PHENOMENOLOGY AND THE HISTORY OF PSYCHIATRY P.J.V. Beumont
Phenomenology is a word much abused in psychiatry. It has come to mean the objective description of the symptoms and signs of psychiatric illness, a synonym for clinical psychopathology as opposed to that other psychopathology which derives from psychoanalytic theory. Thus it is sometimes stated that the phenomenology of a condition is remarkably consistent although its psychopathology is varied. In truth, phenomenology is a technical term in psychiatry with a specific meaning quite distinct from and in a way opposite to that of objective psychopathology. The inappropriate use of the word is unfortunate not only for semantic reasons but also because there is a real danger that the concept to which it refers will be forgotten. Australian and New Zealand Journal of Psychiatry 1992; 26532-545 My purpose is to be an apologist of phenomenology, not an impartial critic. 1 want to rescue the baby being thrown out with the bathwater. To do so, first I will review European psychiatry in the nineteenth century and argue that phenomenology was the culmination of a number of different, and at times conflicting, trends which had preceded it. For this section I have drawn heavily on an historical monograph by Pierre Pichot [ I ] . The analysis is his, but I am responsible for its drastic simplification. Then I will discuss briefly the main tenets of phenomenology and illustrate these by reference to one important feature of psychopathology, viz the delusion. Finally, I will refer to the inf l u e n c e o f p h e n o m e n o l o g y on s u b s e q u e n t developments in psychiatry.
A brief history of psychiatry in the 19thcentury Few psychiatrists today feel a need to consult Malleus Maleficarum, [ 21 although it provides accurate descriptions of patients whom we now must assume
l h e Royal Prince Alfred Hospital and The University of Sydney P J V Beumont MB ChB, MSc. MPhil. MRCP(E),FRCPSYCH. FRACP. FRANZCP. DPM, Profescor of P\ychiatry
were suffering from mental illnesses. Its theoretical stance, based on a belief in an ever-present danger of witchcraft, is too different to our ways of thinking to be useful. Nor would we wish to follow the peregrinations of an errant womb despite the great corpus of literature which viewed hysteria in this perspective. Yet most articles on the history of psychiatry give inordinate attention to ideas such as these. They were current in Medieval and Renaissance times, and represent an archaic approach to the substance of our discipline. Psychiatry itself, like other branches of clinical medicine, emerged only under the influence of the Enlightenment. The ideas we use today are those which were formulated by our predecessors in the 19th and early 20th century and the true history of psychiatry is concerned with their development. During the first part of this period psychiatry was dominated by the French school, and during the second by the Germans. These were the days between the use of Latin and that of English as the international languages of science, and the classical papers were written in the vernacular, in French or in German. The knowledge that most English speaking psychiatrists have of these important texts is biased because it depends on which were chosen for early translation.
Downloaded from anp.sagepub.com at UCSF LIBRARY & CKM on April 10, 2015
P.J.V. BEUMONT
For instance, the works of Freud were accessible to English readers shortly after their original publication, but other equally important contributions were translated only after a delay of many years, if at all.
In France Towards the end of the 18th century, reformers in several countries introduced humane methods of management for the insane. Vincenzo Chiarugi in Florence was one such person, William Tuke in England another. The discipline of clinical psychiatry, however, really started in the 1790s with the appointment of Philippe Pinel as physician to the BicEtre and Salpztriere. At these two institutions the “lunatics” of Paris were confined, and Pinel’s appointment was the first real recognition by the authorities of the medical nature of those afflictions. Pinel’s achievements were varied. First, he fostered the same benign attitudes to the care of his patients as Tuke was to promote at the Retreat in Yorkshire. But while Tuke was a wealthy tea and coffee merchant, a philanthropist motivated by his Quaker religious convictions, and while the Retreat was never intended to be a hospital but merely a place of refuge and care, Pinel was a medical man who introduced medical methods. He undertook the treatment of patients in hospitals for which he created an appropriate institutional framework. Pinel’s other and perhaps major achievement was that he founded the French school of psychiatry. This was a tradition of careful clinical description, directed at defining nosological categories and avoiding speculations about aetiology or pathogenesis. For Pinel and for his famous pupil Esquirol, psychiatry was undoubtedly part of medicine, to be practised as a clinical discipline. Esquirol wrote, “I have observed the symptoms of madness and have studied the ways, the habits and needs of lunatics ...keeping my attention on the facts, I have brought together those of a similar nature. I describe them as I saw them. I have rarely sought to explain them.” (J’ai ohservk les symptcimes de laj3lie;j’ai PtudiP les moeurs, les habitudes et les besoins des aliPnCs ... m’attachant aux faits, j e les rapprochks par les affinite‘s, j e les ruconte que j e les ai w s ,j’ai rarement cherchk a les expliquer (Pichot, p. 12)). It was a psychiatry without psychology. An early but not entirely welcome result of this medical approach was Bayle’s description in 1822 of a series of cases in which paralysis and insanity were
533
related to chronic inflammation of the arachnoid membrane. The influence of his discovery was profound. At the same time as the anatomy of the brain was being studied, an important psychiatric entity had been identified. General Paralysis of the Insane (GPI) has a specific symptomatology, combining neurological and psychiatric signs, a specific course of clinical evolution and a specific neuropathology. It was to serve as a model of psychiatric illness for subsequent generations of psychiatrists. Unfortunately it represents an ideal which seldom has been achieved. Despite its descriptive bias, French psychiatry was no ivory tower discipline, as neurology was to become. Pinel was committed to improving hospital conditions and creating a therapeutic environment. Administrative and medico-legal issues were promoted. The Act of 1838 made provisions for the setting up of psychiatric institutions throughout France and defined legal and administrative structures for the care of mental patients 131. Psychiatry in the 19th century had to do exclusively with insanity. Under the terms of the 1838 Act “alienists” could see only the most serious cases, whether they practised in public asylums or private clinics. This provision was repealed only in 1896, while in England a similar law prevailed until 1915. The milder forms of psychiatric illness were within the province of general medicine, hence their study developed quite separately. Paul Briquet, author of the monumental Trait6 clinique et thhrapeutique de l’hystkrie [4], was a professor of clinical medicine, while Jean-Martin Charcot was a physician in charge of one of the departments of the Saltp&triere that specifically did not admit insane patients. Charcot believed that the manifestations of hysteria could be made the objects of symtomatological description in the same way as other neurological diseases, and for a while, in the 1880s, hysteria and hypnotism were a major interest, a “cutting edge” of medical science. Of course, Charcot had deluded himself, but he created an atmosphere of intense intellectual ferment which greatly influenced such important figures as Pierre Janet and Sigmund Freud. Their contribution to modern psychiatry is another story, not relevant to the present account. By 1880, there were perhaps I20 alienists in France, one for every 300,000 persons. In other developed countries, such as the United States, the ratio was even lower, perhaps one per 450,000. By contrast, in Australia in 199 1 there were approximately 1,500
Downloaded from anp.sagepub.com at UCSF LIBRARY & CKM on April 10, 2015
534
PHENOMENOLOGY A N D THE HISTORY OF PSYCHIATRY
psychiatrists who were members of the Royal Australian and New Zealand College (as well as 620 trainees and others qualified overseas) for a population of about 16,300,000[ 5 ] . The French psychiatric community was a small and coherent society; most of the main figures knew each other well and were sometimes related by family ties. Directly or indirectly, almost all were former pupils of Pinel or Esquirol and had been influenced by the tradition emanating from the great teaching hospitals of Paris. Their history is recorded by RenC Semelaigne [6]. himself a descendant of Pinel’s nephew. Their names appear again and again in relation to a whole series of syndromes: Morel, who described d h e n c e pse‘coce from whence dementia praecox derives, and who introduced the concept of degeneration to psychiatry; Falret, who described,folie circirlair-e,the precursor of the concept of manic depressive psychosis, and who emphasised the importance of the progress of an illness in the delineation of psychiatric entities: “for ... the idea of a natural course of illness that can be foreseen presupposes the existence of a natural kind of disease” (... l’idee d’une rnar-che natuselle a pr-hwir- suppose I’esistence d’irne espkce natuselle de maladie.” (Pich0t~p.16)Laskgue, a friend of Morel and of the famous physiologist Claude Bernard, who described kleptomania, anosesiie hyste‘r-ique (anorexia nervosa), compulsive exhibitionism,folie u deicr-. dPlire de pe‘r-seciriiotis from which paranoia derives - and Laskgue’s sign of sciatica. Among his other activities, Laskgue was commissioned to visit Russia and investigate allegations of the abuse of psychiatry for political ends in that country. Plus ca chanpeder-Sr.tri~o~/’/rr-ei~i~il. Liepzig. Franz Deuticke. 191 I . Translated into English. Zinkin .I. Dementia praecox or the Group of schizophrenias. London: Allen and Unwin. 195 I . 2 1 . Schneider K. Klii1isd7eP.s?.l.h(’purholo,~ip, 1950. Translated into English by Hamilton M. W. as Clinical sychopathology. New York. Grune and Stratton. 22. Faegerman PM. Psychogenic psychosis. London: Butterworth. 1945. 23. New South Wales Ministry for Health. Exposure draft mental health bill. Government Printer. 1989. 24. Kaplan HI. Freedman AM. Sadock BJ. eds. Comprehensive textbook ofpsychiatry. 3rd ed. Baltimore: Williams and Wilkins. I 980. 25. Farrell B. Wilde’s Reader in mental philosophy at Oxford University: personal communication. 26. Mullen PE. A phenomenology ofjealousy. Australian and New Zealand Journal of Psychiatry 1990: 24: 17-28. 27. Parker G. Hadri-Pavlovic D. Boyce P, Wilhelm K. Brodaty H. Mitchell P. Hickie 1. Eyers K. Classifying depression by mental state signs. British Journal of Psychiatry 1990: 157:.55-65.
Downloaded from anp.sagepub.com at UCSF LIBRARY & CKM on April 10, 2015
Phenomenology is a word much abused in psychiatry. It has come to mean the objective description of the symptoms and signs of psychiatric illness, a synonym for clinical psychopathology as opposed to that other psychopathology which derives from psychoanalytic theory. Thus it is sometimes stated that the phenomenology of a condition is remarkably consistent although its psychopathology is varied. In truth, phenomenology is a technical term in psychiatry with a specific meaning quite distinct from and in a way opposite to that of objective psychopathology. The inappropriate use of the word is unfortunate not only for semantic reasons but also because there is a real danger that the concept to which it refers will be forgotten. Australian and New Zealand Journal of Psychiatry 1992; 26532-545 My purpose is to be an apologist of phenomenology, not an impartial critic. 1 want to rescue the baby being thrown out with the bathwater. To do so, first I will review European psychiatry in the nineteenth century and argue that phenomenology was the culmination of a number of different, and at times conflicting, trends which had preceded it. For this section I have drawn heavily on an historical monograph by Pierre Pichot [ I ] . The analysis is his, but I am responsible for its drastic simplification. Then I will discuss briefly the main tenets of phenomenology and illustrate these by reference to one important feature of psychopathology, viz the delusion. Finally, I will refer to the inf l u e n c e o f p h e n o m e n o l o g y on s u b s e q u e n t developments in psychiatry.
A brief history of psychiatry in the 19thcentury Few psychiatrists today feel a need to consult Malleus Maleficarum, [ 21 although it provides accurate descriptions of patients whom we now must assume
l h e Royal Prince Alfred Hospital and The University of Sydney P J V Beumont MB ChB, MSc. MPhil. MRCP(E),FRCPSYCH. FRACP. FRANZCP. DPM, Profescor of P\ychiatry
were suffering from mental illnesses. Its theoretical stance, based on a belief in an ever-present danger of witchcraft, is too different to our ways of thinking to be useful. Nor would we wish to follow the peregrinations of an errant womb despite the great corpus of literature which viewed hysteria in this perspective. Yet most articles on the history of psychiatry give inordinate attention to ideas such as these. They were current in Medieval and Renaissance times, and represent an archaic approach to the substance of our discipline. Psychiatry itself, like other branches of clinical medicine, emerged only under the influence of the Enlightenment. The ideas we use today are those which were formulated by our predecessors in the 19th and early 20th century and the true history of psychiatry is concerned with their development. During the first part of this period psychiatry was dominated by the French school, and during the second by the Germans. These were the days between the use of Latin and that of English as the international languages of science, and the classical papers were written in the vernacular, in French or in German. The knowledge that most English speaking psychiatrists have of these important texts is biased because it depends on which were chosen for early translation.
Downloaded from anp.sagepub.com at UCSF LIBRARY & CKM on April 10, 2015
P.J.V. BEUMONT
For instance, the works of Freud were accessible to English readers shortly after their original publication, but other equally important contributions were translated only after a delay of many years, if at all.
In France Towards the end of the 18th century, reformers in several countries introduced humane methods of management for the insane. Vincenzo Chiarugi in Florence was one such person, William Tuke in England another. The discipline of clinical psychiatry, however, really started in the 1790s with the appointment of Philippe Pinel as physician to the BicEtre and Salpztriere. At these two institutions the “lunatics” of Paris were confined, and Pinel’s appointment was the first real recognition by the authorities of the medical nature of those afflictions. Pinel’s achievements were varied. First, he fostered the same benign attitudes to the care of his patients as Tuke was to promote at the Retreat in Yorkshire. But while Tuke was a wealthy tea and coffee merchant, a philanthropist motivated by his Quaker religious convictions, and while the Retreat was never intended to be a hospital but merely a place of refuge and care, Pinel was a medical man who introduced medical methods. He undertook the treatment of patients in hospitals for which he created an appropriate institutional framework. Pinel’s other and perhaps major achievement was that he founded the French school of psychiatry. This was a tradition of careful clinical description, directed at defining nosological categories and avoiding speculations about aetiology or pathogenesis. For Pinel and for his famous pupil Esquirol, psychiatry was undoubtedly part of medicine, to be practised as a clinical discipline. Esquirol wrote, “I have observed the symptoms of madness and have studied the ways, the habits and needs of lunatics ...keeping my attention on the facts, I have brought together those of a similar nature. I describe them as I saw them. I have rarely sought to explain them.” (J’ai ohservk les symptcimes de laj3lie;j’ai PtudiP les moeurs, les habitudes et les besoins des aliPnCs ... m’attachant aux faits, j e les rapprochks par les affinite‘s, j e les ruconte que j e les ai w s ,j’ai rarement cherchk a les expliquer (Pichot, p. 12)). It was a psychiatry without psychology. An early but not entirely welcome result of this medical approach was Bayle’s description in 1822 of a series of cases in which paralysis and insanity were
533
related to chronic inflammation of the arachnoid membrane. The influence of his discovery was profound. At the same time as the anatomy of the brain was being studied, an important psychiatric entity had been identified. General Paralysis of the Insane (GPI) has a specific symptomatology, combining neurological and psychiatric signs, a specific course of clinical evolution and a specific neuropathology. It was to serve as a model of psychiatric illness for subsequent generations of psychiatrists. Unfortunately it represents an ideal which seldom has been achieved. Despite its descriptive bias, French psychiatry was no ivory tower discipline, as neurology was to become. Pinel was committed to improving hospital conditions and creating a therapeutic environment. Administrative and medico-legal issues were promoted. The Act of 1838 made provisions for the setting up of psychiatric institutions throughout France and defined legal and administrative structures for the care of mental patients 131. Psychiatry in the 19th century had to do exclusively with insanity. Under the terms of the 1838 Act “alienists” could see only the most serious cases, whether they practised in public asylums or private clinics. This provision was repealed only in 1896, while in England a similar law prevailed until 1915. The milder forms of psychiatric illness were within the province of general medicine, hence their study developed quite separately. Paul Briquet, author of the monumental Trait6 clinique et thhrapeutique de l’hystkrie [4], was a professor of clinical medicine, while Jean-Martin Charcot was a physician in charge of one of the departments of the Saltp&triere that specifically did not admit insane patients. Charcot believed that the manifestations of hysteria could be made the objects of symtomatological description in the same way as other neurological diseases, and for a while, in the 1880s, hysteria and hypnotism were a major interest, a “cutting edge” of medical science. Of course, Charcot had deluded himself, but he created an atmosphere of intense intellectual ferment which greatly influenced such important figures as Pierre Janet and Sigmund Freud. Their contribution to modern psychiatry is another story, not relevant to the present account. By 1880, there were perhaps I20 alienists in France, one for every 300,000 persons. In other developed countries, such as the United States, the ratio was even lower, perhaps one per 450,000. By contrast, in Australia in 199 1 there were approximately 1,500
Downloaded from anp.sagepub.com at UCSF LIBRARY & CKM on April 10, 2015
534
PHENOMENOLOGY A N D THE HISTORY OF PSYCHIATRY
psychiatrists who were members of the Royal Australian and New Zealand College (as well as 620 trainees and others qualified overseas) for a population of about 16,300,000[ 5 ] . The French psychiatric community was a small and coherent society; most of the main figures knew each other well and were sometimes related by family ties. Directly or indirectly, almost all were former pupils of Pinel or Esquirol and had been influenced by the tradition emanating from the great teaching hospitals of Paris. Their history is recorded by RenC Semelaigne [6]. himself a descendant of Pinel’s nephew. Their names appear again and again in relation to a whole series of syndromes: Morel, who described d h e n c e pse‘coce from whence dementia praecox derives, and who introduced the concept of degeneration to psychiatry; Falret, who described,folie circirlair-e,the precursor of the concept of manic depressive psychosis, and who emphasised the importance of the progress of an illness in the delineation of psychiatric entities: “for ... the idea of a natural course of illness that can be foreseen presupposes the existence of a natural kind of disease” (... l’idee d’une rnar-che natuselle a pr-hwir- suppose I’esistence d’irne espkce natuselle de maladie.” (Pich0t~p.16)Laskgue, a friend of Morel and of the famous physiologist Claude Bernard, who described kleptomania, anosesiie hyste‘r-ique (anorexia nervosa), compulsive exhibitionism,folie u deicr-. dPlire de pe‘r-seciriiotis from which paranoia derives - and Laskgue’s sign of sciatica. Among his other activities, Laskgue was commissioned to visit Russia and investigate allegations of the abuse of psychiatry for political ends in that country. Plus ca chanpeder-Sr.tri~o~/’/rr-ei~i~il. Liepzig. Franz Deuticke. 191 I . Translated into English. Zinkin .I. Dementia praecox or the Group of schizophrenias. London: Allen and Unwin. 195 I . 2 1 . Schneider K. Klii1isd7eP.s?.l.h(’purholo,~ip, 1950. Translated into English by Hamilton M. W. as Clinical sychopathology. New York. Grune and Stratton. 22. Faegerman PM. Psychogenic psychosis. London: Butterworth. 1945. 23. New South Wales Ministry for Health. Exposure draft mental health bill. Government Printer. 1989. 24. Kaplan HI. Freedman AM. Sadock BJ. eds. Comprehensive textbook ofpsychiatry. 3rd ed. Baltimore: Williams and Wilkins. I 980. 25. Farrell B. Wilde’s Reader in mental philosophy at Oxford University: personal communication. 26. Mullen PE. A phenomenology ofjealousy. Australian and New Zealand Journal of Psychiatry 1990: 24: 17-28. 27. Parker G. Hadri-Pavlovic D. Boyce P, Wilhelm K. Brodaty H. Mitchell P. Hickie 1. Eyers K. Classifying depression by mental state signs. British Journal of Psychiatry 1990: 157:.55-65.
Downloaded from anp.sagepub.com at UCSF LIBRARY & CKM on April 10, 2015
