Vincenzo Chiarugi: Nosology, Pazzia, and the Cure of the «Altered Machine»

Vincenzo Chiarugi (1759-1820) graduated from University of Pisa in 1779 and started to exercise the medical profession one year after. He presumably first approached cases of insanity in 1785 when he became the director of the male sector at Santa Dorotea (Conti, 2015). Three years later, when Peter Leopold’s reformation project was almost completed, the young doctor was appointed chief-physician of Bonifazio (Shorter, 2005, p. 53). Here Chiarugi was in charge of the general assistance and custody of all incurable, disabled, insane, and infectious patients (Chiarugi, 1793, p. I). Dealing with a plurality of conditions, he developed wide medical interests and produced several writings spanning from insanity to dermatology (Gelmetti, 2015, p. 88). In the historiography of medicine and psychiatry, Chiarugi has been assigned to a peculiar place. On the one hand, he has been considered as one of the earliest «enlightened reformers» who treated the insane with kindness and curative intents (Farrar, 1908; Ozarin, 1954; Sederer, 1977; Weiner, 2011a). On the other, his work has been understood under the shadow of the famous “chain-breaker” Philippe Pinel (Conti, 2015; Grange, 1961; Mora, 1954; 1959a, 1959b; Weiner, 2011b). The Chiarugi-Pinel parallel started in 1864 when the Italian alienist Carlo Livi wrote a letter addressed to his French colleague Brière de Boismont claiming Chiarugi instead of Pinel as the founding father of psychiatry (Livi, 1864). From that moment, the work of the Tuscan physician has been repeatedly associated with that of Pinel and it is impressive to see the number of articles that still today include “Chiarugi vs Pinel” in their title (Grange, 1963; Gerard, 1997; Huertas & Del Cura, 2004). In this analysis we shall try to distance ourselves from an intellectual enterprise of foundation and to study Chiarugi’s opera in its own specificity taking into account the institutional context of Florence and Bonifazio during the late years of the eighteenth century.

The most important source for understanding Chiarugi’s vision is his three-volume treatise Della Pazzia in genere e in specie published in Florence between 1793 and 1794. The central term of the book is that of Pazzia, a word carefully selected to express the idea of a «permanent delirium» (Chiarugi, 1793, p. I). Chiarugi repeatedly emphasized the suitability of the word pazzia for describing the core features associated with insanity. Etymologically, the Italian “pazzia” derives from the vulgar “pactiare” and from the Latin “pactum”, meaning “smashed” and, more precisely, “stunned” when used to describe a person (Nocentini & Parenti, 2010). The Tuscan physician affirmed to have examined all Italian, Latin, and European terms used to describe insanity. Dissatisfied by the inaccuracy of the vocabulary, he opted for pazzia as he said it captured the central idea of delirium. The choice of a foreign term, he said it would have been «an insult to homeland» and from Latin, «a too dangerous theft» (Chiarugi, 1794b, p. 6). As a general condition, pazzia was defined by Chiarugi with three criteria, namely the absence of a preceding fever, the constancy of delirium, and the offence to the senses organ (ibid., p. 2, p. 25). Errors of judgement and reason (raziocinio) so commonly observable in the insane, were said to be the result of a foregoing lesion of the nervous system (sistema nervoso) and, specifically, of the «Sensorio Comune» (ibid., p. 32). This «Sensorio Comune» represented in Chiarugi’s account the material substratum for both straight and deranged reasoning. It was described as an organ located somewhere in the brain –perhaps in the «marrow substance» continued the Tuscan physician– which constituted the point of connection between the material and the spiritual domains (ibid., p. 18). 

It should be mentioned, however, that that Chiarugi distinguished three genera of pazzia, namely melancholy, mania, and amenza. While melancholy was conceived as a form of partial delirium limited to few objects, mania and amentia consisted in a universal delirium characterized by fury in the former case, and by immobility in the latter (Chiarugi, 1794a, p. 8). For each genere, he provided a further differentiation in species. In this way, melancholy comprised three species: «Melancolie vere», «Melancolie Spurie», and «Melancolie Furenti» (Chiarugi, 1794a, p. 5-6). Mania included five species: «Mania Mentale», «Mania Reattiva», «Mania Pletorica», «Mania Immediata», and «Mania Consensuale (ibid., p. 92). Lastly, amenza involved two species: «Amenze Attive» and «Amenze Difettive» (ibid., p. 200). Such classification not only informed Chiarugi’s etiological and therapeutical understanding, but it also guided the allocation of the insane at San Bonifazio.

Chiarugi, therefore, assigned a primary role to the body and, particularly, to the brain as regard to the causes of pazzia. By persevering in falsity and misjudgement, he said, insane acted against «human common sense» and their delirious actions were linked to a «physical illness of the brain» (malattia fisica del Cervello) (ibid., p. 22). Interestingly enough, the Tuscan doctor always referred to the body as a «machine» (macchina), an instrument wisely administered by an incorruptible «Soul» (Anima) (ibid., p. 74). Following this view, Chiarugi fiercely criticized Linnaeus and Magbrid’s expression of «mental disease» (Chiarugi, 1794b, p. 10). If mind was the faculty of the Soul, as Chiarugi claimed, the expression “mental disease” would be equivalent of saying “Soul disease”. But for Chiarugi the Soul was a «spiritual Being, unalterable and immutable» created by the «Providential Creator» (Provvidentissimo Creatore) that could not suffer from any disease because of its holy pureness (ibid., p. 12). Thus the action of the Soul on the body is said to be always right since it represented the action of God. Impairment, therefore, emerged exclusively at the flesh level when a «lesion of the physical constitution» prevented the Soul to properly direct judgement and reasoning (Chiarugi, 1793, p. 42). In a sense, delirium was said to be the result of a masterly Soul guiding a broken machine. 

Additionally, since only humans are provided with the divine gift of reasoning, whenever they lose this capacity they get closer to wilderness. The perennial delirium characterizing pazzia reduces men to beasts led solely by their instincts (ibid., p. 23). Insane resembled to Chiarugi as ferocious animals breaking all social rules, perpetrating every deplorable act, gobbling down the most disgusting stuff (Chiarugi, 1794a, p. 144). Melancholics appeared as werewolves just like maniacs look like tigers (ibid., p. 10, p. 85). Their machine was said to experience a moral and physical metamorphosis which from time to time produced startling results. Chiarugi, for instance, mentioned several cases of “superpowers” including surprising resistance to sleep, cold and hunger, vigorous strength, ability to speak unknown languages, portentous memory, and admirable crafting skills (ibid., pp. 94-96, pp. 98-99, p. 118). Insane’s condition appeared so altered to the Tuscan physician that even their appearance was said to mutate (Chiarugi, 1793, p. 187). According to the chief-physician of San Bonifazio, in fact, the best way to evaluate a true pazzia is to observe the patients’ physical traits. The face of the insane holds no secrets for the «physiognomist» (medico fisionomista) as the status of the machine is said to express the distinctive features of every kind of pazzia (Chiarugi, 1794b, p. 238).

In accordance to his complex etiological account, Chiarugi developed a curative project for insanity making of San Bonifazio an authentic therapeutical institution. The treatment of pazzia followed the foremost goal of re-establishing the equilibrium of the «nerve forces» (Chiarugi, 1793, p. 196). Depending on the situation, he recommended two kinds of cures namely sedative and stimulant. Sedative cures were indicated for all cases in which cerebral activity needed to be diminished, most notably in the case of agitated maniacs (ibid., p. 197). To this regard, Chiarugi maintained there was nothing more beneficial than opium. When wisely administered, this «sovereign medicament» was said to be incredibly effective in calming patients down as it was presented to be responsible for a large number of recoveries at San Bonifazio (ibid., p. 201). Another sedative means recommended by Chiarugi was that of baths. In order for baths to be effective, however, it was important to use cold water and to immerge patients for a prolonged amount of time. Quick immersions, in fact, had the opposite effect of waking patients up (Chiarugi, 1793, p. 201). Bloodletting was also proposed as a viable sedative cure. Although it was preferable to carry out several brief emissions, in critical situations patients were induced to pass out after massive jugular bloodletting (ibid., p. 205). In case of furious maniacs, all sedative cures were to be accompanied with preventive restraining methods. Maniacs should be granted a careful vigilance and custody. They should be locked up in rooms without objects, and when minacious, they should be considered like «unreasonable and ferocious animals, removing them the use of arms and legs» (Chiarugi, 1794a, p. 154). Although chains and insults were considered counter effective (ibid., p. 155), Chiarugi illustrated an innovative way elaborated at San Bonifazio for safely restraining the maniacs in bed. Such a procedure involved the use of a solid bed and a sophisticated labor that surely required many people for keeping the maniac still (ibid., p. 156). In alternative to this intricate method, Chiarugi mentioned the use of leather handcuffs (armille di cuoio) and straitjackets (ibid., pp. 157-161). 

On the other side, for all cases in which the nervous force had to be reinvigorated, Chiarugi listed several stimulant cures. In addition to common treatments like vesicants, cauterizing substances, and warm baths (ibid., pp. 214-216), Chiarugi recommended some unconventional methods. One of the most intriguing was that of fustigation. The chief-physician, in fact, praised the «secure advantage» of whipping the insane’s back, arms, and thighs using nettle strips (ibid., p. 215). The intolerable burning sensation obtained trough this flogging, he maintained, was capable of reviving even the most insensible patients (ivi). Another relevant measure recommended by Chiarugi concerned the sapient use of cold. As cold water was assumed to be a powerful stimulant, the Tuscan doctor suggested to dive the insane into rivers, lakes, or sea (ibid., p. 222). In order to obtain a proper excitement, however, it was important for the immersion to be as sudden as possible. In replying to commentators’ claim that immersions frightened the insane, Chiarugi argued that it was exactly the surprise effect that energized nervous activity. The fright generated trough cold water was a healing passion able to reanimate the passive insane (ibid., p. 223). 

Furthermore, it is important to highlight the secondary role that the chief-physician of San Bonifazio attributed to moral remedies. Although there has been an historiographical tendency to list the name of Chiarugi among the initiators of moral treatment (Carlson & Dain, 1960; Conti, 2015; Charland, 2014; Grange, 1961; Mora, 1987; Ozarin, 1954; Sederer, 1977; Shorter, 2005), it must be noted that the Tuscan physician barely considered moral treatment as a curative option. Throughout his treatise, Chiarugi mentioned «moral aid» (aiuti morali) only in a chapter of the second volume when describing the «cure for melancholy» (Chiarugi, 1794a, p. 67). Moral support, in fact, was somewhat specific to melancholy in Chiarugi’s therapeutical project. Within his nosological framework, it must be recalled, melancholy was qualified as a pazzia characterized by a «partial delirium» (Chiarugi, 1793, p. 8). It was thus a peculiar genre of pazzia. From one side, it was conceived as a less serious condition as opposed to the universal delirium of mania and amentia. On the other side, melancholy was the only pazzia for which anatomical dissections did not provide any significant information regarding the so-proclaimed cerebral origin. As remarked several times by Chiarugi, dissections of melancholics’ brains proved unsuccessful in illuminating the «material origin of the disease» (Chiarugi, 1794a, p. 49). So, how was it possible to cure such a mild and immaterial type of insanity. Pharmaceutical and dietetic means were to be employed, but they should leave the first place to the aforementioned «moral aid» (ibid., p. 67). In dealing with melancholics, Chiarugi’s first prescription was that of removing the erroneous ideas from imagination (ibid., p. 66). By opposing passion to passion, the physician must conquer patients’ confidence. He should become the «master of their hearts» keeping a «truly philosophical conduct» and renouncing of any kind of violence (ibid., p. 68). Slowly but surely, he was to guide insane toward the realization of their absurdity taking advantage of healing passions such as hope, fright, and love (ibid., p. 70).

Thus, moral aid concerned the wise use of passions solely regarding the peculiar case of melancholy. This interpretation is further supported by reading the «one hundred cases of pazzia» reported by Chiarugi at the end of his third volume (Chiarugi, 1794b, p. 90). It must be observed that the vast majority of insane at San Bonifazio was treated with physical and pharmaceutical methods. Moral treatment, indeed, was mentioned only once. In the «Observation n° 80» Chiarugi described the case of a thirty-year old man living in marshy places who, after a disappointing love passion, was said to have become inconsolably sad (ibid., p. 218). The chief-physician, therefore, tried to distract him using moral aid such as persuasion, authority, and threats, but everything turned out unsuccessful. Only a mediocre dose of liquid laudanum and warm baths resolved the melancholic episode (ivi).

Primary Sources

Chiarugi, V. (1793). Della pazzia in genere ed in specie: Trattato medico analitico, con una centuria di osservazioni (Tomo I). Firenze: Luigi Carlieri.

Chiarugi, V. (1794a). Della pazzia in genere ed in specie: Trattato medico analitico, con una centuria di osservazioni (Tomo II). Firenze: Luigi Carlieri.

Chiarugi, V. (1794b). Della pazzia in genere ed in specie: Trattato medico analitico, con una centuria di osservazioni (Tomo III). Firenze: Luigi Carlieri.

Livi, C. (1864, September 18-20). Pinel o Chiarugi? Lettera al celebre D. Al. Brière de Boismont Cav. della Legione d’onore del D. Carlo Livi. La Nazione [Firenze].

Until recently, Chiarugi’s treatise was an extremely rare piece of reading. In 1980s, for instance, George Mora noted that there were only a dozens of copies of the book spread around the world (Mora, 1987). The original version was published in Florence in three volumes. The first in 1793 and the remaining two in 1794. In 1808 the first volume was translated in German and published in Leipzig (Gerard, 1997). Since then, there has never been any other translations until the 1987’s English rendering of Mora. The consideration of Chiarugi as a minor author in the history of medicine has also been connected to the intrinsic difficulty of his treatise. The book, indeed, was written in Italian and Chiarugi’s writing has frequently been deemed as unclear and murky. Even Philippe Pinel in his famous Traité médico-philosophique sur l’aliénation mentale (1800) labeled the Tuscan physician’s work as «general and dogmatic» (p. XLI). Chiarugi gained audience with Livi 1864’s letter but mostly trough the efforts of George Mora in establishing Tuscany at the dawn of psychiatry (Mora, 1954). In 1987 the Genoa-born physician completed the first English translation of Della Pazzia. While this work contributed significantly in spreading Chiarugi’s name to a larger audience, it offered a controversial interpretation of the original text. Starting with the title, for instance, the Italian Della pazzia in genere e in specie, trattato medico-analitico con una centuria di osservazioni, has been simply rendered with On Insanity and its Classification. This is an editorial simplification of some historical consequence, since the qualification of “species” and “genera” placed Chiarugi’s work in the nosological tradition of figures like Boissier de Sauvages, and particularly the estimated William Cullen (Charland, 2014b). Translations included in this paper are based on the original versions of 1793/1794 and are offered by the author accompanied with the original Italian. 

Secondary Sources

Carlson, E. T., & Dain, N. (1960). The psychotherapy that was a moral treatment. American Journal of Psychiatry, 117(6), 519-524.

Charland, L. C. (2014). The distinction between ‘Passion’ and ‘Emotion’. Vincenzo Chiarugi: a case study. History of Psychiatry, 25(4), 477-484.

Conti, N. A. (2015). Vincenzo Chiarugi: La pazzia y el Reglamento de Bonifacio en los orígenes de la psiquiatría moderna. Asclepio, 67(2).

Farrar, C. B. (1908). Some Origins in Psychiatry. American Journal of Psychiatry, 64(3), 277-294.

Gelmetti, C. (2015). Storia della Dermatologia e della Venereologia in Italia. Milan: Springer.

Gerard, D. L. (1997). Chiarugi and Pinel considered: Soul’s brain/person’s mind. Journal of the History of the Behavioral Sciences, 33(4), 381-403.

Grange, K. M. (1961). Pinel and Eighteenth-Century Psychiatry. Bulletin of the History of Medicine, 35(1), 442-453.

Huertas, R., & Del Cura, M. (2004). Chiarugi versus Pinel: La carta abierta de Carlo Livi a Brière de Boismont. Frenìa, 4(2), 109-133.

Mora, G. (1954). Vincenzo Chiarugi (1759-1820): His contribution to psychiatry. Bulletin of the Isaac Ray Medical Library, 2(2), pp. 51-104.

Mora, G. A. (1959). Historical Notes: Bi-centenary of the birth of Vincenzo Chiarugi (1749-1820) a pioneer of the modern mental hospital treatment. American Journal of Psychiatry, 116(3), 267-271.

Mora, G. A. (1959). Vincenzo Chiarugi (1759–1820) and his Psychiatric Reform in Florence in the Late 18th Century. Journal of the History of Medicine and Allied Sciences, XIV(10), 424-433.

Mora, G. (1987). Introduction. In V. Chiarugi, On Insanity and its Classification. Canton, MA: Watson Publishings International. (pp. IX-CXLI).

Ozarin, L. D. (1954). Moral Treatment and the Mental Hospital. American Journal of Psychiatry, 111(5), 371-378.

Sederer L. (1977). Moral therapy and the problem of morale. American Journal of Psychiatry, 134(3), 267-272.

Shorter, E. (2005). A historical dictionary of psychiatry. Oxford: Oxford University Press.

Weiner, D. B. (2011a). The Madman in the Light of Reason. Enlightenment Psychiatry. Part I. Custody, Therapy, Theory and the Need for Reform. In E. R. Wallace & J. Gach, History of psychiatry and medical psychology: With an epilogue on psychiatry and the mind-body relation. New York: Springer. (pp. 250-280).

Weiner, D. B. (2011b). The Madman in the Light of Reason. Enlightenment Psychiatry. Part II. Alienists, Treatises, and the Psychologic Approach in the Era of Pinel. In E. R. Wallace & J. Gach, History of psychiatry and medical psychology: With an epilogue on psychiatry and the mind-body relation. New York: Springer. (pp. 281-303).

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