The clinical orientation of Pinel, Esquirol, and their followers was basically empirical. By concentrating on describing observable symptoms and abnormal behaviours, it avoided theoretical controversies. However, many believed that if psychiatry was to become a branch of the medical sciences and to progress, it had to adopt models similar to those accepted by the rest of medicine. According to the anatomoclinical perspective, which was now dominant, diseases were distinct entities. Each disease was defined by a characteristic pattern of symptoms provoked by a lesion or eventually a dysfunction of an organ to be discovered at autopsy. In 1821 Bayle, following this scheme, described the typical clinical symptoms and lesions of the brain in the general paralysis of the insane. Despite the disappointing results of the further anatomopathological studies (brain lesions were observed in only a small proportion of cases), there was increasing conviction that, with better investigation methods, mental disorders, like other diseases, could be explained by somatic causes. The degeneration theory, proposed in 1857 by Morel, which attributed many forms of insanity to the hereditary transmission of dysfunction of the nervous system produced by the noxious effects of environmental factors and whose influence lasted until Kraepelin, is another expression of this biological orientation whose aim was to give psychiatry an undisputed medical status.
The biological and the purely clinical approaches were concerned with different conceptual levels—the discovery of the causes of insanity and the description of its manifestations respectively. Therefore they could easily coexist. Even when the followers of Pinel and Esquirol expressed reservations about the applicability of the biological model to every type of mental disorder, they still believed in the medical nature of psychiatry. The situation created in the German-speaking countries by the school of the 'mentalists' (the term Psychiker by which they were known means 'psychologically oriented'), who were predominant during the first half the nineteenth century, was very different. Influenced by philosophical, religious, and romantic trends, those psychiatrists took a radical dualistic position, postulating the absolute difference between the physical body and the spiritual soul. The soul was the source of the whole psychic life and hence eventually of its abnormal aspect—insanity. A term such as disease, appropriate for the somatic illnesses, could only be used metaphorically in psychiatry. The sins of the patients were the origin of the mental disorders, and psychiatry belonged more to moral philosophy than to medicine. These ideas were developed in various related forms by the majority of the German psychiatrists of the period (Heinroth, Ideler, Langerman, and many others). Their ideological position had two consequences: scientific relations with other schools, such as the French and the English who saw in the publications of the mentalists obscure philosophical theories devoid of medical character, were largely cut off, and they provoked a violent reaction in Germany itself. The most extreme representatives of the contending group of 'somatists' ( Somatiker), such as Jakobi and Friedreich, saw the mental disorders as symptoms of somatic diseases, not necessarily of the brain. In fact for them mental diseases as such did not exist. They defended aggressively their biological and sometimes bizarre hypotheses, such as the aetiological role of intestinal worms, against the mentalists. Finally, around 1850, they gained the upper hand. The publication in 1845 of Pathology and Therapy of the Nervous Diseases by Wilhelm Griesinger, an heir to their school who was also influenced by the French alienists, is a landmark in the history of the German psychiatry. With his appointment in 1865 as professor of psychiatry in Berlin, where he succeeded the mentalist Ideler, medical psychiatry was definitely established in Germany as a branch of the natural sciences.
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