Hans Förstl


Moritz_Psychiatry


Karl Philipp Moritz

GNOTHI SAUTON – Magazin zur Erfahrungsseelenkunde (1783-1793)

Journal of Empirical Psychology - an analysis of 124 case reports.


Karl Philipp Moritz edited Gnothi Sauton, the Journal of Empirical Psychology (1783-1793), which stands as the first of numerous psychological and psychiatric periodicals. We evaluated 124 psychiatric or neurological case reports from the journal according to modern diagnostic criteria and present a brief outline of the contributors' and patients' sociodemographic characteristics, selected case reports and the surmised risk factors. A reliable diagnostic reassignment of the well-described cases was feasible; this may indicate that patients retain similar psychiatric disturbances over the centuries. As in the popular literature of the period, examples of' sentimental students' and 'desperate soldiers' represented the most frequently discussed, prototypical high-risk personalities in the Journal, which marked the step from literature to empirical science. The influences of this ca se material upon contemporary psychiatric writing and thought are reviewed.

In literary (Schrimpf, 1980) and in medical history (Leibbrand, 1941) Kar! Philipp Moritz is best known for his biographical novel Anton Reiser (1785-1790). This novel, inspired by Rousseau, reflected the ideas of the Enlightenment. It was one of the first and foremost examples of 'psychological' writing which concentrated more on the hero's mental than on his external development. Thereby Moritz prepared the ground for German romantic literature (Leibbrand, 1941; Bisanz, 1970). His scientific writings are still considered as matters of marginal interest only, relevant mainly with respect to the literary works of his contemporaries (Frickmann, 1988). It is less weIl known that he initiated the tradition of psychological and psychiatric journals in the German language / (Keil, 1985). He is widely underestimated as the founder and editor of Gnothi Sauton, Magazin zur Erfahrungsseelenkunde (Know Thyself, the Journal of Empirical Psychology), which was published from 1783 until 1793. The term' psychologia empirica' had already been coined by the philosopher Christian Wolff, who understood empiricism as a method for the retrospective confirmation of psychological insights (Frickmann, 1988). For Moritz, however, critical about premature psychological concepts and systems, 'Erfahrungsseelenkunde ' meant the unbiased collection of material. In his call for contributions to the Journal, Moritz (1782) therefore solicited reports from anybody who was interested in advancing knowledge of the human psyche. He was inspired by his aim to create a 'mirror for the human species' (Moritz, 1783) rejected any premature systematic reflections on the material and tried to abstain from any editorial censorship. He tolerated most lively descriptions and the strangest views. The Journal's scope included articles on the psychology of language and education, on psychotherapy and parapsychology. A large part consisted of original case descriptions.   

The majority of 124 case reports provided exhaustive patient data, comprising the names, careers, life events, social status, life styles, temperament, physical diseases, psychopathological syndromes, treatment and course of disease. Only 20 of the 124 reports are unattributed. These were presumably written, rewritten or translated by the editors themselves. A few other cases were rather casually assigned, thus 'a trustworthy officer, whose name I forgot'. A number of reports were taken from other foreign language journals, archives and French encyclopaedias. Most are original contributions, signed with the author's full or abbreviated name, title, and profession. Interested laymen, for example teachers, priests and educated civil servants contributed more reports than medical doctors. Among the many authors, there was only one woman, Ernestine Christiane Reiske, who submitted four carefully described cases. Very often the authors' motivation to contribute a case remains a matter for speculation: in several instances a rather personal approach to the surmised origin, nature, adequate treatment and potential moral meaning of mental disease is expounded. There is no common concept underlying the broad variety of this material, no common interest apart from the belief in the progress of understanding man by investigating mental disease. Of the 124 patients described 95 were men. Most of the 29 female patients were of low social status; their cases are generally sketched with less accuracy and sympathy than the cases of the male patients. Individuals with neurological disturbances belonged to all social classes, whereas a majority of psychiatric patients came from the lower classes. Their disturbances severely interfered with social functioning, thereby attracting the authors' attention. Table 1 shows some of the available demographic patient characteristics.  There are no significant differences in the distribution of gender among the different diagnostic groups, which all show a large male predominance. As would be expected, patients with organic psychoses had a higher mean age than the patients suffering from functional disorders. Considerably fewer of the patients suffering from functional psychoses are married, as compared to those with organic psychosis, stress or adjustment disorders. Only 16 % of the 'schizophrenic' patients are married. This low percentage of married 'schizophrenic' individuals - predominantly men - has repeatedly been confirmed in contemporary epidemiological studies (0degaard, 1953; Häfner et al. 1989). 

The diagnostic labels used by the authors show little resemblance to contemporary concepts and do not conform with strict systematic categories. This is underlined by the fact, that in 27 of 124 cases not even a descriptive term is applied to the reported cases. Most of the terms used in the other 97 cases only appear once throughout the Journal's 10 volumes. Some of the 'diagnostic' terms appear less scientific than literary (' a new Werther', 'a religious Don Quixote', 'a hermit ~ in the turmoil of the city') or cryptic (' a physiological-psychological problem '). Some are simply descriptive (' sense- and speech-lessness '). Only a few of the terms were used repeatedly, but often for rather different disturbanees, e.g. 'convulsiones' (3 cases), 'delirio ' (3 cases), 'hypochondria' (4 cases), 'melancholia' (8 cases). They were not well defined and were usually associated with variable other terms, e.g. 'melancholia and imbecility', 'melancholia and singulari inspirationi divini', or 'motherly cruelty due to melancholia and despair '. However, the authors achieved accurate descriptions of neuropsychiatric syndromes, permitting reliable diagnoses (inter-rater reliability 0'86) according to ICD-9 (WHO, 1978; '. Fleiss, 1981). The neurological syndromes, e.g. of aphasia or agraphia, are portrayed with clear detail and are usually free of any theoretical . speculation, even if symptoms and causal factors are not always strictly separated. Most prevalent among the neurological diseases described were meningitis or encephalitis (4 cases), stroke (3 ca ses) and epileptic seizures (5 cases). The psychopathological descriptions are so accurate that delirium, delusional, catatonic or hysterical states and mood disturbance can be clearly identified. The following example is translated from volume 1 (1783).

Doctor Pihl visited the D... s, a former loca1 merchant, in order to investigate his mental state and he found him in a peculiar outfit. He was dressed in a sleeping gown and wore several iron rings around his body. On his head he wore a huge construction of linen cloth and caps, affixed with ribbons, fine iron bands and attached papers etc. His bed was also prepared with iron rings and plates etc. When doctor Pihl asked him for the reason he wore this outfit and took the strange precautions, he answered that he had to do so because evil spirits would not let him have a single moment of peace. They seared him night and day, had torn out his lung and liver, snatched large parts of his skin etc. ( .. .) Mr. D... s believed he was a direct messenger of the holy trinity, who had now taken over the government of the earth and that the power of all kings and princes was despised and abolished. He in particular had received the order to look after order and justice, and that houses should be kept in a good state although all would be in wretched condition. At  the beginning of his madness, Mr. D ... s had therefore '. gone into many houses and, to further his task, gave order to their prorietors to have them rebuilt immediately. (...) 

Bizarre, persecutory, auditory and coenesthetic delusions and hallucinations characterize paranoid schizophrenia (WHO, 1978). Descriptions of ten male and three female patients are highly suggestive of early-onset schizophrenia. Eight individuals were diagnosed as late onset schizophrenia or paraphrenia. This casts some doubt on the thesis that conditions corresponding to schizophrenia were not satisfactorily described before the nineteenth century (Hare, 1988). Dementia, neurotic and personality disturbances, stress and adjustment disorders, mental retardation and alcohol-related disease, together with the forever fascinating topics of kleptomania (5 cases) and somnambulism (8 cases), were all presented and discussed in great detail. 

In 106 of the 124 studies one or several risk factors were mentioned. The factors listed below were circumstantially discussed and could be classified as folIows:

Disposition (58 cases): the parents' condition at the time of conception; incompatible parental talents; the fact that the mother brought food to a madman during her pregnancy or that she stole during her pregnancy. The presence of congenital temperaments like melancholia as 'balneum diaboli' (i.e. the 'devil's bath '), or hypochondriasis, etc. Having excitable or feeble nerves; hot, thick or congested blood. Suffering from intellectual deficits. Being proud, vain, sentimental, etc.  Physical stress (50 cases): suffering from physical diseases such as fever, plague, worms, hernias, etc.; being infected with madness; having an unfulfilled lovelife, debauchery, committing the sin of Onan and developing consecutive myelomalacia; eating a deficient or a too filling diet, drinking too much coffee or wine.  Social stress (28 cases): lacking education; being unemployed or overworked; being a soldier; remaining single or being unhappily married; having too many children, too low an income.  Mental stress (52 cases): attending comedies or tragedies; studying philosophy or theology; being sentimentally religious; reading any books (19 cases), particularly the Bible, especially the books of Daniel, John or Judith. 

Those issues appear less outdated if compared with contemporary lay concepts of mental   disorders (Angermeyer et al. 1989). Social or mental stressors were never implicated in the pathogenesis of neurological disease, and only rarely in cases of transient organic psychoses. Reports of schizophrenia and neurotic or personality disorders frequently deal with social and mental stress factors. Mental stressors served as decisive triggering or maintaining mechanisms in several spectacular psychotic conditions. The importance of life events in the manifestation of mental diseases was discussed long before their evaluation in our century (Brown & Birley, 1968). 

Two prototypes of presumed high-risk personalities were presented: students and soldiers. Both groups apparently accounted for a significant number of psychiatric patients around 1800, not only among these reports, but for example also among the 164 cases documented by Esquirol (1838): 25 of his patients were students and 33 were soldiers. The 'sentimental student' suffered from intellectual stress as he was a play-addict or read dangerous books. Among the literate population the relationship between literature and life was complex and intense. Goethe's Werther (1774) represented the most famous model of a young sentimental student, who pursued his ideals, failed and committed suicide. Goethe's exhaustive account of Werther's love, despair and dying caused a remarkable death toIl among the sentimental readership (Osinski, 1983; Reuchlein, 1986). A contemporary less dramatic  proof for the 'Werther effect' has recently been published (Schmidtke & Häfner, 1988). During his work at the Journal of Empirieal Psychology, Moritz spent several months with Goethe, who considered Moritz as his' younger and less fortunate brother', in Italy. Their close personal relationship and their mutual interest in the human psyche persisted; however, their approach towards this subject became increasingly different: literary versus empirical (Bisanz, 1970; Schrimpf, 1980). Attending university as a student of theology or philosophy, reading books and going to plays was considered decidedly unhealthy, but could hardly account for a sensational case like the following example of a 'desperate soldier', whose precarious social situation led him into despondency and insanity (volume 1, 1783):

He had lost his father at the age of fourteen. Having finished his apprenticeship as a shoemaker, he went to Danzig. Before he could get a job, his bag together with all his tools was stolen. Unable to work without his tools, he joined the army for 16 years, where he had to suffer much from his officers (...) The idea of murder grew in his soul. It was nourished by his sentimental convictions. He had exaggerated beliefs of future happiness for his life after death. He could only think of one way to get rid of his life, - and this was murder ! (...) He cut the throat of a young girl. Immediately thereafter he went to the police, admitting that he took great pity in wh at he had done. Now he would rather die happily than stay alive. He had turned away from God, but now he would know how to find his way back.  . .  Religion was blamed for turning suicidal patients, forbidden to commit suicide, into murderers, longing for confession, penitence, the death sentence, and salvation with final relief from all earthly misery. Eight of 124 cases deal with suicide, 15 with murder. This over-representation may be partly explained by the fascination of crime and partly as anti-religious propaganda: numerous statements throughout the Journal assume a more than critical attitude towards religion; the resemblance of several reports with the literary models of popular criminal histories by Pitaval or Captain Alexander Smith, which had been translated into German, can hardly be overlooked (Osinski, 1983). Works of literature and of emerging psychological science were still equally subscribed and discussed in literary circles (Osinski, 1983; Reuchlein, 1986). This evidence, which would today be observed with great reservation, was widely quoted in later journals and textbooks of psychiatry. 
The immediate international impact of the Journal is perhaps best documented by Alexander Crichton's Inquiry into the Nature and Origin of Mental Derangement (1798). In the introduction to his work, which made an attempt to replace Thomas Arnold's (1782, 1786) system for the classification of mental illness, Crichton referred to the Journal in which 'I found what I had not yet met with any other publication, a number of well-authenticated cases of insane ; aberration of mind, narrated in full and satisfactory manner, without a view to any system whatsoever' (pp. iv-v, 1798). Crichton translated 21 cases from the Journal, most of them in fuIl. In the first of his volumes 19 of 407 pages and in the second 66 of 455 pages consist of material from Moritz' Journal. The more sensational and dramatic cases were weIl represented and contributed significantly to the empirical basis of Crichton's nosological system, which relied upon  the grouping together of related psychiatric symptoms and signs and remained influential throughout the nineteenth century (Hunter, 1963). In the year when the Journal was issued for the last time, one of the former contributors, Immanuel David Mauehart, founded the General Repertory of Empirical Psychology and Related Sciences, which was soon followed by the Magazine for Psychology and Medicine, and, within the next 20 years, by the psychiatric journals edited by Reil, Hoffbauer and Nasse (Keil, 1985). 

Moritz intended to create a 'mirror for the human species' and with his Journal founded a mirror for reflections on the awakenings of modern psychiatry, on its terminology, epidemiology and nosology. Moritz (1782) was confident that after a few years of unbiased data collection tentative conclusions on the nature of the human psyche could be drawn. However, psychological medicine still has to deal with the issues that were eagerly discussed in the Journal. This might imply that identical mental disorders still enigmatically prevail in a similar fashion now as then. Psychiatrists might simply still think in the same tradition, seeing matters the same stereotyped way for the last 200 years. In any case, the Journal of Empirical Psychology marks the step from literature to empirical science and has to be recognized as a seminal source for German and European psychopathology and psychiatry. 

(An complete version of the paper by Hans Förstl, Mathias Angermeyer and Robert Howard  was published in “Psychological Medicine”, 1991)