THE HISTORIOGRAPHY OF PSYCHIATRY AND ITS DEVELOPMENT: A RE-EVALUATION*

GEORGE MORA

Astor Home for Children, Rhinebeck, New York and Yale School of Medicine

Pinels treatise on mental diseases, which describes his new approach to the treatment of mental patients-thus beginning modern psychiatry, is preceded by an historical description of the early methods of treatment of mental patients whose value in psychiatric historiography has thus far not been duly noted. Thus, psy- chiatry and the history of psychiatry were initiated simultaneously at the end of the eighteenth century in the climate of belief in humanity and in progress of the French Enlightenment. The nineteenth century emphasized exclusively Pinels importance as the initiator of modern psychiatry. But in the last two decades, the emphasis has switched from this historical event more to attitudes toward mental patients and beliefs regarding causes and treatment of mental disorders; attitudes and beliefs which can be traced back as far as humanity has existed, though it remains question- able whether they are an intrinsic part of psychiatry. In fact, while various branches of behavioral sciences have succeeded in delimiting their scope and boundaries in historical terms, psychiatry instead has increasingly presented uncertainties in regard to its scope and its boundaries.

With the advent of dynamic psychotherapy in the last few decades, many forms of human relationships and rituals performed by primitive and ancient cultures in the context of religious and magic practices have been ascribed to the realm of psy- chological healing. It is enough to think for a moment of the interpretation of dreams as performed in primitive cultures, such as the aboriginal Indians or the rites of shamanistic initiation, to understand the implications of this new position.2 Furthermore, psychiatry itself has come to signify, in addition to the traditional meaning of professional treatment by the doctor on the patient, a whole variety of forms of dual and multiple influences on people aflicted with emotional disorders. Thus, the history of psychiatry has greatly enlarged its spectrum by including these early expressions of treatment of mental diseases in its boundaries. The result has been that the end of the eighteenth century, rather than representing the official beginning of psychiatry-as traditionally is held in the history of psychiatry, has come to signify the passage from unconscious forms of psychological healing in cultures and eras unaware of the importance of psychological problems to the intro-

*A modified version of this paper was originally presented at the Xth International Congress of the History of Science, Ithaca-Philadelphia, August 26-September 2,1962. The bibliographic citations have been brought up to date.

See in particular the early literature on, social sychiatry by E. Sapir, R. Benedict, M. Mead, G. Roheim, as well as the more recent studies by 8. Kluckhohn, M. K. Opler, A. J. Hallowell, A. Kardiner, G. Bateson, G. Devereux, E. Erikson and others. A survey on this topic is in: C. Kluck- hohn, The influence of psychiatry on anthropology in America during the past one hundred years, in J. K. Hall (ed.), One Hundred Years of American Psychiatry, New York, Columbia Univ. Press, 1944; see also La Barre W., The Influence of Freud on Anthropology, Amer. Imago, 1958,15,275-328.

%ee, for instance, for the interpretation of dreams by Indians, M. K. Opler, Dream analysis in Ute Indian therapy, in M. K. Opler (ed.), Culture and Mental Health, New York, Macmillan, 1959. For the shamanistic rites of initiation: E. H. Ackerknecht, Psychopathology, primitive medicine and primitive culture, Bull. Hist. Med., 1942, 14, 30-67; Boutellier M., Chamanisme et gudnson mqique, Paris, Presses Univ. France, 1950; Eliade M., Le chamanisme et les techniques de lextase, Paris, Payot, 1951; H. Ellenberger, The ancestry of dynamic psychotherapy, Bull. Menninger Clin., 1956, 20, 288 299. See also in general: Frank J. D., Persuasion and Healing. A Comparative Study of Psycho- pathology, Baltimore, Johns Bopkins Press, 1961.

43

44 GEORGE MORA

duction of forms of psychiatric treatment based on the recognition of psychological factors (moral treatment) .3 Clearly, such an historical landmark-as any other in history-may appear a t times artificial inasmuch as there are exceptions on both sides of it. But, in general, this landmark has its justification so to assume great value in the whole historiography of psychiatry. These considerations on this new position of todays psychiatric historiography have been anticipated here in these terms because thus far they do not seem to have been given enough emphasis. In- deed, a simple review of the development of the history of psychiatry in the last century and a half offers the ground for a much-needed re-evaluation of its own basic assumptions in the light of this newly-introduced viewpoint.

The jirst period of psychiatric historiography thus began with Pinels 23-page historical introduction to his Treatise on Insani ty (1801).4 Of course, many previous authors of psychiatric literature had taken notice here and there of their predecessors. But these early attempts had been highly unsystematic and frequently anectodal, with emphasis on the dramatic and unusual events of the past, taken out of the historical context of their time.6 The philosophy of blind assent to the ancients-in line with the Galenic tradition-still dominated these writers, so to make their descriptions of the early psychological symptoms and forms of treatment a source of amazement and of wonder more than of critical knowledge. The same episodes, such as the history of Erasistratus description of the psychosomatic symptoms pre- sented by King Seleukus son, secretly in love with his stepmother, Stratonika (as narrated by Plutarch and by Lucianus),6 or the miraculous properties of the helle- bore, were monotonously repeated from one author to another. Furthermore, truly significant events, such as the enlightening attitude toward mental patients by physicians-like Aretaeus and Soranus-of the second century A.D., were reported in the same style of amazement and wonder so to deprive them of their positive value. We have to arrive at the end of the eighteenth century, a t which time the

3Unquestionably, early forms of moral treatment can be traced back to the Roman times (Aretaeus, Soranus, first - second centuries A. U.) and to the period of splendor of the Arabic culture (eighth - ninth centuries A. D.). For the late Roman times, see: Caelius Aurelianus, On Acute Dis- eases and On Chronic Diseases, (Eng. Tr.), Chicago, Univ. Chicago Press, 1950, p. 545 ff.; Jelliffee E. S., Notes on the history of psychiatry (trans. of the important works on Greek and Roman psy- chiatry by J. B. Friedreich, F. Falk and H. Nasse), Alienist and Neurologist, 1910-1918, 81-38, (15 articles). For the Arabic culture, see: Desruelles M. and Bersot H., Lassistance aux aliCnBs chez les arabes du VIII au XI1 sihcle, Ann. mbd. psychol., 1938, 96, 689-709; Staehelin J. E., Zur Geschichte der Psychiatrie des Islams, Schweiz. Med. Woch., 1957, 87, 1151-1153.

4This historical introduction appeared in the first (1801) and second (1809) editions of Pinels Traitb mbdico-philosophique sur 1 alibnation mentale. It was not fully translated in the English edition of Pinels book, which appeared under the title A Treatise on Insanity in 1806 in Sheffield (reprinted, New York, Hafner, 1962). A full translation of Pinels introduction appeared in Zilboorg G., A History of Medical Psychology, New York, Norton, 1941, 329-341.

6This is the case for many studies on mental diseases which appeared in the seventeenth and eighteenth centuries, such as by F. Plater, C. Lepois, F. Boissier de Sauvages, C. J. Tissot, J. C. Reil, G. Cheyne, W. Perfect, W. Battie, A. C. Lorry, T. Arnold, J. Daquin and many others.

6This is traditionally believed to be the first known description of a psychosomatic phenomenon, See: Sequin C. A., Erasitratus, Antiochus and psychosomatic medicine, Psychosom. Med., 1948, 10, 355f.; Jelliffee S. E., op. nt.

?References to the extraordinary qualities of hellebore as well as of other plants are frequently found in the medical and in the popular literature concerning mental diseases. The treatise De melancholia by Constantinus Africanus (1010?-1087) who founded Salernos school of medicine offers a detailed presentation of medicinal plants with their specific effects on mental disorders ac- cording to the Greek tradition modified by Arabic and Jewish influences (Costantino LAfricano, Della melanconia, Ital. Tr., Rome, 1st. Stor!a Med., 1959). A history of pharmacological plants in relation to mental disorders has not been written yet. For a survey of this problem, see: Belloni, L., Dall elleboro alla reserpina, Arch. Psicol., Neur. e Psichiatr., 1956, 17, 3-36.

THE HISTORIOGRAPHY OF PSYCHIATRY AND ITS DEVELOPMENT: A RE-EVALUATION 45

reform of the treatment of mental patients took place simultaneously by three different pioneers working independently : Chiarugi, Pinel, and William Tuke, in Italy, France, and England respectively. Of these three, only Pinel was aware of the full importance of his reform under the impact of the innovating spirit of reforms brought about by the French Enlightenment and culminating in the French Revolu- tion. Pinels historical presentation, although not too critical, not too historically correct, and not immune from bias, a t least presented a definite unity by emphasiz- ing the previous misconceptions and failures in the treatment of mental patients, and thus indirectly showing how his own reform constituted a unique event in the history of the treatment of mental patients. This was in accordance with con- temporary historiographic trends-as typified by Voltaire-which aimed at de- molishing centuries-old prejudices and absurd beliefs to present new ideas in a rational, scientific manner.

Pinels conciseness and clarity was no longer present in the other few historical surveys by his contemporary French psychiatrists, such as Tr61at.8 Pinels im- mediate pupils, such as Esquirol, Ferrus, Voisin, and others, were still so over- whelmed by the novelty of their new philosophy of timoral treatment in all areas of psychiatry, from institutional to legal psychiatry to mental deficiency, that they entirely overlooked what was accomplished before them. In a way, this was the approach which was carried on by William Tuke and his successors in England and by the superintendents of the early American mental hospitals. In this country, in fact-as well illustrated by the work of the late A. Deutschg-following the opening of some mental hospitals in some eastern states (Pennsylvania, New York, Con- necticut, Massachusetts), the superintendents of these institutions initiated the magnificent tradition of the moral treatment. The approach of a unique type of mental hospital medical superintendent, to quote Zilboorg, was again of a man humane and learned who was to be physician and guide, master and assiduous pupil.10 The founding of the Association of Medical Superintendents of American Institutions for the Insane in 184411 thus achieved the meaning of an official recogni- tion of the philosophy of moral treatment and initiated a brilliant phase in the history of the American culture. It is a pity that such a philosophy, being so in- dividualistic and original for each one of its exponents (Amariah Brigham, Samuel Woodward, Thomas Kirkbride, Pliny Earle, Isaac Ray, and others), could hardly have been crystallized in a definite form or viewed from an historical perspective.12

Around the same time, in Germany, the so-called psychiatrists of the Romantic school (Heinroth, Haindorf, Groos, Beneke, Ideler, Feuchtersleben, and others) were so engrossed in their theological speculations concerning mental diseases viewed

TrBlat U.; Recherches historipues sur la folie, Paris, Baillibre, 1839. 9Deutsch A., The Mentally I l l in America, New York, Doubleday, 1937 (2, ed., New York,

Columbia Univ. Press, 1948). loZilboorg G., o p . eit., p. 409. As it is well-known, the Association of Medical Superintendents of American Institutions for the

Insane founded in 1844 was the first medical association to be established in this country. Its journal, the American Journal of Insanity, was to play a very important role in the development of American

sychiatry. See: Dunton, W. R., The American Journal of Psychiatry, in Centennial Anniversary fssue 18441944, Amer. J . Psychiatr., 1944. (NO other data given). 45-60.

12This statement can be maintained, in spite of the fact that a family tradition of treatment of mental patients was carried on from one generation to another in some mental hospitals, notably in this country at the Williamsburg Asylum in Virginia by the Galt family, in Europe by the Pinels in France and by the Tukes in England. See.on the many aspects of the moral treatment: J. S. Bock- oven, Moral Treatment in American Psychmtry, New York, Springer, 1963.

46 GEORGE MORA

as sins that they also tended to overlook their predecessors in p~ychiatry.~ If mans diseases acquire meaning only in relation to God, then there is no room for considera- tion bf aberrations of the human mind from an historical perspective. It is no wonder that in this climate of rejection of the old values of the ancien rQgime and of mystic expectation, Mesmer and his followers could find so much acceptance.

In summary, in this first period of modern psychiatry, either the pioneers of the moral treatment in Italy, France, England, and the United States, or the ro- mantic psychiatrists in Germany for different reasons were unconcerned with their predecessors. The few historiographic attempts presented an uncritical and uneven character. The best expression of this historiography-that by Pinel- was still a derivation of the French enlightenment. The new historiographic trends of the Romantic era-all turned toward the heroism and greatness of the Middle Ages- could not find repercussion in psychiatry, which had reached its lowest level during the Middle Ages.

In the second period of psychiatric historiography-which corresponds to the second half of the nineteenth century and the beginning of this century-a differ- entiation of psychiatry with special orientation and significance took place in each country. As a reaction against moral treatment and the theological speculations of the German romantics, there was a search and cult of objectivity in all fields of human knowledge-beginning with history-in this period. Psychiatry began to be accepted as a separate specialty of medicine with its academic teaching and special journals. In France, the emphasis was placed on clinical matters with Esquirol, Ferrus, Georget, Voisin, FodQrB, Falret, Bayle, Calmeil, Lauret, LQlut and Bail- larger; in Germany on neuropathological research with Leidesdorf, Meynert, Wer- nicke, and others. In this country the orientation remained essentially practical and eclectic. As a consequence of the great increase in the number of new immigrants from under-privileged countries, of the rapid industrialization, of the movement of many toward the west, as well as other factors pointed out by A. Deutsch and by S. Bockoven,l* the need for more and larger facilities for mental patients, supported by states, could not be overlooked any longer. This trend was initiated by Dorothea Dix whose tireless work influenced the legislation of many states. In spite of these different trends there were, of course, many interchanges of ideas; many psychiatrists started to travel from their original country abroad to compare ideas and visit hos- pitals, but they were not immuned from nationalistic bias.I5 Thus, the two major orientations-clinical and neuropathological-persisted with the consequence that each representative of either trend found himself engaged in justifying his own philosophy with the support of the historical tradition. So the French school-with Calmeil, Brierre de Boismont, Parchappe, LBlut, Moreau de Tours, Morel, MichBa, LasBgue, Billot, A. Semelaigne, Bourneville16-attempted to investigate the histori-

l3Heinroth and Feuchtersleben, however, wrote historical introductions to their textbooks on mental diseases, published in 1818 and 1844, respectively.

A. Deutsch, op. nt., J. S. Bockoven, op. nt. 19n this country, a number of psychiatrists took trips to Europe in order to become acquainted

with the mental hospitals there. Amariah Brighan toured Europe extensively in 1828-1829, Luther Bell in 1841 and 1845, Pliny Earl in 1849. Others, such as Isaac Ray and John M. Galt, were thorough- ly familiar with the European psychiatric literature.

16L. F. Calmeil, De la folie considdrke sous le point de vue pathologique, philosophique, historigue et judieiaire, Paris, (NO other data given) 1845, 2 vols.; A. Brierre de Boismonts articles on Italian mental hospitals, on Jeanne deArc, on Shakespeare, on Griesinger and on others; J. Parchappes articles on witchcraft and on British mental hospitals; J. LBluts study on Socrates; J. Moreau de

THE HISTORIOGRAPHY OF PSYCHIATRY AND ITS DEVELOPMENT: A RE-EVALUATION 47

cal antecedents of moral treatment, especially emphasizing the famous Colony of Gheel in Belgium. In the meantime, some of the German psychiatrists-such as Nasse, Friedreich, Leidesdorf, Falk, Schule, Meynert18-found the historical ante- cedents of their organicistic philosophy of psychiatry (which explains psychopath- ology on the basis of neuropathology) in the tradition which initiates with Hip- pocrates treatise on epilepsy and continues with Renaissance medicine and the seventeenth-and eighteenth century medical theories up to Galls phrenology. Other German psychiatrists-as Griesingerlg-in their juvenile excitement for the physio- pathological contemporary discoveries on the brain, did not even care to mention their historical antecedents. Ultimately, this contrast between clinical and neuro- pathological trends reflected the basic difference among schools of historiography, which gained great momentum in France, England, Germany, and the United States in the second half of the nineteenth century and which were later critically viewed according to the emphasis on individuals and nations who dramatically break the tradition and initiate new eras, or instead on the social progress which slowly develops and tends to become uniform in many countries. Macaulay, Carlyle, Michelet are representatives of the first school; Ranke, Buckle, Droysen of the second school. TO the enthusiasm for the great and the passion for the hero-worship of the first are opposed the search for objectivity and the respect of universal values of the latter.

To return to psychiatry, (moral treatment focused on the individual and on his unique response-on the basis of his personality-to an individual approach, while organically-oriented psychiatry focused on the common Anlage of each indi- vidual and on the common means geared to modify a pathological condition uni- formly effecting each individual. With the tremendous development of physiological sciences, of pathology, bacteriology, and pharmacology, this latter approach took over in psychiatry toward the end of the nineteenth century. The social events themselves, with the increasing demands for psychiatric services for thousands of low-class people, led to the increase of Dorothea Dixs crusade and to the con- struction of large mental hospitals, state-supported, where Lmoral treatment on an individual basis could not obviously be carried on any longer. So in the last two decades of the past century and the first two decades of this century, a considerable number of historical presentations of psychiatry-either as separate books or as chapters of psychiatric text books-were published in the countries of the western

Tours articles on European mental hospitals; B. Morels articles on the history of psychiatry, on mental hospitals in several European countries and in the United States; C. Mich6a studies on ancient and Renaissance psychiatry; A LtEsBgues articles on Stahl and on German psychiatry; E. Billots mon- ograph on Italian psychiatry; A. Semelaignes work on ancient psychiatry; 1). Bournevilles historical activit as editor of the series BibliothBque Diaboligue.

17Kmong the most important descriptions of the colony of Gheel are in fact that by Moreau de Tour (1845) and by J. Falret (1862).

18H. Nasse, De Znsanza, Commentatio secundum Libros Hippocraticos, Bonn, 1829. Hermann Nasse was the son of Friederich Nasse, a strong believer-with M. Jacobi-in organic psychiatry and a founder (with J. B. Friedreich) of the earliest German journal dedicated to psychiatry. On the others: .J. B. Friedreich, Versuch einer Literatur-geschichte der Pathologie und Therapie der psychischen Krank- heiten, Wiirzburg, 1830; ib., Historischkntisch Darstellung der Theonen uber das Wesen und Sitz der psychischen Krankheiten, Leipzig, Wigand, 1836; F. Falk, Studien uber Irrenheilkunde der Alten, Al1g.Ztschr.j. Psychiatr., 1866, 23, 429-566; M. Leidesdorf, Lehrbuch der psychischen Krankheiten, Erlangen, 1865; H. Schule, Handbuch der Geisteskrankheiten, Leipzig, 1878; Th. Meinert. Psychia- trie, Wien, 1884. Partial translations into English of the works by Nasse, Friedreich and Falk were made by E. S. Jelliffee (see note #3). low. Griesinger, Die Pathologie und Therapie der psychischen Krankheiten, Stuttgart, 1845 (Eng. Tr., London, New Sydenham Society, 1847).

48 GEORGE MORA

hemisphere, especially in Germany. This was not by chance as it was in Germany that historiography particularly flourished a t that time and gave impetus to the related fields-philology, archaeology, and ethnology. Hegel laid down the philo- sophical foundations of this historiography by explaining in dialectic form the entire development of human history. This feeling of having achieved a terminal goal, in which light the previous developments find justification, stimulated some psy- chiatrists to present the whole development of psychiatry in a Iogical and complete form. Ullersperger, Laehr, Kornfeld, Kirchhoff, Kraepelin, Adam in Germany; D. H. Tuke, ODonoghue, Whitwell, in England; DeTornBry, SBrieux, Vi6, Laignel- Lavastine and Vinchon, Semelaigne, Bonnafous-Skrieux in France; Antonini, Del Greco, Lugaro, Padovani, Ferrio in Italy were the representatives of this prevailing organicistic trend in psychiatry, frequently combined with the need to recapture the lost spirit of moral treatment.20 Furthermore, Daniel H. Tuke and R. Semelaigne were the last expressions of the brilliant family tradition of treatment of mental patients by the Tukes in England and by the Pinels in France respectively. In the United States psychiatric historiography developed later and, with the exception of a few studies (such as those by C. B. Farrar and S. E. Jelliffee) at the beginning of the century, it limited itself almost exclusively to the description and evaluation of the achievements of psychiatry in this country. I n line with the pragmatic orienta- tion of the American culture, most of the historical studies (such as those published on the occasion of the centennial of some famous mental hospitals) focused on the concrete progress achieved in the past or on the personalities of the early American psychiatrists rather than attempting to offer a thorough view of the whole develop- ment of psychiatry in the western culture.21

ZoFor Germany: J. B. Ullersperger, Die Geschichte der Psychologie und der Psychiatrie in Spanien, Wursbnrg, Stuber, 1871 (Span. Tr., Madrid, Alhambra, 1954) ; H. Laehr, Gedenktage der Psychiatrie, Berlin, Reimer, 4.ed., 1893; ib., D i e Literatur der Psychiatrie, Neurologie und Psychologie von 1459- 1799, Berlin, Reimer, 1900, 3 vols.; S. Kornfeld, Geschichte der Psychiatrie, in Th. Puschmanns Handbuch der Geschichte der MediZin, Jena, Fischer, 1905, Vol. I11 ; Th. Kirchhoff, Geschichte der Psychiatrie, in G. Aschaffenburgs Handbuch der Psychiatrie, Leipzig, Deuticke, 1912, Vol. IV; ib., Deutsche Irreniirzte, Berlin, Springer, 1921-1924, 2 vols.; E. Kraepelin, Hundert Jahre Psychiatrie, Berlin, Springer, 1918 (Eng. Tr., New York, Citadel Press, 1962); H. A. Adam, Ueber Geisteskrankheit in alter und neuer Zeit, Regensburg, Rath, 1928. For England: 11. H. Tuke, Chapters in the History of the Insane in the British Isles, London, Kegan Paul, 1882; ib., Insanity in Ancient and Modern Life. London, 1878; ib., A Dictionary of Psychological Medicine, London, Churchill, 1892, 2 vols.; E. G. ODonoghue, The Story of Bethlehem Hospital, London, Fisher Unwin, 1914; J. R. Whitwell, His- t.orica1 Notes on Psychiatry, London, Lewis, 1936. For France: M. De Tornkry, Les maladies nerveuses pendant lantiquitd graecoromaine, Paris, 1892 ; P. SErieux, Le traitement des maladies mentales dans les maisons daliEn6s du XVIII sikcle, Arch. de Neurol., 1924-5, 43-44, (4 articles); J. Vi6, Les alibnds et les correctionmires b Suint-Lazare a u XVZI et au X V I I I sikcles, Paris, Alcan, 1930; M. Laignel- Lavastine and J. Vinchon, Les maladies de lesprit et leurs mddecins du X V I au X I X sihcles, Paris, Maloine, 1930; R. Semelaigne, Philippe Pinel el son oeuvre, Paris, Imprimbries Reunies, 1888; ib., Alidnistes et Philantropes. Les Pinels et Les Tukes, Paris, Steinheil, 1912; ib., Les pionners de la psy- chiatrie francaise avant el aprBs Pinel, Paris, Bailliere, 1930-1932, 2 vols; H. Bonnafou-YErieux, Une maison dulidnds et de correctionmires a u X V I I I sibcle, La Charitd deSenlis, Paris, Presses Univ. France, 1936. For Italy: G. Antonini, I precursori d i Lombroso, Torino, Bocca, 1900; F. Del Greco, Apercu critique sur lhistoire de la medecine mentale, in Trait6 International de Psychologie Pathologique, Paris, 1910, Vol. I ; E. Lugaro, L a psichiatria tedesca nella storia e nellattualita, Firenze, Galileiana, 1916; E. Padovani, Pinel e il rinnovamento dellassistenza agli alienati. I suoi precursori. I prede- cessori italiani: Giuseppe Daquin e Vincenzo Chiarugi, Giorn. Psichiatr. Clin. Tech. Manicom., 1927, 55, 69-124; C. Ferrio, L a psiche e i nervi. Introduzione storica ad ogni studio d i psichiatria, neurologia e psicologia, Torino, Utet, 1948.

For other countries: I. V. Kannabikh, History of Psychiatry, Moscow, 1928 (in Russian); 0. Beyerholm, Psychiatrens historie, Copenhagen, Munksgaard, 1937 (in Danish).

21Many contributions of historical significance in the early American psychiatric literature are mentioned in: American Journal of Psychiatry, Anniversary Issue 1844-1944 (Articles by M. K. Amdur, W. R. Dunton, Jr., W. L. Russell, F. G. Ebaugh, L. E. Hinsie and others) and in J. K. Hall (ed.), op. cit. (Articles by R. H. Shryock, W. Overholser, S. W. Hamilton, J. C. Whiterhorn, H. A. Bunker, W. Malamud, A. Deutsch, E. A. Strecker, T. V. Moore, G. Zilboorg and C. Kluckhohn).

THE HISTORIOGRAPHY OF PSYCHIATRY AND ITS DEVELOPMENT : A RE-EVALUATION 49

In the latter part of the nineteenth century, another cultural trend based on strong individualism, started to appear a little everywhere in Europe. Just because of their individualism, the representatives of this trend-from Kierkergaard to Dostoevski and Nietzsche-did not initiate a school and, furthermore, their in- fluence was felt in the literary and artistic, rather than in the scientific, circles. These latter came instead to be dominated entirely by positivism and materialism, and psychiatry was no exception to it. However, a reaction against this was initiated by Dilthey-the first representative of storicism in philosophy-who assigned psy- chology to the sciences of spirit rather than to the sciences of nature. This view did not have repercussions in the history of psychiatry at that point. How- ever, both the school of degeneration of the German Mobius and of the French Morel and the school of criminal anthropology of the Italian Lombroso,22 which flourished at that time, came to signify an expression of neuropathology filtered through the individual personality and ultimately a combination of the organic with the individualistic philosophy of psychology. In the light of these new trends the history of psychiatry progressively lost importance.

The third period of psychiatric historiography is a very recent one, beginning only two decades ago. In the interval between the beginning and the fourth decade of our century fell Freuds introdution of the new dimension, that of the unconscious and its progressive acceptance in psychology. This constituted a complete revolu- tion in psychology inasmuch as its focus came to be on the genetic-historic approach to the individual personality. As the unconscious, by definition, has no history, it is no wonder that Freud himself and the early psychoanalysts remained largely un- concerned with the historical antecedents of psych~analysis.~~ In spite of the fact that,

Among the early historical studies are: C. B. Farrar, Some origins in psychiatry, Amer. J . Psychiatr., 1908, 94, 523-552, 1908, 95, 84101, 1909, 95, 277-294; H. M. Hurd {ed.) The Institutional Care of the Znsane in the Unzted States and Canada, Baltimore, Johns Hopkins Univ. Press, 1916, 4 vols.; E. S. Jelliffees historical studies on general paresis, Korsakoff s psychosis, paranoia, schizophrenia, manic-depressive psychosis and early American ps chiatry which appeared between 1908 and 1930. Among the historical studies on institutions: 1 Psychiatric Milestone. Bloomingdule Hospital Centenary, 1821-1921, New York, (no other data given) 1921; L. B. Briggs, History of the Psychopathic Hospital, Boston, Wright & Potter, 1922; W. L. Russell, The New York Hospital. A. History of the Psy- chiatric Service, 1771-1956, New York, Columbia Univ. Press, 1936. Among the historical studies on

sychoanalysis: C. P. Oberndorf, A History of Psychoanalysis in America, New York, Grune, 1953; f. Hendrick, The Birth of an Institute. Twenty-$fth Anniversary of the Boston Psychoanalytic Institute, Freeport, Bond, 1961; Waugh M. (ed.), Fifty Years of Psychoanalysis in New York, New York, Int. Univ. Press, 1963. Among the biographical monographs: F. J. Tiffany, Life of Dorothea Diz, Cam- bridge, Houghton Mifflin, 1891 ; N. Goodman, Benjamin Rush, Philadelphia, Univ. Penn. Press, 1934; H. E. Marshall, Dorotheu Diz, Forgotten Samaritan, Cha el Hill, Univ. North Carolina, 1937; E. D. Bond, Dr. Kirkbride and His Mental Hospital, Philadeghia, Lippincott, 1947; ib., T . W . Salmon, Psychiatrist, New York, 1950. Among the autobiographical studies: Memories of Pliny Earl, Boston, Dannell, 1898; A. M. L. Hamilton, Recollections of an Alienist, New York, 1916; W. A. White, The Autobiography of a Purpose, Garden City, Doubleday, 1938. In recent years, E. T. Carlson and N. Dain have published a number of studies on early American psychiatry, among which especially important are: Amariah Brighan, Amer. J . Psychiatr., 1956, 112, 831-836, 1957, 115, 911-916; ib., The psychotherapy that was moral treatment, Amer. J . Psychiatr., 1960, 117, 519-524. On moral treatment in American sychiatry, see also: J. S. Bockoven, Moral treatment in American Psy- chiatry, J . New. Ment. As., 1956, 124, 167-194, 292-321 (republ. in volume, op. nt.); N. Dain, Con- cepts of Insanity in the United States, 1789-1865,. New Bruns.wick, Rutgers Univ. Press, 1964.

22For the history of the school of degeneration: G. Genil-Perrin, Hzstozre des ongznes et de lluolu- tion de 1 idke de dhgknhrkscence en mkdecine mentale, Paris, Leclerc, 1913; Wettley A., Zur Problem- geschichte der d6g6n6r6scence, Sudhofls Arch., 1959, 43, 193-213. On Lombrosos criminal-anthro- pological school, M. E. Wolfgang, Pioneers in criminology: Cesare Lombroso (1835-1909), J . C r i ~ . Law. Criminal. & Police Sci., 1961, 52, 361-391 (republished in N. Mannheim (ed.), Pioneers zn Criminology, Chicago, Quadrangle, 1960).

23Among the earliest attempts to present psychoanalysis from an historical perspective: L. Kaplan, Hypnatismus, Animiwus und Psychoanalyse, Historisch-kritisch Versuche, Wien, 1917; M. Dorer, Historische Grundlage der Psychoanalyse, Leipzig, Meiner, 1932.

50 GEORGE MORA

philosophically, psychoanalysis represents a combination of the deterministic frame of reference of the physical sciences with the romantic appeal to the individual un- conscious, the early psychoanalytic movement-in the enthusiasm for the new clinical discoveries-largely overlooked the traditional historical frame of reference of the objective sciences. Rather, a number of early psychoanalysts-from Rank to Jung to Sachs to Roheim-tended to go back to pre-history as a common matrix from which the individual unconscious stemmed. Of course, psychiatry cannot be identified only with psychoanalysis inasmuch as the nineteenth century organicistic trend has continued to persist in our century and, as a matter of fact, has received new impetus by the recent neurophysiological advances and by the introduction of the new psychopharmacological agents. So, even recently, histories of psychiatry have been written (such as that by A c k e r k n e ~ h t ) ~ ~ according to this traditional frame of reference. But the fact remains that psychoanalysis has influenced psy- chiatry to such an extent that it is no longer possible to distinguish between the two.

Coinciding with the process of integration of the psychoanalytic findings into psychiatry in the last two decades, attempts have been made by some to trace the antecedents of the psychoanalytic theory of the unconscious back to men and ideas of the past.25 However, no major work was been published thus far in this area. The only work of broad significance-that of ZilboorgZ6-has a somewhat different focus inasmuch as it represents a history of the unconscious attitudes toward mental patients as crystallized in the most important exponents of acceptance and, con- versely, rejection of them. Undoubtedly, Zilboorgs work constitutes a landmark in the history of psychiatry inasmuch as all the psychiatric events of the past have received new light when viewed from the standpoint of the unconscious. Some have received greater meaning than ever, while others have come to be relegated to a much less-important position. To this latter is ascribed the impersonal philosophy of treatment which took place in the second part of the nineteenth century, while conversely four enlightening periods have come to be more outstanding in psy- chiatry: the one of Aretaeus and Soranus in the second century A. D.; the one of Vives and Weyer, during the Renaissance; the one of the great reformers at the end of the eighteenth century; and, finally, the one initiated by the psychoanalytic movement. Zilboorgs work concludes with the statement that the history of psy- chiatry is essentially the history of humanism and that this history presents a pattern of alternating moments of greatness-typified by the great pioneers-followed by moments of decline. As mentioned above, Zilboorg s book, by representing the history of psychiatry from the point of view of the individual unconscious-as typical of the early psychoanalytic movement-on the background of the intellectual history of Europe, has resulted in a new historiographic trend in psychiatry.

E. H. Ackernecht, Kurze Geschichte der Psychiatrie, Suttgart, Enke, 1957 (Eng. Tr., New York, Hafner, 1959).

26The most important of these studies are: E. L. Margetts, The concept of the unconscious in the history of medical psychology, Psychiatr. Quart., 1953, 27, 115-138; H. Ellenberger, The uncon- scious before Freud, Bull. Menninger Clinic, 1957, 21 3-15; W. Riese, The pre-Freudian origins of psy- choanalysis, in J. H. Masserman (ed.)Science and Psychoanalysis, Vol. 11, New York, Grune & Stratton, 1958; L. L. White, The Unconscious before Freud, Xew York, Basic Books, 1960 (also Garden City, Doubleday, 1962).

2BG. Zilboorg, o p . nt. The following three works are also written from a psychoanalytic viewpoint, but they are less important than Zilboorgs work: X. C. Lewis, A Short History of Psychiatric Achieve- ment, New York, Norton, 1941; W. Bromberg, M a n Above Humanity. A History of Psychotherapy, Philadelphia, Lippincott, 1954 (also New York, Harper, 1959); J. M. Schneck, A History of Psy- chzalry, Springfield, Thomas, 1960.

THE HISTORIOGRAPHY OF PSYCHIATRY AND ITS DEVELOPMENT : A RE-EVALUATION 51

In the meantime, psychoanalysis has turned its focus from the unconscious to the ego-its autonomy, its development, and its mechanisms of defense. Thus far, however, the few studies attempting to review the developments of ego psychology or of the different psychoanalytic schools, have been presented in the limited con- text of modern psychology rather than on the broad background of cultural There is now a need to continue this trend further from the viewpoint of ego psy- chology; namely, from a viewpoint resulting from the interplay between uncon- scious and ways of dealing with it, expressed not so much by individuals but by the culture altogether in line with the developments of cultural anthropology and of sociology.28 Modern historians, such as Burckhardt, Huizinga, Febvre, have at- tempted to excavate deeply into the roots of civilizations, and their followers today are not insensitive to the influence of the psychoanalytic movement.29 A remarkable example of this trend is Dodd's analysis of unconscious elements in the Greek cul- t~re .~O The style of life, the inner motivations, the underlying sociopsychological

27Among the few studies on this point: Thompson C., Psychoanalysis: Evolution and Develop ment, New York, Kelson, 1950; F. Alexander and H. Ross (eds.), Dymanic Psychiatry, Chicago, Univ. Chicago Press, 19.52; F. Alexander and H. Ross (eds.), Twenty Years of Psychoanalysis, New York, Norton, 1953; R. R. Grinker (ed.), Mid-Century Psychiatry, Springfield, Thomas, 1953; 1). Rapaport, An historical survey of psychoanalytic ego-psychology, Bull. Philadelphia Assoc. Psychoanal., 1958,8, 105-120; J. A. C. Brown, Freud and the Post-Freudians, Baltimore, Penguin, 1961; D. Wyss, Die tiefenpsychologischen Schulen von den Anfdngen bis zur Gegenwart, Gottingen, Vandenhoeck und Ruprecht, 1961.

@Aside from the literature on social and cultural psychiatry mentioned in note # 1, see also the studies by B. Laubscher on the South African pagan natives; by G. Roheim on psychoanalysis and anthro ology; by J. Carothers on the African mind; by R. Linton on culture and mental disorders; by M. Fierd on psychiatry in Ghana; by E. Weinstein on psychiatric delusions in the Virgin Islands; by G. Devereux on Mohave suicide; by A. Leighton on the sychiatric disorders mong the Yoruba. A review of the literature up to 1960 is in: R. Kaelbling, comparative psychopathology and psycho- therapy, Acta Psychoth. & Psychosom., 1961, 9, 10-28. As examples of studies on cultural character- istics in the Western hemisphere: G. W. Allport, European and American Theories of Personality; in H. P. David and H. von Bracken, (eds.) Perspectives i n Personality Theory, New York, Basic Books, 1957, pp. 3-24; Mdtraux R. and others, Some Hypotheses about French Culture, New York, Columbia Univ. Press, 1950; 1). C. McClelland, The United States and Germany, J . A h . SOC. Psychol., 1958, 56, 245-255 (repr. in The Roots of Consciousness, Princeton, Van Kostrand, 1964).

Wee in particular: J. Burkhardt, The Civitization ofthe Renaissance i n Italy, Eng. Tr., New York, Harper, 1929 (repr. Harper Torchbooks, 1958, 2 vols.) ib., Force and Freedom: Re$edions on History, New York, 1943 (repr. Meridian Books, 1955); J. Huisinga, The Waning of the Middle Ages, London, 1924 (New York, Anchor Paperback, 1953); L. Fevbre, Le probllme de l'incroyance au X V I sakcle, L a religion de Rabelais, Paris, Michel, 1942 (new ed., 1962); ib., Combats pour I'histaire, Paris, 1953. See also: G. Lefevbre, L a grande peur du 1789, Paris, Sedes, 1932; A. Von Martin, Sociology of the Re- naissance, Eng. tr., London, Kegan Paul, Trench and Trubner (Harper Torchbooks, 1963); N. Cohn, The Pursuit of the Millenium, Kew York, Essential Books, 1957 (Harper Torchbooks, 1961), aside from the extensive literature on epidemics (especially plague) and on witchcraft. Among the recent contributions to the subject of history and psychiatry: R. De Saussure, Psychoanalysis and history; in G. Roheim (ed.) Psychoanalysis and Social Sciences, vol. 2, New York, Inter. Univ. Press, 1950; W. Langer, The next assignment, (1958 Presidential address to the American Historical Association), Amer. Hist. Rev.., 1958, 63, 283-304 (repr. in B. Maslish (ed.) Psychoanalysis and History, Englewood Cliffs, N. J., Prentice Hall, 1963, which contains also several other important apers). For a method- ological and historical review of the relationship between history and psychoyogy, see the volume by H. Gruhle, Geschichtsschreibung und Psychologie, Bonn, Bouvier, 1953, which deals with the psycho- logical value of biographical and autobiographical studies and of personality traits as represented in literature and art. Z. Barbu, Problems of Historical Psychology, New York, Grove Press, 1960, con- stitutes an agile, though a t times oversimplified, presentation of three topics: the historical develop- ment of perception, the emergence of personality in the Greek world and the origins of the English character. A more superficial and not too convincing presentation of history from the psychoanalytic viewpoint is by A. Feldman, The Unconscious i n History, New York Philosophical Library, 1959. Instead, E. Erikson, Young Man Luther, A Study i n Psychoanalysis and History, New York, Norton, 1958 (paperback ed., 1962) is doubtless the most thorough and engaging concrete application of sychoanalysis to history. A similar application has been attempted by K. Eissler, Leonard0 da

f i n c i , Psychoanalytic Notes on the Enigma, New York, Inter. Univ. Press., 1962; ib., Goethe, A Psy- choanalytic Study, Detroit, Wayne Univ. Press, 1963, 2 vols. See also: F. Schmidl, Psychoanalysia and History, Psychoanal. Quart., 1962, 31, 532-548.

WE. R. ]>odds, The Greeks and the Irrational, Berkeley, Univ. California Press, 1951 (paperback ed., Beacon Press, Boston, 1957). See also: E. Rhode, Psyche: The Cult of Souls and Belief in Im-

52 GEORGE MORA

conflicts in which general historiography tries to delve into more and more today- in a word, what Huizinga has called Lconfiguration71 in his brilliant paper on cu1- tural hi~tory~l-form the background on which the history of psychiatry should come to be perceived more in the future. Perhaps this broader historiographic approach will also offer the clue for a clarification of the contrast between the cyclic development of psychiatry, as viewed by Zilboorg, and the more linearly pro- gressive development of medicine.32 Beginning from Vico up to Toynbee, a series of philosophers of history have explained the historical process on a cyclic basis in con- trast to the view commonly held by the theologians and rationalists of explaining it on a linear basis; so that it would seem that psychiatry, more than medicine in toto, adheres to the cyclic development of the historical process. Truly, the fundamental contrast between psychiatry and medicine, as viewed in their historical develop- ment, transcends mere historical theories or methodologies to find its reason in the basic epistemologic ambiguity of psychiatry, which is art as well as science, which- to return to Dilthey-belongs to the sciences of spirit as well as to the sciences of nature. The meaning of psychotherapy, which-under different names in different times and cultures-remains the essence of psychiatry, somewhat justifies the claim of the existentialists that it is ineffable and irrepeatable-thus posing a chal- lenge to any attempt to define it in historical terms.a3

On the basis of the above considerations, it seems that the future historian of psychiatry will, therefore, be confronted with a restatement of his philosophy in terms of a comprehension of past events on the background of sociocultural move- ments and their unconscious roots; at the same time, he will have to take into con- sideration the existentialistic challenge to any historical systematization of the individual psychotherapeutic relationship. The two poles between which psychiatry has traditionally moved-the cultural on one side and the individual on the other side-will, therefore, be represented in these new terms in the history of psychiatry. The present study aims to be a contribution to the definition and clarification of these basic issues.

mortality Among the Greeks, Eng. tr., London, Kegan Paul, 1925; R. De Saussure, Le miracle grec; 6tude psychandlytique sur la civilisation hellenique, Rev. Franc. de Psychanal., 1938, 10, 87-148, 323- 377,471-536; M. P. Nilsson, Greek Popular Religion,, Eng. Tr., New York, Columbia Univ. Press, 1940; ib., A History of Greek ReZigion, Eng. Tr., New York, Oxford Univ. Press, 1949; Lain Entralgo P., Estudios de historia de la mdicina y de la antropologia medica, Madrid, Escorial, 1943, pp. 200-274; ib., Therapeutische Katharsis und Logotherapie im Homerischen Epos, in Medicus Viator, Festgabe Richard Siebecks, Stuttgart, Thieme, 1959, pp. 8-20; H. Jeanmarie, Dionysos, His@.re du culte de Bacchus, Paris Payot, 1951; B. Snell, The Disvovery of the Mind. The Greek Origzns of European Thought, Camdridge, Harvard Univ. Press, 1953 (Harper Torchbooks, 1960).

J. Huizinga, The task of cultural history, in Men and Ideas, New York, Meridian Books, 1959. J*G. Zilboorg, op. cit., pp. 524525. On the development of the history of psychiatry in relatipn

to the cultural scene: J. Bodamer, Zur Phanomenologie des geschichtlichen Geistes in der Psychiatrie, Nervenarzt, 1948, 19, 299-310; E. Wissfeld, Zur Geschichte der Psychiatrie in ihrer Abhangigkeit von der geisteswissenschafftlichen Entwicklung seit der Renaissance, Arch. f. Psychiatr. u. Ztschr. f. d . ges. NeuroZ., 1957, 196, 63-89; Th. Spoerri, Die historische Betrachtung als Methode fur die Psy- chiatrie, in Beitruge zur Geschichte der Psychiatrie und Hinzanatomie, Basel-New York, Karger, 1957, pp. 11-20; J. Wirsch, Ueber Geschichte der Psychiatrie, +id., 21-40; W. Leibbrand, Prologomena zur einer Geschichte der Psychiatrie, Imprensa Medica (Lisbon?; 1959, 23, n.2. As far as Zeitgeist in the history of psychology, see now: E. G. Boring, History, Psychology and Science. Selected Papers, New York, Wiley, 1963.

Without entering into a discussion on existential psychotherapy, the fact remains that history is either devaluated or inversely interpreted transcendentally by each existential philosopher, ac- cording to his own atheistic, or inversely, religious orientation. This basic position has influenced existential psychiatrists, too, who thus far have been disinterested in the development of attitudes toward and treatment of mental patients.