Psychiatry, or the science of mental diseases, is one of the fruits of
the century now drawing to its close. It was only in 1792 that Pinel
struck the fetters off the patients at the Bicêtre and began to treat
them humanely; and as late as 1818 Esquirol reported to the ministry
that criminals, not to say brutes, were better treated in France than
were the insane. The progress of this youthful science within the last
decades may, however, be contemplated with some degree of satisfaction,
and with a strong confidence that the stream of knowledge will be
poured out in still fuller volume in the years to come.
Maturer studies and better-reasoned treatment are gradually enlarging
the class of mental disorders that are curable. Society has also to
thank modern researchers into the causes--the etiology--of those
diseases. By this study we are enabled to oppose the production and
spread of those maladies; and general information about their causes
will directly contribute to the well-being of the community.
Derangement of mind has in all ages had no inconsiderable influence
upon the course of history and the development of civilization; there
is much in society that is mentally unwholesome and many crazes that
psychiatry can show how to avoid. That insanity is a disease of a
particular organ, biologically indistinguishable from a somatic
disorder, was, in former times, not understood. The notion of madness
was mixed up with religious faiths and metaphysical theories. Thousands
were burned at the stake simply because men were not so far enlightened
as to recognise that their victims were mentally sick, instead of
being, as they imagined, bewitched or possessed by devils. Think,
too, of the multitudes of entirely sane and innocent persons who were
sent to the rack and the stake upon the accusations of madmen--mere
crazy delusions! Along with such dreadful results of ignorance, and
contributing to them, we find, in ages widely separated, men’s general
conceptions of the course of nature influenced by superstitions and
religious enthusiasms fostered by the behaviour of the insane, and
accepted largely in deference to teachings of bewildered minds.
About the end of the eighteenth century the sad veil of superstition
began to be lifted. Yet the pathway of knowledge was still a thorny
and difficult one. Many an obstacle remained to be removed. Many a hot
fight had to be fought out. Often and often, even in this nineteenth
century, theologians set their traps to render the scientific pathway
personally perilous. Even as elevated a mind as Heinroth declared that
the cause of insanity was sin.
Alienists to-day no longer regard mental and bodily maladies as
distinct. In the majority of bodily diseases some affection of the
mental powers is observable; so that no scientific physician will
overlook the importance of psychical influences. On the other hand,
bodily symptoms occur in by far the greater proportion of cases
of insanity. We can sometimes predict a severe and almost fatal
derangement of the mind, at a time when hardly any aberration has yet
appeared, on the strength of somatic symptoms that no ordinary person
would remark. Thus, mental and bodily disease are quite inseparable;
and a rational treatment of psychoses must be based upon a solid
foundation of general medical skill.
In spite of all these facts, attempts are still made to withdraw the
care of the insane from the hands of physicians and to intrust it to
the clergy. At a meeting of the German Union of Evangelical Curates of
the Insane, the Rev. von Bodelschwingh, while admitting that “modern
medico-scientific psychiatry had done good service in the recognition,
treatment, and cure of the insane,” yet censured it as “at bottom
materialistic and temporal.” “It leaves,” he said, “sin and grace,
conscience and guilt, quite out of sight, and does not recognise that
forgiveness of sins brings life and spiritual health.” He continued
as follows: “Speaking broadly, the less the bodily physician uses his
_materia medica_ in mental maladies, the better. Such things, for the
most part, only damage body and soul. The bodily physician may be
helpful in the care of the insane, but the prime thing is the treatment
of the sick soul; and this should not be intrusted to the physician in
the main.”[1]
Such utterances are, of course, merely the efforts of the clergy to
extend their power. But inasmuch as they tend to injure patients, not
to say society itself, the interests of civilization call upon men of
science to combat them.
Nor is it by the clergy alone that attacks upon psychiatry are made.
Various causes have conspired to create of late years some distrust
of this branch of medicine. The general public is naturally liable to
misinterpret cases of insanity in which the symptoms are not so obvious
that no onlooker can mistake them, and where the practised eye of the
specialist is required to detect their real nature. Then, too, the not
infrequent differences of opinion among experts in insanity, leading,
as they often do, to contrary judgments about the nature of individual
cases, are cited as so many proofs that psychiatry is an illusory
science, and that its practitioners are not to be trusted to decide
upon the fate of a man.
But this is altogether fallacious. Similar objections would lie against
any other practical science. Name, if you can, the branch of clinical
medicine in which doubtful cases do not occur, or where divergences
of opinion are less frequent than in psychiatry itself. No science
whatsoever is perfect or infallible. In every field our knowledge and
skill have their limits, and there are disputed marches between the
completed conquests of science and the regions her armies have not yet
invaded. Cases in law, as everybody knows, are continually arising
concerning which the greatest jurists pronounce diametrically contrary
opinions. Yet the ideas and terms with which the lawyer has to deal
are, from the nature of things, susceptible of more rigidly exact
definition than those which form the stock of the alienist.
In point of accuracy, psychical pathology simply stands upon the
general level of other branches of clinical medicine. There are
cases upon the border line between insanity and mental sanity, and
concerning them differences of opinion are unavoidable. But how can
that be considered to detract from the value of the general science?
Mistakes occur wherever human judgment has to be exercised. Indeed,
every remarkable advance of human knowledge is secured at the cost of
temporary errors.
No doubt many tendencies in modern psychiatry spring from erroneous
conceptions. The very purpose of this book is to contribute something
toward the clearing up of certain psychological and psychiatrical
notions which have already occasioned not a few disputes and
misunderstandings.
The wisdom of early ages burned the insane as witches and sorcerers,
or, at best, incarcerated them in dismal dungeons and loaded them with
chains. Down to the very beginning of this century insanity was hardly
recognised as a branch of medical science. But now the pendulum has
swung the other way, and there are efforts in many quarters to narrow
more and more the boundaries of mental sanity, until every mind,
decidedly unlike those we daily come in touch with, or manifesting any
extraordinary characteristics is labelled as diseased. Not only are the
less gifted--particularly criminals--frequently considered as insane,
but eminent writers go so far as to pronounce every mind whose capacity
greatly surpasses the average to be a pathological subject.
Such doctrines are examples of a class of errors which frequently
arise from the gradual modification of the meanings of scientific
terms that had never been distinctly apprehended. Among such terms are
those of Genius and Degeneration; and to analyze these conceptions
is the purpose of this work. Their psychological and psychiatric
significations have, as we shall find, been most diversely conceived,
and this has led to many misunderstandings.
Before we enunciate our proper theses it will be convenient briefly
to consider the main symptoms of insanity, so that we may be able
to estimate how far we are in a condition to draw any sharp line of
demarcation between mental sanity and mental disease.