german berrios_historia de la neuropsiquiatría (eng)

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The concept of neuropsychiatry

A historical overview

German E. Berriosa,*, Ivana S. Markovab,1

aDepartment of Psychiatry, University of Cambridge, Addenbrookes Hospital, Box 189, Hills Road, Cambridge, CB2 2QQ, UKbDepartment of Psychiatry, University of Hull, Coniston House, East Riding Campus, Willerby, HU10 6NS, UK

Abstract

The elusive nature of the social practice called neuropsychiatry

is the most important obstacle for writing its history. At different

times, and in different countries, the term has been used to name

different ideological and professional packages. Choosing any of

these as the prototype would, however, bias and regionalize the

historical account. One solution is to identify an ideological marker

or common denominator. To spin its yarn, this paper has chosen the

foundational claim (putatively common to all practitioners of

neuropsychiatry) that all mental disorders are disorders of the

brain. Three among its results are worth noting. One is that the

meaning and exercise of neuropsychiatry will continue to depend

on social, economic and political factors; this augurs future

instability. The second is that each time that the foundational claim

has been uttered in history it has meant something different.

Further research is needed to clarify whether this is due to the way

in which the claim becomes inscribed in different cultural niches;

what is clear is that by using the foundational claim as a marker it

is not possible to establish a continuity in the progress of

neuropsychiatry. The third finding is that users of the foundational

claim require the use of a concept of matter and in this paper

plain and baroque types of matter have been identified. To

explain the origin of mind, those using the plain notion need to

resort to external ingredients and their narratives incorporate bits of

the real world. Users of the baroque definition do not need such

aids. It is not for the historian to judge which of these two

definitions is more felicitous and more conducive to the moral and

aesthetic edification of psychiatry and her patients. D 2002

Elsevier Science Inc. All rights reserved.

Keywords: Brain; Concepts; History; Ideas; Mind; Neuropsychiatry

Introduction

This paper is on the history of the concept of neuro-

psychiatry. This commission can be discharged only par-

tially because there is no stable, positive definition of

neuropsychiatry nor a conceptual core or fulcrum has yet

been identified that may join up the historical periods duringwhich neuropsychiatry is said to have predominated. Fur-

thermore, little is known about the epistemic nature and

value of the foundational claims of neuropsychiatry, e.g., its

concept of matter and the belief that mental disorders are

disorders of the brain. Lastly, little research has been done

on how the economic and social network within which

neuropsychiatry has established itself contributes to its

overall success.

To deal with the above, the following strategy has been

followed: a working definition of neuropsychiatry is

offered; a core claim chosen as leitmotif, namely, that

mental diseases are diseases of the brain; and a classifica-tion of matter (plain and baroque) is proposed. To illustrate

that absence of conceptual continuity between utterances of

core claims, writers have been chosen whose work spans a

period of about 350 years.

Although tempted, we have resisted rounding up the

usual suspects. Some like Griesinger, Meynert or Wernicke

were included because they already live in the pantheon of

neuropsychiatry; Les Empecheurs de penser en ronde were

chosen (Jackson, von Monakow) because they were irrev-

erent and creative and, although paid lip service to, have

been kept at a safe distance; yet others because their claims

have been misunderstood (Cabanis, Bayle) or little known

0022-3999/02/$ see front matterD 2002 Elsevier Science Inc. All rights reserved.

PII: S 0 0 2 2 - 3 9 9 9 ( 0 2 ) 0 0 4 2 7 - 0

* Corresponding author. Tel.: +44-1223-336-965; fax: +44-1223-336-

968.

E-mail addresses: [email protected] (G.E. Berrios), ismarkova@p-

sych.hi-net.co.uk (I.S. Markova).1 Also corresponding author. Tel.: + 44-1482-466-960;

fax: + 44-1482-466-966.

Journal of Psychosomatic Research 53 (2002) 629638


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(Hartley, Battie, Georget). In a way, the choice does not

matter for all are there to illustrate the point that throughout

the years the foundational claim that mental disorders are

disorders of the brain has meant different things. Similarly,

current neuropsychiatry is likewise another reinterpretation

of the foundational claims whose specific features are

determined by the new technologies available and thesocioeconomic needs that they are presumed to meet. No

doubt the future will see many more with their own claims

to truth and progress.

Definitions

Neuropsychiatry has been defined according to assump-

tions, investigative techniques, type of patient it deals with,

therapeutic value or combinations thereof.2 However, nei-

ther cross-culturally nor trans-historically can neuropsychia-

try

3

be considered as a unitary activity: in response to socialand economic need, different types will predominate in

different contexts.4 All types share the foundational assump-

tion5 that mental disorders are caused by changes in the

physical conformation of the brain.6 Although unamenable

to ascertainment, this noninferential claim generates

lower-level predictions, empirically testable as cross-sec-

tional correlations.7 The belief that findings of a positive

covariance at the lower level legitimate the foundationalist

claim is unwarranted (see below).

Psychiatry is a protean discipline8

and neuropsychiatryone of its incarnations. In contrast to others, however, it has

persistent exclusivist claims.9 These need accounting as

does the fact that they have not been subjected to empirical

ascertainment.10 In view of the above, it is not surprising

that the history of neuropsychiatry is presented as one of

darkness to light; although convenient, this received

view requires revision.

History of neuropsychiatry as history of what?

If there is no unitary core to neuropsychiatry, then what isits history the history of?11 Is the history of neuropsychiatry

more like the history of, say, a real object (horse, orchid,

chair, Rosetta stone), a purview (aesthetics, ethics), a dis-

ease (dementia, anxiety disorders); a social practice (priest-

2 Although the definition of neuropsychiatry is notthe objective of this

paper, a historian cannot do without one. Definitions such as it is a branch

of medicine that deals with the relationship between neural processes and

psychiatric disorders [41] are too general. Combined definitions pose

even more trouble: a prominent focus of neuropsychiatry is the assessment

and treatment of patients with psychiatric illnesses or symptoms associated

with brain lesions or dysfunction . . . Neuropsychiatry also encompasses

those symptoms that lie in the gray zone between the specialties ofneurology and psychiatry: impairment of attention, alertness, perception,

memory, language, and intelligence. Fundamental to neuropsychiatry is the

effort to link psychopathology with measurable brain deficits. Where

psychiatric symptoms are likely to stem from brain disorders, but where the

state of technology has not developed sufficiently to establish brain

syndrome linkages, neuropsychiatry must assume the leadership in

pursuing such associations. . . .Many human conditions that currently are

not considered to be in the province of medicine, will, by virtue of

neuroscience discovery, eventually become regarded as neuropsychiatric

disorders. This re-conceptualization will be of historic and monumental

significance to the individuals who suffer from these conditions and to

society . . . a second reason for revitalizing the neuropsychiatric paradigm is

to reduce the stigma associated with psychiatric symptoms. . . [42]. This in

crescendo definition starts by describing what neuropsychiatry does, irrupts

into the gray zones, and ends up bidding for many human conditions.Then, it introduces a foundational claim (effort to link mental symptoms to

measurable brain deficits); and the technology alibi (on this historical

concept see below); lastly, it justifies neuropsychiatry as a stigma reducing

paradigm. With this definition, the historian finds his/her work cut out!3 There is also an activity called behavioural neurology whose

concepts and practice seem to overlap with those of neuropsychiatry and

neuropsychology [43].4 For example, during the 19th century, differences can be found

between European countries in regards to the meaning and practice of

neuropsychiatry. These reflect not only international rivalries but also

internecine disputes about whose consulting rooms these patients

should patronize.5 A foundationalist claim provides a discipline with its epistemic force

(i.e., knowledge creating capabilities) but cannot be empirically proven.

6 Saying that mental disorders have a cause is already biasing the

explanatory die in one direction. For equally cogent is the claim that people

do things for reasons. Causes and reasons constitute, in fact, different

universes of accounting and are governed by different theories and rules. At

a deeper level, the view that mental disorders are effects can be challenged

and the alternative proposed that they are waning and waxing processes.

There is no empirical way to finding out which of these works better.Thus, the view that mental disorders must have a cause, and that that

cause must lie in the brain, remains an article of faith. Its plausibility is a

mirage created by the fact that it fits in with current social expectations.7 Correlations express (incompletely) partial covariances. A correlation

means that some proxy variables (not mind and brain) covary. The

epistemic value of the claim therefore fully depends on the quality of the

proxying. It is rather surprising that while the mathematics of correlations

are acceptably studied, the logic and epistemology of covariation and the

assessment of proxying have been neglected.8 The definition psychiatry is a branch of medicine that deals with

mental disorder begs too many questions. At a deeper level, psychiatry

appears to be just another discipline created by society to perform certain

anthropological, managerial and policing duties. Under the aegis of

medicine and science, psychiatry creates representations of man in normality

and abnormality, and based on these categories, accounts and managerialguidelines. A discipline is a package of ideologies, techniques and social

practices which fulfils a role in social organization. A representation is an

image, model, view, concept or other definitional form that helps someone to

think of something. Because the sensory windows, cognition and language

are machines to generate public representations of the world, representa-

tional theory is central to human culture.9 This concerns the claim that all mental disorders are related to

changes in the brain.10 It is a fascinating aspect of evidence-based medicine that it is not

very good at applying its own rules to itself, for example, little empirical

research seems to exist comparing neuropsychiatry with others types of

psychiatry in terms of overall therapeutic success, etc.11 These types of questions are answered by historiography, which is the

set of ideological principles, techniques and methods used to write history.

G.E. Berrios, I.S. Markova / Journal of Psychosomatic Research 53 (2002) 629638630


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hood, cobblery, medicine, palmistry), an ideology (realism,

idealism), or a blatant construct (French revolution, guilt,

prostitution). Some may say that none of the above, for

neuropsychiatry is a true science. Interestingly enough, this

view demands only one (and narrow) form of history

of neuropsychiatry.12

In this paper, neuropsychiatry is conceived of as theloose activity of researchers who share certain foundational

claims and enact them in specific research programmes. In

each historical period, both the foundational claims and the

apparatus that such groups put in practice will vary accord-

ing to theoretical context and socioeconomic structure.

Specifically therefore, this paper will select as its chain of

being13 the bold belief that mental disorders are all reflec-

tions of changes in the brain. In turn, this foundational claim

will allow us to identify neuropsychiatric approaches to

mental disorder since at least the 17th century.

The foundational claim

The claim that the body (brain) houses the human soul

(or mind),14 and the claim that changes (lesions) in the

conformation or constitution of the body (brain) cause

mental disorder, are historically independent and not alto-

gether clear.15 For example, at the beginning of the 19th

century, there was a debate as to whether the mind or soul

was located in the cerebrospinal fluid or the cortex [1].

Likewise, during the middle of the 19th century, the view

was still defended (by many) that because the soul (mind)

was a marker of the divine, it could not become divided or

diseased. To save the view that mental disorders wererelated to the body, writers resuscitated the proposal that

organs other than the brain, such as the stomach [2], heart

[3] or hypochondrium [4], might contribute to the format-

ting of the mind and its diseases.

The claim that the body (brain) houses the human soul

(or mind) is used often by materialist thinkers, i.e., by those

who believe that at the time the world came into being there

was only matter [5]. So their problem is to explain where

mind came from. According to the type of matter (body,

brain, res extensa, etc.) they prefer, users divide up into two

groups. Some play with a plain concept of matter (i.e., for

them matter is a bundle of atoms, fields, strings or whatever,

but has not got any hidden qualities that can be used to

explain what issues out of matter-like mind). Others playwith a baroque concept of matter (matter includes dynamic

qualities of the type that can explain the origin of mind).16

This is why when it comes to explaining the origin and

shape of the mind, the plain matter people have to search

for additional resources in the context in which the opera-

tion occurs. Baroque matter people, on the other hand,

have less difficulty in that they can find explanations in their

own concept of matter.

17th century

Willis and Sydenham

Claims that some forms of mental disorder are related to

the body can be found in the 17th century literature:

melancholy is commonly defined, a raving without a fever

or fury, joynd with fear and sadness; whence it follows to

be a complicated affect of the brain and of the heart; for, that

melancholick17 persons rave, it proceeds from the fault of

the brain,18 and the disorder of the animal spirits residing in

it; but that they are sadand timorous, this is attributed to the

passion of the heart. [3].19 Willis (1621 1675) was a

baroque matter fellow and packed sufficiently into his

conception of the body (or brain) to explain specific featuresof mind or madness. This was part of his iatro-chemical,

Paracelsian inheritance [6].

While Willis happily paired up brain and heart, Syden-

ham (16241689), who fancied himself as a hater of theory

and a no-nonsense empiricist [7] chose the blood as his

12 It is a narrative mainly consisting of tales of discoveries and

biographies.

13 Chain of being refers to Arthur Lovejoys (1936) model for thehistory of ideas [44] although his assumption that there are some ideas in

western culture that keep recurring century after century and that are sub

specie aeternitatis has been severely contested (on the history of ideas, see:

Kelley [45]; Bevir [46]).14 The literature on the relationship between the mind and the body is

large albeit repetitive; work on when and why the brain became the

representative of the body is less so; indeed, the question of whether the

abandonment of the stomach and heart as sources of patterned emotions

resulted from hard empirical research or simply because it became

obvious has not yet been answered.15 The relationship between these two claims is asymmetrical and

empirical. Indeed, the claim that brain disease causes mind disease is not

logically dependent upon the belief that the mind resides in the brain (this

because the former could be plausibly made without the second being true.).

16 This view is already present among Greek atomists who claimed that

atoms could have different shapes and sizes and used these differences

(in addition to their movement) to account for differences in the visible

objects [47].

17 The 17thcentury medical concept of melancholiaincludeddisorderswhich would currently go under names such as schizophrenia [48].

18 It must not be forgotten that Willis reference to the brain occurs in

the wake of the Cartesian claim that the pineal gland acted as a bridge

between thinking substance and extended substance (mind and body).19 This statement can be variously interpreted. For example, Willis

allusion to the heart can be seen as an early reference to the autonomic

nervous system. This who said it first approach to history is

congratulatory but barren and it is from this perspective that Willis has

been called a neuropsychiatrist [49]. More plausibly, the same statement

can be seen as a metaphorical redescription (in terms of the new

explanatory categories of the 17th century) of that obscure phenomenon

called melancholia. This approach is more promising for at least it

identifies the historical period when a powerful allegory was introduced

into the history of psychiatry.

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explanatory medium: this arises from too vivid and exalted

crasis of the blood. There is also another sort of mania,

which succeeds long-continued intermittent fevers, and at

last degenerates into idiocy.20 This comes from weakness

and vapidity of blood, brought on by over-long fermenta-

tion [8]. Here we see the blood (as a proxy representation

of the body) providing Sydenham with the required meta-phorical help (vivid and exalted blood = mania).21 In this

sense, he is also a baroque matter man.

These claims about the bodily origin of mental disorder

sound as hard as any that we may read nowadays. In what

consists their similarity? There will be little point in saying,

poor Willis and Sydenham, if only they had had fMRI! If

our historical point is right, that ideological packages have

internal coherence and respond to the availabilities and

needs of the time, then fMRI would have offered Willis

nothing as his representation of the brain and the mind was

not coached in visual metaphors. Indeed, his views that

melancholia and mania were associated with the brain, heartor blood resulted from a narrative about animal spirits and

the iatro-chemical structure of the body.22

18th century

Hartley and Battie

David Hartleys (17051757) post-Newtonian views of

matter and his belief in Lockean associationism date him

neatly as an 18th century thinker [9]. He believed that

mental disorder was related to distortions in the vibration

pattern of brain fibres. For example, he explained thedifference between a normal thought and a delusion: thus

suppose a person, whose nervous system is disordered, to

turn his thoughts accidentally to some barely possible good

or evil. If the nervous disorder falls in with this, it increases

the vibrations belonging to its ideas so much, as to give it a

reality, a connection with self. For we distinguish the

recollection and anticipation of things relating to ourselves,

from those of things relating to other persons, chiefly by the

difference of strength in the vibrations, and in their coa-

lescences with each other [10]. Vibrations affecting brain

fibres (matter) play a central role in Hartleys explanation of

mental symptoms.23 Vibrations are produced by external

stimuli (as strings vibrate in response to plucking by a

finger) and the fibre itself contributes naught to the response

pattern. This makes Hartley a plain matter fellow.

William Battie (17031776) rejected the view that the

brain was a gland, that nerves were hollow and that sensation

was due to the circulation of a nervous fluid [11]: themedullary substance was solid and sensation occurred as

the result of pressure on the nerves.24 He, however, also ex-

plained insanity in terms of vibratory mechanisms: insanity

was preceded by nervous overexcitation and followed by

nervous insensitive. Without any externalstimulus, the sub-

ject may see fire or hear sounds (i.e., have hallucinations

and refer them to an external cause). This he called original

madness; on the other hand, an anomalous internal stimulus

to the nerves could cause similar experiences but in that case

the subject had consequential madness [12]. Battie followed

Hartley and also sponsored a plain concept of matter.

Cabanis

Towards the end of the 18th century, and based on a

reconceptualization of matter and mind, Pierre Cabanis

(17571808)25 proposed a new approach to their relation-

ship. His was a view born out of a combination of

associationism, materialism and vitalism. An assiduous

visitor of Madame Helvetius salon at Auteuil,26 Cabanis

was influenced by the work of Condillac, Helvetius, La

Mettrie and dHolbach. In a complex and ambiguous theory,

which according to vantage point speaks with many voi-

ces,27 Cabanis went further than any of his predecessors.

For example, among all the Ideologues,28 he nailed hisflag the highest on the materialistic mast.29

20 The meaning of the putative clinical association between mania

and idiocy is very unclear here for the categories themselves were used

with a sense that we cannot really fathom [50].21 This carry over from Paracelsian times that an excess of some

substance will lead to an increase in the corresponding behaviour (and vice

versa) is still present in current psychopharmacological thinking.22 What we do not know is whether in the privacy of their consulting

rooms Willis and Sydenham used with their patients the same narrative to

justify their treatments. It is likely that they did, as only a few decades

earlier, Napier, the great early 19th century physician, had used his own

brand of descriptive and explanatory narrative to justify his treatments [51].

23 It was after Newton that the split takes place between those who

continue talking about animal spirits and others who chose about the new

concept of vibration [52]. The latter metaphor was clearly more in keeping

with the spirit of the 18th century and caught on quickly [53].24 This view is also discussed by Hobbes: Every great agitation or

concussion of the brain (as it happened from a stroke, specially if the stroke

be upon one eye) whereby the optic nerve suffereth any great violence,

there appeareth before the eyes a certain light, with light is nothing without

(from Hobbes, 1651 quoted in Rand, 1912, p. 150 [54]).25 For biographical details, see Cerise [55] and Staum [56]. Cabanis

was a prototypical Enlightenment thinker: broad, progressist, interested inpolitics, the sciences and the humanities and imbued by the materialistic

philosophy and vitalism characteristic of his period (on the former, see

Rosen [57], Picavet [58] and Temkin [59]; on the latter, see Huard [60] and

Roger [61]).26 After the death of her husband in 1771, Madame Helvetius moved

her salon to the quiet village of Auteuil where it saw its golden period [62].27 Ferrater Mora [63] once said that Cabanis concept would satisfy the

most staunch defender of materialism or spiritualism.28 Despectuous name given by Napoleon to a group of thinkers

(including Cabanis) that opposed his imperialistic politics [64].29 Cabanis will forever be known as the man who said that the brain

secretes thought as the liver does bile. Chazaud [65] has offered an

important analysis of the way in which this quotation, taken out of context,

was used by antimaterialist writers to discredit Cabanis.



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However, his view of matter is baroque for as Moravia

[13] once wrote, it . . .comprises a full array of forces and

properties from whose physico-chemical combination even

the most complex living organisms may emerge. From

the neuropsychiatric viewpoint, Cabanis believed that his

baroque matter (which included a number of functions and

vital energy) could give rise fully to a complex mind.However, he also believed that this kind of analysis

(namely of how matter gives rise to mind) could only be

carried out against the context of a science of man, a sort

of philosophical anthropology which not only included

physiology but also language and hermeneutics. This

allowed him to develop an integrated definition of body

which as sources of patterns of sensations included, in

addition to the brain, the heart, stomach and genitalia.30

This encyclopaedic approach to the study of man went

out of fashion during the 19th century and it is no wonder

that Cabanis ideas were misunderstood and distorted;

without context, his view of the mind sounds like grossmaterialism [14].

19th century

Georget and Bayle

An example of the new materialism can be found in

the writings of E. Georget (1795 1828), a disciple of

Pinel and Esquirol. He escaped the 18th century views of

the latter by modifying their nosology, emphasising the

organic aetiology of mental disorder, introducing the tech-nology alibi (that although all mental disorders are

caused by changes in the brain in some cases we cannot

yet demonstrate it due to lack of the appropriate tech-

nology)31 and by adopting Bichats vitalism.32 The latter

provided Georget with a baroque view of matter.

Georgets theoretical views seemed at the time to be

reinforced by the precocious work of his contemporary A.J.

Bayle (1799 1858), who put forward a unitary view of

general paralysis (i.e., that dementia and mental disorder are

both features of the same disease) as opposed to the dualview predominant at the time [15]. Bayles work has been

considered by some as the first demonstration that mental

disease is physical disease, and hence, conventional histor-

ians have treated his report as the beginning of neuro-

psychiatry [16]. In regard to this, Quetel [17] has made

the following (correct) comment: General paralysis thus

defined might have done no more than figure in psychiatry

nosography (though difficult to situate in the nosography of

Pinel and Esquirol) had it not fitted in so well with the

arguments of those who believed that the etiology of mad-

ness was necessarily organic. . . For the first time, then,

something had been discovered in the brains of the insane!Moreover, these anatomo-pathological lesions were not only

to make general paralysis the model of organic mental

disease, they were also to swing the psychogenetic concep-

tion of madness.

Griesinger

It is to Wilhelm Griesinger (18171868) that the (apo-

cryphal) quotation has been attributed that all mental dis-

eases are just diseases of the brain. Griesinger grew up

during one of the most turbulent periods of German culture

[1820].33 Materialist biologism, the beginnings of a physi-

ology specific for living organisms, vitalism and roman-ticism in arts and politics are only some of the ideologies

that influenced him into being active in student politics and

30 It would be nonsense to consider this proposal as an anticipation

of the views expressed by James and Lange (who also differed from

each other). In Cabanis time, the bodily organs were still allowed to talk

to the brain about the world. This went beyond the descriptions of the

natural functions of the organs but included rich complexes of feelingsand cognitions perceived as emanating directly from them. The entrails

have since been exiled into the silent shadows and can whisper nought,

not even primary, simple sensations (as they did in Lange and James).

For Cabanis, bodily organs could still generate complex feeling patterns

and meanings for the cognitivist view of the brain had not yet been

developed. The study of these concepts might pay handsome dividends

to those neuropsychiatrists interested in understanding the generation of

what is called somatizations, unexplained medical symptoms, etc. etc.

For the issue of whether the body below the neck contributes to the

cognitive organization of the mind remains wide open. This question is

central to the Continental work on coenesthesia. Lukewarm efforts to

deal with this issue can be found in Anglo-Saxon theories on the

relationship between hypochondria and heightened awareness of bodily

sensations [66,67].

31 Used by Kraepelin, and still quoted nowadays, the technology alibi

is not a scientific hypothesis but the tail end of a foundationalist syllogism:

the mind is represented in the brain! the mind is tantamount to a set of

behaviours!hence, all behaviours are represented in the brain! abnormal

behaviours are still behaviours!hence, all abnormal behaviours have

brain representation! the fact that no representation can be found must

therefore be due to faulty techniques. It goes without saying that if some

representation was eventually found, it would be wrong (by the fallacy of

affirmation of the consequent) to suggest that it confers any truth on theearlier propositions of the syllogism.

32 Vitalism is a doctrine according to which the origin and phenomena

of life results from a principle which is different from the physical and

chemical ones that sustain matter in general. Bichat reacted against

metaphysical vitalism, i.e., the idea that the vital principle was part of

nature; for Bichat, such a principle can only be understood if it is

incorporated into each tissue as sensitivity and contractibility [6870].33 Griesinger was a physician [71] (the concept of psychiatrist did not

exist at the time) with interests as wide as mental disorder and public health

in Egypt (for a considerable period of time he worked in Cairo) (on his

work on infections diseases, see Lasegue [72]). His contribution is limited

to a textbook [73], a few papers and the foundation of a wonderful Journal,

the Archiv fur Psychiatrie und Nervenkrankheiten. He was also interested in

the institutional and therapeutic aspects of asylum care.



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changed his mind about the foundations of medicine.34 The

Textbook of Mental Pathology and Therapeutics is an

important book, not so much because of its clinical con-

tentGriesinger was 28 when he published it and had little

psychiatric experience so he borrowed most of his cases

from French and German sourcesbut because of its

philosophical maturity and imaginative proposals, such asthe view that mental disorders were constituted by ele-

mentary units of analysis, which provided the conceptual

basis for the development of descriptive psychopathology.35

Put back into its context, and corrected by what the

words involved meant in the 1840s, the claim that all

mental disorders are disorders of the brain becomes a

complex one. Griesinger reacted badly against gross Ger-

man materialism [21] and was keen on the new physiology

of Wunderlich, Roser and Muller. His concept of lesion,

therefore, was not anatomical but physiological. It is in this

new (and ambiguous) space of the new physiology [22] that

Griesinger decided to locate mental disorders. No wonderthat his decision has been open to varied interpretations; for

example, his (related) view that many psychological events

occur in nonconscious spaces has led some to consider

Griesinger as a pioneer of psychodynamic psychiatry [23].

Griesingers neuropsychiatric concepts, particularly that

of his new physiological space, cannot be translated into

21st century categories without distortion. Although they

were still organic or biological in nature, mental events

occurring in this new space did not necessarily leave foot-

prints for the neuropathologist to see [24]. Thus, the concept

of anatomical lesion is replaced by that of physiological

lesion, a fascinating and transitional concept, that towards

the end of the century, ineluctably led to that of psycho-logical lesion. In this new realm, mental disorders, although

happening in the brain, do not necessarily have representa-

tion. After learning this, neuropsychiatrists interested in the

brain region where god or morality might reside may no

longer want to worship at Griesinges altar. Griesinger seems

to have been also a crypto-dualist in that he was not interested

in extracting mind out of matter; as such his views by-pass the

neat distinction between plain and baroque matter.

Meynert

Influenced by Darwinian evolution and by the new physiology, Meynert (1833 1892) sought to correlate

development and function and form. Meynerts views on

the nature of mental disease have given rise to controversy.

Associationism, localizationism, top-to-bottom inhibition,

regional cerebrovascular variations and neuronal nutritional

status were the five pillars upon which he based his

speculations on the nature and localization of mental illness

[25]. He based his speculative view of the ego as an inner

representation on Herbarts associationism; localizationism

led him to consider projection and association fibres as a

communication network by means of which inhibition of

subcortical functions and cross-boundary lateral talk

could take place, respectively. Putative changes in cerebralblood supply helped Meynert to explain physiological states

(e.g., sleep), symptoms (e.g., obsessions and hallucinations)

and diseases (e.g., mania, melancholia). Nutritional changes

at the cellular level, resulting from haemodynamic changes

or from congenital defect, were considered as the ultimate

causal mechanism.

The contribution of Meynert to the aetiology of mental

illness is not easy to assess and opinions among historians

have been divided. As opposed to his solid neurohistolog-

ical work, with few exceptions, his clinical writings (e.g.,

the concept of Amentia) [26,27] have not withstood the

test of time. He has been portrayed as a brain mythologizerbut this accusation neglects the heuristic role that metaphor

plays in science and the fact that he had a romantic, poetic

approach to the language of neuroanatomy, and this often

spilt over into his neuropsychiatry. The first volume of his

Psychiatrie [25] is just a textbook of neuroanatomy with

in passim references to psychological concepts like ego or

memory and how these issue out of brain [28]. He also

believed that brain activity depended upon brain nutrition

and the latter was controlled by vasomotor activity from

which follows that circulatory disturbance can lead to

mental disorder.36 Meynert believed that matter (the cortex)

started as a tabula rasa and, in this sense, he can be

considered as a sponsor of the plain matter view [25].Why Meynert never published the second (clinical) volume

of his book remains unclear but it is likely that he did not

have the patience to fit the cases he had collected into the

narrow schema delineated in the first volume.

Wernicke

A disciple of Meynert, Karl Wernicke (18481905), is

considered as one of the most important psychiatrists of the

late 19th century [29]. His range and depth of thought were

such that, had he not died young, psychiatry might now live

in a Wernickian world, i.e., his views on classification, thegeneration of mental symptoms and the relationship between

brain and behaviour would have superseded Kraepelins.

From the perspective of neuropsychiatry, the three most

important contributions of Wernicke are: (1) a model to

encompass all brain-related diseases (whether so-called

psychiatric or neurological); (2) the development of a

35 On the relevance of Griesinger for the development of descriptive

psychopathology, see Berrios [50]; on the ideological background of

Griesingers textbook, see Arens [75].

36 This latter speculation has been seized upon by historians as

foreshadowing the debate between cortical and subcortical dementia [76];

one could easily add to that that the same speculation is also redolent of the

way in which much of current neuroimaging work is conceptualized.

34 On the connection of his neuropsychiatric views with social and

dynamic psychiatry, see Dietze and Voegele [23] and Schrenk [74].



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pathophysiological modelto mediate between the brain and

behavioura model which had until then been absent from

psychiatry (including from Kraepelins work) [30]; and (3)

the introduction of the first neuropsychological approach

to mental symptoms [31].

Central to Wernickes model was the idea that the brain

of man was endowed with a system of projection and(transcortical) association fibres, and that the latter was the

organ of consciousness and of the highest intellectual

functions [31]. Lesions of the projection fibres gave rise

to focalized pathology and neurological disease; pathology

of the association system generated mental illness. In this

sense, Wernickes organ of association is redolent of the

concept of neural network and, in current jargon, he was

more of a connectionist [32] than a conventional local-

izationist. Although well hidden from view, Wernicke seems

to have entertained a view of matter richer than Meynerts.

By his time, however, the old concept of baroque matter (as

a matter that contained hidden qualities and mechanismswhich could explain how matter and mental disorders

emerged) had gone together with vitalism (at least in the

area of neurobiology) [33]. Hence, it is not possible to

classify his views according to our types.

Les Empecheurs de penser en ronde

It is an interesting question why Jackson, von Monakow,

Goldstein and Guiraud, have not had more impact on neuro-

psychiatry. It remains a challenge to find out why their

innovative ideas are paid lip service but never allowed to

fertilize neuropsychiatry. There is only space here to touch

upon the former two. They have been chosen for differentreasons: Jackson because he has had more impact on

Continental (Janet, Ribot, Freud, Goldstein, Piaget, Guiraud,

Ey) than Anglo-Saxon psychiatry or psychology [34]; and

von Monakow because his extraordinarily interesting views

about longitudinal localization of mental symptoms, etc., are

little known in the Anglo-Saxon world [35].

In general, the history of medicine (and psychiatry) tends

to be the history of the victors. The victors do not need to

have truth or reason on their side but just find themselves in

the adequate social conjuncture. In each historical period,

there are also losers and by symmetry they do not need to be

wrong or without reason. The historian of ideas is thereforeas interested in the losers as in the victors, for the ideas of

the former are often imaginative, coherent and irreverent

and hence threatening to the social order. In this sense, the

writers included in this section were all losers.

Jackson

J.H. Jackson (18341911)37 spent most of his clinical

life giving opinions on the nature of mental disorder. In

1894, he published The Factors of Insanities (FI), a paper

of relevance to neuropsychiatry [34]. There is little written

on Jacksons contribution to psychiatry [36]; and on his lack

of impact on British psychiatry.38

Jackson had a hierarchical model of the nervous system

with the upper layers inhibiting the bottom ones. Evolution

pushed function from less to more complexity but lessstability; dissolution39 was a force that pushed in the oppos-

ite direction.40 Jackson proposes that insanity41 originates

from the action of four factors.42 Factor 1 concerns the

depth of dissolution. Factor 2 concerns the the person

who has undergone dissolution.43 Factor 3 relates to the

rate of dissolution, i.e., how slow or fast the removal of

control was. Factor 4 is also about personal variables and

provides lists of putative elements and themes around which

positive mental symptoms may concrescence. Together with

Factor 2, Factor 4 feeds meaning into Jacksons model.44 The

Factor of Insanities is about the way in which the four

factors interact to give rise to two classes of symptoms(positive and negative) [37]. The model is unable to generate

37 On Jackson, see Critchley and Critchley [38] and Lopez Pinero [77].

38 The issue of why Jacksons thinking has had so little influence on

British, and later, Anglo-Saxon psychiatry (as compared with Neurology),

is interesting [78]. Some years ago, the symptoms of schizophrenia were

classified into positive and negative but neither the terminology nor the

underlying model were in fact Jacksonian but Reynoldian [37]. Because of

this error, it was predicted that the positive/negative nomenclature will

disappear [79].39 On the concepts of evolution and dissolution in Jackson, see

Smith [80,81].40 Jacksons conceptual model was not meant to be mapped onto the

real CNS and he said so. However, efforts have been made to findanalogical links [82,83].

41 Insanity according to Jackson is a generic term tantamount to any

departure from mentation and hence refers both to ordinary physiological

states (e.g., sleep), chronic brain diseases and temporary toxic states. He

seems to have advocated a continuity (rather than a categorical) view of

mental disease, which in practice stretches from physiological states to all

gradations of insanity. In this regard, he introduces the concept of mental

diplopia by which he meant clashing definitions of the same behaviour

such as using insanity for proper madness and for a mild degree of

drunkenness. Jackson wondered why postepileptic coma (which he calls

acute temporary dementia and has a strong negative element) is not

considered as an insanity by alienists while postepileptic mania is!

Jacksons concept of insanity or dissolution is only meaningful when

compared against a standard, and he seems to use the state of the same

person before the disease.42 Jackson mentioned but declined to develop his views on a fifth

factor. This concerned the possibility that dissolution might affect regions

or localities of the highest cerebral centres.43 20 years earlier, Jackson (1874) describes Factor 2 as the kind of

brain in which reduction occurs [84]. This rephrasing may reflect maturity

of thinking and a mellowing in attitudes towards the mentally ill. Jackson

lists two aspects of being a person that influence the shape of the ensuing

insanity (variables pertaining to the individual and genetics) but does not

provide an account nor tells whether the variability is quantitative or

qualitative. Personal factors, according to him, show best in states of minor

dissolution. Features pertaining to the person include age, intelligence,

education; and genetic factors concerned not on the inheritance of specific

mental disorders but of a tendency to give out to dissolution.44 For an analysis of this paper, see Berrios [85].



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predictions on specific symptoms (such as hallucinations,

delusions, imperative ideas, depressions, retardation, etc.).

His views on mind, matter, their relationship and the

foundational claim are difficult to map in a coherent way.

He was so much of a dualist that he borrowed Cliffords

concept of concomitance45 to explain how mind and

matter might interact.46

In this sense, Jackson escapes theplainbaroque matter dichotomy used in this paper as this

applies to materialist thinkers.

Jacksons stance vis-a-vis the foundationalist claim is

equally unclear. It is true that he believed that all insanities

were related to the brain, but his concept of insanity is so

utterly different from what was going on in his time and

indeed nowadays, that it is difficult to link the two. For him,

insanity was: (1) on a continuum with other states such as

drunkenness or dreaming (hence, he called them states of

temporal insanity); and (2) only its negative symptoms

actually reflected pathology (i.e., lesions or dissolution of

the higher, human, inhibiting layers of the brain); positivesymptoms were the expression of evolution, of normal

activity produced by the release of normal tissue.

When put together, his views do not tally well. Given his

strong dualism, one would have thought that his concept of

mind was sufficiently autonomous and ontologically inde-

pendent to contain even its own diseases. Although not a

religious man [38], it is likely that, at some level, Jackson

still harboured the (19th century) belief that the mind (or

soul) was an indivisible and intangible principle inhabiting

the (indivisible) temple of the cortex, and as such it was

beyond the reach of disease.

von Monakow

Constantin von Monakow (18531930) authored three

books, founded three journals, became a mentor to major

international figures [39] and together with R. Mourgue, a

French psychiatrist and historian of science, wrote one of

the most important (and neglected) 20th century books on

neuropsychiatry. von Monakow and Mourgue (1928) started

by proposing the notion of Horme, i.e., the tendency of all

living beings to develop all their genetic potential [39]. In

each individual, the Horme is governed by Syneidesis, i.e.,

by a principle that regulates and balances all instincts in the

interest of the given individual. These principles govern both function and structure, and hence, Monakow and

Mourgue develop a neuropsychiatric model of the type that

Guiraud [40] called dynamo-morphological.

Based on the assumption that neuropsychiatry is a sub-

field of biology, the authors imported into neuropsychiatry

the notion of chronogenetic localization. This concept

required that the variable time be built as a parameter into

all neuropsychiatric phenomena. Functions (e.g., move-

ment) are processes, which like music, unfold in time and

according to a specific kinetic melody. Hence, it would bea mistake to attempt to localize processes (i.e., brain

functions) in terms of specific brain sites (i.e., space alone).

Since most mental symptoms are considered as resulting

from disordered brain function, it follows that it would be

equally erroneous to try to localize symptoms to specific

brain addresses. Influenced by Jackson, von Monakow and

Mourgue believed that chronogenetic localization was a late

acquisition in evolutionary time, and hence, regarded it as a

complex but unstable mechanism.

One of the implications of the concept of chronogenetic

localization is that both cross-sectional studies and tra-

ditionallongitudinal studies (as collections of cross-sectionalsnapshots) are inadequate for the capture of neuropsychiatric

symptoms. The latter, von Monakow and Mourgue insisted,

have to be observed as they unfold in time according to their

own kinetic melody; for example, a hallucination is fully

understood only when an entire token or hallucinatory

episode, which may last minutes or hours, has been studied.

In addition to its conventional cross-sectional features,

such an episode includes real longitudinal information, such

as modulations in intensity, changes in imagery and accom-

panying emotions, which can only make sense when inte-

grated along a time dimension. From an aetiological

viewpoint, knowledge of these longitudinal variables may

in fact provide more information on the brain localization ofthe symptom than traditional static snapshots.

Conclusions

Neuropsychiatry can be defined as a package of ideo-

logies and social practices loosely woven around the foun-

dational claim that mental disorders are disorders of the

brain. In some psychiatric constituencies, such as the Anglo-

Saxon one, neuropsychiatry has become the predominant

incarnation of psychiatry. This predominance is due to its

ability to embrace the images of man, society and tech-nology demanded by the postmodernist world. One of those

images concerns the claim that mental disorders are related

to the brain, and part of its history has been studied in this

paper. One finding has been that although during the last

300 years the claim has been regularly uttered, on each

occasion, it has meant something else. The second finding is

that those who have uttered it can be divided into those who

used a plain or baroque concept of matter; this distinction

breaks down after the division of the 19th century when

vitalism and other qualitative forms of animating matter

disappear from neurobiology. To explain the development

and complexities of the mind, sponsors of the plain view of

45 On Clifford (1845 1879), see Berrios [86].46 Jackson (1932) wrote: The doctrine I hold is: first that states of

consciousness (or, synonymously, states of mind) are utterly different from

nervous states; secondly, that the two things occur togetherthat for every

mental state there is a correlative nervous state; third, that, although the two

things occur in parallelism, there is no interference of one with the other.

This may be called the doctrine of Concomitance [87].



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matter need to resort to external resources; sponsors of the

baroque view of matter do not.

The history of neuropsychiatry is yet to be written.

Regional studies need to be undertaken of other components

of the neuropsychiatric package such as its performance as

social practice, its rhetoric, its relationship to science,

neurobiology, technology and big industry (psychopharma-cology, medical insurance, neuroimaging, genetics). These

regional histories will then have to be brought together in

order to understand the success of the set of activities that go

under the generic name of neuropsychiatry. Anything less

cannot work.

Acknowledgments

To the memory of Professor Roy Porter, great historian of

medicine and psychiatry, recently deceased.

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