C / Juan

Ignacio Luca

Francisco López-Muñoz

Gabriel Rubio

The neurobiological interpretation of the mental functions in the work of Santiago Ramón y Cajal

Keywords: history of medicine, hypnotism, mental functions, psychiatry, psychology, Santiago Ramón y Cajal, Sigmund Freud, sleep, Spain

Cajal fi rst had contact with the fi elds of psychiatry and psychology through the experimental study of hypnotism. He interpreted this phenomenon as an aberrant failure of the machinery of the brain. It may be that Cajal's initial interest in the theory of hypnotic suggestion eventually led him to study the biological phenomena related to sleep and dreams, in the neurophysiological explanation of which he disagreed openly with Freud's postulates. Finally, Cajal studied the histophysiological mechanisms of the higher mental functions (thought, intelligence, memory, perception, etc.). He proposed that the pyramidal cells of the cerebral cortex, which he called 'psychic cells', formed the substrate of these functions; he proposed the law of 'avalanche conduction', and he speculated on the possibility of a phenomenon of neuronal plasticity in relation to learning processes. After being awarded the Nobel Prize in 1906, Cajal's interests in psychological aspects began to decline.

Introduction

Santiago Ramón y Cajal ; Fig. 1) did his most intense scientifi c work around the turn of the nineteenth century, when psychiatry, under the The origin of this movement dated from the mesmerist theories of 'universal magnetic fl uid', which was extremely popular outside clinical circles in the Europe of the fi rst half of the nineteenth century. It entered the medical fi eld thanks to the study by the French school in Paris of the problematic condition of hysteria [START_REF] Gauld | A History of Hypnotism[END_REF]. The application of hypnotism to the study of hysterical paralysis by Jean-Martin Charcot (1825Charcot ( -1893) ) at the Salpêtrière hospital in Paris laid the foundations for the establishment of psychoanalysis and psychotherapeutic techniques [START_REF] Ellenberger | El descubrimiento del inconsciente[END_REF]. In addition to studying this unpleasant disorder using the semiological criteria that he systematically employed in other pathologies, Charcot decided to apply hypnotic techniques to the analysis of hysteria, describing his results to the Paris Academy of Sciences in 1882: Sur les divers états nerveux déterminés par l´hypnotisation chez les hystériques. He thus adopted the aetiopathogenic hypothesis of autosuggestion in the study of hysteria and gave scientifi c credibility to hypnosis as a diagnostic tool in psychiatry [START_REF] Diéguez | Breve historia de la psiquiatría[END_REF]. 1 Although some authors claim that Cajal's research preferences did not include the fi eld of psychiatry/psychology [START_REF] López-Ibor | Historia de la psicopatología en España[END_REF], this assertion requires some clarifi cation. It is true that publications , maintained the somatic character that had been consolidated over the last third of the nineteenth century. It was undoubtedly these scientific influences that assigned mental disorders to alterations in the anatomical substrate, and this led to the hypothesis that the mental processes governing everyday life (thought, consciousness, intelligence, imagination, memory, etc.) must also be located in a particular anatomical substrate. This approach to understanding the psyche and its disorders inevitably linked up with the morphological and neurobiological proposals put forward by Cajal.

However, the origins of Cajal's contacts with the psychiatric and psychological fi elds lie in a less organicist movement, and one less scientifi cally important, which at that time was sweeping all before it and which would be the source of the Freudian psychoanalytical trends: hypnotism.

by Cajal dealing specifi cally with this fi eld amount to no more than 1.7% of his global scientifi c output, according to a bibliometric study carried out by our group [START_REF] López-Muñoz | Aproximación a la producción científi ca de Cajal desde una perspectiva bibliométrica[END_REF] on a total sample of 353 scientifi c publications. There are only six publications specifi cally on this subject -or nine if we include the international versions of some of these works, mainly published in German journals, and other texts of a histological nature in which the author dedicates special sections to the topics covered in the present study, such as that of the Croonian Lecture (1894a, 1894b; see Appendix A). To this output, we should add three manuscripts, fi nished before Cajal's death but not published, and subsequently lost during the Spanish Civil War [START_REF] Durán | Cajal. Escritos inéditos[END_REF]) (Appendix B), and, also on psychiatric/ psychological subjects, four forewords to books (Appendix C). This complete body of works shows that Cajal's interest in psychiatric and/or psychological topics was neither scant nor trivial. Indeed, his written output in this fi eld is even greater than that of some of the most prestigious Spanish clinical doctors of the period, and it has been claimed that 'it is not that Cajal could have been and eminent psychologist -he actually was one' (Elguero, 2004: 16).

In what follows, we shall analyse this scientifi c output, generated mainly in the period 1890-1910, which we have broken down into three main groups: the experimental study of hypnotism; the hypothetical proposals on the mechanisms of sleep; and the study of the histophysiological mechanisms of higher mental processes. In this regard, it may be that Cajal's initial interest in hypnotic suggestion led him, over time, to the study of biological phenomena related to sleep and dreams, and fi nally to the attempt to attribute a histological explanation of a biomechanical and physiological nature to the higher mental functions, such as memory, perception and thought itself.

Phenomenon of hypnotic suggestion: Cajal's fi rst approach to the study of brain functionalism

Psychiatric movements linked to the use of hypnotism rapidly became popular in Spain [START_REF] González | El hipnotismo en España durante el siglo XIX: una visión histórica a través de sus protagonistas[END_REF]. During his period as Professor of Anatomy in Valencia (1883-87), Cajal carried out scientifi c research on an area of morbid psychology, which he referred to as the phenomena of suggestion and artifi cial somnambulism. It was precisely at this time that hypnotism reached its scientifi c peak, thanks largely to the controversial scientific confrontation that began in 1883 between two French groups: the Charcot school at the Salpêtrière hospital in Paris and the group led by Hippolyte-Marie Bernheim (1837Bernheim ( -1919) ) and Ambroise Auguste Liébault at the University of Nancy. While the followers of Charcot saw hypnotism as a type of 'induced neurosis' which might serve as an experimental model for the study of hysteria, the disciples of Bernheim and Liébault went back to Braidist principles, attaching greater importance to the phenomenon of suggestion (and its therapeutic application) than to that of hypnotism itself [START_REF] Diéguez | Sobre la introducción del hipnotismo en España: la recepción de los planteamientos de las escuelas francesas[END_REF][START_REF] Gauld | A History of Hypnotism[END_REF].

In his own experiments with hypnosis, Cajal favoured Bernheim's psychotherapeutic conception [START_REF] Timoner | La psicología sugestiva en Ramón y Cajal[END_REF][START_REF] Youssef | Ramón y Cajal and hypnosis[END_REF] rather than the specifi c experimental focus of the Charcotian trend, 2 even though he had previously stated that 'we should note that despite three centuries of positive science, the attraction of the magical still runs deep in the human spirit' (Cajal, 1923: 192). Concerning Cajal's initial reservations, we have to bear in mind that during the second half of the nineteenth century the supporters of hypnotism as a scientifi c medical discipline had to face a considerable number of detractors (including the Catholic Church), who associated it with the popular charlatanism, spiritism and other phenomena of occultism and demonology [START_REF] Albarracín | Intrusos, charlatanes, secretistas y curanderos[END_REF]. Nevertheless, interest in these metapsychic areas became consolidated, from the point of view of systematic scientifi c study, around many important scientifi c fi gures of the era, including Cajal. 3 Youssef [START_REF] Youssef | Ramón y Cajal and hypnosis[END_REF] suggest that it may have been the psychiatrist Luis Simarro (1851Simarro ( -1921) ) who introduced Cajal to hypnotic techniques. After 7 years of training in Paris, Simarro settled in Madrid in 1887, the year after Bernheim published his famous work De la suggestion et de ses applications à la thérapeutique (1886). In the same year, Cajal was assigned to the Professorial Appointments Committee for Descriptive Anatomy, and he had to move to Madrid. This enabled him to visit a variety of institutions carrying out micrographic research, including a private laboratory run by Simarro and devoted to the histopathological study of disorders of the nervous system where the psychiatrist was applying all the latest techniques developed abroad. 4 It has been suggested by [START_REF] Youssef | Ramón y Cajal and hypnosis[END_REF] that during this visit Simarro may have brought his colleague up to date with the latest French approaches to hypnosis.

Cajal felt that some manifestations of 'this new science, the direct heir of medieval sorcery' corresponded to anomalies of brain dynamics (Cajal, 1923: 192). Based on this notion, he set about a methodical scientifi c analysis, and to this end he founded, together with some colleagues from the Agricultural Club discussion circle, a Committee for Psychological Research, 5 with its headquarters in his own home: 'My home was witness to a procession of strange kinds of hysterics, neurasthenics, maniacs and even accredited spiritual mediums ' (p. 193).

Among the studies, Cajal highlights the experiments in hypnosis carried out on healthy subjects (physicians and lawyers, among other volunteers) and, above all, its therapeutic application. Among the achievements in terms of therapy, several stand out: the radical transformation in the emotional state of the patients (an almost instantaneous change from sadness to joy); the restoration of appetite in extremely emaciated hysteroepileptics; the cure, through simply giving an order, of a range of chronic paralyses of an hysterical nature; the sudden cessation of attacks of hysteria with loss of consciousness; the eradication of memories of painful and harrowing events; the complete removal of labour pains in healthy women; indeed, surgical anaesthesia, etc. (p. 193) He wrote a scientifi c article, Dolores de parto considerablemente atenuados por la sugestión hipnótica, which was published during his time in Barcelona (Cajal, 1889). Durán and Alonso (1960) have suggested that the subject of this article was his own wife, Silveria Fañanás, and that Cajal put his experience in hypnosis into practice to reduce the pain during the birth of their sixth child. 6 The method used was as follows: during the last ten days before birth, hypnotic suggestion was practised with the patient, with messages referring to a speedy birth with light and easily bearable pains, despite 'awareness of the stronger pains'. As to the success of the venture, Cajal remarks that: two phenomena attracted our attention: the extreme rapidity of the birth and the considerable reduction of the pain, the subjective manifestation of the contractions … We can consider the second phenomenon, absence of pain, as being truly brought about by hypnotism. (Cajal, 1889: 486) This was possibly the fi rst time that the use of hypnotism in reducing labour pain had been documented in a scientifi c publication. 7 Nevertheless, [START_REF] Youssef | Ramón y Cajal and hypnosis[END_REF] confi rm that Cajal's contribution to the therapeutic application of hypnotism made no scientifi c impression whatsoever, since the journal in which it was published (Gaceta Médica Catalana) was not distributed internationally, and his discovery was not mentioned by any signifi cant author in this fi eld in subsequent reviews, in relation to either hypnosis (Bernheim in his successive studies, Pierre Janet, Morton Prince, Luis Wolberg, Milton Ericson), or gynaecology (Joseph DeLee).

Once all the data of scientifi c interest to Cajal had been collected, the Committee for Psychological Research was wound up. The number of case reports collected by Cajal and his Committee on hypnosis and suggestion in wakeful states, among volunteers as well as mental and somatic patients, was very large. Nevertheless, Cajal never managed to publish the data generated by this research, although they may have formed part of a manuscript entitled Ensayos sobre el hipnotismo, el espiritismo y la metapsíquica (Essays on hypnotism, spiritism and metapsychic). From his correspondence with the publisher Ramón Pueyo, it appears that Cajal would have had these essays printed if he had not died before it could be done. By great misfortune, the unpublished originals were subsequently lost during the course of the Spanish Civil War.

The great attraction of this 'new science' for Cajal doubtless derives from its close links with the study of the brain. Thus, not only did he concern himself with gathering extensive case records of his own, but he also studied the fi ndings of many foreign researchers. From his perspective, hypnotic suggestion was an aberrant failure of an almost perfect machine, the brain. As a conclusion to this research activity, Cajal admitted that: the experiments in suggestion caused me both amazement and disillusionment: amazement to see the reality of phenomena of cerebral automatism that had previously been considered as nothing more than the theatrical trickery of circus mesmerizers; and painful disappointment to see that the highly esteemed human brain, the masterpiece of creation, suffers from the enormous defect of suggestibility. (Cajal, 1923: 194) However, despite closing down the Committee, Cajal's experiments and interest in hypnosis lasted for the rest of his life, and he even returned to these techniques during his Madrid period.

Cajal and the analysis of neurobiological mechanisms in higher mental processes

Cajal maintained his interest in formulating psychological hypotheses to explain the workings of the mind throughout his life. On the subject of his interest in psychological fi elds, he wrote in his memoirs, Recuerdos de mi vida: 'The problem attracted us irresistibly. We realized the crucial importance, for the construction of a rational psychology, of precise knowledge of the brain's texture' (Cajal, 1923: 189); and he concluded that 'knowledge of the brain means knowledge of the material channels of thought and volition' (p. 189). Elsewhere in the same book he says: in the fashion of the entomologist hunting for butterfl ies with magnifi cent colours, my attention, in the orchard of the grey matter, was drawn to delicate and elegant cells, the mysterious butterfl ies of the soul, the beating of whose wings might one day, who knows, reveal the secret of mental life. (p. 222; original italics)

On the anatomical location of the higher mental functions Cajal's fi rst approaches to the study of the histological mechanisms of the mental functions took place during his time as Professor of Normal Histology and Pathological Anatomy at the University of Barcelona (1887-92). Towards the end of this period, he gave a series of lectures at the Academy and Laboratory of Medical Sciences of Catalonia, which were later published as El nuevo concepto de la histología de los centros nerviosos (Cajal, 1892). 8 In this work, Cajal refers to a topic hotly debated around the turn of the century, and one that linked up with the reductionist ideas in science: the anatomical (or histological in this case) location of the higher mental functions. For Cajal and for many other neuroscientists [START_REF] Køppe | The psychology of the neuron: Freud, Cajal and Golgi[END_REF], from the purely mechanistic standpoint, the appropriate place to locate these functions is the cerebral cortex, so that each individual cell in the peripheral nervous system would have a specifi c representation in a cortical cell. Likewise, in the same publication Cajal (1892) proposes the pyramidal cells of the cerebral cortex as the ideal candidates for forming the substrate of the higher mental functions (thought, perception, The arrows on the fi gure show the direction of the nervous impulse arriving at the cerebral cortex from the afferent fi bres of the white matter (G), passing fi rst to the apical dendrites of the pyramidal cells, and then through the connections between cells via the horizontal collaterals of these pyramidal cells, which he called 'psychic cells' (source: Cajal, 1894a: 462)

annually on a biological topic by a prestigious researcher responsible for some relevant discovery. In his lecture, delivered on 18 March 1894, Cajal also referred to the physiopsychological interpretations of his histological discoveries, possibly at the suggestion of his friend and colleague Albrecht von Kölliker (1817Kölliker ( -1905)), Professor of Anatomy at the University of Würzburg, who alerted him to the particular interest of British scientists in the physiology of the nervous system [START_REF] Jones | Santiago Ramón y Cajal and the Croonian Lecture[END_REF]. In his speech, which was published in both French and Spanish, Cajal (1894a, 1894b) speculates on the possibility of a phenomenon of neuronal plasticity in the cerebral cortex, and relates it to the process of learning and the development of intellectual and artistic abilities and so on. The basis of his hypotheses was the increase in the number of connections between the neurons of the cerebral cortex ('differentiation and abundance of the protoplasmic processes and quantity of collateral and terminal nervous branches ';Cajal, 1984b: 159). These are the pyramidal cells, which he again refers to as 'psychic cells' (Fig. 2) because of their fundamental role in the integrative circuits of the cerebral cortex, through so-called 'cerebral gymnastics', in other words, mental exercise. Cajal himself recognized that: memory). Indeed, he considers them among the most important structures of the human nervous system, and refers to them as 'psychic cells'. 9

Psychological interpretations of the histological fi ndings: the law of avalanche conduction and the inference of the neuronal plasticity phenomenon In 1894 Cajal was invited by Sir Michael Foster , secretary of the Royal Society of London, to deliver the Croonian Lecture, 10 a lecture given this anatomic-physiological hypothesis is not in principle original, since there are plenty of physiologists and psychologists who have sought the somatic characteristic of intelligence in the richness of cellular associations, but what is new is that it is founded on positive facts of structure, rather than on pure suppositions about functionalism and relationships between nerve corpuscles. (p. 159) But despite his quite visionary thesis, the conclusion of the Croonian Lecture seems rather speculative for a person as prudent as Cajal: '… it is quite probable that … the pyramidal cells have an entirely particular intraprotoplasmic structure, perfected in superior intelligences, a structure that would not exist in the corpuscles of the spinal cord or the ganglia' (p.160).

Both in this and in subsequent works, Cajal (1894a, 1895a) describes, in support of his hypothesis, how animals lower down the phylogenetic scale lack the giant pyramidal cells typical of the higher animals, and how the connections are made only between neighbouring cells, while in the more evolved animals the connections run into thousands, and contact is made with neurons located in different regions, linking the cortex with the spinal cord. However, in contrast to the narrower reductionist postulates, Cajal (1895a: 497-9) proposed his law of 'avalanche conduction' or 'nervous avalanche', whereby: all peripheral impressions, registered by the (sensitive or sensory) protoplasmic arborization of a single cell, would propagate in an avalanche towards the centres … in other words, the number of neurons involved in the conduction grows progressively from the periphery towards the brain, in whose circumvolutions (tertiary sensory foci) resides the base of the conductive cone.

Thus, sensory impressions, for example, would constitute basic units or 'impression units' that would be registered in individual cortical cells, even though the sensory impressions would be registered by hundreds of cells and hundreds of times -cells which, moreover, would make hundreds of cortical connections. According to Cajal, one impression unit would be a 'simple movement registered, during sensory impression, by a single retinal cone or rod or by a ciliated cell of the cochlea' (p. 499).

These new Cajalian perspectives were closer to the psychological trend of associationism. Indeed, Cajal's neuronal theory provided a bridge between associationists and localizationists, especially when Cajal asserted that the 'impression unit' is stored in a neuron: 'we consider it likely that each group of pyramids, connected automatically to a sensory cell, conserves in a latent state various images, or rather, the impression units which that cell transmitted to it at various times' (p. 499; original italics). Thus, the sequence is clear: one unit, one neuron and each neuron connected to others so as to generate ideas by means of 'association fi bers' [START_REF] Køppe | The psychology of the neuron: Freud, Cajal and Golgi[END_REF]. This Cajalian relationship between neuron theory and the associationist postulates had a decisive infl uence on numerous scientists at the time, including Sigmund Freud (1856Freud ( -1939) ) who in 1895 began work on a text that would eventually be published in 1950, entitled Entwurf einer Psychologie (Fig. 3). Freud supports the same ideas as Cajal on this subject, contributing the concepts of nervous energy (Cajal's 'impression units') and contact barrier (a kind of early, speculative approximation to the concept of synapse). With these two elements, Freud attempts to explain the phenomenon of memory as a gradual destruction of this barrier after successive nervous impulses, the resistance to subsequent sensory impressions decreasing with each new impulse ('memory traces'). However, as [START_REF] Køppe | The psychology of the neuron: Freud, Cajal and Golgi[END_REF] points out, Freud took a long time to position himself behind Cajal's neuron theory, and until 1895 supported the dynamic theory of representation, based on the reticularist perspectives of Camillo Golgi (1843Golgi ( -1926) ) and Joseph von Gerlach (1820-96): peripheral sensory impressions would be transmitted to the spinal cord but would not be stored, but rather represented 'as the alphabet exists in a poem' (Køppe, 1983: 9), being combined in units of higher category and interpreted in the cortex, not independently, but as combinations.

On the channels of consciousness

In 1896 Cajal published a scientifi c work devoted specifi cally to this psychophysiological fi eld entitled Interpretaciones conjeturales sobre algunos puntos de histo-fi siología neurológica. He remarks that his discoveries on the histological structure of nerve centres (and those of other European histologists) had begun to be taken into account by psychologists 'with a view to throwing light on the mechanism of mental acts' (Cajal, 1896: 381). With regard to the question of why spinal cord cells produce movement and brain cells produce ideas, Cajal here supports the polyzoism hypothesis of Joseph Pierre Durand de Gros , according to which each nerve cell, regardless of its location, would be capable of refl ecting a part of the stimulation coming from the outside world. 'The nervous system would consist, then, of innumerable consciousnesses, as many as there are cells', though there would be 'a cerebral one, superior, and with autocracy over all the rest' (p. 388). Thus, 'what we would call the self, or the person, would be none other than the cerebral consciousness, which is ignorant of -as it is exterior to -the conscious self of all the subordinate ganglionic individualities' (pp. 388-9; original italics). Cajal's passion for these topics was so great in the 1890s that when he became a member of Spain's Royal Academy of Medicine in 1898 he considered giving his inaugural lecture on 'The physiologic-psychological inductions deriving from recent histological research'. Fortunately, he changed his mind as he thought the subject matter 'incomplete and premature', and opted for a purely histological topic [START_REF] Valenciano | Cajal (recuerdos y refl exiones de uno de sus últimos alumnos)[END_REF]. 11 The text of this fi rst proposition was never published, and is now considered lost. Likewise, in the fi rst Spanish edition of his major work, Textura del sistema nervioso del hombre y de los vertebrados (1898)(1899)(1900)(1901)(1902)(1903)(1904), he includes a brief chapter of a physiological nature on refl ections about the mechanisms of thought, of consciousness, of sleep, and so on, a chapter he omitted from the French version, Histologie du système nerveux de l'homme et des vertebrés (1904,1909), which is much more widely known internationally [START_REF] Del Pino | Cajal y la sociología de la ciencia en España[END_REF].

Summary: the dynamic factors of the substratum of the spirit

After some years in which he did not address the problem of the neurobiological mechanisms of mental processes, Cajal returned to the subject in the foreword dated 22 April 1904 to a book, Introducción al Estudio de la Psicología Positiva (see Appendix C) by Tomás Maestre Pérez (1857-1936), Professor of Legal Medicine at the Faculty of Medicine in Madrid. In this text, Cajal associates greater intellectual development with the richness and quality of the neuronal associations in the brain. However, he hypothesizes on the intimate biological location (the 'material substrate') of the 'dynamic factor … whose mission is to stimulate and sustain the combustion in the furnace of thought so as to forge … higher concepts.' (Cajal, 1905: iii). The cellular source of this mysterious principle ('be it called soul, will, activity, energy or whatever'; p. iii) would lie, according to Cajal, in one of the two types of cells in the cerebral cortex, that is, 'the pyramids or long-axon cells, and the short-axon corpuscles' (p. iii). It would be the cerebral pyramids through which 'the train of thought runs', but the short-axon corpuscles (much more developed in the human brain than in that of lower animals) may also house part of this dynamic factor, insofar as their dendrites receive information from the associative and sensory pathways and transmit it to the long-axon neurons. These latter cells would act as 'energy condensers', which would lead, depending in the circumstances, to the principal pathways (Cajal, 1905).

Cajal also mentions here, as he did in his Croonian Lecture, the importance of proper upbringing and education and of external infl uences for the process of intellectual development: interneural association, despite its hereditary nature, is liable to be infl uenced and disturbed in childhood and adolescence by education and habit; thus, it frequently occurs that a brain capable of attaining sophisticated organization is transformed into a mediocre organ due to the fact that such infl uences … suspend or moderate the growth of the conductors responsible for logical association … It is sad to see how these wretched slaves of the brain, shackled to tradition and routine by the subtle bonds of nervous fi bre -a chain more effective than that of a convict since they wear it in their souls without perceiving it -ingenuously take liberty for justice, suggestion for truth; faith for reason; goodness for talent … (Cajal, 1905: iii) In spite of making such conjectures, Cajal is aware of the limitations for reliably clarifying these intimate mechanisms of mental processes, as well as the 'substratum of the spirit'; he writes: all the efforts of brain histology to plough the land, to discover paths, to scour the darkest corners of the virgin neuronal jungle, will be in vain unless physiology can reveal to us the nature of the nervous wave, and the transformations it undergoes to generate the phenomena of memory, of impulsion and of awareness; unless it can explain to us how each sensation, each idea, each act of volition, apart from its representative content, impregnates the self with a specifi c emotional aura. (p. iv; original italics)

And continues:

As things stand today, it cannot be denied that objective psychology or mental histology or the nascent science, whose purpose is to subordinate the series of mental acts refl ected in consciousness to a parallel series of physico-mental phenomena effected by cells, is still largely reduced to the quite primitive and speculative method of the physiological interpretation of the anatomical evidence … the cerebral physiology of understanding and volition continues to constitute the great enigma … The most important processes, namely, memory, association, awareness, logical operations, imagination, the entire emotional sphere -indeed, all the most intimate and crucial aspects of mental life -stay in the background. (pp. iv-v) Even so, Cajal's optimistic scientifi c spirit reappears at the end of the foreword: But let us not despair. The task is a long one but the future of mankind is longer still. The abyss is a deep one, but to bridge it there are innumerable generations of wise scholars … Let us trust in the resources of that admirable human brain which struggles to understand itself. In time, it shall become, because it has a will to do so, its own master and its own architect. (p. vi)

Cajal and theories on sleep: the antithesis of Freud

Cajal's interest in investigating the neurobiological mechanisms of sleep and dreams may constitute, as mentioned above, a projection of his research on hypnotism. In 1908 he published a paper on theories of dreams, Las teorías sobre el ensueño, 12 which begins: 'Dreaming is one of the most interesting and most wondrous phenomena of brain physiology' (Cajal, 1908: 87). After a brief summary of the contributions from the most prestigious 'essayists in this fi eld' (Marie de Manaceine, Henri Bergson, Alfred Maury, Yves Delage), Cajal focuses on the perceptions and visual hallucinations of dreams, using self-explorations (of which he says he has analysed thousands) obtained after autosuggestion the previous day. With regard to methodology, he argues that '… given that when we dream, memory and voluntary activity are annulled or severely weakened' (p. 90), for the study of these phenomena it is necessary to concentrate on a phase of sleep 'during which the analytical self overcomes the dream, scrutinizing it and judging it' (p. 91; original italics) -that is, the phase just before waking. In order to analyse these visual images he proposes a kind of training (creation of a habit) by means of vigorous autosuggestion just before sleep. Although he admits that the success of this procedure is quite variable (once or twice out of a hundred, improvable with self-training), 'the exploratory programme is to carry out, enabling the study, during the fi nal phase of dreams, of some of their principal attributes. ' (pp. 91-92). Cajal calls this procedure 'the introspective method'.

Cajal gives examples of self-analysis of his dreams of the type 'I found myself in the middle of a dense forest', 'I dream that I'm walking along a street in Madrid', 'we dream that we are examining a book ' (p. 92-96), dealing with the study of the colour, the perspective and the relief of the images in the dream, as well as the eye and head movements. His conclusions on self-experimentation through this method of introspection are as follows: (a) the visual hallucinations of dreams have the same relief as the sensations themselves; (b) the colour of visual hallucination can attain the same richness of tone as external reality; (c) the form of the mental projection undergoes great fl uctuations during sleep; (d) the visual fi eld of the dream is fi xed, not varying in relation to eye or head movements; (e) the brilliance of the colours disappears before waking, fading to greyish tones; and (f) the visualized objects may correspond not to real events, but rather to a heterogeneous mixture of many real sensory memories (Cajal, 1908).

Concentrating in particular on the anatomical 'substractum' [sic] of these phenomena, Cajal asks himself: 'Do they arise in the associative, higher or projective centres?, Are the retina and the optic nerve involved?' (p. 90). His analyses of introspection eventually led him to decide that there was no retinal substrate. The defi nitive evidence came from experiments with 'people who went blind as adults; those who could populate their memory in the early years of their life with pictures dream with optical images, despite lacking both retina and optic nerve.' (p. 97).

Although he mentions setting out the neurophysiological theories on these phenomena ('as we shall see later', he writes), it appears that these explanations were to be given in a publication that never actually saw the light of day -the 1908 paper concludes: 'to be continued'; see Appendix B.

In addition to this paper and its proposed continuation, Cajal seems to have intended to publish a book on 'sleep and the phenomena of dreaming', but he never did so, despite the numerous data recorded in a manuscript that was also lost during the Civil War. Nevertheless, some of his ideas on the subject were preserved thanks to the 1908 paper, his correspondence and, above all, an interesting foreword he dedicated to a work of poetry by the writer Marcos Zapata , even though it was published six years earlier, in 1902 (Appendix C). In this letter-foreword, Cajal attempts to provide a neuro-physiopsychological explanation of dreams:

Everyone will have noticed that when we sleep, the ideas and events in the special world that unfolds before us are usually (and there are exceptions that if we think about it actually prove the rule) totally unconnected with the thoughts that preoccupy us and with our everyday tasks and demands. If we analyse dreams carefully, we see that they often involve scenes from our childhood or youth, rarely remembered, or capriciously fragmented and absurdly combined images, whose sensory elements and residues have not been refreshed for a long time, so that they remain outside the fi eld of consciousness … We can deduce from this that when we sleep we do not rest completely, but rather that part of the brain that became weary while we were awake; the fallow lands of the brain, that is, the cells in which unconscious images are recorded, stay awake and become excited, rejuvenating themselves with the exercise they did behind the back of the conscious mind … Through such gymnastics, these extraordinary contingents, a kind of reserve of ideas, attain the condition for rapid mobilization when the various demands of wakeful work and the unforeseen exigencies of fi ght require them. And since many daytime brain operations activate and tire out groups of cells scattered throughout the brain, especially those responsible for the highest of mental activities, that is, the critical faculty, constantly alert to the acts of speaking and listening, the majority of dreams consist of scraps of ideas, unconnected or weirdly assembled, somewhat like an absurd monster without proportions, harmony or reason. (Cajal, 1902;reproduced in Durán and Alonso, 1960: 164-5) Cajal was in the habit of noting down the content and course of both his own dreams and those of other people, in an effort to interpret their meaning. He also studied the different theories on the matter, so fashionable at the time, and especially the ideas of Sigmund Freud, with which he disagreed openly, although his way of expressing this disagreement was at times perhaps somewhat superfi cial or trivial for an eminent scientist. Indeed, in a letter to his friend Gregorio Marañón (1887Marañón ( -1960)), Cajal writes, in relation to Freud's approach to dreams: … I consider as collective lies both psychoanalysis and Freud's theory of dreams; nearly all the fi ndings of the wise Viennese scholar can be explained by individual or collective suggestion. Of this I shall speak if I manage to live long enough to write another book on dreams, in which I summarize thousands of self-observations contradicting Freud's theory. (Durán and Alonso, 1960: 165; see also [START_REF] Elguero | Metodología de la investigación: los ejemplos de Freud y de Cajal (Discurso de Recepción como Académico de Número)[END_REF] Moreover, in another letter, 13 he returns to the matter: I fi nd I must refer to Freud and criticize some of his more daring assertions. Why, in more than fi ve hundred dreams I have analysed (without counting those of people I know), is it impossible to verify, except in extremely rare cases, the doctrines of the surly and somewhat egotistical Viennese author, who has always seemed to me more preoccupied with the idea of founding a sensational theory than with the desire to serve austerely the cause of scientifi c theory. (Durán and Alonso, 1960: 165-6) Apart from the letters, Durán and Alonso (1960) also reproduced some notes Cajal wrote on the pages of Freud's books in his library, for example: '… the interpretation is so subtle (in the forgetting of verses, words and phrases) that it is impossible to believe the author' (p. 166). Even in his fi nal memoirs, El mundo visto a los ochenta años, published in 1934, the year of his death, Cajal continued to express his disagreement with Freud on this issue. We agree with the opinion of [START_REF] Ibarz | La psicología en la obra de Santiago Ramón y Cajal (Zaragoza: Institución 'Fernando El Católico[END_REF] and [START_REF] Elguero | Metodología de la investigación: los ejemplos de Freud y de Cajal (Discurso de Recepción como Académico de Número)[END_REF] who argue that these differences between the two scientists in the interpretation of sleep-related phenomena were nothing more than the extension of their methodological approaches: a purely physical interpretation in the case of Cajal and a mental one in the case of Freud. Moreover, with the passage of time, and as Freud became a widely recognized fi gure in the fi eld of psychiatry, Cajal would never succeed in understanding his innovative theories. Despite Cajal's great interest in discovering the intimate neurohistological mechanisms of dreams, the task must have seemed to him an impossible one. This emerges from the remarks he made in a letter to his friend and disciple, the Augustine priest Zacarías Martínez Núñez (1864-1933): 14 it would not be of much interest to you what histologists imagine to give a physio-chemical or cytological explanation to sleep. The fact is that nobody is really sure about the matter... Truly, the nervous machinery is so complex, and its delicate anatomy still conceals so many mysteries, that just now it would be quite rash to attribute sleep to a known histological factor, when it may well be that some other, unknown aspect is involved … (Durán and Alonso, 1960: 164) From enthusiasm to self-criticism: Cajal's period of refl ection on his psychological theories In 1906 Cajal was awarded the Nobel prize for his histological work, so he may have decided to concentrate his research on this fi eld to the detriment of all others (such as psychology). Perhaps, too, his interest in psychological matters also began to decline because, in contrast to the reliable facts verifi ed in his morphological publications, his psychophysiological postulates always remained in the realm of conjecture and speculative hypotheses. It was for this reason that he embarked on a period of self-criticism in relation to this aspect of his previous scientifi c activity, which may indeed have contributed to the fact that his work in the fi eld of psychology has gone largely unnoticed and ignored until recently [START_REF] Elguero | Metodología de la investigación: los ejemplos de Freud y de Cajal (Discurso de Recepción como Académico de Número)[END_REF][START_REF] Ibarz | La psicología en la obra de Santiago Ramón y Cajal (Zaragoza: Institución 'Fernando El Católico[END_REF].

In this regard, it can also be noted that Cajal even felt the need to withdraw the neurobiological account of mentation that he had developed earlier in his career. In 1895 he had published his paper, Algunas conjeturas sobre el mecanismo anatómico de la ideación, asociación y atención (also published in German; see Appendix A), and some of his conclusions have already been discussed above. He set out to explain the intimate mechanism of certain mental acts -such as attention, association of ideas, sleep and wakefulness -through morphological changes in the neuroglial cells of the grey matter, which would act as an electrical commutator of the nervous currents. According to Cajal (1895: 506):

during the state of relaxation, the neuroglial appendices … would penetrate between the nervous arborizations and the cells or their protoplasmic appendices, as a result of which the passage of the currents would become suspended or severely hindered. This explains mental repose and sleep, be it natural or induced (by narcotics or by hypnotism) … During the state of contraction, the pseudopods would contract, absorbing, as it were, the protoplasm of the secondary appendices, so that previously separated cells and nerve arborizations came into contact. Via this mechanism the brain would pass from a state of repose to one of activity.

Likewise, implicating the perivascular neuroglia, he develops a theory of attention:

Under the infl uence of the will, the fi xed pseudopods in the capillaries of a more or less considerable group of perivascular neuroglial cells would contract, and the capillary, stretched in all directions towards the adjacent grey matter, would increase its diameter and occupy nearly all the lymphatic cavity surrounding it. This would permit congestions of the grey matter as precise and restricted as required by the monoideism of attention. (pp. 507-8; original italics) However, nearly 30 years later, he wrote that 'in all those extremely speculative ramblings one can detect the presence, quite true to her nature, of the madwoman of the house' (Cajal, 1923: 290). Nevertheless, in the Spaniard's defence, it should be stressed that in the 1890s there was a scientifi c view quite prone to these types of interpretation. Thus, some pathologists, for example Jacques-Raphaël Lépine , tried to explain the morphological basis of states of hypnosis and absentmindedness, and psychiatrists, such as Eugenio Tanzi (1856-1934) and Ernesto Lugaro (1870-1940), that for hallucinations and other psychological processes. Even Mathias Duval (1844Duval ( -1907) ) attempted to account for sleep-wakefulness variations through the ameboid retraction of the expansions and arborizations of nerve cells in different phases of conscious or unconscious functional activity. Thus, during sleep (natural or induced by narcotics), the nervous ramifi cations would retract, interrupting the passage of the nervous current, while in the state of being awake the opposite would occur [START_REF] Duval | Hypothèse sur la physiologie des centres nerveux: Théorie histologique du sommeil[END_REF]. These postulates are refuted at several points by Cajal (1895), who proposes as an alternative the somewhat bizarre hypothesis of the neuroglial cells.

The passage of time and incipient morphological discoveries led Cajal to retract his bold claims, and he affi rmed defi nitively that the participation of the neuroglia in the mental acts of attention and association of ideas was: a frankly inadmissible conjecture … Moreover, the processes of attention, association of ideas, emotion, intellectual phenomena, etc., are so enormously complex and so enigmatic today, from the histological, histochemical and energetic perspectives, that all research carried out in this direction would appear quite audacious … Centuries, perhaps thousands of years, will pass before man is able to catch a glimpse of the unfathomable mystery of the mechanism, not just of our own psychology, but even of that of the simplest insect. (Cajal, 1923: 290-1)

Epilogue

Leaving aside his sporadic incursions into the histopathological study of the brains of patients with mental disorders, such as schizophrenia, the two topics within the psychiatric/psychological sphere that most attracted Cajal throughout his life were undoubtedly the mechanisms of sleep, in the interpretation of which he openly disagreed with Freud, and the relations between nervous centres and mental processes, chiefl y with regard to their biological basis. Indeed, Cajal went so far as to use the term 'psychic cells' to denote the pyramids of the cerebral cortex. However, this question -a highly fashionable one around the turn of the last century due to the infl uence of the positivist and associationist bio-philosophical schools -was of such a nature that Cajal, despite having put forward some interpretive hypotheses, considered it excessively prone to erroneous, speculative and fanciful explanations. In response to the question of whether the supreme phenomenon of consciousness has its substrate in all the brain cells or exclusively those of association, Cajal (1896: 392) concluded:

We are not impatient to contemplate the grand edifi ce [of the intimate functioning of nervous centres] in all its fi nished glory. The supreme synthesis will come only much later, when all the material has been gathered, and when neither the chemistry nor the structure of the nerve cells hold any more secrets for us.

More than a century later, these prudent words still have the ring of truth.

Notes

1. But the historical importance of the debate that emerged on the subject of hysteria and hypnotism lay in its infl uence on a young man who attended Charcot's lectures, Sigmund Freud (1856Freud ( -1939)), who together with Josef Breuer published Studien über Hysterie in 1895, and began studying the therapeutic effects of the techniques of suggestion and hypnosis, eventually developing his method of Freie Assoziation. The culmination of this work, in 1898, was his defi ning achievement: the postulate of psychoanalysis. However, Freud's theories would never be well received by Cajal. 2. Various authors from Valencia also joined in this discussion, including Faustino Barberá (1850Barberá ( -1924)), who in his publications aligned himself with Bernheim's line of thought. 3. It suffi ces to mention, with [START_REF] Diéguez | Sobre la introducción del hipnotismo en España: la recepción de los planteamientos de las escuelas francesas[END_REF]), the Englishman Frederic Myers (1843-1901), the Swiss Théodore Flournoy , the French Nobel laureate Charles R. Richet (1850Richet ( -1935) ) and the German Wilhelm M. Wundt (1832Wundt ( -1920)), considered to be the founder of experimental psychology. 4. It was during this visit that Simarro showed Cajal Golgi's silver nitrate method (his famous reazione nera), so crucial for his future histological career (Cajal, 1923). 5. Similar to those organized in other countries at this time, such as the Society for Psychical Research, founded in 1882 by English and American doctors. 6. This hypothesis is more than plausible, since Cajal could hardly have carried out such an act of obstetrics with a stranger, given his minimal experience as a clinical physician. 7. Bernheim, in his De la suggestion et de ses applications à la thérapeutique (1886), does not mention this aspect, though he does dedicate a chapter to various disorders, including menstrual problems. 8. The following year, this article was translated into German and published in a prestigious German journal. 9. Today, we know that these prefrontal cortex cells form part of an area closely linked to the executive functions of the brain [START_REF] Goldman-Rakic | The 'psychic cell' of Ramón y Cajal[END_REF], above all certain cognitive functions such as memory, so that Cajal's proposal was indeed largely correct. 10. The Croonian Lecture was established in honour of the seventeenth-century English physician William Croone (1633-86). 11. Nevertheless, in the introduction to his new speech, he mentioned that his original idea 'referred to the incongruences and maladaptations of man in the moral, intellectual and physical spheres' (Elguero, 2004: 20).

D. Textbooks and memoirs referred to in the text

(1898-1904) Textura del sistema nervioso del hombre y de los vertebrados (Madrid: Imprenta y Librería de Nicolás Moya). (1904,1909) Histologie du système nerveux de l'homme et des vertebrés, Vol. 1, 1909;Vol. 2, 1904 (Paris: A. Maloine). ( 1923) Recuerdos de mi vida. Historia de mi labor científi ca, 3rd edn (Madrid: Imprenta de Juan Pueyo). ( 1934) El mundo visto a los ochenta años. Impresiones de un arteriosclerótico, 2nd edn (Madrid:

Librería Beltrán, Tipografía Artística).

FIG. 1 .

 1 FIG. 1. Santiago Ramón y Cajal in 1899, aged 47 (source: http://www.redaragon.com/ cultura/ramonycajal)

FIG. 2 .

 2 FIG. 2. One of the six fi gures used byCajal to illustrate his Croonian Lecture.

FIG. 3

 3 FIG. 3 Portrait of Sigmund Freud, from c.1895; on the right are his handwritten notes for his Entwurf einer Psychologie, in which he shared the postulates, supported by Cajal, on 'psychological neurophysiology' (source: http://www.loc.gov/exhibits/freud)


A Historical Dictionary of Psychiatry. All in all, it is diffi cult to imagine anyone alive today more qualifi ed to undertake it.

IAN DOWBIGGIN

University of Prince Edward Island R. Gregor y Lande. Madness, Malingering , and Malfeasance:

The Transformation of Psychiatry and the Law in the Civil War Era. Washington, DC: Brassey's Inc., 2003. Pp. xii + 231. $27.95. ISBN 1-57488-352-6.

There is an old adage, namely, that military justice is to justice as military music is to music. R. Gregory Lande's study of military justice during the American Civil War is confi rmation of this saying even though that may not have been his intention in writing this book. During the Civil War the military was forced to confront various forms of misbehaviour. Although offi cers were occasionally brought before military tribunals, the overwhelming number of cases involved ordinary soldiers.

The overriding concern of military commanders was, of course, combat effi ciency, and anything that proved a barrier had to be dealt with quickly and effectively. Misbehaviour, desertion, malingering, malfeasance and alcoholism -all of which threatened to undermine morale and reduce the number of soldiers available for combat -were causes for the convening of courts martial. In theory the military legal system had built in safeguards to inhibit prosecutorial bias and protect the rights of the accused. In practice, however, the accused had few rights. Prosecuting offi cers were generally experienced, whereas soldiers had no right to legal counsel. In many cases the mental status of the individual became an issue, yet military tribunals lacked the expertise required to identify mental illnesses or mental defi ciency.

Courts martial were by no means trivial occurrences. Penalties were often harsh. Between 1861 and 1865, 267 enlisted men were executed. With but a few exceptions, those who received the death penalty were privates; not a single offi cer was executed. More than half had been convicted for desertion; a quarter for murder; and less than ten per cent for rape or mutiny. African Americans were far more likely to face execution; no less than fi fty-two received the death penalty (a number far in excess of their representation in the army).

Madness, Malingering, and Malfeasance is a bifurcated book. Its research base is impressive. Lande has mined unpublished military records at the National Archives, and supplemented these with published government documents, military legal treatises and selected medical texts, as well as newspaper accounts, memoirs and diaries. His description of specifi c courtsmartial proceedings provides an invaluable insight into the workings of the military justice system during the Civil War.

The analytic and interpretative aspects of the book, on the other hand, are deeply fl awed. The subtitle -The Transformation of Psychiatry and the Law in the Civil War Era -is misleading. Lande does not demonstrate any change in psychiatry. More important, Lande is poorly versed in the history of nineteenth-century psychiatry. He relies on Albert Deutsch's The Mentally Ill in America, which was fi rst published in 1937, but the history of psychiatry has been a vibrant and exciting fi eld of study since the 1960s, and there is a vast literature which has gone far beyond Deutsch's classic and pioneering book. Yet Lande is apparently ignorant of this literature, a knowledge of which is indispensable if one is going to write intelligently about psychiatry. For example, although writing about the Civil War career of William Hammond, Lande did not consult Bonnie Blustein's full-length biography (Preserve Your Love of Science: Life of William A. Hammond, American Neurologist, 1991). Similarly, his comments about alcoholism ignore a very large and revealing secondary literature dealing with this subject. The result is that his research in military records dealing with courts martial is vitiated by the absence of any context.

The history of military justice is certainly a subject worthy of study, and Lande has performed an important task in examining military records and presenting materials which other scholars will fi nd useful. It is a pity, however, that he did not take the time to consult secondary sources which might have enabled him to present his material in a more illuminating and sophisticated manner.

GERALD N. GROB Rutgers University

Lynette A. Jackson. Surfacing Up: Psychiatry and Social Order in Colonial Zimbabwe. Ithaca: Cornell University Press, 2005. Pp. xiii + 230. ISBN 0-8014-8940-7.

Surfacing Up is a study of psychiatric practice in Ingutsheni Asylum (later Ingutsheni Mental Hospital), in colonial Zimbabwe. Ingustsheni was a facility that housed both African and European patients, but segregated them by race, and provided drastically unequal living conditions and therapeutic regimens. Jackson gives a chronological overview of the institution, and situates it in the larger social and political history of Zimbabwe. But her closest attention is dedicated to critical readings of patient case fi les, of which she obtained an impressive number.

Jackson's method hinges on the pliable and subjective nature of madness, particularly in colonial contexts, with their sharp political and cultural divides. She reminds her readers throughout that her approach does not entail a denial of the reality of illness, but involves training a critical eye on diagnostic practice. As she writes early on: 'If one defi nes the insane as those who are


News and Notes

The Titicut Follies: the forgotten story of a case of psychiatric censorship

THOMAS SZASZ* State University of New York

Psychiatry, being closely associated with both sex and violence, is a popular subject in the cinema. The most famous psychiatric fi lm of all times, One Flew Over the Cuckoo 's Nest (1962) -based on Kesey's novel and directed by Milos Forman -was seen by millions and is often credited with stimulating social reform. If by 'social reform' we mean advancing the cause of liberating imprisoned 'patients' from imprisoning psychiatrists, there is no evidence that it had such an effect. However, a very different fi lm -The Titicut Follies (1967), a documentary by the noted fi lm maker Frederick Wiseman (b. 1930) -might have made a desirable impact, had many people seen it. But it was banned.

In the 1960s Wiseman received permission to fi lm, for 29 days, inside the Bridgewater State Hospital, an institution for the criminally insane. The movie he made there -his fi rst documentary -was shown to great acclaim at the New York Film Festival in 1967. The Massachusetts Attorney General proceeded to bar public screenings and the state's Supreme Court ruled that the movie constituted an invasion of the privacy of the Bridgewater guards and patients. Today, The Titicut Follies, if it is remembered at all, is dismissed as representing the kinds of inhumane psychiatric conditions that, thanks to drugs and deinstitutionalization, we have put behind us.

Wiseman does not interview his subjects, nor does he narrate or comment on what happens. He describes his approach to fi lm-making as follows: '[My fi lms are] based on un-staged, un-manipulated actions … I think I have an obligation, to the people who have consented to be in the fi lm, … to cut it so that it fairly represents what I felt was going on at the time in the original event.' [START_REF] Wiseman | Frederick Wiseman[END_REF]. In May 1987, The Titicut Follies was the subject of a forum at the University of Massachusetts. The anonymous reviewer for the New York Times (1987) reported:

It was a rare screening of the fi lm that, under court guidelines, can be shown only to professionals in the legal, human services, mental health and related fi elds. … A documentary fi lm about brutality at a state hospital for the mentally ill, made 20 years ago and promptly banned, has proved that its power to provoke debate has not diminished. … 'Titicut Follies' shows men like Jim, kept naked in solitary confi nement for 17 years. Guards who are shown taunting him about his dirty cell later complain that when they control unruly patients with tear gas, the fumes cling to their clothes. The title of the documentary comes from an annual variety show given by inmates and guards; Titicut is an Indian word describing the region south of Boston, where the hospital is located. 'Titicut Follies' … is the only American fi lm ever censored for reasons other than obscenity or national security … The United States Supreme Court has twice refused to hear Mr. Wiseman's appeal. Mr. Wiseman said in an interview this week: … 'If the First Amendment of the Constitution protects anything, it's a journalist's right to report on conditions in a prison.' … Blaire Perry, a lawyer for Mr. Wiseman who was on the panel, said, 'In 20 years, not one patient or his family has ever objected to the showing of the fi lm.' … Today, the state hospital is in a modern building. By all accounts, the staff is better trained and there are more legal safeguards protecting the patients, many of whom have never been convicted of a crime. But the hospital is still surrounded by barbed wire, staffed by 220 prison guards … There are 25 nurses and 49 psychiatrists, psychologists and social workers for 436 patients, according to Mary McGeown, a spokeswoman for the Corrections Department. Bridgewater is still overcrowded, understaffed and underfi nanced, according to one panel member, Dr. Robert Fein, assistant commissioner of mental health. [emphasis added] What is the staff better trained for? No matter how many psychiatrists, psychologists, nurses and social workers are in such a 'hospital,' they are all jailers.

On 6 April 1993 -twenty-six years after it was banned -The Titicut Follies was shown on the Public Broadcasting System and reviewed by fi lm critic Walter [START_REF] Goodman | An unhealthy hospital stars in 'Titicut Follies[END_REF] in the New York Times: Frederick Wiseman's remarkable fi rst documentary, an unsparing visit to the Bridgewater State Hospital for the Criminally Insane, in Massachusetts, was banned by the state's Supreme Court on the grounds that it violated the privacy of inmates, several of whom were shown naked. The ban was fi nally overturned in 1991. … As in all his reports, Mr. Wiseman abjures narration. The pictures tell his stories, and he has never presented more powerful pictures. The 90-minute fi lm opens and ends with a chorus line from what was evidently an annual show called 'The Titicut Follies.' You'll have to guess who among these costumed performers are inmates, who are guards. The stage, where odd behavior reigns, blurs the lines of sanity and confers an hour of equality. ... One man outtalks the doctors with a fervent yet coherent plea to be sent back to an ordinary prison. … Many of the encounters have an unsettling ambiguity. A psychiatrist … questions an inmate about his sexual proclivities: 'What are you interested in, big breasts or small breasts?' Is he working or just curious? The hardest scene to watch is of a forced feeding. The doctor smokes a cigarette as he inserts a long rubber tube into the patient's nostril and pours a liquid into a funnel; you want to call out to him to fl ick the lengthening ash onto the fl oor before it drops into the funnel. … In the years since Mr. Wiseman made 'Titicut Follies,' most of the nation's big mental institutions have been closed or cut back by court orders. How much this ostensible victory for civil liberties has helped the mentally ill remains in dispute.

The Titicut Follies, unlike One Flew Over the Cuckoo's Nest, was a unique fi lm: it humanized madness and depicted the psychiatric invalidation, persecution and dehumanization of so-called mad persons. For that offence, the American psychiatric establishment, assisted by the American legal establishment, banned the showing of the fi lm. This unique violation of the First Amendment has escaped both legal and psychiatric attention.

Today, the Bridgewater State Hospital is a 'health care facility' affi liated with the University of Massachusetts Medical School. In 2003 the National Commission on Correctional Health Care lauded it as its 'Facility of Year'. An essay by Jaime [START_REF] Shimkus | Bridgewater State Hospital a model of integration[END_REF], publications editor of the organization, presents a brief history of the hospital, but does not mention The Titicut Follies or the conditions described in the fi lm.

In the days of insane asylums, the truth about psychiatry was apparent: the madhouse was a snake pit, and snake pits were limited to insane asylums. Today's 'snake pits' -dispersed throughout society -are concealed by a façade of pseudomedical 'diagnoses', 'talk therapies', 'treatment advocacy centers', 'alliances for the mentally ill' and the nominal and bureaucratic transmutation of insane asylums into 'health care facilities'.


from such morbifi c causes as are capable of rendering more vivid the feelings of the mind' by

Keywords: apparition, Ferriar, ghost, hallucination, Hibbert, histor y, psychiatry, psychopathology, spectral illusion

à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

'The varieties of effects resulting from such morbific causes as are capable of rendering more vivid the feelings of the mind' by S. Hibbert (1825)

G.E. Berrios

To cite this version:

G.E. Berrios. 'The varieties of effects resulting from such morbific causes as are capable of rendering more vivid the feelings of the mind' by S. [START_REF] Hibbert | Sketches of the Philosophy of Apparitions[END_REF]. History of Psychiatry, 2007, 18 (1) The construction of the concept of hallucination in the cultures of the West cannot be understood without considering the concept of 'apparition' from the historical, theological and literary perspectives [START_REF] Green | Apparitions[END_REF][START_REF] Gurney | Phantasms of the Living[END_REF][START_REF] Parish | Hallucinations and Illusions. A Study of the Fallacies of Perception[END_REF][START_REF] Sidgwick | Report on the census of hallucinations[END_REF]Tyrell, 1943). The rich literature on apparitions provided the medical notion of hallucination not only with a structural matrix but with a language of description. This is the reason why current talk on hallucinations remains biased in the direction of visual perception and incorporates doxastic, some will say, fi duciary elements in its defi nition.

The history of the concept of apparition is rich and complex and is inextricably linked to the history of religion in general and of demonology in particular. Most known cultures seem to contain the view that, whether dead or alive, persons may, in certain critical situations, 'appear' to other humans, either as individuals or as groups. Very early in Christianity, [START_REF]On the Literal Interpretation of Genesis: An Unfi nished Book[END_REF] classifi ed 'visions' into corporeal, imaginative and intellectual. Corporeal visions were supernatural manifestation of an object to the eyes of the body. It either stimulated the eye in the usual way that other stimuli do, or an agent superior to man modifi ed the visual organ so that a sensation was achieved. Imaginative visions represented an object by means of imagination alone, without the aid of the visual organ. Intellectual visions 'perceive' without a sensible image, that is as an act of pure understanding. It has been claimed that this was Augustine's 'most serious attempt to account for errors of sense perception' [START_REF] Matthews | Knowledge and illumination[END_REF]).

Augustine's views reverberated through the ages and can still be found, for example, in Calmet's Traité sur les apparitions des esprits (1751). The standard belief that at least some apparitions were supernatural (resulting from something external stimulating the perceptual system) began to be challenged at the beginning of the nineteenth century. In the event, the naturalization and secularization of apparitions gave rise to the modern concept of hallucination which was redefi ned as a disorder of perception occurring in the absence of any external stimuli. This did away with the millennial belief that hallucinations may have a communicational function either between human beings or between a human being and an external power (e.g., deities) [START_REF] Berrios | On the fantastic apparitions of vision (by Johannes Müller)[END_REF]. The Classic Text below is a good representative of the challenge mentioned above and includes the two types of arguments referred to. Samuel Hibbert (1782-1848) was born in Manchester and educated at the Manchester Academy. He refused to work at his father's business (a linen merchant) and started an early literary career turning his pen to whatever was available at the time [START_REF] Sutton | Ware, Samuel Hibbert (1782-1848[END_REF]. After a spell in the Lancashire militia, Hibbert took an MD degree at Edinburgh University but never practised.

The author

His studies and the friendships he made in Edinburgh (e.g., with David Brewster) left him with a taste for natural history and chemistry. In 1817 Hibbert undertook a geological survey of the Shetland Islands, reporting the presence of chromate of iron and of a native form of hydrate of magnesia. He also became involved with the Society of Antiquaries of Scotland, helping with the running of their museum and with some editorial work.

In 1823 Hibbert read a paper on 'Spectral illusions' before the Royal Society of Edinburgh, and his book on the subject, Sketches of the Philosophy of Apparitions, was published in 1824 (see [START_REF] Hibbert | Sketches of the Philosophy of Apparitions[END_REF]. Probably infl uenced by Ferriar's Essay (1813), Hibbert proposed a physiological account of apparitions. Some of his contemporaries understood his work as a defence of materialism (Anon., 1828). Although the debate on the extra-natural aspect of some apparitions was to be revived at the end of the nineteenth century by the powerful psychical research movement [START_REF] Oppenheim | The Other World: Spiritualism and Psychical Research in England 1850-1914[END_REF], the medical concept of hallucination did not benefi t from these studies and remained locked within its narrow mechanistic framework [START_REF] Berrios | The History of Mental Symptoms[END_REF].


Dimitrios Adamis
email: dimaadamis@yahoo.com

Trust, UK Oxleas Nhs

Adrian Treloar

Finbarr C Martin Guy'

Alastair J D Macdonald

A brief review of the history of delirium as a mental disorder

Keywords: delirium, historical concepts, history, outcome, prognosis

We review the most important concepts about delirium, from ancient times until the twentieth century. We also focus on the question of how these concepts have dealt with the particular problems posed by prognosis and outcome. Althought different terms have been used, a robust description of delirium has existed since antiquity -at some times as a symptom and at others as a syndrome. It is clear that, throughout the millennia, delirium has been -and still is -a highly lethal syndrome; a poor mental outcome for survivors was often noted. Not until the twentieth century was it thought that delirium was marked by a full recovery among survivors, and this was probably due to the desire for a clear distinction from dementia.

Introduction

Despite the 'three millennia of delirium research' [START_REF] Francis | A half-century of delirium research: time to close the gap[END_REF][START_REF] Francis | Three millennia of delirium research: moving beyond echoes of the past[END_REF], delirium remains hard to defi ne and diffi cult to study. Delirium is usually assumed to be an acute, fl uctuating, transient and reversible condition caused by physical illness. Once the acute episode has remitted, the premorbid level of functioning is reached again, with personality reappearing intact. But experience and research shows that this is not always the case; delirium is often irreversible especially in the elderly and those with pre-existing dementia. While the two international classifi cations (ICD, DSM) can increase the concurred validity of a diagnosis between the professionals and facilitate the communication between them, both systems have been criticized regarding the defi nition of delirium. ICD and DSM defi ne delirium as a disorder (even when the aetiology is known) but then characterize delirium as a syndrome [START_REF] Lindesay | Delirium in the Elderly[END_REF]. As the two systems do not defi ne delirium according to outcome, it has been argued that (at least in survivors) delirium should be defi ned according to cognitive reversibility (Treloar andMacdonald, 1997a, 1997b). This paper will review the most important of these concepts about delirium, from ancient times until the appearance of the two classifi cation systems. Special attention will be paid to the question of how those concepts have dealt with the particular problems posed by prognosis and outcome.

Specifi cally, we will discuss how defi nitions of delirium have striven to:

(a) accommodate delirium within the current nosological system; (b) assign diagnostic criteria that distinguish it from other mental disorders; (c) classify it according to aetiologies; (d) clarify the prognosis from the clinical manifestations.

We will review the recent literature; papers were selected after searching electronic databases (MEDLINE, EMBASE, IBSS), but mostly after manual searching of the references of previous papers and reviews. Throughout this review we will use the term 'Delirium' when the actual word was used, and 'delirium' when applying the modern equivalent.

The concept of delirium throughout the centuries

Ancient and medieval times

The word Delirium was fi rst used in medical writing by Celsus in the fi rst century AD (2.8; 3.16) to describe (either as a symptom or as a syndrome) mental disorders during fever or head trauma (Celsus 2.7). Additionally Celsus used the term phrenitis as an alternative to Delirium. Phrenitis had previously been introduced by Hippocrates in 500 BC (Prognostikon 4, in Lipourlis, 1983) to describe mental abnormalities caused by fever, poisoning or head trauma. It has been suggested that the current nomenclature about delirium is confusing because of the different names used to defi ne and describe it [START_REF] Lindesay | Delirium in the Elderly[END_REF][START_REF] Lipowski | Delirium: Acute Confusional States[END_REF], and that the clinical meaning of the syndrome remained consistent through the centuries until the nineteenth century [START_REF] Berrios | Delirium and confusion in the 19th century: a conceptual history[END_REF][START_REF] Lipowski | Delirium: Acute Confusional States[END_REF], but it is worth noting that Hippocrates used about sixteen different words to refer to and name the clinical syndrome which we now call delirium [START_REF] Lipourlis | Ιπποκρατικη Ιατρικη [Hippocratic Medicine[END_REF], such as ληρος (leros), μανια (mania), παραφροσυνη (paraphrosyne), παραληρος (paraleros), φρενιτις (phrenitis), ληθαργος (lethargus), etc. It is diffi cult to fi nd the exact meaning of these terms, e.g., the term παραφροσυνη (paraphrosyne) can be used as a meaning of madness but can also mean a decline in or a loss of consciousness. An apparent uniformity of nomenclature during antiquity may thus be due to the translation of many distinct words as 'Delirium' in English [START_REF] Caraceni | Delirium: Acute Confusional States in Palliative Medicine[END_REF].

The word delirium derives from the Latin deliro-delirare (de-lira, to go out of the furrow) -hence, to deviate from a straight line, to be crazy, deranged, out of one's wits, to be silly, to dote, to rave [START_REF] Lewis | Harpers' Latin dictionary. A New Latin Dictionary Founded on the Translation of Freund's Latin-German Lexicon[END_REF].

A second suggestion about the etymology of the word (cited in [START_REF] Schuurmans | Early recognition of delirium: review of the literature[END_REF] is that it came from the Greek word ληρος (leros) which means silly talk, nonsense. Althought both words have a similar meaning (and phonetics), it is unlikely that delirium is derived from the Greek for two reasons. First, the etymological root of ληρος is possibly from the archaic '*la' (I shout), from which the Latin word lamentum (lament) also derives, and second, it is very rare -or even unknown -for the Greek letter 'η' to transform to the Latin 'i' and vice versa [START_REF] Babiniotis | Ιστορικη γραμματικη της Αρχαιας Ελληνικης γλωσσας. Ι. Φωνολογια [Historical Grammar of the Ancient Greek Language[END_REF].

Hippocrates (in [START_REF] Lipourlis | Ιπποκρατικη Ιατρικη [Hippocratic Medicine[END_REF]) used the term phrenitis to describe an acute onset of behavioural problems, sleep disturbances and cognitive deficits which were usually associated with fever, while he used the term lethargus to describe inertia and dulling of the senses. He believed that lethargus can change to phrenitis and vice versa. According to Hippocrates gnashing during fever (for those who did not have this before illness) was a sign of the development of delirium and death. If delirium coexisted with gnashing, the death was almost certain (Prognostikon 3). Hippocrates identified another rather peculiar prognostic sign: older people with pain in the ear during fever were less prone to develop Delirium (Prognostikon 4), but we need to remember that only 10% of people lived more than 60 years at that time [START_REF] Minois | History of Old Age: From Antiquity to the Renaissance[END_REF].

Celsus was probably the fi rst to report occasional non-febrile causes: 'Raro sed aliquando tamex ex metu delirium nascitunatura… (Rarely, but now and then, however, Delirium is the product of fright …)' (Celsus 3.18), but he suggested the same remedies as in other types of Delirium, except that for non-febrile Delirium wine could also be given. Celsus (3.18) said that not all deliria were reversible but in some cases, although the causes disappeared, patients continued to be insane (he used the word 'dementia' probably to mean insanity). However Soranus insisted that Delirium could never occur without fever and that insanity often started with it [START_REF] Lipowski | Delirium: Acute Confusional States[END_REF].

During the medieval period a remarkably accurate description of Delirium was given by the historian Procopius (History of the Wars, II.xxii-xxxiii) who described an epidemic of a possible bubonic disease in Constantinople in AD 542 (cited in [START_REF] Bury | History of the Later Roman Empire from the Death of Theodosius I. to the Death of Justinian[END_REF]. He described hallucinations occasionally preceding the disease. Some victims became violent with insomnia, excitement, shouting, rushing off in fl ight (perhaps resembling the modern concept of hyperactive delirium), while others drifted into coma, forgetting all those familiar to them, and seeming to sleep constantly, and they could die from lack of food or water if nobody cared for them (perhaps resembling hypoactive delirium). Procopius assumed that those who developed Delirium of either form were the lucky ones because, he believed, delirious people do not feel pain. Many medical authorities of medieval times such as Oribasious of Pergamon, Alexander of Tralles (Trallianos) and Paulus of Aegina (Aeginitis) reviewed and interpreted previous works by Hippocrates, Celsus, Galen, Sonarus and other medical predecessors.

In the mid-eighth century an Arab physician, Najab ub din Unhammad, listed nine classes of psychopathology, including the Souda a Tabee (febrile Delirium), according to [START_REF] Graham | Medieval Minds: Mental Health in the Middle Ages[END_REF]. The Souda a Tabee was subdivided into Souda where patients showed impairment of memory, loss of contact with the environment and childish behaviour; but when Souda reached a chronic state, it became Jannon (agitated reaction) characterized by insomnia, restlessness and, at times, beast-like roars [START_REF] Graham | Medieval Minds: Mental Health in the Middle Ages[END_REF]. Rhazes, a famous Persian physician, was in favour of a unifi ed concept of delirium and described a condition named 'sirsen' which corresponded to both lethargus and phrenitis and was due to fever or to excessive wine (Lipowski, 1990: 9).

The encyclopaedia of Bartholomeus Anglicus which was translated into English in 1495 had chapters on mental illness, reviewing all previous works. He introduced the word 'paraphrenesis' to distinguish Delirium caused by febrile illness (with a better prognosis) from Delirium 'phrenesis' caused by disease of the brain and its membranes, with a poorer prognosis (Bartholomeus Anglicus, De proprietatibus, 1535, quoted in Hunter and Macalpine, 1963: 1-4).

Throughout ancient and medieval times good descriptions of what we now call delirium existed, but with many different names. The principle subtypes of Delirium were described either as separate illnesses or as different forms of the same illness. Controversy existed about the outcome of Delirium, but general agreement was reached. With a few exceptions it was caused by febrile illnesses, and delirium was a grave clinical situation.

Sixteenth to eighteenth centuries

During the sixteenth century more writings appeared on phrenitis and Delirium. 'Paraphrenesis' reappeared as a term to distinguish delirium caused by fever, but it was also used by Guainerio to describe a pre-delirious phase (Lipowski, 1990: 10).

In the English medical literature the word 'delirium' was probably fi rst used by Cosin (1592) in his book Conspiracie for Pretended Reformation: viz. Presbyteriall Discipline. This book was one of the earliest to put forward the defence of insanity. Delirium was defi ned as a 'weakenes of conceite and consideration' and Lethargie as a 'notable forgetfulness of all things almost that heretofore an man hath knowen or of their names' (Cosin, 1592;quoted in Hunter and Macalpine, 1963: 44). Earlier, in 1547, Andrew Boorde distinguished delirium from fever, 'phrenyse' (phrenesis) from that toxic state caused from the use of hyoscyamus 'frantickenes' (Hunter and Macalpine, 1963: 13-15). The poor prognosis of delirium was recounted by Philip Barrought in 1593, who described 'phrenesis' as a 'continual madness' joined with acute fever and said that it was an incurable and deadly condition in most cases, and if it resolved it may be followed by a loss of memory and reasoning (see [START_REF] Lindesay | The concept of delirium[END_REF]Lipowski, 1990: 11). One important contribution in the sixteenth century was the work of Ambroise Pare, a surgeon who wrote about delirium as a complication of surgical procedures. He described delirium as a transient condition that commonly followed fever and pain due to wounds, gangrene, and operations involving severe bleeding of the patient (see Lipowski, 1990: 11-12).

An interesting contribution to the concept of delirium was made by Thomas Willis. He explained delirium pathogenesis with his theory of animal spirits, departing from the traditional humoral theory. He accepted the theory current at the time that delirium and 'frenzy' (phrenesis) differed only in duration of their mental disturbance but he believed that delirium could also occur in conditions which were not accompanied by fever-like drunkenness or hysteria. He did not accept the idea that an infl ammation of the diaphragm can cause 'paraphrenesis' (he had seen an autopsy of an abscess involving the diaphragm but the patient had not had delirium or paraphrenesis during life). He also stated that the prognosis of delirium depended on the nature of the febrile illness, the patient's age and previous health, and that while delirium may be resolved after the fever settled down, cases of protracted delirium might lead to 'a state of perpetual raving (madness), to melancholy, or to a state of foolishness and stupidity' (Eadie, 2003: 153). Another infl uential work in the seventeenth century was that of Richard Morton who suggested that delirium represents a waking dream -a theory which infl uenced developments in the next century (see Lipowski, 1990: 12).

By the beginning of the eighteenth century most medical writings distinguished Delirium on the one hand from phrensy or phrenesis on the other. The former was by then a general term for short-term madness or raving and the latter for a state caused mainly by fever or other physical illnesses. Phrensy or phrenesis was further divided into phrenesis and paraphrenesis. The former was associated with supposed brain infl ammation, the latter with infl ammation of other organs. However, paraphrenesis was also used to describe the prodromal stage of delirium. It was well recognized that delirium, although transient in most cases, was a serious clinical condition with bad prognosis, and that in some cases, despite the cessation of fever, mental dysfunction could continue and could be permanent. Further, a shift from the humoral explanation of delirium towards to a more 'chemical' hypothesis -the infl ammation of the 'animal spirits'-was taking place. Finally, parallels with dream states were emerging. These shifts in the meaning and notions of aetiology of delirium are refl ected in two English medical dictionaries published at the beginning and in the middle of the eighteenth century. Quincy (1719) stated that mania or madness 'is a Delirium without fever' and that 'Delirium is the Dreams of waking Persons', while James (1745) stressed the relationship between Delirium and the disturbances of the sleeping-waking cycle (see Lipowski, 1990: 13;[START_REF] Lipowski | Delirium: how its concept has developed[END_REF].

In 1746 a treatise on delirium by Frings appeared which according to Lipowski (1990: 13-15;[START_REF] Lipowski | Delirium: how its concept has developed[END_REF] was the fi rst one in English. There is controversy about this book: Frings claimed that he translated it from a Latin text and that he was for 'Some Time Physician to Don Francisco, Late Infant of Portugal'. Hunter and Macalpine (1963: 371-2) suggested that the name Frings was a pseudonym as nothing is otherwise known about the author, the Don Francisco of Portugal nor the Latin text. Whoever he (or she) was, Frings took against the 'Galenists' who used bleeding as a treatment for delirium despite the book being dedicated to Dr James Monro of Bethlem hospital, where bleeding was the usual practice. Frings used the term Deliriums to refer to mental disorder generally and included states with, without or after fever. He followed the current classifi cation of 'phrensy' (phrenesis) and 'paraphrensy' (paraphrenesis) and he divided Deliriums in fever into two types, according to clinical manifestations: the 'ridiculous' when the patient was happy and cheerful, and the 'serious' when the patient was angry. He said that the latter had a bad prognosis (Lipowski, 1990: 13-15). David Hartley in 1749 described hypnogogic and hypnopompic phenomena and visual hallucinations in delirium, and in 1794 Erasmus Darwin introduced disorientation and alteration of consciousness to distinguish delirium from 'madness' (see Hunter and Macalpine, 1963: 379-82, 547-51). He also named the febrile delirium with the Hippocratian word 'Paraphrosyne'.

Nineteenth century

In the nineteenth century the terms which described delirium developed even greater ambiguity. According to [START_REF] Berrios | Delirium and confusion in the 19th century: a conceptual history[END_REF] and [START_REF] Berrios | A History of Clinical Psychiatry: The Origin and History of Psychiatric Disorders[END_REF], this was partly for linguistic reasons especially in France where 'delire' was used to refer both to specifi c errors of judgement (delusions) and to phrenesis. Thus there was a need for a term for organic delirium, so the term 'confusion mentale' was introduced. Although Berrios has suggested that this did not infl uence British psychiatry, it has parallels with Darwin's views at the end of the previous century, who used the term Delirium to describe what would today be regarded a somatic hallucination.

As when a patient is persuaded he has the itch, or venereal disease, of which he has no symptom and becomes mad from the pain this idea occasions. So that the object of madness is generally a delirious idea, and thence cannot be conquered by reason; because it continues to be excited by painful sensation, which is a stronger stimulus than volition. (Darwin, 1796;quoted in Hunter and Macalpine, 1963: 548) The term 'confusion' as a synonym for delirium is in widespread use in all countries to this day.

During the nineteenth century, old terms such as phrenitis, phrensy, phrenesis, lethargy and paraphrensy or paraphrenesis gradually disappeared from medical language, and discussion turned mainly towards the psychopathology of delirium and its relations with dreams, and to disturbances of consciousness as a core feature of delirium.

At the beginning of the nineteenth century [START_REF] Sutton | Tracts on Delirium Tremens, on Peritonitis, and on some other Infl ammatory Affections, and on the Gout[END_REF] proposed the term Delirium tremens (because of the marked tremor of the hands) caused by excessive drinking or as a result of sensitivity to alcohol in certain people, and distinguished it from phrenesis. Greiner ( 1817) is credited with introducing the concept of the clouding of consciousness as the main feature of delirium. He believed that fever caused disturbances in the organ of consciousness in the brain, and that delirium's course, severity and clinical picture depended on the duration and degree of fever, as well on the patients' previous experiences and habits. He held that as fever fl uctuates so does consciousness, and the patient may have lucid periods. He also believed that there was a close relation between dreams and delirium and that delirium represented a dream during the waking state. The association between delirium and clouding of consciousness was further explored by Hughlings Jackson in the 1860s [START_REF] Hogan | The "dreamy state": John Hughlings-Jackson's ideas of epilepsy and consciousness[END_REF]Lipowski, 1990: 23-5;[START_REF] Lipowski | Delirium: how its concept has developed[END_REF]. In 1870 Hood reported cases of 'senile Delirium' and he stated that this was potentially reversible but could be fatal if not treated (see Lipowski, 1985: 290). [START_REF] Berrios | Delirium and confusion in the 19th century: a conceptual history[END_REF] has suggested that during the second half of the nineteenth century the clouding of consciousness became the primary clinical criterion separating delirium from the rest of the insanities, but as late as 1879 von Krafft-Ebing stated that clouding of consciousness could exist in other mental disorders such as twilight states, stupor and ecstasy, while Kraepelin in 1915 wrote that clouding of consciousness could happen in transient hysterical states, catatonic stupor, melancholia and excitement (see Lipowski, 1990: 26).

In summary, the nineteenth century saw the introduction of two new concepts: clouding of consciousness and confusion, and an attempt was made to distinguish delirium caused by alcohol as a separate condition. Clinical symptoms rather than aetiology and prognosis became the focus of defi nitions [START_REF] Lindesay | The concept of delirium[END_REF].

Twentieth century

At the end of the nineteenth and the beginning of the twentieth centuries, although the infl uence of Kraepelin's work was enormous, his view that the natural history of any mental illness must become part of its defi nition [START_REF] Berrios | Delirium and confusion in the 19th century: a conceptual history[END_REF] did not seem to affect defi nitions of delirium. This may be partly due to the agreement -unanimous at the time -that the outcome of delirium was either death or full recovery.

At the beginning of the century [START_REF] Pickett | Senile dementia: a clinical study of two hundred cases with particular regard to types of the disease[END_REF] proposed a distinction between Delirium and confusion in elderly people, believing that Delirium always has an organic cause while confusion could be caused by other nonorganic factors. A few years later Bonhoeffer described acute organic brain disorders as 'symptomatic psychoses' which included simple Delirium, hallucinosis, amentia, 'epileptic type' and symptomatic stupor, all of which were characterized by clouding of consciousness. He thought that 'delirium acutum' had a bad prognosis. Bonhoeffer suggested that the brain could react to exogenous noxae caused by physical illness and thus grouped these under 'acute exogenous reaction types' [START_REF] Hoff | Die Bedeutung des exogenen Reaktionstypus Bonhoeffers fûr die moderne Psychiatrie[END_REF][START_REF] Neumarker | Karl Bonhoeffer und das Konzept der symptomatischen Psychosen[END_REF][START_REF] Neumarker | Karl Bonhoeffer and the concept of symptomatic psychoses[END_REF]. Eugen Bleuler held that it was not the type of noxae but their intensity and duration of infl uence that were signifi cant in the development of these reactions, while Kraepelin argued that the distinctive features of the reaction types were not caused by the external damage itself but by their rapid development. Around the same time Adolf Meyer proposed a similar model of 'reaction types', of which the 'dysergastic reaction' represented acute organic disturbance, later explored by Wolf and Curran in 1935 (see Caraceni and Grassi, 2003: 3;Lipowski, 1990: 31).

Manfred Bleuler and Klaus Conrad disagreed about clouding of consciousness as a diagnostic criterion [START_REF] Neumarker | Karl Bonhoeffer und das Konzept der symptomatischen Psychosen[END_REF][START_REF] Neumarker | Karl Bonhoeffer and the concept of symptomatic psychoses[END_REF], but Kurt Schneider (1947, 1948: 37-40) in discussing the 'exogenous reaction' which he called 'körperlich begrundbare Psychosen (physically related psychosis)' emphasized clouding of consciousness as a central diagnostic feature. He also accepted the possibility of chronicity and dementia. [START_REF] Engel | Delirium, a syndrome of cerebral insuffi ciency[END_REF] used EEG to investigate delirium and found that it was associated with a reduction of cerebral metabolic rate as indicated by an increase in slow wave activity. Lipowski, who worked and wrote extensively on delirium (e.g., [START_REF] Lipowski | Delirium: Acute Confusional States[END_REF][START_REF] Lipowski | Delirium: how its concept has developed[END_REF], is regarded as the father of modern research into this condition.

During the last part of the twentieth century, attempts were made to defi ne mental disturbances, including delirium, by consensus, and two classification systems emerged: the DSM (Diagnostic and Statistical Manual of Mental Disorders) of the American Psychiatric Association and the ICD (International Classifi cation of Diseases). A crucial factor in the development of ideas about delirium was demographic change, especially in developed countries, with an increasing proportion of hospital beds occupied by men and women in their seventies or eighties, often with multiple physical and cognitive problems [START_REF] Jefferys | An ageing Britain -what is its feature?[END_REF].

Discussion and conclusions

In summary, it seems that despite the different terms that have been used, a robust description of delirium has existed since antiquity -at some times as a symptom and others as a syndrome. A further dichotomy was whether its defi nition depended on possible aetiology(ies) and its association with physical illness, or on clinical symptoms; each was thought more signifi cant at different times and by different authorities. Given what we now know to be the protean manifestations of delirium, it is not surprising that defi nitions which were based on symptoms differed considerably. Philosophical theories about the body, the psyche and their relationship also infl uenced defi nitions of delirium since this is one of the few clinical conditions in which it is evident that a physical cause can produce mental problems. To this day, there has been universal agreement about the gravity of delirium and its bad prognosis, and also that if outcome was not death, full recovery was likely, although a few observers over the centuries suggested that delirium may lead to a more permanent mental disturbance even after its immediate cause was removed. It was not until the phenomenologicallly-focused nineteenth century that the pursuit of a syndrome took over from the attempt at a diagnosis with its prognostic and management implications. Not until the twentieth century was it thought that delirium was marked by a full recovery among survivors, and this was probably due to the desire for a clear distinction from dementia.

Most authorities agreed that delirium is connected with the presence of acute physical illnesses, especially infl ammation and those causing fever.

We conclude that if delirium is anything it is a variety of syndromes with a variety of causes. Therefore, perhaps we will always have to study delirium by seeing it as a 'fi nal common pathway' of symptomatology, and begin to explore cautious therapeutic interventions according to the aetiology of the delirium.