Some comparative psychiatric studies in the 19th century

Introduction

Emil Kraepelin (1856–1926) is often viewed as a founder of transcultural psychiatry and his works are counted as a milestone in the field because he set new standards for cross-cultural comparative psychiatric investigation (Bendick, 1989; Dech, Ndetei, & Machleidt, 2003; Jilek, 1995; Pfeiffer, 1994). However, even before Kraepelin’s work, publications already existed in this field with reflections about the complexity of relations between mental disease, race, and culture (Oda, Banzato, & Dalgalarrondo, 2005). There are convincing arguments that other authors should be listed along with Kraepelin, such as the French psychiatrist Jacques-Joseph Moreau de Tours (1804–1884) or the US physician Benjamin Rush (1746–1813), who was a professor at the Institution of Medicine and Clinical Practice at the University of Pennsylvania (Oda et al., 2005).

Other authors have located the real beginnings of cross-cultural psychiatry in the period after World War II (Bains, 2005), with developments in social psychiatry (Wittkower & Rin, 1965) and ethnology as well. Today a major focus of cross-cultural psychiatry is on the consequences of globalization for mental health, and, especially, on the care of migrants (Kirmayer & Minas, 2000; Knischewitzki, Machleidt, & Calliess, 2013; Machleidt & Sieberer, 2013; Mastrogianni & Bhugra, 2003). Kraepelin’s role as a founder of cross-cultural psychiatry has been reevaluated (Steinberg, 2015). The aim of this paper is to discuss some important cross-cultural studies published prior to Kraepelin’s work in Java relevant to current debates in the field.

Investigations in Java before Kraepelin

The Java-born psychiatrist with Dutch ancestry Pieter Cornelis Johannes van Brero (1860–1934) investigated mental disorders among the local population of Java (van Brero, 1896). After studying medicine in Amsterdam and Utrecht he returned to his homeland, which is today a part of Indonesia. From 1892, he worked as a second physician at the Dutch state hospital for mental disorders in Buitenzorg (today Bogor) in West Java. He observed that insanity and paranoia seemed to occur rather often, whereas he did not find any case of compulsive disorder or melancholia. He also described shamanism, latah, and amok among the local population. He asked whether these abnormalities had equivalents in the European world and whether they were related to ecstasy during shamanic practices to hypnotic states.

According to van Brero, latah is a mental state in which the afflicted person makes movements against his will. When making these involuntary movements, the person is fully conscious and claims feelings of reluctance. Latah is triggered by an order given or observing of the movements of other persons, or else by fright (van Brero, 1894). Van Brero mentioned van der Burg (1840–1905), a Dutch physician and corresponding member of the Dutch Royal Academy of Sciences in Amsterdam, who had also reported on latah during his stay in Batavia (today Jakarta) (van der Burg, 1884; NNBW, 1918). Citing the US surgeon and neurologist William Alexander Hammond (1828–1900), van Brero suggested a connection with a similar disorder called miryachit occurring in Siberia.

A decade earlier, Hammond had published two identical articles about miryachit in the US medical journals New York Medical Journal and The Aesculapian (Hammond 1884a, 1884b). Hammond described a phenomenon of echopraxia, where the afflicted imitated movements, which occurred among the Yakut population in the area around the confluence of the rivers Ussuri and Amur—a region near the modern city of Khabarovsk. Moreover, Hammond related miryachit to the “Jumping Frenchmen of Maine”—a disorder which likewise comprised echolalia (where the afflicted imitate speech) and echopraxia (Hammond, 1884a, 1884b; Roberts, 1878). Statements regarding a possible etiology were cautious. These included the burden of long winters.

On the other hand, van Brero (1894, pp. 944–945) subscribed to the then widespread racist notion of colonialized people being supposedly immature and unable to govern themselves, which was used as an excuse for colonial subjugation. In this line of argument, van Brero also subscribed to the prejudice that these colonialized people have a “neurological deficit” which was supposed to consist in “frail power of will over the lower centra [of the brain]”, a claim that was absolutely unsupported by scientific evidence yet widespread in the imperialist constructions of his time (Gould, 1993; Heinz, 1998).

Van Brero also discussed a heritable predisposition for latah and a connection with the maladie des tics (tic illness), which had been described by the French physician Georges Gilles de la Tourette (1857–1904), a view also mentioned by the German physician Heinrich Botho Scheube (1853–1923), professor at Kyoto Medical School (Scheube, 1903). Hermann Emminghaus (1845–1904), who was a tenured professor of psychiatry in Dorpat, Russia (today Tartu, Estonia), also mentioned the phenomenon of latah in his textbook of psychiatry and assumed it was an irritation in the action of reflexes, characterized by “enormous jumpiness” (Emminghaus, 1878, p. 47). This nosological placement is striking, because a possible connection between latah and startle disease, a neurological disease with distinct startle responses to tactile or acoustic stimuli and hypertonia is often discussed today (Simons & Hughes, 1993).

A few years after van Brero’s publications, the Swiss physician Otto Stoll (1849–1922) declared the latah disorder to be a form of echopraxia. According to him, the cause was an “imitative effect of suggestion”. He referred to the case of a 14-year-old boy who was a patient at the psychiatric hospital in Nancy, then run by the French psychiatrist and hypnosis researcher Hippolyte Bernheim (1840–1919). Through suggestion, symptomatology similar to latah could be induced in the patient (Stoll, 1904, p. 108).

Van Brero (1896, pp. 27–28) also wrote about shamanism, especially among the Dayak people in Borneo. Dayak shamanism was performed by both men and women, though men behaved like women in such states. A shamanic ceremony was accompanied by repetitive dances, changes of sex (in male shamans), and finally, ecstasy. In the ecstatic state, shamans sang, screamed, threw themselves to the ground, and danced or jumped around with grotesque facial expressions. In the process, they received divine prophecies and spoke in a “ghost language”. Van Brero related shamanism to hypnotism.

A third disorder described by van Brero was the condition known as amok. He likened amok to epilepsia larvata, but noted that “regular” epilepsy seldom occurred among the local people. Moreover, status epilepticus never occurred in amok, and the phenomenon did not affect women (van Brero, 1896). Because he hardly found any hints of an organic disorder in amok, van Brero supposed the lack of control over passions, which he had observed to be a “typical trait” of Malayan peoples, was the origin of amok: a slight indisposition in daily life would lead to either exaltation or apathy. According to him, the basis of all of these abnormalities was a degeneration of the “race”, which was supported by “anomalies” of the skulls of the native people, associated with an “imperfect development of the mind” with regard to ethical judgment and intellectual abilities. This ideological attitude declaring colonized peoples as inferior was influenced by contemporary theories of degeneration and recapitulation.

It is noteworthy that van Brero revealed epistemological problems that had their origin in problems of classification of psychiatric diseases and in the objectification of their causes. Hence, van Brero argued, it was difficult to figure out which of various agents were responsible for the development of diseases. In dementia paralytica, Dementia combined with palsy, for example, it might be syphilis, alcohol consumption, or intellectual tiredness. On the other hand, the search for the origins of diseases was facilitated in regions of the world where people were “not [educated] or semi-educated” because life presented fewer distractions than did the modern world. Thus, in his view, the range of possible factors influencing psychiatric disorders remained moderate. However, he argued further, somatic diseases like beriberi, tuberculosis, and malaria also influenced psychiatric disorders as did the consumption of intoxicants. Indeed, van Brero related the intake of cannabis to the occurrence of mental diseases in British India (van Brero, 1896, p. 27).

The Swiss physician Otto Stoll (1849–1908), who worked mainly as an ethnologist and geographer, discussed the prominent role of suggestion in the case of amok (Stoll, 1904). His monograph which could be acknowledged as a pioneering work of comparative psychiatry across different cultures is the compendium Suggestion und Hypnotismus in der Völkerpsychologie [Suggestion and Hypnotism in Ethnic Psychology], first published in 1894. At that time, hypnosis was having a profound impact on psychiatric theory and as a treatment option through the work of the French neurologist Jean-Martin Charcot (1825–1893) and others (Chertok, 1966; Lehmann, Hartung & Kiseier, 2004). Stoll also considered cultural aspects which contributed to suggestibility. Certain convictions about honor and “the right of bloody revenge” which were deeply rooted in the culture could provide a basis for amok. On the other hand, amok occurred suddenly and paroxysmally, so secondary triggers such as psychosis, febrile delirium, or drug intake had to be taken into consideration (Stoll, 1904, pp. 111–112).

The German physician Christian Rasch, who lived in Görlitz at the end of the 19th century, also published studies on amok in Malaysia and supported the idea of a “suggestive influence or an imitative effect” as the main pathological mechanism, based on certain personality traits of the Malayan people like heroism and fortitude (Rasch, 1895, pp. 856–857). In another review article, he discussed various opinions regarding the influence of the climate on mental diseases and concluded that people who are prone to develop nervous diseases should not stay in tropical regions for long periods of time (Rasch, 1898, p. 775).

Investigations of African American and Native American populations in the US

Several studies at the beginning of the 19th century examined mental health problems in specific populations of the United States. One early study by Benjamin Rush, a professor of medicine at the University of Pennsylvania, investigated the influence of living conditions on alcohol consumption. Rush referred to the consequences of alcohol intake for Native Americans, which claimed more lives among them than pestilence and war (Rush, 1823, p. 27), but his book was still far from being a comparative cross-cultural study.

The US psychiatrist James Woods Babcock (1856–1922), who mainly worked in the city of Columbia in South Carolina, considered the connection between disease and factors of “race” and social influence (Babcock, 1895). He argued that among native African peoples mental diseases were “nearly unknown”, and that the same observation could be made among slaves in the Confederate States of America. But since the “emancipation” of African Americans—i.e., since they had been freed from slavery—the occurrence of mental diseases had allegedly increased. Furthermore, Babcock noted that no case of paralysis, dipsomania, or opium use had occurred until 1883, while by the time of publication of Babcock’s article (1895), all these disorders had appeared in the African American population. He also described differences in the frequency of disorders among African Americans compared to the “white population”: according to his findings, mania occurred 20 percent more often, while melancholia was observed relatively seldom. Babcock’s arguments reflected common prejudices of white Americans that African Americans should not have been freed from slavery—not to mention a lack of adequate epidemiological research.

The works of two other authors also supported the view that living conditions could influence the occurrence of psychiatric diseases: Henry Johns Berkley (1860–1940), who worked in Baltimore as a professor of psychiatry, and Abraham H. Witmer (born 1845), who worked in Washington as a physician, anatomist, and tutor. Berkley (1895) noted that dementia paralytica often occurred among African Americans, and was frequently associated with arteriosclerosis. A main cause of the disease were the difficult living conditions of African Americans. Before the American Civil War of 1861 to 1865, “colored idiots and epileptics had been known but never a colored lunatic”, wrote Witmer in the year 1891 (p. 669). Suicides were rare among African Americans. Babcock claimed that the number of African Americans who suffered from mental diseases rose considerably up until 1880 (Babcock, 1895). As a consequence, from then on, the ratio of sick to healthy people in the African American population was similar to that in the white population. Moreover, types of insanity no longer differed between the groups, and cure rates were also similar. No “race” would subsequently have any kind of “immunity against the usual types of insanity” (Witmer, 1891, p. 676). Similarly, publications of that time explained that insanity increased among African Americans with the demands of a life to which they were supposedly unaccustomed, that is, the life that came after “emancipation”, with its freedoms and exposure to the progress of civilization. In contrast, Witmer (1891) emphasized that “health and morality had been carefully shepherded before their emancipation” (p. 674).

All of these authors ignored the continued oppression, racist killings and lynchings, and the segregation and poverty of African Americans following the end of slavery. They also did not consider that access to the health care system improved for many African Americans after being freed from slavery. Both factors probably contributed to increased health care service utilization rates. Indeed, a critical review at the time found no scientific evidence for an actual increase of mental sickness after liberation. Babcock (1895) used statistical data from the U.S. American Census Office and statistics from several hospitals to describe recent changes and noted that the claim of a rise in the prevalence of mental disorders after liberation was based merely on “experience of individual observers” (p. 423) or “recognized by Southern asylum superintendents” (p. 424). Statements about African American health benefitting from a “shepherded” life in slavery were not only unscientific but their uncritical presentation revealed the racist prejudices of the authors, who also claimed that African Americans were somehow unfit for liberty and kept needing to be “civilized”.

These authors also discussed religion as an influence on mental illness, but again approached this in a way that denigrated the religious beliefs and practices of African Americans. For example, Witmer (1891) postulated that former slaves lacked experience of the world and had no good philosophy or religion. With regard to the heredity of diseases, he wrote: “the history of their freedom is still too young for there to be any impact from the degenerative influences of civilization on the offspring of recently liberated slaves” (p. 675).

Studies in the Orient and Turkestan

In the 1840s, the French psychiatrist Jacques-Joseph Moreau de Tours published a 30-page monograph about mental diseases in the Orient. Moreau de Tours is also famous for his research into the mental effects of hashish (Moreau de Tours, 1845). He visited lunatic asylums in Asia Minor, Egypt, and the island of Malta during the years 1836 to 1840. In the course of these visits, he questioned both patients and wardens. According to Moreau de Tours, exaltation of religious feelings and unhappy love were prominent causes for mental disorders in the Orient (Moreau de Tours, 1843).

Regarding the influence of religion, the French psychiatrist Abel-Joseph Meilhon (born 1860) also made a number of remarks, suggesting that the Islamic religion played a protective role against mental disease. Before becoming a public health officer, he had served as an assistant physician in the mental hospital of Aix-en-Provence. At this institution, he also treated mentally ill patients from the French colony of Algeria, and in particular from the provinces of Algiers, Oran, and Constantine (Meilhon, 1896b, p. 19; Keller, 2007). He claimed that while mania seldom occurred in France, it was the most frequent kind of mental illness among the Algerian population. According to Meilhon, Arabs in general suffered less from mental diseases than did Europeans and one cause were the high temperatures in Northern Africa, which wearied people and dulled their nervous activity. At the same time, he weakened his own claim by noting that the climate could not play a predominant role in the occurrence of mental diseases. Another observation Meilhon made was that the frequency of mental diseases appeared to be higher in Algerian cities than in rural areas. He explained this finding as an artifact of better medical facilities and diagnostics available in the cities.

In other claims, Meilhon contradicted some of his own previous statements. Mentally ill patients suffered from exaltation, rather than the above mentioned blunting of nervous activity. Moreover, the closer one approached the equator, the more often there were assassinations, which he regarded as climate-associated emotional vehemence. Drug consumption also played an important role in mental diseases, especially “kif” in Algiers (a substance made from hemp). Deliria often had religious content, occurring superficially and episodically. Melancholia was less common than mania and was similar to the same condition in European people (Meilhon, 1896a and b).

In the region of Turkestan, or Central Asia, systematic psychiatric research did not develop before the end of the 19th century. Until then, there had only been a few descriptions of strange mental phenomena affecting the various peoples who lived in the region. On the whole, such descriptions concerned culturally embedded phenomena which were mostly connected with shamanism. These early descriptions were ethnological observations.

The beginning of the 19th century saw the incorporation of the northern territories of Turkestan (which today correspond to parts of Kazakhstan) into the Russian Empire. In 1832, the Russian ethnographer Aleksej Iraklievich Levshin (1797–1879) published a multi-part monograph about the Kazaks and Kyrgyz. Among other things, he reported on shamanic phenomena (Levshin, 1832), which he compared with those already known from Siberia. He described these shamanic practices as “magic and trickery” (p. 65), because they were not an integral part of the religion of the Kazaks and Kyrgyz, but were rather used for medical cures.

In the second half of the 19th century, other parts of Turkestan such as the emirate of Bukhara or the khanate of Khiva were incorporated into the Russian Empire under the leadership of General Konstantin Petrovich von Kaufman (1818–1882). At that time, the first systematic medical investigations were conducted. A man named “Petzold”, known only as a co-worker of the Dorpat professor of pharmacy Georg Dragendorff (1836–1894), investigated local remedies in Turkestan when he joined an expedition led by von Kaufman in 1871. Although he mentioned remedies for what appear to have been neurological disorders, such as “shaking of the head”, his work does not include any detailed information about psychiatric disorders (Dragendorff, 1872).

In comparison, reports about opium consumption were abundant. Compared to other drugs, opium was one of the most important drugs in Turkestan – not only as an intoxicant, but also through long tradition as a remedy. Sources on opiate use exist from the end of the 19th century, even though again, these do not derive from psychiatric studies, but from travelogues. For example, books by the Austro-Hungarian orientalist Hermann Vámbéry (1832–1913) were very popular. It was not until the 1920s that systematic research was conducted. Forerunners were Preobrazhensky (biographical data unknown) and Leonid Anciferov (1891–1934), who became the chief physician of the psychiatric hospital in Tashkent in 1921 (Latypov, 2012; Turaeva & Engmann, 2014).

Three decades earlier, however, the physician Aleksandr L’vovich (Solomon Judovich) Shvarc (born 1872), who worked in Tashkent (Turkestan, today Uzbekistan) early in his career, had published a multi-part report about his work in the outpatient clinic for men in Tashkent city from 1886 to 1897. Women had been treated there from the end of the 1880s onwards. In his report, Shvarc described the local people as “illiterate” and “retarded” (Shvarc, 1897, p. 1267). Two percent of patients in the ambulatory clinic had “nervous” (or mental) disorders. Shvarc reasoned that this low number also indicated a lower rate of incidence compared to the Russian motherland. Cultural and economic development together with increased employment usually led to a greater exertion of brain activities, but according to Shvarc, in Turkestan the situation was the reverse. If the occurrence of mental disorders was connected with exertion of the brain, it would be understandable why the rate of occurrence of such disorders would be fairly low in Tashkent. These conjectures were not based on any scientific investigation, but reflect colonial attitudes to the local people, declaring them culturally backward. Shvarc also supposed that most of the mentally ill did not get into medical care. At the time of Shvarc’s publication, most treatment of psychiatric disorders was carried out by local healers (so-called “tabiba”). Many mentally ill people appear to have been opium users (“tariaki”, “kuknary”) who lived alone and destitute on the streets and in the cemeteries of Tashkent. Thus, the use of intoxicants, including alcohol, appeared to contribute to the development of nervous and mental diseases (Shvarc, 1897, 1900). Mental diseases among the local population did not reveal major differences to those of the Russian population. The most prominent disorder was neurasthenia, followed by neuralgia affecting the intercostal, sciatic, or trigeminal nerve. Conspicuously, in cases of syphilis, Shvarc (1897) claimed tabes dorsalis did not occur.

Discussion

The literature reviewed shows that studies of the frequency and configuration of psychiatric disorders in different cultures were carried out long before Kraepelin’s cross-cultural study in Java in 1904. Many of the works cited in this paper have been forgotten. A common issue in these studies is the question of whether the described disorders are distinct and thus culture-bound, or whether cultural and religious peculiarities merely shape the basic symptoms of similar types of diseases. The latter view was examined exhaustively by many 19th-century authors, as discussions of latah illustrate.

The “pre-Kraepelinian” authors quoted in this article did not postulate a purely biological explanation for psychiatric disorders. Cultural aspects, social conditions, and the influence of religion, race, and climate were discussed as triggers or reinforcers of diseases. All the authors classified disorders from other cultures in terms of the categories of diseases established in Europe or the West. However, it is noteworthy that even these categories were inconsistent and a matter of dispute. Moreover, new theories influenced explanations of cross-cultural disorders, as exemplified by latah or amok, in which the question of suggestion prevailed over other theories, reflecting the importance of hypnosis research in the last few decades of the 19th century. Discussions about the multiple causality of mental disorders anticipate current discussions regarding the etiology and precipitants of such disorders.

Nineteenth-century accounts also reveal racist and dehumanizing attitudes. For example, Witmer (1891) stated that African Americans had been “carefully shepherded” in their slavery, and Shvarc (1897) described the local Turkestan population in general as retarded. As cited above, van Brero (1896) explained mental disorders by anomalies of the skull. Craniometry, measurement of the skull, was a common step in any investigation of psychiatric status because the shape of the skull was thought to reveal the anatomy of the brain (cf. Emminghaus, 1878, p. 25). Craniometry also became a widespread instrument for supporting racist views and declaring other populations as inferior (cf. Gould, 1993).

Such views went hand in hand with degeneration theory. Mainly based on the works of the French psychiatrist Bénédict Augustin Morel (1809–1873), one tenet of degeneration theory was that social milieu, intoxicants, moral behaviour, and other factors could affect both the body and the soul (Heinz, 1998; McCulloch, 2001). In addition to degeneration theory, Heinz (1998) notes that Ernst Haeckel’s (1834–1919) recapitulation theory was used to argue that indigenous people had primitive, primordial, or archaic mental states that reflected a lower stage of phylogeny. According to Engstrom (2008, p. 590), there was general agreement on an “essential difference” between the minds of Europeans and those of others, especially colonial populations. In addition to that, models of psychopathology were influenced by social Darwinist ideas, which considered that different peoples could be placed on a continuum of stages of development from lower to higher (Littlewood, 2001). Taken together, these ideas gave free rein to oppression and dehumanization of people in colonized territories.

The etiological explanations given by the authors must be understood in relation to the state of knowledge at their time. However, the concept of race used by these authors has been thoroughly critiqued in recent decades and rejected as having no biological foundation. As Livingstone (1993, p. 133) put it: “genetic variability among the populations of organisms … does not conform to the discrete packages labelled races or subspecies”. Instead, Livingston suggested using the term “cline”, which refers to “a continuous graduation over space in the form or frequency of a trait” (p. 133).

While there is no direct line between the “pre-Kraepelinian” authors and present-day work in cross-cultural and ethno-psychiatry, the cross-cultural research of the 19th century is relevant to the origins of the field both because it is a source of descriptions of mental disorders and diseases among different peoples of the 19th century, and because it provides information about the way differences were perceived by “Western” researchers. In short, these studies are of interest for both psychiatric and ethnological research.