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Some of my unfortunate patients labored under the horrors of a most gloomy and desponding melancholy. Others were furious and subject to the influence of a perpetual delirium. Some appeared to possess a correct judgment upon most subjects, but were occasionally agitated by violent sallies of maniacal fury; while those of another class were sunk into a state of stupid idiotism and imbecility. Symptoms so different and all comprehended under the general title of insanity, required on my part, much study and discrimination. (Philippe Pinel, A Treatise on Insanity, 1806)⁸⁰

Like other doctors working in hospitals and asylums during the mid-eighteenth century, Philippe Pinel, chief physician at the Salpêtrière, noticed the many different mental sufferings that were all classified under the broad title of insanity. Dissatisfied with the lack of discrimination between them, he writes:

It is to be hoped, that our system of classification, independent of its methodical clearness and discrimination, will continue towards the establishment of proper rules for the internal government of lunatic hospitals and serve to discover or confirm some general indications of treatment, which in order to avoid empirical experiments, ought to be respectively adapted to each species and variety of mental derangement. (Philippe Pinel, A Treatise on Insanity, 1806)⁸¹

It was during this time, as the first “lunatic hospitals” emerged, that physicians tried to systematically “carve nature at its joints.” This meant studying the genus of insanity and classifying its varied species, creating distinct categories of insanity based on their different symptoms, hoping to offer each distinct illness the treatment it required. As German E. Berrios and Ivana S. Marková have amply documented, this process of demystifying madness may have had its roots in Enlightenment thought. Be that as it may, the weakness of its premises and procedure would quickly become all too clear. After all, if indeed madness is, first and foremost, a cultural object with a historical index, and as such not conducive to being framed or reframed as a natural kind, to be fixed and measured objectively (like gold, tree, or tiger, each of which could presumably be easily “carved at the joints”), then the aforementioned classificatory project never stood much of a chance and, in all likelihood, could never have been accomplished completely.⁸²

As stated above, during the seventeenth century, the Galenic view, which considered madness as a functional disturbance of the body caused by an imbalance of the four humors or the six non-naturals, always existed side by side with spiritual and metaphysical explanations that conceived madness as the result of a foreign invasion (and, hence, proposed remedies to expel these very invaders). But, as the eighteenth century brought about a general secularization of thought and life, new questions regarding human beings and the nature they are part of (developments we now associate with the so-called “Scientific Revolution”) dramatically changed the moderns’ idea of madness overall.

According to Berrios and Marková, during this time, madness increasingly began to be viewed as a natural kind. Like plants, physical and mental diseases were now seen as sharing common, ontological features that can be used to classify them once and for all. During this period, most classifications applied the method devised by the father of modern taxonomy, the Swedish botanist, zoologist, and physician, Carl Linnaeus (1707–78). This classificatory method used a privileged set of features of the species and phenomena at hand to group both plants and diseases. In his 1759 work, Genera Morborum [Classification of Diseases], Linnaeus argued that the system that served the botanist might as well also serve the physician. By classifying diseases into classes, genera, and species, physicians can gain more clarity about disease: “Symptoms are to disease as leaves and stems are to plants.”⁸³ Thus, for example, his Class V, the Mentales (“Diseases in which the Functions of the Mind are disturbed”) contains “1. Ideales: those in which the Judgment is principally affected,” among them Delirium, Mania, and Melancholia; “2. Imaginarii: those in which the Imagination is principally affected,” such as Vertigo and Hypochondriasis; and “3. Pathetici: those in which the Appetites and Passions are principally affected,” such as Bulimia, Erotomania, and Nostalgia.⁸⁴

Linnaeus’ close friend and collaborator, François Boissier de Sauvages (1706–67), a professor at the medical school of Montpellier, was a vigorous classifier, who argued that medicine should follow the botanical model of classification by observable signs. He criticized the Galenic tradition, which classifies diseases according to imaginary anatomy and hypothetical causes, instructing his followers to stick to the testimony of their senses.

Unlike these botanical models, which were based on the observed characteristics of the disease, by the late eighteenth century, William Cullen (1710–90), an influential professor of medicine and physics at the University of Edinburgh, suggested diseases be classified according to their possible etiology, that is, according to the cause of their disorders and natural history. In his First Lines of Physic, Cullen gave the name neurosis to a class of diseases that, in his definition, included irritation of the “nerves,” rather than focal lesions in the brain per se.⁸⁵ One of the four “orders” of the neuroses was a group of “insanities” or so-called “vesaniae,” whose examples included amentia (idiotic insanity), melancholia (unsound mind in a sorrowful manner), mania (unsound mind in a furious manner), and oneirodynia (intense mental disturbance associated with dreaming).⁸⁶

Another classification system was offered by the celebrated French physician Philippe Pinel (1745–1826), with whom we opened this section, who suggested turning back to detailed clinical observation, noting the course of disease, and incorporating the patient’s life history. In his Medico-Philosophical Treatise on Mental Alienation or Mania, Pinel presented a classification of mental disorders that included four classes of insanity: maniacal insanity, melancholia, dementia, and idiocy.⁸⁷ Maniacal insanity, according to Pinel, was typically temporary – yet sometimes chronic – and frequently curable. Melancholia was defined by “a dreamy taciturn manner, touchy and suspicious, with a desire to be left alone.”⁸⁸ Dementia was seen as gradually eroding the victim’s thoughts and could not be cured. Finally, idiocy was the term used to describe a condition in which the intellect is not fully developed. These categories were still largely in use until the mid-nineteenth century, when hundreds of other psychiatric classifications were published across Europe.

The stage is now set for the historical and conceptual question that interests us here: what became of the category of schizophrenia when the term was coined, and what led to its diagnosis and definition in the first place?

During this modern Enlightenment period, the concept of mental disease as a cluster of mental symptoms was first introduced, theoretically delineated, and clinically applied. As Berrios notes, descriptive psychopathology was also soon introduced as a new language in the field of mental afflictions. Its method and technical idiom served a new profession, namely “alienism,” which would become the precursor of “psychiatry,” and which, as soon as it emerged, established itself as a trade, a science, and a medical practice.⁸⁹ During the rise of the asylum system, conflicts erupted between alienists, on the one hand, and legislatures, the clergy, and civil society, on the other.

The idea that complaints were signs of disease allowed mental symptoms to be thought of as smaller units of “mental disease,” understood as a condition, a disorder, or, indeed, an illness. Whether the symptoms were mere exaggerations of “normal” mental functions on a wider spectrum, or whether, on the contrary, they were a categorically distinct new phenomenon was a much-debated question during the nineteenth century. Psychologists tended to argue for the former, and alienists for the latter.⁹⁰

Most of the data collected on mental illness during this period came from the asylums. The deplorable sanitary conditions in these institutions – with their overcrowding, outbreaks of epidemics and infections, and downright neglect – led to high mortality rates among patients. In response to these conditions, physicians were legally obliged to be present in the asylums and keep records of their observations. The large cohorts of patients treated in the asylums were considered not as individual sufferers, but rather as inferior, pathological specimens.⁹¹ Data collected from these patients then served as a foundation for the newly developed field of psychopathology.⁹²

One important question for psychopathologists was to determine what differentiates normal from abnormal behavior and experience. And because no biological markers were available to answer this question, deviance from the proper, ethical, and acceptable social norms, together with patients’ self-reports on their state of mind, became the defining criteria to determine mental illness. Indeed, the science of psychopathology, which started out from this “hybrid platform” due to an absence of clear biological markers and tests, has not changed much in its contrary ambition and inclination. To this day, clinicians still base their examinations both on the observed behavior and the subjective experience of the individuals they treat. The latter reveal two opposed aspects of a single phenomenon, which lead to contrasting paradigmatic explanations and self-understandings of the same symptoms (the objectively observed and recorded, on the one hand, and the subjectively experienced and reported, on the other).⁹³

But the mere differentiation between the normal and the abnormal or the psychopathological, which determined who would be placed in the asylums, was never enough. “The Era of the Asylum,”⁹⁴ as Edward Shorter, a social historian specializing in the history of the insane, aptly names this period, saw an ever-increasing need to place the mentally ill also in different wings of these institutions. In its footsteps, a further differentiation among those committed to the asylum became necessary. Some criteria used to place patients in different areas of the building were completely unrelated to the person’s illness (e.g., male or female), but some were based on their diagnosis (e.g., agitated or quiet, acute or chronic, rational or irrational, continent or incontinent, epileptic or non-epileptic, organic or functional, criminal or non-criminal).⁹⁵

Psychiatry was in fact “a profession in reverse,” writes the sociologist Andrew Abbott. It began with the establishment of its institutions, that is to say, the asylums, and only later developed its expert knowledge regarding the mental illnesses that the residents in these houses supposedly suffered from.⁹⁶ It was only after the asylums were established that the further professionalization of alienism (i.e., the study, understanding of, and caring for those who suffered from “mental alienation” in Europe and, in this respect, the precursor of psychiatry as a scientific discipline) took place through the development of local professional societies, textbooks, journals, training procedures, and examinations, and perhaps even more importantly, through largely unsuccessful efforts to establish a uniform systematic description of diseases, a so-called nosographic lexicon.⁹⁷ In the process, the asylums enabled “a minor epistemological revolution,” and theories that assumed that madness was in the body became more and more prevalent.⁹⁸

The insanities, during this period, were seen as disorders of the senses and of the movement of the nervous system, without fever or focal lesion. They were differentiated from conditions like Parkinson’s disease and multiple sclerosis, for which clear lesions of the brain were indeed found. It was neurology, the other new profession that emerged during this time, that explicitly aimed to treat these latter conditions. Insanities such as hypochondriasis, hysteria, anxiety disorders, obsessive-compulsive disorder, and neurotic depressions were now named “psychoses,” while the term “neuroses” was reserved for what was increasingly believed to be a psychological conflict.⁹⁹

Not only were the “psychoses” contrasted with the “neuroses,” in the nineteenth century the former term also came to replace the more general and colloquial concept of madness, together with the different symptoms that define it such as hallucinations, delusions, mental confusion, irrationality, and thought disorders. Aspiring to offer not merely a symptom-based classification system, but, as in the rest of medicine, a system that classifies different illnesses based on causation (as different diseases may exhibit similar symptoms but nonetheless have distinctive causes), the psychoses were further divided into more specific diagnostic groups during this period: “functional” versus “organic,” “endogenous” or “exogenous,” while “acute and chronic” cases were now also distinguished for the first time. Madness with no “known anatomical lesion” was named “functional psychosis,” and included diagnoses such as delirium hallucinatorium, mania, melancholia, circular psychosis, paranoia, and acute dementia.¹⁰⁰ Forms of “organic psychoses,” by contrast, were related to other physical diseases like syphilis, but also to diseases of the brain, such as brain tumors, and to those thought to arise from other nervous disorders, such as epilepsy.

As mentioned, yet another differentiation was created within the psychoses between forms of psychosis that were seen as caused by external agents, such as toxic substances, infections, syphilis, alcoholism, and brain infections. These were considered to be based on “exogenous” causes. Yet other forms of psychosis, such as neurasthenia, hysteria, epilepsy, and migraine were considered to arise from internal sources and were thus labeled “endogenous.”¹⁰¹

In the nineteenth century, mental disorders thus came to be thought of as classifiable not unlike plants, animals, or minerals, according to either external features (i.e., their visible symptoms) or, as was common practice in other fields of medicine, based on their presumed causes.¹⁰² It was precisely with such a classificatory zeal that mental illnesses were increasingly approached. What emerged was the understanding that there is a correspondence between the causes of different mental illnesses, some possible visible damage to the brain, various observed symptoms, and the final outcome of the condition. This growing insight enabled Emil Kraepelin (1856–1926), the main figure discussed in the next chapter, to group together several existing diagnoses into two large nosological entities, which would come to be known as “the twin pillars” of the modern classification of so-called psychiatric diseases: “manic-depressive insanity,” on the one hand, and dementia praecox, the precursor of schizophrenia, on the other.

The criterion of “prognosis,” or outcome, was central to Kraepelin’s system of diagnosis, and was more precisely defined in terms of “curability” and “incurability.” In Kraepelin’s early writings, there were thus two groups of “madness”: manic-depressive insanity, where the hope of “complete restoration” was possible, and dementia praecox, a steadily progressive kind of mental illness, whose inevitable outcome was deterioration and which resulted in dementia.