Thomas A. Ban
Neuropsychopharmacology in Historical Perspective
Education in the Field in the Post-Neuropsychopharmacology Era
Classifications of insanity in the late 18th and early 19th century
Educational Series 2. Bulletin 7, Vignette 3
This “vignette” is based on Thomas A. Ban’s notes from the 1990s, made in preparation for a Composite Diagnostic Evaluation in which a patient could be diagnosed simultaneously in several selected classifications from the 19th and 20th century, on the basis of a semi-structured interview.
Classifications of insanity in the late 18th and early 19th century
William Cullen’s (1777) classification of the vesaniae had a major impact on classifications of “insanity” during the 19th century. His separation of “partial madness” from “universal madness” has remained one of the organizing principles of psychiatric nosology to date.
In the early 19th century several classifications of “madness” were advanced. Most of these classifications shared some common features with Cullen’s (1877). In this “vignette,” the essential features of three classifications from the period, Vincenzo Chiarugi’s (1793-4), Philippe Pinel’s (1798, 1801) and Johann Christian August Heinroth’s (1818) are be presented.
Vincenzo Chiarugi (1759-1820), was an Italian physician whose name in psychiatric history has become associated with the “outlawing of chains” for restraining patients (Morra 1959). It was Chiarugi’s (1793-4) influence that, in 1789, the Regulations of the Royal Hospital of Santa Maria Nuova in Florence, “forbade brutality towards patients” and “described hygienic measures to be applied by the nursing staff under medical supervision” (Pichot 1983).
Chiarugi adopted Cullen’s (1777) classification with some minor modifications. Thus, in his treatise, Della Pazzia in Genere e Specie (Insanity and Its Classification), published in 1793-4, he recognized three classes of “madness”: “melancholia,” ”mania” and ”amentia,” with several sub-forms. He characterized “melancholia” by ”partial distortion of reality with regard to one or a few ideas”; “mania” by “general insanity with violence and impetuous actions, disconnected speech, disorganized sequence of ideas, poor judgement and abnormal actions;” and “amentia” by “general insanity with deficiency of both intelligence and volition” but “without emotional manifestations.” Furthermore, Chiarugi distinguished among three sub-forms of “melancholia”: “true melancholia,” characterized by “constant depression of spirit, restlessness and impatience”; “false melancholia,” characterized by “happiness or elation due to erroneous ideas”; and “violent melancholia,” characterized by “hatred directed against self or others.” He also recognized three stages of “mania”: the first, characterized by ”agitation and shamelessness”; the second, by “violent impulses”; and the third by ”remission” and separated “congenital amentia” from ”acquired amentia” (Menninger, Mayman and Pruyser 1968).
Philippe Pinel (1745-1826) was a French physician, whose name (similar to Chiarugi’s but probably with a much wider recognition) has become associated with the “humanization of treatment of the insane” in psychiatric history. Pinel studied medicine at Toulouse, then at Montpelier where he became familiar with the research of Boissier de Sauvages’ (1762) that stimulated Cullen (1769) to develop his classification of diseases. As a translator of Cullen’s (1777) “First Line on the Practice of Physics” from the English original into French, he was also thoroughly familiar with Cullen’s classification (Pichot 1983). In 1786 Pinel became a “staff physician” at “Maison Belhomme” a private home for wealthy mental patients. In 1993 he was appointed chief physician of Bicetre hospice, a large facility for men in need of care with a psychiatric division, and in 1995 of Salpetriere, a similar facility to Bicetre for men, where he stayed for the rest of his life (Pichot 1983; Shorter 2005).
Pinel’s first classification of insanity was published, in 1798, in his Nosographie Philosophique and the final one, in 1801, in his Traité Médico-Philosophique sur l’ Aliénation Mentale ou la Manie. It was an empirical classification based on "observable facts without mixing metaphysical discussions or certain disquisitions of the ideologists” in which, by "meticulous description of the appearance of objects," mental derangements were "distributed" into five different “species." Although Pinel (1798) was critical of the classification of both Boissier de Sauvages (1762) and of Cullen (1777), the roots of his classification were in Cullen’s three “genus” of vesaniae with the separation of “partial madness” from “universal madness” and both from “amentia.”
The first species of “mental derangement” in Pinel’s classification was “melancholia or delirium (delusions) on one subject exclusively.” It was characterized by a syndrome in which “the powers of perception and imagination were frequently disturbed without any excitement of the passions.” Other features included ”taciturnity, thoughtful passive air, gloomy suspiciousness and love of solitude.” The second species was “mania without delirium (delusions).” It was characterized by a syndrome in which “the functions of the understanding were often perfectly sound, while the patient was driven by his passions to acts of turbulence and outrage…” The third was “mania with delirium (delusions). It was manifested in "periodical delirium (delusions) united by extravagance and fury." The fourth was “dementia or the abolition of thinking faculty” that was characterized by “mental disorganisation, where the ideas and internal emotions appear to have no connection with the impressions of sense, and to succeed each other without order, and to vanish without leaving any traces of their existence." The fifth was “idiotism or obliteration of intellectual faculties” that was characterized by “total obliteration of the thinking faculties or a privatization more or less absolute of all ideas and emotions.”
Johann Christian August Heinroth (1723 -1843) was a German physician who studied theology before entering medicine. Heinroth’s Lehrbuch der Storungen des Seelenlebens (Textbook of the Disturbances of Psychic Life) published in 1818, was instrumental for earning Johann Christian Reil’s term “Psychiatry” wide acceptance. It was also in this text that Heinroth coined and introduced the term “psychosomatic medicine.” For him, “insanity was by “nature a loss of liberty and the result of sin and misdeeds” (Steinberg 2004). Yet, in his monograph, System der psychisch-gerichtlichen Medizin, published in1825, he addressed legal aspects of “insanity.” Heinroth’s career culminated in 1927 with his appointment as professor of “physical medicine” at the University of Leipzig.
In Heinroth’s classification, concepts from Thomas Reid’s (1785) “faculties of the mind” (such as “intellect,” “emotion” and “volition”) were combined with William Cullen’s (1877) terminology (such as “orders,” “genera” and “species” adopted from botany, and integrated with generally recognized “psychic processes,” such as “exaltation” and “depression”). On the basis of these considerations, Heinroth (1818) recognized three “orders” (“exaltation,” “depression” and “mixed excitation and depression”), nine “genera” and 36 “species” of “insanity.” The nine “genera” in Heinroth’s (1818) classification are: Verrücktheit (paranoia), in which “exaltation” becomes manifest in pathology of “intellect” (cognition); Wahnsinn (“insanity”), in which “exaltation” becomes manifest in pathology of “emotions”; manie,” in which “exaltation” becomes manifest in the pathology of “volition”; Blödsinn (“dementia”), in which “depression” becomes manifest in the pathology of “intellect” (“cognition”); melancholia, in which depression becomes manifest in the pathology of “emotions”; Willenlosigkeit (“abulia”), in which “depression” becomes manifest in the pathology of ”volition”; Verwirtheit (mental confusion), in which a mixed order of “exaltation” and ”depression” becomes manifest in the pathology of “intellect” (“cognition”); Wahnsinnige Melancholie (delusional melancholia), in which a mixed order of ”exaltation| and “depression” becomes manifest in the pathology of ”emotions”; and Scheue (fright), in which the mixed pathology of “exaltation” and “depression” becomes manifest in “volition.”
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March 1, 2018