Classifying differences: the dementia praecox and schizophrenia categories used by Brazilian psychiatrists in the 1920s

Abstracts

Analisa o modo como os psiquiatras brasileiros Henrique Roxo e Murillo de Campos conceituaram e distinguiram as categorias diagnósticas de demência precoce e esquizofrenia, no final da década de 1920, em artigos publicados no principal periódico psiquiátrico à época. Observa-se como ambos se apropriaram do conhecimento europeu que forjou tais categorias e como as representaram no contexto da institucionalização da psiquiatria no Brasil. Busca compreender como esse processo de nomeação e definição cientifica de diagnóstico se articulava à produção da diferença entre o que deveria ser considerado fenômeno, no que se refere à patologia mental.

demência precoce; esquizofrenia; classificação psiquiátrica; história; Brasil

ANALYSIS

Classifying differences: the dementia praecox and schizophrenia categories used by Brazilian psychiatrists in the 1920s

Ana Teresa A. Venancio

Researcher and professor at the Casa de Oswaldo Cruz/Fundação Oswaldo Cruz Casa de Oswaldo Cruz/ Fundação Oswaldo Cruz. Av. Brasil, 4036/404, 21040-361 - Manguinhos - Rio de Janeiro - RJ - Brazil. [e-mail]

ABSTRACT

This article analyzes how the Brazilian psychiatrists Henrique Roxo and Murillo de Campos understood and differentiated between the diagnostic categories dementia praecox and schizophrenia at the end of the 1920s in scientific articles published in the principal psychiatric journal of the time. We note how the aforementioned psychiatrists incorporated the European knowledge that created these diagnostic categories and how they represented them in the context of the institutionalization of psychiatry in Brazil. We seek to understand how this scientific diagnostic naming and defining process developed in conjunction with the definition of the difference between what should and should not be considered phenomena, with respect to mental pathologies.

Keywords: dementia praecox; schizophrenia; psychiatric classification; history; Brazil.

This article analyzes how two Brazian psychiatrists understood and differentiates between the diagnostic categories dementia praecox and schizophrenia in scientific articles published in the 1920s. The papers analyzed here were presented at the 3rd Brazilian Conference on Neurology, Psychiatry and Forensic Medicine held in July 1929 by the Brazilian Neurology, Psychiatry and Forensic Medicine Association (Sociedade Brasileira de Neurologia, Psiquiatria e Medicina Legal) in Rio de Janeiro. In the same year, Henrique Roxo (1877-1969) published "The current conception of dementia praecox" in issue No. 2 (Sept-Oct 1929) of the official journal of this scientific association, Arquivos Brasileiros de Neuriatria e Psiquiatria, and Murillo de Campos published "The schizophrenia or dementia praecox group" in the following issue (November).

At the first analytic level, we note how the aforementioned psychiatrists incorporated the European knowledge which created these diagnostic categories and how they represented them in the context of the institutionalization of psychiatry in Brazil. To this end, we begin with the assumption that the meanings given by the Brazilian psychiatrists to the categories dementia praecox and schizophrenia - created, respectively, by the German specialist Emil Kraepelin (1856-1925) and the Swiss specialist Eugen Bleuler (1857-1939) - are not necessarily equivalent to the common use of these terms by European psychiatrists, nor represent an equivocal or eclectic interpretation in relation to the original meanings of these categories, deriving from psychiatric knowledge produced overseas. The manner in which they were interpreted and disseminated in our context, stressing some aspects to the detriment of others, was based on influences during the reproduction and consolidation of psychiatric knowledge in the world of science in our country during that period.

On a second level, we sought to understand how the scientific naming and definition of phenomena related to physical-moral disorders¹, in the debate surrounding diagnostic classification, was related to the distinction between what should and should not be considered phenomena related to mental pathology. As we know, the act of classifying and the creation of classifications are present in societies and cultures of all kinds. They serve to establish and organize parameters for differentiating among objects and people, and result in symbolic systems of representation and action in the world, used by the individuals involved in the area in their daily routines. Also, we consider here the more general sense of the act of classification in the field of psychiatry: that which places concepts in a hierarchy, in an attempt to do more than just facilitate action, to make the existing relationships between people intelligible, socially unifying knowledge with respect to the universe around them (Durkheim, Mauss, 1981, p.451). Furthermore, the conditions on which the classifications depend are - above all - social. According to Durkheim and Mauss, man's forms of social organization, since primitive classifications, determined the place of things and people in the natural order. Therefore, "Far from logical relationships between things serving as the basis for man's social relationships, in reality the opposite is true" (p.451).

From this perspective, the diagnostic categories obey the general principles of hierarchy formation and intelligibility that constitute the act of classification. These principles conform to the characteristics of the scientific world, which are differentiated historically. We cannot forget that the act of classifying the physical-moral disorders using specialized psychiatric knowledge was a diversified social and intellectual event in time and space. During the nineteenth century, among the alienists, the definition of one's own classification was part of professional 'maturity' and conferred prestige. Similarly, in the following century, national psychiatric institutions began to create their own classifications (Berrios, 2008, p.115).

We seek here more than a simple history of concepts - a humanistic approach whose object is the semantics, etymology and changes in meaning of categories. We intend to observe how, in a single historical context, important individuals in the construction of psychiatric knowledge in Brazil conferred different meanings to the dementia praecox and schizophrenia categories, in an attempt to understand how questions pertinent to psychiatry in that time period in Brazil were represented. In summary, treating the local discourse with respect, we intend to inventory the repertoires the actors in question used to circumscribe and make sense of the physical-moral disorder states called dementia praecox and schizophrenia; observe how each author defined his repertoire with respect to the definition, 'symptoms,' origin or cause and treatment; discover any possibilities for common ground in the concepts contained in these repertoires; and verify the creation, or not, of oppositions or complementarities between the different sets of categories in question.

The Actors

According to Bercherie (1989), the creation of the schizophrenia category in 1906 is strictly related to the appearance of the 'psychodynamic trend' in psychiatry, which emerged in Germany in the 1900s. That trend was opposed to the Kraepelinian psychiatric approach which established static correlations between symptoms and injuries, similar to the anatomical-clinical medicine of the nineteenth century. This trend was the first to create a dialog with Freud's ideas, given that the Freudian formulations with respect to the concept of a 'divided self', based on the importance given to the 'unconscious,' were already known in educated and scientific circles at the time.² The approximation of and dialog between Bleuler and the Austrian neurologist Sigmund Freud (1856-1939) strengthened through Carl Gustav Jung (1875-1961)³. At the time, Jung was an assistant physician in Burghölzli, where Bleuler was a prestigious psychiatrist (McGuire, 1993, p.14, 15).

As Bleuler (1911) himself states, the creation of the schizophrenia category was expressly to oppose the idea of the existence of a dementia whose pathological development was characteristically and determinatively early or juvenile. The new category, originally in the plural - the group of schizophrenias - was also used to stress the assumption that one could not deduce a single morbid entity from its symptoms and evolution. It defined a pathological state in which the individual appeared to be clearly divided, in full, by the separation of his psychological functions. This split was first and foremost with respect to mood, resulting in a basic loosening of associations, which hampered the directive mental synthesis of the self and favored the pregnancy of the 'complexes': a group of ideas invested emotionally around a central, partially or totally repressed nucleus, or in other words, a group of repressed, interconnected ideas in a complete complex that plagued the individual and drove him to think, feel and act in a certain manner. "The complexes constitute, in their action on the thinking and behavior of the subject, the true psychological motivating factor" (Bercherie, 1989, p.226).

Based on this perspective of schizophrenia, we can understand the circumscription Bleuler established for his "fundamental symptoms": mood disorders, impaired association, autism and ambivalence. He thus defined the existence of an affliction that involved various internal moral spheres - thought, mood, will - but whose distinctive feature was the fact that there was a psychological splitting in the individual. Schizophrenia was defined as a pathological state that represented the internal desire to overcome an intolerable situation, in which the individual created another meaning for his existence and for the reality of which he was an integral part (Venancio, 1998).

In Brazil, historiography indicates that the first psychiatrist to introduce the idea of schizophrenia to Brazil was Hermelino Lopes Rodrigues (1899-1971), a Bahian physician who entered the Bahia School of Medicine in 1916 and, four years later, transferred to the Rio de Janeiro School of Medicine (Silveira, 2009; Mendonça, Coelho, Gusmão, 2000). He finished his studies there and was simultaneously a student of Henrique Roxo and a disciple of Juliano Moreira (1873-1933), with whom he worked at the National Asylum for the Insane (Hospício Nacional de Alienados). Encouraged by these psychiatrists, in 1926 he applied for a full professorship in psychiatry at the Minas Gerais Federal University's School of Medicine and was hired based on his defense of the theses "Etiopathogenesis of dementia praecox" and "Clinical study of schizophrenias". Silveira (2009, p.584) confirms that "Lopes Rodrigues was extremely interested in the great scientific debate of the era, the replacement of the Kraepelinian concept of dementia praecox with the contributions of the Swiss Eugen Bleuler and his ideas about schizophrenia".

Therefore, it was in the context of the recent introduction of the concept of schizophrenia in the academic world of psychiatry, in the middle of the 1920s, that Henrique Roxo and Murillo de Campos presented and debated their ideas on the correctness of this diagnostic category.

Henrique de Brito Belford Roxo graduated from the Rio de Janeiro School of Medicine in 1900, where he defended his dissertation "The duration of elementary psychological acts in insane individuals." This was a time in which clinical psychiatry consolidated its position as an autonomous field with respect to forensic medicine, although public psychiatric care had already been a government duty, first under the Empire, and then under the Republic, during the preceding fifty years.

Henrique Roxo's decades-long professional career coincided with the institutionalization of psychiatry as a scientific field in Brazil. Psychiatry established connections with and differentiated itself from other fields then emerging or already established - not just forensic medicine, but also neurology and psychoanalysis. His dissertation for his doctorate in medicine was supervised by Teixeira Brandão, a Brazilian psychiatrist who, in 1883, was the first professor in the recently created area of Clinical Psychiatry and Nervous Conditions and, in 1887, he became director of the National Asylum for the Insane, remaining in the position for ten years. Later, from 1904 to 1907, Henrique Roxo took the place of his former advisor in managing the Observation Pavilion (Pavilhão de Observação)⁴ of the National Hospital for the Insane, since the latter was unable to continue in the position after becoming a federal congressman.

During his career, Roxo visited the psychiatric clinics in Heidelberg and Munich, where he met the German Emil Kraepelin, and became one of the most illustrious names in Brazilian psychiatry, participating on the commission appointed by the Brazilian Association for Psychiatry, Neurology and Forensic Medicine from 1908 to 1910 to develop the first Brazilian psychiatric classification. The purpose of the Brazilian nosological project was to break away from the taxonomies that used natural science methods. The new system reinforced the hegemony of German diagnostic categories and classification models, especially those based on Kraepelin's work, indirectly proposing that psychopathologies should be universal and, therefore, that European classifications could serve as a model for the Brazilian classifications (Venancio, Carvalhal, 2001, p.155, 156).

At the end of the 1920s, when he wrote the article on the concept of dementia praecox, Roxo was already a prominent, 52 year old psychiatrist. In 1925, he published the Manual of psychiatry [Manual de psiquiatria]. Similar to international textbooks, it's purpose was to be a great treatise on Brazilian psychiatric knowledge. He began participating in the university academic world as a substitute professor in clinical neurology and clinical psychiatry at the Rio de Janeiro School of Medicine in 1919, and in 1921 became a full professor of psychiatry at the same school.

In 1919 he mentioned (Roxo, 1942) that the Federal Supreme Court legalized dual posts as a full professor and director of the Psychopathology Institute of the National Hospital for the Insane (formerly Observation Pavilion of the National Asylum for the Insane). This allowed the School of Medicine to develop its academic activities relatively independently of the Hospital, which was run by Juliano Moreira beginning in 1903. The Psychopathology Institute maintained the tradition of the Observation Pavilion as the entryway for admission of patients to the Hospital: they remained 'under observation' there by physicians who were studying at the School of Medicine under the supervision of Henrique Roxo.⁵

Our second actor is Murillo de Campos, on whom very little information is available. This leads us to assume that he was younger than Henrique Roxo and did not obtain the same level of prestige. He seems to have been part of a new generation of psychiatrists who worked under the supervision of Juliano Moreira at the National Hospital for the Insane and Henrique Roxo at the Rio de Janeiro School of Medicine, later becoming an associate professor at the School of Medicine. His professorship dissertation, published in 1928, was entitled "Constitutions in psychiatry: contribution to their study." Among his work we are aware of, published in the 1920s and 1930s, we note his dedication to specific topics, such as the book on spiritism, published in 1931 together with the forensic medicine specialist Leonídio Ribeiro, and his work on epilepsy, published in 1934. He did not try to publish a textbook, like Henrique Roxo and other well-known psychiatrists of the time, whose books and successive updates remained 'mandatory' references for students and professionals in psychiatry.

Murillo de Campos also dedicated his efforts to the discussion on the subject of hygiene. From at least 1925, he was the head of the psychiatric clinic at the Central Army Hospital (Hospital Central do Exército) and wrote articles on "mental hygiene in the army," published in Arquivos Brasileiros de Higiene Mental in 1925 and on "military hygiene," in a book published in 1927. His interest in the subject was certainly in vogue in Brazilian psychiatry in the mid 1920s, with the establishment of the Brazilian League for Mental Hygiene (Liga Brasileira de Higiene Mental) in 1923 and the publication of its journal, the Arquivos Brasileiros de Higiene Mental. In 1925, the young psychiatrist contributed as secretary-general of the new board of this association, after the founder of the League, Gustavo Riedel (1887-1934), stepped down for health reasons (Piccinini, 2008).

Murillo de Campos was one of the group of psychiatrists who, in the beginning of the 1920s, promoted psychoanalysis as a therapeutic practice, publishing articles and teaching courses on it. According to Perestrello (1987), in May 1924, the Brazilian League for Mental Hygiene created a 'psychoanalytic clinic.' Some years later, in 1928, the inaugural class of the course on psychoanalysis applied to education, taught by Júlio Pires Porto-Carrero (1887-1937) referred to various individuals who "were in involved with psychoanalysis. In addition to the special mention of Juliano Moreira, Franco da Rocha, Antonio Austregésilo and Medeiros de Albuquerque, he cites Afrânio Peixoto, Genserico de Souza Pinto, Murillo de Campos, J. Martinho da Rocha, and Carneiro Ayrosa de Paula (in Rio de Janeiro)" (Perestrello, 1987, p.13). That same year, Murillo de Campos is said to have helped establish the Rio de Janeiro chapter of the Brazilian psychoanalysis association (p.25). The following year, with the authorization of Juliano Moreira and together with Carneiro Ayrosa, he also created a 'psychoanalytic clinic' in the Hospital for the Insane (p.13).

As with other psychiatrists of the era, Henrique Roxo and Murillo de Campos took part in the Brazilian Association for Neurology, Psychiatry and Forensic Medicine, a forum for debate and promotion of psychiatry in our context. The Association was the heir to the first Brazilian psychiatric institution, the Brazilian Association for Psychiatry, Neurology and Related Sciences (Sociedade Brasileira de Psiquiatria, Neurologia e Ciências Afins), founded in 1905 at the main offices of the National Medical Academy at the initiative of Juliano Moreira and Júlio Afrânio Peixoto (1876-1947), young physicians at the time (Amarante, 2001). Its journal was Arquivos Brasileiros de Psiquiatria, Neurologia e Ciências Afins (1905-1907), which was also the first Brazilian journal on psychiatry, and was printed in the Printing and Binding Offices of the National Asylum for the Insane where the majority of workers were patients. Initially, the Arquivos were quarterly and contributors included physicians and alienists such as Teixeira Brandão, Miguel Couto, Henrique Roxo, Carlos Penafiel, Franco da Rocha and Ulysses Vianna.

Two years later, the association was reestablished with the name Brazilian Association for Neurology, Psychiatry and Forensic Medicine, and its bylaws were prepared in 1907 by Afrânio Peixoto, Henrique Roxo and Carlos Eiras. Its official journal came to be called Arquivos Brasileiros de Psiquiatria, Neurologia e Medicina Legal. The journal was published from 1908 to 1918 and was also printed in the Printing and Binding Offices of the National Asylum for the Insane. It continued the numbering of the previous journal and stated that its founders were Juliano Moreira and Afrânio Peixoto. The editorial in the first issue of 1908 announced: "in its fourth year of existence, this journal will continue to be a natural part of good scientific relations between our alienists, neurologists and forensic medicine specialists and the rest of the world" (Editorial, 1908).

The creation of this psychiatric scientific association - and its journal - was part of an ongoing movement of ideas and actions at the end of the nineteenth century through the first two decades of the following century whose objective was to transform the sciences in Brazil.⁶ Psychiatry was part of this movement to make science a profession, and the Association played a fundamental role by defending the use of specialized language and methods, and encouraging scientific debate; becoming a member of a network of international conferences publishing news and sending representatives; promoting interaction with members of European associations; and publishing articles based on clinical research.

According to Amarante (2001), in 1919, cuts in public expenditures due to the high cost of paper and ink ac - a reflection of post-war shortages - affected the printing and binding of Arquivos, which continued to be produced by the Printing Offices of the National Asylum for the Insane. It was then that the journal's name changed again, to Arquivos Brasileiros de Neuriatria e Psiquiatria, and it began to be printed by a commercial printer, Besnard Frères, on Rua Buenos Aires in downtown Rio de Janeiro. This time, the numbering was not continued and 1919 was treated as Year I, but it continued quarterly publication.

The first issue of the new journal published the minutes of the 4th meeting of the Association, held on March 27, 1919, when it was decided that the physicians Juliano Moreira, Antônio Austregésilo and Ulysses Vianna would be chief editors, and Faustino Esposel, Heitor Pereira Carrilho and Waldemar de Almeida would be editors. Beginning with the issue published in the second quarter of 1919, Henrique Roxo also became one of the chief editors.

According to its bylaws published in 1919, the Brazilian Neurology, Psychiatry and Forensic Medicine Association had the same objective, that of promoting the institutionalization of psychiatry in Brazil, by committing to

support the development and progress of psychiatric specialties; survey the national contribution in specific specialties, promoting them in national and foreign scientific circles, study and publish psychiatric resources on the appearance and spreading of mental disorders; represent the interests of the insane in our country, in particular by addressing their medical and legal issues and influencing through all means available the perception of how best to assist them (Arquivos Brasileiros de Neuriatria..., 1919, p.57).

It was in this context - and through the intermediation of the scientific authority in which the aforementioned association printed its publication - that a well-known psychiatrist educated at the end of the nineteenth century and a young psychiatrist and physician, interested in psychoanalysis, began to debate the dementia praecox and schizophrenia categories.

Henrique Roxo's categories dementia praecox and schizophrenia

Roxo (1929) delineates an opposition between the two pathological concepts, first presenting Kraepelin's definition of dementia praecox and then discussing Bleurer's definition of schizophrenia. The text makes clear, from the start, his preference for Kraepelin's ideas, which he calls an "ingenious vision", compared to Bleuler's interpretation of schizophrenia, which he considered too generalizing. The opposition established between the definition of dementia praecox as a well-defined and circumscribed "clinical entity" and the concept of schizophrenia as a "pathological group" in which various other morbidity profiles could be included or with which other morbidity profiles could be confused, is a good synthesis of Henrique Roxo's opinion. And it was not by chance that the text was entitled "The current conception of dementia praecox." For the Brazilian psychiatrist, the appearance of the concept of schizophrenia did not imply a paradigm shift, since "Bleuler did not eliminate dementia praecox, but rather replaced it with schizophrenia, which was much broader" (p.70). For Roxo, it was as if there was a single nature, a pathological essence, which was better described by the nosological category dementia praecox.

When presenting his point of view, Roxo uses two analytic resources. First, he defines each of the diagnostic categories, describing their characteristics, sometimes called attributes. Then he shows the existence, in the international psychiatric context, of criticism of Bleuler's concept of schizophrenia, taking special note of the position of Professor Henri Claude⁷, presented in 1926 "at a conference of French alienists and neurologists at Lausanne" (Roxo, 1929, p.84). This second resource included the reflections of the Brazilian psychiatrist in the specialized debate then in vogue and supported the construction and legitimization of his authoritative discourse, in criticism on the meaning given to the concept of schizophrenia by Bleuler.

We note many similarities with respect to the characteristics established by Roxo (1929) for each of the diagnoses (see Table 1): hallucinations; inability to adapt to the social and family environment; the fact that the pathology does not always appear early nor result in memory loss, but rather manifests itself as a disturbance of will and affectivity. One of these characteristics, despite being common to both diagnoses, is related to in a complementary manner to the definition of schizophrenia. Thus, the attribute "inability to adapt to environment" serves to corroborate the idea that this diagnostic category represents a wide pathological group, since inability to adapt socially is common to many types of mental disturbances (p.81).

Two attributes, however, appear to differentiate dementia praecox from schizophrenia: that related to mental condition and that related to mood. In the first case, dementia praecox is characterized by a "mental deficit," and "weakening of intelligence," a loss of mental capacity that would appear at the start of the disease, even though the pathology might not occur in the first phases of the individual's life. Schizophrenia, on the other hand, would not entail lowering of mental capacity, but rather a disruptive event, a "mental disassociation."

With respect to affectivity, note that Roxo (1929) uses the two diagnostic categories interchangeably to discuss the controversy with respect to its loss (or not). Thus, he states that "the most impressive symptom of schizophrenia is affective dementia," and that "one of the most characteristic signs of the disease is the defect in the ability to modulate mood, a true affective rigidity" (p.82). Continuing in the context of the discussion on schizophrenia, the author notes that "in relation to affectivity, some claim that there is really a loss of affectivity in dementia praecox" and that "the complexes that represent a group of ideas strongly impregnated with an affective coefficient exert an irrefutable influence on dementia praecox" (p.82; emphasis added). Here Roxo treats the category of dementia praecox as a synonym for schizophrenia, if we consider, as we saw, that the idea of complexes was strongly associated with the concept of schizophrenia by Bleuler. This synonymy, rather than expressing an error or ambiguity, serves to confirm his position, favorable to the concept of dementia praecox over schizophrenia. Updated with the new nomenclature and the associated concepts (such as complexes), the psychiatrist defends the use of the dementia praecox category. Also, he maintains the more general idea of an unfavorable pathological evolution, with a fatal termination, in which the patiente's personality becomes increasingly affected, demented, in detriment to the defense of the idea of a psychological splitting of the patient that would not necessarily lead the individual to imbecility.

Furthermore, he defends the idea that schizophrenia, or dementia praecox, should not be seen as a mood disease due to an "affective anomaly", but rather as a pathology whose 'evolution' results in increasing affective disinterest, because the patient isolates himself in his 'interior castle' as if in a daydream, the only place where feelings remain. Thus, according to the author, what characterizes schizophrenia or dementia praecox is not an affectivity anomaly, but rather the lack of exercising affect, since it would just be a "question of lack of practical use, of a deficiency of pragmatic activity" (Roxo, 1929, p.82). This lack of pragmatism would thus lead to a global deterioration of the individual.

Other characteristics were presented as pertaining to each of the diagnostic categories in question. The disproportion and disconnection between feeling, thinking and will, to the extent that the integrity of the individual's entire personality is affected, was considered to be dementia praecox. Autism, on the other hand, was an important concept in the Bleulerian diagnostic scheme and, as Roxo (1929) demonstrated, it did not seem to correspond to the concepts previously associated with dementia praecox by Kraepelin.

Roxo's (1929) greater emphasis on the irreducibility of the pathological mental profile designated as dementia praecox is also reflected in his formulation with respect to schizophrenia. He then describes several characteristics stressed by Bleuler: "schizophrenia is an affliction with an organic basis that appears in a person predisposed to it due to a constitutional infirmity, with a considerable psychogenic superstructure, or in other words a general psychological disorder which includes even the instincts" (p.84). Even though Bleuler had affirmed the existence of an organic dimension to schizophrenia - even if not proven scientifically - the original aspect of his diagnostic methods was always the emphasis on the psychoaffective dimension of the morbidity profile, well described using the idea of complexes. In this context, Roxo identified the tension between the physical-organic and moral-psychological dimensions as critical for the definition of psychiatric diagnosis profiles. Guided by the idea of the existence of this dual dimension, his description of the schizophrenic pathology appears to defend the preponderance of organic factors, while still citing a psychological superstructure, and opposed to a greater definition of the infrastructure.

Murillo de Campos' categories dementia praecox and schizophrenia

Compared to the text by Henrique Roxo, Campos (1929) does not focus on Kraepelin's dementia praecox category. After a brief explanation, he simply stresses that the essential points of the category were exactly what were criticized: not all cases evolved into dementia; the disease could stop progressing at any stage in its evolution or even regress; and onset was not always early (p.156). With this description of dementia praecox, under the subtitle "Some historical data", the author abandons this diagnostic category, concentrating on what he felt was more essential: the debate regarding schizophrenia.

The denomination of schizophrenia types and the characteristics of this pathology, presented by Campos (1929), are the same as those mentioned in Roxo's text (1929). Hallucinations, autism, mental disassociation, affective dementia, and affective rigidity define the schizophrenic profile according to both authors. They differ, however, in the authority and legitimacy they confer on Bleuler and his description of schizophrenia. Roxo, although he mentions the division established by Bleuler between essential and accessory symptoms, did so in a summary paragraph, in the context of reporting criticism of the category created by the Swiss-German psychiatrist (p.86). In Campos' article, the division between fundamental and accessory symptoms structures the text, and the author's intention was to present the material in a way that almost literally follows the thinking of the Swiss scholar, as published in his principal works.

Using this analytic procedure - that most faithful to the 'master' - Murillo de Campos reports that he tried to prevent inappropriate judgments regarding the concept of schizophrenia, which Bleuler himself had noticed at the Conference of Alienists and Neurologists in France and Francophone countries, held at Geneva-Lausanne in August 1926: "When I read French articles on schizophrenia, I have the impression that I am a legendary person to whom words I never said and acts I never performed are attributed" (cited in Campos, 1929, p. 155).⁸ This was the same conference Henrique Roxo (1929) cites in his text as "a conference of French alienists and neurologists held in Lausanne" (p.84), then positioning himself in favor of the critics of Bleuler - criticism that Bleuler would probably have considered unfounded, since, according to Campos (1929), Bleuler did not agree with the version of his conception of schizophrenia presented by his French peers.

There was, thus, a controversy between Henrique Roxo and Murillo de Campos, who respectively opposed and defended Bleuler's ideas. As we saw, the fundamental question for Roxo was maintenance of a clinical perspective that could guarantee the well-delimited circumscription of a nosological entity that, though related to factors of a psychological nature, would maintain as a basis the physical-organic events that take over the patient and result in total intellectual weakening (even if not always early, quick or complete). He remained, thus, faithful to the organic perspective promoted by Kraepelin.

For Murillo de Campos, the schizophrenia category enabled understanding and discussion of the 'psychological' mechanisms so important to his interest in psychoanalysis. The description of these mechanisms in schizophrenia appears in Campos (1929) principally in the various discussions on the 'complexes.' For this author, the incoherent gestures, delirious ideas and psychosensorial disturbances common to autism would cover the 'complexes.'

With the intention of remaining faithful to the Swiss master, he then presents Bleuler's own definition for this concept: "a group of memories, representations or ideas, with strong affective meaning and without the ties that should bind them, in the normal state, to the individual psychological unit" (Campos, 1929, p.161). From then on, the complex category is added to explain that, as with schizophrenia, "in mental diseases the exteriorization of the complexes is principally through clinical symptoms", which always maintain a relationship of meaning with the complexes themselves (p.162). The complex appears as an explanation not only for the specific case of schizophrenia, but also for the relative difference between mental pathologies. Moreover, the set of complexes in a specific case form the "content of the psychosis", as if the symptoms, especially those considered accessory - stereotypy, mutism, etc. - were hiding the significant core of the complexes (p.163).

Despite his interest in the complexes and psychological mechanisms in schizophrenia, Campos (1929) also discussed the tension between the physical-organic and moral-psychological dimensions as critical for the definition of psychiatric diagnoses. As with Henrique Roxo, he discussed Bleuler's ideas on the organic origin of the schizophrenic profile in detail. According to him, the origin could be demonstrated by the anatomopathological lesions and by toxic phenomena, although the nature of the organic process that provoked them was still undiscovered. However, after affirming that Bleuler's hypothesis was that organic origins caused the fundamental symptoms and the accessory symptoms derived from them, Campos (1929) addresses the psychological dimension, mentioning the delirious ideas and sensorial and visual hallucinations, seriously questioning the possibility that a "constitutional disease" could predispose an individual to schizophrenia. This would include the functional psychoses, that is, those related to the functioning of the subject, for which an organic nature could not be fully proved.

Based, however, on what he considered the fundamental process in schizophrenia - a disassociation of psychological faculties - Campos refuted Professor Henri Claude's criticism of Bleuler with respect to the need to differentiate between different schizophrenias due to symptom variations. To this end, the Brazilian psychiatrist argues that both Kraepelin and Juliano Moreira did not support the division of the concept of schizophrenia, anchored in the degree of severity of the clinical profile, like H. Claude did - the latter defended by Henrique Roxo. This differentiation in relation to the seriousness of the clinical profile was the basis for Roxo's (1929) presentation on the therapies and prognoses for dementia praecox or schizophrenia. If it is a 'true' dementia praecox, with atrophy of brain cells, treatment serves no purpose: "If, however, it is schizophrenia, that is dementia praecox without an intelligence deficit, without brain cell atrophy and chronic inflammation lesions, much can be done" (p.90).

Campos' (1929) perspective on the subject of treatment is different. He argues that Kraepelin himself referred to the possibility of a cure for dementia praecox and that, "according to Bleulerian doctrine, it is important to stress that the cases of a 'cure' for dementia praecox are not so rare that its incurability should be established as a principle" (p.182). In the Bleulerian sense, Campos notes, they are principally 'social cures', i.e. the return of the patient to his social environment and his activities, instead of 'clinical cures', which would be concerned with the regression of the patients' constitutional characteristics. According to this Brazilian psychiatrist, replacing the dementia praecox category with schizophrenia could lead to reestablishing the idea that patients could be cured. In these cases, the author suggests psychological therapy, and discusses the forms and possibilities of this type of treatment.

Conclusios

The analysis presented here focused on how our actors - Henrique Roxo and Murillo de Campos - have been remembered and referenced in the medical-psychiatric field. In this way, we were able to situate the social actors based on the place they occupied and the specialized environment in which they worked, and through these symbolic locations, understand how they understood and disseminated the diagnostic categories dementia praecox and schizophrenia. These categories were understood and debated in the context of the reception of psychoanalysis in Brazil where, as in other national contexts, it entered the world of specialized knowledge through medicine, and was exclusively related to this area for several decades. The ideas of our actors, presented here, express the existence of a conflict between a more clear and unrestricted adhesion to Freudian psychoanalytic concepts and the defense and maintenance of a medical perspective more anchored in anatomopathological knowledge and less related to considerations on the psychodynamic character of mental pathologies.

Our first step was to verify that the description of the fundamental factors related to dementia praecox and schizophrenia were basically the same in the versions developed by Henrique Roxo and Murillo de Campos, as shown in the Tables. However, the way in which they value certain attributes to the detriment of others, and even their thoughts on the greater or lesser usefulness of therapy for the physical-moral disorders known as dementia praecox and schizophrenia, demonstrate their different perspectives on the value placed on one category or the other. Both psychiatrists agreed with the need to relativize the principally early-onset character of the dementia and its effect on memory, as well as affirm the existence of an organic origin for schizophrenia. However, at the same time we observed Henrique Roxo's clear deference to the Kraepelinian concept of dementia praecox, whereas Murillo de Campos stressed the pertinence of the concept of schizophrenia.

There seem to be two classificatory principles that govern this differentiation between the theoretical positions. The first is related to the greater or lesser dynamism of the pathological event, that is, the possibilities of symptomatological transformation or of the expression of certain fixed pathological characteristics. Based on this same principle, Henrique Roxo argued for adoption of a concept - dementia praecox - that very clearly reflected a well-defined and circumscribed 'clinical entity' whose characteristics led to full intellectual weakening (even if not always early, quick or global). Murillo de Campos, however, adhered to the idea of a mental pathology with a more fluid, dynamic character, not always expressed by an univocal evolution of symptoms. The second principle regards the greater or lesser attention to the physical-organic or moral-psychological dimensions to be paid in the analysis and treatment of mental pathologies. In relation to classification, as already mentioned, neither psychiatrist refuted the organic nature of dementia praecox and schizophrenia. However, while Murillo de Campos focused on the psychological aspects of schizophrenia - both to explain the pathological event and propose therapeutic measures - Henrique Roxo favored, in dementia praecox, the presentation of the organic events (generally cerebral) that affected the patient's intelligence, mood and will, in relation to which he arrived at a less favorable prognosis regarding treatment and cure.

What we observed is that both classification principles - dynamism or immutability of the pathological profile and differing attention to the organic or psychological dimensions of morbidity events - are combined in the task of making the circumscription of the mental pathologies intelligible. From the point of view of the two Brazilian psychiatrists, the greater dynamism of the pathological event appears associated with the predominance of an analysis of the psychological factors recognizable in the event. However, the presence of certain less mutable pathological characteristics in the texts of both authors is related to the emphasis by both on organic aspects.

Moreover, the preference for different terms included in these classificatory principles produced specific hierarchies: a greater emphasis on dynamism and attention to the psychological-moral dimension of the pathological event corresponded to less emphasis on the immutability of the symptoms, associated with an emphasis on the physical-organic dimension of the subject, and vice-versa. In the end, our two actors attributed different meanings to the difference related to mental illness. From a comparative viewpoint, Henrique Roxo had a static view of the disease, in which the physical-organic characteristics were more important in the identification of the pathological difference. Murillo de Campos, on the other hand, felt the dynamic characteristic of the schizophrenic morbidity was directly related to psychological aspects that, in his understanding, were more crucial in the definition of the difference referred to as mental illness.

NOTES

REFERENCES

• ABNP. Archivos Brasileiros de Neuriatria e Psychiatria Rio de Janeiro: Sociedade Brasileira de Neurologia, Psiquiatria e Medicina Legal, ano 1. 1919.
• AMARANTE, Paulo et al. (Coord.). Projeto Memória da Psiquiatria no Brasil: catálogo de periódicos não-correntes em psiquiatria da Biblioteca de Manguinhos. Rio de Janeiro: Fundação Oswaldo Cruz. CD-Rom. 2001.
• BERCHERIE, Paul. Os fundamentos da clínica: história e estrutura do saber psiquiátrico. Rio de Janeiro: Jorge Zahar. 1989.
• BERRIOS, German. Classificações em psiquiatria: uma história conceitual. Revista de Psiquiatria Clínica, São Paulo, v.35, n.3, p.113-127. 2008.
• BLEULER, Eugen. Dementia praecox or The group of schizophrenias New York: International Universities Press. 1911.
• CAMPOS, Murillo de. O grupo das esquizofrenias ou demência precoce. Archivos Brasileiros de Neuriatria e Psychiatria, Rio de Janeiro, n.3, p.155-188. 1929.
• DUARTE, Luiz Fernando Dias. Da vida nervosa nas classes trabalhadoras urbanas Rio de Janeiro: Jorge Zahar. 1986.
• DURKHEIM, Émile; MAUSS, Marcel. Algumas formas primitivas de classificação. In: Mauss, Marcel. Ensaios de sociologia São Paulo: Perspectiva. p.399-455. 1.ed., 1903. 1981.
• EDITORIAL. Archivos Brasileiros de Psychiatria, Neurologia e Medicina Legal, Rio de Janeiro, ano 4, n.1, 2. 1908.
• MCGUIRE, William (Org.). A correspondência completa de Sigmund Freud e Carl G. Jung 2. ed. rev. Rio de Janeiro: Imago. 1993.
• MENDONÇA, José Lorenzato de; COELHO, Ronaldo Simões; GUSMÃO, Sebastião Nataniel Silva. História da psiquiatria na Faculdade de Medicina da Universidade Federal de Minas Gerais (1911-1961). Revista Médica de Minas Gerais, Belo Horizonte, v.10, n.2, p.125-129. 2000.
• PERESTRELLO, Marialzira. História da Sociedade Brasileira de Psicanálise do Rio de Janeiro: suas origens e fundação. Rio de Janeiro: Imago. 1987.
• PICCININI, Walmor. História da psiquiatria. Gustavo Kohler Riedel (1887-1934). Psychiatry On Line Brazil, São Paulo, v.13, n.2. Disponível em: http://www.polbr.med.br/ano08/wal0208.php Acesso em: 27 out. 2009. 2008.
• ROXO, Henrique. Instituto de Psiquiatria. Anais do Instituto de Psiquiatria, Rio de Janeiro, v.1, p.3-11. 1942.
• ROXO, Henrique. Conceito atual da demência precoce. Arquivos Brasileiros de Neuriatria e Psychiatria, Rio de Janeiro, n.2, p.79-91. 1929.
• SÁ, Dominichi Miranda de. A ciência como profissão: médicos, bacharéis e cientistas no Brasil (1895-1935). Rio de Janeiro: Editora Fiocruz. 2006.
• SILVEIRA, Renato Diniz. Psicanálise e psiquiatria nos inícios do século XX: a apropriação do conceito de esquizofrenia no trabalho de Hermelino Lopes Rodrigues. Revista Latinoamericana de Psicopatologia Fundamental, São Paulo, v.12, n.3, p.582-596. 2009.
• VENANCIO, Ana Teresa Acatauassú. Ciência psiquiátrica e política assistencial: a criação do Instituto de Psiquiatria da Universidade do Brasil. História, Ciências, Saúde - Manguinhos, Rio de Janeiro, v.10, n.3, p.883-900. 2003.
• VENANCIO, Ana Teresa Acatauassú. O eu dividido moderno: uma análise antropológica da categoria esquizofrenia. Tese (Doutorado) - Programa de Pós-graduação em Antropologia Social, Museu Nacional, Universidade Federal do Rio de Janeiro, Rio de Janeiro. 1998.
• VENANCIO, Ana Teresa Acatauassú; CARVALHAL, Lázara. A classificação psiquiátrica de 1910: ciência e civilização para a sociedade brasileira. In: Jacó-Vilela, Ana Maria; Cerezzo, Antonio Carlos; Rodrigues, Helianade Barros Conde. (Org.). Clio-Psyché ontem: fazeres e dizeres psi na história do Brasil. Rio de Janeiro: Relume/Dumará. p.151-160. 2001.

¹

The goal of the use of the concept of physical-moral disorders was to "designate all alterations in the 'normal' state of a person as broadly as possible, in what is assumed to be a culturally defined manner" (Duarte, 1986, p.13). These are analytic categories used to group the states indicating that the person "does not get along with others", including not just "problems allocable solely to physical causes", but also "to others solely allocable to the generic action of major religious, cosmological or socioeconomic principles" (p.26, 27).

²

When Bleuler wrote about schizophrenia, psychoanalysis - as a Freudian theory based on the idea of the unconscious - already existed. This idea was in the seventh chapter of

The interpretation of dreams (1990), and in 1906 Freud had also already published

Studies on hysteria (1893,1895),

Psychopathology of everyday life (1901) and

Three essays on the theory of sexuality (1905).

³

Carl Gustav Jung, a Swiss psychiatrist, is recognized today as the founder of an analytic psychology in which the unconscious is the central concept. At that time, the start of the twentieth century, Jung communicated with the father of psychoanalysis and their letters (1906 - 1913) encouraged him to deepen his study of the unconscious. Their exchanges were also extremely rich for Freud, who adopted the basic idea of a complex, created by Jung.

⁴

The Observation Pavilion of the National Asylum for the Insane was created by Decree 1559 dated October 7, 1893. The same act also established an increase in the number of physicians at that institution, including an ophthalmologist and a health director. The Pavilion was to provide a preliminary assessment service for new patients, with the objective of admitting patients sent by public authorities due to suspected mental alienation for free care. It focused on the practical activities of clinical psychiatry and mental conditions of the Rio de Janeiro School of Medicine (Venancio, 2003, p.888).

⁵

On the controversial relationship between the psychiatric care provided by the National Asylum for the Insane, run by Juliano Moreira, and the relative autonomy of the Observation Pavilion, headed by Henrique Roxo, see Venancio, 2003.

⁶

On this topic, see Sá, 2006.

⁷

Henri Charles Jules Claude (1896-1945), a French psychiatrist and neurologist, was an assistant physician at the Hospital da Salpêtrière and, from 1922 to 1939, worked at the Hospital Sainte-Anne. He is considered an important actor in the introduction of Freudian psychoanalytic theories into French psychiatry, and created the first laboratory for psychotherapy and psychoanalysis at the University of Paris School of Medicine.

⁸

All quotations in this article have been freely translated from the

Publication Dates

• Publication in this collection
  22 Feb 2011
• Date of issue
  Dec 2010

History

• Accepted
  Aug 2010
• Received
  Dec 2009