Abstract
The aim of this article is the study of psychiatry in Portugal between 1884 and 1924, the period when it became institutionalized, and when works that marked its scientific evolution were published. This paper summarizes the various historiographical approaches, and its approach to the subject is closest to the conceptual history carried out by German Berrios in Cambridge. The study attempts to correlate the key actors and their works with the history of different scientific ideas, its differences, and the influences of foreign authors. The diseases, syndromes, symptoms and pathologizations in this historical period were also studied, justifying a constructionist perspective. Finally, the various therapies are discussed, from institutional to pharmacological and psychotherapeutical.
Introduction
Within the scope of historical studies in psychiatry there are many thematic subdivisions, led by scholars of diverse backgrounds. The historiography reveals different approaches, from the more traditional, which value humanitarian and medical advances, to the more critical, which seek to develop a social and institutional history, relying on the social sciences and studying, mainly, alienism and the history of psychiatric institutions. Focusing on the Portuguese situation, the present study follows a conceptual history approach that is seldom used in our country, taking as its main reference the work of German Berrios, who redefined the study of the subject, broadening it and favouring an internalist approach (Berrios, 1996). His model of symptom formation from a constructionist approach offers a genuinely cultural history of psychopathology, seeking to record the many symptom-expressions, as well as the existing cultural and social dynamics (Berrios, 2013). His work may lend a new sense to the task of rethinking psychopathology.
Medical and scientific context
In an international medical-scientific context, I will describe the discoveries and developments of nineteenth-century medicine, with the anatomo-clinical model, the patho-physiological mentality and the birth of microbiology, and concomitant semiological and nosographic development. I will also mention the start of the study of psychic and social causes of disease at the end of the nineteenth century, which would later extend into psychosomatic medicine.
In addition to an account of the main pharmacological discoveries, I emphasize the first psychogenetic formulations (Lain Entralgo, 1950/1998), 1 in an exceptionally rich historical period. It included: debates on hysteria and hypnosis, marked by the confrontation between the schools of Salpêtrière and Nancy in France (López Piñero, 1990); the recognition of the unconscious; the work of Charcot; the redefinition of the frontiers between neurology and psychiatry; and the birth of psychoanalysis and the development of psychotherapy, with different approaches, from Janet and Freud to rational-based psychotherapies (Gauchet and Swain, 1986). Also, a distinction was drawn between neuroses and psychoses, as a result of the psychodynamic renewal movement, and there was a classificatory zeal, particularly in the field of psychoses. The differences between the German and French schools resulted in a split that led to a recognition of Kraepelin’s work, which gained widespread acceptance despite initial resistance. There was, on the other hand, significant progress pertaining to organic conditions that presented mental symptoms, such as the redefinition of dementia, the discovery of the aetiology of general paralysis, the description of states of mental confusion, and a better understanding of epilepsy.
Psychiatry as a medical specialty, albeit an incipient one, was constituted in Portugal in 1911, with public medical care, professional, scientific, legislative and official teaching activities, and new institutions, in addition to forensic medicine practice, research, and publications and their dissemination. The unrelenting campaign for institutionalization dated back to the 1880s, with the impetus of the activities of António Sena, Júlio de Matos and Magalhães Lemos at the Hospital do Conde de Ferreira, which was opened in Porto in 1883. By contrast, the situation at the Rilhafoles hospital, opened in Lisbon in 1848, was subject to criticism and frequent denunciations, and was considered a poor institution despite Miguel Bombarda’s efforts starting in 1892.
Attempts at unofficial teaching in Lisbon, Porto and Coimbra were limited; a journal of the speciality, Revista de Neurologia e Psychiatria, lasted for a short time (1888–9), while the journal O Positivismo (1878–82) featured several texts for public disclosure and instruction, written by Matos, among others.
The assimilation of scientific knowledge came mainly from France and Germany, and then from Italy and Britain. The consolidation of a scientific psychopathology resulted from training trips, correspondence, internships, books and other publications. In epistemological terms, psychiatry emerged as a natural science, when positivism was the most influential current in the philosophy of science, and a somatic interpretation of mental illness became widespread.
As for psychology, despite its late emergence, its importance was recognized, but it was mainly reduced to nervous physiology. The importance and the prestige of biology led to a frequent biologization of social phenomena, and it is significant that several key actors were also teachers of physiology and histology. Histopathology laboratories were central in developing investigation techniques, and clinical and anatomo-pathological methods were seen as the reliable means of progress and investigation.
Articles in medical journals emphasized professional recognition and the importance of care and social advocacy, with examples drawn from forensic cases, sometimes in disagreement with the courts. The alienist movement always insisted on the primacy of science, on state intervention in public care, and on criticizing the backwardness of care institutions, which sheltered only a small percentage of patients, with the associated risks to society (Pereira, 2014). The alienists had in common their biological and hygienist training, their involvement in social, philanthropic and educational activities, a deep faith in science, their defence of liberal or republican ideas, and their demand of reforms in public care, with the necessary social and welfare legislation. They believed that other disciplines, such as biology, sociology, anthropology, criminology and pedagogy, should converge with psychiatry. Their philosophical and scientific references were remarkably eclectic, and included Comte, Littré, Darwin, Spencer, Haeckel and Lombroso. In the reform of 1911, led by Júlio de Matos, chairs of Neurology and Psychiatry and a course on Forensic Psychiatry were set up; the leaders of this reform wanted a more practical medical education, and a professional organization with a greater number of alienists. The reform had less impact on medical care. Rilhafoles and Hospital do Conde de Ferreira were kept, attached to the Faculties of Medicine in Lisbon and Porto, respectively, and in Coimbra the projected Manicómio Sena was repeatedly postponed, so the Religious Orders provided medical care.
In psychopathological terms, there were noteworthy personal contributions. The alienists sought to describe symptoms as natural entities, and no one did this more systematically, or with more erudition, than Matos. Despite the predominance of the somatic-biological perspective, a renewal began to take place, especially in the 1920s, through the works of Sobral Cid, who was by then Professor of Psychiatry in Lisbon; the teaching and publications of Egas Moniz; and works by Alberto Brochado. Taken together, these contributions presented a more psychological, less strictly biological, approach. Others, such as Lemos and Elísio de Moura, were less concerned with systematizing, and closer to an attitude of clinical empiricism.
However, nothing was published to report the knowledge gained and the progress made, apart from Matos’s manuals. The two 1924 publications by Cid (1924a/1983, 1924b/1983) show the theoretical adoption of the psychodynamic renewal. There were only two asylums in Portugal; they were overcrowded and their technical and human resources were scarce. The lack of institutions and human resources made individual treatment impossible; instead, rigid institutional routines were followed, resulting in high mortality and morbidity, and physical restraint and isolation were used. Cid, who recognized the drawbacks of prolonged hospitalization, was particularly sensitive to these limited methods.
Analysis of scientific publications – books and articles in the main periodicals – in the period before the 1911 reform and in the ensuing years, clearly shows that there was a continuity between the two periods, which can only be separated artificially. (An exception was the state provision of education in psychiatry, neurology and forensic psychiatry in the three medical schools – Lisboa, Porto and Coimbra – after 1911.) This continuity is confirmed by an analysis of the laws and regulations at the Hospital de Rilhafoles and the Hospital do Conde de Ferreira, namely regulations focusing on the organization of the medical service, rules of admission and discharge, surveillance systems, and the role of various technicians. An 1889 law, written and proposed by Sena, ordered the construction of new units and suitable provision of care for the criminally insane, with the creation of annexes to the penitentiaries, but it was never enforced. Despite the work of and proposals made by key actors, their vision of care, legislation and education was never implemented, with the exception of some medical and legal advances, and in the legal requirement of forensic expertise in cases involving suspected mental illness. Following the proclamation of the Republic in 1910, Matos’s decree of May 1911 ordered the creation of seven asylums and ten agricultural colonies, as well as the eagerly awaited public education programme (Matos, 1911a). The decree reveals his ideas: an ‘institutionalizing utopia’ relying on the meticulous, complete scientific organization he advocated, as well as his belief in the importance of resorting to the forensic expertise of alienists, and of periodic technical and administrative inspections, emphasizing treatment alongside social protection (Pereira, 2014). The works of Cid in the 1920s reveal a more critical view of the situation of asylums, with a recognition of the difficulties and limitations of their therapeutic role. He insisted that they should be subdivided and have more differentiated objectives and practices, and instead of the idea of the asylum as the only centre of treatment, he defined care facilities as also including the dispensary, the psychiatric clinic and family assistance.
Thus, it may be concluded that while the reforms of the Republic brought progress and echoed legislation from more developed countries, they either failed to be implemented or were only partially enforced. The new facilities that were to be set up in the reform of 1911 were not built and, in the absence of the projected wards and agricultural colonies, the terrible conditions of the asylums deteriorated.
Key actors
The first significant figure in Portuguese psychiatry was António Maria de Sena (1845–90), Professor of Physiology at the University of Coimbra, who became Director of the Conde de Ferreira Hospital in Porto in 1883. He was an intern at the Laboratories of Physiology and Histology in Paris, and later worked in Zurich, Leipzig, Berlin and Vienna, but he was particularly enthusiastic about the time he spent in Munich, where he was taught by Gudden, and in Vienna under Meynert. He created a brain anatomy laboratory in his hospital, and published Os Alienados em Portugal (Sena, 1884), an historical, statistical, administrative and care-oriented study, manifestly influenced by Herbert Spencer’s evolutionism. This work heavily criticizes the neglect and the dire conditions at the Hospital de Rilhafoles in Lisbon. Sena adopted Krafft-Ebing’s nosography and, following Maudsley and Morel, conceived insanity as a regressive movement of man. The second volume of Os Alienados em Portugal deals with an organizational experiment carried out in the Hospital Conde de Ferreira. This hospital became the most important nucleus of alienism in this period, with the collaboration of Sena’s disciples, Matos and Lemos. Sena also took an interest in criminology (Sena, 1889), revealing the influence of Lombroso, and defending the prophylaxis of mental illness through asylum confinement as a social benefit.
Miguel Bombarda (1851–1910) was Professor of Histology and General Physiology in Lisbon University. From 1892 he undertook the reorganization of the Hospital de Rilhafoles, an institution that suffered frequent criticism, even within Lisbon’s Society of Medical Sciences. Bombarda founded and was the editor-in-chief of the journal A Medicina Contemporanea, in which he published hundreds of notes, articles, commentaries and polemics, denouncing the situation of the insane and the state of care, and supporting science and scientific morality, biology, medicine and the physician in a new conception of society. Despite appealing to the naturalist monism of Haeckel, and valuing Darwin, he defended in several writings the hereditary transmission of acquired characters (as did Sena), even writing that ‘Lamarckian ideas dominate science across the whole doctrine of transformism’ (Bombarda, 1909). In classificatory terms, he adopted the ideas of Krafft-Ebing, although he also admired Schüle and Magnan, making degeneration the classifying axis of mental illness. Despite his heavy biologism, Bombarda defended the importance of the social environment but viewed sociology as an extension of the biological sciences. In his main work (Bombarda, 1898b) dedicated to Ernst Haeckel, he develops his views on the philosophical aspects of psychiatry and biology, and their relation to society. Psychological associationism and localizationism made him believe that all psychic mechanisms took place in a straightforward fashion: sensation, perception and association corresponded with the anatomical model of the interneuronal network, broadening out to encompass society and the universe, in an integral naturalism. In addition, Bombarda defended scientific morality, as well as progress and evolution through public education and science, and socialism as the radiant future of humanity. The church and religion were perennial targets in his writings, since he saw in them great obstacles to the exalted march of humanity. In the clinical context, he published a remarkable book (Bombarda, 1896b), recognized by French authors such as Henri Ey and Georges Lantéri-Laura, in which he described systematized delusional jealousy, at a time when its distinctiveness was undervalued. Bombarda was murdered by a patient on the eve of the Republican revolution, of which he was the leading civilian organizer.
Bettencourt Rodrigues (1854–1933) took his medical course in Paris, and later worked with Charcot, Bouchard and Ball, presenting a thesis on general paralysis. Returning to Portugal, he undertook two pioneering initiatives: he set up a course on neuropathology and psychiatry in 1887/8, and started Revista de Neurologia e Psychiatria (1888–9), the first medical journal of the specialty. His application for the post of Director of the Hospital de Rilhafoles was unsuccessful, so he continued a clinical, scientific and literary career in Brazil, returning to Portugal after the Republican victory and dedicating himself to an active political career.
Magalhães Lemos (1855–1931), a disciple of Sena, was Professor of Neurology and Psychiatry in Porto. Having worked under Charcot and Magnan, he remained linked to an anatomo-clinical orientation, relying on cerebral anatomy and seeking to relate focal lesions to morbid manifestations. Most of his work was neuropsychiatric, starting almost always from a neurological matrix, and later appealing to associationist psychology. He saw himself as a disciple of Magnan, who advised him to make a trip to study Gheel (Lemos, 1886), and he then showed he was in favour of ‘non-restraint’, while criticizing the lack of medical care in the colony. He reviewed the Portuguese situation (Lemos, 1907) and advocated the creation of new asylums with annexed colonies. He also emphasized the importance of psychology, but valued it mainly in connection with neurobiology, defending associationism and quoting Stuart Mill and Herbert Spencer (Lemos, 1912). In a work on hallucinations (Lemos, 1911), he defended Tamburini’s anatomo-physiological theory, which should in his view be harmonized with the psychological theory proposed by Séglas, thus revealing his knowledge of the psychopathology of Séglas (1895).
Júlio de Matos (1856–1922) entered the scientific and philosophical debate early on, in the pages of the journal O Positivismo; he defended the works of Darwin, Wallace and Haeckel, and also the full acceptance of transformism and its integration in the positivist programme, while remaining loyal to the defence of Darwinism. He was the most prolific author in Portuguese psychiatry, an organized and systematic theoretician, who reviewed the main clinical conditions and was the most important figure in the phase of its official structuring. He became Director of the Hospital do Conde de Ferreira after the death of Sena, and, later, Head of the Hospital of Rilhafoles (later renamed Hospital Miguel Bombarda) after Bombarda’s death. The publication of his Manual das Doenças Mentaes (Matos, 1884) marked the beginning of a pioneering oeuvre; a very different book, Elementos de Psychiatria (Matos, 1911b), was the first textbook when, in the year of its publication, psychiatry became officially taught. The May 11th decree on psychiatric care, by Matos, authorized the government of the Republic to build new asylums and to create agricultural colonies, foreseeing the future possibility of establishing family colonies for incurable patients who were able to work. Hospitalization sought to harmonize two apparently contradictory aims: shelter and treatment on the one hand, and the only effective defence mechanism for society on the other. Among Matos’s prime interests were forensic psychiatry and criminology, which influenced legislation and the subjects of his most important works: A Loucura (Matos, 1889), which was translated into Italian by Lombroso who also added a preface; three volumes of medico-legal reports (Matos, 1902/1903/1907); and translating and prefacing Garofalo’s books. Matos was one of the founders of the journal O Positivismo (1878–82), which was very important in Portuguese science and culture. His Republicanism was anti-socialist. In his Manual he admits that his own nosological classification was based on Morel’s aetiological-symptomatic classification, modified and augmented by Ball, and adds a new type of madness: ‘Without delusion / Lucid insanity’ (Matos, 1884: 65). In his mature work Elementos de Psychiatria (Matos, 1911b), he accepted, with slight modifications, the classification proposed by Eugenio Tanzi (1905/1909), confirming his proximity to the Italian school, including the criminal anthropology of Lombroso. Matos supported the ideas of degeneration, which he thought had been highlighted by the psychiatry of his day. He did not change his doctrinal principles, but his critical disposition meant he kept his distance from the positivist orthodoxy and remained closer to Littré. A defender of Darwinism in all fields, he remained immune to the influences of psychodynamic psychiatry across Europe, and gave little credit to psychotherapies.
Egas Moniz (1874–1955) was a professor of neurology who became famous for his main achievements: cerebral angiography and pre-frontal leucotomy (Fernandes, 1983; Pereira and Pita, 2000). In the period under review, he published works that had an influence on Portuguese psychiatry. Thus, in 1901 and 1902 he presented two dissertations on the physiology and pathology of sexuality (Moniz, 1901, 1902), later collected in a single volume in 1913. The theme was innovative in Portugal and the work received moral criticism. In 1912, in the opening lecture of the Neurology course, he addressed the themes of neuroses, hysteria, and psychotherapy, referring to Déjerine and defending Babinski’s ideas about hysteria (Moniz, 1912). In 1914 he published a work in which he elaborated on the theme of hypnotism by referring to the schools of the Salpêtrière and Nancy, addressing simulation and suggestion, defending once more the opinions of Babinski on hysteria, and asserting that they had triumphed in the meeting of the Societé de Neurologie de Paris in 1908 (Moniz, 1914). In 1915, he wrote a paper based on his first lecture of the neurology course, ‘As bases da psychoanalise’ (Moniz, 1915); this was the first scientific work published in Portugal on the subject, and it was by a neurology professor, when even lecturers in psychiatry did not refer to this topic. In his book A Neurologia na Guerra (Moniz, 1917), he presented, in addition to neurological conditions, the main psychopathological clinical conditions that affected soldiers on the frontline, where Portuguese troops were involved. Moniz’s works on sexuality, hypnotism, psychoanalysis and neuropsychiatry in war were pioneering works in this field in Portugal, and they contributed to redefining not only the scope of neurosis but the frontiers of psychiatry.
Sobral Cid (1877–1941) obtained his graduate and doctoral degrees in Coimbra and went on to Lisbon in 1911. In 1923, after Matos’s death in the previous year, he became his successor as chair of Psychiatry in Lisbon. In ‘Clínica das perturbações da memória’ (Cid, 1923a/1983), he offers a psychological approach to hysteria, borrowing from Pierre Janet and Freud. Then came a seminal work, ‘Classificação e sistemática geral das psicoses’ (Cid, 1924a/1983), in which he critically reviews earlier classifications of mental illness, rejects the theory of degeneration, and introduces European psychiatric modernity through authors such as Kraepelin, Bleuler and Kretschmer. Cid considers the understanding of patients’ acts in their social context as being scientific, on the same level as the anatomo-physiological causal explanations, and overcoming the naturalistic biological reduction by integrating the psychological dimension. This inchoate reintroduction in mental medicine of the individual subject (Lain Entralgo, 1982) is evidence of the influence of new theoretical conceptions that were spreading with the works of Pierre Janet, Sigmund Freud, Henri Bergson and Karl Jaspers.
The paper ‘A vida psíquica dos esquizofrénicos’ (Cid, 1924b/1983) was greatly influenced by the work of Eugen Bleuler, the first psychiatry professor to attempt to incorporate psychoanalytic thinking into his clinical practice. In this text, Cid tries to show the evolutionary and dynamic character of symptoms using psychological defence mechanisms, and incorporating concepts from Bleuler, Freud and Jung to show the comprehensibility of symptoms and to emphasize the importance of ideo-affective complexes. He accepted Kraepelin’s classification, considering his work as the solid foundation on which contemporary psychiatry was to be built. As for clinical conditions pertaining to endogenous psychoses, Cid considered that two natural families had been isolated: manic-depressive psychosis and dementia praecox. He believed that Bleuler’s monograph had made great progress in the psychological understanding of the latter disease, accepting the more appropriate designation of schizophrenia.
In the 1920s, Cid (following Moniz’s work in the previous decade) redrew the classifications and boundaries of neuroses, psychoses and organic conditions, redefining the relations between neurology and psychiatry.
Alberto Brochado (1893–1944) was a little-known figure in Portuguese psychiatry. His inaugural thesis dealt with the psycho-physiological aspects of music – an unusual subject. He was a disciple of Lemos, worked in the Hospital do Conde de Ferreira, and was lecturer in Psychiatry and Neurology in the Faculty of Medicine of Porto from 1927. His works developed new approaches to psychopathology, applying the ideas of the French school (Capgras, Clérambault, Levy-Valensi), among others, and showing great interest in the study of psychological processes. In Brochado’s main contribution to the progress of psychopathology in Portugal (Brochado, 1922a), he supported a globalist vision of aphasias, citing works by Hughlings Jackson, Von Monakow and Mourgue, and supporting Bergson’s work and Bergsonian themes. Brochado committed suicide on the eve of his doctoral presentation.
Elísio de Moura (1877–1977) was Professor of Neurology and Psychiatry at the University of Coimbra. A precursor of psychosomatics, he was a practical clinician and an heir to the French School, both the Salpêtrière and Nancy, and to authors such as Charcot, Magnan, Babinski and Dupré. Unlike most of the alienists of his time, he was a catholic physician who devoted himself to charitable works and social institutions. He was rather a mythical character, and left almost no written work, but late in life he published Anorexia Mental (Moura, 1947), a work which alone confirms its author’s great clinical and psychological intuition.
Luís Cebola (1876–1967) was an alienist who did not work in a university, but published many books intended for popular consumption, and collaborated with the daily press. He was not concerned with psychopathological issues, but mainly in gathering sculptures, writings, poems and drawings made by patients; he founded the Museum of Madness in Telhal, a unit linked to the religious orders, in which he worked for many years, despite being a Republican. He had a lifelong interest in ergotherapy, and he confessed that his abiding aspiration was patients’ re-adaption to social life by means of directed work. Cebola was presumably greatly influenced by Paul Dubois’ defence of a persuasive therapy founded on reason. He made eclectic use of the physical therapies of the time, but was averse to psychosurgery, which he viewed negatively.
Diseases, syndromes, symptoms, pathologizations
In studying the main affections of this period – diseases, syndromes, symptoms and pathologizations – I wish to avoid the evolutionary hierarchization prevailing at that time, such as that of Matos. Likewise, this paper rejects presentism, which would lead to a reductive presentation based on current classifications that may be just as questionable as those of the period under study.
For Sena, as for Bombarda, the classification of diseases was based on the Krafft-Ebing’s classification (Krafft-Ebing, 1897), although both also valued Schüle and Magnan, while Lemos, although a follower of Magnan’s views (Magnan, 1897), was averse to excessive theorization and to great syntheses that science could not accommodate, citing as an example the history of dementia praecox and paranoia. In his Manual, Matos (1884) employed Morel’s classification revised by Ball, but in his Elementos de Psychiatria (1911b) he follows Tanzi’s classification system, going from accidental psychoses to constitutional ones. He retains neuropsychoses in those with an abnormal nervous constitution (neurasthenia, hysteria and epilepsy), and ends up close to Kraepelin in his acceptance of dementia praecox, raising some reservations as to the extent of the paranoid form; in mental anomalies, which Matos calls ‘true degenerations’, he includes sexual aberrations, imbecility, moral insanity and paranoia. The theory of degeneration, the principal axis of previous classifications, was abandoned in the paper by Cid (1924a/1983), after the dissemination of Mendel’s works and the acceptance of Kraepelin’s system for the classification of psychoses 2 (Kraepelin, 1907/1984), and with the adoption of the term ‘schizophrenia’, in full agreement with the works of Bleuler and Kretschmer, the most influential authors in Cid’s work.
General Paralysis
General Paralysis, a widespread and dreaded disease in this historical period, was well analysed by Matos, who emphasized, with Baillarger, the existence of two essential symptoms: those of paralysis and those of dementia. But the most debated question was that of aetiology, with both Matos and Lemos (who wrote a monograph on the subject: Lemos, 1889) arguing for a plurality of causal, toxic and infectious agents, including alcohol and syphilis, but with syphilis not playing a greater role than any other infection or intoxication. Thus, Matos (1911b: 344) separately describes syphilitic pseudo-general paralysis and paralytic dementia, admitting difficulties since the symptoms could present great similarity.
This subject had been much discussed at the International Congress of Medicine in Madrid, and Bombarda (1903: 165–6) wrote in a note about it, based on his observation and on clinical intuition, that ‘where there is no syphilis, there is no general paralysis’. Quétel (1986: 205) reported that in 1913 Noguchi and Moore discovered the treponema in the encephalon of general paralytics, and from an obscure neuropsychiatric disease it became the encephalitis of the tertiary period of syphilis, contributing to a redefinition of the relations between neurology and psychiatry and dealing another blow to the already weak doctrine of degeneration. Pulido Valente, who had been an assistant to Matos, and who would later be a professor of internal medicine, had studied the disease in 1917–18, and in 1921 he had given a brilliant lecture on its aetiology and pathogenesis, published only many years later (Valente, 1989).
Hysteria
Matos relied on Charcot, Legrand du Saulle and Ball to separate psychic and somatic symptoms, according to externally observable manifestations, naming it ‘hysterical insanity’ (Matos, 1884: 212). Later, he agreed with Tanzi that neuropsychoses revealed a nervous degeneration, and thus hysteria was a constitutional disposition, usually hereditary, with the nerve centres reacting paradoxically to insignificant stimuli (Matos, 1911b). He had reservations regarding Pierre Janet’s theories because he considered them to be exclusively psychic. Like Tanzi, Matos accepted the Nancy School’s criticisms of the artificial results obtained by suggestion in the Salpêtrière School, as well those regarding the relations with hypnotism defended by Charcot. Matos also accepted the existence of some degenerative symptoms, for which the treatment included suggestive psychotherapy, either in wakefulness or through hypnosis. By contrast, Bombarda (1897a), in a case of hysterical somnambulism, employed Janet’s formulation and the idea of a hysterical psyche, but the psychological vision was in the end obscured by the idea of degeneration, thus considering hysteria a psychic illness and a degeneration (Bombarda, 1897b). Later, the greatest advocate of Babinski’s ideas about hysteria was Moniz, who simplified Babinski’s definition by writing that ‘it is a special psychic state characterized by disturbances which suggestion can either induce or cause to disappear’ (Moniz, 1917: 256). Believing that Babinski’s ideas had triumphed in heated debates over hysterical phenomena, Moniz began to use the term pithiatism. Cid’s formulations were more psychological, using the contributions of Janet and Freud (Cid, 1923a/1983). In turn, Brochado (1922b) defended Janet and criticized Babinski, positing that morbid conditions of mental pathology should be considered as simple syndromes, in agreement with authors like Philippe Chaslin.
Melancholy
Matos (1884) presents melancholy in his Manual as a generalized or partial delusion of a depressive nature, with a period of invasion and then a disease state in which the intellectual delusion appears. Later, Kraepelin’s influence is present, but it is interesting that Matos places melancholia and mania in the transition group between accidental and constitutional psychoses, because they are the product of the convergence of endogenous and exogenous causes, and while exogenous causes may be important, there may also be a strong hereditary predisposition (Matos, 1911b). As for the secondary symptoms, Matos mentions stupor, anxiety and delirium, listing their various contents, but he always considers delusion to be secondary, as an attempt to explain the constant symptoms, be they somatic or mental. A case study by Lemos (1903) is surprising for its attempt at psychological penetration, despite the limitations carried by the associationism and physiologism it professes, based on Cotard and Séglas. In Matos’s (1911b) Elementos de Psychiatria, mania was already defined as an affective disorder, a phase of Kraepelin’s manic-depressive psychosis; but it was Cid (1924a/1983) who fully accepted Kraepelin’s classification. Later works by Brochado modernized the approach to melancholy. 3
Dementia praecox
Matos, like Séglas, expressed reservations regarding the scope of Kraepelin’s paranoid form, but he followed with interest the evolution of Kraepelin’s thinking and welcomed the news that Kraepelin was going to remove Magnan’s chronic delusion from dementia praecox, where it had been included as paranoid dementia, to create a new group: the paraphrenias (Matos, 1914). In 1924 Cid made a presentation on the psychological conception of schizophrenia, adhering to Bleuler’s ideas and writing that what characterizes the psychological process of schizophrenia is the ‘dissociation of personality into autonomous complexes, centred on the child’s instinctive primary tendencies that psycho-ontogenic evolution failed to socialize’ (Cid, 1924b/1983: 159–60).
Paranoia
In the study of paranoia, a contribution by Matos is recognized in the manuals of Ballet and Régis. Paranoia was one of Matos’s favourite subjects, and he wrote a whole book on it (Matos, 1898), which was recognized in the manuals of Ballet (1903: 494) and Régis (1914: 448). Matos identifies most closely with the Italian school of Tanzi and Riva, in their defence of the atavistic doctrine that sees psychic evolution being arrested at the stage at which ‘primitives and savages halted’ (Matos, 1911b: 564), seeing a clear anachronism in the presentation of paranoia in his time. This position, analogous to that of Tanzi, seems to owe more to a sociological and cultural version of evolutionism than to Darwin’s biological evolutionism. Bombarda (1899) severely criticized this conception, writing that if the faith of primitive man were equal to that of the paranoiac, man today would still be primitive, and there would have been no evolution. Cid and Brochado advanced the idea of a paranoiac constitution, with a nucleus of prevailing ideas strongly rooted in the personality that commanded all the psychic symptomatology. Given the scope of dementia praecox, the status of paranoia eventually became more restricted.
Epilepsy
In this period in Portugal, epilepsy was studied by Bombarda, who dedicated a book to the subject (Bombarda, 1896a). He considered that ‘true epilepsy’ was a type of degeneration, and that epilepsy that was secondary to other affections was pseudo-epilepsy. At one point the author defends the heredity of acquired characters by adaptive necessity, rooted in the struggle for existence as the basis of the perfection of species, in a Lamarckian conception featuring Darwinian elements. Regarding epilepsy, Bombarda describes psychopathological changes from childhood incurring permanent weakness and imbalance of the mind. The relations of epilepsy with crime are also considered, referring to the importance of the Italian School. Although he criticizes the hasty generalizations in Lombroso’s work, Bombarda felt that much truth was condensed in the Italian’s main book, L’Homme criminel (Lombroso, 1887), and he shows great similarity to Lombroso’s criminology. The insistence on stigmatization and its subdivision into anatomical, psychic and social stigmas points to the potential risk presented by degenerates. Chaslin (1896), in his review of Bombarda’s (1896a) book, comments on the seduction of the theory of degeneration and warns of its dangers. The more neurological view of Lemos (1898) allowed him to write that the study of epilepsy has been renewed and many of the new contributions have come out of anatomical-clinical and experimental research. Epilepsy, long regarded as a prototype of essential diseases, was no more than a syndrome that could be triggered and derived from various pathological conditions. Lemos quotes Gowers as saying that it was a disease of the grey matter of the brain, an irritative affection of the cerebral cortex capable of paroxysmally disrupting the functions of psychomotor centres. He then refers to Hughlings Jackson on the onset of seizures, with the aura regarded as the outer echo of a central process, the first phenomenal expression of the brain’s paroxysmal discharge. The ideas of Lemos, and his theoretical affiliation to Magnan’s school, which did not cover hysteria and epilepsy in the context of degeneration (unlike Schüle and Krafft-Ebing), allowed him more easily to integrate new neurological contributions that were more distant from the idea of degeneration. Matos distinguished in epilepsy the symptomatic and idiopathic forms, the first being a syndrome and not a disease. But he admits a ‘masked epilepsy’, as defined by Morel, manifested not with attacks, but with mental seizures or delusions (Matos, 1911b: 462). Idiopathic epilepsy had its main aetiological role in heredity and, in most cases, presented physical stigma. In the psychic equivalents, Matos focuses on character, as studied by several alienists (e.g. Legrand du Saulle, Krafft-Ebing), emphasizing the inclination to crime (Lombroso, Tanzi). The idea of epileptic character was to continue, thanks to the influence of Lombroso, although almost all the alienists raised criticisms of and limitations to his work. As Temkin (1971: 317) showed, the observations focused on patients in long-term confinement in psychiatric institutions, at advanced stages of disease, and with characteristics that made their social exclusion desirable. Matos (1911b: 472) himself admitted that epileptics living outside asylums were ‘nos semblables et nos frères’, but those who were hospitalized were mentally retarded or demented. 4
Moral insanity
This was defined by Matos (1911b: 530–1) as a degenerative situation, characterized by the absence or perversion of feelings of piety or probity, which in their elementary form constituted the minimum moral sense indispensable to collective life. Matos (1884: 282–91) had already written on lucid insanity, which he considered synonymous with moral insanity, citing Maudsley to characterize this form of madness. Matos (1911b) sought to separate illness and anthropological anomaly, preferring, for the latter, Tanzi’s designation of ‘constitutional immorality’; in discussing these topics, Matos used a dialogue with Tanzi and Lombroso. He accepted Tanzi’s criticisms of Lombroso’s identification of the moral insane with the epileptic, but he noted that Lombroso’s (1887) synthesis was not pure reverie, for ‘a group of epileptics, masked or psychic, is mentally characterized by symptoms of moral insanity’ (Matos, 1911b: 537). The treatment would be, for him, exclusively for prophylaxis, and when necessary under criminal law. Bombarda (1905: 141–2) also addressed the subject, almost always from a medico-legal perspective, also considering moral insanity to be a form of alienation, a mental illness. Healing and treatment in the tradition of the Enlightenment gives way to concern for social protection, with the sick considered as degenerate, irresponsible and potentially dangerous beings. 5 As Matos (1908: 672) wrote, ‘in the insane, we see the patient whom Pinel dignified; we do not see the degenerative agent made prominent by psychiatry’.
Neurasthenia
Moniz showed in 1912 how the vast field of neuroses or functional diseases of the nervous system had been gradually restricted. He referred to several diseases that were now considered organic, but he supposed that some would probably always remain in this field, like hysteria, psychasthenia and neurasthenia, which he called the consecrated psychoneuroses (Moniz, 1912). Matos spoke of a syndrome secondary to various affections and of neurasthenia-disease, which could be acquired or constitutional, in which obsessions were important. The somatic symptoms were based on a constant and painful sensation of fatigue, digestive and sleep disorders, dreams of impotence, neuralgia and genital dysfunctions. The psychic part was similar to simple melancholy. The simple acquired form was Beard’s disease, and Matos recognized the exemption of neuropathic or psychopathic predispositions (Matos, 1911b). 6 Constitutional neurasthenia, on the other hand, was degenerative, with obsessions and episodic syndromes of hereditary degeneration.
Theses on neurasthenia were presented in Lisbon, Porto and Coimbra between 1890 and 1914, after which the term disappeared. As in other countries, the psychogenetic conception of neuroses, and depressive and anxious states, progressively replaced the old condition of melancholy, the less serious forms of which were first assimilated to neurasthenia. The history of neurasthenia reveals that diseases could be constructed or invented, and its disappearance had to do with the classificatory reconfiguration of the field of neuroses, while the malaise it revealed continued later under other names.
Organic diseases
In his book Elementos de Psychiatria, Matos (1911b) dedicated a chapter to mental confusion, a clinical condition that had been well studied by Chaslin, Séglas and Régis; it was increasingly recognized and studied in general hospitals. The theme was updated by Cid, who, with greater concern for the connection with medicine, published in A Medicina Contemporanea articles reviewing the topic of symptomatic and toxic psychoses, following Bonhoeffer and Régis, in a work close to internal medicine (Cid, 1923b).
Suicidal behaviour
Several monographs from the 1880s connect suicide caused by mental alienation, as well as a spontaneous suicide based on real reasons, with freedom of thought and will. Matos (1884) admitted that suicide could exist independently of madness. In 1917, a thesis by Silva – the first showing Durkheim’s influence and the sociological influence – defended the study of suicide as a social phenomenon, and not just from the psychological or psychiatric points of view already studied by Esquirol and Brierre de Boismont (Silva, 1917).
Sexual anomalies
The importance of Krafft-Ebing and his Psychopathia Sexualis (1895) loomed large, as an ever-present reference. Bombarda (1898a) states that this book demonstrated the degenerative disease of the inverted and perverted, who were not vicious but sick. Matos (1911b: 517) also categorized ‘sexual aberrations’ as mental anomalies or psychic degenerations since, in the genesis of such psychoses, only heredity could be invoked. Using a classification by Bianchi, he divides ‘sexual aberrations’ into quantitative and qualitative anomalies, with these in turn subdivided into inversion and perversions (p. 529). But the better-informed and larger work on the topic was an earlier one by Moniz (1901, 1902), A Vida Sexual (Volumes I and II), which was an editorial success. In the 4th edition (Moniz, 1918), the author added, as a prologue, his lecture on psychoanalysis from his Neurology course. As Moniz never updated the book as a whole, it became unbalanced, since an introduction to Freud’s work did not provide a harmonious opening to a text based on the views of Krafft-Ebing.
Neuropsychiatry in war
From the standpoint of the medicine of its time, the publication by Moniz of A Neurologia na Guerra (1917) was of great importance. The author had contacts with the main neurological and psychiatric centres in France and personal relations with French doctors in these centres. Having been appointed by the Faculty of Medicine in Lisbon as a delegate for the study of the latest advances in neurology, on which the war had brought new data, Moniz decided to extend his report and publish this book intended for medical students. In the final four chapters he addresses neuropsychiatric issues, dividing the emotional disturbances into nervous accidents, mental accidents, and intermediate disturbances. Regarding mental accidents, Moniz describes what he calls ‘battle psychoses’, which occur mainly in individuals who, Dupré considered, have an emotional constitutional predisposition, and for whom the emotional shock was the precipitant.
The two great syndromes that Moniz (1917: 226–8) describes are ‘hallucinatory onirism and mental confusion’. The first was constituted by the morbid dream that could be transformed from a mute dream into an active dream, the basis of the dream being the events of the battle. The patient had to live through the fearful spectacle of the battlefront, either during sleep or when awake. The scenes could be single or multiple, in a painful revival of the circumstances in which the emotional shock had taken place. The vision could either be fleeting or take the form of a full experience unfolding through the day, in what was called ‘the prolonged dream’. The other syndrome was mental confusion: obnubilation, disorientation, agitation or torpor, with amnesia. Intermediate emotional disturbances were those that belonged at the same time to nervous accidents and psychic accidents, and the patients ‘appeared either confused or pithiatic’. Moniz argues that it is possible to separate the functional disturbances from the organic ones, using, for the former, psychotherapy aided by electrical applications. But those he calls ‘curved’, referring to camptocormia, were mostly functional patients, and in some of these cases, he admitted organicity.
Moniz reviews hysteria, from Charcot to Babinski, arguing for the pithiatic view, according to which suggestion can induce or remove hysterical symptoms. He recognized that war neurology had brought to the surface clinical facts already emphasized by Charcot, and that in the wounded there began to emerge contractures and paralyses that lacked the characteristics of organic affections, but that differed from functional disturbances insofar as psychotherapeutic processes were powerless to heal them. Regarding treatment for such affections, Moniz considered that psychotherapeutic treatments should not be abandoned, because the organic lesions could be associated with pithiatic disturbances. Electricity and massages were the most commonly used physiotherapeutic treatments. Moniz also approached the theme of simulation, speaking of true simulators and unconscious simulators, but admitting that this distinction is elusive, and stating that ‘pithiatism often verges on simulation’ (Moniz, 1917: 4). 7 He believed that in certain cases it might be necessary to resort to more violent electrical applications, isolation and strict surveillance, and he sympathized with Clovis Vincent who had been accused of using violent treatments such as ‘torpedoing’ (torpillage). Simulation and psychoneurosis were presumed to be so intimately connected that it seemed plausible that patients would seamlessly move from simulation to self-suggestion and vice versa.
Prison insanity
This subject, which was discussed at the end of the nineteenth century and the start of the following one, caused a controversy between Bombarda and Matos in 1903. Bombarda (1897c) had defended the view that confinement in cells was responsible for outbreaks of mental illness, or prison insanity, due to the direness of isolation between four walls. He found little evidence of stigmatization among the patients studied, and supposed the harmful effects of incarceration on the psychic life of the prisoners led to prison psychosis. The most interesting aspect in this controversy is that Bombarda and Matos referred to the same authors (Krafft-Ebing, Schüle, Kraepelin) to reach opposite conclusions. It becomes clear that the differences of opinion were rooted in their differing assessment of the importance of the environment and of the prison environment specifically; for Bombarda this was an important factor, while for Matos it mattered little in comparison with the fundamental importance of bio-anthropological factors. For Matos, most of those condemned to severe sentences suffered from hereditary degeneration, so that it made no sense to speak of prison insanity (Matos, 1903a, 1911b).
Psychoanalysis
New concepts and authors more distanced from naturalism helped to modernize psychopathology. In Portugal, the explanation of psychoanalysis and Freud’s work was pioneered by Moniz (1915), in an article that references Régis and Hesnard’s book (1914/1929) – also cited by Cid and Brochado – which would become one of the first reference works on psychoanalysis. Moniz then extended his interest in the subject in articles such as ‘O conflito sexual’ (1921). Also relevant were the works on the same topic by Cid, who also mentioned Pierre Janet, who was hardly known in Portugal.
Bergson and Bergsonian themes were referenced by Brochado. In an article on the pathology of language and perception, Brochado (1922a) criticizes localizationist theories of aphasia, which would have delayed advances in cerebral physiology, and defends a globalist vision. He distances himself from Lemos and from associationism, citing Bergson, William James and Janet. He gives examples derived from the experience of World War I, with contributions from Head, Von Monakow and Mourgue, which lead him to support the idea that any psychological fact incurs influence of the whole personality, including the influence of the unconscious. Brochado (1922a: 56–7) also valued linguistics, and was familiar with Saussure’s Cours de Linguistique Générale (1916/1972), and the work of Hughlings Jackson. These contributions revealed the influence of new approaches and conceptions, and tried to correct the limitations of somaticism and the excessive biologism of positivist science, by emphasizing the importance of psychology as an autonomous discipline, distinct from physiology, and favouring a biopsychological attitude. Kretschmer (1921/1954) and Bleuler (1911/2005) are present in, and prized by, Cid. The work of Jaspers is less commonly cited, and it was disseminated later, first through the teaching of Barahona Fernandes from 1935, but more influentially through the more accessible clinical work of Kurt Schneider (Fernandes, 1966).
Therapeutic approaches
Moral treatment was often mentioned, referring, as a rule, to a set of attitudes and techniques in dealing with the insane. These included: hospitalization, isolation from their previous environment, medical authority, a good rapport with patients, protection of individuals from society and from themselves, a pedagogical attitude in an attempt to convince the patient of the wrongness of their ideas or emotions, manual labour and occupation, control by the hospital, and acquisition of regular habits. Asylum was thought necessary for serious cases, and there were no disagreements about this among the alienists. ‘Moral treatment’ was supplemented by physical treatments, especially hydrotherapy, and secondarily by electricity, as well as diets, drugs, rest, isolation, and physical restraint. The most commonly used drugs were hypnotics and sedatives. An influential book by Eduardo Motta (1901) played an important role at the beginning of the twentieth century, with medication forms complementing handbooks in a pragmatic way, as did diets and rest cures. Work was highly prized, both in workshops and as agricultural labour. At this time there were also new drugs, such as veronal used as a hypnotic, phenobarbital for epilepsy, narcotherapy by scopolamine, and salvarsan for general paralysis. The use of Von Jauregg’s malariotherapy to treat general paralysis marked the beginning of enormous hope for physical therapies. The history of treatments in psychiatry results from convergences between materia medica, nosology, therapeutic empiricism, the doctor–patient relationship, and social control (Berrios, 2008). Psychotherapy emerged out of hypnotism and suggestion, which were recognized as useful in the treatment of hysteria and neurasthenia, used together with rest, electrotherapy, massages and a dietary regimen, and proper feeding. It was only at the end of the nineteenth century that psychotherapy arose in the strict sense, with the gradual abandonment of hypnosis and the recognition of the importance of suggestion to a subject in a vigilant state, leading to psychotherapy by suggestion. By contrast, we witness the rise of therapies by persuasion, rooted in rationality, and, later, the first references to the psychodynamic movement appear with Janet and Freud (Bercherie, 1983; Berrios, 1984). The first references to these developments – their dissemination, indications and therapeutic use – can be detected in Portugal in the 1920s, when they were spread via the influence of French authors.
Conclusions
The key medical actors in this study shared common overall characteristics, but, by studying each one in detail and by reference to specific areas, we begin to discern significant differences and contrasted opinions. Analysing the key actors shows that the differences between them are much greater than is generally thought, and the view that alienism was a pre-scientific phase is simplistic and reductive. The prehistory of modern psychiatry, as it is often described, overlooked the continuity within various fields, and the complexity of the relations among history, science, ideology, and social and cultural contexts. The temporal dimension is decisive, since it makes us realize the intellectual stature of Matos and Bombarda, within the context of the nineteenth-century science and philosophy, shaped by figures such as Darwin, Spencer and Haeckel. Moniz and Cid belonged to a different historical time, and the conceptual modernization that they achieved makes their works more intelligible to present-day readers. Their incorporation of recent authors and concepts results in a language closer to our own. However, revisiting the classic authors is essential in carrying out historical, social and conceptual hermeneutics.
The work of Cid and Moniz updated psychiatric thinking in the last part of the period under review, redefining the relations between neurology and psychiatry, going beyond the notion of degeneration, and incorporating European authors, such as Kraepelin, Bleuler and Kretschmer. Their work allowed the spread of the psychodynamic movement and the psychotherapeutic formulations that arose in the late nineteenth century, and gained greater definition in the first decades of the twentieth century in Portugal.
As for the affections studied, and accounting for the distinction between terms and concepts, most are not considered mental illnesses nowadays, but rather symptoms, syndromes, pathologizations and depathologizations, or diseases with clear organic foundations. Suicide was included in this paper because it was viewed more broadly than a symptom of madness; war neuropsychiatry was featured because of interest in its effects on the Portuguese society of the time; and prison insanity for the interest it aroused in alienists and the controversies to which it gave rise. It should be noted that certain terms, which have been replaced by other names, have disappeared; that some terms still in use underwent changes in meaning; and that there was a recomposition and fragmentation of diseases. The constructionist perspective seems fully vindicated.
Understanding the nature of mental illness remains a challenge. The contribution of the human sciences began to emerge early in the twentieth century, prefiguring social and cultural psychiatry as a complement to biological research. Initially linked to physiology and anatomo-pathology, psychiatry is enhanced by psychological or biopsychological approaches, experimenting with more diverse forms of treatment, and showing greater theoretical and practical eclecticism.
Footnotes
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.