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Victor Kandinsky, MD: Psychiatrist, Researcher and Patient

Vladimir Lerner, Eliezer Witztum and T. Dening History of Psychiatry 2003 14: 103 DOI: 10.1177/0957154X03014001006 The online version of this article can be found at: http://hpy.sagepub.com/content/14/1/103

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History of Psychiatry, 14/1, 103112 Copyright SAGE Publications 0957-154X [200303] 14:1; 103-112; 035138

Victor Kandinsky, MD: psychiatrist, researcher and patient

VLADIMIR LERNER and ELIEZER WITZTUM*

Edited by Dr T. DENING

Psychiatrists are the sons of their time Asylums are the results of its epoch. (Rokhlin 1975)

Introduction In the history of world psychiatry, and especially in Russian psychiatry, several famous gures have contributed to the discipline of psychiatry, and left their names as eponyms. One of them, Victor Kandinsky (18491889), is associated with a clinical syndrome named after him, a syndrome still diagnosed in European psychiatry. It is interesting to note that in American psychiatry Kandinskys name is connected with a completely different clinical state (Lerner, Kaptsan and Witztum 2001). In this paper we present biographical data concerning Kandinsky as physician, researcher and mental patient. The information about Kandinskys life, work and illness was collected from different sources such as his works, letters, biography, memories of friends and relatives, and medical documents. Medieval authors used supernatural explanations for mental disorders, for example, possession by the devil, evil spirits or divine entities. Such

* Address for correspondence: Professor E. Witztum, Beer Sheva Mental Health Center, Beer Sheva, 84170, PO Box 4600, Israel. E-mail: elyiit@actcom.co.il

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explanations continued to be used until the scientic literature of the nineteenth century (Brink 1974, Neugebauer 1979, Jamison 1995, Ingram 1997). Only after psychiatry became an independent discipline did systematic detailed studies of mental disorder begin to appear (Kannabikh 1934). Autobiographical descriptions by a person with a mental disorder can enlighten us about the agonized internal world of the insane, a world that is dark, mysterious, bizarre and alien for normal people. Despite medical progress and the new technologies to investigate the human brain, the subjective experience of illness remains elusive and can only be received from a person who has VICTOR KANDINSKY experienced it. Furthemore, a subjective description of such an internal experience by an expert psychiatrist may be particularly illuminating as to the nature of madness (Jamison 1995). Biographical accounts of patients have certain methodological difculties. They are not direct, rst-hand accounts, but come from secondary and tertiary sources (diaries, letters, memories of family and friends), and therefore they reect different attitudes, biases and sometimes contain discrepancies and contradictory data. Even testimonies of close relatives cannot convey the whole picture, and they represent only a partial one (Frosch 1990). Although various forms of biographical data may be valuable, it is important to nd autobiographical material, especially if it is produced by a physician. The course of Kandinskys life was complicated and ended tragically. It is important to note that much of his research in psychopathology was based upon his own experience, and his writings are signicant sources in assessing his psychiatric condition. From a psychopathological point of view, Kandinsky was an interesting patient, and he himself described his clinical picture with great detail, both in the acute phase and throughout his whole life. Kandinsky lived in a critical time in the history of psychiatry, when psychiatry began to crystallize as an independent discipline. His contribution to Russian psychiatry was signicant, because he incorporated the basic knowledge of his time by translating recent works of Kraft-Ebbing, Kahlbaum,

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Charcot, Magnan, Meinert and Wundt into Russian and elaborating on them. He also contributed to world psychiatry by creating new concepts such as mental automatism and pseudo-hallucination, but his singular contribution was the detailed description of his own state of mind and illness. During his life, Kandinsky was acknowledged for his work and contributions both by his fellow Russian psychiatrists and abroad. Unfortunately, his personal life remains almost unknown. Kandinskys background Victor Kandinsky was born in small village in Siberia on 24 March 1849. His father was a merchant, whose house was known as a cultural salon for musical and literature parties (Maksimov 1900). In his family, two characteristics are prominent: one related to art and music, and the other to psychiatric illness. Several members of the family (nephew and cousins) were well known as artists and musicians, for example, the famous painter Vassily Kandinsky was his nephew. As for mental illness, two of his cousins suffered from paranoid schizophrenia with long-term psychiatric hospitalization (Rokhlin 1975). Little is known about his childhood and adolescence (up to the age of 14), except that he was an only child and that his mothers pregnancy and his birth were normal. Throughout his life he did not suffer from signicant physical problems, and he did not smoke or drink (Rokhlin 1975). At the age of 14 he left Siberia to live in Moscow, where he gained entry to a well known Gymnasium and graduated cum laude, which allowed him to enter Moscow University Medical School without examinations. In 1872 he nished medical school and began to practise as a general physician in one of the Moscow hospitals. Early in his career he was interested in research; for example, from 1874 to 1876 he published 31 papers on different topics including original contributions and literature reviews (there were three papers in psychiatry). His colleagues described him as diligent and meticulous, and as spending most of his time in his work. In his private life he was said to be modest, gentle and sympathetic (Rokhlin 1975). From September 1876 to April 1879 he served in the military as a physician, including participation in the Russia-Turkey war (187778). His rst mission was on a battleship, as the ships physician. During that period he became ill; in May 1877 he was sent to a psychiatric hospital as a patient and stayed there until April 1878. He fell in love with one of the nurses who treated him, and after his recovery they married. After spending the next six months abroad on leave, in October 1878 he returned to Russia and was readmitted with a deterioration in his mental state. In April 1879 he was discharged from military service due to his psychiatric condition. In 1881 he moved to St Petersburg and began to work as a junior psychiatrist in a psychiatric hospital (The Miraculous Nikolai) where he worked until his suicide in 1889.

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His medical and scientic work can be divided into two periods. The rst was in Moscow (187276), when he worked as a general physician and was doing research in philosophy and psychology of medicine. The second period (188189) was in St Petersburg, when his research concentrated on psychopathology (e.g., hallucinations, pseudohallucinations) and forensic psychiatry (a book about the capacity to stand trial was published posthumously by his widow) (Rokhlin 1975). During the second period he was most creative, producing the work for which he received the acknowledgement of the scientic community in Russia and Europe. Kandinskys marriage appears to have been harmonious but, although they wanted children, they did not have any. Their friends described his wife as loving and devoted to him; she helped him in all areas including his scientic work. After his suicide in 1889, she assumed custodial care of his scientic writings and posthumously published his scientic papers and two books. After she had nished this, she too killed herself (Panina and Rokhlin 1975). Kandinskys malady From the recollections of Kandinskys contemporaries, it is known that his illness rst appeared in 1877, and that it included a suicide attempt. While he served as physician on the ship during the battle with the Turks he jumped to the sea to kill himself, he was saved and the nurse who took care of him later married him; he called her mother and gave her a lot of attention (Panina and Rokhlin 1975). The rst episode of illness lasted about two years according to his own description. In his work on hallucinations he wrote: To my sadness, during two years I suffered from insane hallucinations . . . I felt various and abundant hallucinations in all my senses except taste. The most frequent and vivid were visual, tactile, and common sensibility (Gemeingefhl) hallucinations (Kandinsky 1880). During his rst psychotic episode he avoiding describing his feelings and experiences and gave only vague and unclear answers to the physicians. Later he paid attention to the stages in the development of his disorder. At rst there were only delusions: In the rst months of my malady there were no hallucinations. This period was generally characterized by intense but chaotic intellectual activity (for which Kandinsky coined the term intellectual delusion): a lot of ideas that ran speeding but not in the right course, experienced as forced and false. Gradually the hallucinations appeared, and the delusions faded. In his book about pseudohallucinations Kandinsky described numerous and varied psychopathological symptoms, such as delusions of persecution together with grandiosity, and delusions of inuence which he experienced during the acute phase. He illustrated in detail all the symptoms included in mental automatism (telepathy, reading and broadcasting thought, enforced speaking and enforced motor movements). He concentrated especially on

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various forms of abnormal perception, and he described disturbances in different modalities: visual, auditory, olfactory and tactile. He also described pseudohallucinations, imaginary scenarios and hallucinations of common sensibility (Berrios 1996) and autoscopic and musical hallucinations which appeared, sometimes simultaneously with a disturbance of consciousness. The latter were experienced as an oneiroid state. This set of symptoms was accompanied by a labile affect that varied from hypomanic to depressive. The depressive affect was more common, with suicidal ideation and a number of suicide attempts (Kandinsky 1880). In his medical record, which was in an archive in St Petersburg (Rokhlin 1975), there is a note from his wife that he suffered from mental disturbance from May 1877 till April 1878 and from September 1878 till May 1879. This indicates that he had at least 2 psychotic episodes with an intermittent remission lasting 4 months. Kandinsky himself noticed only one psychotic episode, which continued for about 2 years. The next episode appeared in 1883 after a full remission of 4 years. Between 7 and 16 March 1883 he stayed at home, but then his condition deteriorated and he was admitted to a mental hospital until his discharge on 20 April. Kandinsky recorded that this episode was brief and I was restored to health, and full insight to my condition developed during 2 months (Kandinsky 1880). According to recollections of his friends and colleagues, besides suffering from psychotic states, Kandinsky also had depressive episodes without need for hospitalization. Korsakov, the famous Russian psychiatrist, wrote in a letter to a friend: I met Kandinsky. He felt well but claims that from time to time he suffered depression (Rokhlin 1975). The deterioration of Kandinskys mental state in 1889 can be inferred from his decreased participation in the Psychiatric Society of St Petersburg (which met four times a year). He had been quite active, giving lectures and being nominated as secretary at the rst congress of Russian psychiatrists in 1887, but in1889 he became passive and attended only one meeting (in January). He committed suicide in September 1889 (Rokhlin 1975). His friend, the publisher Sabashnikov, wrote, after the present episode, Kandinsky returned to his work prematurely. In transitional periods between illness and recovery, Kandinsky usually suffered from suicidal ideation. On this occasion, he surrendered to the urge, went to the hospital, got a large amount of opium from the pharmacy, returned home and took a lethal dose. Even in that situation he continued to write and to describe his own experience: he took a page of paper and wrote, I swallowed several grams of opium, still able to read and then in a different hand writing, hardly reading and then he was found dead (Panina and Rokhlin 1975). A famous German psychiatrist, A. Rothe, wrote in Kandinskys obituary: In a paper that Kandinsky left on the table there is documentation that in his last breath he was engaged in science

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and his last words were, I am not able to write more because I cannot see. Light! Light! Light! . . . (Rothe 1890). In a publication of 1880, Kandinsky, though not yet a psychiatrist, had diagnosed himself as suffering primary insanity (Kandinsky 1880). By primary he meant that his malady was not secondary to organic cause or to substance abuse. Later, when he became psychiatrist, he changed the diagnosis to paranoia hallucinatoria (Kandinsky 1890a) and criticized the psychiatrist who had diagnosed him as suffering from melancholia. He analysed the symptoms of depression which followed his delusions and hallucinations, and came to the conclusion that depression was secondary and most probably stemmed from the psychotic experience. I was depressed, but the depression was not the principal problem. The depression was a response to changes in lifes condition, discontinuation of work, separation from close friends and nally the realization that I am ill and illnesss outcome will be dementia (Kandinsky 1890a). The two diagnostic terms that he applied to himself primary insanity and paranoia hallucinatoria, as well as ideophrenia a term which he used in his suggested diagnostic classication (see below) perhaps resemble the modern diagnosis of schizoaffective disorder. In this condition, there is a combination of affective and psychotic symptoms with good remission between episodes. Kandinskys rst episode lasted a year and a half, followed by a full remission for four years, with full functioning in his clinical and scientic work (Kandinsky 1890a). His friend and neighbour wrote, we visited each other frequently, he was a physician-psychiatrist, with erudite knowledge in philosophy, of friendly and vivid personality with a skilful capacity to elaborate complicated subjects and in a short time to be an authority among his circle of friends (Kandinsky 1880). Kandinsky continued his scientic work after his psychotic episodes, suggesting that he was in a state of full remission. For example, from 1879 to 1883 he published two books and several articles, and translated three books from German into Russian. In 1882 he even elaborated a psychiatric classication. But the next remission after his psychotic episode of 1883 appeared more slowly. According to his wifes letters, his mental state was uctuating (Kandinsky 1890a) and, in his own observations, only after 2 months insight appeared but still together with auditory hallucinations that gradually diminished and disappeared a month later (Kandinsky 1890a). After the psychotic episode of 1883, he returned to his clinical work. After two years, in 1885 he was appointed as senior psychiatrist in the Miraculous Nikolai Psychiatric Hospital, and prepared two books for publication, one about pseudohallucinations (Kandinsky 1890a) and the other on forensic psychiatry (Kandinsky 1890b). His wife published these books post-humously. At the time of his premature tragic death in 1889, he was still at the peak of his productivity. As a psychiatrist Kandinsky realized that scientic and clinical knowledge

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of the psychotic episode was desperately needed, and with this understanding he continued his self-observation on the impact of the psychotic state on cognition, behaviour and inter-personal relationships. Conclusions The main professional contributions of Kandinsky were in three areas: psychopathology, forensic psychiatry and psychiatric classication. In psychopathology, his works on hallucinations included a detailed description of his own experiences. He borrowed the name pseudohallucinations from French psychiatry and called his book About Pseudohallucinations. Later he came to the conclusion that the term pseudo could be confusing and returned to such terminology as hallucination like, hallucinoides, illuminations and illustrations (Kandinsky 1880, Berrios and Dening 1996). Jaspers discussion of these phenomena did much to draw attention to Kandinskys work (Jaspers 1963). Berrios (1993) claimed that choosing to quote Kandinsky in this matter was odd since Kandinskys book (originally published in Russian in 1880) is little more than a description of his own hallucinations. In 1882 Kandinsky elaborated a classication system for mental illness, with 16 diagnostic categories, which was quite sophisticated for his time. The categories were (Rokhlin 1975):
I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. XVI. Hallucinations. Melancholia. Mania. Ideophrenia. Paraphrenia. Dementia primaria acuta. Dementia primaria chronica. Paralysis generalis progressiva. Psychoepilepsia. Psychohysteria. Psychosis periodica et psychosis circularis. Delirium tremens potatorum. Delirium acutum. Dementia secundaria. Imbecillitas. Idiotismus. Psychoses constitutionals cum degeneratione.

His third major contribution was in forensic psychiatry. In 1864 the legal system in Russia, which was based on a jury system, began to invite psychiatrists as expert witnesses in questions of responsibility when the accused suffered from mental illness. The standard opinion at that time was that any person who suffered from any mental illness was not responsible. In his book, entitled On the Matter of Irresponsibility (Kandinsky 1890b), and

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in his papers and lectures, Kandinsky argued against this general and undifferentiated approach, suggesting that every case should be examined individually according to specic diagnosis and the clinical state at the time the crime was committed. He also demonstrated that clinical states could be dynamic over time. For example, a patient who could not stand trial at a particular time might later improve and would then be able to stand trial. He also differentiated between the ordinary clinician and the forensic psychiatrist, believing that only a forensic psychiatrist should be permitted to give expert opinion to the court (Kandinsky 1890b). Kandinsky wrote, The witness should deliver the plain facts, the witness from the medical profession should testify only on medical fact, the expert in the forensic area should extrapolate from the clinical materials and deduce from them conclusions that will help juries and the judge to arrive at the correct decision in the specic case (Kandinsky 1890b). It is important to note that, at that time, many psychiatrists, including prominent and well-known professors, could not understand the necessity of forensic psychiatry as a separate discipline and argued against it. Many aspects of this discipline that today appear commonplace were rst introduced by Kandinsky towards the end of the nineteenth century and were revolutionary in that period. We believe that Kandinskys life and work exemplies a ne model of coping with a debilitating mental disorder. For this, alongside his clinical and scientic contributions, he deserves to be remembered in the history of psychiatry.

REFERENCES Berrios, G. E. (1993). Phenomenology and psychopathology: was there ever a relationship? Comprehensive Psychiatry, 34, 21320. (1996). The History of Mental Symptoms: Descriptive Psychopathology since the Nineteenth Century (Cambridge: Cambridge University Press). Berrios, G. E. and Dening, T. R. (1996). Pseudohallucinations: a conceptual history. Psychological Medicine, 26, 75363. Brink, A. W. (1974). The Life of the Reverend Mr George Trosse: written by himself, and published posthumously according to his order in 1714 (Montreal: McGill-Queens University Press). Frosch, W. A. (1990). Moods, madness, and music. II. Was Handel insane? The Musical Quarterly, 74, 3156. Ingram, A. (1997) Voices of Madness (Gloucestershire: Sutton Publishing). Jamison, K. R. (1995) An Unquiet Mind: a Memoir of Moods and Madness (New York: Alfred A. Knopf). Jaspers, K. (1963). General Psychopathology, translated by J. Hoenig and M. Hamilton (Manchester: Manchester University Press). Kandinsky, V. K. (1880). [About hallucinations]. Meditsinskoe Obozrenie, 13, 81524. (1890a). O Psevdohallucinatsiakh. Kritiko-klinicheskii etud. [About Pseudohallucinations. Criticalclinical Study] (St Petersburg: Isdanie EK Kandinskoi). (1890b). K Voprosu o Nevmenyaemosti [On the Matter of Irresponsibility] (Moscow: Izdanie EK Kandinskoi). Kannabikh, Y. V. (1934). The History of Psychiatry (Moscow: Gos. Med. Izd).

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Lerner, V., Kaptsan, A. and Witztum, E. (2001). The misidentication of Clerambaults and Kandinsky-Clerambaults syndrome. Canadian Journal of Psychiatry, 46, 4413. Maksimov, S. V. (1900). Siberia and Penal Servitude (St Petersburg). Neugebauer, R. (1979). Medieval and early modern theories of mental illness. Archives of General Psychiatry, 36, 47783. Panina, A. L. and Rokhlin, L. L. (1975). [Elucidations of M. V. Sabashnikovs Recollections of V. Kh. Kandinskii]. Zhurnal Nevropatologii i Psikhiatrii im S S Korsakova, 75, 43943. Rokhlin, L. L. (1975). The Life and Works of the Eminent Russian Psychiatrist V. Kh. Kandinsky (18491889) (Moscow: Meditsina). Rothe, A. (1890). D-r med W. Ch. Kandinski. Necrolog. Allgemeine Zeitschrift fr Psychiatrie und psychisch-gerichtliche Medicin, 46, 550.

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