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.
Psychiatric Classification and the Making of Schizophrenia
Western history, since its early depiction in the Old Testament, had shown two fundamental ways of conceiving madness. While the first implies that health and illness exist on a spectrum as relative states of greater or lesser equilibrium, the second view implies that mental illness is categorically different from mental health.
The diagnosis of dementia praecox, which later gave way to schizophrenia, was born in the nineteenth century, a period that in the history of madness, mad people, and mad institutions was characterized by attempts on the part of the medical profession to create distinct categories of so-called disease entities as natural kinds. Just as botanists had shown that, based on their natural properties, pine trees were similar to each other and different from elm trees, psychiatrists, doctors, and other clinicians hoped to reveal the exact nature of mental disorders, and to differentiate between their distinct natural kinds in the clearest of terms. Unlike some of the earlier views of mental disorders, which saw the body and mind as constantly oscillating between health and illness, and considered health as a form of humoral and moral equilibrium, the mainstream view of alienists in the nineteenth century was that mental disorders were completely different in kind from normal mental states.
Nineteenth-century European medicine, with its laboratories and hospitals, supported the notion that diseases are specific, objective, physical entities that exist outside their unique manifestation in a particular human being.103 Regardless of the place or person in which they are located, disease entities were believed to have typical symptoms, to follow specific courses, produce particular outcomes, and obey an underlying biological mechanism. These disease units were viewed not only as different from health, but also as having clear boundaries that separated them from one another. It is in the framework of this episteme, to cite Michel Foucault’s well-known term, that we see a general shift from “dis-ease” to diseases and from “mal-aise” (a state of discomfort) to malaise (an illness).104