chief pupil, M. H. Meige, who collected his master’s principal lectures for the 1895 publication of his main work: “Clinical lectures on mental and nervous diseases”. The first lecture of 14 January 1894 deals with hallucinations, and is a perfect example of Jules Skglas’ simple and direct style: “It might be supposed that an hallucination is a symptom which is always easy to recognise. Do not be taken in, Gentlemen, by this apparent simplicity. You will encounter a good number of errors of diagnosis in this respect, and there is no shortage of observations where one sees, described under the name hallucinations, phenomena to which they bear no relation. “The definitions of the hallucination are multiple. The best, in my opinion, and at the same time the most simple, is that which describes it as a perception without an object. A patient hears voices, maintains energetically that they fell upon his ear, even repeats what they said; yet the patient is alone, without an

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interlocutor, and he himself remarks frequently upon the fact. It is a purely subjective phenomenon, and often the only criterion we can obtain of it, is the subject’s statement that he heard it”. In the course of the 28 lectures, examples and clinical cases abound, illustrating the psychiatric diagnosis. Thus, in lecture 18 of 19 March 1894, dealing with the possessed persecuted, Jules Skglas makes the distinction between external demonopatby (“the demon is situated outside the patient, and persecutes him from the exterior, so that he is subject to sensory hallucinations of all kinds. In this case, the patient is in the same relation t o the demon as ordinary systematic persecuted subjects in relation to other types of persecutors (Jesuits, police, freemasons, etc.”); internal demonopatby, where the patient is inhabited by the demon as in diabolical possession (”Not only does the patient hear the voice of the devil and suffer from his insults, but he carries the devil within him; he has become the latter’s dwelling place, his slave; he must submit to his will, perform the acts which the devil commands; he is no longer even in control of his own thoughts. It is the devil alone who speaks, acts, thinks, and the possessed person is unable to oppose his all-powerful influence”); and true demonomania (“in which not only does the patient believe himself possessed by the devil, but imagines that he himself is the devil”). It was Jules Skglas who wrote the entire semiology of Gilbert Ballet’s famous “Treatise on mental pathology”, published in 1903. O n the subject of ideas of negation, he writes: “This general term applies to two slightly different sorts of intellectual manifestation. ”Sometimes, the negative character of the language used by the patient simply reflects a morbid tendency to opposition, to systematic contradiction (negativity). “Sometimes, and most commonly, this term refers to a specific conviction, reflecting the idea of change, of destruction, of absence, of non-existence. Strictly speaking, this is what is meant by the phrase: delusional ideas of negation. “Insane negators have no name, no age; they have no family, no feelings, no organs; they deny everything, the existence of the outside world and even their own existence.” H e set down his observations and clinical ideas in his work on “Delusion of negations” (1897). Fransois-Rkgis Cousin

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Principal works SEGLAS (J.), Troubles du langage chez les alie‘nks [Language disorders in the insane], Paris, 1892. SEGLAS (J.), Legons cliniqtles sur les maladies mentales et nerveuses [Clinical lectures on mental and nervous diseases], (Salp8 trihre 1887-1894), collected and published by Dr Henry Meige, Paris, Asselin et Houzcau, 1895, 835 pages. SEGLAS (J.), Dkire des nkgations [Delusion of negations], Paris, 1897. SEGLAS (J.), “Skmiologie des affections mentales” [Semiology of the mental disorders], Chap. IV, Book I, 74-270, in Truite‘ de puthologie mentale [Treatise on mental pathology], edited by Gilbert Ballet, Paris, Doin, 1903.

Principal references “Skglas et le groupe de la Salpttrihre” [SCglas and the Sa1pCtrib-e group], in BERCHERIE (P)., Les Fondements de la clinique. Histoire et structure du savoir psychiatrique [The foundations of the clinic, History and structure of psychiatric knowledge], Paris, Seuil, La Bibliothhque d’ornicar, 1980, Chap. 13, p. 153-170 COTARD (J.), CAMUSET (M.), SEGLAS (J.), D u de‘lire des nigations aux idkes d’&ormiti [From the delusion of negations to ideas of enormity], preface by J.-P. Tachon, Paris, L’Harmattan, 1997.

Language Disorders in the Insane (1892)

Neologisms.-Although strictly speaking the word neologism only applies to the creation of a new word, we will also include under this description, so as not to create excessive divisions, cases where normal words are distorted or diverted from their usual meanings (paralogisms). Indeed, in mental medicine, all these signs have a similar meaning. These new words come into being through the same processes as those that occur in ordinary language. As regards their mode of appearance, their psychological significance, neologisms can be divided into two major classes: passive neologisms and active neologisms. Passive neologisms are those that result from automatic processes; active neologisms are created deliberately. In the first case, the elements, words, images, ideas form their own associations; in the second, a deliberate act is involved. Passive neologisms, the result of simple psychological automatism, are explicable by the general law of association by contiguity or resemblance, and finally form through association of assonance or of representations. Here is one example taken from outside mental disorder. “In French slang,” says Mr Lefkvre, “of which we know a little thanks to the excellent work of Mr Marcel Schwob,

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we have encountered the expression ‘linges’ [linens] used to refer to the players of the card game bonneteatd. The sequence of associations would seem to be the following: bonneteau, bonnet, bonnet making, linen. Here we have a somewhat strange neologism, yet we see that it is easily explained by the rule of association. A similarity of words or visual images leads us from bonnet to linens.” In the insane, passive neologisms of the same automatic origin are found, for example, very frequently in manic states, where new words form through assonance, with no meaning for the patient, and thus result from the extreme rapidity of associations of ideas, of various mental representations, following each other like the patterns in a kaleidoscope. They are also found in acute or chronic alcoholism, in progressive general paralysis, where the speech is sprinkled with words diverted from their meaning, used in place of others because they are more sonorous, more high-flown; where one sees patients, impaired in particular in their memory, forget the normal nouns, and use circumlocutions to replace the forgotten word and finally pronounce unintelligible syllables and sentences. The same is true in dementia sufferers who, as a consequence of their impaired memory, divert words from their meaning, mispronounce them and thus form new words; and whose speech often becomes limited, when the ruin of their faculties is complete, to the automatic repetition of incomprehensible words or syllables with no apparent link other than a more or less complete degree of assonance. In the language of imbeciles, one also frequently encounters poorly articulated words, syllables with no other association than that of consonance, which makes their language resemble that of children who say bow-wow for dog or moo-moo for cow etc. In idiots, the poorly articulated sounds, the unformed cries they make cannot be described as neologisms, even passive ones. There is a further type of invented word which can be

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included in the category of passive neologisms, but which is nevertheless formed by a process other than the one we have just described. The new words, as Brosius has observed, appear to be the result of impulsion. It is a physical reflex following a momentary impression, with not the slightest link between idea and word. At the same time, movements in the other muscle groups may also be observed. This is therefore no more than a phenomenon of release, analogous to the interjection which occurs under the influence of strong emotion, and appears thus to relieve the overcharged sensibility. Cotard gives a similar interpretation of these facts: “Under the influence of a state of exaltation of the moral sensibility, acts which, in the normal state, never occur without the prior intervention of the intelligence, take on the character of mime-like manifestations, acts succeeding directly from moral impressions, without intermediate intellectual activity. As a result, articulated language takes on an absurd, illogical, incoherent character. It would seem that the words arise in accordance with certain affinities which link them to various emotional states, with no kind of logical connection. This leads to the frequent repetition of certain meaningless words or syllables. Language approaches the condition of the interjection or curse.” Even at the physiological level, strong feeling is enough to cause meaningless syllables or incoherent words to be uttered. We observed a person of this type, highly impressionable, but in no way insane, who under the influence of strong emotion uttered meaningless words, incomprehensible syllables. The most common of these interjections was as follows: “Beeah!” She pronounced, she said, these syllables as if not of her own volition and seemed to find that it gave her a great deal of relief. Similar phenomena occur in the deranged. Recently, Mr Fkrk reported to the Biology Society the case of a subject with persecution mania who pronounced the word

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“crouque”, every time he grew excited, and he pointed out that this neologism was produced by nothing other than the association of spasmodic vocal movements with an emotional state. In maniacs, it is common to observe combinations of syllables, strings of meaningless new words, which are assigned no specific meaning by the patient, but which are solely symptoms of a state of physical excitement. Cases of the same kind are also found in anxious melancholia. A patient of this kind observed by Cotard, said to him: “I was in a terrible state of anxiety and nervous agitation, I could not stop talking and I felt that my speech was no longer controlled by my intellect.” The language of the demented is also sometimes larded with neologisms of the same kind. It is also common to see patients affected with obsessive ideas pronounce occasional meaningless words when they are experiencing an anxiety attack. This is found notably in certain forms of onomatomania, but may also occur in other varieties of obsession. A patient of this kind whom we observed for a long time in our Salpikriire practice, who suffered from obsess’ion but not onomatomanla, pronounced the words: “Bibi-Raton” in order to stop his anxiety attacks. He had acquired this habit because he remembered that once, in the grip of an attack, he had pronounced these words suddenly, explosively and spontaneously, and that this particular form of interjection had brought to an end the painful emotional state he was experiencing at that moment. By contrast with these previous cases, active neologisms are created intentionally and correspond to an idea of some kind, although this may not necessarily be clear in the individual’s mind. Completely meaningless to any other person, they acquire a special significance if one has the key. These types of neologism are found everywhere in day-to-day language. Certain literary schools use them to the point of excess; in politics, we witness the creation of new words

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every day: opportunist, radical, centre-left, free-trader, etc., which are meaningless in themselves, but are the result of prior intellectual effort. Instead of the incoherent associations we saw in the previous examples, active neologisms are rooted in systematic multiple associations, coordinated in a certain direction, which culminate in the creation of a new word. Instead of associations of images, we have complex ideas, multiple syntheses, which reveal, not psychological automatism, but active thought. These considerations already suggest (a hypothesis in fact confirmed by clinical work) that this variety of neologism is connected above all with systematic delusions, whatever their type: persecution, grandeur, mysticism, eroticism, hypochondria. Once he has organised his delusion, more or less ingeniously depending on his mental resources, after long reflection, long searching, after considering the arguments, discussing their value, the patient, so to speak, concentrates them into new words which seem to express his mistaken convictions more precisely than the ordinary terms. However, it is worth noting that, once the word has been found, it will subsequently suffice. The word condenses the thought and, from that point on, the successive syntheses which led to its creation are almost forgotten. There is nothing left to explain, nothing to look for, the word says it all and its presence conceals, finally, a considerable impairment of mental capacity. Is this not unfortunately the case, even in the normal state, for many builders of scientific systems whose high-sounding and picturesque language serves simply to hide the weakness and hollowness of their theories? Like the chronically deranged, they worship the word; they are, as has been said, “logolaters”. In many cases it is very difficult to know the reason why the expression was chosen. Sometimes, it is vivid, comprehensible, so directly connected with the idea it is to express,

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that the latter is easy to decipher in the newly formed word which designates it. For example, a woman suffering from persecution mania and complaining of being watched, describes herself as being the object of pursuit by “Eyers”. Another, suffering from general sensitivity disorders, complains of painful sensations along the spine, which she attributes to the actions of a “spiniodorsal” convict. Another persecution mania sufferer hearing distant voices of varying timbres, describes them as “polyphonic” and “telephonic”. There are also certain words which, in themselves comprehensible, only become neologisms through their association with others, for example terms such as: glossy legs, fiery file.. .; vivid images, which often correspond to particular sensations experienced by the patient who tries to describe them as clearly as possible. These are the most simple cases, but there are others where it is difficult to grasp the relation between the neologism and the idea to which it applies, and where the patient is obliged to explain what he means. Here the neologism results from prior associations of ideas; something similar to those mnemonic “tricks” used to remember certain names, in such a way that at a given moment the invented word comes to mind instead of the word it was intended to recall. At other times, the neologism has its origin in auditory hallucinations, where the patient hears words which initially are not understood and which subsequently acquire a special meaning. A patient of Brosius, having heard the word “Kizfteck” while eating, subsequently employed that same word every time he wanted to say: “I have eaten enough.” Another quoted by Snell, who constantly heard the syllables “bi, bi”, had himself called “Bishop”. These cases, in which the neologisms first appear in the form of auditory hallucinations, are very common, and

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one often encounters patients whom one asks why they use this or that word to designate, for example, persecutors, who reply: “But I don’t know, it is they who told me that they were called so.” One patient we observed claims to be in contact with a spirit whom she called “Papanita”. It was he, she added, who had told her that this was his name. As lunatics generally use these neologisms to excess, and as the ideas or the things to which they refer are extremely varied, it can be helpful, from this point of view, to classify them into different categories. This has been done by D r Tanzi, who proposes the following grouping, useful as a guide in the search for the ideas expressed by these new sounds.

FIRST GROUP.-Names tbat allude to symbolic persons or beings. One of our patients claims that she is a victim of persecution by the Bouliqueurs. Another is being pursued by Vampas; a third by Eyers; another by Bobs and Majors. SECONDGROUP.-Names that allude to physical agents or states. One female suffering from persecution mania is tortured by nitral; another by the squirling machine. THIRDGROUP.-Names that allude to physiopathological agents or states of a hallucinatory kind. Many patients with aural hallucinations complain of being telephoned; one of our patients refers to the characters who speak to him as injectors. Another is emplastered, emplagued, emtanned by the fundament. Another one undergoes torture by a spiniodorsal convict who unspines her back. APPENDIX.-Terms analogous to the above, but with a sexual aspect. For example, the previous female patient

experiences genital hallucinations and on this subject always uses the word “coucouze”. A persecuted patient of M. Marandon de Montyel experienced genital hallucinations which he referred to by the term “nonentation”.

FOURTHGROUP.-spells,

exorcism rituah, evocations.

One of o u r female mental patients pronounced the words:

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“Zut! Du flan!” (Tush! Pudding!) to stop genital hallucinations.

[.-I

A female patient of M. Saury employed the spell: “God thirteen”, to avoid the tortures of souls in purgatory.

FIFTHGROUP.-hfetaphysical and pseudo-scient$c terminology. A male patient of Tanzi wrote a book on antbropofotology; another was an expert in philosophical alitiomety. Lemotamatomel is, for one lunatic, the symbol of eternity. SIXTHGROuP.-~utode~omin~tions. We currently have under observation a female patient with delusions of grandeur and persecution who, when asked who she is, replies: “I am the Queen of France Zazi.” A male patient, quoted by M. Lefkvre, described himself as “foudroyantissimeur” (the superthunderer). GROUP.-Non-systematic and absurd neologisms. SEVENTH This final group contains the passive neologisms, but also certain active neologisms, such as those that make up the language of one of our female patients, with delusions of grandeur and persecution, who claims to know every language and who, when spoken to in a language of her choice, answers merely with a string of meaningless and totally incomprehensible syllables. It is notably the neologisms in this final category which Martini seemed to have in mind. However, we believe that this writer took the hypothesis too far in claiming to have established a link between the patient’s state of mind and the use of certain special vowels; and when, in the same cases, he considers the increasingly restricted use of consonants as a sign of intellectual deterioration. From his specific research, Doctor Tanzi draws a number of conclusions of some interest. For example, he concludes that the frequency of occurrence of active neologisms, in terms of their meaning, is in accordance with the grouping above. Establishing the ratio of the number of neologisms

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collected with the number of patients, Tanzi finds 239 neologisms for 168 patients. There are therefore some who have several neologisms to their name, belonging either to the same or to different groupings. Double neologisms are found more frequently than anywhere else in metaphysical delusion, and it is understandable that they can more easily multiply in such a broad domain than in the necessarily narrow confines of personal delusion. Of the 239 new words, only 83 are genuine neologisms; the others are better described as paralogisms, an unusual ending or an alteration of meaning, in the patient’s vocabulary. True neologisms are found above all in the first and the last group. Metaphysical neologisms are encountered not only in patients who are simply unbalanced, but also in the genuinely insane. The classification of neologisms from a grammatical point of view is difficult to establish. However, substantives and adjectives are the most common (90%); then verbs and a few interjections. Compound phrases clearly fall outside this classification. It is interesting to note that the same neologism is encountered in lunatics living far apart and unknown to each other. This identity of thought in patients living in different environments shows that the laws of delusion are far simpler and more uniform than might be imagined. It is also worth noting in these lunatics, who otherwise use different neologisms, the superstitious importance attached to figures, in particular those which, like 13, 3, 7, are considered to have a Cabalistic significance. In the reasoning insane too, one often encounters philosophical ideas which seem to be the fruit of a single plant, and it would almost be possible to constitute a special school of philosophy from all the writings of these different patients. Neologisms which apply to personifications are above all directed at maleficent figures. In those that allude to physical agents or states, it is easy to recognise new sensations, a

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hallucinatory departure point. The same is more or less true for the third group. Neologisms associated with genital ideas indicate an interpretation rather than a description, and, as such, are more associated with disorders of ideation than of perception. Often, the neologisms applied to persecutors are marked by superstition and reveal a belief in supernatural powers. Non-systematic neologisms are often difficult to grasp, and their inventors, who sum up their delusion in this way, cannot or will not reveal their meaning. They imposed themselves on the consciousness without logical genesis, and it is often this mysterious origin that fascinates the patient. There is no purpose in looking for any kind of analogy in the formation of neologisms with the language of children, as the lunatic is already in possession of a complete language. However, there are a few, notably in the last group, which considerably resemble primitive language. What characterises all these neologisms is the presence of delusional ideas which, in a certain way, they condense. Moreover, they reveal a tendency to exaggerate the importance of the word, a sort of faith in its mysterious virtue. From the very numerous cases where patients suffering from systematic delusions create metaphysical neologisms, results the fact that the delusion is in no way partial, monomaniacal. However, alongside the typical delusion, there are always general delusional tendencies which give these patients a resemblance to unbalanced individuals. To summarise, neologism is not in itself a pathological symptom, but it becomes the sign of a morbid disorder when, as always in systematic lunatics, it expresses an element of superstition developing in the mind and attaining almost the proportions of an idiefixe. O n the basis of these various considerations and, in addition, by comparing and assimilating neologisms with numerous documents from the field of Folklore, Dr Tanzi associates neologisms with an aspect of atavistic regression. Without going so far, it could at least be said that the

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active neologism denotes a delusion which is already highly systematised, tends towards chronicity and exists against the background of intellectual deterioration. Its appearance therefore heralds a poor prognosis. However, this unfavourable prognostic significance should not be applied without distinction to all neologisms of whatever kind. It is this confusion, evinced by a number of authors, which has always engendered differences of opinion on the prognostic value of the neologism: such as the disagreement between the conclusions in the early work of Damerow and of Martini, one seeing it as a sign of incurability, the other reporting two cases in support of the opposite view. The former is certainly right, but the latter is perhaps not wrong and the question, it seems to us, could be resolved by making the following distinction. The active neologism denotes a chronic, incurable, condition, an intellectual impairment which can only deteriorate, reflected in parallel modifications in the neologisms which will become less logical, less rational. As for passive neologisms, while some of them are connected with incurable states of dementia, of general paralysis, we have seen that they can also be encountered in very benign cases, in excitement mania for example. Therefore, their prognostic value is variable, and they are not in themselves, like the previous ones, a consistent sign of incurability. When found in large numbers in a single patient, neologisms give rise to speech which is initially incomprehensible when one does not hold the key. One has the impression of dealing with someone suffering from incoherent dementia, while often the patient is simply suffering from chronic, still highly systematised lunacy, and not a state of characterised dementia. One can, from the following sentences taken from the interrogation of one of our patients on admission, gain an idea of all the facts we have just described. Among the

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neologisms scattered throughout her speech, are encountered examples of almost all the categories described above. Q.-How did you come here? A.-I do not want to be thought mad. I have been lively since my last charge; I am straight, not being back to front. Q.-I would like to know.. . A. (interrupting)-I am incognito, the Lair of the country must have warned you.. .(Pause, the patient seems to listen, murmurs a few words in a low voice and resumes). This sauce is killing my head. Q.-What is the sauce? A.-I know what I know. Q.-You have a complaint about the sauce. A.-Stick to your business, sir. When one is a man, one does not play dumb. Are you made of card-sauce? Are you made of cardboard? Q.-What is card-sauce? A.-Perhaps you like matelote better? Is it grub enough! Q.-What relations do you have with card-sauce? A.-I have been head of all the sauces for fifty-five years; I want the fortune I am owed; I am under the protection of the lair. Q.-You are referring to the societies? A.-I know what I’ve been told. Q.-What you have been told? A.-I am answering. Q.-Was it stupidities that you were told? A.-There you are talking; it is rubbish; I take no notice, I reply. Q.-They were nasty to you? A.-I was charged, but I have the protection of the lair, I have created animals. Q.-So you are powerful? A.-You are treating me as dumb, I am a brain. It is not the genuine that you need, but an imitation; I will not answer any more.

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Q.-What

Anthology of French Language Psychiatric Texts are the sauces you were talking about just

now?

A. (getting excited)-All of them, every one, evevery, evevery, evevey. You are encoiling your business, if you are not dreverying it. Through this special language, at first sight so incoherent, it is easy to perceive, not only that one is dealing with a delusion that is still highly active, but it is even possible to recognise a sufficient number of symptoms to define it. In this short interrogation, the patient revealed ideas of persecution, injurious aural hallucinations, ideas of power and of wealth, and one can already establish a diagnosis of chronic and evolving systematised delusion of persecution and grandeur. Information obtained in fact confirmed this diagnosis. Apart from neologisms, the speech of the deranged also presents other specific alterations in its content. Often they insert syllables, words or even incidental phrases, interpolated within the main sentence. This is what Merckel refers to as Embololalia. Sometimes, syllables are added to the word as prefixes o r suffixes, thus creating a certain resemblance with what is popularly called double Dutch. 1. This woman has always been of a lively character; proud, self-satisfied; at the same time mistrustful and very uncommunicative. She was only perceived to be ill in 1870. She claimed that she was being followed in the street, that she was being watched, that people were talking about her behind her back. Then that she believed that everyone was talking rubbish to her, wanted to rob her. Later, she had ideas that she was being poisoned, found that meat tasted bad, complained of smelling bad odours and all sorts of unpleasant sensations throughout the body. She never specifically referred to prosecutors. Five or six years ago, she began to employ incomprehensible words. For four years, she has talked of wealth being stolen from her, claimed to be the owner of several houses which she believes she has built, said that she is descended from a rich family, possesses great powers, great knowledge. Previously, she has never had any nervous episodes. We would add that an uncle of the patient died insane with ideas of persecution and that a sister, also with persecution mania, is currently interned.

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Or else, words or sentences are added, often meaninglessly: as in the individual quoted by Kussmahl, who ended his sentences, to give them greater length, with Wiederum duwiederumdu and the doctor quoted by Franck, who used to say: “The patient slept well, hedera, relieved herself twice, federa.” A woman interned at the Salp&ri&realways finishes her sentences with “once and for all”. One of M.A. Marie’s patients began all her phrases with these neologisms: “Araken-Doken-Zoken. ” At other times, the extra words added have a meaning. One of our patients often inserts into her speech the words “of course”, intended according to her to drive away evil influences. Another sprinkles her phrases with the words “tell me”, or else “do you see”, and claims in this way to establish contact with characters who inspire her. A third, “to keep within her rights,” employs a certain formula which she always begins with “5 times 5 make 25”. Indeed, one often finds inserted entire sentences, in some way symbolic, that are intended to ward off malign influences. In a few cases, certain phrases interposed into speech give it a totally incoherent appearance, when in fact they are only a response to hallucinations, where the patient is holding two conversations at the same time, one with his invisible interlocutor, the other with the real person present. Examples of this fact can be observed quite frequently. We even knew a patient who would hold two conversations in this way, but with the specific feature that a sentence addressed to the real interlocutor was pronounced in her normal voice, while breathing in, whereas the other, responding to the hallucination, was pronounced while breathing out in the manner of a ventriloquist. We would also mention the paraphrases which certain patients use to excess, developing their fixed idea in every aspect to an infinite degree; the allegorical turns of phrase, the comparisons, the sentences with which they lard their speech. Excessive use of pleonasm is also common, as is the

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accumulation of qualifiers, as with the patient in M. Falret’s department who refers to men as “mortal human men” and says that she is tormented by ”demoniac supernatural sacred theology”. There are those who, by contrast, are content always to repeat the same expressions. For example, we saw in our public practice a patient suffering from general paralysis of the insane who attached to every noun the adjective “little”. She took us into her room to show us her little candle, in a little candle holder, on her little bedside table, and we could not leave her without having admired the little bed, the little clock, the little pieces of furniture arranged around the little room belonging to this paralytic, a person who was nonetheless proud and self-content. Sometimes it is a syllable added to the majority of words which patients use to excess; such as general paralytics who constantly employ the prefix “super”, and describe themselves as super-wise, super-rich, etc. In other cases, the same word is repeated over and over, sometimes with no meaning for anyone and even for the patient, who thus resembles a child seduced by a word which it does not understand and yet continues to repeat. Repetition of the same word is sometimes associated with hypochondria. “I knew,” says Morel, “a woman possessed of a certain dose of hypochondria who, afraid of losing the power of speech, felt obliged to repeat incessantly the same word, the same sentence.” This repetition of a single word can also be connected with a superstitious idea, as found in certain individuals who attach importance to the number three. Conversely, there are those who, under the influence of a fixed idea, employ circumlocutions to avoid pronouncing certain words. (Kussmahl’s superstitious aphrusiu .) Other lunatics, before answering a question, have the habit of repeating the sentences pronounced by their interlocutors, just as certain people of sound mind, wanting to

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prove that they are listening, repeat the ends of the phrases they hear. This is a variety of echo quite different from the so-called reflex echolalia of imbeciles, idiots or even the demented. In this case, patients confine themselves to repeating mechanically, monotonously, the words or phrases pronounced in their presence, without paying any attention to them and above all without attaching any meaning to them. (Echo-sprache, Romberg, Brosius.) Here is an example taken from Brosius: Q.-How goes it? A.-How goes it? Q.-What do you want to do today? A.-What do you want to do today? What do you want to do today? What do you want to do? In other cases, the patient takes the last word or last syllable heard, to form the first syllable of a new word by assonance. This is a very common sign in one of our persecuted patients. You say in her presence: “New Year’s Day,” and she continues: “Daylight, lighthouse,” etc. She does the same when the initial word comes spontaneously into her mind, or comes from an aural hallucination. Another woman, when asked about her health, would reply with the words: the, Themis, Themistocles. (Lauzig. These sorts of word game are not in fact rare in the insane. One patient, who claims to be Lady Mountbatten, replies, when people seem surprised at her new status: “But is it not true that I am indeed battened down?” Another, speaking of Bishop Freppel, would simply pronounce the words frigida pellis.

Gilles de La Tourette (1857-1904)

Born into a family of physicians in the Poitiers region, where he began his studies, Gilles de La Tourette entered the Paris hospital service in 1882. He became a student of Brouardel and of Jean-Martin Charcot (1825-1893), father of modern neurology and holder of the first Chair of diseases of the nervous system at the Salpttrikre. Together with Paul Richer (1849-1933), Gilles de La Tourette is considered to be Charcot’s most faithful student. It was Charcot, as we know, who in his 1878 thesis described the hysterical fit, who 3 years later reintroduced hypnotism (“Contribution to the study of hypnotism in hysterics”) and, above all, who was to develop the Salpttrikre school dogma (“Clinical studies on hysteria or hystero-epilepsy”, 1885), all decorated with a wealth of illustration due to his talent as a draughtsman. Gilles de La Tourette and Paul Richer, the two students most respectful of the Master’s orthodoxy, are often contrasted with two other figures. The first was Joseph Babinski (1857-1932), who in his rejection of hysteria went so far as to propose the term pithiatism (net001= I persuade and t a z p o ~= curable) despite his constant opposition to the Bernheim’s (1840-1919) Nancy school. The second was Jules Dkjerine (1849-1917) who, after Raymond, was to succeed Charcot and whose method was to keep hysterics in total isolation, criticising the public clinical case presentation lessons as triggering factors in the disorder.

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While Gilles de La Tourette is known today for having given his name to the convulsive tic syndrome, most of his writings concentrate on hysteria, a disorder to which he devoted his entire working life. “Hysteria consists of a common basis, the stigmata, from which the paroxysms evolve. The study we have made of the former (volume I of the Treatise) will lead us to a knowledge of the latter (volumes II and I11 of the Treatise). Paroxysms, as their name suggests, should be seen as real episodic phenomena in the symptomatic picture of neurosis: the contraction of a limb, for example, is simply the temporary exaggeration of the diathesis of the same name, always ready to produce its effects. However, in certain cases, the paroxysms can take on such characteristics that they definitively replace the normal state: the contraction or the paralysis can set in as an almost permanent state. Furthermore, in the psychic field, we will see that certain paroxysms of a somnambular nature, known since Azam by the name secondary states, can become predominant to the extent that the primary or interparoxystic state is, so to speak, suppressed, entirely pushed into the background. This shows that in hysteria, the paroxysm is not always what the theory suggests, an acute and transitory eminent state. As well as the acute paroxysm or fit, there is the prolonged paroxysm or paroxysm state. At the highest level, we have the permanent paroxystic state or secondary state. In short, words only have the value which is attributed to them to represent ideas.. . We are much more pleased t o stress now one of the most common characteristics [of hysterical paroxysms], perhaps the best one: the possibility, even after a very long period, of an immediate return to the normal or interparoxystic state. A two year-long paralysis will disappear suddenly, often just as it arose; an attack of lethargy which has kept the patient isolated from the whole world for a month, will suddenly cease as if there were no transition between life and death. Suddenness of onset and cessation, that is the most striking characteristic of hysterical paroxysms. The dumb who speak, the blind who see, the deaf who hear, the paralytics who walk and the dead who come to life are hysterics. It is hysteria which brings about the cures to which the description miraculous has been applied.”

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Gilles de La Tourette had written, a few years before his “Treatise”, a book on the Mother Superior of the Ursuline Congregation of Loudun, Sister Jeanne des Anges, a possessed hysteric, who had hit the 17th century headlines by passing on her disorders to the whole religious community. The introduction to the nun’s memoirs is written like a whodunnit. An ambitious nun becomes Superior of the Convent and chooses as her spiritual adviser the most licentious curate in the small provincial town. The priest, a man by the name of Urbain Grandier, refuses and sister Jeanne des Anges becomes subject to apparitions in which she is visited at night and incited to do evil: “He spoke to her of love affairs, incited her with caresses both insolent and shameless and pressed her to grant him that which she was no longer free to give and which by her vows she had consecrated to her Sacred Spouse.” The manifestations developed into bewitchments, into diabolical possessions which led to exorcisms which themselves increased the symptoms: fits of convulsions, obscene erotic delusions. ..all culminating in the condemnation of the innocent Grandier, who after being subjected to the torture of the boot, was burned alive. The hysterical disorders continued and enriched the community: pregnancy, hallucinations ... A Jesuit, Father Surin, called upon to perform the exorcism, was himself sucked in by the deleterious climate: “He made her [Sister Jeanne des Anges] stand completely naked before him and on the pretext of punishing Isaacaron, the demon of impurity of whom she was unable to rid herself, he ordered her to administer discipline to herself.” Fransois-Rkgis Cousin

Principal works LA TOURETTE (G.) de, Trait; clinique et thkrapeutique de l’hystkrie d’apr2s l’enseignement de la Salp2trikre [Clinical and therapeutic treatise on hysteria according to the Salpttrikre teaching], preface by Dr J.-M. Charcot, Paris, Plon. Vol. I, 1891: Hystkrie normale ou interpdroxystique [Normal or interparoxystic

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hysteria] ; Vol. I1 and 111, 1895: Hystkrie paroxystique [Paroxystic hysteria]. LA TOURETTE (G.) de, Sceur Jeanne des Anges, supkrieure des Ursulines de Loudun; autobiograpbie d ’ttne byst&qtte posskdke, d’apris le manuscrit inkdit de la Bibliotkque de Tours [Sister Jeanne des Anges, .Mother Superior of the Ursulines of Loudun; autobiography of a possessed hysteric, according to the unpublished manuscript of the Tours Library]. Preface by D r J.-M. Charcot, and autographic reproduction (with Dr G. LeguC), Paris, Delahaye et Lecrosnier, 1886. Principal references

CERTEAUX (M.) de, La Possession de Loudun [The possession of Loudun], Paris, Archives No 37, Gallimard-Julliard,

SOUQUES (A.), Peige (H.), Les Biograpbies rnidicules [Medical biographies], Paris, Baillibe, 1939. TRILLAT (E.), Histoire de l’hysteiie [History of hysteria], Paris, Seghers, MCdecine et Histoire, 1986.

Study on a Nervous Disorder Characterised by Lack of Motor Co-ordination Accompanied by Echolalia and Coprolalia

OBSERVATION I1 (PERSONAL). (Thefirst part was recorded by M. P. Marie, bead of clinic of M. Cbarcot.)

S. J.. ., born on 1st July 1864 at Le Havre; book-keeper in an office of the Ministry of Public Works. Father in good health; mother has history of tuberculosis. She lost a daughter from pulmonary tuberculosis; four other children died young; three are still in good health. It is impossible to identify any nervous, syphilitic or alcoholic antecedents in the parents who are settled small shopkeepers and seem to live in relatively comfortable circumstances. S . . .was never ill during his childhood; he was very intelligent and won every prize in his class. In his last year he won the Prize of Honour; at that time (July 1880) his teacher noticed that his right shoulder and arm were from time to time lifted by small sudden and involuntary movements. A short time after, he entered an office and was able to write despite these movements until the month of JanuaryFebruary 1881, at which time he had to stop all work. The movements were beginning to become generalised; they had affected the right leg, and around the month of June (1881) the left leg in turn became affected. Around the month of January of that same year phenomena of another type had appeared: involuntarily and conjointly with these movements, s.. .would utter a slight, and initially inarticulate

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shout, a sort of Hem! and Hah! produced loudly enough to be heard easily by the people around him. He consulted Dr Gibert (of Le Havre), who placed him on tonic and hydrotherapy treatment, which the patient, by his own admission, followed very irregularly, and from which he obtained no improvement. Throughout the whole of 1881 and until October 1882, when the patient entered the Salp&tri&re Hospice (Bouvier Ward, Department of Professor Charcot), the movements continued to increase while the strange vocal phenomena became increasingly distinct. At that time, his condition was as follows: seventeen years old, tall, quite thin, in excellent general health, good appetite, a good sleeper, in no pain; gentle and shy character, pulse 82: slight basic anaemic murmur, without lesions, and no history of rheumatism. With no apparent stimulus, S. performs a series of very singular movements, localised and generalised, occurring sometimes on one side of the body only, sometimes on both sides at the same time. These movements are rapid: on the head, they affect the epicranial muscles, the muscles of the forehead, of the pavilion of the ear, of the commissure of the mouth which is pulled rapidly upwards and outwards; the patient performs a series of grimaces in which neither the eyes nor the tongue participate. These grimaces are usually combined with very rapid swinging and lifting movements of the arms, while simultaneously the legs, especially the right leg, bend and straighten alternately, the right foot striking the ground hard. At the moment this set of bizarre movements reaches its peak, S . . .utters a hoarse and inarticulate shout. At times, these phenomena occur very frequently; emotions cause them to recur: sleep, which is very good, makes them stop completely. Not a day nor even a half-hour passes without their occurrence: they affect eating only in that, if the glass or the fork is picked up when a spasm occurs, they are sometimes projected suddenly beyond their original destination. A short time after his entry to the hospital and following regular and more detailed examination, a highly

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characteristic phenomenon was quickly noted. The shout which S.. .uttered in certain circumstances took on a highly specific character; for although the Hab! Hah! still persisted, the patient would now faithfully echo words and even short sentences which he heard spoken: “Here is Mr Charcot. ”-“Charcot” he would immediately repeat, while exaggerating his customary movements. And he would add: “Ah! here is Mr Charcot, Mr Charcot, Mr Charcot;” all the while persisting in his grimaces and contortions. Apart from these sorts of nominal suggestions, so to speak, spoken aloud and beyond the patient’s control, there existed ideational suggestions which he expressed in the same way. One day S.. .heard the director of the hospice tell a housekeeper that she was not carrying out her functions correctly: immediately, ’while performing his contortions, he repeated out loud: “Damn it, doesn’t do her job, doesn’t do her job.. .,’ We stress this element of coarse language, for with S.. ., this crude aspect of the word or of the sentence which accompanies the gesture is consistent. When the patient has not been struck by a word, by an event which he can express by language, he often accompanies his contortions with the word sbit, regardless of who may be listening. In the same way, he will express an ordinary idea in a dirty manner: Mr X.. .comes into the room: “Ah! here is that old b.. .X, the old b.. .!”-all said quickly and in front of a person for whom he should and does feel the greatest respect. A lady comes into the room: “Ah! damn it:. ..her.. .she must have, etc.”: two or three short sentences of the utmost obscenity, said with an exaggerated accompaniment of tics and contortions, swinging of the arms, stretching and bowing, lifting of the shoulders, swaying and shaking of the head. These words are so involuntary that he sometimes pronounces them in front of his mother for whom he has great affection, and on a day out was obliged to leave a restaurant where he had scandalised the patrons by his loud and obscene utterances. We would add that there was nothing obscene about his gestures. S...was also forced to imitate by his

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gestures, just as he imitated by repeating the words he heard, but perhaps in more limited circumstances. S.. .would be in the courtyard of the Salpctrikre infirmary: X. . .approaches: “Aha! Aha! X. . .X.. ., shit, shit,” says S. . .lifting his arms in the air and lowering them alternately while at the same time raising his right leg to quite a height. Then the movements would stop, or even if they had not occurred, X.. .and many others who made a game of it, would repeat the usual gestures and words, and the force of imitation would be so strong in him that lifting his arms and his right leg he would teeter and fall to the ground, although without doing himself damage. Around the months of May-June, S.. .met at the hospice a person with whom he entered into regular correspondence. From that time, the state we have described became worse on account of the obstacles that were placed before this liaison. Formerly, he sometimes had sufficient control over himself not to pronounce his customary filthy words: after this, the gestures and words were performed and pronounced with unaccustomed indulgence and frequency. At this juncture and in the light of the inefficacy of a treatment which was very irregularly followed, the patient was restored to his family on 1st July 1883. H e returned to Le Havre in this state, experiencing such sorrow that he several times thought of leaving the parental home and returning to Paris. Until the end of 1883, there was no apparent improvement: gradually, however, towards the month of January 1884, a certain sedation took place; imperceptibly, these most extreme phenomena improved and that is the state in which we find S.. .on 15 July 1884, with his family in Le Havre, a state the description of which we complete by means of the particular documents provided by his father and mother in his absence. S.. .has imperceptibly lost the habit of uttering obscene words but continues with his echolalia; if addressed in the street, he rarely fails to repeat his own name. The big disordered movements have also disappeared: all that remains

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is limited movements of the whole right arm; the eyeballs of both eyes also move rapidly; finally, a phenomenon which had not been noted during his stay in the hospital, he from time to time repeatedly protrudes his tongue. All emotions have a very strong effect on him: he jumps, his mother says, when called, and although the improvement is considerable he has not yet been able to return to work. His general state is excellent; his intelligence clear and lively. S.. .has caught certain habits of laziness and idleness while awaiting a final cure. Since he has been in Le Havre he has followed no treatment and attributes his improvement to the great sorrow he experienced over several months: he still speaks of the Salpktrike only in very good and affectionate terms for the people who cared for him, towards whom, he tells us with sincerity, he will continue to feel the greatest gratitude. There is in him no sensory disorder: his heart is strong, his visual field normal.

Observation VIII (UNPUBLISHED). Reported by Professor A. Pitres (of Bordeaux). Miss X.. ., aged fifteen years, was a patient at the hydrotherapy establishment of Longchamps, in Bordeaux, for a period of several months during the winter of 1883, where she was treated for convulsive choreiform attacks accompanied by the sudden and involuntary utterance of crude or obscene words. Miss X...is highly intelligent; she learns with ease the lessons given to her by her governess; she plays the piano well. She is tall and strong. Her periods have not begun. Her mother has never had any nervous accidents. Her father has a painless convulsive facial tic. She has an aunt who is odd, almost deranged, who lives in isolation and is subject to nervous attacks, to bulimia and sometimes to

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periods of sadness during which she absolutely refuses to speak. At the age of nine, Miss X.. .began to have choreiform tics in her limbs and face, irregular and sudden spasms. At the same time she often found herself giving strong utterance to a few banal or crude phrases. After a few months, these incidents ceased. But a year later, they began again. The convulsive spasms reappeared, first in the shoulders, then in the arms, then in the face. At this time they began to be accompanied by indistinct guttural noises. At the age of thirteen, these noises became clearly articulated sounds. Usually on these occasions, the patient would say: “Go away, go away, imbecile.”A little later, the emission of words became more frequent, even clearer and the words were taken from a vocabulary of the crudest, filthiest kind. This state has persisted virtually without alteration until the present. Miss X.. .belongs to a family which holds a very high position. Her education has been excellent. She has never been apart from her mother who has surrounded her with the most gentle and continuous surveillance. It is to be wondered where and how she has been able to learn the words which she pronounces: “bloody hell, fuck, shit, ” etc. Never, at times of calm, has she employed any of these coarse expressions. When Miss X.. .is in the presence of a person whom she finds intimidating, she can, by strength of will, stifle the sounds and, by convulsively tightening her lips, prevent the phrases she utters being understood. All that can be heard then is a sort of indistinct grunting. It appears that as soon as she is free, she produces with an unaccustomed abundance the coarse phrases which are a part of her habitual vocabulary. Never are the words pronounced without being accompanied at the same time by a series of convulsive spasms of the muscles of the face, of the shoulders and of the trunk. However, quite often the convulsive spasms take place without any speech being uttered and we have seen

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that at other times the words can be stifled and made incomprehensible by an intense effort of will. During sleep, the spasmodic movements cease completely, and no involuntary speech occurs. No apparent sensory disorders, no paresis of the limbs. Professor Pitres writes furthermore, in a communication dated 27 October: “Miss de M.. .has not, it would appear, clearly shown signs of echolalia. It is true that we have never looked for it by loudly pronouncing in front of her the coarse words which are familiar to her. O n the contrary, the patient’s mother had sought to replace these words with neutral expressions, banal exclamations. To this end she had commanded the governess to shout, several times a day, in front of her daughter: ‘Oh my God!’ or ‘Mummy!’. The governess performed her task conscientiously, but the patient did not repeat the exclamations which she heard uttered in her presence. “Only one event observed by the governess seemed to be related to echolalia. One evening in 1883, while Miss X.. .was undressing for bed, a dog came and barked beneath her bedroom window. She immediately began involuntarily to imitate the barking of this dog, and was unable to fall asleep until one o’clock in the morning, because at every minute her whole body was shaken by muscular spasms accompanied by loud barking, similar to that of the dog. Another quite curious fact: Miss X.. .had a marked tendency to imitate gestures or to strike bizarre poses by which she had been impressed. One day when visiting a fair with her governess, she saw a cardboard Gargantua, whose mouth opened and closed regularly, engulfing everything presented to it. The child watched this spectacle for a moment with astonishment, and throughout the rest of the excursion continued to open and close her mouth involuntarily as she had seen the Gargantua do.” [...1

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As regards the diagnosis, it is appropriate here to establish certain divisions according to the different periods through which the disorder passes: 1st case. i%e individual is only afected by lack

of motor

coordination, muscular spasms; the condition will probably become established over time, but currently it is characterised by this symptom alone. With what other disorder could it be confused? There is one which is immediately obvious, and for which there is sometimes considerable difficulty in establishing a differentiation; we are referring to chorea, especially in the early stages of our condition, which is the most common case in children. However, an attentive observer will not long be deceived; the lack of motor coordination in chorea does not resemble the muscular spasms which affect our patients. While the movements of the choreic are somewhat slow, the fingers twist, the mouth deviates, and these signs occur successively, slowly and over a fairly long period, sufferers from our condition experience sudden spasms, muscular discharges. Beard was right: “These manifestations have an instantaneous character. Moreover, having jumped, shouted, or performed other acts of the same nature, the jumper immediately returns to the normal state. The explosion, like that of the revolver, so to speak, is sudden, and also like a revolver, the jumper is ready for a further explosion under the influence of an appropriate stimulus. If we examine a jumper, five seconds after jumping, we find in him no sign, no indication of what he has just done, and nothing to tell us what he is capable of doing.” These are certainly not the characteristics of true chorea, of Sydenham’s chorea. Moreover, if one asks a choreic to carry a glass in his mouth, he will be unable to do it without spilling the liquid on the floor; if, on the other hand, one of our sufferers has a spasm, the glass will go flying, but only if the spasm occurs at that precise moment, and we have seen in our observations that strong mental

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resistance-by contrast with the choreic-could momentarily suspend the convulsions. Moreover, there is only a likelihood of confusing the two disorders when the chorea reaches the chronic state, since the condition we have described is chronic from the start. Furthermore, it never presents those acute epiphenomena which are observed in chorea; patients are never confined to bed by the violence of the movements. Finally, there is no incidence of the paralyses which occur quite commonly in chorea. Before going any further, we would like to say something about a variety of coordination loss limited to the muscles of the face, which develops chronically and which, to distinguish it from fifth-pair neuralgia, has been given the name painlessfacial tic. Given that, as with our patients, during the early or remission period, the lack of coordination sometimes seems to be largely limited to the muscles of that area, we felt that it would be useful to attempt to identify the differences. There is no doubt that there exist convulsions limited to the nerves of the facial muscles, either partial or general, which can in many cases be traced to their real cause: anterior facial neuralgia, traumatism or even hysteria; of these we shall say nothing. But there are others which can exist independently of a known cause, and even exist in different members of the same family; it is in these cases that the difficulties can become considerable. However, if one wishes to accept the painless facial tic as a specific morbid entity, it nevertheless remains true that its precise restriction to the nerves of the facial muscles and its consistent localisation will prevent error, since, in the disorder we have described, the muscular spasms, although sometimes confined to the region of this nerve, quickly become more general, at least for a certain time. Finally, we are not averse to recognising that, in certain cases, these painless facial tics may perhaps constitute a first stage in the development of our condition, and that it is possible for it to remain at this stage, as we see in observation VIII, which

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describes a girl whose father had a painless facial tic, and who herself presented the symptoms of our disorder in full.

2nd case. f i e lack of motor coordination is combined with inarticulate shouts. In this second period, diagnosis becomes significantly easier, although we do not yet possess a real pathognomic symptom. During a muscular spasm, at the height of a convulsion, the patient emits an inarticulate shout; in this case, is the diagnosis clarified by the new symptom? Here, what we are seeing is chorea; in this condition, the various phonatory or respiratory muscles can be affected, and produce a particular glottal sound. However, just as in Sydenham’s chorea, there may be contractions of the muscles of the face or of the limbs, independent of each other, likewise these convulsions in so-called diaphragmatic chorea can exist o n their own. In our disorder, one must not lose sight of the fact that, each time a sound is produced, this always coincides with a muscular convulsion. The patient jumps, he shouts; everything returns to normal. This is not the case in chorea, and, moreover, we are not taking account here of a host of contingent conditions which would never allow the diagnosis to go astray, if that were possible. We will say nothing concerning the initial shout in the epileptic or hysteric attack; the subsequent clinical picture is so striking that to think of it is to establish the differentiation. However, this is not the case for certain shouts, for the barking which occurs otherwise than during attacks in hysterics, even accompanied by lack of motor coordination. However, in these patients, there are always either previous convulsive attacks, or sensory disorders, or a shrinking of the visual field, all phenomena which we have never observed in our subjects. As for the barking epidemics which occurred particularly during the Middle Ages, apart from the fact that few examples are now encountered, or even isolated cases, they were sufficiently distinguished by mental disorders, and by bizarre acts, from the convulsive

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attacks which are largely predominant in phonation-related phenomena.

3rd case. Lack of motor coordination and inarticulate shouts are combined with the utterance of articulate words with echolalia and coprolalia. Beyond this period, the diagnosis, so to speak, establishes itself. During a spasm, the patient pronounces a word; this may simply be the repetition of a word he has just heard; otherwise, it has an obscene character. Believe me, there is no other condition which presents this highly specific set of symptoms. It is well known that, during the somnambulistic phase of hypnotism, the subject may exhibit echolalia, but what a difference of state! And even if this echolalia persists by suggestion after awakening, where is the lack of motor coordination? Certain aphasics can pronounce the same obscene words over and over again. Trousseau quotes the case of a woman who would offer her guests a seat, saying to them: “Pig, animal, blasted beast.” However, he adds, “many of this lady’s acts otherwise seemed perfectly sensible, and she did not seem impatient nor to understand the meaning of the abuse she was uttering.” Finally, these words formed her entire vocabulary. Believe me, there is no need to insist further: might the aphasics have had hemichorea or athetosis? The treatment of this singular disorder, or at least a radical treatment, remains to be developed. Indeed, a reading of our observations reveals to what extent attempts at curative procedures were fruitless; all the sedatives of the nervous system failed. Only one method seemed to relieve the symptoms and to bring about those favourable periods of remission: isolation, combined with tonics of all sorts, preparations of iron, hydrotherapy. Patients also seemed to do well with the prolonged use of static electricity combined

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with hydrotherapy and isolation, but all these are only adjuvants; they may perhaps inhibit the development of the illness, especially when the patients are treated early. However, we can offer no conclusion in this respect, and we greatly fear that the prediction of Beard: “Once a jumper, always a jumper,” will subsequently receive further confirmation.

Alfred Binet (1857-1911)

Born in Nice in 1857, Alfred Binet always had eclectic interests ranging across subjects as varied as biology, psychology and theatre. Appointed in 1892 as director of the Sorbonne’s laboratory of experimental psychology, the following year he founded the first review specifically dedicated to psychology: L Xnnbe psycbologiqtre [The psychological year]. He is mainly familiar to the public through his work on the quantitative evaluation of intelligence. H e worked with Thkodore Simon (1873-1961) and together, in 1905, they constructed the first metrical scale of intellectual development. This method of quantifying mental age would be revised several times, in 1908, 1911, 1917 (the University of Stanford’s Terman test, Binet-Stanford test with Intelligence Quotient) and in 1949 by Renk Zazzo. Originally, it began as a quantification scale (Binet and Simon scale) used to differentiate children capable of following the normal school curriculum from those who could not (retarded). He was also the inventor of the term fetishism and was interested in the memory processes of human calculators and chess players (simultaneous blind games). “The operations that Mr Inaudi performs are additions, subtractions, multiplications, divisions, root extractions; he solves by means of arithmetic problems corresponding to first degree equations, and, in addition, one of his favourite exercises

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is to tell you the day corresponding to any date you give him. For him these are exercises in mental arithmetic.. . “At each show, he performs the following operations simultaneously and from memory: lo a subtraction of two 21-figure numbers; 2 O an addition of two 5-figure numbers; 3 O the square of a 4-figure number; 4 O the division of two 4-figure numbers; 5 O the cube root of a 9-figure number; 6 O the fifth root of a 12-figure number.. . “The study of calculating prodigies presents us with the same question [that of partial memories] from another point of view: in these people, no memory is destroyed; but one of the memories, the memory for numbers, acquires abnormal extension, which attracts amazement and admiration, while the other memories, considered as a whole, have nothing special about them; they may even be below normal levels. “In undertaking an inquiry on blind chess playing, our guiding purpose was to study a phenomenon of memory.. .” Alfred Binet recalls his conclusions on the specific type of visual memory used by these players to produce a geometric visual image of the pieces in relation to each other, of the possible moves (imagination or visualisation or else position memory). He then described the other two important factors: memory in the strict sense of the word and knowledge. “The second element of the blind game is recapitulation memory, or the ability to repeat all the moves in the same order in which they were made. The blind game is based on the exercise of both these memories, the position memory and the recapitulation memory. This distinction seems much more important than the one which is usually derived from the visual and verbal nature of the images. It is not a theoretical distinction, but a real distinction, which was spontaneously suggested to us by a large number of blind players. “The third condition of the blind game is difficult to sum up in a few words. The players refer to it as the chess player’s knowledge and experience. We have shown that it consists of a considerable body of knowledge into which the recent memory of a game in process merges.” Frangois-RCgis Cousin

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Principal works

BINET (A.), FkRi (C.), Le Magnktisme animal [Animal magnetism], Paris, Bibliothkque scientifique, Alcan, 1 vol., in-8, 1894. BINET (A.). Etudes de psychologie exphimentale, le Ftichisme dans l’amour, la vie psychique des micro-organismes [Studies in experimental psychology, fetishism in love, the psychical life of micro-organisms], 2nd ed., Paris, Doin, 1891.

BINET (A.), Psychologie des grands calculateurs et joueurs dgchecs [Psychology of the great calculators and chess players], Paris, Hachette, 1894, 364 pages. Principal references

BINET (A.),€crits psychologiques et pkdagogiques, choisis et prCsentks par G. Avanzini [Psychological and pedagogical writings chosen and presented by G. Avanzini], Toulouse, Privat, 1974.

The Measurement of Intelligence

I recently proposed, with Dr Simon, a synthetic theory of the operation of the mind, which it might be useful to summarise here, as it will show clearly that the mind is a

whole, despite the multiplicity of its faculties, that it possesses an essential function to which all the others are subordinate; and having looked at this theory, it will be better understood what conditions tests need to fulfil in order to grasp the whole of intelligence. In our opinion intelligence, considered independently of the phenomena of sense, of emotion and of will, is above all a faculty of knowledge, which is directed towards the outside world, and which seeks to reconstruct that world in its entirety, by means of the small fragments of it that we are given. That which we perceive of it is the element a, and all the highly complex activity of our intelligence consists in welding to this first element a second element, the element b. All knowledge is therefore essentially an addition, a continuation, a synthesis, where the addition is either done automatically, as in external perception, where 1. Extract from A. Binet and Th. Simon,Les Id& modwnes sur les enfints,

Edition 73,

p. 86-91.

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seeing a small spot, we say: “That is our friend walking along the road over there,” or alternatively the addition is done following conscious research, as when a doctor, after long examination of a patient’s symptoms, concludes: “It is a burst aneurysm, he is going to die,” or when a mathematician, having pored over a problem, says: “x equals such and such.” Now, it should be noted that in this addition to the element a, a host of faculties are already at work: understanding, memory, imagination, judgement, and above all speech. But let us keep just the essential and, since all this culminates with the invention of an element b, let us call the whole task an invention, which takes place after an understanding. We need only to add two more lines, and our scheme is complete. The operation we have described cannot be carried out haphazardly, without knowing what it is about, without adopting a certain line, from which one does not deviate; what therefore is needed is a direction. Nor can the operation be carried out without the ideas that it raises being judged as they occur, and rejected if they do not suit the intended purpose. Therefore, there must be evaluation. Understanding, invention, direction and evaluation, intelligence is encompassed in these four words. In consequence, we can already conclude from all the above that those four functions, which are primordial, will need to be assessed by our method and will therefore fall within the scope of special tests. However, since the purpose is specifically to measure an intelligence in the process of development, a child’s intelligence, let us see how this intelligence might differ from that of an adult. We will avoid empty words; let us not say that the childish intelligence differs from ours only in degree, not in nature-but let us try as precisely as possible to grasp the essential difference which divides them. In all that 1. Translator’s note: the French original is “censure”, which translates literally as censorship. In the context, I have chosen to use the word evaluation as the connotations of the literal translation might cause confusion for the Anglo-Saxon reader.

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follows, we will be thinking of a young schoolchild aged eight o r nine, but it is understood that the differences we identify will be greater with respect to a younger child, and smaller with respect to an older one. There exist between the child and the adult a number of intellectual differences. Some can be ignored here, being without importance. For example, a child has less experience than an adult, knows less, has fewer ideas, knows fewer words; it will be noted as well that he has other goals, other interests, other preoccupations; for example, the sexual instinct is not yet as well developed as in the adult; and all this does indeed have practical consequences; thus, by the fact of his ignorance alone, a child could not take independent control of his life. But these are not differences in the psychical organisation of intelligence, and they do not need to concern us. Even if these differences did not exist, the child would still have a child’s intelligence. In order to characterise this intelligence, let us return to our scheme, which consists of direction, understanding, invention and

evaluation. The young child, in whatever he undertakes, shows a weakness of direction: he is scatterbrained and fickle; he easily forgets what he is doing, or becomes bored with what he is doing, or is deflected by a fantasy, a whim, a passing idea. In a conversation, or in telling a story, he jumps from one subject to another, by associations of ideas and abrupt changes of subject. You can see this lack of direction when he is on his way to school; he does not head towards his goal in a straight line, like an adult, but moves in a zigzag, constantly stopping or diverted from his route by some spectacle which interests him, which makes him forget his purpose and, for example, move from one pavement to another. And when he is absorbed in some occupation, he forgets everything else, and constantly has t o be reminded: “Now pay attention!” His understanding is superficial. No doubt, he perceives external objects, their shape, their colour, their distance,

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their sound, almost as exactly as an adult, and his senses are extremely acute; as a result, he can judge and compare simple sensations, colours, weights, lengths, with remarkable accuracy. But if perception needs to go beyond simple sensations to genuine understanding, it shows signs of weakness. It has been said of the child that he is a good observer, but that is an illusion; he may be struck by a detail which we would not have noticed, but he will not see a whole, an overview of things, and, above all, he is unable to distinguish between the secondary and the essential. If asked to recount an event that he has witnessed, it becomes clear that his view of it is purely superficial, and that he has been struck by the appearance, and not by the hidden sense. Moreover, profound interpretation is impossible for him, as it requires language, and he is still in a phase of sensory intelligence; the verbal phase begins later; and, in consequence, there are many words which are very clear to us which he does not understand, or to which he attaches false ideas. And even if careful study is made of the language he uses, it will be clear to what extent it remains sensory: he uses very few adjectives, a few more nouns, especially verbs, which shows that he is mainly sensitive to that which expresses action; particularly rare are the conjunctions, for, because, ;f; when, little words which are perhaps the most noble parts of language, the most logical, as it is these which express the subtle relations between ideas. He uses concrete words much more than abstract ones. All this tends in one direction: an understanding which is sensory in nature and remains always superficial. His power of invention is likewise limited; to begin with, it is more imaginative than reasoned, more sensory than verbal; and furthermore, it does not go deep, it does not evolve, it is undifferentiated. We have two very clear examples of this. If asked what he thinks of familiar objects, to tell us what they are, his thinking immediately runs along utilitarian lines; he defines each thing by its use, and this use is envisaged in its most restricted and most banal form;

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“What is a knife?-it’s for cutting; a horse is for pulling a cart; a table, for eating from; a mother, for preparing a meal; bread, for eating; a snail, for crushing.” Likewise, the purpose of work is to avoid punishment or to be rewarded. Another example where the child’s mentality shows itself candidly, is when he is asked to describe pictures; shown a scene of poverty representing, for example, some unfortunates collapsed on a bench, the child aged five to six will say: “That’s a man. . .that’s a woman. . .that’s a tree;” a child aged eight to ten will try to describe what he sees: “The man is sitting on a bench, there is a woman near him;” it requires an adult intelligence to see beyond the picture, to understand the meaning, and to say: “These are homeless people, people living in poverty, people who are suffering.” NOW,let us take note of what these answers tell us about the child’s mentality; they prove that the gift of invention that he possesses is still little differentiated; the young child interprets the picture by means of vague, banal images, which could fit all sorts of pictures and as a result fit none. To recognise that the picture contains a man or a woman is a banal observation; specialisation is greater when the position of the characters, their behaviour and activities are described; specialisation goes even further when the child moves beyond description, and gives an interpretation of the meaning of the scene. Listing, describing, interpreting, these are the three stages in the evolution of thought; this evolution consists in the journey from the vague to the precise, from the general to the specific; it is a journey which the young child is in the process of making. The power of evaluation is, in the child, as limited as the others. He has little awareness of the accuracy of what he says and what he does; he is as clumsy of mind as he is of hand; he is remarkable by his ability to talk rubbish, to be unaware that he does not understand. The whys with which we are harassed by his curiosity cause us little embarrassment, as he will be naively content with the most absurd becauses. He distinguishes very badly between what he

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imagines or desires and what he has really seen, and this confusion explains many of his lies. Finally, everyone knows the child’s extreme suggestibility which lasts to around the age of fourteen; it is complex in nature, since it is related to character as well as to the imperfection of intelligence; in any case, this suggestibility is yet another proof of the lack of evaluation. With this mentality, as we have just described it, the child greatly resembles, in terms of intelligence, an adult imbecile; and if we had the space for it, we would show a whole series of questions and problems and difficulties to which the adult imbecile and the normal child respond in exactly the same way. It is the same lack of evaluation and direction, the same superficial understanding, the same undifferentiated invention. However, one cannot help but feel that there is not and cannot be a complete resemblance between two beings whose potential is so different. The adult imbecile has completed his development, while the child is just beginning his. And precisely because he is in the process of development, the child possesses a certain number of very interesting qualities, of which nothing has been said in our earlier scheme, and which are nevertheless very characteristic of his state. The first is the power of his memory; the child’s memory is quick and lasting, because this quality is necessary to all subsequent development; a mind devoid of plasticity would be incapable of transformation. Compared with the adult, the child has a better memory; he may not learn more quickly, but he retains what he has perceived for longer. Another important childish characteristic is that excess of activity which he continuously needs to express, which makes him restless and noisy, and so refractory to the discipline of silence which the school seeks to impose. How many times do we hear him enjoined: “Keep quiet!” A command which alternates with that other one: “Now pay attention!” Finally, the third characteristic, children are constantly engaged in experiments of all sorts to find out about external objects or to exercise their faculties; from

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the earliest age, they pick up objects, handle them, hit them, suck them ...and later on, they spend hours and hours in play; the child is essentially someone who plays; play, understood in its most profound sense, is a preparation for the acts of adult life, a sort of entertaining rehearsal before the serious performance; play is a distinguishing characteristic of all beings in the course of development. It is hardly necessary to add that the adult imbecile does not play. It is this very particular mentality which we are going to seek to assess by means of a set of tests. Necessity, as they say, is the mother of invention. N o doubt we would long have continued with the status quo of fragmentary tests, if we had not been obliged, two years ago, for genuinely social purposes, to carry out measurements of intelligence by the psychological method. We wished to try, on a small scale, to organise classes for abnormal children. Before these children could be taught, they had to be recruited. How could this be done? We have already said that the opinion of teachers regarding children’s intelligence needs to be checked, and that a pupil’s slowness in school does not mean much when school attendance has been irregular, or when information is lacking on school attendance, as happens so often in Paris. So what was to be done? Every day, we were brought a schoolchild about whom we lacked essential information; neither the parents, nor the teachers, nor the child’s school record could help us. We were genuinely reduced to our own resources. The child was there, in our surgery, alone with us; after a quarter or half an hour of questions, we had to reach a precise judgement, a judgement of great significance for us, as it would influence the child’s whole future. It was in these conditions that we developed, with the help or our dedicated colleague, Dr Simon, a method of measuring intelligence to which we gave the name metric scale. It was constructed slowly, using studies conducted not only in primary and nursery schools with children of all ages, from three to sixteen, but also in hospitals and

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hospices, with idiots, imbeciles and defectives, and finally in all sorts of milieus and even in the army, with adults both literate and illiterate. After hundreds of verifications and improvements, my considered and now definitive opinion is not that the method is perfect; but that it is the method which had to be employed; and if it is improved by others after us, as we indeed hope, they will only improve it by employing our own procedures and by drawing on our experience. The guiding principle of this measurement is as follows: to develop a large number of tests, both rapid and precise, presenting a growing level of difficulty; to try these tests with a large number of children of different ages; to note the results; to find which tests can be done successfully by a given age, and which ones children even as little as one year younger are on average unable to do; and then to construct a metric scale of intelligence with which it can be determined whether a given subject possesses the intelligence appropriate to his age, or is ahead or behind, and if so by how many months or years.

Philippe Chaslin (1857-1923)

Philippe Chaslin’s first interest was in mathematics. He came to medicine through the influence of his grandfather, who had contributed to the writing of the huge, 100-volume Dechambre Encyclopaedic Dictionary of the Medical Sciences. Parisian by origin, Chaslin became a medical resident at the age of 25, was appointed chief physician at Bicttre at 32, and ended his career at the Salpkrihre as did his friend and colleague Jules Skglas (1856-1939). The two alienists were similar in personality, both reserved to the point of shyness, both completely devoted to public service. It was in 1895 that Chaslin defined “Primitive mental confusion”. Today his book is forgotten, but the term mental confusion would be passed on to posterity, although it had numerous detractors. In these critiques, the new concept was attacked with regard to the primitive nature of the mental confusion, on the connections between the episode and the patient’s stupidity, each author taking care to describe exogenous causes of the said confusion. Chaslin’s ,mental confusion derives from the “stupidity” described by Etienne Georget (1795-1828) who had proposed this term to replace Esquirol’s (1772-1840) “acute dementia”. This was thus a nosographic entity which was developed throughout the 19th century to define those transitory states during which an accidental absence of understanding is observed. From his initial description, Chaslin made the distinction

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between idiopathic primitive mental confusion and symptomatic mental confusion. The refinement of Chaslin’s semiological description is only equalled by the simplicity of his language, which is drawn from everyday vocabulary: “That which strikes one first is the appearance of the patient: the dazed, bewildered and stupefied air, inert and dull, the empty and expressionless gaze, the pale face, livid like that of the truly sick, untidy, dirty, clothing disordered or torn, he mutters in a more or less coherent fashion, comes and goes to no apparent purpose, sometimes with an unsteady or heavy gait, or staggering as those suffering with tumours of the cerebellum; then sometimes he sits on the ground, lies down, stands up with gestures that occasionally coincide with his speech, but at other times bear no connection with it; again, he may remain seated in a chair, indifferent to what goes on around him, content to make a few arbitrary gestures, continuing his incoherent chatter or plunged in silence; at yet other times, finally, if lying down, he may confine himself to a gesticulation and a mussitation which occasionally give way to periods of absolute tranquility or instead to an agitation which makes him leap suddenly from his bed.” When, more than 15 years later, Chaslin published his treatise “Elements of a semiology and a clinical approach to mental disease” (1912), he was to show himself more cautious with regard to the triggering factors of this mental confusion. Describing a clinical observation of delirium of exhaustion, he concludes: “This is indeed a typical delirium of exhaustion (or primitive mental confusion) quite clearly resulting from malnutrition, since L.. .has twice fallen into an intense confusion which was for several days, the first time, genuine stupidity.. . “All the causes of exhaustion can lead to this state: infections after the infectious period as such (which itself gives rise only to infectious delirium), childbirth, through exhaustion due to pain or loss of blood, excessive effort (bicycle races), numerous epileptic fits, privations, starvation, etc. What is the mechanism? Could it perhaps be in each case a ‘self-intoxication’?This is quite possible, especially as cold or heat stroke can give rise to very similar disorders. Traumatism, physical or emotional shock, also leads to states

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of confusion, as we will see later, to the extent that it is coming to be thought that (primitive) confusion is a syndrome which, being able to appear under so many different influences, including poisoning and infection, must invariably correspond essentially to a specific cellular modification, always approximately the same, since the reactions of the economy in all vary little.”

Fransois-RCgis Cousin

Principal works CHASLIN (P.), La Confusion mentale primitive [Primitive mental confusion], Paris, Asselin et Houzeau, 1895, part I, Chap. 1, “Symptomatologie de la confusion mentale primitive et idiopathique” [Symptomatology of primitive and idiopathic mental confusion]. CHASLIN (P.), Elments de skmiologie et clinique mentales [Elements of a semiology and a clinical approach to mental disease], Paris, Asselin et Houzeau, 1912, 956 pages.

Principales rifirences COHEN (C.), Philippe Chaslin, sa vie, son cruvre [Philippe Chaslin, his life, his work], Dissertation for the CES in Psychiatry, Paris X, Bichat, 1990. LANTERI-LAURA (G.), GROS (M.), Essai sur la discordance dans la psychiatrie contemporaine [Essay on discordance in contemporary psychiatry], Paris, EPEL, 1992.

a

Elements of a Semiolo y and a Clinical Approac to Mental Disease

General discordance. Incoherence (Disharmony) between the different signs of the disorder.-Although this is not the place, I nevertheless believe that I should include a brief aside on the incoherence of the delusion, because this general discordance very often accompanies the other. It may be encountered in dementias, particularly general paralysis of the insane (GPI). But where it is most striking is in dementia praecox where the patient will tell you, for example, with a smile, that he has just been cut into pieces, etc. It is apparent that the discordance is between the emotion and the delusion. For this reason I have preferred to employ the name discordant insanities for all those types which have , been classified provisionally by the name “dementia praecox”. My meaning will become clearer in the chapter where I deal with the subject, but here I wish simply to note the great diagnostic significunce of this symptom of general discordance, of which incoherent polymorphism is only a specific case, and which often signifies dementia or future dementia. I have already spoken (p. 34), of discordant mimicry. Later on, I will discuss the other discordances.

[...I

Parrot language (psittacism).-Giv.

..is

a dementia

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praecox patient whose condition takes a particular form, verbal discordant insanity, specifically because its sole manifestation is a totally automatic language, incoherent and furthermore full of automatically produced expressions (SCglas’s passive neologisms). As the complete observation is given in the chapter on discordant insanities, here I will quote just one passage. At the beginning of the conversation, Giv.. .often gives sensible replies, followed by completely incomprehensible sentences and words, accompanied by expressive miming as if there were some meaning in them. We were talking about his travels and I asked him: Q.-You have been to Alaska as well? A.-Yes (this is not true); we will see that later. I am going to enlist as a veteran aide-de-camp. Q.-What is that? A.-That is your business. It is the pond in Simaeus; I am looking into a pond if I become involved in your business: Aide-de-camp, that is the pond in Simaeus; the azenu you tell him to clear off, to keep running, yet still lodge somewhere, if you make clay run, it will lodge in the azena.” Obviously, it is meaningless. It is a language unrelated to any thought, completely separated from the intelligence. There are times when Giv.. .talks to himself like this in the courtyard, always inventing new words in a purely automatic way. This parrot language, wbetber it contains invented words or not, should not be confused with the other forms where there are deliberately invented words (p. 108) or symbolic words, as in persecution mania where its significance is completely different (see p. 72 on the differential diagnosis between the different forms of language with regard to incoherence). It is encountered in states of alcoholic dementia, organic dementia, senile dementia where it often takes the form of rambling, etc., but also in states where there is profound confusion accompanied by loquacity, such as the

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example I gave for incoherence (p. 69). In short, in all the states where there is a profound temporary or permanent weakening of the intelligence. It is a discordance between the intelligence and language. It is close to that which I call

declamatory litany.

GENERAL REMARKS. Discordance and discordant insanities.-Is each of the types which I have described under the general title discordant insanity a distinct type of a derangement or simply a form of a derangement? Is the common link between these types, the “discordance”, sufficient to make it just one derangement? I could avoid answering, since I have said often enough that the clinical approach alone does not so far allow us to decide the question and that nosography is not my concern. The words clinical type prove nothing one way or the other. In any case, clinically there is a link between these types; it would appear that there are intermediate forms; finally, the discordant insanities appear to develop very roughly in threeperiods, a beginning, state and, finally, terminal period. It is largely Kraepelin who used the term “dementia praecox” to describe the hebephrenia of Hacker and Kahlabaum, Kahlbaum’s catatonia, paranoid dementia, and who sought to make it an entity (although with reservations). He also attached to it the hallucinatory systematised insanities, which are somewhat distinct clinically and which I resolutely exclude. Dementia in the discordant insanities.-This word “dementia praecox”, chosen by Kraepelin, is the wrong one, since, as we have seen, the dementia generally arises only after many years. For this reason, Bleuler employs the word “schizophrenia” to describe these conditions and I have chosen the term discordant insanities, where the word discordance corresponds to Erwin Stransky’s intrapsychic

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ataxia and Urstein’s intrapsychic disharmony. The dementia, even when it arrives, generally does not appear very profound; it is quite similar to the dementia of the systematic insanities where it is usually absent or very partial. The dementia praecox sufferer is always less demented than he appears. If “premature” dementia means that the disorder begins very early, that is wrong again, since, in contrast with the cases which begin at the age of 8 (S. de Sanctis’ hyper-premature dementia), there are those which begin late, in maturity or even in old age, and there have been descriptions of “late dementia praecox”, of late catatonia! To return to the dementia syndrome, it may genuinely appear very early and in a very accentuated form in young people; such cases were already mentioned by Morel and they might retain the name dementia praecox that is appropriate to them: this applies above all to hebephrenia, making it the true and perhaps the only dementia praecox. But the case of the systematic madman Lab.. .H. (p. 685), who experienced true juvenile dementia, suggests two things: either that the age of puberty or adolescence can be fatal, together with the period around the age of 50, whatever the clinical type; or that both hebephrenia and all the types which culminate in dementia in youth should be grouped together, under the name Morel’s true dementia praecox. Here again, I only mention this difficult question in passing. Connections with epilepsy.-We have seen the hebephrenia of Her.. .(p. 407) , as a complicating factor in epilepsy. Epileptiform fits have been reported in several of our patients. This raises the idea that there may be connections between juvenile epileptic dementia and “dementia praecox”. This is another point on which we know little. Meaning of discordance.-I have already said that the symptoms often very closely simulate dementia: cool incoherent delusion, indifference, bizarre acts of various kinds, or else complete inactivity of the intelligence with performance of lower order occupations, stupor with bizarre poses, incoherent acts, etc., and despite this, usually no signs of

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feeble-mindednessas such, even temporary, no loss of memory, no errors of judgement. Some authors nevertheless maintain that these signs indicate dementia. I have already discussed all this, and I will not return to it. For me, so long as there is no diminution of memory and judgement, there is no dementia; moreover, such a diminution must not be a consequence of confusion, stupidity or depression. It must be pure, in order to have its full meaning of definitive intellectual enfeeblement. All that can be said is that these incoherent, discordant symptoms, indicate that very probably there will be one day in the evolution of the disorder a period of dementia, but I say one day, since it is impossible to be specific, as we see these symptoms go into remission, disappear, yield to a more o r less complete, more or less lasting, cure. And it is only after a longer period, sometimes several years (14 years in the case of Geo. ..), that the relapse occurs and may be final. Is it always? Neuro-epithelial dementia and discordant insanities.-While the clinical types of these insanities provide material for endless discussion on the question of their connections, the matter of their external boundary gives rise to equally many quarrels which might be described as Byzantine, since they lack decisive elements and the debates are purely verbal. I wish to make no more than a distant allusion to the connections and differences that exist between this “dementia praecox” and Kraepelin’s manicdepressive insanity, over which the disciples and adversaries of that eminent master exchange blows. Fortunately, the anatamo-pathological work of Klippel and his school is approaching the question in a more effective manner. In a certain number of cases of hebephrenia, they have described specific lesions above all affecting the noble tissue, which are quite distinct from ordinary dementia1 lesions. This early research seems to me more important than all the accumulated essays in Germany and elsewhere for or against

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“dementia praecox”. Since the clinical approach has proved inadequate until now,’ it is for pathology to intervene. Having made these preliminary remarks, I will now begin a general description of the discordant insanities.

GENERAL DESCRIPTION. The principal common feature of the discordant insanities is that of a discordance, a disharmony between the symptoms, which appear up to a certain point independent of each other, all this before declared dementia occurs. Klippel has found neuro-epithelial lesions in certain cases. If this finding were to extend to all cases and all types, all the types described would have to be grouped together into a single one, and classified amongst the mental disorders of known cause. However, we are not yet at that point. There are generally insanities, neuroses or intoxications in the family. The patient’s childhood is usually abnomzal. Principal types

{

loHebephrenia and attenuated hebephrenia; 2 O Paranoid insanity; 3 O Verbal insanity; 4 O Catatonia.

In all types epilepsy-like attacks may be found. The evolution may be intermittent in hebephrenia, even in catatonia. The prognosis is bad, as complete cures are doubtful, although there may be relative improvements. Treatment is non-existent.

1. Nevertheless, it is able to distinguish the systematised insanities from the discordant insanities, although there may be connections between the former and paranoid insanity.

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lo Hebephrenia.

Onset between age of 8 and 25 or even 30 (some authors

go further). Sudden or slow, sometimes imperceptible. Onset period.-Laziness, indifference, slowness in work, opposition, anger, sadness, in other words, character change. Sometimes excitement without reason, running away, tics, laughter, grimaces, strange fleeting poses, childishness (below the patient’s level), vague delusional ideas, night or daytime fears without reason. Onanism. Complaints about health. Hysteria-like attacks. Migraines, headaches, anorexia, constipation, insomnia, nightmares, etc. Generally, the teacher is the first person to notice a change in the appearance, the work, the behaviour: teacher and family naturally assume that the child is lazy and indifferent, while the latter is often aware of falling ill. State period.-Accentuation of all these phenomena, but certain different aspects may be observed depending on the case: Depression and sadness, pseudo-melancholy, more or less vague delusional ideas of self-accusation, persecution, hypochondria, tendencies to suicide, to anxiety attacks, complaints about impotence, difficulty in moving, thinking, acting. Sometimes some cataleptic phenomena, strange poses, slowing down of speech and actions. Excitement with chattering, agitation, pseudo-mania, satisfaction, anger, wild laughter without reason, childishness, jokes, mannerisms, tics, stereotypical and extravagant movements of all kinds, disordered and bizarre writings, strange words, but generally with correct spelling, occasional running away, criminal acts, etc. Ideas ofpersecution of a more or less specific nature with or without hallucinations of different senses (electrocution, poisoning, etc.). Ideas ofgrmdeur of various kinds. All these delusional ideas, these emotional and motor

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disorders vary, generally intermingle or more or less predominate, with a strange and disordered appearance. But what is most remarkable is that this is generally very superficial. Beneath all these symptoms there often appears a complete indifference, an apathy which grows continually, which can moreover be interspersed with emotional attacks, negativism, a short period of stupor characterised by varying levels of so-called catatonic phenomena (see below, p. 837). Along with this retention of intelligence, judgement, memory, sometimes a surprising degree of attention, of orientation in time and space: in short, it appears that the intelligence remains intact, at least for a very long time, but that the patient does not use it, since he no longer works, generally does nothing, apart perhaps from childish tasks (below his age) or purely automatic acts. As a result, with his sometimes apparently forced pose, his incoherent gestures, his often contradictory mimicry, his laughter or ironic smiles, his grimaces, his wild imaginings, which vary from one moment to the next, or his mutism, he very often gives the impression of being a simulator or someone who is mocking his interlocutor and who is putting on an act. Frequent weight variations depending on the patient’s state. Usually good general state. More or less complete epilepsy-like attacks at long intervals. This state can continue for years without the onset of true dementia. In other cases, dementia arrives with terrifying speed, in a few months (true dementia praecox). Dementia period.-The intensity of the feeble-mindedness can be highly variable, from very profound to scarcely apparent. The former symptoms generally lose their acuteness and become monotonous: agitated or depressed, with stereotypical gestures or speech, the patient remains standing, lying or crouched in a corner, dirty, untidy, moving only to gulp down his food which he partly spills over himself; in short, apparently reduced to a purely vegetative and automatic life, sometimes like an idiot; I say apparently, as in certain cases it is surprising to find beneath this envelope

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of dementia, with this sovereign indifference, this apathy and absolute mutism, an intelligence much less damaged than one might imagine, as if simply dormant. Another curious thing is that a certain number of these patients retain a very lively intellectual mimicry, while others, on the contrary, although much more rare, have the appearance of profound idiots. It can happen that the very low level of dementia allows the patient to be used for tasks of little complexity. Others eventually return to some extent to their former activity. Finally, a few, more rare, may play a small role in society, but are no longer what they were; the improvement, the cure, is relative. Attenuated hebephrenia.-The disorder takes a form which greatly resembles neurasthenia; however, by contrast with the latter condition, there is an extreme indifference, a pathological laziness, with certain symptoms which might also suggest hebephrenia: bizarre gestures, strange fleeting poses, tics, grimaces, laughter, childishness, in short, in a highly attenuated form, those which are encountered in full hebephrenia. Diagnosis.-A t the onset, and in children, with: Neurasthenia (rarer in children, efforts by the patient to combat the disorder). Obsessions (which sometimes precede hebephrenia, no indifference, no change of character as such, awareness of the disorder). Tics (another mental state). Chorea (character of the movements). Tubercular meningitis (signs of meningitis). Epileptic dementia (multiple attacks and fainting, predominant loss of intelligence, slowness of movements). Juvenile general paralysis (true dementia, signs of GPI, lumbar puncture). Brain syphilis (dementia, physical signs). Epileptic turbulence (epilepsy attacks, generalised excitation).

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40 1

Moral insanity (sometimes precedes hebephrenia, no stereotypies or delusions). In the absence of injornaation, in children and adults, o n e may be obliged to wait a long time, but the following should be eliminated: Exhaustion delusion (temporary feeble-mindedness). Epileptic delusion (generally short, with exceptions, but can be very debilitating; look for epilepsy, not forgetting hebephrenia-related epilepsy-like episodes). Mania (much more generalised; sometimes debilitating, but never stereotypies, mannerisms, grimaces). Melancholy (rare in children, stable appearance, true moral suffering, mimicry, no stereotypies). Chronic systematic insanity (systematisation, concordance of symptoms, the opposite of indifference, reticence and not negativism, different mimicry). Acute insanity (frequent polymorphism of the delusion, but less incoherent unless there is excitation; concordance. Cool incoherence suggests hebephrenia). Hysteria (very great suggestibility, dream delusion, specific convulsive fits, etc.). In the dementia period, it is a matter of semiological diagnosis of which I have spoken at length (p. 255). 2 O Paranoid insanity.

Onset generally in youth rather than in childhood, sometimes in adulthood.

Rapid onset:

Multiform delusional ideas with or without hallucinations, of persecution, of grandeur, of hypochondria, of negation, of bodily transformation, delusion of imagination, etc., with excitation, depression, anxiety, agitation, rapture, often independent of the intellectual side, etc.-Intelligence apparently intact. Then, successively and very rapidly, the agitation, the emotional reactions lapse, the delusion becomes highly extravagant, absurd, mobile, diffuse, contradictory, as much

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as and more than in GPI, usually with indifference or euphoria, ironic mimicry, incoherent and apparently purely verbal chatter, and retention of intelligence and memory, while more or less complete signs of motor emancipation develop: stereotypies, tics, strange acts, collectionism, monologues, invented words, in short, the so-called catatonic signs; or a pseudo-stupor with mutism, in which the patient vegetates motionless in a corner; or a mixture of mutism and monologue, etc., etc. Dementia1 appearance due to the indifference, the untidy dress, the gluttony, the automatic acts, the mutism or incessant chattering, etc. Finally, true dementia sets in after a few months or several years, with varying degrees of severity. No physical signs. Dugnosis.-with all the states which are accompanied by incoherent delusion, especially with: Alcoholic delusion (specific characteristics, specific dream delusion, physical signs). Infectious delusion (dream delusion, physical signs). Exhaustion delusion (dream delusion, confusion, mimicry, physical signs). Hallucinatory delusion (predominant hallucinations). Epileptic delusion (sometimes difficult; signs of epilepsy, usually short duration). General paralysis of the insane (true dementia, physical signs, lumbar puncture). Chronic systematic insanity (obvious systematisation). Systematic acute insanity or “immediate delusion” (greater systematisation or else excitation; concordance: frequent additional mental debility).

3 O Verbal discordant insanity.-It is rare. In pure cases, after a largely similar onset to the previous forms, the insanity consists of complete incoherence of language, with constantly invented words, apparent retention of meaning in the speech, intonations, laughter, smiles,

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gestures, in short the appearance of normal speech contrasting with the absence of meaning. Dialogues and monologues; retention of intellectual mimicry, of automatic habits; total indifference and adaptation to the asylum. However, from time to time, a meaningful sentence, especially at the beginning of a conversation, indicates that intelligence as such may be less damaged than language and that perhaps the disorder of the latter prevents thought (?). The duration seems very long. Diagnosis.-With: all the cases where there is incoherent language, but which are immediately eliminated by the very large numbers of invented words in verbal insanity (see p. 194). However, particular care must be taken not to confuse it with long-standing systematic insanity with symbolic language (the sentences are more correct, there are obvious delusional ideas). Catatonia.-Onset as in the previous types, or almost immediate state of catatonia. The so-called catatonic stupor and excitation with specific agitation are of variable duration, sometimes with remissions of varying length. A few rare and fleeting delusional ideas or hallucinations. I shall restrict myself to giving the list of signs said to be catatonic, but which are veery fdr from pathognomic of discordant insanity, and do not all occur together: Stupor; catalepsy; muscular rigidity; malleability; automatic docility; imitation of gestures; echolalia; mutism; negativism; deliberately twisted and wrong answers (Vorbeireden). Refusal of food; eating in secret. Invented words; chatter and litanies, declamatory litany; writing with the same characteristics (sometimes, by contrast, astonishingly reasonable). Stereotypies of pose; stereotypies of movements; mannerisms and grimaces; impulses; self-mutilation. While the patient is in stupor, he usually retains all his attention and memory; he continues to receive impressions, but seems not to use them for intellectual activity because of an absolute indifference, a controlling apathy; but once 4O

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he does this work, he does not seem to have any difficulty, any more than for movements. It would seem, therefore, that there is no “inhibition”, no obstacle slowing the progress of the ideas. The delay before responding or acting might come from association by contrast, what Kraepelin calls Sperrung in opposition to Hemmung (this is merely a hypothesis). Frequentphysicalsigns: Unequal pupil size; dilatation; exaggerated reflexes; salivation; stopping of the menses; hypothermia; stupidity through stupor; stupidity through negativism; acceleration or slowing of the pulse; considerable weight variations; vasomotor problems; epilepsy-likeattacks. True dementia sets in gradually along with the monotony of the so-called catatonic signs. Duration very long. Diagnosis.-When all the symptoms are fully present, it is difficult to make a mistake. However, catatonia could be confused with states characterised by stupor, catalepsy, stereotypies, although in all these states the so-called catatonic signs are usually partial and transitory: Infectious delusion (confusion or dream delusion, no negativism, somatic state). Infectious dementia (true dementia, no negativism, commemoratives, physical signs). Traumatic delusion (sometimes very difficult, if there is traumatic stupor; commemoratives, generally no negativism, no stereotypies nor mannerisms). Epileptic delusion (essentially fleeting, often state of confusion, no stereotypies, signs of epilepsy). GPI (no negativism, signs of dementia, organic signs). Brain tumours (no negativism, confusion, organic signs). Idiocy with stereotypies [these stereotypies are very similar to those of catatonics] (commemoratives, physical signs, intellectual state of idiocy). Melancholy with stupor (appearance of sadness, great fixity of stupor, much less negativism). Hysteria (suggestibility, exaggeration, commemoratives).

Eugen Bleuler (1857-1939)

Swiss German by origin, Eugen Bleuler published almost all his writings, which for a long time were unavailable in French translation, in German. The fact that we were nevertheless able to include an extract in this anthology is because Bleuler presented his conception of “schizophrenia”, which brought him to the attention of the scientific world at the end of his career, in a report to the 30th session of the Congress of French and Frenchspeaking Alienists and Neurologists held in Geneva-Lausanne in 1926. Bleuler had received an international education which gave him access to the early 20th-century psychiatric literature of different European countries. Having studied medicine and begun his training in psychiatry in Berne, he continued in Paris with Charcot” and Magnadk, then in London and finally in Munich. Returning to Switzerland, he completed his training at the university clinic of Burgholzli in Zurich with Auguste Forel. In 1898 he took over the latter’s professorial chair, and until his retirement in 1927 maintained the institution as a prestigious place of learning at a time when the Great War was about to interrupt the fruitful dialogue between the German and French schools. His students included such figures as C.G. Jung, Karl Abraham, Ludwig Binswanger, E u g h e Minkowski* and his own son Manfred. It was through Jung that Bleuler came in contact with the ideas of Janet* with whom Jung had studied in 1902-1903, before publishing his 1907 book Uber die Psychologie der D.P.

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Jung was also pivotal in the relations between Bleuler and Freud. Bleuler’s academic authority underpinned the publication of jahrbucb fikr psychoanalytiscbe und psycbopatbologisbe Forscbung, founded in 1908 with Jung as its editor-in-chief. Bleuler was a member for less than a year, from January 4 to November 27, 1911, of the Psychoanalytical Association and during that time published “Freud’s psychoanalysis. Defence and critical remarks by Professor Bleuler”. This was sufficient for the names of Bleuler and Freud to be closely linked, in the eyes of many French authors such as Dide and Guiraud*, in what they saw as the psychoanalytical study of dementia praecox. It was in fact in 1911, in Handbuch der Psychiatrie, edited by Professor Aschaffenburg, that Bleuler published his book Dementia praecox oder Gruppe der Scbizopbrenien. The concept of schizophrenia was introduced to French psychiatrists notably by Eugkne Minkowski*. However, in his 1926 report, Bleuler was keen both to declare the unity of the entity he had described (“all the clinical forms that we have defined under the name schizophrenia, genuinely constitute one and the same entity, whether from a clinical, heredetiological, aetiological or anatomical point of view”) and to distinguish himself on one issue - that of the origin of schizophrenia - from psychoanalysis. He accepted that all the Freudian mechanisms, i.e. the displacement of affective factors, symbolism, condensation, are found in schizophrenia. The same was true for the role of sexuality, but Bleuler could not accept Freud’s theory on “the evolution of the sexual instinct, let alone the purely psychogenic origin of schizophrenia. Only some of the symptoms are psychogenic, and these are the most apparent; however they are far from the essential and fundamental manifestations of the schizophrenic process.” In 1926, Bleuler accentuated the distinction he had already made in 1911 from a theoretical point of view, between primary symptoms, produced directly by the mysterious, no doubt organic, schizophrenic process, and secondary symptoms constructed by psychogenesis. It was to inspire many authors and, for example, when the Congress of French and French-speaking Alienists and Neurologists held a new session in Geneva-Lausanne 20 years later, Henri Ey* gave a paper “From the principles of H. Jackson

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to the psychiatry of Eugen Bleuler” in honour of the creator of the concept of schizophrenia.

F. Rkgis Cousin Principal works BLEULER (E), La Psycbanalyse de Freud [Freud’s psychoanalysis], Jahrbuch, 1911, French translation, Clichy, GREC, 1994. BLEULER (E), Dementia praecox oder Gruppe der Schizoprenien [Dementia praecox or the group of the schizophreniasl, Leipzig und Wien, Denticke, 1911. English translation Zinkin, New York, International University Press, 1950. BLEULER (E), La Scbizophrinie. Rapport au Cong?-t?s des mkdecins aliknistes et neurulogistes de France et des pays de languefrangaise [Schizophrenia. Report to the Congress of French and Frenchspeaking alienists and neurologists], 30th session, Geneva-Lausanne, Paris, Masson, 1926.

Bibliographical references GUIRAUD (P.) and EY (H.), “Remarques critiques sur la schizophrCnie de Bleuler” [Critical remarks on Bleuler’s schizophrenia]. Ann. midico-psycbol., 1926, 1, 355-365.

EY (H), Des Principes de Hugblings Jackson 2 la psychopathologie d’Eugen Bleuler [From the principles of Hughlings Jackson to the psychopathology of Eugen Bleuler]. Congress of alienists and neurologists, Geneva-Lausanne, 1946.

Schizophrenia

Within the context of a simple report, I shall only be able to indicate the essential points. The data before us for discussion are complex; some of my assertions are only correct with reservations, which it will not always be possible to specify. Nor will I be able to mention all the exceptions. I would like, however, to express a wish that the discussion should only deal withfacts and concepts. Whether or not a name is well chosen, is of purely secondary interest. I am also keen to warn you against the dangers of a discussion on the application of the notion of dementia to schizophrenia. This discussion is condemned to remain fruitless if each of us does not first clearly establish the meaning he gives to the word "dementia". There is not one, but several dementias. It is a word the meaning of which is more social than pathological. When in 1886 I left the Zurich clinic to become chiefphysician at the Rheinau asylum (Switzerland), I took with me a certain number of young patients with whom I had managed to achieve no improvement. I hoped, by devoting myself completely to them, to attain a better result, especially as the patients were immediately placed in an asylum in the countryside and were therefore in conditions

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relatively more favorable that those which a suburban establishment had been able to offer them. These patients were labelled with the most varied diagnoses: melancholy, mania, paranoia, mental confusion, etc.; with time, however, they all evolved towards the same specific form of dementia. Ten years later, Kraepelin described this form under the name Verblodungs-psycbose (dementia1 psychosis), which he later replaced with the term dementia praecox. It was a stroke of genius on Kraepelin’s part to define the group of manic-depressive psychosis at the same time as dementia praecox. For it was precisely this opposition which highlighted the Kraepelinian notion of dementia praecox and which made it possible to determine its limits. Nonetheless, it took a long time for Kraepelin’s conception to be accepted even in his country of origin. For many years, I was, I think, the only person to recognize the full significance of this conception and to adopt it unreservedly. Moreover, the principal obstacle resided not in the facts themselves, but in the name chosen to designate them. From the beginning, Kraepelin reported social cures for the psychosis described; the name dementia, however, gave rise to the idea of a totally incurable disorder, and that is why the very superficial objection was advanced over and over again that in the great majority of cases the condition was neither dementia nor premature. In order to cut short any objection of this kind, I proposed the name schizophrenia. * But even after this modification, people in many places continued to try to distinguish cases with a more benign evolution from those which culminate in a state of final degeneration and to perceive them as an autonomous clinical entity. [...I Schizophrenia is distinguished from all other disorders by the following characteristics: First, from the anatomical point of view: in all 1. If Chaslin’s term: “discordant madness”, had already existed at the time, I could just as easily have chosen it.

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pronounced cases of schizophrenia, anatomo-pathological modifications are observed in the brain, alterations of a sufficiently distinctive character and which are not found in the other psychoses. The intensity of these modifications roughly corresponds to the severity of the primary symptoms; these modifications have a chronic character in cases where the evolution is chronic, an acute character during acute attacks of the disorder. Schizophrenia is thus not only

a clinical entity, but at the same time an anatomo-pathological entity. A list of all the symptoms of schizophrenia would be very long. This disorder is more easily defined, from a semiological point of view, in negative terms. Primary problems of perception, of memory orientation, of motor coordination are completely absent in schizophrenia. Likewise, the characteristic signs of the organic psychoses (senile dementia, general paralysis, etc.), such as imprecision and slowing of the perceptions, reduction in the number of simultaneous associations and their determination by the instincts of the moment, difficulty of recall, becoming most severe in the case of recent memories, mood swings, etc.; all these symptoms are not a part of schizophrenia. Nor do we find in the field of schizophrenia problems of an epileptic nature, such as the slowing, hesitation and egocentric confinement of thought, the difficulty in relinquishing a subject, emotional perseverance, the tendency to become lost in useless details.

We could enumerate the principle symptoms of other disorders in the same way and observe that they are not found in schizophrenia. The only exceptions are manic-depressive psychosis and the neuroses, the symptoms of which are found in schizophrenics; however, in the latter they are accompanied by the characteristics signs of schizophrenic dissociation. The result of all this is that the group of schizophrenias possesses well-defined characteristics which make it possible to distinguish it from all other disorders and which make it an autonomous entity.

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In all forms of schizophrenia, however mild, we find a specific disorder of thought characterized by a loosening (Lockerung) of the normal associations. To the question: “Where is Egypt?”, it would not occur to any normal being to reply: “Between Assyria and the state of Congo.” To begin with, to associate in one’s mind one of the world’s oldest states with one of its most modern is only possible when the notion of time, which in the normal person inevitably plays its role in the unconscious, has been neglected by the sick person. But to connect them with the notion of Egypt is even more bizarre from a purely geographical point of view. The most obvious idea, such as “North-East of Africa” or something like it, does not occur to the patient but instead the idea of a country from another continent which does not even have a common frontier with Egypt, and then that of another country which is only indirectly connected with Egypt through the intermediary of Sudan. And yet the patient’s reply proved that he was perfectly familiar with the geographical position of Egypt. To bring out the full measure of this disorder of associations, it would have been necessary to give a whole further series of examples. We cannot do that here. Nonetheless, the example quoted will suffice to give an idea of what we mean when we speak of a loosening of associations. Many other problems, relating to logic and concepts, can be deduced from this loosening, such as deficiency of judgement, imprecision, the condensation of several concepts into one, etc. In the affective sphere we observe a marked problem which, in severe cases, can be so pronounced that for a period of years not a single sign of emotion may be observed. Patients lead a purely vegetative existence, showing no interest even in their own persons, to the extent that even the instinct of self-preservation seems to be entirely absent. They have to be fed, put to bed and got up; in the event of fire, they remain unmoving amidst the flames and would let themselves be burnt alive if no one came to their

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aid. Impassive, they are able to tolerate the worst treatment without saying a word. In less severe cases, these problems are less pronounced, but at bottom the dtferences are solely of degree and not of nature. The emotional responses are uneven; normal in relation to certain events, they may be entirely absent with others, and this lack of affectivity often appears to increase in proportion to the importance of the events. At such moments, sometimes the affectivity is “rigid”, it is out of step with the changes occurring either in the outside world or in the individual himself; it no longer possesses the necessary mobility; it is as if there is a form of emotional adiadochocinesia; sometimes unpredictable and paradoxical affective responses occur (parathymia, paramimia). Often two opposing feelings may simultaneously color the same mental representation (ambivalence). In milder cases we also encounter inadequate contact with the world outside, an inner life turned in on itself (autism). The disorders of association and of the emotional life, described above, together with autism, are absent in no pronounced case of schizophrenia. They seem to me to constitute the essential signs of this condition. For this reason, we will call them the cardinal symptoms. Apart from the cardinal symptoms, there exist secondary symptoms. These are symptoms that are sometimes present, sometimes absent. It is rare to find them all in a single patient. Some of them are seen only in schizophrenics, for example the patient’s sensation that his thoughts have been taken over by an outside force or, on the contrary, “created” by enemies, that his will is under the control of external influences, that he has been hypnotized, etc. Lucid, well oriented patients, but who exhibit incoherent delusional ideas or present mass hallucinations, notably kinesthetic hallucinations of general sensibility (they are being electrocuted, beaten, burnt, cut into pieces, raped, etc.), or else perform impulsive acts with no plausible motive, are only found among schizophrenics. Schizophrenic confusion,

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particularly in its chronic form, is markedly different from confusional states with other causes. Catalepsy, stupor, hyperkinesis, stereotypies, negativism, echopraxia, automatism, in a word catatonic symptoms are encountered in their pronounced forms almost solely in schizophrenias or at most in mixed forms (analogous symptoms, observed in epidemic encephalitis, are of a markedly different character). At bottom, the secondary symptoms also bear the mark of schizophrenia; thus, for example, there is no difficulty in distinguishing the hallucinations of alcoholic delirium from those of schizophrenia. Indeed, Kraepelin arrived at his definition of dementia praecox above all on the basis of the secondary symptoms. It would thus be possible to establish a long list of specific features which only exist in the schizophrenia group. And although we never find all schizophrenic symptoms combined in a single patient, it is nonetheless true that those he does present almost always bear the characteristic mark of that disorder. Just as one variety of the European race differs from every other variety of the same race by numerous particular signs; nevertheless, no individual of a given variety carries all its distinctive signs, and two individuals of the same variety can apparently present nothing but different or even opposed signs. However, the disparities observed in the different clinical pictures do not give us a sufficient basis to subdivide the group of schizophrenias. These disparities are nothing but the external expression of a single fundamental process. Schizophrenia, like tuberculosis for example, can appear in various clinical forms. A syndrome which today looks like a catatonic, paranoid, confusional or dementia1 state, may well be replaced the next day, or have been preceded by, any other syndrome of a schizophrenic nature. It is true that the majority of terminal states no longer revert to any significant degree and scarcely change their appearance, and also that the onset of the condition allows us, in certain cases, to predict, with a high level of probability, the

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subsequent evolution as well as the specific characteristics of the terminal states which they will eventually reach. Slow developing paranoid forms, for example, generally retain their paranoid character until the end, while the insidious onset catatonic forms always culminate in pronounced and durable states of degeneration. It nevertheless remains true that, in general, the f o r m which the condition takes at the beginning do not allow one to predict with certainty thefirms

which it may take in the course of the successive phases of its development. The initial form may give way to any other terminal form. We may even quote the opinion of a number of French alienists in support of this thesis. We would refer, for example, to one of the best manuals of psychiatry that we have, by Rogues de Fursac. One cannot but be astonished that some persist in considering these syndromes as independent disease entities. Thus, all the many attempts to separate the paranoid forms from schizophrenias as a whole have totally failed. W. Mayer, for example, has demonstrated that two-thirds of the patients used by Kraepelin as a basis for his description of the paraphrenias group, became clearly schizophrenic within nine years of the creation of the concept of paraphrenias, a proportion at least as great as that observed in cases beginning with acute hebephreno-catatonic symptoms. The same can be said of the differences observed in the speed of development. A chronic paranoid dementia, progressing imperceptibly for some twenty years, seems at first sight to have nothing in common with an acute catatonia which, often, breaks out suddenly and disappears after a few months. Nevertheless, if we look closely at the history of the latter patients, we find that the condition develops in them, in a more or less insidious fashion, for decades, while from time to time manifesting acute episodes. In each phase of development, the condition can become stationary or even improve. Before and after each acute episodes, there

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is a period of chronic development; and even in cases which, apparently, evolve in the slowest and steadiest possible way, the possibility of an acute episode can never be excluded. For this reason, the intensity and severity of the condition are excessively variable, but intermediate degrees provide a continuous link between the most severe and the most benign forms, so that there is no distinct boundary here which would make it possible to establish a precise distinction. Thus, each of the symptoms listed above may vary to a greater or lesser degree between two extreme limits, independently of all the other symptoms, whether in a single patient or between patients. It is therefore wholly impossible to establish a maximum intensity beyond which the condition in question could not go. This applies in particular to the syndrome which is customarily called “dementia”. In quality, the dementia will always be specifically schizophrenic; in intensity, it will vary from a scarcely perceptible intellectual impairment to the most extreme degree of stupidity. l%e distinction between demential forms and nondemential forms is exclusively one of degree and not of nature. Every form of schizophrenia can culminate in a demential state by a simple increase in the intensity of its symptoms. Declared dementia, of a schizophrenic kind, can be characterized by the fact that false and inappropriate associations occur in very large numbers, that the interest taken in the outside world is modified, or entirely absent, and that the affective life appears to be blocked. If the number of false associations is very high, if the affectivity is severely blocked, the schizophrenic dementia appears highly pronounced. If, on the other hand, the abnormal associations only occur rarely and if the emotional life continues to be expressed in an adequate manner, the dementia is not greatly marked or even one prefers, in these cases, not to refer to dementia at all. However, this is only a dtference of degree, 1. It is not difficult to observe to what extent this dementia differs from organic dementia or oligophrenic dementia.

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and in both cases the disorders are of exactly the same nature; simply, in one of the two cases, they have reached a n extreme level of intensity and, at the same time, extend to almost all the patient S responses, while in the other, they are less intense and less frequent and leave more and more space f o r normal behavior. The materials of thought remain entirely intact in both cases. Mental confusion too, is simply the expression of an increase in the intensity of the disorder of associations. And while the loosening of associations which leads to the confusion seemed to present certain specific nuances, these same nuances are nevertheless present, only to a lesser degree, in other forms of schizophrenia. This is why, when people speak of confusion in schizophrenia, they simply mean cases where the majority of associations deviate from the normal in the direction we have just described. Where deviations of this order occur less frequently, they disappear into the mass of other schizophrenic problems. The attempt to separate severe cases from benign cases, as autonomous entities, is further rendered redundant by the fact that any case of schizophrenia may remain stationary at any stage in its development or even partially retreat. If we further add to what has been said that the search for hereditary factors brings all forms of schizophrenia back to the same family traits and that the principal cause of the condition itself is always to be sought in a particular constitution, we are in a position to declare that all the clinical f o r m s which we have combined under the name schizophrenia

do indeed constitute one single entity both f r o m a clinical and a heredo-biological, etiological and anatomical point of view. Whether or not one wishes to call this entity an illness then becomes merely a matter of taste. For my part, and in the current state of our science, I consider schizophrenia to be an illness. However, I can easily understand the hesitation of French alienists not only to speak of illness here, but even to recognize the validity of the clinical entity which I have sought to identify. The

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French are undoubtedly the best psychologists and creators of systems, and we.. .the worst! It is worth remembering that Griesinger, the first professor of psychiatry at the faculty of Zurich, to whom we owe the first modern manual of psychiatry in German, contributes not one single personal observation in that manual; he borrows them all from French work, no doubt seduced by their exemplary psychological descriptions. From a psychological point view, an acute catatonia, a hebephrenic mania, an interpretative delusion, a primary chronic dementia, are evidently entirely different states, and the essential issue is whether or not a patient lapses into dementia. The clinical pictures of French psychiatry thus deserve the name of entities just as much as do schizophrenia or manic-depressive psychosis, but they are entities of a different order.

[...I Clinical pictures of a psychological nature present the great advantage of specifying, in each particular case, essential psychological relations, together with the patient’s manner of behaving and the social impact of the disorder. Moreover, they encourage the psychiatrist to psychological observation-if, that is, he is capable of it. The excellent words of Skrieux and Capgras on interpretative delusions would probably never have seen the light of day if French psychiatry had perceived things from a different angle. O n the other hand, however, today we are discovering in a group of apparently entirely separate diseases such a collection of common symptoms, and factors which are similar in their evolution and etiology, that it no longer seems permissible to ignore that similarity. And as this etiology, this evolution and this symptomatology are found nowhere else, we cannot do other than to call them an entity and contrast them with other entities. In this sense, we are permitted to refer to a morbid entity, a disease or a group of diseases.

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In so doing, we are perfectly at liberty to retain the former notions, such as catatonia, mental confusion, paranoia, interpretative delusion, etc. Simply, we will see them as subdivisions of the new entity or, if you prefer, species of the same genus.

[-..I

The tendency to push the classification of mental disorders too far often leads to results of a terrifying sterility. In this respect it is sufficient to recall the thirty-one varieties of hallucinatory states listed by Chaslin, the thirty-one names and thirty-one particular syndrome categories which he assembled in his conceptions of primary mental confusion. The utility of such a classification remains highly dubious; moreover, no one up to the present can boast of having found precise signs to define these particular subdivisions of schizophrenia; it would seem to be sensible to conclude from this that, for the moment, none can be given. With time, perhaps new criteria will be found. In the meantime it is prudent to maintain the current position, i.e. not to separate that which one cannot differentiate. Didgnosis: Contrary to the general opinion, the concept of schizophrenia is as precise as is possible for any fact found in nature. There is no room for it to be confused with any other mental disorder. At most, it has some connection with Kraepelinian paranoia. We perceive the latter today as a psychogenic reaction, occurring in a particular variety of schizoid constitution. Thus it would be differentiated from schizophrenia by the absence of anatomical lesions and of their symptoms. Schizophrenia therefore includes all the degrees which travel imperceptibly from normality through to the most severe forms of dementia, of confusion or catatonia. It is evident that the mild forms are the most difficult to recognize, as are mild forms of debility or tuberculosis. This difficulty is further exacerbated here by the fact that the innate character, observed in the individual before the presumed start of the illness, presents the seeds of the same

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essential traits as declared schizophrenia. Sometimes observation incidentally reveals the presence of a delusional idea or of hallucinations in an individual who behaves normally in everyday life and who is considered sane by those around him. We call these cases latent schizophrenia. It is often reasonable to diagnose this former schizophrenia if, in the past of a psychopathic person, one finds, at a given moment, a sudden turn in the individual’s personal development, a change of character in the direction of schizophrenia. But it is above all by closely studying the past of declared schizophrenics that we become aware of the existence of the latent form; a number of singularities are identified in this past, the schizophrenic nature of which no longer presents the shadow of a doubt in the light of current observation; the hitherto latent disease has become declared by a simple exacerbation of the former state. Aslong asschizophreniaremainslatent, it isusually labelled degeneration or, in our terminology, psychopathy. The diagnosis of schizophrenia only becomes possible when the appearance of an indubitable symptom of that psychosis definitively settles the question. Magnan’s “paranoid reactions” are obviously encountered equally in schizophrenics and in simple degenerates. The presence of the characteristics of a schizophrenic process enables them to be recognized as schizophrenic, while the absence of these signs in no way rules out such a diagnosis; for purely schizophrenic reactions can occur in the course of any schizophrenia and at any stage in its development. In practice, it is also sometimes difficult to make the distinction between schizophrenia and neurosis. Hysterical, neurasthenic, obsessional symptoms, in a word all the neurotic symptoms, can be encountered in schizophrenia. That is why cases where the onset is insidious are often wrongly identified as neuroses. This is of great importance, from the point of view of both prognosis and treatment. Combinations of schizophrenicsymptoms with those of other psychoses.-What is quite clear is the connections of the former with organic psychoses. If a schizoid individual is

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affected by general paralysis or senile dementia, or Korsakoff's syndrome, schizophrenic symptoms will very quickly complicate the clinical picture of those psychoses. '

r... I

Moreover, it can happen that certain manic states and in particular, certain melancholic states are simply direct expressions of a schizophrenic process. In the event of the simultaneous presence of schizophrenia and manic-depressive psychosis, the prognosis depends on the intensity of the schizophrenic process. Combinations of schizophrenia with epilepsy are probably as varied as combinations of schizophrenia with manic-depressive psychosis. If schizophrenia develops in a mental defective, the cornbination of the two conditions presents no marked peculiarity. At most it might be observed that oligophrenic paranoia, resulting from mental deficiency and the tendency to hallucinations, is often difficult to distinguish from paranoid forms. Pathology.-Schizophrenia is a physiogenic disorder, i.e. its basis is organic. However, it possesses so psychogenic a superstructure that the great majority of the visible symptoms of this disorder, such as hallucinations, delusional ideas, together with a patient's whole behavior, relate to psychological factors and mechanisms. Some psychoanalysts even go so far as to claim that schizophrenia as a whole is a psychogenic disorder. This view is undoubtedly wrong. Schizophrenia shares with the organic psychoses, on one side, the existence of symptoms deriving directly from a cerebral process, and with the neuroses, on the other side, the development of psychogenic symptoms on the basis of a particular constitution. The organic origin of schizophrenia can be demonstrated today with a great wealth of evidence. We have already 1. In the event that an organic sychosis, after partial destruction of the brain, ceases to develop, the resu ting sequela can show distinctly schizophrenic characteristics.

P

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spoken above of the anatomo-pathological data. From a clinical point of view, it should be noted that the majority of acute attacks occur without any apparent psychical reason and that the whole chronic evolution towards dementia is also independent of the psychical situation. The illness is encountered in all classes of society and is no less common among the rich than among the poor. Despite all the problems and all the emotional shocks that it caused, the last war did not increase the number of schizophrenics. Finally, it is almost always possible to distinguish, without too much difficulty, psychogenic symptoms from physiogenic symptoms, for example a crepuscular state of a psychogenic nature, from an acute attack of catatonia or from confusion of an organic nature. We do not yet know anything specific on the nature of the organic process which underlies schizophrenia. Certain circumstances would suggest a primitive chemical disorder. For some time, French alienists in particular have drawn attention to the possibility of a connection with liver failure. However, we are still a long way from an understanding of the physiological conditions of schizophrenia. A toxic agent or cerebral lesions might be the cause of the primary symptoms, amongst the psychical symptoms that we know, schizophrenic associative disorder being naturally one of the most elementary. The majority of the other symptoms can be deduced from this without great difficulty. Nonetheless, this is only a hypothesis, therefore the value of schizophrenia as a clinical unity is entirely independent. I assign relatively little importance to this hypothesis insofar as this symptom itself is, in my opinion, simply the expression of a more general disorder of the individual’s psychical life, a disorder which so far we have not succeeded in identifying. We also observe nervous irritation at the basis of some of the hallucinatory expressions and we have reasons to allow that problems in the function of the central nodes play a certain role in the genesis of the symptoms of an emotional and catatonic nature. I would

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almost say that the primary disorder extends in particular to the I@ of the instincts. However, I am not at present able to prove the validity of this assertion, nor to say with sufficient precision what is the nature of this disorder of the instinctual life. That is why I have not said more about it here. Logical disturbance, including delusional ideas, are easy to imagine, as consequences of the loosening of normal associations, while some types of hallucination, particularly hallucinations of general sensibility, together with those of alcoholic delirium, are nothing more than the results of real nervous excitement falsely interpreted, in other words paresthesias which, as a consequence of thought disorders, are projected outwards and objectified. But hallucinations produced in this way, once the individual has become aware of them and understood their direction, can subsequently be summoned up directly and produced by psychical means. Thus, the sensation of being electrocuted is interpreted in the early stages of paresthesia in a given way; but it can subsequently be summoned up psychically to serve the delusional ideas. The hallucinations are often of the same kind. Of the auditory hallucinations, musical hallucinations are generally of organic origin; by contrast, verbal hallucinations, voices, are-at least in terms of their content-psychogenic. But it is more than likely that there exist yet other mechanisms which contribute to producing verbal hallucinations. Catatonic symptoms, with the severe disorders of ideation, of will and of motility which characterize them, suggest a specific organic disposition; nonetheless, psychical factors can exercise great influence on them. One need only remember the fact that these symptoms, as a result of ambient circumstances, can suddenly disappear or reappear, from one moment to the next. It seems likely that certain fits of mania and particular certain f i t s of depression, observed in the course of schizophrenias, have nothing to do with a cyclothymic

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temperament. Nonetheless, it is difficult to specify the link that connects these fits with the schizophrenic process itself. As regards the psychogenic reactions occurring on the basis of cardinal disorders of a schizophrenic type and under the influence of temporary difficulties, they are perfectly clear. These are, quite evidently, states of excitement of all sorts, crepuscular states, attacks of delusion, acute or chronic syndromes of a hysterical, “neurasthenic” or hypochondriac character. The distinction between psychogenic and physiogenic symptoms in schizophrenia has very great implications both with regard to prognosis and to questions of a practical order, such as, for example, damages in law or insurance. Organic symptoms always indicate that the morbid process will persist or develop. Psychogenic symptoms, on the other hand, are simply reactions which fade away completely when the causes disappear. However, if the cause persists, the symptoms can become chronic, as occurs, for example, in delusion of persecution developing on the basis of certain complexes. Moreover, it must be said that the origin of most symptoms is mixed. Imagine, for example, that the marriage of a younger sister arouses, either in the conscious or the unconscious of a patient, whose schizophrenia had hitherto been latent, the sentiment of her own incapacity to love. This psychical trauma can produce a state of excitement if the patient was already previously a schizophrenic; on the other hand, however, the schizophrenic process itself, without the addition of the trauma, would not have been sufficient to produce such an attack. From a therupeutic point of view, it is above all the psychogenic sequels of severe attacks which attract our attention. After an acute attack, one often finds that the patient fails to return to reality; instead, he remains attached to certain delusional ideas or to certain psychological tendencies, for example that of suicide. It is true that the difficulty in returning to normal life shows that the

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schizophrenic process has not entirely ceased; however, by means of psychotherapeutic procedures, it is often possible to make the patient abandon his morbid attitude. The situation is similar to that of a normal man who, after a very vivid dream, has difficulty returning to reality. Where organic symptoms are predominant, our resources and treatments prove ineffective. O n the other hand, when we find ourselves faced with a pronounced psychogenic superstructure, the prognosis in large part depends on the treatment. It is the skill and experience of the doctor which decide the patient’s subsequent destiny. Many a patient who would have been condemned to spend the rest of his days in an asylum is able, under the influence of the appropriate treatment, to resume his outside occupations. Schizophrenia is the only psychosis where the doctor can really do something effective to restore the individual’s essential faculties. The content of the hallucinations and the delusional ideas, apart from in severe crepuscular states of catatonic delusion, is determined by the patient’s desires and fears. Certain of these desires and of these fears have been repressed and consequently remain unconscious. This is why the hallucinations and the delusional ideas emerge, very often, directly from the unconscious and are not recognized by the individual as a part of his personality. In chronic delusions, even if the confusion is very strong, one can discover the deep meaning of the delusional ideas. An understanding of the psychological mechanisms, discovered by Freud, proves particularly important here. The great majority of desires, particularly sexual desires, are expressed in a symbolic manner; the everyday terms of language receive a new meaning; several ideas are “condensed” into a single idea, etc. All these Freudian mechanisms, i.e. displacement of affective factors, symbolism, condensation, occur in schizophrenia. The same is true of the predominant role of sexuality. In the schizophrenic woman there exists scarcely a single delusional idea which is not essentially, or even solely, motivated by sexuality. And in the man we also find, in every

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case, the existence of sexual complexes, either on their own, or alongside other complexes. Having observed these connections in the normal and in a whole series of patients, and having learned to appreciate their role in neuroses and psychoses, I am an adherent of the ideas of Freud. But I cannot accept his theory of the evolution of the sexual instinct and even less so that of the purely psychogenic origin of schizophrenia. Only a part of the symptoms are psychogenic, and these are the most apparent ones; but they are far from being the essential and primary expressions of the schizophrenic process. In schizophrenics, before the apparent emergence of the disorder, and in members of their family too, we find highly characteristic peculiarities in their manner of being. These peculiarities are in every way the same as those that patients exhibit as the residue of a former schizophrenic attack; in addition, from a qualitative point of view, they are of exactly the same nature as the symptoms of declared schizophrenia. In these conditions, the latter appears as simply an exaggeration of the fundamental peculiarities. We refer to these peculiarities as a whole by the name schizoidism. Where they go beyond the boundaries of the normal without there being question of an evolving morbid process, we speak of scbizopatby. Finally, where the cerebral process has occurred, we use the term schizophvenia. The schizoid way of thinking and feeling is an exaggeration of a normal function, found in every sane individual who, depending on the circumstances, reacts sometimes schizothymically, sometimes otherwise (schizothymic reactions). It should be noted that there is an imperceptible gradation of schizothymic reactions from those of the normal man to those of the schizophrenic, passing via the schizoid and the schizopath. Obviously, the schizophrenic process initially appears as a new and independent element, a separate hereditary factor (“gene”), coming in addition to this schizoidism; but the gradations we have just referred to suggest a hypothesis which does not see schizophrenia as simply an

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exaggeration of schizoidism. That hypothesis remains possible; just as in manic-depressive psychosis there exists a rising scale which leads from the asyntonic reactions of the normal individual, past the cycloids and cyclopaths, through to the declared forms of manic-depressive psychosis; here again, genealogical research finally confirms the close links between these manifestations of the same type. Those who claim that Kretschmer and I divide the whole of humanity into two classes, the schizoids and the cyclothymics, are completely wrong. The two modes in question are in no way mutually exclusive and, in their pathological exaggerated forms, they have, in hereditary terms, as little connection with each other as hair color with musical talent. As we have already said, it has been suggested by some that the intervention of a new and autonomous factor is required to transform schizopathy into schizophrenia. Our current knowledge in no way makes this hypothesis indispensable. It should, however, be noted that schizophrenics show more signs of degeneration than manic-depressives, paranoiacs and the normal, and that in severe cases of schizophrenia there are generally more signs of dysplasia than in mild cases. This would seem to suggest that a constitutional weakness at least creates a predisposition to schizophrenia. This would explain the fact that schizophrenia is relatively often combined with epilepsy, which itself has some links with dysplasia. It could, however, be objected that intelligent individuals are just as prone to schizophrenia as stupid ones, although the latter include more dysplasia sufferers. Gentlemen, I have tried to show you that the concept of schizophrenia is not simply a product of the imagination, but that it applies to whole series of facts and includes issues which can contribute to the progress of our science. I have no doubt that French psychiatry, as soon as it begins to examine this concept, will succeed, with the spirit of clarity and precision that characterizes it, in developing it and rendering it truly fertile.

Pierre Janet (1857-1949)

Pierre Janet, who began the 20th century better known throughout the world than his contemporaries Bleuler* and Freud’l-, has gradually been forgotten, although many of his ideas have passed into the common pool of psychiatric thought, without their origin always being remembered, the most striking example being the notion of “dissociation”. Janet’s longevity, together with the intense intellectual activity which he maintained until the end of his life, gave him the time to construct through his oeuvre an arch between the work of his teacher Charcot and that of his own students who, like Henri Ey“ and Jean Delay (1907-1987), did not publish most of their texts until after the Second World War, beyond the historical limit which would have warranted their inclusion in the current volume of this anthology. Pierre Janet, took the agrlgation in philosophy in 1882, and initially taught from 1883 to 1899 at the Le Havre secondary school. Looking for a subject for his thesis, he frequented the town’s hospital departments and began to explore the activity of hysterical patients through hypnosis. Charcot discovered the results of Pierre Janet’s first experiments from a note presented by his uncle Paul, himself a professor of philosophy at the Sorbonne, at the Society of Physiological Psychology. In his philosophy thesis on “Psychological automatism. Essay on the lower forms of human activity” (1889), Pierre Janet uses the theory of

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total or partial mental automatism to explain the amnesia which is observed in the states of “double consciousness” to which AzamK had just drawn the attention of the scientific world. For Janet, hysterical symptoms, to which he believed these doubling phenomena belonged, come from subconscious fixed ideas developed from traumatic events experienced in the past, which the fits reproduce. After participating in 1899 in the 1st International Congress of Hypnotism in Paris, Janet began his medical studies, on Charcot’s advice, attending not only the latter’s department but also those of Jules Falret, the son of Jean-Pierre Falret“, and of Skglas“. Janet presented his thesis in medicine “Contribution to the study of the mental accidents of hysterics” to a jury chaired, shortly befdre his death, by Charcot, who created the laboratory of experimental psychology for him in his department at the Salp&ri&re.Janet would work there until 1910 when, following a disagreement with Dkjerine (1849-1917) who, after Fulgence Raymond (1844-1910), succeeded to Charcot’s department and chair, without ever having been his pupil, the laboratory was transferred to a neighbouring department. In “The mental state of hysterics, mental accidents” (1892), Janet develops the notion of the “field of consciousness”, attributing these accidcncs to the shrinking of this field due to the psychological weakness of the patients in which they occur. In 1597, Janet was himself given the chair of experimental psychology at the Sorbonne, then in 1901, thanks to the support of Bergson, he was appointed ahead of Alfred Binet“ (1857-1911)to the same chair at the ColKge de France. It was in this latter institution that he taught until 1935, disseminating his teaching around the world in the course of long conference tours conducted between the wars, notably in North, Central and South America. From 1901 onwards, Janet concentrated on the psychological analysis of “psychasthenia”, a term he invented to replace Beard’s “neurasthenia”. He expounds his conception in “Obsessions and Psychasthenia” (1903) published in the work of the SalpGtrihre psychology laboratory (for this reason, the second volume is co-signed by Raymond). Here, it is the function of the real which is degraded by a lowering of psychological tension with experiences of derealisation and depersonalisation and the emergence of conscious obsessive ideas, by contrast with hysterical fixed

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ideas which are subconscious. As regards the question of the relations of obsessive and hysterical ideas with consciousness, Janet is close to Freud. However, in 1913, at the International Medicine Congress in London, in which the latter had refused to take part, Janet-having severely criticised Freudian doctrine and claimed to have preceded him in the discovery of the unconscious and in the development of the cathartic method-attracted a violent response from C. G. Jung (1875-1961). In this affair, the latter’s attitude towards his two masters was ambiguous: he opposed Janet, with whom he had followed a course a few years earlier at the Salpttribe and whose ideas on dissociation are found in his Psychology of the D.P. (1907), in the name of Freudian orthodoxy, yet he was himself on the point of breaking with Freud. The latter would subsequently claim that he had no knowledge of Janet’s work before his first publications, yet mentions his name in the texts which we present in this anthology and, to support the scientific value of his Studies on hysteria (1895), he stresses the extent to which his own conception is close to Janet’s. When, on a trip to Vienna in his eighties, Pierre Janet wished to pay him a courtesy visit in Bergasse Strasse, Freud instructed a servant to say he could not receive him. Janet expounded his therapeutic conceptions in “Psychological Medications” (1919), then in “Psychological Medicine” (1923). The analysis of psychological economies governs the choice between treatments through rest and isolation intended to reconstitute the psychic energy, and cathartic treatments such as psychoanalysis or his own technique in which, after revealing the traumatic memories by means of hypnosis and suggestion, their reintegration, dissociation and finally their liquidation make it possible to release the energy allotted to them. “From anguish to ecstasy” (1926) contains the courses that Janet gave at the Coll6ge de France until 1935. He continued to hold consultations at the Sainte-Anne Hospital until the Second World War. Pierre Janet was to have chaired the World Psychiatry Congress organised by Henri Ey after the war, but his death meant that this Congress was finally chaired in Paris in 1950 by his pupil Jean Delay. It was by reference to the notion of “psychological tension” that the latter was to propose classifying psychotropic drugs into psycholeptics, psychoanaleptics and dysleptics, depending on whether they lower or raise the psychological tension or “divert

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mental activity by creating a situation of low psychological tension with a reduction in the operations of synthesis and adaptation to present reality, but also by producing a powerful movement of dream release.” This proposal was the origin of modern psychopharmacological classifications. However, it is the term “dissociative disorders” chosen by the American Psychiatric Association’s D.S.M. I11 (1980), then by the 10th edition of the WHO’SInternational Class6cation ofDiseases (1992) to designate the mental accidents of hysteria, thereby referring to the theory of psychical dissociation as the mechanism generating that neurosis, which has led to the rediscovery of Pierre Janet in the last decade or two. Jean Garrabk

Principal works JANET (P.), L ’Automatismepsychologique. Essai de psychologie exp&imentale sur Les formes infrieures de 1’actiuite‘ humaine [Psychological automatism. Essay on the lower forms of human activity], Paris, Fklix Alcan, 1889. JANET (P.), Contribution b I’hude des accidents mentaux des byste‘riques[Contribution to the study of the mental accidents of hysterics], Paris, Fklix Alcan, 1893.

JANET (P.), Les Obsessions et la Psychasthinie [Obsessions and psychasthenia], Paris, Felix Alcan, 1903. Reprint in Classics in Psychiatry, New York, Arno Press, 1976. JANET (P.), LesMidicationspsychologiques[Psychological medications], Paris, Fklix Alcan, 1919. JANET (P.), La Midecine psychologique [Psychological medicine], Paris, Flammarion, 1923. JANET (P.), De l’angoisse Li l’extase [From anguish to ecstasy], Paris, Felix Alcan, Vol. I, 1926, Vol. 11, 1928.

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Principal references

Milunges oferts 2 Monsieur Pierre Janet [Mixtures offered to Mr Pierre Janet], collective work, Paris, D’Artrey, 1939. Bulletin de psychologie de 1’UniversitC de Paris en hommage Pierre Janet [Bulletin of psychology of the University of Paris in homage to Pierre Janet], Psychologie puthologiqtle [Pathological psychology], 184.XIV, p. 1-4, NOV.1960. ?i

Mental Accidents of Hysteris

§ 2. DOUBLING OF THE PERSONALITY.

A great number of hysterical symptoms seem to depend on certain fixed ideas, certain suggestions, but should this explanation be extended, as Mr Moebius has attempted, to all such symptoms and extended into a definition of hysteria? It is this which several authors have found highly questionable and which has been justly criticised by Mr Oppenheim, then by Mr Jolly. Let us try to refine these somewhat broad criticisms by following the method which we have proposed in order to examine the definitions. 1' A large number of hysterical symptoms, markedly localised like those above, hyperaesthesias, tics, paralyses, spasms, do not seem to be a part of any idea, any aspect of the subject's imagination. In whatever way they are questioned, and despite their willingness to assist, patients insist that it is not their intention to move their arm, to close their fist, to make a grimace; moreover, they are completely unaware of such spasms, do not even feel them, observe their own symptoms with astonishment with no knowledge of how they occur. There are, in fact, two categories of hysterical symptoms, which can be easily distinguished by the examination of tics or spasms. One type takes place wben the suEject is thinking about it; they disappear when

Mental Accidents of Hysteris. Doubling of the Personality 433 the subject is distracted or asleep; these are easy to connect with an idea. Very often, however, the pathological movement occurs even when the patient is not thinking about it; the spasm persists despite distraction, sometimes despite sleep. These are not, at least in appearance, symptoms which depend on any mental representation. Initially perhaps, the subject may have been aware of an emotion, of a vague idea, but it is clear that these conscious phenomena disappeared very early and that they no longer exist. 2’ The hysteric does not only show permanent symptoms of this type; she exhibits a much more frequent and much better known phenomenon, the attack. However, this attack is not a simple act like a contraction of the hand, it is a very complex set of convulsions, of shouts, of words. Subjects do not have in their minds a representation of this whole series of phenomena, may even be unaware of them, since, in the majority of cases, they awaken from the attack with little idea of what has just occurred. These attacks, which recur with monotonous regularity, seem to depend on some physical phenomenon, for they are independent of the subject’s thinking, and they may sometimes be induced, not by arousing the subject’s ideas, but simply by pressing a point on the body, for example the ovary or the epigastrium. 3 O Let us consider symptoms which are more specifically moral, delusions and somnambulism, which are incontestably associated with hysteria; once again, there is no fixed, clear and simple idea which presents itself. Subjects have no awareness of what occurs during the states of somnambulism or delusion, and do not think about them. When the symptom occurs, it consists of a whole long series of very varied sensations and thoughts which the patient had in no way expected. In short, even if we leave aside the stigmata, and consider only the other symptoms, it is impossible to relate them all to bodily changes brought about by conscious representations.

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Let us change our point of view, therefore, and concentrate our definition on another phenomenon. Once again, it is the work of Mr Charcot and his students which has shown the great importance of the role of somnambulism in hysteria. This phenomenon initially occurs spontaneously in these patients in many circumstances, and may subsequently be induced artificially in most, if not all, hysterics. The absence of memory with regard to all that occurred during the somnambulism, when the subject reverts to the normal state, appears to us to be the sole consistent and essential characteristic of the somnambulism, and this amnesia, followed by a periodic return of the memories, establishes a sort of divide between the two states. An individual who is truly somnambulistic lives in two different ways, he has "two successively alternating psychologically existences;" in one he has sensations, memories, movements, which he does not have in the other, and consequently he presents, to a more or less marked degree, depending on the case, two characters and, in a certain way, two personalities. The simplest somnambulism should be considered as identical to those great phenomena of double existence which are sometimes so clear; it is always the result, the manifestation, of a doubling of the personality. If somnambulism is understood in this way, it is easy to observe that a large number of hysterical symptoms may be connected with it. Not only the long periods of dual existence, but states of very short duration during which the patient seems to walk or to act automatically, and phenomena such as disappearances, reveries, ecstasies, etc. We have sought to show that, following the example of Mr Charcot, it is possible to establish the closest links between somnambulism and hysterical attack; both these phenomena are brought about in the same manner, give rise to the same amnesia followed by alternating memory, lead to the same doubling of the personality. Moreover, all these states are characterised by automatic regularity, for the second existence is often a rudimentary psychological one in

Mental Accidentsof Hysteris. Doubling of the Personality 435 which sensations and ideas are few, and do not control and modify each other. The fixed ideas which we have seen play such a significant role while hysterics are awake, are here still more powerful and develop with greater regularity. It is possible to interpret most of the attacks as a more or less complete reproduction of a former emotion, action, or idea in a second existence, which is comparable to a somewhat rudimentary somnambulism. These studies on hysterical attacks and somnambulism seemed to bring together and to combine an important category of hysterical symptoms-the periodic symptoms-but seemed to neglect the permanent symptoms, those disorders of movement otherwise so well described in the work of Mr Charcot and Mr Moebius. Is the distinction between these two groups of facts so absolute? We do not believe so; we have sought to combine them by studying the signs of second personality in the interval between episodes of somnambulism and attacks. The study of post-hypnotic suggestion carried out in an intelligent manner, although apparently without the subject’s knowledge or awareness, the analysis of so-called unconscious acts and of the automatic writing of mediums, have once again shown us the same doubling of consciousness. However, the second group of psychological phenomena, instead of alternating with the first, now develops simultaneously below and outside the subject’s normal thought process. In short, not all the phenomena which occur in the brain are united in a single personal perception, a part remains independent in the form of elementary sensations or images, or else aggregates more or less completely and begin to form a new system, a second personality independent of the first. These two personalities are not content to alternate, to succeed each other, they can coexist to a more or less complete degree. A large number of hysterical symptoms are connected with this type of semi-somnambulism, just as hysterical attacks are connected with the somnambulism. We have been obliged to recognise that in many

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symptoms, the fixed idea which, according to Mr Charcot’s theory, must cause and maintain them, could not be expressed by the patient, because he had absolutely no awareness of it. We now understand that these ideas can exist in him, although he is not conscious of them. Nor is this simply a plausible assumption, it is a fact which can be demonstrated clinically. How many times have we shown that subjects, by automatic writing while awake, were able to express these fixed ideas? Even more often we have found that subjects, in one hypnotic state or another, would completely recover the memory of these subconscious fixed ideas. Similar fixed ideas, existing outside personal perception, play a crucial role in hysteria; they can be responsible for the most varied disorders of movement; they may cause hyperaesthesias, or even bring about hallucinations, for the separation between the two consciousnesses is far from absolute, and a phenomenon which was produced in one by a whole series of associations of ideas can appear suddenly in the other; they can disturb and obsess the mind, cause the strangest lapses of memory and even kinds of delusion. The power of such ideas depends on their isolation; they grow, “take up residence in the mind like a parasite,” and cannot be halted in their development through the efforts of the subject, who is unaware of them, because they have an existence apart in a second area of thought separate from the first.

I... I The most important study to confirm our early work is undoubtedly the article by Messrs Breuer and Freud, recently published in NeuroLogisches CentraLbLatt. We are very pleased that these authors, in their independent research, have so precisely verified our own, and we thank them for their kind reference. They show by numerous examples that the different symptoms of hysteria are not spontaneous idiopathic manifestations of the disease,

Mental Accidents of Hysteris. Doubling of the Personality 437 but are closely connected with the causative trauma. The most common symptoms of hysteria, even the hyperaesthesias, the pains, the ordinary attacks, should be interpreted in the same way as the symptoms of traumatic hysteria, by the persistence of an idea, of a dream. The directness of the connection between the causative idea and the symptoms may vary, but it always exists. However, it should be noted that the patient, in his normal state, is often unaware of this causative idea which is only clearly apparent during natural or induced periods of secondary state, and it is precisely their isolation which gives these ideas their power. The patient is cured, according to these authors, when he is able to become fully conscious of his fixed idea. “This division

of consciousness, which has been clearly observed in certain celebrated cases of dual existence, exists in a rudimentary way in all hysterics; the disposition to this dissociation and, at the same time, to theformation of abnormal states of consciousness, which we propose to define by the term hypnoid states, constitutes thefundamental phenomenon of this neurosis. ,,This definition confirms those we have already given, which seek to group all the symptoms of the disease around a principal phenomenon, the doubling of the personality.

3. SHRINKING OF THE FIELD OF CONSCIOUSNESS The definitions above are undoubtedly very general, and apply to a large majority of hysterical symptoms; however, it is also clear that they almost entirely omit other equally common and very important characteristics, by which I mean the stigmata. Some authors have tried to explain the stigmata in the same way as the other symptoms, and to connect these too with the fixed ideas. This explanation would be simple, in accordance with the principles we have adopted, but we have seen that neither the evolution, nor the characteristics

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of the fixed ideas could be observed in the anaesthesias. They can be considered as proof of a weakening of the nervous functions, an exhaustion of the organs. However, that is not a theory, it is simply a correct but banal description of the fact itself; the nature of this exhaustion remains to be interpreted. We are scarcely in a position here to discuss a specific theory, for most of the authors who discuss this exhaustion have expressed themselves in a very vague and confused manner. For us, the question is as follows: is this exhaustion, which is incontestable, and the original causes of which-be they heredity, degeneration, intoxication or accidental lesions-we will not examine here, situated in a particular sensory organ, or does it affect the upper parts of the brain in a general fashion? Can we say that the tactile anaesthesia, the shrinking of the visual field, are specifically connected with a failure in the function of the nervous centres which govern these tactile or visual sensations, or are these anaesthesias simply a particular manifestation of a weakness affecting all the functions of the cerebral cortex, and therefore part of a general disorder of the psychological functions? We do not think that the stigmata are due to local lesions of the sensory apparatus, of the muscles, of the nerves, nor of the centres: lo the stigmata are too mobile, they disappear too easily as soon as any alteration occurs in the subject’s thinking; a suggestion, an association of ideas, attention in particular, can eliminate these losses of sensitivity and muscular impotence as if by magic; 2 O the stigmata are contradictory, that is to say organ function is real and persists at the very time when it seems to have been suppressed. We have shown in numerous studies that tactile sensation, visual sensation even at the periphery of the visual field, continued to operate, despite the anaesthesia, that memories were reproduced despite the apparent amnesia, that movements were possible and that they even retained their strength despite the weakness, despite the amyosthenia

Mental Accidents of Hysteris. Doubling of the Personality 439 indicated by the dynamometer. These facts can be demonstrated through any number of precise experiments, but they can also be shown by the simplest clinical observation. Hysterics walk, run without falling, without colliding with obstacles, as would true anaesthesiacs, patients whose visual field was genuinely reduced to a single point. They may be seen to work, lift burdens, do prolonged exercises if they do not feel observed, while they present astonishing muscular weakness, extremely rapid fatigue as soon as they are submitted to examination. We were very pleased to see the same observations independently made by Mr Jolly: he speaks of children with a complete hysterical amaurosis and adds: “These children who appear incapable of perceiving light, nevertheless avoid obstacles placed unexpectedly before them, and yet do not proceed by touch.. ., they do not resemble the truly blind.. .there must be some form of perception here,” and further on: “I have many reasons to believe that this deafness cannot be real.. ., I have no doubt that the child heard the conversations.” Mr Oppenheim also states: “The hysteric has lost the will to put in motion particular groups of muscles.. ., it is quite a different thing to put these muscles in motion by an effort of will or by the intermediary of an affective state.” This rapid reappearance and maintenance of the phenomena do not allow us to believe in a localised exhaustion. The general exhaustion of the cerebral functions has been described by many authors; “the hysterics, wrote Mr FCrC, are in a permanent state of psychical fatigue which results in a weakening of the sensibility, of the movement, of the will.” “The fundamental fact of hysteria, writes Mr Oppenheim, is the irritable weakness, an abnormal excitability combined with exhaustion; these characteristics are found above all in the sphere of the affective phenomena.” Mr Jolly, taking up Oppenheim’s conception, also speaks of an extreme nervous weakness which leads to an exaggeration of the affective phenomena, but he adds that this formulation lacks precision and does not account for the specific

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facts. Like this author, we believe that the significance of this cerebral weakness needs to be specified. As the essential functions of the brain are psychological functions, it must be shown, by the analysis of the moral phenomena, in what this psychological deficiency consists. We have previously proposed to study a psychological phenomenon which had already been described with some vagueness amongst the disorders of character in hysterics, but which seemed to us to be the principal expression of that deficiency. We refer to a weakness of the attention, or rather to a state of perpetual distraction which is observable in most of these patients. The attention is slow to settle, difficult, accompanied by symptoms of all kinds, is very quickly exhausted, and gives only minimal results, forming only ideas that are vague, doubtful, surprising and unintelligible. If the attention is considered from its motor aspect, in its application to action, the same characteristics are found: voluntary acts are difficult, slow, of short duration, interspersed with innumerable halts. Often, even this feeble degree of attention seems to disappear entirely, and any attention, any voluntary act becomes impossible, the subject becomes unable to understand what he reads, or even what he hears, to make the slightest voluntary movement. Aboulia, aprosexia, hesitation, doubt, we feel we must stress, are the essential psychological characteristics of the hysteric. Obviously, these characteristics are found in more or less similar form in other types of patients, but that is not a sufficient reason to neglect them in the hysteric. These weaknesses of the attention are so great that they not only affect intellectual work but even normal life, ordinary thought which requires a certain continuity of attention. The patient notices little of events around him, has very poor awareness of all the situations of life and above all is aware of only a very small proportion of events, seems always to forget the majority of the impressions he should absorb. If we try to verify this state of mind in a more precise manner, we find that a hysterical woman cannot

Mental Accidents of Hysteris. Doubling of the Personality 441 perceive several sensations simultaneously. As soon as she is occupied with feeling one phenomenon, she becomes indifferent to all other forms of stimulation performed on parts of the body and on normally sensitive organs. She shows the same distraction in respect of memory and while she is thinking of one idea, she forgets all the contrary notions of which she was perfectly conscious a moment before. Finally, the same characteristic is observed in her actions and movements; she never voluntarily performs more than one movement at a time and becomes unable to perform it as soon as she is distracted by a sensation or another movement. This latter point has received special study in the interesting work of Mr Pick. Distraction of this kind rarely exists in the normal man and only occurs through excessive concentration on a complex problem; in the hysteric, the process is much more simple. “It is an exaggerated state of distraction, which is not momentary and does not result from voluntary attention directed solely to one end; it is a natural and perpetual state of distraction which prevents such people appreciating any sensation other than that which currently occupies their mind.” We have previously tried, not to explain, but to encapsulate all these many facts in a simple formula. The psychological life is not solely constituted by a succession of phenomena following on one after another, forming a long chain which stretches in only one direction. Each of these successive states is in reality complex; it encompasses a multitude of more elementary facts and only owes its apparent unity to synthesis, to the systematisation of all these elements. We have proposed to use the term “jield ofconsciousness or maximum scope of consciousness” to describe the greatest number of simple, or relatively simple, phenomena able to be combined at any one moment, which can be simultaneously associated with our personality in a single personal perception. This field of consciousness, understood in this way, is highly variable: an orchestra conductor simultaneously hearing all the instruments, and

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following the opera score either from the page or by memory, combines in each of his states of consciousness an immense number of facts. The person asleep and dreaming, the patient during a fit of ecstasy, on the other hand, contain in their conscious thoughts only a very small number of facts. It is easy to see, in studying the distraction of hysterics, that their field of consciousness seems very small, it is entirely filled by a single relatively simple sensation, a single memory, a small group of motor images, and is no longer able to contain others at the same time. This shrinking of the field of consciousness is but a manifestation of the general cerebral exhaustion which has often been recognised. The most precise way to describe this exhaustion is as follows: it is a particular moral weakness which consists in the inability shown by the weak subject to unite and to concentrate his psychological phenomena, to assimilate them into his personality. This approach makes it possible to group a large number of facts, of character traits which have often been described in hysterics. Their fleeting enthusiasms, their exaggerated and easily relieved despairs, their unreasonable convictions, their impulses, their whims, in short, that whole excessive and unstable character, seem to us to depend on the fundamental fact that they are always entirely given over to the immediate idea, without any of those reservations, those mental restrictions which give thought its moderation, its equilibrium and its transitions. “It is also the shrinking of the field of consciousness, wrote Mr Laurent, to which must be attributed the fear of hysterics, their astonishment, their emotionality, their manifestation of the intensity of impressions. Since a given impression will suddenly erase the ideas which existed previously, the hysteric find himself in the position of a man who suddenly learns or sees something he does not expect. This impression drives out the other ideas, dominates the intelligence and, depending on its nature, may cause astonishment, fear, joy; since there is nothing to counter-balance it, since no reasoning occurs, it

Mental Accidents of Hysteris. Doubling of the Personality 443 is the instinctive expression of thought which is shown.” The same remarks can be applied to the sudden impulses of these patients and to their sudden changes; this is simply the somewhat more precise psychological expression of the condition which was previously described by the vague title of irritable weakness. We think that it is possible to go a little further and that the stigmata, the anaesthesia itself, can be considered as governed by this psychological characteristic. The anaesthesia behaves like a distraction; it is variable, mobile; it often disappears when the subject can be induced into an effort of attention. It is neither profound nor complete, since it allows elementary sensations to subsist in the form of subconscious phenomena which in many cases are easy to observe. By means of the distractions themselves, it is possible to produce losses of sensitivity which have all the characteristics of hysterical anaesthesias. When the distribution of the anaesthesia changes, which is very frequent, one observes alternations, equivalences in the lost sensations. “Sensibility, Cabanis formerly wrote, seems to conduct itself in the manner of a determined quantity of fluid, which, each time it flows in greater abundance into one of its channels, becomes proportionally less abundant in the others.” If you oblige the subject, by attracting his attention, to recover feeling on his left side, he loses it on the right side. If you obtain total tactile sensitivity, the shrinking of the visual field increases to such a degree that the subject becomes momentarily blind, as I have observed several times without expecting it. If you then try to increase the visual field, the tactile anaesthesia will increase. These alterations often occur spontaneously and certain subjects seem to have the choice between several forms of equivalent anaesthesias. These alternations apply not only to the anaesthesias, but to many other phenomena, and that is why hysterics are not cured when one symptom has been more or less completely eradicated. The weakness of thought subsists and they lose on one side what they had seemed to

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regain on the other. The localisation of the anaesthesia can be governed by a suggestion or a fixed idea, but the anaesthesia in itself and the stigmata in general are manifestations of the deficiency of personal perception, of the shrinking of the field of consciousness. Mr J. Hkricourt, in summing up our study on hysterical anaesthesia, employs a very felicitous expression which precisely expresses our thinking. “It is by a sort of laziness that the principal personage suppresses a whole series of sensations, those which are the least indispensable to him, in order to limit the field of a n activity which he would have some dtficulty in maintaining... this rejection of a whole group of awkward psychic elements seems to constitute a sort of spontaneous psychological autotomy of which, moreover, there exist unquestionable cases. Thus, we know that people who squint in one eye totally suppress the vision in the eye with strabismus and in reality only see through one eye, although both eyes are equally sensitive to retinal sensations.” We think, therefore, that the stigmata can be described by means of the following formula: “It is as i f t h e elementary psychological phenomena were as real and as numerous as in normal individuals, but, because of the shrinking of the field of consciousness, because of this weakness in the faculty of synthesis, were unable to come together into a single perception, a single personal consciousness.” This new conception, to which we have been led by the study of stigmata, in no way contradicts the conclusions of our previous studies on symptoms. The doubling of the personality is much more likely to be the immediate consequence of this weakness of psychological synthesis. This weakness allows psychological phenomena to subsist, but does not associate them with the idea of the personality. Somnambulism and subconscious acts can be perceived as secondary groupings, systematisations which are accessory to these neglected psychological phenomena. “It is as i f t h e system of psychological phenomena which forms personal perception in all men has been broken up in these individuals and

Mental Accidents of Hysteris. Doubling of the Personality 445 has produced two or more simultaneous or successive groups, usually incomplete? which steal from each other the sensations, the images and consequently the movements which should normally be combined within a single consciousness and a single power. ” Suggestibility itself and diseases by representation are part of this general conception: the exaggerated development of certain ideas depends on their isolation, and this isolation is a consequence of the shrinking of the field of consciousness. The heightening of automatic phenomena usually results from a diminution in the power of the voluntary activity which draws together present phenomena at every moment of life. It is these conceptions together which we have designated by the name mental disintegfation and it seems again, on the basis of the analyses above, that this idea can provide the means to encompass a large number of hysterical phenomena. Several authors have accepted this account of the facts and have added to it with new examples. Mr Pick considers the diminution in the power of attention, the shrinking of personal perception? to which he adds the shrinking of motor impulse, as the characteristic of hysteria. Mr Laurent expresses himself in much the same way: “We say hysteric, because today it is the only scientific word which refers to the mental shrinking, the minus habens conscientiae, if we may thus express the mental state of this-perhaps very intelligent-individual, all of whose mental faculties are marked by a stigma undoubtedly more fixed than one is accustomed to find in hysteria.” No doubt this shrinking of the field of consciousness must be found in a large number of patients, in many of the deranged (we do not believe that we should say in all), in neurasthenics, in the stupid, even imbeciles and idiots. Should it be concluded from this that we have wholly confused the hysteric with the idiot? One might just as well say that the naturalist confuses the dog and the lizard because he describes them both as vertebrates. The shrinking of the field of consciousness is a major pathological

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characteristic which is expressed in a thousand different ways. All the descriptions and studies contained in this work have tried to show how this characteristic is expressed in the hysteric. We would simply recall here that the elementary psychological phenomena subsist almost without alteration, that a part of them separates completely from the personality, which gives rise to marked anaesthesias, amnesias, and paralyses, that these dissociated phenomena group together to form psychological states distinct from normal consciousness. We do not believe that the weakness of psychological synthesis occurs very often in this form outside hysteria.

Paul Sirieux (1864-1947) and Joseph Capgras (1873-1950)

Paul SCrieux was undoubtedly one of the foremost European alienists, firstly by birth (his father was French, his mother English), then by his missions abroad (Report on assistance for the insane in France, in Germany, in Italy and in Switzerland), and finally by the promoter’s role he played in introducing Kraepelin’s German classification into France at the beginning of the 20th century. Together with Joseph Capgras, he described delusion of interpretation. Both men were pupils of Valentin Magnan (1835-1898), and were appointed to different posts as chief physicians to the Seine insane asylums in the Paris region, before finishing their careers at the Sainte-Anne clinical asylum. Their principal joint work: “The reasoning insanities” was published in 1909, the culmination of a whole series of publications spread over several years. In it, they define reasoning insanities as delusions of interpretation that are constitutional in origin. This pathological constitution is very close to the paranoiac constitution of the German authors, which forms following emotional shocks (sorrows, disillusion, damaged self-esteem) and becomes fixed into an emotional state which explains the development of the delusion. “In delusion of interpretation, the significance of this paranoiac constitution is crucial, for by contrast with that which takes place in the dementia1 psychoses, there is, we know, neither radical

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alteration nor dissolution of the character, but a hypertrophied and unilateral development of certain pre-existing tendencies. There is no point of separation between the subject’s former personality and the interpreter’s personality. The latter is simply the extension of the former which, persisting with its tendencies, its character, its customary modes of reaction, influences the development of the delusion, the choice of conceptions, and the activity as a whoie.” The delusional interpretations (exogenous and endogenous) expand, become systematised and make the delusion chronic, but with no terminal dementia. “Before describing the characteristics of delusion of interpretation, we need to define delusional interpretation. It is a false reasoning which takes as its starting point a real sensation, a correct fact, which, through associations of ideas linked to tendencies, to affectivity, and through mistaken inductions or deductions, takes on a personal meaning for the patient, who is uncontrollably driven to refer everything to himself.” “One of them, for example, takes another patient for a spy, and the nurses for policemen in disguise. He is not so naive as not to realise that he is surrounded by undercover agents provocateurs, in the pay of his enemies. And he explains that he has long been the victim of a thousand attacks. People follow him, mock him by whistling, shake their newspapers in his face, spit when he passes; the threatening or obscene gestures are all around: head scratching, hand rubbing, a woman lifting her skirt. At night people make the doors and windows creak with the express intention of keeping him awake. He receives catalogues for orthopaedic devices: what clearer proof could there be that someone wishes to cripple him? Why is there a group of people in front of the newspaper kiosk: to hide from him an article, a picture that concerns him. Pointless! The newspapers, full of allusions to him, reveal his past and his destiny under pseudonyms; the illustrated papers reproduce his picture; even the advertisements are about him! ” The delusions of interpretation are traditionally contrasted with the acquired psychoses in Magnan’s chronic delusions with systematised evolution. “As for chronic systematised delusions, these need to be divided into two groups in order to avoid classifyingentirely distinct types

Paul Slrieux (1864-1947) and Joseph Capgras..

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under a single label: on the one hand, acquired psychoses which, profoundly injuring the subject’s mentality, lead eventually to dementia; on the other hand, constitutional psychoses which, do not alter the personality, of which they are simply an exaggeration, and which do not lead to intellectual impairment.” The reasoning insanities involve three stages: initially, there is a process of incubative meditation; the second, so-called systematisation phase, sees the construction of the delusion with the addition of retrospective interpretations; finally comes the terminal phase of resignation where at best the delusion becomes encysted without disappearing. “We shall detach from it a condition we want to call dClire d’interprhation (delusion of interpretation). Whilst the psychoses leading to dementia include chronic hallucinations, our cases have exclusively delusions.. . They were, therefore, characterized by (a) multiple and organized delusions, (b) absence of hallucinations, (c) normal intellect, (d) chronic course, and (e) incurability without terminal defect.” Paul Skrieux and Joseph Capgras described different clinical forms of delusions of interpretation, depending on the predominant theme: delusion of persecution, delusion of grandeur, delusion of jealousy, erotic delusion, mystical delusion, hypochondriac delusion, self-accusation delusion. Also worthy of note is Capgras’ original work on the illusion of doubles (1923). This syndrome, according to Capgras, is an agnosia of identification of someone familiar to the patient; today, its cause is considered to be neurological. FranGois-RCgis Cousin

Principal works

SERIEUX (P.) and CAPGRAS (J.), Les Folies raisonnantes. Le dilire d’interpritution [The reasoning insanities. Delusion of interpretation], Paris, Alcan, 1909.

CAPGRAS 0.) and REBOUL-LACHAUX (C.), “L’illusion des sosies dans un dClire systkmatisk chronique” [The illusion of

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doubles in a chronic systematised delusion], Bulletin de la Soci&i de midecine mentale, 1923.

Principal references SERIEUX (P.) and CAPGRAS (J.), Les Folies raisonnantes. Le dilire d’intelpritation [The reasoning insanities. Delusion of interpretation], preface by Collie, M. Laffitte Reprints, Marseille, 1982, 392 pages. LUAUTE (J.-P.), “Les dilires d’identifications des personnes: une approche neuro-psychologique” [The delusions of identification of Deode: a neuro-Dsvcholoeical amroachl. Neuro-ow. 1992.

The Reasoning Insanities Delusion of Interpretation (1909)

INTRODUCTION.

For a long time the terms “systematized delusions” in France, and “paranoia” abroad, were used to describe psychopathic states-acute or chronic, primary or secondary, with or without intellectual impairment-characterized, in approximate terms, by the organization of a more o r less coherent set of delusional concepts, a sort of fantastic or absurd tale which becomes, for its author, the unquestionable expression of reality. They were simply subdivided, depending on the nature of the delusional system, into delusion of persecution, delusion of grandeur, delusion of jealousy, mystical delusion, erotic delusion, hypochondriac delusion.. .Founded as it was on so superficial a criterion, this highly simplistic attempt at classification united facts that were disparate in nature. Today, in establishing the autonomy of a psychosis one would no longer rely merely on the color of the delusional ideas; one needs to study the particular grouping of the symptoms and the evolution of the morbid disorders as a whole; finally, as far as is possible in the current state of psychiatric knowledge, one needs to take account of their causes and their genesis. When approached

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in this way, “systematized delusions” emerge as no more than a morbid manifestation likely to occur at the beginning or in the course of otherwise very different mental illnesses. Acute or secondary delusions disappear from the classification as entities in their own right. Characterized by polymorphism and a lack of coordination between delusional ideas, by the coexistence of symptoms of excitement, depression or confusion, sudden beginning and ending, or progressive onset of dementia, sometimes subsequent to infections or intoxications, they are usually associated with mental degeneracy, intermittent insanity, dementia praecox. As for chronicsystematized delusions, these need to be divided into two groups in order to avoid classifying entirely distinct types under a single label: on the one hand, acquired psychoses which, profoundly impairing the subject’smentality, lead eventually to dementia; on the other hand, constitutional psychoses which do not alter the personality, of which they are simply an exaggeration, and which do not lead to intellectual impairment. In the latter group we are seeking to identify a nosographical group which we call “chronic psychosis with delusional interpretations” or, more briefly, “delusion of interpretation”, on account of its most striking feature. Obviously, the differentiation of this form is justified by a set of other significant attributes. While most dementia1 systematized psychoses originate from predominantly sensory and quasi-permanent disorders, all the cases we classify under the above term are, almost exclusively, characterized by delusional interpretations; hallucinations, which are always episodic when they occur at all, play almost no part in them. Before describing the characteristics of delusion of interpretation, we need to define what is meant by delusional interpretation. It is a false reasoning which, starting from a real sensation, a correct fact, through associations of ideas linked to tendencies, to affectivity, and through mistaken inductions or deductions, takes on a personal meaning for the patient, who is uncontrollably driven to relate everything to himself.

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Delusional interpretation is different from hallucination and illusion, which are sensory disorders: the former a perception without an object, the latter a mistaken perception of its object. A mystic who sees the Virgin appear to him in the shadows is experiencing a hallucination. Don Quixote, when he mistakes the windmills for giants, is the victim of an illusion. We restrict this term illusion to error of the senses, though interpretation has sometimes been referred to as “mental illusion”. We would also draw attention to a common error whereby interpretation is confused with hallucination. For example, a patient claims to have heard certain words, certain curses; in fact, these words were actually spoken. Delusional interpretation differs from delusional ideas, where concepts are imaginary, either entirely invented or, at least, not deduced from an observed fact. As Regis has said, the former is correct in its point of departure, the latter erroneous in its very origin: “delusional interpretation is to the delusional idea somewhat as illusion is to hallucination.” It is more difficult to separate delusional interpretation from false interpretation. A number of authors have indicated differential signs which, despite their value, do not apply to all cases. Error, it is said, is usually rectifiable; delusional interpretation cannot be corrected. Error remains isolated, circumscribed; delusional interpretation tends to spread, to radiate, it combines with analogous ideas and organizes itself into a system. Error does not have the self as its object; delusional interpretation has the self as its object, is markedly egocentric in character. Error does not necessarily have an impact on the subject’s activity, it often remains theoretical; delusional interpretation tends to fulfil itself, guides and dominates activity. Error arises in the normal brain, interpretation on pathological terrain. In the former there is no lesion of the personality, with the latter there is. Would it suffice to say that delusional interpretation is absurd and unacceptable for people of sound mind? Not at all: many delusional interpretations, frequently more

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plausible than errors, have achieved a following amongst sane and intelligent people. Common to very different psychoses, this mode of affective judgement is also encountered in states of passion; a slight affective state, or even a predominant idea is sufficient to cause it. One cannot, therefore, seek to found the autonomy of a morbid entity on the existence of delusional interpretations. Delusion of interpretation is a chronic systematized psychosis characterized by: 1. the multiplicity and organized character of delusional interpretations; 2. the absence or scarcity of hallucinations, their episodic nature; 3. the persistence of lucidity and of psychic activity; 4. the evolution of the interpretations by progressive extension; 5. incurability except through terminal dementia. A functional psychosis whose origin should be sought, not in the action of a toxic agent, but in a psychopathic predisposition, in abnormalities in the development of the centers of association in the brain which are responsible for distortions of judgement, failures of the critical sense, disorders of affectivity, delusion of interpretation is essentially a congenital malformation, in short a form of degeneracy. Delusion of interpretation should be ranked amongst the psychopathic states artificially grouped under the name “reasoning insanities”, where sufferers, outside their “partial delusion”, retain their mental capacities, with an often remarkable ability to argue and defend their convictions. Interpreters do not deserve to be described as “alienated” in the etymological sense of the term (alienus, outsider): they remain in contact with their milieu, they appear normal; some manage to live in liberty until the end without attracting attention except through certain oddities; most are confined, not because of their delusional ideas, but on account of their violence and impulsive character which make them dangerous. If one talks to them, reads their correspondence or their “memoirs”, not only may one not encounter any irrational content, but one observes that they express

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themselves correctly, their associations of ideas are normal, their memories accurate, their curiosity lively, their intelligence intact and sometimes refined and penetrating. One can observe no active hallucinations, no excitement nor depression; no confusion, no loss of affective feelings. Prolonged or repeated conversations are often necessary for certain oddities to be observed. Some formulate complaints that are very plausible, perhaps legitimate, worthy of investigation. A woman accuses her husband of immorality: he has been unfaithful, tried to poison her, embezzled her money, arbitrarily confined her. A man complains of the injustice of his superiors, the hostility of his entourage, malevolent insinuations or allusions. An illegitimate child claims to have proof that he belongs to a particular great family. With certain interpreters, the judgements they pronounce seem to be invariably erroneous: one might simply see in them reasoners whose thinking is mistaken, with a habit of perceiving events from a particular angle, of systematizing everything from a questionable initial concept, a fixed idea which controls their false interpretations. Their delusional conceptions-if it is indeed delusion rather than error-remain plausible, they do not seem to involve damage to the syllogistic faculties. Others, who do not differ from the previous ones by any essential trait, give a singular turn to what they say. Their judgements, while retaining an appearance of logic, become excessively strange: the conviction arises that they are the inventions of a sick imagination. One of them, for example, takes another patient for a spy, and the nurses for policemen in disguise. He is not so naive as not to realise that he is surrounded by undercover agents provocateurs, in the pay of his enemies. And he explains that he has long been the victim of a thousand attacks. People follow him, mock him by whistling, shake their newspapers in his face, spit when he passes; threatening or obscene gestures are all around: head scratching, hand rubbing, a woman lifting her skirt. At night people make the doors and windows creak with

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the express intention of keeping him awake. He receives catalogues for orthopedic devices: what clearer proof could there be that someone wishes to cripple him? Why is there a group of people in front of the newspaper kiosk: to hide from him an article, a picture that concerns him. Pointless! The newspapers, full of allusions to him, reveal his past and his destiny under pseudonyms; the illustrated papers print his picture; even the advertisements are about him! He has known the acclaim of the people, has been honored by the military, bowed to by a minister, being treated as a son by a great lady: he was substituted as a child. It is vain to deny his true origin; the truth is clear. The clinical facts corresponding to delusion of interpretation, picked up in France by a few observers, remain dispersed in a variety of nosological groupings, depending on the predominance of one symptom or another. If the existence of sensory disorders is observed-or thought to be observed-they are classified as hallucinatory systematized delusions. If a subject manifests aggressive reactions, relentless claims, the diagnoses is “persecutory delusion”. Finally, cases whose originality cannot be contested are attributed to mental degeneration. However, while it is legitimate to consider interpreters as unbalanced, it is nonetheless the case that they constitute an homogeneous group, meriting a distinct place in the proteiform assembly of degenerates. They should be kept radically distinct from the hallucinatory delusions group. As for persecution mania, because of the similarity of the reactions, it arbitrarily brings together cases which in reality are distinct. Amongst other heterogeneous types it includes a few interpreters-those who, quick to attack, continually pursue their imagined enemies-while leaving out the resigned, non-aggressive interpreters. It also encompasses those unbalanced subjects who, under the influence of an obsessive idea, employ all their intelligence and all their abnormal activity, not for the construction of a delusional tale, but for the satisfaction of their morbid passion. For

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this latter type we reserve the name “pretenders” (delusion ofpretension). The term persecution mania, when applied to cases of delusion of interpretation, is not appropriate for patients who sometimes are neither persecuted, nor persecutors. The study that follows concentrates solely on interpreters, those subjects who, more than all others, manifest the strange coexistence of reason and insanity and who well deserve the description of the “reasoning insane”. We will successively describe the symptoms, the expression, the evolution and the varieties of delusion of interpretation. We will then attempt to describe its genesis, to differentiate it from delusion of pretension, from symptomatic interpretative psychoses and hallucinatory systematized delusions. Finally, having recalled the manner in which it was perceived in the last century, we will seek to justify the autonomy of this morbid type and to situate it within a nosographic classification. Therapeutic and medico-legal considerations will complete the monograph.

1. It is to these two clinical types-delusion of interpretation and delusion of pretension-that the term “paranoia” should be confined. This highlights the nosological affinities of these forms and also remains in accord with the etymology of the word which indicates, not the abolition or diminution of psychic activity, but a deviation of the intellectual faculties, a distortion: paranoia is to the normal state somewhat as paradox is to the truth. 2. This study is based on almost sixty observations, some forty of them personal, made over a period of several years, often ten and in some cases even twenty. We owe six previously unpublished observations to the generosity of Professor Regis to whom warm thanks are due. We have only been able to ublish twenty, several in summary, and only a few in detailed form. It shou d be noted that in order to avoid repetition, we will not specify the absence of sensory disorders for each observation: we have always looked carefully for hallucinations, even when this point is not explicitly mentioned. Bibliographic information is mostly provided in chapter VII (History).

P

Vladimir Serbsky (1858-1917)

A doctor’s son, Serbsky was born in Bogarodsk in the province of Moscow. Gifted in the exact sciences, he began by studying mathematics and physics at Moscow University before turning to medicine. Having completed his studies, he worked under Sergei Sergeievitch Korsakov (1854-1900), the first director of the Moscow University Clinic, first as his loyal collaborator, subsequently as his successor. According to Korsakov, Serbsky’s doctoral thesis on catatonia is one of the finest works of Russian psychiatric literature. For Serbsky, catatonia was a “complex of symptoms” and not an autonomous disease as described by Kahlbaum (1828-1899) in 1874. Initially, he worked under his mentor in M.F. Becker’s private clinic, then from 1885 to 1887 was in charge of a clinic at Tambov in Moldavia. During this period he undertook an educational visit to Vienna, where he spent time in the practices of Obersteiner and Meynert, where he met Freud who worked there from 1883 to 1886. Returning to MOSCOW, Serbsky entered the university clinic where he rose through the ranks of the hierarchy, from assistant to professor (1903) to director. In 1895-1900 he published a work of “Legal psychopathology” in which he defended the rights of the mentally ill in medico-legal procedures. He took part in the foundation by Korsakov of the Muscovite Society of Neuropathology and Psychiatry and of the first

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Russian “Journal of Neuropathology and Psychiatry”. Since the latter was first published only after Korsakov’s death, Serbsky became its first editor-in-chief. in 1903However, it was in the Annales m6dico-psychologiquesY 1904, that he published a contribution to the study of dementia praecox in which he took the side of the French school in its quarrel with the conception of that condition as formulated by Emil Kraepelin in the 6th, 1899 edition of his famous treatise. That is why we have chosen to include here an extract from these French texts by Serbsky where he develops arguments against the single nature of this Kraepelinian view of dementia praecox. In 1911, Serbsky resigned from his professorial position out of solidarity with his colleagues who had been sacked from their posts at the University of Moscow on account of their progressive ideas. For this reason, the end of his life was marked by material difficulties, his only resources coming from his private clients. Nonetheless, he continued to participate in the activities of the Society and on the editorial committee of the “Journal of Neuropathology and Psychiatry”. On his death on 5 April 1917, his positions as professor and director of the university clinic were restored. However, Serbsky or his name were still to experience a further post mortem disgrace. For the Soviet government had the curious idea of giving the name of this liberal psychiatrist, this defender of the rights of the mentally ill, several years after his death, to the Moscow Institute of Medico-legal Psychiatry, the institution where in the 1970s and 1980s political dissidents were “treated” for “torpid schizophrenia”. The name Serbsky having been connected in the West with this abusive use of psychiatry for purposes of political repression, condemned by the World Psychiatry Association, the publication of this extract provides an opportunity to reveal the true face of this Russian psychiatrist. Denis P. Morozov

Principal works SERBSKY (V.P.), “Psychopathologie judiciaire” [Legal psycho1900. pathology], MOSCOW,

VZadimir Serbsky (1858-1917)

46 1

SERBSKY (V.P.), “Contribution ?I 1’Ctude de la dkmence prkcoce” [Contribution to the study of dementia praecox], Annales mkd.psychol. (18), Nov.-Dec. 1903, p. 379-388; (19) Jan.-Feb. 1904, p. 19-34; (19) March-April 1904, p. 188-203.

Bibliographical references

KERBIKOV, KORVINA, NADJAROV and SNEJEVSKI, Psychiutrie[Psychiatry], Moscow, Meditzina, 1968. French trans., Moscow, Mir, 1971. GARRABE 0.) and MOROZOV (P.), “Les kcrits franfais de Vladimir Serbsky” [The French writings of Vladimir Serbsky], Annales mid. psychol.

Contribution to the Study of Dementiu Prdecox (Continuation and end ')

111.

In contracting the perhaps excessively broad frame of dementia praecox, we should only include disorders which present the two essential and most characteristic traits: lo that the disease begins in adolescence; and 2O that the onset of an unfavorable terminal period is rapid, marked by more or less pronounced dementia. The disorder usually appears at the time of puberty, or a little later, and in any case before the organism is fully developed in physical and psychical terms. The extreme limit for the start of the illness, in relatively rare cases, is between the age of 25 and 30; in the vast majority of cases, the disorder arises before the 25th year. In certain cases, the dementia is evident from the beginning of the condition; however, it can happen that it becomes apparent only after the acute period, or else following several relapses. Apart from Morel's somewhat vague indication of the possibility of dementia praecox developing at the time of 1. See the Annales of November-December 1903 and the January-February 1904.

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puberty in degenerates, it is, as is known, the identification by Kahlbaum in 1863 of hebephrenia as an autonomous form, which develops during puberty and manifests itself principally by phenomena of psychical weakness, which has mostly prompted the study of dementia praecox. The clinical picture of hebephrenia was not given until a few years later, by a pupil of Kalbaum, Hecker. The principal traits of this disorder, developing between the ages of 18 and 22, can be summed up as follows: the mood is inconsistent and changeable, although in the initial phase it is depression that dominates (Initial MeZanchoZy), but this depression is superficial and likely to vary: the patient, having wept over his sins and his misfortune, having been a prey to fear and panic, becomes suddenly joyful and performs stupid and absurd acts. Such changes are rapid, sudden, unexpected. The patient gives the impression of playing and parading his feelings and moods. In these cases there are generally some delusional ideas, but these ideas are disconnected, extremely variable: it is sometimes self-accusation, sometimes ideas of persecution, sometimes erotic ideas. They bear the character of something imagined, invented by the patient to amuse himself and to play the fool (Kahlbaum’s “confabulation”). As regards the sphere of the will, one observes a tendency to disordered activity, abrupt, impulsive movements, to absurd behavior, in the form of feigned childishness; sometimes the motor disturbance may be as violent as an attack of furor. In a few cases, there may be a tendency to vagabondage, to purposeless wandering. What is quite characteristic in hebephrenia is to encounter formal problems of speech and writing. Sentences are poorly or casually put together, logical construction is lacking, patients lose themselves for long periods, are incapable of ordering their thoughts which follow each other with no sign of punctuation. There is also a tendency to repeat the same phrases and the same figures of speech, provincial expressions, a particular jargon, words which are either foreign or outmoded. In their conversations, and likewise in

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their letters, patients commonly employ indecent or cynical expressions, often mixing them with sentimental and poetic expansions or else with a mass of absurd and exaggerated words. It is within this same category of facts that one should include the taste for a particular kind of self-pity, for theatrical poses, for the use of diminutives of names and a tendency to imitate defects of pronunciation, such as childish lisping, etc., etc., although Kahlbaum considers several of these signs to be characteristic of catatonia. The prognosis is entirely unfavorable, although specific terminal dementia, of which clues have already been noted from the initial period of the condition, does not generally attain a very pronounced degree. It is for this reason that patients are often considered normal; and as for their peculiarities of speech and behavior, which often resemble deliberate imbecility, they are believed to be feigned, to be simulated manifestations. Such patients often find themselves brought before the criminal courts, especially those who distinguish themselves by failings of a moral nature. While rarely attaining absolute dementia, hebephrenic dementia is sometimes accompanied by temporary bouts of disturbance, which may go as far as furious attacks (brought on by external causes or by hallucinations). It is only during such periods that the pathological weakness and irritability may become clearly apparent, in individuals who are still able to carry out their normal tasks and are considered to be no more than slightly simple. In the majority of cases, according to Hecker, a certain psychical weakness, a softness and inaptitude for intellectual work, may already be observed in childhood, although these defects do not exclude the possibility of development and do not necessarily result in the child being much more backward than his comrades. These individuals are quite often characterized by an abnormal skull shape, traumatisms to the head, masturbation, etc. As for the accidental causes of the

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disorder, certain psychical emotions may sometimes be implicated, such as anger, sorrow, etc. The specific course of the disease and its early development into dementia constitute the most characteristic traits which make it possible to distinguish hebephrenia from all other psychical disorders which may occur, whether at the time of puberty or any other age. The conceptions of authors who have most recently examined the question are highly contradictory; Kalbaum, in 1889, had proposed distinguishing from the hebephrenia group a particular form to which he gave the name heboid or heboidophrenia. Other than symptoms of a general nature, the peculiarities of the thinking process, the impairment of intellectual activity, heboidophrenia is distinguished by the predominance of disorders in the domain of the moral sense, such that at a superficial examination, patients produce the impression not of individuals suffering from a psychical disorder, but who are instead badly brought up and spoilt. This form ordinarily ends with recovery, and should therefore be distinguished from hebephrenia which leads eventually, after a relatively rapid evolution, to the collapse of brain activity. The description given by Daraszkiewicz of “a grave” form of hebephrenia also merits consideration; here, the dementia attains a much more pronounced degree than that described in the characteristic picture of the disorder presented by Hecker. The contradictions between the different observers principally relate to the following three points: lo To the question of the existence of hebephrenia as a disorder distinct from other pathological forms, with a genuine claim to autonomy. 2 O T o the relations of the said disorder with other morbid forms and views regarding pathogenesis. While some definitively place it in the group of degenerative forms, considering it to be a congenital form, where age merely plays the role of an incidental determinant, as the manifestation of seeds already pre-existing ab ovo; others link the

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genesis of the illness completely and entirely to the period of puberty, to the alterations which in that period occur throughout the whole economy; and recently in particular, it is the theory of self-intoxication by the substances produced in the genital glands which is increasingly gaining ground. 3 O To the description of the clinical picture of the disease: a whole series of cases which do not fit the framework of the typical and characteristic picture provided by KalbaumHecker, have made it necessary for ideas on juvenile dementia to be considerably expanded and with hebephrenia considered as a sub-variety of a more general group, definitively known by the name dementia praecox. At the present time, there is no further question as to the necessity of assigning a separate place to this pathological form, or rather to a whole group of disorders beginning in youth and leading rapidly to dementia; and since dementia develops by different paths, we can therefore establish a certain number of types of the said disorder: 1.-In certain cases, it is absolutely impossible to identify any acute stage of the disease; one simply observes a slow and gradual impairment of cerebral activity,. just as it is extremely difficult or even absolutely impossible precisely to establish the start of the condition. Little by little patients become distracted, forgetful, unable to work: sometimes, these phenomena develop in such a way as to culminate in a very marked deterioration; sometimes, they stop at a certain degree of moderate dementia, which nevertheless encompasses the whole sphere of psychical activity and is everywhere manifested by signs of weakness and deficiency. Thus, as regards the intellect, it is the weakness of judgement and intellectual deficiency which are the most marked; as regards psychical sentiments, it is their obtusion, the patient’s indifference to his surroundings; as regards the will, it is apathy, the absence of all interest and all energy. Sometimes it is possible to follow the symptoms of intellectual weakness and a lack of general equilibrium from

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youth; in other cases, by contrast, the disease develops in apparently gifted individuals of great promise. The process in question cannot be considered simply as arrested development, even when the dementia attains only a moderate level; in all these cases, sufferers become demented, more stupid than they were before, in other words they show phenomena of regressive development, which can in certain cases attain a very marked degree. Although sufferers can sometimes carry out menial tasks, requiring no particular effort, they are totally incapable of performing more demanding occupations. 11.-In other cases the evolution of the disease, having as its basis a general diminution of psychical activity, is accompanied, especially in the initial period, by extremely varied phenomena, of differing degrees of acuteness, and even of a violent nature, similar to general paralysis, where the fundamental characteristics of dementia may temporarily combine with various other phenomena. There may also be hypochondriac fears of a variable and vague nature, as well as marked delusional hypochondriac ideas with corresponding emotional disorders; there may be a tendency to mysticism, self-accusation (worries about imaginary offences), a vocation to enter a convent, disconnected and un-systematized ideas of persecution, ideas of grandeur with or without hallucinations, which often appear absurd from the start. Sometimes, it is the tendency to reason in a wholly puerile manner which predominates; at other times, the taste for naive and exaggerated discussion; sometimes, it is clearly obsession which is at work. Often, sufferers are subject to impulsions, for example, to attack, to create disorder, or to break windows. Their mood is often depressed, especially at the start of the disease; this depression is sometimes interspersed with bouts of excitement, imbecilic laughter, puerile acts; what is often striking from the start is the psychical obtusion, the apathy, the indifference. Notably deserving of attention is a very particular factor

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specific to the disease, one which is manifested by many of these patients, who give the impression that their disorder is of little matter, feigned; it is as if they give the impression of having let themselves go, and that with a little effort they could regain control of themselves. It is for this reason too that their reasoning, the peculiarities of their behavior are taken for deliberate childishness, and sufferers to be pretending or at least to be indulging deliberately in strange tricks. As for psychological particularities in the manifestations of the disease, this nuance specific to the disorder, and which occurs throughout the clinical picture, is intimately related by certain authors to the age of the patients, with reference to the similar particularities encountered in healthy subjects during puberty (Hecker); others explain them by the degenerative nature of the morbid process (Fink, Sterz), or else by the reciprocal effect between the biological phase and a serious predisposition (Krafft-Ebing); yet others find the explanation for the particular manifestations of the disorder in a disturbance to the principal regulator of the psychical functions, the attention (Ischisch, Daraszkiewicz). This latter view seems hard to accept, for that which constitutes the basis of dementia praecox is not an impairment in a specific domain, but a general dementia, a more or less uniform deterioration of every aspect of psychical activity, revealing itself equally in impaired judgement, in an obtusion of the feelings and a weakening of the will; evidently, the attention is also affected, but this should not be seen as the principal and fundamental cause of the whole pathological process. On the one hand, in many cases of dementia praecox there are no observable attention problems of any significance; on the other hand, these problems are encountered to a very marked degree in neurasthenia and other different disorders where the clinical picture is very different. A more probable view is that expressed by KrafftEbing, that a large part is played in this disorder by the particularities of the biological phase and those of an as yet

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unformed psychical life, linked to phenomena of psychical degeneration. It is likely that hebephrenia is simply a mode of emergence of the disease at the time of puberty, evolving on a terrain of serious predisposition. The different signs of the initial period of illness, the successively varied grouping of the symptoms in each specific case, the very wide variations in the condition of the sufferer, the aggravations which may occur not only at the beginning but also during the subsequent course of the disease, all these render the general physiognomy of dementia praecox very vague. That which constitutes the common element is, apart from age, a foundation of psychical weakness and an incurable state leading to an unfavorable outcome. From this form of dementiu praecox, taken as a type, a certain number of subvarieties can nevertheless be distinguished, although not clearly as they merge imperceptibly into each other across a host of transitory states. In certain cases, it is Hecker’s typical picture of hebephrenia in particular which dominates (hebephrenic form); in other cases, it is one or another set of motor phenomena, belonging to the complex of catatonic symptoms (catatonic form); in yet others, and at least during certain period of the disease, it is un-systematized but often rebellious delusional ideas (paranoid form). I believe it necessary, however, to emphasize again the fact that this distinction can only be fully established in a few very clear cases; but that which is most frequently observed is symptoms relating to different forms, whence the great difficulty of attaching the disorder to a given subvariety. In.-Finally, in a number of other cases, dementiapraecox may be seen as a secondary dementia, that is as an incurable terminal state of an acute psychical disorder, and principally subsequent to acute mental confusion (amentia, dementia

acuta). The clinical picture of the acute period of the disease in these cases gives no reference point for establishing an

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unfavorable prognosis and the process evolves in the same manner as in cases which conclude with recovery. Sometimes, an acute disorder of this type concludes with virtual recovery, leaving only an insignificant defect, often imperceptible at first sight; on this terrain, exacerbations of the condition or relapses will subsequently occur, which each time have the effect of further reducing psychical activity overall, and which thus give rise to a constantly progressing dementia. It is disorders which evolve in such a way that I propose to refer to as progressive (secondary) dementia. This type of dementia praecox is distinguished from its predecessors by the fact that the acute manifestations do not possess that particular nuance which is specific to the acute periods of the latter; here diagnosis is often possible only after the outcome of the disease. However, there exists no good reason to view these cases as completely distinct from dementia praecox, as the terminal state is frequently identical to typical hebephrenic dementia. The consecutive acute exacerbations which develop in progressive dementia in the form of attacks on a terrain of general psychical deterioration likewise often take a particular course, with symptoms which render them similar to the other forms of dementia praecox. As for the improvements which occur in progressive (secondary) dementia, they can clearly only be envisaged as remissions of a single pathological process; but the typical picture of the initial attack, together with the subsequent attacks of the same nature, although often with a few particular traits, lead us to conclude that they are also relapses, which each time leave deeper and deeper traces. It would be excessively important for the diagnosis of dementia praecox to possess reliable physical signs, but at present these are lacking. The exaggerated reflexes and pupillary inequality indicated by Kraepelin are far from

Contribution to the Study of Dementia Praecox

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being consistent signs; moreover, these phenomena are also often observed in severe forms of amentia and are a general indication of the gravity of the condition. The same is true of the different convulsive states which occur in the initial period. The muscular twitching, the mechanical excitability, which Bernstein considers an important sign for the diagnosis of dementia praecox, has also failed to live up to the hopes which had been placed in it. First, according to the observations of Bernstein himself, muscular twitching, during the period of puberty, constitutes a physiological phenomenon; in consequence, no conclusion may be drawn from its presence; next, observations show that, even at a more advanced age, it cannot be considered as a diagnostic sign. O n the one hand, it may be absent in dementia praecox; on the other, according to the observations of Soukhanoff and Gannouchkine, very marked muscular twitching is observed in the period following the period of puberty in more than half of cases and in the most diverse forms of psychical disorder. Neither the presence nor the absence of muscular twitching, therefore, is pathognomic for any specific pathological form. Thus, for the present, the diagnosis of dementia praecox can only be based on the age of the individual, the particular evolution of the disease, and the few particularities in its manifestations, where these exist (such as hebephrenic and catatonic symptoms); also, on the fact that the disorder often bears from the start the signs of future dementia; and finally and principally on the unfavorable outcome. At the beginning of the disease, diagnosis is easy when there exists a gradual and slow reduction in cerebral activity, i.e. when it is the first type. Dementia praecox is distinguished from states of neurasthenia and overstrain, with which it is often confused, by a more or less uniform and gradual impairment of psychical activity as a whole. Likewise, diagnosis presents no difficulty where the typical picture of hebephrenia is present or in those catatonic and paranoid forms where the phenomena of psychical impairment are marked from

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the beginning. But in other cases, differential diagnosis is required with amentia, periodic psychoses, attacks of delusion in degenerates; it is often excessively difficult and sometimes not possible without long observation of the patient, on the basis of the outcome of the disease. As for diagnosis of the terminal period, this is only difficult for secondary dementia, particularly as, in this latter case too, oddities are quite often observed in the patient’s behavior, repeated gestures and mannerisms, stereotypical movements and poses, as well as a whole series of other symptoms which are considered by some authors as characteristic of dementia praecox. In this case again the differential diagnosis is based, on the one hand, on the age of onset of the disease, and on the other, on the whole course and character of the acute period. There is not the slightest reason to associate with dementia praecox cases where the disorder begins at a more advanced age, after psychical individuality has already formed and the acute period has evolved, following the empirical period characteristic of any one of the acute fundamental forms, even if the disorder evolves into dementia. The terminal states of these types of disorder should be attached entirely, not to dementia praecox, but to secondary dementia; and it may even be wondered if cases of type I11 dementia praecox, where the acute symptoms fit easily into the framework of some typical clinical picture, should not also be related to this secondary dementia group. This is, in fact, merely a dispute about terminology, for in these cases the secondary dementia entirely corresponds to the conception of dementia praecox, given that it presents the latter’s fundamental trait, i.e. the development of an incurable state before the organism has had time to form. Evidently, this latter condition should be closely associated with the fact that the terminal states in these cases often present a large number of traits characteristic of typical hebephrenic dementia. However, I perfectly accept that other psychoses may arise during adolescence, and develop into

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dementia. Later, we will be able to distinguish them from dementia praecox; in the current state of knowledge, we are unable to do this, as we possess not a single sign which would allow us to establish a differential diagnosis between secondary dementia of adolescence and dementia praecox. The pathological anatomy of dementia praecox is still unknown. We can only assume that at the basis of dementia lie anatomical deteriorations which are yet to be discovered. The theory of self-intoxication as the determining cause is very attractive, but for the moment it is far from solidly grounded. As for the theory of self-intoxication by sexual products in particular, it is purely hypothetical and based on not the slightest positive evidence. According to Kraepelin, the factors in its favor are: firstly, the close relation between the disorder and the period of puberty, menstrual problems, the act of childbirth; and secondly, the absence of any external determining cause. These considerations do not stand up to criticism, for the simple fact that the same reasoning could be invoked as regards the determining causes of a large number of pathological forms (amentia, periodic psychoses), where on the one hand the evolution of the disease is closely linked with genital processes, and, on the other, there is likewise a lack of outside determining causes. Should dementia praecox be brought back into the framework of the degenerative psychoses or not? The question remains to be resolved. It is incontestable that, in a large number of cases, hereditary predisposition plays a major role. Very often, a more or less pronounced psychical weakness, the lack of general equilibrium and other abnormalities which had existed in these subjects since early childhood, oblige us to consider dementia praecox as a psychosis which is not only degenerative but also original, fatally linked to the individual’s abnormal constitution ab ovo. Perhaps the period of puberty simply strikes the final blow in the development of the disorder, given that this

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period demands an increasingly high degree of activity from an insufficiently developed organism. Treatment will remain ineffective as long as the fundamental etiological conditions are not known. For the future, a certain degree of hope may be founded on serotherapy and opotherapy. However, even today, intelligent intervention can be useful and, at least in certain cases, halt the progressive deterioration of the individual. From this point of view, it is the general way of life which is most important, and above all well regulated occupations, mechanical and other tasks appropriate to the patient’s strength. It is for that very reason that, for these patients, confinement in asylums where there exists no systematic organization of work may often essentially be harmful and lead to a rapid deterioration of psychical activity. O n the other hand, either within the family if the conditions there are right, or in well-organized clubs or groups, they can be made to achieve quite good results through rational activity. In this respect, it is essential to take note of the fact reported by several authors (Neisser, Professor Korsakoff), that long periods confined to bed are harmful to these patients and should only be prescribed at periods of acute aggravation and disturbance; as soon as these phenomena disappear, the aim should be to develop and fortify the active side of their psychical life.

Gaetan Gatian de Clirambault (1872-1934)

It might be said of Clkrambault that he is both one of the last representatives of alienism founded on clinical practice of alienation, and one of the first of modern psychiatry based on the identification of psychopathological structures underlying this clinical practice. Gaetan Gatian de ClCrambault was the descendant of a family of the minor provincial nobility which claimed several illustrious ancestors: Descartes (1596-1650), Louvois (1641-1691), Alfred de Vigny (1797-1863). With a gift for drawing, he attended the School of Decorative Arts and then, in keeping with family tradition, went on to study law. However, he was attracted to medicine and quickly moved into psychiatry. Appointed as a medical resident to the asylums in 1898, he was to spend almost his entire career at the Special Infirmary [the Infirmerie] of the Paris Police Prefecture, where the first chief physician had been Laskgne". Successively deputy (1905), then chief physician (1921), he would retain his position at the Pointed Tower, as the institution was called in Paris slang, being accessed via the Conciergerie prison of the Palace of Justice in the island of the City, where it was located at the time, a construction surrounded by medieval towers. (It was in the Conciergerie prison that Queen MarieAntoinette [1755-17931was incarcerated and condemned during the Terror by the Revolutionary Tribunal). This place would provide a privileged forum for the

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observation of a very large number of patients with the legal obligation of describing their disorders in a certificate, which established whether or not the subjects under examination needed to be confined in an asylum. It has been remarked that this art, of which Clkrambault was a past master, involved an instantaneous, photographic clinical analysis, in which phenomena were approached diachronically, without regard for synchronic aspects. It appears that Clkrambault, who had the opportunity to see certain patients again during subsequent admissions to the Infirmerie, would ask his asylum colleagues for news of confined patients. His career at the Infirmerie was interrupted by the Great War during which ClCrambault performed brilliantly as a doctor in a front-line fighting unit, no doubt recalling his intellectual soldier ancestors. Seriously wounded and decorated, at the end of the war he was assigned to a French military hospital in Morocco, which had been a Protectorate since 1912. There, ClCrambault discovered traditional Morocco garments and began his ethnographic and artistic research on drapery, accumulating the plates of his long forgotten photographic work, the artistic and ethnographic value of which has recently been rediscovered. ClCrambault added Arabic to the languages he already spoke. His work at the Infirmerie was to make Clkrambault a teacher, the Master of t h e Pointed Tower. His clinical lessons attracted a large audience of doctors, but also of non-doctors, which caused trouble, just as Charcot’s lessons at the Salpttrih-e had previously done. In this way, outside the teaching of the Faculty and in rivalry with it-and perhaps all the more attractive for that-he developed what amounted to a school of thought which strongly marked his pupils, and notably one of them, Jacques Lacan (19011981). Clkrambault would quarrel with the latter who had taken the initiative of publishing, without first informing the master, an article in the review La Semaine des H6pitaux expounding his ideas on paranoia. Lacan did not include this article when his own Writtngs (1966) were published, while naming Clkrambault as his sole teacher in psychiatry. Between 1902 and 1935 (posthumous), ClCrambault published 140 papers to learned societies or to conferences on a wide variety of subjects, with the intention of one day combining these texts

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into a single work giving an overview of his perceptions. The circumstances of his death deprived him of this opportunity. In pqrallel with his scientific work, Clkrambault gave a course at the Ecole des beaux-arts on the history of drapery from Antiquity (for this purpose, he used the Graeco-Roman statuary in the Louvre) through to the traditional Mediterranean garments recorded in his photographic collection. He also published articles or notes in ethnographic reviews. In November 1934, Clkrambault committed suicide using the officer’s army revolver which he had kept. The will he wrote to explain his act suggests an episode of melancholia: he considered himself dishonoured by the suspicion that the painting which he wished to leave to the Louvre has been fraudulently acquired in a sale. (The piece was the Sur L’Euu by the Impressionist painter Gustave Caillebotte [ 184848941). Clkrambault left to the Muske de 1’Homme at the Trocadkro the 4,000 photographs he had taken. One might imagine that this attack of melancholia had been triggered by the failure of a cataract operation and the imminent prospect of blindness, a calamity for this artist of the clinical and photographic gaze. Clkrambault’s last text, published posthumously under the title “Memories of a physician undergoing a cataract operation” (1935), is the observation of his own gradual loss of sight. The suicide of one of Paris’ most prestigious psychiatrists triggered the publication of a series of articles representing Clkrambault as a sort of Dr Caligari, especially as a press campaign had previously criticised the operation of the Infirmerie, although its target was more the Prefect of Police that the chief physician.. In 1942, one of Clkrambault’s last students, Jean Frktet, collected his texts into a volume entitled “Psychiatric Work” with a preface by Paul Guiraud*, which thus contained only those relating to our discipline. Of the seven parts which form the work, the most important are: -the first: “Collective delusions and associations of the insane” (Lashgue’s “shared delusion”); -the second: “Toxic psychoses and mental disorders of chronic intoxication (alcohol, chloral and ether)”; -the fourth: “Passionate psychoses”, notably with a description of erotomania with which Clkrambault gives a new meaning to that long-standing term of psychiatric language;

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-and finally the fifth: “Mental automatism”. It is this latter, “Clkrambault’s syndrome”, which in recent decades has given rise to the greatest number of studies, with the Russian school comparing it with Victor Kandinski’s (1849-1899) pseudo-hallucinations (1843) and the Heidelberg school with Kurt Schneider’s (1887-1967) so-called first-rank symptoms. Clkrambault’s doctrine with regard to mental automatism-since it could evidently not apply to passionate psychoses-was presented as arising out of the strictest medical organicism, in the opinion of Ey“, developing a mechanistic and linear conception of mental pathology. However, the account of it that he gave using the neuro-physiological terminology of his time can be read as an attempt at an early phenomenological description of disorganisation in space, of the spatiality of psychotic thought, like the description of the temporality of such thought put forward by Eugkne Minkowski“‘ at the same time, a comparison which the latter himself made in homage to Monsieur de Clkrambault. In recent years there has been growing interest in Gatian de Clkrambault’s biography, which even inspired Yves Marciano to produce, in a re-worked form, a film called Le Cri de La soie [The Cry of Silk ] (1996), an interest which extends to his non-psychiatric, photographic and ethnographic work, with several exhibitions since 1990. Denis P. Morozov

Principal works GATIAN DE CLERAMBAULT (G.), called G.-G. de ClCrambault, CEuvre psychiatrique r h i e et pubLike par Jean Frktet [Psychiatric work collected and published by Jean Frktet], Paris, P.U.F., 1942. Reprint under the title CEuvres psychiutriques [Psychiatric Works], Paris, Frknksie, 1970. “Lettre de Monsieur de ClCrambault il’occasion de la discussion sur l’automatisme mental” [Letter by Monsieur de ClCrambault on the occasion of the discussion on mental automatism], L’Enc+hale, June 1927, p. 574-576.

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CLhAMBAULT (G.-G.) de, Passion krotique des ktofis chez la femme [Female erotic passion for fabrics], Le Plessis-Robinson, Les Empecheurs de penser en rond, 1991. CLERAMBAULT (G.-G.) de, L ’Automatismemental [Mental automatism], Le Plessis-Robinson, Les Empikheurs de penser en rond, 1992. Bibliographical references LACAN (J.), Structure des psychoses parunohques [Structure of the paranoid psychoses], Sem. h6pp.,July 1931, p. 437-445. GUIRAUD (P.), Pryace A Z’CEuvrepsychiatrique[Preface to the Psychiatric Works], 1942. TISSERON (S.) ed., Gaetan Gatian de CZkrambauZt, psychiatre et photogruphe [Gaetan Gatian de Clkrambault, psychiatrist and photographer] (reproduction of 160 photographs), Le PlessisRobinson, Les Emp&cheursde penser en rond, 1990. RUBENS (A.), G.-G. de CZhumbuuZt. 1872-2934.Le muitre des insends [G.-G. de Clkrambault. 1872-1934. Master of the insane], Le Plessis-Robinson, Les Empicheurs de penser en rond, 1998.

Passionate Delusions; Erotomania. Claiming. Jealousy

PATIENT DESCRIPTION. 1921

Dr de C.. .precedes his description with a theoretical lecture of which we give here only a summary. The full lecture will appear very shortly in the Annales mkdico-psychologiques.

I.-Erotomaniac delusion is a morbid passionate syndrome. It is not an interpretative delusion. There is a case for linking this syndrome with the delusions of claiming and the delusions of jealousy, under the heading morbid passionate delusions. The basis of the interpretative delusions is their paranoiac character, in other words a sentiment of mistrust. They expand in every direction; the subject’s whole personality is involved; the subject is not stimulated; the concepts are multiple, changing and progressive; they extend by circular radiation; the early stage cannot be identified, etc. Passionate syndromes are characterised by their pathogenesis, by their components which may be either common or specific, their ideative mechanisms, their polarised scope, their hyperaesthenia which may sometimes attain an appearance of hypomania, the initial involvement of volition, the notion of a goal, the single controlling concept, the vehemence, the instantaneous

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nature and completeness of the conceptions, a common conviction of right, etc. Morbid passionate syndromes are sometimes autonomous and pure, sometimes combined with other delusions (intellectual or hallucinatory). In this case, they are either prodromal or supplemental. Generally, they lose intensity as they lose purity. Erotomaniac delusion develops in three stages: a stage of hope, a stage of pique, a stage of rancour. The conceptions of erotomaniac delusion are grouped on the one side into an initial postulate and deductions from this postulate (all facts relating to the object), and, on the other side, into various imaginative and interpretative themes (facts relating to the events of the chase). Amongst these conceptions, there are some which are specific. These have great importance for guiding the questioning process, initially as goals, subsequently as elements of conviction for the physician. The things to look for are not specially the facts (which the patient can always deny), but rather the patient’s points of view; now these points of view are contained in the specific formulae. In interrogating such patients, it is not sufficient to question them, they must be activated. In particular, one must remember to bring into play the element of Hope in the erotomaniac syndrome. If this is not done, many erotomaniacs continue to be classified as persecuted-persecutors, when they should be classified as amorous persecutors. 11.-The components of the feeling which generates the postulate are Pride, Desire and Hope. The evolution and reactions depend, very largely, on individual character, the degree of morality, education. The conceptions that we consider to be specific are as follows. Fundamental postulate: It is the Obect who began it and who loves the most or is the only one to love. (N.B.: Object usually of high birth, classic notion.) Derived themes considered as obvious:

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The Object cannot achieve happiness without the suitor. The Object cannot achieve full value without the suitor. The Object is free. His marriage is invalid. Derived themes which can be demonstrated:

Continuous vigilance of the Object. Continuous protection of the Object. Approach measures by the Object. Indirect conversations with the Object. Phenomenal resources available to the Object. Almost universal sympathy aroused by the romance in progress. Paradoxical and contradictory behaviour of the Object. These formulae rarely occur all together. The last one (paradoxical behaviour) is of capital importance. It is never absent. It gives rise to accommodations with the facts, of the following kind: the Object is assumed to hesitate out of pride, timidity, doubt, jealousy, or else fundamental inability to act; a mysterious friend dominates him to an improbable degree; or else, he wants to test the subject, etc. All these conceptions relate to the behaviour of the Object. Ideas of persecution develop subsequently, with regard to the events of the chase. They are not diffuse, but now strictly grouped around the idea of the pursuit. The only goal of the persecutions is separation from the Object; or else they originate from the Object himself. At the pique and rancour stages the subject, impatient and humiliated, believes herself to hate the object, in accordance with a psychological reversal of a general nature. Grievances which, at the beginning, were hypocritical become sincere, the subject becomes demanding. At this point she brings up old injuries, which are largely fictional, and recent injuries, which are real but attributable to her alone.-The unconscious hope persists. If these secondary themes of persecution develop and if the delusion tends to become diffused, this suggests that the erotomaniac delusion is not pure but combined. A form of radiating expansion, culminating in an ordinary set of

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persecutions, shows that the erotomania is either prodromal, or secondary. In pure cases, no global and absurd megalomaniac conceptions. No retrospection. Never hallucinations. The above-mentioned specific conceptions differentiate erotomaniac delusion from so-called normal passion.

Observation.-Admission Certtficate

D. . .Liontine, age 28, waitress.-Erotomania. Pique Stage.-Secondary interpretations of both favourable and hostile nature.-A captain under whose orders she has worked wants to marry her and yet persecutes her.-Innumerable collaborations. Manifestations. Machinations.-Letters both accusing and affectionate. Measures for reproaches and implicit declarations. Expectations. Insults and threats to the Captain’s wife.-Refusal to believe he is married. Exaggeration of the Personality.-Lively and expansive presentation to a degree unusual in this form of delusion.-Possibility of a Polymorphous Delusion in its early stages. Dr de Clkrambault (Infirmerie spiciale), 1st February 1921. Information At the Infirmerie spiciale, the patient easily agreed that her persecutor began with matrimonial desires, and affirmed his paradoxical behaviour. On the other hand, she absolutely denied that she felt or had felt the slightest fancy for him. However: 1’ she maintained that he was not married; 2’ she admitted the possibility of forgiveness.-Gradually, she admitted that she would marry him, if he was prepared to change his behaviour (specific formulae). Confronted with this Persecutor, she reproaches him for keeping silent. Questioned on this point “would she like to

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marry him”, she denies it, but appears radiant, then objects only that she would have to study his character before saying yes, and that anyway it is not for the woman to take the first step. Would she like to become his mistress? Certainly not. However, we object, one cannot get to know a man without having lived with him. By a series of graduated replies, which would take too long to report, she accepts the idea of a trial marriage, which would only be legalised later. Tomorrow, they would look for accommodation and furniture.-She leaves vexed by the officer’s silence, but in her cell she writes, when asked anew, a letter in which she repeats that tomorrow he and she would go in search of accommodation to live in during their trial period. The Ideas of Persecutions are polarised. The fact that she changes her tasks, that musicians come and play in the restaurants, that she quarrels with her family, is due to the influence of the officer, until now. However, the Delusion of Persecution seems to be showing a tendency to diffuse, which would separate it from the Pure Erotomaniac Type. At Sainte-Anne, the day of the session of the S . C. M. M., we find her a little surly, very annoyed by her internment, for which she holds the officer solely responsible, very irritated at being questioned incessantly. She calls the officer rude names.

Presentation At the session of the Sociktk clinique she is cheerful, but speaks little. She says that the officer loved her although she had no interest in him; she only learned of this officer’s love from what her companions said. Far from loving him, she felt for him something of an aversion, finding him to have a proud and cold air, and his blue eyes, which all the women talked about, had an unpleasant effect on her. She insists that he had never revealed his love to her either by

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speech or look. When asked if she agrees to marry him, she makes no objection to the principle, and uses delaying tactics alone: the officer should have said something, his behaviour is strange for a man who claims to be in love, etc. When we speak of intervening, she appears to refuse, but on leaving, when we repeat our offer, she offers us a joyful t hank-you. During the discussion, she repeated in various forms the paradoxical behaviour, the rejection of marriage and the admission of being ready to forgive.

COMMENTARY The presenter would point out that the officer manifestly made a profound impression on the patient, from the first day, and that the passion arose in her before any interpretation. The patient only believed she had heard talk about her and the officer because she was thinking of him intensely. Moreover, she does not seem to have interpreted in her favour any look or gesture by the officer, at least at the beginning. In fact, her passion was spontaneous, and the interpretation only came later. The interpretations followed the direction of her desires, a normal state of affairs. The opposite would be unacceptable. The patient attempted to come closer to the Object under false pretences (changes of task, reminder of an old or even doubtful accident, etc.). She denies that the officer is married. She declares his behaviour contradictory, paradoxical. When asked appropriately, she says she is ready to forgive. All this is standard in such cases. The patient is still at the piqued stage; she still consciously retains hope. Although reticent, she appears to be slightly hypomaniac; that again is a common trait. The presenter wonders whether this case will remain indefinitely one of essential erotomania. Indeed, the behaviour of the patient, despite her reticence, is expansive

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sometimes to excess, there seems to be a tendency for the ideas of persecution to become diffuse; finally, she is clearly a defective. For all these reasons, we are perhaps in the early stages of a gradually extending polymorphous delusion, in which case this patient’s erotomania is simply prodromal.

DISCUSSION An affective substrate can be observed in every variety of mental forms, manic or melancholy delusions, obsessions and phobias, sexual abnormalities, and delusion of persecution; it is even found at the origin of spasms and tics. It is therefore not sufficient to mention the affective element, it must also be defined and its intensity measured. The delusion of the paranoiac accords with his character. Character is, roughly speaking, the sum of all the minor daily emotions, formed into habit, the quality of which is established for the whole of life and the quantity more or less established for each day. In the passionate personality, by contrast, an initial ideo-affective node occurs, in which the affective element is made up of a strong, profound emotion, which lasts indefinitely, and claims all the powers of the spirit from the very beginning. The paranoiac’s feeling of distrust is longstanding, the start of the delusion cannot be identified in the past; the passion of the erotomaniac or of the claimant has a precise starting date. The paranoiac’s distrust controls the entire ego’s relations with the environment as a whole, and changes his conception of his ego; the passion of the erotomaniac and of the claimant do not alter their conception of themselves, and only alter their relations with the environment on the occasion and in the domain of their passion. From these different departure points result profound differences in the general tonus of the psyche and in the scope of the delusion. The passionate personality, either erotomaniac, or

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claiming, or even jealous, has a specific goal from the start of his delusion, his delusion immediately brings his will into play, and that precisely is a differential trait: the interpretative delusive lives in a state of expectation, the passionate delusive lives in a state of effort. The interpretative delusive wanders amidst mystery, anxious, amazed and passive, reasoning about everything he observes and seeking explanations which he only gradually discovers; the passionate delusive moves towards a goal, with a conscious requirement, complete from the start, and is deluded only in the domain of his desire: his thoughts are polarised, as is his will, and because of his will. The mode of extension of the delusion will therefore be special. As all imaginative or interpretative work is restricted, so to speak, to the space which lies between the object and the subject, conceptions will be developed not in circles, but in sectors; although the views will enlarge with time, they do so within the same sector, in which the angle of aperture does not change. By contrast with this process, in the interpreter, the conceptions constantly radiate in every direction, using every event and every object; moreover, in some patients, the themes gradually change; their extension is radiative, the subject lives in the centre of an infinite circular network. The conclusion of such an effort, for the subject, is that his entire personality is either threatened or exalted; he is surrounded by a general conspiracy, or else he is king and master of the worlds. Leroy, on one hand, and also SCrieux and Capgras have noted with regard to claimants the absence of absurd megalomania and of transformation of the environment. The interpreter often has a retrospective view, looks for explanations in the past; this is because, by contrast with the passionate personality, who is in a hurry, the interpretative is at leisure; the passionate personality, being essentially driven by will, tends towards the future. The first and principal convictions of the erotomaniac

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are obtained by deduction from the postulate. Nothing similar is observed in the interpreter. In him one sees no parent-idea from which chains of ideas might emerge; his ideas start from every point, so to speak, of his mind; certainly, they are coordinated but there is no hierarchy between them, and above all no single dominant idea. Remove from an interpreter’s delusion some particular conception which seems to you the most important, remove even a large number, and you will pierce a network, not break the chains; the network will survive in all its immensity and other links will spontaneously form. O n the other hand, remove in the passionate subject’s delusion the single idea which I have called the postulate, and the whole delusion collapses. Such delusion is similar to Prince Rupert’s drop, which disappears if you simply break the tip. Once the delusion has gone, the subject’s only option will be to create another one, when he is ready for another attack of passion. It is true, such an experiment is impossible in the case of the erotomaniac; it would be less so in the case of the claimant; it is sometimes achieved in cases of jealous delusion by the departure or death of the supposed rival. The delusion ceases sometimes for a considerable period, but is reborn because its source is not solely in the Passion, but also, very largely, as we have said, in character. None of the convictions of the interpretative subject can be said to be the equivalent of the postulate. He has no controlling idea. The nature of the postulate is that it is primary, fundamental, generative. The interpretative personality’s explanatory convictions are secondary to innumerable interpretations. In such delusions, there is no parent-cell. It is not true to say that the interpretative has a prevalent idea, unless the term is deprived of its meaning of original idea, and is assigned a very broad symptomatic meaning, as is given to the word obsession in lay language, where it is used to signify a recurring idea. In that case, however, it is not a single, but several prevalent ideas which we find in the interpreter. German psychiatry extends this

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term prevalence both to the interpretative delusions and to what we call the delusions of passion, to the obsessions and phobias, and finally to melancholy ideas; this is only correct from a semiological point of view, i.e. if one ignores the mechanisms of the delusion. The term prevalent idea, taken in its restricted sense, only applies to the passionate subject. Even then, it is inadequate because in ideo-affective disorder, it seems to place the emphasis on the ideative adamant (although we acknowledge that this is not the intention of the authors). Furthermore, it does not bring out the logical, embryo status which we attribute to the Postulate. We have therefore avoided this word. In the ideo-effective node which constitutes the postulate, it is clear that, of the two elements, the earliest one is the passion. In our case, the patient states that nothing in the looks, in the attitude, in the words of her Object, suggested that she was loved; she only found out, she claims, through the words of her companions. If such words did exist, they would not have been sufficient to create the state of passion. In addition, our patient shows to what degree she was haunted, from the first day, by the fascinating regard of her Object; finally, if there was mystification on the part of her companions, it was precisely because of the penchant they had remarked in her. The passionate mechanism of erotomania explains why it appears so frequently in hypomaniac form. The erotomaniac is an excitable personality who has been stimulated, as is the claimant, in whom this trait has been noted by Leroy, Capgras and SCrieux. It might also be said, in the light of the notion of a goal which is dominant from the beginning, that the erotomaniac, from prior to the phase of pique, is already a claimant, but a benevolent one. SCrieux and Capgras have already made the distinction between claimants and interpretatives. We have adopted all their differential criteria, but we have added the notion that they all proceed from a single fact: the pathogenesis of passion. The initial awakening, the single and immediately

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conscious objective, the neglect of all interests other than those of passion, are all passionate traits; from this derives the restriction, which we consider typical, of the ideas of persecution and grandeur to the interests of that passion alone, and the habitual absence, noted by the authors, of enormity in the end conceptions. It is true that passionate delusions are highly interpretative; however, interpretation is a consistent aspect of emotional states, and in passionate delusions it is, in both senses of the word, secondary; and if it does take on some importance, it grows in limited constellations, not in a network. The cases where interpretation becomes truly invasive are mixed cases. The mutual combination of intellectual forms (interpretation, claiming, erotomania, jealousy) is a common event, but the study of the pure cases obliges us to attribute to each factor only that which derives from it. Passionate syndromes may also combine with hallucinatory delusions, with or without dementia. These again are mixed cases, which help us judge the previous ones correctly. These syndromes are psychological, we should therefore expect to see them function incidentally on the most varied terrains. As soon as they appear, their arrival is marked by the introduction of a volitional element which, until now, was absent. This is a mark of passion. All the differential criteria between interpretative delusion and claiming delusion, so well described in the book by Skrieux and Capgras, are also valid in the comparison between interpretative delusion and erotomaniac delusion. If our dialectic were not to be accepted, theirs too would be in danger. We continue to believe that the formulae we have given as specific are indeed so. They make it possible to make the distinction from so-called normal passion and from nonamorous persecuted-persecutors. Indeed, no normal and unrequited victims of passion nourish our postulate, that of being loved more than loving,

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or claim to know the true thoughts of the Object better than that Object; they will not say that the conduct of the Object is entirely paradoxical (for example, that the Object smiles while sending them to prison), nor that a whole host of people is interested in their romance. Nor would such persons deny that the Object is married. All their efforts, if effort there is, begins from the idea that they can make themselves loved, a view totally the reverse of the Postulate. These formulae also differentiate the erotomaniac who has become a persecutor from the non-amorous persecutedpersecutor. No persecuted-persecutor ever expresses the idea of totally paradoxical conduct in his enemy, and that is because their is no reason to think such a thing; dual behaviour would suggest dual feeling, and what would be the second feeling in the ordinary enemy of the persecutedpersecutor? True, the latter might say incidentally, with regard to some particular action of his enemy, that this action is simply an act: war, for example, for certain persecutors is seen as an act performed for their benefit, but would this assessment be applied to the imaginary enemy’s entire behaviour? Perhaps it is a patient without megalomania and without feeble-mindedness? O r a patient in the position of a persecuted-persecutor and at the age of erotomania, pursuing an object of the other sex? That is the crux of the matter. A clinical formula is only as good as its conditions of presentation. This is true for the typical formulae of ordinary persecuted subjects and melancholics, to whom we alluded. Moreover, it is generally recognised that a diagnosis cannot be reached on the basis of a single sign. Every sign can present a source of error. O u r formulae are only specific insofar as a clinical sign can be; and if very different cases present identical formulae, that would be an interesting curiosity, but would not prevent these formulae being of great assistance in the quest for a diagnosis, and of establishing conviction in the event of supporting data being found.

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Furthermore, even if we are wrong, one thing remains.

The full picture of erotomania exists nowhere. The various sources contain only descriptions without method which do not identify the constants, and which provide no kind of plan nor criteria for the questioning process. These constants, these criteria and the model for such a plan remain entirely to be formulated. We have tried to do this, because cases of erotomania come through our practice in large numbers.

Maurice Dide (1873-1944) and Paul Guiraud (1882-1972)

The name Guiraud is closely linked in the minds of French doctors with that of Maurice Dide (1875-1944). The “Psychiatry of the practising doctor” (1922) which they published together provided several generations of practitioners with an introduction to the study of mental medicine. Having finished his medical studies in Montpellier, Guiraud completed his psychiatric training in Paris. During the First World War he deputised as physician in charge at the Toulouse asylum for the man who would become his friend, Dide, who had been mobilised. It was on the latter’s return that they wrote the “Dide and Guiraud”. The two then went their separate ways, with Guiraud pursuing his career in the Paris region, notably in the Villejuif asylum, today the Paul Guiraud Hospital, then at the Sainte Anne hospital where he worked from 1933 to 1952, while Dide remained in Toulouse until his retirement there before the Second World War. During the latter, Dide, despite his age, played an active part in the organisation of the Resistance in southwest France. In 1943 he was arrested by the German police and deported to Buchenwald where he died on 26 March 1944 from wounds inflicted by his executioners. Maurice Dide and Paul Guiraud were part of that generation of psychiatrists marked by the similarity of symptoms between the psychical sequelae observed in the survivors of the Von

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Economo epidemic of lethargic encephalitis between 1917 and 1920 and the manifestations of the hebephrenic forms of dementia praecox. Thus, although they accepted with a degree of reluctance Bleuler’s and Freud’s notion of schizophrenic psychosis-since it was clear to them that it was the former’s application of the latter’s ideas to Kraepelin’s dementia praecox which led German language psychiatry to make this broad grouping-they opposed the inclusion of hebephrenia or dementia praecox proper in the same group. From a neurobiological point of view, they saw the loss of dynamism of the instinctive life, the thymhormia (from the Greek Bupo~,heart, feeling, and oppq, movement, momentum) due to an impairment of the basic encephalic structures, as the primary cause of hebephrenia stricto sensu. Guiraud, on his own after the Second World War, developed the conception which Henri Ey“ in his “General Psychiatry” (1950) described as neurobiological monism. In the same year, he was one of the speakers on the psychopathology of delusions at the first World Psychiatry Congress in Paris. In 1956, under the title “Clinical Psychiatry”, Guiraud published a reworked edition of the volume published with Dide more than thirty years before, without changing his ideas on hebephrenia. It is interesting to see that the notion of athymhormia has since been used to explain the paradoxical action of certain neuroleptics on so-called deficient forms of schizophrenia. Likewise, in neuropsychology, a modification in the affectiveemotional life similar to athymhormia has been linked, by means of modern medical imaging, to lesions in the neuronal circuits precisely involving cerebral structures which Guiraud, on the basis of histological criteria, believed to be damaged in hebephrenia. Jean Garrabk

Principal works DIDE (M.) and GUIRAUD (P.), Psychiatrie du rn6decin praticien [Psychiatry of the practising doctor], Paris, Masson, 1926.

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GUIRAUD (P.), Psychiutrie gbnirale [General psychiatry], Paris, Le Franqois, 1950. GUIRAUD (P.), Psychoputhologie des ddires [Psychopathology of the delusions], Reports of the International Psychiatry Congress, Paris, Hermann, 1950. GUIRAUD (P.), Psychiutrie clinique [Clinical Psychiatry], Paris, Le Franqois, 1956.

Bibliographical references "Colloque Dide et Guiraud", [Dide and Giraud colloquium], L h o l k o n psycbzutriqm, 1993, 0ct.-Dec. 58 (4), p. 649-701. HABIB (M.), Neurologie des bmotions et des motivations [Neurology of the emotions and the motivations], Reports to the 96th Congress of French language Psychiatry and Neurology, RCunion, 1998.

Clinical Psychiatry (1956) Chapter IV Hebephrenic Syndrome

In contemporary psychiatry, hebephrenic syndrome, as

I define it, constitutes a part of Bleuler’s schizophrenia; there it corresponds fairly exactly to the syndrome described by Kraepelin under the name dementia praecox, after he had separated the paraphrenias from it in 1912. But this term dementia praecox, a source of interminable discussion on “dementia” and the incurability of the syndrome, should not be retained. I prefer to choose a neutral name which simply indicates that it is a juvenile syndrome.

A. DIRECT SYMPTOMS While in maniac syndrome there is more or less general agreement on the fundamental symptoms, which are also the direct symptoms, in hebephrenic syndrome, there remains room for discussion first on the fundamental clinical symptoms and then on the symptoms which originate directly in the cerebral process which is the source of the disorder. The view advanced with Dide since our first edition is that hebephrenic syndrome “is characterised by a primary and premature softening of the instinctive sou1~e5

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of mental Zije, originating directly in the activity of the central encephalitic region, the seat of the primitive psyche. That is why we have proposed the term juvenile athymhormia, from Bupos (mind) and oppao (thrust). This conception and description overlaps with V. Monakow’s biological conception on Home and with the psychological conceptions of Jung, Berze and Kretschmer who describe the disorder by reference to “damage to the sources of vitality” or a “primary deficiency of psychic activity” or finally a “loss of vitality”. My intention is to look at the question in terms of pathogenesis; here, this point of view simply serves to structure the clinical description. The direct symptoms, that is those which result from a malfunction of the central encephalitic region, are as follows.

a) Anhormia.-This is the weakening of the primary psychic vital dynamism in the instinctive domain. The proclivities towards nutrition, sexuality, defence, social activity lack vigouy, while at this period of life they should be at their highest degree of activity. Sometimes the damage to the eating instinct is expressed directly by the absence of need for food and a refusal to eat. Usually this instinct survives in the form of an elementary biological activity, passively accepting what it is given without the active propensity to seek for food.

b) Athymia.-Specific feeling-described in the semiology by the name thyme and affect, which is nothing other than the subjective aspect of vital horme in all its multiple nuances-also lacks vigour. That is not to say that thymic elements are completely absent, but they do not follow their normal progressive course; often affect remains at a passive and infantile stage instead of evolving towards an active affect, bearing the full stamp of individuality.

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c) Inertia.-The lack of vigour in vital activity is characteristic. There is an absence of general motor initiative, of spontaneity in effort, of sustained effort, a constant need for stimulation, difficulty in substituting one form of activity for another, inability to use the motor reflexes in sequence in order to enact the instinctive tendencies. d) Non-integration o r disintegration of the Ego.-In 1930, Bleuler, rectifying his picture of the primary symptoms, stated that the most primitive authentically schizophrenic symptom is an elementary weakening of the synergy (Zusarnrnenarbeit) of the functions which integrate into a whole both the different instinctive tendencies and intellectual activity in the strict sense. In my opinion, this aspect, which I am highlighting because of its clinical and nosographical importance, is not a genuine direct symptom but a consequence of the global anhormia of the instincts. Indeed this anhormia, which is observable for each specific instinct, is sufficient to explain their inability to integrate into a vigorous and stable Ego. I attach great nosographical significance to the global damage to the dynamism of the psyche and to the disintegration of the Ego. I shall differentiate hebephrenic syndromes from delusional syndromes by the presence or absence of this global damage, although there exist transitional forms between them. e) Damage to the subcortical motor centres.-I consider this damage to be direct in the sense that the neurophysiological abnormality can affect not only the reticular region where all the nerves of the organism converge, but also the organisation of motor and psychical regulation (muscular tonus, centres of initiating functions, of iterative repetition, of rhythm of execution, of termination). This is indeed direct damage, but it does not seem to constitute the essence of the syndrome although it plays an important and often unrecognised role. Problems in these regulatory systems greatly affect intellectual activity in the form of disturbances

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to the thinking process which will be described in greater detail.

fl

Damage to the vegetative centres.-The same remark applies as for the symptoms in the previous group. Damage to the vegetative centres which regulate vasodilatation, sweat secretion, skin nutrition, the vegetative functions of the different viscera, is sometimes highly accentuated, sometimes scarcely apparent. In the theory I am advancing it is, in sum, the global instinctive anhormia which constitutes the direct and fundamental problem, but multiple derived symptoms are involved in the clinical expression of the syndrome. These are syndromes of propagation, a consequence of the lack of general activation of psychic activity, which have the effects of inhibiting and disturbing the intelligence, the ability to act, affect. The analytical study of this variety of derivative problems will take up many pages. Besides these symptoms of propagation, one will need to describe the reactive symptoms which are also of great importance and constitute delusions and impulsive reactions. The anhormia, it is true, is not total, but rather an hypohormia which prevents the realisution of the instincts, so that these survive more or less at the state of tendencies which, although they are unable to be effectively fulfilled, are nevertheless expressed in the form of delusional substitutes; moreover, the deficiency symptoms themselves are also expressed in the form of delusion (influence). The anhormic unitary conception of the disorder maintained from the start by a certain number of authors is not the only unitary, or even the only neuro-physiological, conception. A much larger and also very longstanding school of opinion backs another theory, that of discordance, dissociation, dislocation. As early as 1903, E. Stransky was already referring to intrapsychic dislocation. Later, Urstein used the term intrapsychic disharmony. Bleuler, when in 1911 he

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gave the name schizophrenia to his group of diseases, described the symptoms analytically, but gave the group the

name of the symptom which seemed to him the most characteristic, i.e. the dislocation (Spaltung) of the association of ideas, a process which occurs arbitrarily; I have just mentioned his more unitary 1930 theory on the disintegration of the Ego. Chaslin gave the illness the name discordant insanity. Approaching it from the purely clinical point of view, he was struck by “the cocktail of disparate symptoms” which appear impossible to unify within a single encompassing conception, and which do not constitute, at least for some time, a genuine dementia. Other authors speak of a dissociating dementia, others stress the non-concordance between the symptoms of the affective, intellectual and active components.

[...1

J. APPROACH TO PATHOGENESIS AND AETIOLOGY My aim in this edition is to link the essential symptoms

to the malfunction of a functional anatomical system. In 1922, in agreement with a certain number of authors: Reichardt, Kuppers, Kleist, etc., we maintained with Dide that hebephrenic syndrome results from the functional deficien-

cy of the mesencephalic-diencephalic vegetative centres. Recent work has shown that we need to add to these subcortical centres archaic portions of the cerebral cortex, in particular the agranular rhinencephalic cortex including a part of the orbital lobe, the anterior callosal gyrus, the temporal pole including the amygdaloid nucleus, the anterior insula. Moreover, in this area where the primitive psychic functions are integrated, we need to add a contingent of proprioceptive and exteroceptive fibres which, in the mesencephalic-diencephalic reticular system, contribute to this global integrating activity.

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The arguments in favour of this view are as follows. 1. Appearance of typically hebephreno-catatonic mental syndromes in epidemic encephalitis, an illness located essentially in the mesencephalic-diencephalic area. In other more diffuse infectious nervous diseases, hebephrenic syndromes are more rare and less marked. 2. Subcortical localisation of the motor and vegetative catatonic symptoms. 3. States of atonia, sleep, adynamia (Hess) produced in cats by direct electrical stimulation, resembling hebephrenic symptoms. 4.Appearance in certain cases of hypothalamic tumours, before intracranial hypertension, of stuporous states with emotional indifference, lack of interest, lack of care, Cushing’s emotional negativism. 5 . Similarity with states of strangeness in so-called temporal epilepsy with many hebephrenic symptoms (painful feeling of interior strangeness). It is pointless to insist further on this well-known range of arguments (see Psychiatrie ginirale). Whenever any cause inhibits or disturbs the physiological activity of that large region of the brain, one will see the appearance of the direct symptoms of hebephrenic syndrome and often also the array of derived symptoms. At this point, I should mention a certain discordance between the theoretical hypotheses and the terminology. The syndrome as I have described it should be called thymhormia and not hebephrenia; the first term sums up the direct symptoms, while the second refers only to an aetiological circumstance and makes the syndrome a disease of youth. However, it is true that most athymhormic syndromes appear at an early age and immediately. It is only later on, and in a relatively small number of cases, that chronic delusions come to complicate the pattern of indifference and inertia. It would seem that ClCrambault was

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right to invoke the age rule in the sense that, when the process develops in a young patient, it is expressed in the form of athymhormic dementia praecox, while in an older subject it takes the form of paraphrenia. Having specified that point, we can now return to hebephrenic syndrome and examine what morbid causes may effects the diencephalic-rhinencephalic region. We find: 1. Genetic variety. This is by far the most important. That is why Kraepelin’s dementia praecox, then schizophrenia were considered to be endogenous conditions. The research on twins is characteristic; Kallman’s most recent statistics (1950) show a concordance of 86.2% for schizophrenia in monozygotic twins. This statistic requires some reservation since schizophrenia, as conceived by Kallman, has excessive clinical scope and takes in many cases which we would classify neither as hebephrenia, nor as delusions. This approach increases the level of coincidence. However, even if this percentage is accepted, there would remain approximately 14% of cases with no genetic origin. For a long time and in many studies, Marchand has described a hereditary degenerative form characterised in anatomical terms by encephalosis, that is to say a purely neuro-epithelial attack without inflammatory reactions. He describes the distinctive characteristics of this variety as follows: very early mental abnormalities, instinctual perversions, bizarre behaviour, schizoidism, insidious and gradual onset. Even in the most favourable cases, there is never a complete cure, there remains a degree of permanent deficiency. Symptoms of a neurological nature are absent, the cephalo-rhachidian fluid remains normal. Like Marchand, I believe that the simple premature forms with a predominance of deficiency symptoms are almost always of genetic origin, but the same is true for many intermittent and delusional forms in which reactive

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symptoms are apparent. Almost all the authors accept the evolutive severity of the simple, early onset forms and the little effect which treatment has on them. 2. Varieties with an exogenous cause. Any exogenous cause exclusively or predominantly affecting the central cerebral system, especially during youth when it is most vulnerable, is capable of producing a hebephrenic syndrome. These causes comprise infectious illnesses with a mesencephalic-diencephalic predominance (epidemic encephalitis), infectious illnesses with no precise affinity but which may possibly be localised in the central cerebral system (syphilis), microbial toxins with a diencephalic affinity (typhoid fever), diencephalotropic toxic substances built up in the organism (Buscaino), focal lesions developing in the region of the third ventricle (tumours).

K. PATHOLOGICALANATOMY In the theory I am advancing, it is understood that there can be no unequivocal pathological anatomy in hebephrenic syndromes resulting from multiple causes. The unity of the syndrome is the result of the localisation in the same region of diverse causes with different histological expressions. Almost all the histological research has concentrated on cases of so-called genuine 6.e. genetic) schizophrenia. But it should be recognised that the observations are far from being as clear as those already made for the other nervous hereditary systematic diseases, both from the point of view of localising the lesions in a system and with regard to the intensity of the cell damage. One point, however, is generally recognised. The lesions are exclusively neuro-epithelial, and do not affect the vessels and the meninges (Klippel and Lhermitte, 1904 to 1909). From the beginning, there has been a debate on the respective significance of the cortical and subcortical lesions,

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because the researches of E. Fungeld, Josephy, etc. coincided

with the new theories on the psychical role of the brait: stem. Their is a general acceptance of the predominance of thc cortical lesions in the pre-frontal lobe and also in the ante rior callosal gyrus, in the insula, the orbital lobe, and the anterior part of the third temporal lobe. It should be noted that many of these regions belong to the agranular rhinen cephalon, in close connection with the diencephalon. One particularity of the cortical lesions is their appear. ance in the form of cell clearings, particularly in the third layer, with no vascular reaction, and moderate gliosis. Certain authors claim to have found similar empty areas in normal subjects or in other mental syndromes. These areas should not be confused with the larger sections of degeneration due to obliterative endarteritis. For the subcortical lesions, we would cite the recent research of 0. and C. Vogt on eight cases of catatonia. In all eight cases the large cells of the central-median nucleus of the thalamus are damaged. Sometimes the anterior thalamic nucleus (W. Funfgeld) and the lateral nucleus are damaged at the same time. In the same laboratory, K. von Buttlar Brentano has described serious lesions in the hypothalamic nuclei of catatonics. These observations have not been confirmed by the more recent research of W. Wahren. A. Hopp has found cell lesions in the putamen, only in cases of catatonia. Having specified the topography of the lesions, we need to describe the elementary cell damage (cortical and subcortical). These are: Melting cells (0.Vogt). The lesion begins with a vacuolation of the cell body and of the dendrites; the lipid-containing vacuoles multiply, grow, come together, isolating fragments of dendrites, largely dissolving the cell body. The nucleus becomes larger; the nucleus membrane loses its chromatic affinity, the nucleolus is pale and eventually loses its individuality.

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Shrivelled cells, suffering from lipid sclerosis, with shrivelling of the cell outline, nucleus and nucleolus well preserved. In the white substance of the gyri and in the oval centre, Buscaino long ago described irregularly rounded sections with metachromasia, and sometimes a melting of the central substance. This lesion is also observed in mental confusion cases and in acute delusion (cluster disintegration). In the subacute hebephreno-catatonic varieties many authors describe an acute swelling of the oligoglie which is nothing other than the degeneration of the oligoglie described by Penfield and Grynefeltt. Agreement is far from having been reached on the pathological anatomy of hebephrenic syndrome. Many authors are not convinced of the presence of visible lesions, and declare with G. Steiner: “There exists as yet no pathological anatomy of schizophrenia.” The topectomy frequently practised in hebephrenia has sometimes revealed a significant thickening of the pia matw, which has cast doubt on the neuro-epithelial theory. It should be noted that topectomy is almost always practised after numerous electro-shocks, using Sakel’s method, or even double lobotomy. It is no surprise to find a pia m a t w reaction afterwards. Moreover, not all the cases operated on are of genetic origin and they may result from various forms of meningo-encephalitis. The pathological anatomy of non-genetic cases is highly variable depending on the cause. Sometimes there may be inflammatory reactions with perivasculitis (epidemic encephalitis), sometimes toxic cell lesions. In its current state, pathological anatomy does not constitute an argument for or against a pathogenic theory. I believe that we need to put our faith above all in neurophysiology, experimentation, and local tumour related lesions.

Eughe Minkowski (1885-1972)

There are few authors in whom the life and the work are so closely intertwined as in Eugkne Minkowski. This French psychiatrist was born in Saint Petersburg to a Lithuanian Jewish family, began his medical studies in Warsaw, which was then part of the Russian Empire, and, on account of his origins, was obliged to finish them in Munich where he obtained his diploma in 1909. In order to be able to practise in Russia, he retook it in Kazan. Returning to Munich, this time to study philosophy, he was caught by the Great War. As a refugee in Zurich, he worked for a while with Eugen Bleuler* at the Burgholzli. He then joined the French army as a volunteer, and his experience as a military physician in the trenches restored his original medical vocation which his interest in philosophy had apparently replaced. Having acquired French nationality through military service, he settled permanently in Paris where, in 1926, he presented his thesis on “The notion of loss of vital contact with reality and its applications in psychopathology”. In this thesis, inspired by the notion of the “life force” introduced by Henri Bergson (1859-1941)in Creutive Evoltltion (1907),Minkowski perceives the loss of vital contact with reality, which he compares with Bleuler’s autism, as the essential factor in schizophrenia. The work of the French philosopher includes elements from Freud’s Science of dreams, which Bergson had discussed in his courses at the Collige de France, and from ideas advanced at the

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same institution by Pierre Janet,* in particular those relating to the splitting of consciousness studied by Azam*, Morton Prince (1856-1926) and William James (1842-1910). It was through this Bergsonian perspective that French-speaking psychiatrists would approach the study of the group of psychoses described in 1911 by Bleuler, until 1926 when the latter presented his ideas directly in French. According to Minkowski, the study of the personality can be approached either from the point of view of its structure, by determining the phenomena of which it is composed in the present, as was the approach of the French psychological school, or by seeking in the past the events which are reflected in it, as was the method of the German school. For him, Bleuler’s work contained both tendencies. Minkowski expounded his own conception in “Lived Time. Phenomenological and psychopathological studies” (1933), describing in schizophrenia a process of spatialisation of the Self, which ceases to experience the sensation of time. 7%e Divided Self (1960) by the Scottish psychiatrist Ronald Laing (1927-1989) referred to this phenomenological analysis and “Lived Time” was translated into English in 1972. Minkowski, together with Ludwig Binswanger (1881-1966),was the founder of psychiatric phenomenology. Between the wars, he pyblished numerous texts, in particular in the volumes of the Evolution psychiutrique, the review which was behind the creation of the society of the same name (a name which illustrates the still active influence of Bergson’s Creative Evolution), of which Minkowski would be general secretary until the Second World War. During this period, the Society suspended its activities and publication of the review, and its French Jewish general secretary, a, World War I veteran, was lucky to escape deportation. The Evolutionpsychiatrique paid homage to E u g h e Minkowski on his jubilee in 1956 with the publication of a major volume. Minkowski devoted the end of his life to the writing of an extensive “Treatise on psychopathology” (1966), probably one of the last to be written by a single author. Several of these texts have recently been reprinted in annotated form. As our anthology piece, we have chosen a passage from the 1926 thesis on schizophrenia. Jean GarrabC

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Principal works MINKOWSKI (E.), La Scbizopbrknie [Schizophrenia], Paris, Payot, 1927. 2nd edition, Paris, DesclCe de Brouwer. MINKOWSKI (E.), “Etude sur la structure des ktats de dkpression” [Study on the structure of states of depression], Schweizer, Arcbiv. fiir Neurologie und Psycbiatne, 1930, 26, 2, p. 230-257. Reprint, Paris, Le Nouvel Objet, 1993. MINKOWSKI (E.), Le Temps vkcu. Etudes pht!nomt!nologiques et psycbopatbologiques (Live$ Time. Phenomenological and psycbopatbological studies), Paris, Evol. Psy., 1933.2nd edition, Neuchatel, Delachaux et Niestlk, 1968. MINKOWSKI (E.), Trait; de psycbopathologie [Treatise on psychopathology], Paris, P.U.F., 1966. 2nd edition, Le PlessisRobinson, Les Emptcheurs de penser en rond, 1999. MINKOWSKI (E.), Au-del2 du rutionnalisme morbide [Beyond morbid rationalism], Paris, Montrkal, L’Harmattan, 1997.

Bibliographical references

Lgvolution psycbiatrique, “Hommage ? Eugkne i Minkowski” [Hommage to Eugkne Minkowski] (35 authors), 1956, 1, Jan.-March, p. 1-401.

The Notion of Loss of Vital Contact with Reality and its Applications in Psychopathology

I. VITAL CONTACT WITH REALITY.

It is our intention in this work to explain the manner in which we conceive the essential problem of schizophrenia together with the psychopathological mechanisms which determine the particular features of that condition. Kraepelin had reached a synthetic, very broad notion of dementia praecox, the result of a merging of particular clinical forms which had previously been considered more or less independent of each other, such as catatonia, hebe phrenia and paranoid dementia. The so-called simple forms of dementia praecox were added to these. This synthesis raised a new problem. As a result of the merging, into a single notion, of apparently totally different clinical forms, the symptoms and even the syndromes supposedly characteristic of each of them lost their value. As Kraepelin showed, the symptoms are interchangeable, largely inconsistent and lead to identical terminal states. They must therefore all have something in common, be simply the more or less accidental expression of an underlying mop bid process which is always the same. This is what gave rise to the need to reduce the whole range of symptoms and clinical

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pictures currently encompassed by dementia praecox to a fundamental problem, and to spectfj its nature. Obviously, the place to look for this problem is not amongst the ordinary clinical symptoms, such as hallucinations, delusional ideas, catatonic manifestations or states of excitement or depression. There is nothing consistent or characteristic in these symptoms, as we have just seen. Since it is to constitute their common basis, the fundamental problem cannot be found among them. It must be sought outside them, at another level. The efforts to complete the synthesis of dementia praecox and to make it a genuine nosological entity therefore return quite naturally to the elementary functions of the psyche. It is here that one may hope to find the key to that specific behaviour which occurs in all dementia praecox, despite the infinite varieties which distinguish them from one another in symptomatic terms. However, the common notions of psychology quickly prove inadequate. By taking as one's point of departure the traditional trio: intelligence, feeling, volition, one observes that the disorder in question cannot be related to any of these faculties. Neither aboulia, nor indifference, nor lack of emotion, and even less so feeble-mindedness, are characteristic of dementia praecox. It is more a question of elective eclipses of each of these faculties occurring in relation to certain outside situations, than of their global disappearance. The result is a shift in psychopathological conceptions. They move in the direction of the factors which regulate the psyche, towards the higher faculties. Kraepelin himself, having spoken of a weakening of the effective powers of the will and of a loss of interior unity, relates these two conditions to a general failure of the ideas, of the feelings and of the tendencies. He speaks, in this respect, of a disorder of abstraction. The consequence of this, he believes, is the incapacity to transform perceptions into more abstract ideas, lower feelings into more general feelings, isolated impulses into more consistent tendencies. Kraepelin

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even sketches out a psycho-physiological hypothesis of dementia praecox, locating this faculty of abstraction in the upper micro-cellular layers of the cortex. Masselon, for his part, places the emphasis on problems of attention and likens the attitude of dementia praecox sufferers to a perpetual distraction. Weygand, adopting Wundt’s notions, speaks of aperceptive dementia. However, none of these conceptions relating to the higher functions of the psyche, is sustainable. Unable to explain the essential problem of dementia praecox, they are increasingly giving way to notions of a different order. Expressions such as “discordance” (Chaslin), “intrapsychical ataxia” (Stransky), “intrapsychical disharmony” (Urstein), “loss of interior unity” (Kraepelin), “dissociation” (Claude and Levy-Valensi), “schizophrenia” (Bleuler) involve the idea that it is not one or other function which is damaged, but rather their cohesion, the harmonious interplay between them. To employ an image, the essential disorder does not damage one or more faculties, whatever their order in the hierarchy of the functions, but is rather located between them, in the “interstitial space”. However, all these expressions are, essentially, simply a statement of fact, a name for the particular disorder presented by dementia praecox sufferers or schizophrenics. This is important in itself since, in this way, discordant disorders are clearly separated from true dementia. But as psychologists, and in psychiatry that is what we all are, we cannot stop there. Chaslin, for example, sees attenuated hebephrenia as a discordant state of the psychical faculties. But what then are

the factors which, in the normal state, are responsible for the concordance of those same faculties? That is the question which arises and which, for the moment, remains unanswered. We are not yet able to establish a clear idea of the fundamental problem of dementia praecox, as we do not yet know with which factor of the normal psyche it is related. It is here that comparisons and metaphors come to our

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help. It is as if they become inevitable when one seeks to identify the essential features of dementia praecox. Kraepelin speaks of an “orchestra without a conductor”, Chaslin of “a machine without fuel” which, in terms of its capacity to work, is, it is true, different from a damaged machine. Mr Anglade, with whom we had the good fortune to discuss these questions, told us that he no longer employed the expression “dementia praecox”; instead, he simply spoke of dissociated patients. In describing their state, he would compare them to a book without a binding, where the pages have become mixed with the result that the volume is illegible, even though all the pages are there, without exception; what a difference from a book in which all the pages are torn. We ourselves, in trying to obtain an idea of the schizophrenic process, have more than once come upon the following image: a building is made of bricks and mortar; both bricks and mortar can crumble, and in each case the building will collapse. However, the two things are different: the ruins are not the same, will not look the same, will not have the same value; it will be easier to reconstruct a new house with intact bricks, than with dust. These metaphors could not be better calculated to express the increasingly pressing need to separate the schizophrenic process completely from feeble-mindedness. Moreover, they seem to come much closer to the veritable character of schizophrenia than all the psychological definitions we listed earlier. However, our spirit of precision rebels. These metaphors should be seen as no more than games, ingenious and agreeable to varying degrees. They should be denied all access to science, at least to true-exact-science, that spirit tells us. And yet, has not one of the greatest contemporary philosophers, Mr Bergson, reminded us, once again, that a whole aspect of our life, and not the least important, lies entirely outside the realm of discursive thought. The immediate, the most essential data of consciousness, belong to this order of things. They are irrational. Yet they are nonetheless part

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of our life for all that. There is no reason to sacrifice them to the spirit of precision. O n the contrary, one should try to catch them in action. Psychology, until now a desert terrain, burnt beneath the excessive rays of exact science, will then perhaps be transformed into a verdant and fertile plain, will finally move closer to life. Should we not draw inspiration from this tendency for the problem which particularly concerns us here? It is here that the notion of vital contact with reality emerges. Bleuler specified the cardinal symptoms of schizophrenia, relating to the patient’s ideation, affect and volition. But at the same time, thanks to the notion of autism, factors relating to the subject’s relations with his surroundings began to play an increasingly important role in the conception. The lack of real goals and of controlling ideas, the absence of emotional contact took the concept along a new path. All these problems seemed to converge towards one single notion, as we have tried to show, that of the loss of contact with reality. Vital contact with reality seems indeed to be related to the irrational aspects of life. The ordinary concepts developed by physiology and psychology, such as stimulus, sensation, reflex, motor response, etc., pass by, without affecting it or even brushing against it. The blind, the mutilated, the paralysed can live in far more intimate contact with their surroundings than individuals whose sight is intact and who are in possession of their four limbs: schizophrenics, on the other hand, lose this contact without their sensory-motor apparatus, their memory, or even their intelligence being damaged. Vital contact with reality relates to the very foundation, the essence of the living personality, in its relations with its surroundings. And once again, these surroundings are not a set of external stimuli, or atoms, or forces or energies. No, they are that moving tide which surrounds us on every side and which makes up the medium without which we could not live. “Events” like islands

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emerge from it, they shake the most intimate fibres of our personality, penetrate them. And our personality penetrates them in its turn, vibrates in unison with them, like a stretched cord, and, combining them with the factors of which its intimate life is constructed, responds in a personal way, not by muscular contractions, but by acts, by feelings, by laughter or tears, which come to rest on the tides of the ambient future, are lost in them like a drop of water, disappear into the infinite which lies beyond our knowing. This is how that marvellous harmony between ourselves and reality is established, the harmony that allows us to follow the way of the world, while still maintaining the notion of our own lives. We will say nothing more here regarding this important point. However, what has just been said is sufficient to make it likely, at the very least, that vital contact with reality relates to the intimate dynamism of our lives. The rigid concepts of our spatial thinking cannot encompass it. Metaphors seem much more appropriate here than definitions. It is through them that the notion of vital contact with reality can be clarified. A totally novel notion? Undoubtedly not. Fortunately, we would even say, since changes that are too revolutionary are generally worth little. In his theory of psychasthenia, Janet speaks at length of the function of the real. This notion, while not identical with that of vital contact with reality, shares with it many common points. And does not the circumstance that two different paths lead in the same direction prove that we are dealing with things that are true and important, which are “in the air” of our time, so to speak. The notion of vital contact with reality and the interpretation of schizophrenia as the loss of this contact fill us spontaneously with ease. The notion seems as simple and plausible as it could be. The novice can assimilate it quickly and use it without difficulty. As enthusiasts, we might almost go so far as to say that this notion is the principal

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outcome of the evolution of the concept of dementia praecox. Does this mean then that this whole powerful current of clinical psychiatry has finally led to nothing more than a notion of general psychology and psychopathology? We do not think so. It is likely to render yet further services, as we will see later on. But even if that were not the case, this new piece of knowledge would not be without value. Moreover, is this not the fate of many other clinical notions in psychiatry? Mental confusion too owes its origins to the need to reduce the field of the dementias. It replaces the group of acute curable dementias proposed by Pinel. Defended above all in France by Delasiauve, it then emigrated abroad. During its evolution, having undergone numerous alterations and extended its boundaries, it again achieved recognition in its native land, largely thanks to the work of Chaslin. Finally, under the impetus of Toulouse, Mignard and Juquelier, it culminated in a notion of a general character, the notion of autocondziction. This particular aspect of the evolution of our clinical notions in psychiatry should not surprise us; is it not the case that a clinical entity only becomes clear and specific to us once we have succeeded in giving it a solid psychological foundation? In this way we see modern psychiatry seeking to identify the disorders which generate the clinical entities that it studies. I think that I can claim, in part at least, paternity of the notion of vital contact with reality, as the central point of schizophrenia Obviously, I did not “invent” this notion in its entirety. Ideas which do not seek a link with either the past or the present, are generally of little value. The works of Bergson exercised a great influence on me. Moreover, we find the idea of a profound disturbance in the relations with the outside world throughout Bleuler’s book on schizophrenia. However, Bleuler puts the emphasis on the cardinal and elementary symptoms of that disorder, relating to the patient’s ideation, affect and volition, and although he stresses the loss of contact with reality (autism), he

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nevertheless does not perceive this loss as a generative disorder from which all the others arise. Vital contact with reality is not for him an essential life regulating factor, to which the other psychic functions might be subordinate. Loyal to associationism, he defends, in his theory of schizophrenia, the view that a specific problem in associations of ideas is the primary problem in this disorder. He goes on to seek an organic basis for this problem. In presenting the notion of schizophrenia to French alienists, I have not been able to prevent myself striking a personal note. Who could blame me? The critical analysis of a foreign work can only serve as an introduction to the study. If it succeeds in arousing the reader’s interest in the work, it has achieved its goal. Moreover, when one has truly tried to make another’s ideas one’s own, when one has really lived them, without being content simply to adopt them wholesale, one is not always subsequently able to distance oneself completely. In fact, this has little importance. Science progresses quite apart from the persons of its labourers, for which it has, at bottom, little regard. Thus I made vital contact with reality the central point of the conception of schizophrenia. As a result, a certain duality emerged between Bleuler’s master-work and my analysis. This duality has been admirably demonstrated by Villey-DesmCsaret in his thesis. In addition, Mr Mignard was kind enough to underline the personal note that I had contributed to the notion of schizophrenia, above all under the influence of Bergsonian ideas. Today, I emphasise this point precisely in the interest of discussion. Thus the criticism, for example, that “we are, from the start, struck by this fact that the profound imbalance in the contact with reality is in schizophrenia not a consequence of other psychological troubles, but an essential point from which all the cardinal symptoms of that mental disorder ensue, or at least from which they may be envisaged in a uniform manner,” that criticism, we say, with

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all the consequences it entails, applies far more to my conception than to that of my master. The notion of loss of vital contact with reality, as the essential problem of schizophrenia, has moreover taken my thinking and my research in a direction which is perhaps not entirely devoid of interest. We will attempt to explain it in the chapters that follow.

11. INTELLECTUAL DEMENTIA AND SCHIZOPHRENIC DEMENTIA The initial enthusiasm over, the need arises to analyse and situate the notion of vital contact with reality more precisely than has been done so far. The brief formula that schizophrenia consists in a loss of contact will not suffice in the long term. We require more. The purpose now is to see how, from this point of view, we can interpret the essential characteristics of the schizophrenic process, that is to say to what extent this notion may prove fertile when tested, and may contribute to the progress of our science. We require it to be not simply an explanatory hypothesis, but also a working hypothesis. We were saying earlier on how much influence the work of Bergson had exercised on our thinking. The notion of vital contact with reality became, so to speak, the meeting point between the clinical efforts of the Zurich school and Bergsonian ideas. In this way, the direction in which we should seek to progress was already laid out for us. We followed it, reinforced by the conviction that psychology, and psychopathology with it, can only gain from contact with philosophy, as true philosophy has always been an inexhaustible source of knowledge and understanding of human psychology. It is hardly necessary to give a detailed exposition here of the ideas of Bergson. They are sufficiently well-known these days. Let us simply recall the fundamental opposition between intelligence and instinct which he establishes.

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“While instinct,” says Bergson, “is moulded on the very form of life, intelligence, by contrast, is characterised by a natural incomprehension of it. “Intelligence, as it emerges from the hands of nature, has as its main subject that which is solid and without organisation. It can only form a clear representation of the discontinuous and the immobile. It is only at ease in what is dead. It invariably behaves as if fascinated by the contemplation of inert matter. Hence its astonishment when it turns towards the living and is confronted by organisation. “Precisely because it always seeks to reconstruct and reconstitute using what is given, the intelligence always misses whatever is new at each moment of a story. It does not accept the unpredictable. It rejects all creation. Concentrating thus on what is repeated, solely preoccupied with matching like to like, the intelligence turns away from perceiving time. It rejects the fluid and solidifies everything it touches. We do not think real time, but we experience it.” (Bergson, Creative Evolution.) It was inevitable that psychopathology would sooner or later be led to ask the question, even if Bergson’s conceptions had not tended to cast a new light on the problems on which the notions of standard psychology had previously foundered. The aim was to see, at the same time, to what point psychopathological facts might be able to confirm the data brought out by the intuitive genius of the great philosopher. In the end, such an experiment is perfectly natural. Morbid processes, often acting in an elective manner, dissociate, so to speak, the different functions and show them to us naked. Pathology often succeeds where physiology is unable to disentangle all the complexity of the factors which come into play. In life, intelligence and instinct or, in other terms, the factors of our psyche which relate to the solid, to the inert, to space, on the one hand, and to the experience of time, to dynamism, on the other, are mutually interlinked and form a harmonious whole. Insufficient of its own to sustain

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individual existence, each of these two groups of factors complements the other, at the same time restricting, in a natural and appropriate manner, its field of action. But may not this harmony, under the influence of pathological alterations, undergo significant disturbances? For example, might not instinct become damaged? In this case, will not the intelligence, deprived of its natural brake, seek as best it can to replace the failing instinct, and will it not thus end in monstrous forms? Conversely, may not the elements of the intelligence be the seat of the initial damage, with secondary preservation or distortion of the factors relating to duration? Such are the questions which now arise. These questions in no way lead to abstract speculation, as some might have feared. O n the contrary, as we will see later on, they lead to a series of facts, to facts which, perhaps not being understood in the usual manner of envisaging psychopathic phenomena, have perhaps been somewhat neglected by our predecessors. We will begin by comparing, from this point of view, the two major mental processes which psychopathology has so far succeeded in identifying, that is to say the schizophrenic process and feeble-mindedness which both, with varying rapidity, lead to specific and dissimilar terminal states. In recent times, many authors have stressed the fundamental difference between these two major disease processes. However, despite the obvious nature of this difference, it is far from easy to specify. Certainly, we can define feeble-mindednesswithout problem as a loss of judgement and memory. But this ceases to be the case for schizophrenic deficiency. That is something completely different. The word “dementia”, still sometimes employed, only very imperfectly reflects the essential character of this deficiency. “In a schizophrenia, even advanced, all the elementary functions of the psyche, in so far as they are accessible to exploration, appear intact. In particular, memory is retained in schizophrenics, by contrast with the truly demented.” (Bleuler.) Often one is surprised to find in these patients

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“beneath a dementia1 envelope an intelligence much less damaged than one might believe, as if simply dormant.” In fact “the symptoms of discordant madness often very closely simulate dementia: cool incoherent delusion, indifference, strange acts of various kinds, or else total inactivity of the intelligence with occupations reduced to a lower order, stupor with bizarre attitudes, incoherent acts, etc. and despite this, usually no sign of feeble-mindednessin the strict sense, even temporary, no loss of memory, no error of judgement.” “By contrast with the true organic demented, whose intellectual functions are more defective than is apparent at first sight, it would seem that nothing is irredeemably lost, that a little effort would suffice to restore motion to a whole cerebral life.” Nonetheless, these people are seriously ill and “are often apparently reduced to a purely vegetative and automatic existence, like idiots.” (Chaslin.) What then are they lacking and in what way do they differ from those who are, strictly speaking, demented? It is the problem of this fundamental difference which we will attempt to examine now, taking as our starting point the opposition between intelligence and instinct to which we referred earlier. This starting point, inspired by Bergsonian ideas, will confer, in addition to a general direction, a specific character on our research. Rather than simply comparing what the patients are lacking, our purpose will be at the same time to identify what remains intact in them and to specify the difference, in their reactions and their entire way of being, in this respect as well. We will begin the study of the two processes in question by comparing the ultimate degrees of degeneration which they attain. 1. We have quoted here the words of Chaslin on the discordant insane, as this notion largely covers the same category of patients to which Kraepelin

refers by the term dementia praecox and Heuler by schizophrenia. O n the subject of the differences between the conce tions of these three,authors, see my article “The genesis of the notion of sciizophrenia, etc.”, L’Evolution psychiutriqrre, Payot, 1925.

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For the moment we have chosen as representatives of feeble-mindedness solely sufferers from general paralysis of the insane. This disorder possesses, for our research, the advantage that it generally affects individuals in the prime of life. This means that their feeble-mindedness does not overlap with other factors such as, for example, the physiological changes of old age which occur with senile dementia. It exists, so speak, in the pure state. I ask a general paralysis sufferer in the idiot stage: “Where are you?” H e replies: “Here.” In case this is a purely verbal and automatic response on his part, I insist: “But where here?” The patients taps his foot to indicate the place where he is, or points to it or gestures to indicate the room he is in. “But here?” he says, even seeming surprised and irritated by our insistence. This is not a contingent reaction, but unquestionably a manifestation which we encounter in these patients with surprising frequency. The schizophrenic, for his part, if in general he answers the question asked, usually does so correctly, mentioning the place where he is. O n the other hand, how often will he tell us that, although he knows where he is, he does not feel that he is where he is, that he does not feel in his body, that “I am” has no precise meaning for him. Factors of two different types are involved in our orientation in space. Static-type factors situate objects in relation to each other in geometric space, where everything is immobile, relative and reversible. But in addition we live in space and the ego which acts places before itself at every moment the fundamental notion of “I-here-now” and makes it an absolute point, a veritable centre of the world. In normal life these factors are interpenetrated. O u r knowledge and our mental images are grouped around the fundamental “I-here-nowYy and allow us to say, depending on the circumstances: “I am now in Paris, in London or in my study.” In the general paralytic, knowledge, memory, in short,

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the static factors, are lacking. ’ He is disorientated in space, in the usual sense of the word. Nonetheless, the fundamental framework of “I-here” remains intact and active. The schizophrenic, on the other hand, knows where he is, but the “I-here” no longer has its habitual tonality and is absent. At a less advanced stage, we observe in the general paralytic reactions of a slightly more complex structure, but which retain the same character. To the question: “Where have you come from?”, the patient replies: “From where I was before.” H e is obviously disorientated in space, incapable of naming the place he has come from. Nonetheless, the dynamic framework of the change of place reflected in the relation: location X before, location Y now, remains intact. The following examples belong to the same category of facts: Q. Where are you?-A. Where I washed myself this morning. O r else: where I have been for some time. Q. What is this house?-A. It is the house where I have been placed. Q. Who is this gentleman?-A. It is a gentleman who is here. Q. What are you doing?-A. For the moment I’m staying here. Let us now place a general paralysis sufferer who has reached the dementia phase in front of a mirror and ask him: “Who is that?” He replies: “Me.” We continue: “But who me?” He then gives his name and profession. This reaction is considerably less consistent in schizophrenics at an advanced stage of the disorder. They reply: “me”, and then “my activity, my personality”, or else: it’s energy, or finally, immediately expanding along the lines of their delusional ideas, give answers such as “I, the son of Claude Farrhre.” One of our patients replies: “I know who it is,” 1. We will leave aside the question of whether these elements are irreparably destroyed or whether they simply no longer play a useful part, on account of functional problems.

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several times repeating the “I know” to make it clear that she no longer feels it. “I know who it is,” she continues, “but it is simply an observation, there is nothing in it; it’s a funny looking character, a fixed stare, oblique and icy.. .” In this way, with the final vestiges of psychical activity, the general paralysis sufferer follows the path traced by the social self. The schizophrenic, on the other hand, does not, and always exhibits a certain degree of depersonalisation. The affirmation of the self is lacking here. The sense of substitution also remains long intact in the general paralysis sufferer. If asked the date, he will instinctively pick up the newspaper. A totally demented patient will answer the question: “What day is it?”-“I have nothing that will tell me.” Another, when asked his date of birth, replies: “I can’t tell, I have not got my wedding ring.” Engraved on his wedding ring is not the date of his birth, but of his marriage, but he does not realise that; on the other hand, he knows that there are ways to substitute for a failing memory and instinctively looks for them. The schizophrenic’s behaviour is completely different. He will often know the date, but this knowledge no longer has a precise meaning for him; he no longer uses it in the way that is appropriate to the requirements of everyday life. It is above all the pragmatic aspect which is affected. One general paralysis sufferer, presenting a state of profound dementia, answers the question: What are you doing?-“I am awaiting events and making plans.” Another patient, having attained an extreme degree of intellectual degeneration and virtually lost the power of speech, notices that I have forgotten my hat in his room and laughs about it. For the schizophrenic, on the other hand, everything relating to events, plans, movement, seems no longer to exist. These few comparisons establish the fundamental difference between the terminal states attained in the feeblemindedness associated with general paralysis of the insane,

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on the one hand, and the schizophrenic process on the other. There is no way they can be confused. It is the static factors which are lacking in the first case, while in the second case, by contrast, it is mental dynamism which has disappeared. Obviously, this formula is too simplistic. In particular, the word dynamism can lead to confusion. It is also used in physics. Here however, in the study of motion, as Bergson has so clearly shown, time is already conceived as a straight line and thus assimilated to space. Everything that is motion and progression, everything that is real time, is immediately excluded from this conception. True dynamism, as a set of factors relating to the experience of duration, is completely different. That is what we are speaking of here. Moreover, we are doing so in an imperfect and provisional manner. It could not be otherwise. We still lack a solid base in this domain. To establish one would involve nothing less than to specify and to group all the phenomena of our lives relating to real time, and then to see how they behave, both in the normal psyche and in the diseased psyche, in other words to create a psychology and a psychopathology of the experience of time. A difficult task if ever there was one, but also an indispensable task for anyone who wishes to understand the human soul, both in its normal operation and in its pathological deviations. However, Kntil we can do better, we believe that the formula by which we have summed up our observations adequately reflects the difference observed. Moreover, the contrast we have just established between the terminal states of those with general paralysis of the insane and of schizophrenics, can be taken further. It also casts light on the earlier phases of these two disorders and brings out, in the terms adopted at the start of this study, the essential features of each of them. Let us begin with general paralysis of the insane. The further we move away from the terminal period, the

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more difficult it is to interpret the facts. Nonetheless, the essential character described earlier can be identified. The fixed framework of years, months, weeks, in short, the notion of measurable duration, i.e. time assimilated to space, is often lost. But this is far from signifying that any notion relating to time has disappeared. A patient may be able to recount correctly, in chronological order, what he did during the war, yet no longer know either when the war began, nor when it ended. The memory of a succession of a certain group of facts is retained, while the ability to relate them to a fixed point, to a specific year, seems to have disappeared. In this way, the spatial image of duration disappears. The elements of which the notion of time is made up, deprived of the grip of this fixed framework, can flourish freely, so to speak. In their extreme mobility, they invade the individual’s entire psyche. There is nothing but immediate succession, extreme penetration and speed, in the delusional fantasies and plans of the sufferers. ’ Expressions such as: just now,immediately, recently, sometimes, recur with surprising frequency in their speech. One patient tells us every day about her husband who, according to her, is supposed to come to fetch her. He is already there, he is coming up the stairs, he will be in the room at any moment and will take her away immediately afterwards. O r else, there are cars which travel at eight hundred kilometres an hour, or trips to Argentina completed in five minutes. They live, one would say, solely in the future. It is above all the future which features in what they say. 1. Here perhaps lies one of the essential differences, examined from this point of view, between the behaviour of general paralysis sufferers and that of certain maniacs. The latter’s diseased plans remain, it would seem, within the framework of measurable duration. They still take account of time, in the normal sense of the word, and set their lans for ”tomorrow”, “the day after tomorrow” or in a “few days”, while t e general paralytic lives above all in the immediate succession which overflows everything. However, this view is nothin but a simple supposition, and it is not our intention to say any more on t e subject today.

K

a

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This dynamism invades the whole individual, overflows, extends throughout the universe. These are the symptoms of the delusional period of general paralysis of the insane. The patient makes plans for the immediate future, grandiose plans, totally without limits. He will go straight to the Longchamp horse races, and then around the world. He will also blow up all the islands of the Ocean, then fetch the moon and put it in a glass. He is all-powerful, capable of doing anything, performing grafts, cross-breeding animals, raising the dead. Moreover, he involves all living beings in this extraordinary blossoming of his strength. He distributes his millions, wants the whole world to be happy; takes all the doctors and all t,he nurses on his fantastic journeys. He will go to Rome to request marriage licences for all the curates and nuns; he will have all the fish set free. Now let us compare with this picture the way a female schizophrenic patient, after several years of illness, describes her state of mind: “All about me is immobility. Things appear in isolation, each for itself, without evoking anything. Certain things which ought to form a memory, summon up an immensity of thoughts, paint a picture, remain isolated. They are understood rather than experienced. They are like pantomimes, pantomimes being played around me, but I am not involved, I remain outside. I have my judgement, but the instinct for life is lacking. I am no longer able to invest my activity with a sufficient sense of life. I can no longer move from soft strings to tight strings, and yet we are not made to live on the same theme. I have lost contact with all kinds of things. The notion of the value, of the difficulty of things, has disappeared. There is no longer any resonance between them and me, I can no longer give myself up to them. There is absolute fixity around me. I have even less mobility for the future than for the present and the past. It is as if there is in me a sort of routine which prevents me envisaging the future. Creative power has been erased in me. I see the future as a repetition of the past.”

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This, I must point out, is not a page from a novel. No, they are the words of a patient who spends her days in bed, in a state of complete inertia, who, when she gets up, moves like an automaton, who has auditory illusions and exhibits ideas of bodily transformation, and who finally, in her home, taking advantage of a moment of inattention, set fire to her clothes in order, as she explains, to experience strong sensations which she is entirely lacking. Is not this the keystone of the whole problem of schizophrenia? This question &ems all the more plausible in that the words of this patient are by no means an isolated and exceptional occurrence. O n the contrary, we find similar, not to say identical, manifestations with surprising frequency in schizophrenics, if only we pay attention. We will hear them say that their “ideas are as motionless as statues” or that they are “static and fail to move towards completion” or employ other similar expressions, which reflect the immobility which gradually invades them and from which they suffer, when they are conscious of their state. Moreover, their attitude and their reactions also often bear the stamp of this morbid immobility and we encounter it even in the stereotypical movements which, at bottom, are simply an eternal recurrence, totally without progression. One could not imagine a greater contrast with the picture, described above, of the sufferer from general paralysis of the insane. In stressing this contrast more strongly, we have in fact done no more than to specify an important difference, observed by all those who have had to deal with the question. f i e specificity of the terminal states constitutes, as we know, one of the essential criteria to which Kraepelin refers in constructing his synthetic notion of dementia praecox. He speaks, in these cases, of Verblodung, explained by Mr Nayrac in his thesis as follows: “Ordinarily, French authors have translated this by the word dementia which, as we will see, has a tendency to arouse confusion, as Verblodung refers, in our opinion, to something other than

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dementia. If for no other reason than respect for vocabulary, we have chosen to employ another word to designate it. In day-to-day language, Verblodung expresses the fact of making someone shy, ashamed, to the point of appearing intellectually retarded. In the absence of a French equivalent we have translated Verblodung by ‘paradementia’.” Bleuler speaks of schizophrenics as having affective dementia and thus underlines, once again, the fundamental difference between schizophrenic degeneration, on the ont hand, and intellectual dementia or quite simply dementia, on the other. For my part, in giving priority to the factors relating to the expression of personality, that is to say the personal activity of the subject, I have referred since my earliest work on schizophrenia to pragmatic dementia. However, the combination of these two terms is perhaps not quite appropriate. It would seem preferable to suppress entirely the word dementia, if that expression is to signify the progressive enfeeblement of the intellectual faculties, and to speak of pragmatic deficit. In any case, the proposed term seems to have touched on an essential aspect of the problem. We have found valuable confirmation of our view in the recent research by Mr Claude and his students. These authors also stressed, in the cases described by them under the name schizomania, the discordance between intellectual activity and pragmatic activity. In conclusion, we would quote the definition of dementia praecox given by Dide and Guiraud. “The disorder, say these authors, is characterised by the

immediate and premature softening of the instinctive sources

of mental l f e , originating directly in organic and cenesthesic activity. The purely intellectual operations are only modified consequentially; for a long time, their disorder consists of obstruction and contradictory orientation and not a primary disappearance of the function. The weakening of the vital force and of affect is the necessary and sufficient factor that characterises the disease.” They therefore propose to replace “dementia praecox” with the term “juvenile

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athymhormia” which would properly express the “loss of force of the cenesthesic and affective soul”. Setting aside the organicist interpretation which Dide and Guiraud give to their conception, together with the question of the existence of the “cenesthesic soul”, we are only too happy to recognise, in psychological terms, the common points between the ideas of these two distinguished alienists and our own research, as described in the previous pages, in particular as, firstly, this similarity is not simply a matter of simple formulae or definitions, but concerns the demonstration of precise facts, of which more later, and secondly, because Dide and Guiraud, far from adopting the Bleulerian term schizophrenia, instead employ the term “dementia praecox” in its most restrictive meaning. We attribute great importance to this circumstance. The concordance of opinions, existing despite different starting points, serves as a valuable confirmation. In addition, the observations of Dide and Guiraud, applying as they do also to the case of dementia praecox, in the restrictive sense of the word, validate what Kraepelin and Bleuler have always stated, by which we mean that under no circumstances may dementia praecox, in whatever way this term is used, refer to true dementia, as a primary failure of the purely intellectual functions, as is found in general paralysis of the insane, for example. Our own experience induces us to side with this view. The late spontaneous recoveries, impossible to foresee in advance, and occurring after long years of illness in subjects who apparently exhibited every sign of total and lasting degeneration, point to the same conclusion. We can do no better than to recall here again the words of Chaslin, quoted above, on the subject of the discordant insane.

Henri Ey (1900-1977)

The abundance and richness of Henri Ey’s psychiatric and philosophical work makes it extremely difficult to select an extract which is representative of his thought. Since the halfcentury during which he published was marked by the brutal interruption of scientific life brought about by the Second World War, we finally chose a text published just at the beginning of that conflict, which acts as a chronological limit for this anthology. This contribution to the collection offered to Pierre Janet* for his 80th birthday is a link both in the history of ideas in psychiatry in general and in that of Ey’s thought, insofar as it prefigures his later development. Henri Ey was born and died at Banyuls-dels-Aspres in the French parts of Catalonia. After a secondary education in a religious college near Albi, Toulouse-Lautrec’s native city, he did his medical studies in Toulouse. He was then accepted as a medical resident to the Paris psychiatric hospitals, where he received his psychiatric training. In this, he was influenced by the work of Paul Guirauab,followed the courses of Pierre Janet* and studied philosophy at the Sorbonne. Following a period as clinical chief to Professor Henri Claude at the Clinic of Mental Diseases and Diseases of the Encephalon at Sainte-Anne hospital (the only academic post he would hold throughout his life), in 1933 he was appointed chief physician at the Bonneval asylum near Chartres (today the Henri Ey Hospital)

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where he would remain until his retirement in 1970. He then returned to the family home and continued his scientific labour with the help of the large library and archives he had built up in the course of his professional life. The young Ey was from its beginning a member of the €volution psychiutrique [Psychiatric Evolution] society, a group which formed around Eughne Minkowski’b based on the review of the same name. The choice of this name, inspired by the title of the work by Bergson-who in 1927 had just received the Nobel Prize-Creative Evolution (1907), highlights the intent of its members: to bring about evolution in psychiatry by incorporating into it the new elements from philosophy, phenomenology, psychoanalysis, linguistics and neurobiology. Henri Ey began his prewar publications with “Hallucinations and delusion” (1934), prefaced by Jules SCglas, his first approach to a question which would remain a constant theme in his work. In 1938 he brought out an “Attempt to apply the principles of Jackson to a dynamic conception of psychiatry”, of which he would publish a second, much expanded edition in 1975. It was on the basis of the ideas of Hughlings Jackson (1835-1911),himself inspired by the philosophical “organicism” (not to be confused with medical organicism) of Herbert Spencer (1820-1903), that Ey would develop his own organo-dynamic theory, thus opening the way to neo-jacksonism. In the text dedicated to Pierre Janet in 1939, he establishes a parallel between three dynamic conceptions of psychiatry: that of Janet himself and those of Freud and Jackson. After, the war, Ey succeeded Minkowski as general secretary of the Evolution psychiutrique, which had closed down during the German occupation, and this was to provide the background to the majority of his subsequent scientific activity. He organised at Bonneval a series of colloquia which were highly influential, notably those on “The problem of the psychogenesis of the neuroses and psychoses” (1960) and on “The unconscious” (1966). The essence of the courses he gave in his study circle at Sainte-Anne is contained in the three volumes of the “Studies.” In 1950 Ey successfully organised in Paris the first World Psychiatry Congress, chaired by Jean Delay, which marked the resumption of the international exchanges interrupted by the war. So successful was this congress, that it led shortly afterwards

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to the creation of the World Psychiatry Association. Ey was

elected its first general secretary and retained this post until the sixth Congress in Madrid in 1966. Several of his publications over this period would be produced for the congresses. In 1955 Ey managed the publication, with more than one hundred and thirty collaborators, of the first edition of the “Treatise on psychiatry” in the Medico-Surgical Encyclopaedia, which traces the progress of the discipline after these first world congresses. In 1960 Ey published a “Manual of Psychiatry” which would run to six French editions-the sixth being published posthumously in 1989-and translations in several languages. Finally, in 1963, came the first edition of Consciousness, curiously the only one of his books to be translated into English, although it is the most philosophical and most of the others have also been translated into the Latin languages,Japanese and Russian. Ey spent the last period of his life writing what amounted to his Summation, a work of several thousand pages: “Treatise on Hallucinations” (1977). Only the first part, “Birth of Medicine”, of what would prove to be his final, uncompleted work, received posthumous publication (1981). Several of the works we have mentioned have recently been reprinted. A Perpignan-based body, the Henri Ey Foundation, is given over to the preservation and study of this crucial contribution to 20th-century psychiatry. Jean Garrabk

Principal works

EY (H.), Halltrcinations et ddire [Hallucinations and delusion] (preface by J. SCglas), Paris, Alcan, 1934. EY (H.) and ROUART (J.), Essai d’application des principes de Jackson 2 une conception dynamique de la psychiatrie [Attempt to apply the principles of Jackson to a dynamic conception of psychiatry], 1975. Reprint (preface by J.-C. Blanc), Paris, L’Harmattan, 1997.

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EY (H.), “La psychopathologie de Pierre Janet et la conception dynamique de la psychiatrie” [The psychopathologies of Pierre Janet and the dynamic conception of psychiatry], in M6langes oferts d Monsieur Pierre Janet [Mixtures offered to Mr Pierre Janet], Paris, D’Artrey, 1939. EY (H.), Estudios sobre 20s delirios (1950), reprin (Evocacion de H. Ey, J. Garrabk), Madrid, Triacastela, 1998. EY (H.), BERNARD (P.) and BRISSET (Ch.), Manuel de psychiatrie [Manual of Psychiatry], Paris, Masson, 1st edition 1960, 6th edition 1989. EY (H.), La Conscience (Consciousness), Paris, Desclke de Brouwer, 1st edition 1963, 3rd edition 1983. EY (H.), “Esquisse d’une conception organo-dynamique de la structure, de la nosographie et de l’ktiopathogknie des maladies mentales” [Approach to an organo-dynamic conception of the structure, the nosogroaphy and the aetiopathogenesis of mental diseases], in GRUHLE (H.W.), JUNG (R.), MAYER-GROSS (W.), MULLER (M.) eds, Psychiutrie der Gegenwart. Farschung une Praxis. Baud 1/2. Grundlagen und Methoden der Klinischen Psychiutrie, Berlin, Springer, 1963, p. 720-742. EY (H.), Trait4 des hallucinations [Treatise on hallucinations], Paris, Masson, 1973. EY (H.), Nuisance de la midecine [Birth of medicine], Paris, Masson, 1981.

EY (H.), Schizophrtkie. Etudes cliniques et psychopathologiques [Schizophrenia. Clinical and psychopathological studies], Introd. J. Garrabk, Le Plessis-Robinson, Les Empicheurs de penser en rond, 1996.

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Bibliographical references “Hommage A Henri Ey” [Homage to Henri Ey], L’,6volation

pychiatrique, 1977, XLII, 111/2, p. 605-1138. GARRABE (J.), Henri Ey et la penske psychiatrique contempomine [Henri Ey and contemporary psychiatric thought], Le Plessis-Robinson, Les EmpGcheurs de penser en rond, 1997. PALEM (R.M.), Henri Ey psychiatre et philosophe [Henri Ey psychiatrist and philosopher], Paris, Rive droite, 1997.

Actualite‘ de l’euvre de Henri Ey [Update on the work of Henri Ey] (international Perpignan colloquium, 3 1 0ct.-1st Nov. 1997), Paris, L’Harmattan 1998.

The Psychopathology of Pierre Tanet and the Gynarnic Conception of Psychiatry

Today, much is said about “dynamism”, about “dynamic” disorders, and perhaps it is sometimes nothing but talk for the sake of talking. There are, to my knowledge, three genuine great dynamic conceptions, that of Jackson, that of Janet, and that of Freud. Why are all three of these dynamic? Because they take account of the concept of force. What defines a dynamic theory in pathology is the perception of the state of health as a balance of forces and the state of illness as a disturbance in this balance. But in that case, it will be said, are not all physicians “dynamists”? No, for since the quarrel between the physicians of Cos and the physicians of Cnide, many doctors have perceived illness as the juxtaposition of a body foreign to the organism, like a parasite) which produces symptoms which are in some way independent of those systems of forces that are the physiological functions. For them, pathology is reduced to a few simple anatomo-clinical relations which can be understood with no special study of the prior physiological functional equilibrium. In mental medicine, this tendency, opposed to

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B

1. The ideas of Monakow and of Mourgue are so profoundly Jacksonian in ins iration that, interesting as they are, we will not give them special consi eration here.

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the ancient Hippocratic spirit and to any dynamic conception, is even preponderant. It is expressed, in the simplest manner, in the claim that the study of the physiological functions and of the balance of forces of the personality is absolutely unnecessary in the diagnosis and understanding of mental disorders. To put it yet another way, while dynamic conceptions in psychiatry require study of the hierarchy of the functions destroyed by illness, mechanistic conceptions claim to do without such study. As can be seen, the notion of dynamic equilibrium is thus neither so general nor so widespread as might be imagined. This should further add to the merits of those who have fought to defend this ancient tradition of medicine which, going beyond “vitalism”, comes close to “naturism”. It is from this perspective that the immense work of Pierre Janet can be appreciated at its proper value. Naturally, in psychiatric circles, so generally imbued with the “mechanistic” spirit, this work strikes few echoes. There is something a trifle amusing in the form of synonymy which in this respect has made its appearance in psychiatric studies. The sole purpose of the word “psychasthenia”, that neurotic mechanism of psychical weakness, was to replace the term obsessional neurosis, a term which the majority of alienists adopted without accepting the dynamic conception which it implies. We believe that the work of Pierre Janet has greater merits than that of being responsible for certain patients being labelled, wrongly, as psychasthenic. My intention in this brief study is to reveal the deeper meaning of that work. I undertake this examination by reference to the conception which I personally find the most satisfactory, that of Jackson, the principles of which I have sought to establish in concert with J. Rouart. Now, if we compare this manner of seeing with the psychopathology of P. Janet, we are struck

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1. Henri Ey and J. Rouart, Essai d’application de principes de Jackson d une conception dynamique de la neuro-psychtatrie. Preface by Prof. Claude. One volume. Collection de Monographies de l’Encipahle, Paris (Doin, 1938).

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by the essential similarity of the dynamic conception which animated them both. This is particularly obvious from a reading of the collection of lectures which M. Janet published in 1932, under the title: La Force et la Faiblessepsychologiques [Psychological strength and weakness] (ed. Maloine). The three major “Jacksonian” principles are as follows: 1. Sickness dissolves hierarchical functions; there is therefore a need to study typical “levels of dissolution”. 2. There are two modes of dissolution: isolated dissolutions and uniform dissolutions of the functions of relational life. The former correspond to the disorders studied in neurology, the latter are states of insanity studied in psychiatry. 3. Any study of the disorders of the hierarchical functions must be conducted from a dual perspective, since certain of these disorders are the consequences of a deficiency (negative disorders), while the others reveal the surviving contribution of the neuro-psychical functions (positive disorders). Let us therefore see what resemblances and what differences can be revealed between the psychopathology of Pierre Janet and this dynamic conception.

I. THEHIERARCHY OF THEPSYCHICAL FUNCTIONS AND THE DISSOLUTION OF THE PSYCHICAL FUNCTIONS IN THE WORK OF P. JANET. The fundamental aspect of the thought of M. Pierre Janet is perhaps his hierarchy of the functions of the real, with its underlying psychological tension. For him, that which we call the psychical functions are nothing other than a series of behaviours, which govern our connection with reality. It is as if human activity took place on a scale of increasingly 1. The page numbers referred to in brackets in this paper refer to this work.

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complicated and difficult levels of thought up to the apprehension of the world of objects. There is thus a series of functions or of degrees of the real which, without too much betraying M. Janet’s thought, we can present as follows (cf. Force et faiblesse psycbologiques, p. 24): The first degree (the least objective) is that where we somewhat confusedly feel ourselves think; it is, one might say, the awareness of thinking, the first Cartesian term of knowledge.-The second is that of ideas, those subjective psychical combinations which strive towards the real and are already at one remove from the purely subjective.-The third, that of the imagination, is where, in the form of fictions, we construct realities which correspond to our behaviour in play. The fourth is that of the dead past which is a reality, already more real, one might say; it is memories of real things which correspond to our memory behaviours.-The fifth degree is the distant future which is governed by our predictive behaviours-The sixth degree is the ideal which corresponds to our purposive behaviours.-The seventh, the degree of the recent past, which is lived almost as the present and comprises a series of feelings of “presence”.-The eighth is that of the near future, governed by behaviours of expectation and preparation.-The ninth degree is that of our psychical present, our currently conscious psychical reality.-The tenth, that of our present actions, corresponds to the feelings which regulate our actions.-The eleventh is that of current events, an even more synthetic construction of the present.-The twelfth degree, that of spiritual and social reality, includes all the behaviours which attach us to others.-Finally, the thirteenth is that of the reality of objects, the existence of external bodies, separated from our mind by that operation which is the perception of the real. Certainly, such a classification might appear arbitrary, in terms of the number of degrees, which can be increased

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indefinitely, but it would be a great mistake (one which is very generally made) to consider this hierarchy of the functions of the real as a purely abstract view. In reality, M. Pierre Janet likes to make his studies look simple, but the didactic and wonderfully Socratic nature of his teaching reveals, to those ready to understand, a powerfully “phenomenological’’ and deeply lived penetration of the real. Whether he is examining the “behaviour of the apple basket” or of “waiting and expectancy” or of “command and obedience”, his work concentrates totally on concrete facts. From the point of view that concerns us, the hierarchy of the functions of the real corresponds to the development of the functions in a genetic perspective which, moreover, often shows through the analyses. The constant reference to primitive, archaic types of thought combines with Jackson’s idea of the evolution of the functions and reveals its Spencerian inspiration. If we might be permitted to express one regret in this regard, it would be that M. Janet did not delve more profoundly into the layers of the instinctive life and did not look, in this respect and from this resolutely genetic point of view, at the hierarchy of the functions of the real in terms of the evolution of the instinctive life. It is here that, without mutual exclusion, Janet and Freud could and should complement each other. It is well known how M. Pierre Janet largely began by dealing with the neuroses, and the extent to which his studies on hysteria and the obsessions remain valid. Hysteria should (the remark has been made too often for there to be any need to insist), it would seem, have led M. Janet, through his studies on hypnosis, to a deeper analysis of the instinctual mechanisms of the unconscious. He looked at these disorders in a purely ”formal” manner, using the notion of the shrinking of the field of consciousness, which is also a sort of regression. But it was above all his study and his interpretations of obsession, or rather of obsessional psycho-neurosis, which were the starting point for Janetism. Obsession is not an isolated phenomenon, but a state of

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weakness of psychical activity, of the psychological tension, a weakness such that psychical strength, unable to express itself through its higher acts, disperses to lower levels of behaviour and derived ideas. Since then, this fundamental scheme of a lowering of psychological tension and of disorders of the functions of the real has been properly extended by Janet to most of the other psychopathic states. He said that “dementia pruecox” was in this respect a form of “psychasthenic dementia”.-As regards manic states, he showed how agitation (p. 105 to 106), far from a condition of strength, is on the contrary a waste of strength, brought about by a failure of control, which can, to a certain extent, make them comparable with “epileptic discharges” (p. 92 to 104). His writing on epilepsy is entirely Jacksonian in spirit, and it is a matter of surprise that, in speaking of the epileptic attack as a loss of control, as a phenomenon of de-inhibition, not once in the book to which we refer did Pierre Janet refer to the work of Hughlings Jackson. This entire book in fact constitutes a very effective effort to connect with weakness of psychological tension, or if you like with the dissolution of the psychical functions, a whole series of psychopathic states which the author perceives, sometimes jokingly, as lower level “economic balances”. However, it is above all with regard to delusions and hallucinations that his thought coincides very precisely with the dynamic conception inspired by Jackson’s principles. This needs to be underlined. These psychopathic aspects, delusions of persecution, of influence, all delusional hallucinatory activities, are such that the dynamic conception seems difficult to apply to them unless there are first subjected to rigorous analysis. O n this point Janet’s work, far outstripping (does it need to be stressed?) our own efforts in this respect, has brought some definitive 1. I hope I may be permitted, in homage to M. Janet, to make particular reference to two of my own works. While M. Janet was writing his article on the “the beliefs of the hallucinated person” (Revue philosophzque, 1932), I was writing mine on “the belief of the hallucinated person” (A.M.P., 1932).

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clarification. These troubles can only be perceived as disturbances in belief behaviours and in the feelings which correspond to them. “The delusive is an individual who ranks his speech poorly in the hierarchy of degrees of reality” (p. 15). He is also an individual in whom the psychical operations are broken down into their primitive elements, essentially double by the very structure of social functions and notably of language. For those who have understood this, delusion and hallucination, envisaged within this dynamic perspective, become very clearly understandable. Thus the psychopathology of Pierre Janet as a whole fully coincides with the first Jacksonian principle. It considers mental illnesses as regressive, inferior manifestations of thinking which, as it weakens, becomes distanced from the real and produces, before it disappears-I was going to write, before it falls asleep-the whole range of states of madness.

11. NEUROLOGICAL DISORDERS AND PSYCHOSES. We have just briefly recalled the essence of Janet’s psychopathology with regard to neurotic and psychotic states. It should moreover be stressed that, for him as for us, the distinction between psychoses and neuroses, “convenient in practice, is absolutely false from the clinical point of view.. .it is a difference which is relevant to policemen and lawyers, but of no interest to physicians” (p. 3). However, things become much more complicated in psychological problems, due to the fact that there is a pathology of motor and sensory disorders of a neurological type, Soon after his works on delusions of persecution (lournal de sychologie, 1932), my little volume “Hallucinations and delusion” was publis ed, a work which, I believe, is so closely allied to the conception of P. Janet, that I can see in it nothing other than the elaboration in my thinking of that of the Master to whom I had passionately listened, ten years earlier, at the Colkge de France.

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a pathology which, if one is “psychologically minded”, one is reluctant to associate with psychiatry, and which, if one is “neurologically minded”, one associates purely and simply with mental medicine. M. Janet very clearly stated his position with regard to this problem in the pages (p. 9 to 15) dealing with the distinction between organic disorders and functional disorders. Having rejected the division between acquired and constitutional psychoses (which is similar in fact, from a certain point of view, to the one that follows), he concluded that there is a difference between “organic illnesses and functional illnesses”. Here are a few passages (p. 9 and 10) which are characteristic of his perception:

“I would be disposed to maintain a distinction which today remains highly incomplete, the strange distinction between what are called organic diseases and functional diseases. This distinction is one that is quite often applied. For example, take a man who has just suffered a brain haemorrhage and presents hemiplegia with loss of speech. The diagnosis consists of saying: in this man certain organs indispensable to the function of walking or speech have been destroyed. The diagnosis is one of organic destruction. O n the other hand, here is a young person who presents the same paralysis of the right side and phenomena of mutism. One might, by certain specific observations, by a study of all the reflexes, a psychological study of all the functions, say: it’s strange, there are no organs destroyed, there is no organic destruction which corresponds to her paralysis of the right side or to her mutism. Essentially, her organs are healthy; she could easily speak and walk; why doesn’t she? We say: she does not because she is not functioning. We can understand this example better by looking at mechanical objects: here is an automobile which ran for a certain time on the road and which, faced with a slight slope, a gentle slope, comes to a halt: it goes no further. Whatever adjustments are made to the controls, nothing

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moves; something in the car is not working. You can have two different accidents, two forms of accident and it is very important for the driver to make the diagnosis for treatment. Why does this machine not work?-Because it is broken. This often happens. One of the wheels is broken and prevents the others turning: this is an organic destruction. The automobile needs to be dismantled to find the broken part: there is an organic lesion. However, after examination, you might also say: nothing in this car is broken; the fact that it does not go is not due to damage, nor to internal breakage; it will not go quite simply because the petrol tank is empty. This is not the same thing as the previous accident. This distinction immediately invites discussion. Is the notion that I have just expressed-organic lesion and functional disorders-perfectly clear? This distinction assumes a strange principle: it assumes that, in a living being, there may be serious disorders without any organic change, disorders which formerly were called functional, and are now called psychasthenic. “All these disorders were understood as conditions which applied to the spiritual principle, to the element in us which is not visible. Now, is this conception admissible today? Is it true that in the functional disorders of the neuropath who has no cerebral impairment, there is no impairment elsewhere? I have just told you that there are diseases of the liver, of the intestines, that there can be every kind of intoxication, there is no disease without lesion, and it is neither logical nor correct to suspect such a thing.” Without forcing the issue, one could say that the distinction admitted by Janet, between “organic” disorders and “functional” disorders, is nothing other than the Jacksonian distinction between isolated dissolutions of a neurological 1. This final and important sentence would greatly surprise all those who, seeing M. Janet as a “psychologist”, cannot even conceive, and are entirely unaware, that his view not only does not rule out but requires an organic cause for psychoses.

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type and uniform dissolutions of a psychiatric type. Only, when these terms “organic” and “functional” are used, they serve to obscure a classification which, under the form: isolated dissolutions or ungorrn dissolutions, is perfectly clear. For to say that certain disorders of the relational life, certain disorders of our movements, of our sensations, of our behaviour are sometimes organic and sometimes nonorganic is, as M. Janet clearly emphasises, somewhat strange, since all depend on organic lesions. And, one might add, to say that some of these disorders are “functional” and others “non-functional” is also to have a very strange idea of the psycho-motor functions, for all of them, whether it be a disorder of motility or an obsession, are disorders which disturb the functions of the relational life. I think that the distinction which we have “exhumed” from Jackson’s conception, between partial (or “local”) isolated dissolutions of the basic sensory-motor functions and uniform dissolutions of psychical activity, arranged into a series of psychopathic levels, is the only one which can shed a little light on this matter, which is essential to a correct understanding of the relations between Neurology and Psychiatry. Let us stop here for a moment. Here we have a cut nerve, and a series of movements are lost; here again a softening of the brain, and disorders of the visual functions: in both cases, the disorders are partial; certain movements and certain perceptions no longer occur or are impaired. Here now is a patient suffering from catatonia: he has delusions, his entire social life is impaired, he refuses to eat, he speaks not a word; or here again is a man who is distressed because all his actions fall under “prohibitions”; he can do nothing without believing that every one of his actions is going to give him the croup: in both cases we have disorders of the personality and of the psychical life as a whole; it is as if the functions of adaptation to the real or the higher psychical functions no longer operate normally. That is the concrete meaning of the distinction. Let us ask ourselves a question on this subject. Are there

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lesions in both occurrences? M. Janet believes, as we do, that there are. Simply, we recognise that the disorder structure is not the same; M. Pierre Janet perhaps goes further than us in thinking that, in cases of neurosis or psychosis, it is general somatic problems, congenital or acquired, and not nervous ones, which produce psychopathic syndromes. This must sometimes be true, but it seems evident that many brain processes also cause the psychical functions to regress, in a uniform and global manner, to levels that are characteristic of the different psychoses. The pathology of intoxication, of hereditary defects, of syphilis, of epidemic encephalitis, of brain tumours, of degenerative brain disorders, etc. provides more than enough evidence of this. Thus, except with regard to this latter point, we find in the work of M. Pierre Janet, in terms which he himself judges inadequate, perfect agreement with the Jacksonian distinction (the basis of the definition of neurological fact and psychiatric fact), between isolated sensory-motor functional dissolutions and uniform dissolutions of psychical activity. But the point at which the agreement between the two conceptions is the most marked is this: in both cases (and for psychoses and psycho-neuroses as well as neurological disorders) these two types of disorder of the relational life are determined by organic disorders, for as Janet wrote in the passage quoted above: “There is no disease without lesion, and it is neither logical nor correct to suspect such a Ihing.’’

111. DEFICIENCY DISORDERS A N D THE MECHANISM OF THE SYMPTOMS In the Jacksonian conception of psychopathic states, a distinction is made between negative signs of destruction or impairment of the functions, and positive signs which indicate the survival of certain functions. We know how such a dstinction overlaps with M. Bleuler’s distinction between

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primary and secondary signs. This is also one of the fundamental aspects of a dynamic conception, in which the symptoms of an illness are seen as governed, certainly, by organic aetiological factors, but which refuses to accept that the lesion mechanically creates all the symptoms. I have often stated in this respect that we can only understand the relations which link the symptom to the lesion if we assume a gap between them, the organo-clinical gap, filled by the surviving psychical forces. Such a view of things explains the active character of the symptoms, which cannot be explained without reference to systems of forces, to underlying functions. It is this point of view in M. Pierre Janet’s conception which, it seems to me, is the least “elaborate”. Certainly, it is there, as necessarily present in any dynamic conception, but M. Janet seems to have concerned himself most especially with deficiency disorders, and less with the surviving psychical aspect, whence the lack of this clear distinction in his work. In this respect one might see in M. Janet’s work a dynamic conception that is more “formal” and “intellectual’’ (applied almost exclusively to the higher, and notably to the social, functions), than emotional and instinctual. It is in this that he differs from M. Freud, And yet, in the Jacksonian conception, which up to now we have been able to match rigorously to Janet’s theory, it seems natural and obvious to include, in the different levels of dissolution of psychical activity, those unconscious forces which organise it. All regression is not only a weakness, as M. Janet says, but it is also a release of the lower forces, which themselves have their history. To the point that a genuine “natural history” of psychopathic states should be both a pathology of the lost functions, admirably studied by Janet, and a pathology of the positive symptoms, full of surviving psychical powers. This is the point, we feel, and as I have already indicated, where Pierre Janet’s studies should find their complement in those of Freud, at least within the perspective of a Jacksonian organic conception. By this means

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perhaps, Janet’s psychopathology, by including into the very basis of his system the notion of an instinctive force, which is lacking in it, might cease to be so indifferent to contents, to tendencies, to affective powers, in fact, tofeelings, envisaged not only as regulators of functions, but as phenomenological realities. For that which appears in the Janet’s theory as a lack which his brilliant conceptions have never been able completely to overcome, is the absence of a driving force: instinct. For my part, I believe that any dynamic conception is necessarily “vitalist”. That is why it is in such powerful conflict with medical theories, which have their origin in 19th-century mechanistic atomism. That is also why I may perhaps be forgiven for regretting that M. Janet, who did so much in psychiatry to fight against mechanistic doctrines, is not sufficiently “Jacksonian” and “vitalist” to recognise the importance of instinct in the evolution and the dissolution of the neuro-psychical functions.

We were saying at the beginning of this short paper that there are three dynamic conceptions of neuro-psychiatry, Jackson’s, Janet’s and Freud’s; let us briefly compare them. A Jacksonian, i.e. fully dynamic, conception, is based on three principles: 1. The pathological is incomprehensible without the notion of a hierarchy and a development of functi0ns.A. The pathology of the relational life comprises a neurological pathology, of so-called isolated dissolutions, and a psychiatric pathology, of so-called uniform dissolutions. In these two domains, disorders are due to somatic or cerebral organic lesions.-3. The whole symptomatology of the levels of dissolution consists of the study of negative deficiency disorders (higher functions destroyed or disturbed), and of positive disorders corresponding to the contribution of surviving functions. From the latter point view, the

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development of symptoms allows and requires the play of the lower instinctual powers. For Freud, there is total agreement on the first Jacksonian principle. As regards the second and third, however, the divergence is very great. Freud recognises the psychogenesis of psychical disorders, i.e. that there is no dissolution by organic factors, and hence no negative disorders, in certain uniform dissolutions described as neurotic. If we now compare the psychopathology of Pierre Janet with Jacksonian theory and Freudian theory, the points of resemblance and difference will emerge clearly. Janet differs from the Jacksonian conception only insofar as he does not give the same importance to the development of positive disorders by instinctive and subconscious underlying powers, although this difference is simply incidental to the system. Janet differs from Freud, as does Jacksonism itself, in that he does not recognise the pure psychogenesis of psychopathic states, and moreover does not include in his psychopathology the influence of the instinctual life. It is easy to see the advantage of “Jacksonism” as a synthetic dynamic doctrine: it makes it possible to extend “fJanetism” as fir as “Freudianism” without filling into the latter’s errors and excesses. The reflections we have just presented aim to highlight what is to us the primordial aspect of the “dynamism” of Janet’s psychopathology, in other words its close solidarity with Jacksonian principles, which bring it into proximity to Freudian psychopathology. The significance of M. Janet’s magisterial work clearly does not require the help of Jacksonism to be obvious to any thoughtful individual, but it seemed to us that the comparison of these two perspectives might contribute to a better understanding of the profound biological significance of so fertile a doctrine. We have mainly referred in this paper to the recent work of M. Pierre Janet, and to the essential principles of a conception, of which the psychasthenic theory of obsessions constitutes only a fragment; but we must again stress the

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historical function of his studies, an authentic link between the psychiatry of the 19th century and that of the 20th. The theory of the different degrees of psychological tension provides a route from the nosography of the end of the last century to the current psychiatric movement. Not the least interesting aspect of this gigantic work, begun at the Salpctriitre and continued at the Collige de France, is the profound continuity of M. Pierre Janet’s views. Nothing could be more interesting in this respect than the studies on “psychological automat ism”, “neuroses”, “idlefixes” ,‘‘0bsessions”, “anxiety”, “ecstasy” and “psychological medications”, which emerged in the development and construction of that remarkable dynamic conception. One does not know which is the more greatly to be admired, the ingenuity or the profundity in the work of this great master of French psychiatry, incarnating as he does in one harmonious whole the spirit of finesse and the spirit of geometry.

Principal references

ALEXANDER (F.G.) and SELESNIK (S.T.), The History of Psychiatry :an Evaluation of Psychiatry Thought and Practicefrom Prehistoric Times to the Present, Harper and Row, New York, 1966. Trad. frang. Armand Colin, Paris, 1972.

BERRIOS (G.E.), The History of Mental Symptoms, Cambridge University Press, Cambridge, 1996. ELLENBERGER (H.F.), The Discovery of the Uncon-

scious, The History and Evolution of Dynamic Psychiatry, Harper Collins, 1970. Trad. frang. (2‘ id.), Histoire de la dkcouverte de l’inconscient, Fayard, Paris, 1993. GOLDSTEIN (J.), Console and

Clusszh.The French psy-

chiatric Profession in the Nineteenth Century, Cambridge University Press, Cambridge, 1987. Trad. franC. Consoler et classtfier, Les Emptcheurs de penser en rond, Le PlessisRobinson, 1997. MOREL (P.), Dictionnaire biographique de la psychiatrie, Synthelabo, Le Plessis-Robinson, 1996.

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PICHOT (P.), Un sidcle de psychiatrie. 2' id., Le PlessisRobinson, Les Empccheurs de penser en rond, 1996. PICHOT (P.) and REIN (W.) L 'approche clinique en psychiatrie. The Clinical Approach in Psychiatry, Le PlessisRobinson, Les Empccheurs de penser en rond, 1993.

POSTEL (J.), Dictionnaire de psychiatrie et de psychopathologie clinique, 2' kd., Larousse-Bordas, Paris, 1998. SEMELAIGNE (R.) Les Grands Ali6nistes frangais (t. I), Steinheil, Paris, 1894. SEMELAIGNE (R.), Aliknistes et philanthropes (les Pinel et les Tuke)' Steinheil, Paris, 1912. SEMELAIGNE (R.), Les Pionniers de la psychiatrze frangaise, Baillikre, Paris, (t. I), 1930, (t. II), 1932. WEINER (D.R.), The Citizen-Patient in Revolutionnary and Imperial Parisy The John Hopkins University Press, Baltimore, 1993. ZILBOORG (G.)yA History of Medical Psychology, Norton and Co , New York, 1941.

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