175-

Historiography of mental systems and diseases

G. E. BERRIOS*

The history of psychiatry is ailing from migrant worker-disease.

Philosophers, sociologists, social anthropologists, professional historians and
others have discovered that psychiatry is the ideal testing ground for their pet
theories. Just like the atomic scientists of old, the new-age ones hit and run,
leaving much conceptual fall-out behind. They rarely stop to ask what might
happen to patients and psychiatric services alike if, through some crevice in
the soil, the fall-out feeds some proverbial political monster who (as it
happened in Italy not long ago) decides to implement their views?
It is not altogether clear how concerned the new-age specialists are for the
subjects of their research. It is to be expected, however, that they should be
concerned, for they benefit from the existence of those labelled mentally ill
as much as clinicians are accused of doing. Whilst clinicians seem to pay
back in their way, what do fair-weather historians give back to patients? Very
little, it seems. Can this abuse be ameliorated? For a start, psychiatrists
would rather share their discipline with dedicated historians, that is with those
who, as a result of writing on the history of psychiatry, develop empathy, a
feel, for the subjects of their research (who, after all, are fellow human
beings). Rather than behaving like gold-diggers, historians should settle on
the ground they mine, and be active in its re-landscaping. Clinicians do not
want historical voyeurs or subjects who use their writings to act out their
hang-ups: the mentally-ill deserve better than this.
Exploitation can also be corrected by convincing historians to do more
work on the history of mental symptoms and diseases. This short paper will
argue that this work is both useful, legitimate, and best done in close
collaboration with clinicians. Unfortunately, the new-age travellers often
crowd clinicians out of their own land by making them feel that their
historical efforts are amateurish and lacking in historiographic sophistication.

* Address for correspondence: Department of Psychiatry, University of Cambridge,

Addenbrookes Hospital (Box 189), Hills Road, Cambridge CB2 2QQ, UK.

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176

It is important, however, to remember that it was these amateurs who put

1
together the first anthologies and created the first historical accounts.
However linear, internalist, or naively-realist this work may now be thought
to be, on what grounds are we to claim that it is inferior to what is written in
current PhDs? Where is the yardstick? Have issues concerning historical
validity, factuality and constructionism been already resolved? Where and by
whom?
It is time, therefore, that the worm turned. Clinicians may not be able to
understand the fine points of modern historiography, but have much to offer
that is historically relevant. Central to this is their knowledge by acquaintance
resulting from the long-term usage of the languages of description and
observation of behavioural changes. There is nothing wrong with the
internal accounts that might issue from this experience. Hence, it will also
be suggested in this paper that the history of symptoms and diseases may
provide the conceptual basis for all historical approaches including those keen
on macro-concepts and overarching theories.

The past
That psychiatric understanding and creativity are enhanced by knowledge of
their history was clear to nineteenth-century alienists, and some like Calmeil,
Morel, Trelat, Semelaigne, Kirshoff, Winslow, Ireland, Mercier, Bucknill and
Tuke wrote special works on psychiatric history. Most, such as Pinel, Heinroth,
Esquirol, Guislain, Prichard, Feuchtersleben, Connolly, Griesinger, Lucas,
Falret or Dagonet, included historical chapters in their classical textbooks.
Yet others, such as Haslam, emphasized the value of historical semantics:
Mad is therefore not a complex idea, as has been supposed, but a complex
term for all the forms and varieties of this disease. Our language has been
enriched with other terms expressive of this affection ....3 Heinroth himself,
influenced by eighteenth-century historicism,4 interpreted his role as one of
rescuing lost historical insights from some primordial (and fully mythical)
psychiatric past. He also subscribed to a cyclical, Vico-inspired conception,
according to which history was but the recurrence of a few great themes:
The development of mental forces in humanity is accompanied by an ever
advancing, ever more degraded degeneration of these forces.&dquo; Psychiatry,

1
As for example, the work of the late Richard Hunter and his first class collection of historical
material.
2 As expressed, for example, in books such as: Lefebre G. La Naissance de la histonoriographie
moderne (Paris: Flammarion, 1971).
3
4
Haslam, J., Observations on Madness (London: J. Callow, 1809), 4.
Engel-Janosi, F. The Growth of German Historicism. Studies in History and Political Science,
Series 62, No.2 (Baltimore: Johns Hopkins University, 1944).
Heinroth, J. C., Lehrbuch der Störungen des Seelenlebens (translated by J. Schmorak), 2 vols.
(Baltimore: Johns Hopkins Press, 1975), 40.

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 177

however, could escape this eternal cycling by following a developmental

path: A study of the kind and degree of recognition and treatment of mental
disturbances observed in early antiquity shows that these bear a striking
imprint of the childhood of the human spirit.&dquo;
Pinel, on the other hand, made use of a presentistic approach and saw
history as a mere preparation for the present. Perhaps influenced by the
progressism of the French revolution, he regarded the past of psychiatry as a
museum of failed endeavours, and criticized old men, ideas, and even books:

English monographs on mental alienation during the second half of the

eighteenth-century promise a great deal in view of the avowed intention of
their authors to concentrate on specific topics; but this promise is rarely
fulfilled. Vague and repetitious argument, old fashioned clinical approach
and lack of clinical facts and doctrine contribute to this failure.&dquo;
Prichard, whose historical sense had been sharpened by his interest in
matters anthropological, utilized historical material in a different way.
Wanting to break away from associationism, he adopted a simplified form of
faculty psychology and proceeded to attack what he called (following Pinel)
the intellectualistic view of insanity (i.e. that it was due to a primary
disorder of intellectual functions): It has been supposed that the chief, if not
the sole disorder of persons labouring under insanity consists in some
particular false conviction, or in some erroneous notion indelibly impressed
upon belief ... from Mr Lockes time it has been customary to observe the
insane reason correctly from wrong premises ... that this is by far too
limited an account of insanity and only comprises one among various forms
of mental derangement, every person must be aware...8
Bucknill and Tuke also included various historical chapters in their
Manual, for instance, on what they called lay descriptions of insanity, then on
the opinion of medical writers, on the concept of insanity, and on aspects of
treatment, and classification.
But few nineteenth-century alienists made their historiographic tenets as
explicit as the Austrian Feuchtersleben. Quoting Goethe he stated: All
professional men labour under a great disadvantage in not being allowed to
be ignorant of what is useless ... every one fancies that he is bound to
transmit what is believed to have been known. Feuchtersleben, however,
proposed that only the empirical sciences should be allowed to dismiss the

6 Heinroth (1975), op. cit., 41.

7
. Second edition (Paris: Brosson,
Pinel, Ph., Traité medico-philosophique sur laliénation mentale
1809),xix.
8 Prichard, J. C. A., Treatise on Insanity and Other Disorders Affecting the Mind (London:
Sherwood, Gilbert & Piper, 1835), 3.
9
10
Bucknill, J. C. and Tuke, D. H. A Manual of Psychological Medicine (London: Churchill, 1858).
Feuchtersleben, E. von., The Principles of Medical Psychology (translated by H. E. Lloyd and B.
G. Babington) (London: Sydenham Society, 1847), 23.

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178

past as a mere history of errors; as to the rest of sciences, and this included
medical psychology, the history of a science [was] properly the science
itself. The new science of psychiatry belonged to both spheres or types of
science: That part of it which was philosophical contained an abstract of
that state of philosophy in every age, while that which is empirical has by no
means attained such precision and clearness as to render a knowledge of
previous opinions superfluous... He concluded: I am, therefore, obliged to
treat the history of our branch of the profession ....This he proceeded to
do in a chapter of three thousand words.
Kahlbaums great book on Die Gruppirung der psychischen Krankheiten,
perhaps the most important nosological book during the second half of the
nineteenth-century is, in essence, a historical book - and one of the best I
know - on the various classificatory paradigms for mental disorder. Thus, the
first part, which runs for about sixty pages, is fully dedicated to studying
systems which Kahlbaum classifies as multiple (e.g., Platter and Sauvages),
simple (Stark, Esquirol, Reil), and unitary (Neumann, Friedreich, Jacobi,
2
Flemming, etc. ) .
Gine y Partagas, one of the great Catalan alienists of the nineteenth-
century, presciently believed that insanity had, throughout the ages, reflected
social values: Given that the various branches of human knowledge tend to
reflect the moral and political development of the nations, no one is a better
example of this than the branch of medicine that deals with mental illness.&dquo;
Influenced by Comtean and Darwinian ideas Gine also believed that because
psychiatric concepts had an independent historical provenance, it was
legitimate to separate psychiatry from neurology.

Twentieth-century clinical historians

In their use of historical information, writers of twentieth-century psychiatric
textbooks have fared no better than their nineteenth-century counterparts. 14
The historical chapters included in these works are narrative in style, and
rarely contain (as the accompanying clinical chapters always do) references
to recent research. Their authors iterate the conventional, and rehearse the

11
Feuchtersleben (1847), op. cit., 24.
12
Kahlbaum, K., Die Gruppirung der psychischen Krankheiten und die Eintheilung der Seelenstorungen
(Danzig: A. W. Kefemann, 1863), 4-58.
13
Giné y Partagás, D., Tratado Teónco-Práctico de Frenopatologia (Madrid: Moya y Plaza, 1876), 1.
14
Kaplan, H. I. and Sadock, B. J. Modern Synopsis of Comprehensive Textbook of PsychiatrylIII
(Baltimore: Williams and Wilkins, 1981); Arieti, S. (ed.). American Handbook of Psychiatry, Vol.1,
(New York: Basic Books, 1974); Ey, H., Bernard, P. and Brisset, Ch. Manuel de psychiatrie (Paris:
Masson, 1974); Forrest, A. D., Affleck, J. W. and Zealley, A. K. (eds) Companion to Psychiatric
Studies (Edinburgh: Churchill Livingstone, 1978); Sluchevski, I. F. Psiquiatria. Spanish translation
by Florencio Villa Landa and Manuel de la Loma (Mexico: Editorial Grijalbo, 1960); and Alonso-
Fernández, F. A. Fundamentos de la Psiquiatria Actual, Vol.I (Madrid: Paz Montalvo, 1976).

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 179

oft-told tale of a mythical continuity of ideas starting with Hippocrates and

leading Areteus, Galen, Platter, Linne, Cullen, Chiarugi, Pinel,
to
Griesinger, Kraepelin, Freud, Jung and Schneider. The twentieth-century
secondary sources for this continuity view
usually are the books by
Zilboorg,15and Alexander and Selesnick,16 which are mechanically quoted by
the authors of these chapters without ever checking the originals.
Hence, historical information offered in current clinical textbooks is rarely
organized in terms of hypotheses, and predictably, the same pictorial
illustrations by Durer, Hogarth, Arnold, Floury, Tardieu and Brouillet are
printed. Whilst perhaps helping psychiatric trainees or residents to answer a
few examination questions, this fragmentary presentation creates the
impression that the history of psychiatry is bereft of concepts and theories.
Far more research is needed into the history of psychopathology. For as
long as psychiatry remains a descriptive discipline (i.e. one in which the
capture of clinical data depends on the recognition and naming of
behavioural forms), it will be essential to understand how its language came
to be formed. The quality of fit between descriptions and behavioural
phenomena depends both upon the quality of the descriptive system and the
stability of the phenomena themselves. But whilst the latter is, to a large
extent, guaranteed by neurobiology, the former is a function of semantic
organization and of the stability of the psychosocial matrix in which the
naming activity takes place.

Current state of the art

In spite of the exploitation by migrant-workers there is little doubt that the
history of psychiatry (less so that of descriptive psychopathology) is going
through interesting times. For this we should be grateful to many.&dquo; The
revival, in a way, started about twenty-two years ago, with occasion of the
Yale Symposium on the History of Psychiatry&dquo; and where an evaluation was
made of the fruits of traditional historiography.9 It was this innovative spirit
that led Marx2 to state that psychiatric history required a view of history, a

15

16
Zilboorg, G., A History of Medical Psychology (New York: Norton, 1941).
Alexander, F. G. and Selesnick, S. T., The History of Psychiatry : An Evaluation of Psychiatric
Thought and Practice from Pre-historic Times to the Present (New York: Harper, 1966).
17
For this see issue 3 of History of Psychiatry (1991) which is fully dedicated to current
scholarship.
18
Mora, G. and Brand, J. L. (eds), Psychiatry and its History. Methodological Problems in Research
IL: Charles Thomas, 1970).
(Springfield,
19
Braceland, F. J., Foreword. In: Ibid, vi1.
20
Marx, O. M., What is the history of psychiatry? American Journal of Orthopsychiatry, xl (1970),
593-605, 603.

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180
definition of psychiatry and a precept of what psychiatry should be, and later
to develop a Lakatosian view of history as a tentative construct.21 Similar
views have been expressed with respect to the history of the behavioural
sciences22 and of medicine. 23
Since the Yale symposium, around which time the Foucaultian industry
has started to rise, many of the generalizations of its mentor24 have
undergone correction.25 This approach was also criticized by an important
nucleus of French clinicians with historical interests that included great men
such as Ey, Baruk, Lanteri-Laura, Trillat, Bercherie, and Postel. They all
published first-rate work based on their own brand of historical analysis.
Social historians have also made important contributions26 and their work
has certainly counterbalanced medical excesses. In some cases, however,
they have shown idiosyncrasies of their own, leading clinicians to feel that
over-emphasis on the explanatory value of social variables may lead to a
neglect of the biological aspects of insanity. It is clear that their perspective is
more relevant to the understanding of phenomena such as the creation of

asylums than to the detailed internal structure of descriptive psychopathology.2

Some years ago, complex issues in the history of the behavioural sciences

21
Marx, O. M., History of psychology: a review of the last decade. Journal of the History of the
Behavioral Sciences, xiii (1977), 41-77.
22
See Young, R. M., Scholarship and the history of the behavioural sciences. History of Science, v
(1966), 1-51; and the excellent book by Danziger K., Constructing the Subject. Historical Origins of
Psychological Research (Cambridge: Cambridge University Press, Cambridge, 1990).
23
Clarke, E. (ed.), Modern Methods in the History of Medicine (London: Athlone Press, 1971);
Porter, R. and Wear, A. (eds), Problems and Methods in the History of Medicine (London: Croom
Helm,
24
1987).
25
Foucault, M., Histoire de la folie à lâge classique (Paris: Gallimard, 1972).
Sedgwick, P., Michel Foucault. The anti-history of psychiatry. Psychological Medicine, x1
(1981), 235-248; Castel, R., LOrdre psychiatrique. LAge dor de laliénisme (Paris: Minuit, 1977);
Swain, G., Le Sujet de la fohe: naissance de la psychiatrie (Paris: Privat, 1977); and Gauchet, M. and
Swain,
26
G., La Pratique de lespnt humain (Paris: Gallimard, 1980).
Dörner, K., Bürger und Irre. Zur Sozialgeschachte und Wissenschaftsozaologie der Psychiatne
(Frankfurt: Europäische Verlagsanstalt, 1969); Jones, K. A History of the Mental Health Services
(London: Routledge & Kegan Paul, 1972); Scull, A. T. Museums of Madness. The Social
Organization of Insanity in Nineteenth-Century England (London: Allen Lane, 1979); and Scull, A. T.
(ed.), Madhouses, Mad-doctors and Madmen. The Social History of Psychiatry in the Victorian Era
(London: Athlone Press, 1981); Alexander, M. D. The Administration of Madness and Attitudes
Towards the Insane in 19th century Paris. Doctoral Dissertation (Baltimore: John Hopkins Press,
1976); Castel, R., Castel, F. and Lovell, A., La Société psychiatnque avancée (Paris: Grasset et
Fasquelle, 1979); Blasius, D., Der vervaltete Wahnsann. Eine Sozzalgeschichte des Irrenhauses
(Frankfurt: Fischer Taschenbuck, 1980); Cooter, R., The Cultural Meaning of Popular Science.
Phrenology and the Organization of Consent in 19th Century Britain (Cambridge: Cambridge
University Press, 1984); Digby, A., Madness, Morality and Medicine (Cambridge: Cambridge
University Press, 1985); Alvarez-Uria F. Miserables y Locos (Barcelona: Tusquet, 1983); Comelles,J
M. La razón y la sinrazón (Barcelona: PPU, 1988); Porter, R., Mznd-forgd Manacles (London:
Athlone Press, 1987).
27
Werlinder, H., Psychopathy. A History of the Concepts: Analysis of the Origin and Development of a
Family of Concepts in Psychopathology (Uppsala: Acta Universitatis Upsaliensis, 1978); Janzarik, W.
(ed.), Psychopathologie als Grundlagenwissenschaft (Stuttgart: Enke, 1979); Wallace, E. R. IV and

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 181

seemed briefly illuminated by the application of Kuhnian ideas.&dquo; Indeed,

many consoled themselves in the belief that the behavioural sciences and
their history were so backwards because they inhabited some kind of
primitive pre-paradigmatic limbo.29 This attitude is likely to have delayed
the development (or re-discovery) of an epistemology of the inexact
sciences3 which, at least since the time of Dilthey and Weber, has been
staring us in the face. An equally naive historiographic view led Zilboorg and
Alexander and Selesnick31 to consider all pre-Freudian psychiatry as pre-
historical. Be that as it may, there seems to be a legitimate need32 for
historical studies that ask specific questions about the genesis of the
descriptive categories of psychopathology and about their interaction with
the psychological and philosophical context.

The historiography of psychopathology

It should be clear by now what the differences are between psychiatry and
descriptive psychopathology. Whilst the latter is the language of description,
and its units of analysis are the symptoms that characterize the various forms
of mental illness, psychiatry is the name for the set of activities dedicated to
the implementation of the descriptive language (which includes taking
biological, psychological and social action) and which is currently considered
as abranch of medicine.
The young psychiatrist and historian venturing into this field is likely to be
confused by the various ways in which the history of psychopathology is

Pressley, L. C. Essays on the History of Psychiatry (South Carolina: Hall Psychiatric Institute, 1980);
Simon, B., Mind and Madness an Ancient Greece. The Classical Roots of Modern Psychiatry (Ithaca:
Cornell University Press, 1978); Sauri, J. J., Historia de las ideas psiquiátricas (Buenos Aires: Carlos
Lohle, 1969); Roccatagliata, G., Storia della psichiatria biologica (Florence: Nuova Guaraldi, 1981);
López Piñero, J. M., Origenes históricos del concepto de neurosis (Valencia: Instituto de Historia de la
Medicina, 1963); López Piñero J. M., Historical Ongins of the Concept of Neurosis (translated by D.
Berrios) (Cambridge: Cambridge University Press, 1983); Lopez Piñero, J. M. and Morales
Meseguer, J. M.. Neurosis y psicoterapia. Un estudio histórico (Madrid: Espasa-Calpe, 1970);Clarke,
B., Mental Disorders in Earlier Britain: Exploratory Studies (Cardiff: University of Wales Press, 1 975);
Dewhurst, K., Hughlings Jackson on Psychiatry (Oxford: Sandford Publications, 1982; Bercherie, P.,
Les Fondements de la clinique. Histoire et structure du savoir psychiatrique (Paris: La Bibliothèque
dOrnicar, 1980); Postel, J. and Quétel, C. (eds), Nouvelle Histoire de la psychiatne (Paris: Privat,
1983); Leibbrand, W. and Wettley, A. Der Wahnsinn (Munich: Karl Alber, 1961).
28
29
Kuhn, T., The Structure of Scientific Revolutions (Chicago: Chicago University Press, 1962).
Farrell, B. A., The progress of psychology. British Journal of Psychology, lxix (1978), 1-8;
Warren, N., Is a scientific revolution taking place in psychology? Scientific Studies, 1 (1971),
407-413; Lambie, J., The misuse of Kuhn in psychology. The Psychologist : Bulletin of the British
Psychological
30
Society, i (1991) 6-11.
Helmer, O. and Rescher, N., On the epistemology of the inexact sciences. Management
Science, viii (1959), 25-52.
31

32
Zilboorg (1941) (Note 15), op. cat.; Alexander and Selesnick (1966) (Note 16), op. cit.
Daumezón, G., Légitimité de lintérêt pour lhistoire de la psychiatrie. LInformation
psychiatrique, lxv (1980), 647-653.

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182
written. They should know, however, that the so-called biographical,
anthological, narrative, socio-political, institutional and conceptual
approaches simple reflect fashions and theoretical influences, and that
method and theory are less important for the final result (just as it is in the
case of psychotherapy) than historical imagination and honesty and
thoroughness in the management of the data.
Further problems seemed created by the fact that the history of
psychopathology could be written from the perspective of the history
of medicine, on occasions still traditional in approach,33 and from the more
advanced perspective of the history of science. The history of psychiatry was
born under the aegis of medical history ;34 and hence the biographical
approach was one of the first to appear, soon followed by anthological and
narrative publications. Intellectualistic approaches of the chain of being
type35 developed after the 1930s and psychiatric historiography followed as
illustrated by the Zilboorg volume.36 Historical accounts remained pegged to
the traditional approach of history of medicine (i.e. were intemalist, linear,
and Whiggish37) until the time they were challenged by Michel Foucault.
The few studies on the history of psychopathology that were to appear during
this period were equally traditional in approach.38
The history of science had also its traditional period until the conceptual
revolution started during the 1950s. The debate between the various forms
of realism and social constructionism has not yet abated.39 The internalist
view was based on the belief that science consisted of a piecemeal
accumulation of observations from which theories emanated.4 Inductivism,
the technical name for this mode of theory-generation, made assumptions
about the nature of truth, the regularity of nature, and the contexts of

33
See: Renouard, P. V., Histoire de la médecine. 2 Vols (Paris: Bailliére, 1846); Boyer, L., Histoire
de la médecine. In Dechambre, A. and Lereboullet, L. (eds), Dictionnaire encyclopédique des sciences
médicales (Paris: Masson, 1872), 1-209; in relation to Spain, the excellent: Bujosa, F., Filosofia e
Hastoriografia Médica en España (Madrid: Consejo Superior de Investigaciones Cientificas, 1989).
34
See, for example, the approach of Kirchhoff, Th., Geschichte der Psychiatne (Leipzig: Franz
Deuticke,
35
1912).
36
Lovejoy, A. O., The Great Chain of Being (Boston: Harvard University Press, 1936).
37
Zilboorg (1941), (Note 15), op. cit.
Butterfield, H., The Whig Interpretation of History (London: Bell, 1931); Hesse, M. B., Reasons
and evaluations in the history of science. In Teich, M. and Young, R. (eds), Changing Perspectives in
the History of Science. Essays in honour of Joseph Needham (London: Heinemann, 1973), 127-147;
Agassi, J., Toward an historiography of science. History and Theory. Studies in the Philosophy of
History. Bei heft 2 (Middletown, CT: Wesleyan University Press, 1963).
38
See, for example, Altschule, M. D. The Development of Traditional Psychopathology. A Sourcebook
(New York: John Wiley, 1976).
39
On this see the Bloor, D., Knowledge and Social Imagery. Second edition (Chicago: University of
Chicago Press, 1991); Jardine, N., The Fortunes of Inquiry (Oxford: Clarendon Press, 1986) and
Jardine,
40
N., The Scenes of Inquiry (Oxford: Clarendon Press, 1991).
For a very early manifesto of this view see Laugel A. Science et philosophie (Paris: Mallet-
Bachelier, 1863).

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 183

discovery and justification, all of which have come under attack.&dquo; Although
in this model there apparently was little room for non-intellectual and
contextual considerations, it gave rise to good works in areas such as the
history of the natural sciences and medicine.42 This traditional approach was
less successful in the field of the behavioural sciences (including the history
of psychopathology) because categories such as discovery, observation,
replication, evidence, and experiment,43 were even harder to define, and
because these subjects depend so much on the deft use of metaphors.44
In the English-speaking world, the conceptual revolution alluded to
above started during the 1950s in the work of Toulmin45 and Hanson46 who
proposed new models for scientific change. Following the lead of Gaston
Bachelard, the much neglected French historian of science, 41 these authors
challenged the image of science as an exercise in pure rationality, and
suggested that historical accuracy had been sacrificed to superficial order and
dubious progressivist views. Philosophers of science were also dissatisfied
with the inductivist view which was, in fact, challenged by Popper as early as
1934.48 Although Poppers notion of falsification was not free from
inductivist assumptions, the libertarian tones of his prose served as an
exhortation against non-cognitivism and irrationality. Popper also attacked
psychoanalysis as non-scientific and this caused some consternation amongst
historians of psychiatry. Imre Lakatos49 went on to propound a rational
reconstruction of the past and this view influenced notable historians of
psychiatry such as Otto Marx.50 Since this time the philosophy of science has
struggled to remain under the umbrella of a cautious realism. 51
In his Structure of Scientific Revolutions&dquo; Kuhn offered a bad pastiche
of Bachelardian ideas by suggesting that science was a succession of

41
42
Kragh, H., The Historiography of Science (Cambridge: Cambridge University Press, 1987).
See, for example, Hall, J. K. (ed.), One Hundred Years of American Psychiatry (New York:
Columbia University Press, 1944).
43

44
Danziger, K. (1990). (Note 22), op. cit.
On this see: Sternberg, R. J., Metaphors of Mind. Conceptions of the Nature of Intelligence
(Cambridge: Cambridge University Press, 1990); Leary D. E. (ed.), Metaphors in the History of
Psychology (Cambridge: Cambridge University Press, 1990).
5
46
Toulmin, S., The Philosophy of Science (London: Hutchinson, 1953).
47
Hanson, N. R., Patterns of Discovery (Cambridge: Cambridge University Press, 1958).
See Lecourt, D., Gaston Bachelards historical epistemology. In Marxism and Epistemology.
Bachelard,
48
Canguilhem, Foucault (London: NLB, 1975 (first published in 1969)), 25-116.
49
Popper, K., The Logic of Scientific Discovery (London: Hutchinson, 1968).
Hacking, I., Imre Lakatoss philosophy of science. British Journal for the Philosophy of Science,
xxx (1979), 381-410; Lakatos, I. and Musgrave, A. (eds), Criticism and the Growth of Knowledge

(Cambridge:
50
Cambridge University Press, 1970).
See Marx (1977), (Note 21), op. cit.
51
The literature in this area is enormous. The psychiatrist will find useful Suppe, F. (ed.), The
Structure of Scientific Theories (Urbana: University of Illinois Press, 1977); Meyer, M., Decouverte et
justification en science (Paris: Klincksieck, 1979); Smith, P., Realism and the Progress of Science
(Cambridge: Cambridge University Press,1981); and Jardine (1986), (Note 39), op. cit.

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 184

prevailing paradigms. One problem with Kuhns model was the ambiguity of
its operative categories, for example, paradigm has more than twenty
meanings.53 This account proved popular in the 1960s and had some
influence on the history of the behavioural sciences,54 causing the neglect of
the profounder work of Dilthey,55 Politzer,56 and Bachelard57 and of the
Continental historiographic schools.58
Psychiatry is not a contemplative but a modificatory activity and clinicians
are primarily interested in the power of psychopathological descriptions to
predict the outcome of disease; such power as they may have is assumed to
stem from their truth-value, i.e. their capacity to picture the reality of
mental illness. To reach this ideal state, symptom-descriptions must be
unencumbered by semantic confusion and based on multiple and reliable
clinical observations. The history of psychopathology could be defined as the
historical study of the words, concepts and putative disorders of behaviour
involved in the definition of symptoms&dquo;9 and their clusters.6 Such history

52
See Kuhn, (Note 28), op. cit., also Stove, D. C., Popper and After: Four Modern Irrationalists
(Oxford: Pergamon Press, 1982); and Hacking, I. (ed.), Scientific Revolutions (Oxford: Oxford
University
53
Press, 1981).
Masterman, M., The nature of a paradigm. In Lakatos, I. and Musgrave, A. (eds) Criticism
and the Growth of Knowledge (Cambridge: Cambridge University Press, 1970), 59-90
54
Tortosa, F., Mayor, L. and Carpintero, H. (eds), La Psicologia Contemporánea desde la
Historiografia
55
(Barcelona: PPU, 1990).
Dilthey, W,. Einleitung in die Geisteswissenschaften. Vol. I (Leipzig: Duncker und Humboldt,
1883); Martin-Santos, L., Dilthey, Jaspers y la comprensión del enfermo mental (Madrid: Paz
Montalvo, 1955); López, A., Comprensióne interpretación en las ciencias del espintu (Murcia:
Universidad de Murcia, 1990).
56
See Roelens, R., Une recherche psychologique méconnue, le courant dramatique de G.
Politzer à aujourdhui. La Pensée No.103 (1962), 76-101; Deleule D. La Psychologie, mythe
scientifique (Paris: Laffont, 1969); Pohtzer, G., Critique des fondements de la psychologie (Paris: Presses
Universitaires de France, 1967 (first published in 1927)).
57
See Lecourt (1975), (Note 47), op. cit.
58
See Chartier, R., El Mundo como Representación. Historia Cultural: entre Práctica y Representación
(Barcelona: Gedisa, 1992); Bauer, H., Kunsthistorik. Eine kritische Einfuhrung in das Studium der
Kunstgeschichte (Munich: Oskar Beck, 1976); Juliá, S., Historia Social/Sociologia Histórica (Madrid:
Siglo Veintiuno, 1989); Gagnon, S., Man and his Past. The Nature and Role of Historiography
(Montreal: Harvest House, 1982).
59
In regard to the definition of symptom and sign in descriptive psychopathology, the historian is
at the convergence point of two traditions: on the one hand, the older semiological approach
started at the beginning of the nineteenth century in the work of Landre-Beauvais, A. J.,
Séméiotique, ou traité des signes des maladies (Paris: Brosson, 1813); on the other, the modern
linguistic one, started at the beginning of the twentieth by De Saussure; on this see: Korner, E. F.
K., Ferdinand de Saussure (Madrid: Gredos, 1982); Malmberg, B., Teoria de los signos (Madrid: Siglo
Veintiuno, 1977); Lanteri-Laura, G., Les Apports de la linguistique à la psychiatrie contemporaine
(Paris: Masson, 1966); Berrios, G. E., Descriptive psychopathology: conceptual and historical
aspects. Psychological Medicine, xiv (1984), 303-313
Clusters refer here to the way in which certain symptoms show a higher statistical probability
of being found together. Corroboration for such phenomena can be made by observational (clinical)
or statistical means. Clusters have been fundamental to the development of nosological theory, i.e.
to the view that symptom-sets or syndromes reflect the activity of specific causal mechanisms (see
Faber, K., Nosography in Modern Internal Medicine (London: Milford, 1923; also Hoche, A., The
significance of symptom complexes in psychiatry. History of Psychiatry, ii (1991), 329-343).

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ought to be able to estimate how much of their earlier meaning do symptom-

descriptions retain when transferred from one historical episteme to the
next. For example, can it be assumed that the term hallucination means in
1994 the same as it did in 1814 when it was first operationalized? If it
cannot, how can the differences be made explicit?
To map these complexities the clinical historian may resort to a convenient
model. One such is that of Braudel,61 who viewed history as a harmonic
conglomerate of processes of short, medium and long duration. Past
psychiatric events can find explanation at each and all of these levels; some,
like the accident that killed Wernicke (which, by the way, changed the
direction of taxonomy and pathogenesis), can be dealt with as short
processes; others, like the impact of Faculty Psychology on psychiatric classi-
fication and aetiological theory, are better understood as medium-duration
ones; yet others, like the changes in the understanding of madness, are better
defined as long-duration, probably trans-epistemic processes. Yet another
objective of historical psychopathology is breaking secular epistemological
codes, i.e. uncovering the rules that have controlled psychiatric discourse
throughout the centuries, and thereby making explicit the assumptions that
have inspired such discourse (e.g. concepts of disease, and views on the
nature of man).

Sources for a history of psychopathology

Historical research differs from clinical research in that in the former
techniques and questions may determine what is to count as the object of
inquiry and as its supporting data. Depending on how this object is defined,
the clinician interested, say, in the history of schizophrenia will find that
earlier centuries offer nothing or a great deal. In current clinical research in
psychiatry, on the other hand, workers are not expected to determine the
boundaries of their object of inquiry: these are given in operational
definitions (such as DSM III-R).62 However, the historian would be ill-
advised to use the categories included in the latter as it would lead to
hopelessly anachronistic studies. This does not mean the DSM III-R
definition of schizophrenia itself cannot be object of historical inquiry: it can,
but its history will have little to do with the history of dementia praecox or
of what was before called intellectual insanity; instead, it will have to do
with the history of the social context that led a group of psychiatrists in the
North East of the USA to arrive at this definition of the disease.
The question then arises as to whether the historian of psychiatry requires

61
62
Braudel, F., La Historia y las Ciencias (Madrid: Alianza Editorial, 1980).
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Third
Edition, Revised (Washington, DC: American Psychiatric Association, 1987).

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186

the presence of an invariant element, whether biological or psychological, to

trace back the history of a particular disease or abnormal behaviour. If it is
the case that there is a fixed neurobiological basis for schizophrenia, then, the
name under which it has travelled throughout history, or the concepts used
to explain it, or even whether or not it was considered as a disease, all
become irrelevant. Likewise, if a psychological invariant is postulated, as
George Devereux wanted to do in relation to psychodynamic structures,63
once again the history of a phenomenon related to such structure may gain
trans-historical or trans-cultural continuity. But if only social invariants are
considered, this may, perforce, be locked within specific cultural contexts
and not be sufficient to move from one episteme to the next.
The assumption of trans-historical invariants is, on the other hand,
notoriously vulnerable to challenge, particularly from social constructionist
thinkers who believe that such elements constitute the thin end of a realistic
wedge. In this regard, two powerful metaphors seem to control the historical
study of nosology. One pictures the clinician as cataloguing species in an
exotic garden (i.e., assumes a sort of ontological invariance for most
diseases); the other envisages a sculptor carving shapes out of formless
matter, i.e. creating clinical forms. The garden approach encourages a view
of the discoverer as a powerful eye, as one who can break away from
misleading descriptions and find the true one; it must, however, explain
why the clinician-naturalist happens to be there in the first place. The
creationist approach requires that an account be offered of the inner vision
that has guided the clinician-sculptor. This account demands that the latter
is seen against his/her social context. This contextualization ranges from
severe social constructionism, which may go as far as explaining theory-

making in medicine in terms of the personal history of her practitioners,64 to

milder forms of social accounting which leave room for scientific progress
and for the role of the internal logic of science.65 When writing on the history
of schizophrenia, therefore, the clinician must decide on which of these two
views he feels more comfortable with. Whilst traditional medical history has
followed the garden metaphor, current history of psychopathology has felt
the influence of the creationist view.66

63
See Devereux, G., Normal and abnormal. In Basic Problems in Ethnopsychiatry (Chicago: The
University of Chicago Press, 1980), 3-71.
64
For the debate on this topic see: Barnes, B., Scientific Knowledge and Sociological Theory
(London: Routledge & Kegan Paul, 1972); Bury, M. R., Social constructionism and the
development of medical sociology. Sociology of Health and Illness, viii (1986), 137-169; and
Nicolson, M. and McLaughlin, C., Social constructionism and medical psychology: a reply to M.
R. Bury. Sociology of Health and Illness, ix (1987), 107-126; and Bury, M. R., Social
constructionism and medical sociology: a rejoinder to Nicolson and McLaughlin. Sociology of
Health and Illness, ix (1987), 439-441.
65
See Jardine (1991), op. cit.
66
See, for example, Berrios, G. E., Alzheimers disease: a conceptual history. International
Journal of Genatric Psychiatry, v (1990), 355-365.

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A history for clinicians

As mentioned above, the history of psychopathology is, together with clinical
and statistical analyses, part of the general process of calibration to which the
language of psychiatry must be periodically subjected. Calibration here
means re-adjustment of the descriptions to: (1) changes affecting the

biological foundations of the symptoms (caused, for example, by genetic

mutations); (2) shifts in psychological models leading to a different concep-
tualization of normal and abnormal behaviour; or (3) variations in the social
import of symptoms or diseases. Unfortunately, historical information of this
nature is not as freely available to clinicians as statistical and clinical data.
One cause for this is the fragmentary nature of historical knowledge on
psychiatric symptoms; another, disagreements on the way in which to present
this information; yet another, a reluctance, on the part of professional
historians, to work in this field.
If historical research is about identifying reasons and explanations for the
periodic re-creation of symptoms, how might the products of this research be
presented in order to have maximum impact? I believe that the historical
styles called in this article conceptual and quantitative6 offer the right
framework within which to account for the history of terms, concepts and
behaviours, the three crucial components in the formation of mental
symptoms. Modem statistical techniques can then be used to map regional
usage, and identify clusters and patterns, such as they are, hidden in many
historical clinical databases. For example, the use of psychotropic drugs
seems to have caused changes in the manifestations of disease, and the
resulting attenuated or distorted symptoms are harder to evaluate; in this
regard, patient cohorts studied before such medication was available contain

67
Quantitative methodologies have been made easier by the advent of computer technology.
Basically, this approach consists in treating historical databases as if they were sets of case notes
studied in retrospective clinical studies. Such work has four stages: choice of diagnostic criteria,
inter-rater reliability studies, data capture, and data analysis. Diagnostic criteria can be chosen that
are contemporary to the database (for example, if one is to test the historical reliability of the

category in question) or to the current researcher. Once the operational definitions are ready two
raters should be trained to rate the data independently. Kappa coefficients should be calculated for all
symptoms and those which are <0.70 should be re-defined. The captured data may be entered into
a computer spreadsheet or matrix and subject to the usual tests for quality control. Statistical

analysis should be carried out having in mind that data in this type of study (except for patients age,
duration of stay, and a few other variables) tend to be categorical - i.e. symptoms rated as present
or absent. This determines the type of statistical techniques to be used. When data are adequate,
pattern recognition techniques such as principal component analysis, cluster analysis, and
discriminant function analysis can be used with advantage. Results can be rewarding: for example,
that the data do not support the conclusions that a given alienist drew at the time by simply eye-
balling his data; or that a prototypical patient (extracted from a database on the strength of which a
new disease was invented!), does not correspond to the current definition of the disease.

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important information, and should be analysed by means of all the current

statistical techniques.68
Thus, clinical historians have a contribution to make not only to
psychiatric culture, but also to clinical knowledge. Based on the belief that
mental disorders are but complex and distorted reflections of dysfunctional
brain sites and states, they will seek to determine which past psychiatric
phenomena noise, and which were descriptions of faint biological
were

signals modulated by the expressional grammar of diseased individuals and

the interpretive codes of their cultural groups.
Throughout history, the descriptive language of psychiatry has shown
periods of stability and change. Whereas change attracts much soul-
searching, stability is taken for granted. But the historian should ask why
descriptive psychopathology has remained in steady state for a considerable
period of time. He will find that devices such as symbols, myths, mentalities
and other social constructions are as steadying a factor as the biological
signal captured by the symptom. Their relative contribution, however, is yet
unknown and should be of interest to the clinical historian, particularly when
some of these time-honoured categories are challenged.69

Towards history of psychopathology

a new

The clinically-based, collaborative approach outlined above may cause

discomfort amongst professional historians, who may fear that clinicians will
appropriate and distort the history of medicine in general, and that of
psychiatry in particular. These unfounded fears have led some to overstating
the autonomy of medical history. In the case of psychopathology, this
preoccupation can be reflected in an over-emphasis of its social factors; while
social history must be considered as important, over-preoccupation with
macro-concepts and social questions may take attention away from the
complex internal story of psychiatric symptoms. One consequence of the
predominance of the social approach is that few young historians (who
understandably are trying to make a name for themselves) bother with
clinical analysis, preferring to write the sort of work that will gain favour in

68
As examples of this, see: Berrios, G. E., Epilepsy and insanity during the early 19th century.
Archives of Neurology, xli (1984), 978; Berrios, G. E., Depressive pseudodementia or melancholic
dementia: a 19th century view. Journal of Neurology, Neurosurgery and Psychiatry, xlviii (1985), 393;
Berrios, G. E. and Quemada, J. I., Andre Ombredane and the psychiatry of multiple sclerosis: a
conceptual and statistical history. Comprehensive Psychiatry, xxxi (1990), 438; Berrios, G. E.,
Affective disorder in old age: a conceptual history. International Journal of Geriatric Psychiatry, vii
(1991),337.
69
For example, see the attack on the notion of mentality by Lloyd, G. E. R. Demystifying
Mentalities (Cambridge: Cambridge University Press, 1990) or the superb analysis of symbols by
Garagalza, L., La Interpretaci&oacute;n de los Simbolos. Hermen&eacute;utica y Lenguage en la Filosofia Actual
(Barcelona: Anthropos, 1990).

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fashionable circles. Thus, the history of psychopathology has been left to

elderly clinicians who lack the technological knowledge or drive to tackle the
complexities involved, or has been confined to the introductory sections of
clinical writings.
The ethical pangs of the 1960s, provoked by the anti-psychiatry
movement, have given way, particularly in English-speaking psychiatry, to
the descriptive and theory-free efforts of the 1970s. Those who have made
the calibration of the nomenclature of psychiatry their business, particularly
the pundits behind DSM III-R, regularly show great ignorance of the
conceptual history of symptoms and diseases. They need the assistance of
professional historians. The unenthusiastic response of the latter, however,
(who remain interested in loftier issues) has led to the development amongst
clinicians of a do-it-yourself historical industry which struggles valiantly
against lack of historical training, limited access to primary material, and
linguistic obstacles. As a consequence, high standards of research in the
history of psychopathology, which should be as strict as in any other area of
medicine, have not been achieved.
There is, therefore, a need for collaborative work between clinicians and
historians, and in this article it is suggested that the first step in such
collaboration should be the calibration of descriptive psychopathology. For
example, an analysis should be carried out of its conceptual structure and
historical origins. A general model might then be tested by studying
individual symptoms. The model suggested in this chapter is based on the
nest of Chinese boxes analogy:71 the inner boxes contain philosophical-
psychological explanations, the outer boxes sociopolitical ones. Reliance on
the inner boxes may often be sufficient to understand the genesis and
evolution of certain symptoms, and the historical results of this approach are
here called conceptual history. Emphasis on inner boxes, however, should
not be interpreted as a rejection of the explanatory power of the outer ones:
it only means that the latter do not need to be called upon on each occasion;
over-explanation is as much a fault in the history of psychiatry as under-
explanation. Indeed, it is clear that explanation in the history of
psychopathology is as much in need of rules for the management of
complexity as any other area of science. 71
The development of parallel concepts in the area of abnormal psychology
has been treated with reticence by historians of psychology; for example, the
history of abnormality, of personality disorder, of hallucinations, etc., has
been left untouched .7 This is not surprising. Classical psychological

70
See Berrios (1984), op. cit.
71
Bechtel, W. and Richardson, R. C., Discovering Complexity (Princeton, NJ: Princeton University
Press,
72
1993).
The traditional history of psychology was a well populated field, and tended to emphasize the
biographical and thematic aspects of psychology (e.g., Boring, E. G. A History of Experimental

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 190

historiography has concentrated on three issues: (a) the philosophical sources

of psychology; (b) historical mechanisms leading to its separation from
philosophy; and, (c) reliability and validity of competing psychological
theories. Only the occasional enterprising historian has worried, inspired by
the Kuhnian fashion, about the paradigmatic status of psychology.
Since the main concern of the conventional historiography of psychology
has been the understanding of languages and theories, and their capacity to
explain normal behaviour, it is understandable that little mention has been
made of the historical moment when the categories of normal behaviour
began to be applied to sick, abnormal or deviant behaviour. Likewise, few
have puzzled about why it took so long for the terminology and explanatory
mechanisms of normal psychology to be applied to psychopathology.

Final commentary
This article has dealt with the historical needs of clinicians and with the
historiographical approaches that, in their ignorance or naivete, they are
happy to follow. These approaches, called conceptual and quantitative
relate to the historical analysis of symptoms and diseases, and to the
statistical analysis of historical databases, respectively. The said historical
analysis must be mindful of the fact that it is dealing with a complex mixture
of sub-scripts which directly and independently relate to the history of the
words, concepts and behaviours involved in the construction of a symptom.
In this sense, the history of descriptive psychopathology is seen as paying
attention both to constructional elements (by accepting that the semantic
content of the terms involved may markedly change from period to period,
and is socially-dependent) and to the (often biological) invariants that
confer continuity to particular forms of peculiar behaviour. In this latter
respect, clinical historians entertain a form of naive realism of which (qua
medics), they do not need to feel ashamed.
Collaboration between professional historians and clinicians could render
the conceptual history approach into a fine art. The ensuing body of
knowledge not only would provide real historians with solid foundations for
their macro-concepts, but also constitute a direct contribution to clinical
understanding and patient care. A result like this should be the best remedy
for those chronically affected by historiographic pangs.

Psychology (New York: Appleton-Century-Crofts, 1950); Murphy, G., An Introduction to Modern

Psychology (London, Routledge & Kegan Paul, 1949); Watson, R. I, The Great Psychologists (New
York: Lippincott, 1978); Lowry, R., The Evolution of Psychological Theory (Chicago: Aldine, 1971);
Klein, D. B.A History of Scientific Psychology (London: Routledge & Kegan Paul); Hearnshaw, L. S.,
The Shaping of Modern Psychology (London: Routledge, 1987). The current historiography of
psychology, on the other hand, shows much influence from history of science and hence has lost the
narrative simplicity of old (see, Danziger (1990), (Note 22), op. cit; Tortosa
et al, 1990, (Note 54),
op. cit.; Leary (1990), (Note 44), op. cit.)

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