In 1918, Emil Kraepelin wrote:⁽¹⁾

He pointed out that, in the first decades of the 19th century, many of the books dealing with psychiatric themes were still written by medical doctors, such as Reil (who coined the word psychiatry), who had few contacts with mental patients or even by philosophers and theologians, and that only in the great scientific centres had specialists appeared ‘who had decided to spend their life in the study and treatment of mental diseases’.

The history of psychiatry as a medical specialty has to be distinguished from the history of psychiatric medical knowledge which began in ancient Greece with the birth of medicine as a science. For more than 2000 years, only physicians observed and treated mental illnesses, and institutions were created in which the ‘lunatics’ and the ‘insane’ were received. But, as rightly pointed out by Kraepelin, the truth is that psychiatry was not really a medical specialty. One can argue about the precise date of the appearance of psychiatry as a specific field of medicine and of the psychiatrist as a specialist, devoting his professional competence exclusively to the care of the mentally ill. Denis Leigh recognizes that ‘some degree of specialization occurred [in England] among respectable physicians’ in the middle of the eighteenth century when the monopoly of Bethlem was broken and new ‘lunatic hospitals’, such as St Luke’s were opened.⁽²⁾ On the other hand, the American historian Jan Goldstein stresses that in France the language, as an exact reflection of the underlying reality, began to use expressions such as homme spécial to describe a physician specializing in a branch of medicine such as psychiatry only around 1830.⁽³⁾

Despite those divergences, it is generally accepted that the work of Philippe Pinel constitutes a turning point. His role has several aspects. He is known worldwide as the physician who ‘liberated the insane from their chains’ in a dramatic initiative he started in 1793, at the height of the French revolution, at the Bicêtre asylum, and completed 3 years later at the Salpêtrière asylum. However, the reality is more complex.

Pinel, who was born in 1745, had studied medicine, translated Cullen’s books into French, and published scientific papers on various subjects. He acted as a physician in a small Parisian ‘madhouse’, the Pension Belhomme, in which wealthy lunatics were confined at the request of their families. At that time most of the Parisian insanes were confined for a few weeks in the general hospital—the Hôtel Dieu. If their state did not rapidly improve, they were considered as incurable and send to Bicêtre or the Salpêtrière, built a century before, which also received other social deviants like beggars and prostitutes. Pinel, who was known by his politically influential friends for his progressive scientific ideas, was appointed physician to Bicêtre. The division for the insane was under the direction of an overseer (surveillant), Pussin, who had already introduced humanitarian reforms in the care of the patients. Pinel’s merit was to approve and systematically develop Pussin’s empirical measures and to propose an explicit scientific theory for their mode of action. Inspired by Crichton’s views about the nature of the ‘passions’ by Condillac’s psychology, and by the ideas of Jean-Jacques Rousseau, he created the traitement moral which he claimed to be effective with patients previously considered as incurably ill.

The improvement of the conditions in which the insane were cared for, supported and expanded by Pinel, was not an isolated French phenomenon. In Tuscany, Chiarugi in 1789 had already asserted that the basis of the extensive reforms he had introduced in the local asylum for the insane was that ‘it is a supreme moral duty and a medical obligation to respect the mental patient as a person’. In England, where public had been shocked by the inhuman treatment to which King George III had been submitted during his mental illness; and where, a pious Quaker, William Tuke, deeply affected by the conditions in which the wife of a member of the Society of Friends had died in York lunatic asylum, decided to set up a special institution under the government of the Friends ‘for the care and accommodation of their own members’. At the Retreat, opened in 1796 near York, physical restraints were largely abolished, and religious and moral values were emphasized in relations with the patients.

Chiarurgi’s reforms did not survive the upheavals caused by subsequent wars and the political divisions of Italy, and Tuke’s creation of the Retreat had not been prompted by medical considerations but was the expression of religious humanitarian purposes. The role played by Pinel was decisive, not so much because of the changes he promoted in the conditions of the patients, although they had a profound influence, but because he made the study and treatment of mental disorders a branch of medicine.

In 1801, Pinel published the Medico-philosophical Treatise on Mental Alienation. In it, he presented the various clinical manifestations he had observed; proposed a simple nosological system largely borrowed from older authors; examined possible aetiological factors; and described his ‘moral treatment’ in detail. The book has remained a landmark in the history of psychiatry, even being considered by the philosopher Hegel as a ‘moment of capital importance in the history of humanity’. For Pinel, insanity was a disease and the patient affected by it remained, despite the loss of his reason, a human being. Its study, like the rest of medicine, had to be ‘a science which consists of carefully observed facts’. Goldstein⁽³⁾ has shown that Pinel’s main preoccupation was to prove this scientific nature of the new medical specialty by repudiating the previous practices of the ‘empirics’ and ‘charlatans’—the two terms being practically synonymous. He had accepted the method Pussin had developed empirically and transformed it in his moral treatment by providing a scientific theory of its mode of action. A curiously premonitory aspect of his emphasis on the necessity of a scientific methodology is to be found in his Tables to Determine How Probable is the Curability of Alienation, published in 1808. He provided statistical data on the efficacy of his therapeutic method according to the types of mental disorders and in comparison with spontaneous evolution, and concluded that medicine can only be a true science through the use of the calculus of probability!

If, because of the international influence of the ideas expressed in his book, Pinel is the founder of psychiatry as a medical discipline, he was not a psychiatric specialist in the strict meaning of the term. Although he retained his position at the Salpêtrière until his death in 1826 and is known today for his contributions to mental medicine, he had many other medical interests which gave him, in his time, a leading position among the Paris physicians; his Philosophical Nosology, published in 1796 and a classical reference for several decades, deals with general pathology. The case of his pupil and successor, Esquirol, who became the prototype of the psychiatric specialist was very different. At the Salpêtrière he was only in charge of the ‘section of the insane’. He was later appointed medical director of the Charenton psychiatric asylum near Paris and owned in addition a small clinic, in which he treated his private patients. All his activities were exclusively dedicated to the study and treatment of mental disorders and the teaching of psychiatry. His book, On Mental Diseases published in 1838, in which he collected his previous publications, acquired a fame as great as Pinel’s Treatise. In 1913, Karl Jaspers recognized that the later great representatives of German psychiatry, such as Griesinger and Kraepelin, were strongly indebted to Esquirol. He, and the school he founded, effectively developed one of the basic tenets of the new medical specialty. For Esquirol, careful objective observation and analysis of the symptoms and the behaviour of the patients were fundamental. He originated the descriptive clinical approach expanded by his pupils. Even more than Pinel, he was suspicious of unproved theories and when he eventually suggested relations between pathogenic factors and syndromes, he remained extremely cautious in his interpretations. Zilboorg, the psychoanalytically oriented historian of psychiatry, has accused this predominantly descriptive approach of creating a ‘psychiatry without psychology’ because, lacking psychodynamic concepts, its attempted objectivity remained at an allegedly superficial level.⁽⁴⁾ The truth is that it laid the foundations of the present description of the mental disorders. The ‘atheoretical’ descriptive approach adopted in the present nosological systems— both the American Diagnostic and Statistical Manual and the International Classification of Diseases—whose proclaimed purpose is to emphasize the medical character of psychiatry is, in this respect, a return to Esquirol’s principles.

By the end of the eighteenth century it was recognized that the study of mental alienation was part of medicine. However, mental diseases were of such a nature that it was not possible to treat the insane in the same conditions as patients affected by other diseases. Their most obvious manifestations had social consequences. According to the prevailing philosophical view, the mentally ill were deprived of free-will by their illness. In practice, they were unable to participate in the normal life of the society and were often considered as potentially dangerous. Because of this, they had generally been confined in madhouses of various kinds. One of the aspects of the reforms initiated by Pinel had been to make more explicit the difference in nature between the socially deviant behaviour of the insane, which, being the consequence of an illness, belonged exclusively to medicine, and the other deviations which society had to control and eventually to repress. The implementation of this fundamental distinction during the first half of the 19th century helped to give psychiatry its specific shape as a profession by being at the origin of forensic psychiatry and by leading to the formulation of precise rules concerning the commitment of the insane to institutions of a strictly medical character.

The legal code promulgated by Napoleon in 1810 stipulated that ‘no crime or delict exists if commited in a state of dementia’, with the old term dementia being used as a synonym of Pinel’s mental alienation. This legal provision, introduced in similar forms in other countries, opened an important domain of activity to the medical profession of psychiatrist. Because of their now recognized specialized knowledge, the alienists were to help the judges in determining whether the mental state of an individual convicted of a ‘crime or delict’ was normal or pathological, with decisive consequences on the subsequent decision. The title of Esquirol’s Treatise mentions explicitly that it describes mental diseases ‘in their medical, hygienic and medico-legal aspects’. The conflict (which still exists) between the judges, usually supported by public opinion, who took a restrictive view of the concept of mental disease; and the psychiatrists, who tended to expand it to include new types of deviant behaviour, is illustrated by the violent controversies provoked by Esquirol’s description of ‘homicidal monomania’. They had an even more famous counterpart in England. J.C. Pritchard, an admirer of
Esquirol, had isolated ‘moral insanity’ as a specific mental disorder in two books published in 1837 and 1842; in the second, he examined its ‘relations to jurisprudence’. Half a century later, in 1897, Henry Maudsley, who was in favour of the use of this diagnosis, recognized that this category, although internationally accepted by the psychiatrists, corresponded to

The general acceptance of the new medical concept of mental alienation implied the existence of adequate facilities for the treatment of the patients. The creation of new asylums—the term was retained—and the reorganization of the old ones were the answers. The French law of 1838 that fixed the detailed rules for the expansion of the new system to the whole country and for its functioning and financial support had a model character. Similar results were obtained in, for example, England with the Asylum Act 1828 and the Lunacy Act 1845. Outwardly, the new system was the extension, under more humane conditions, of the previous institutional practices. However, it had radically original features. While recognizing the necessity of protecting society, it stressed the fact that the insane had a fundamental right to be protected and medically treated in a competent way. The deprivation of liberty for the patients which it still implied, was strictly controlled to prevent possible misuse and was anyway justified, according to Esquirol and most contemporary psychiatrists, not only by the loss of free will, which was a consequence of the illness, but also by the therapeutic value of separation from a pathogenic milieu.

The asylum system became the central element of psychiatric care and was both the consequence and determining factor of the emergence of psychiatry as a medical specialty to which it gave, until the end of the 19th century and even beyond, an original character. The asylums acquired a quasi-monopoly in the care of the mentally ill. The few private institutions reserved for the wealthier members of the population, which often belonged to alienists in charge of the asylum, were generally submitted to the same legal rules. Private practice with ambulatory patients, as existing today, was exceptional or dealt with cases which were not then considered to belong to mental alienation. As a result, the study of mental illness was predominantly restricted to the more severe forms of disorder. Another consequence was that the alienists in charge of patients committed to the asylums had a dual function, a fact that differentiated them from other hospital physicians. In addition to their medical duties, they were involved in legal procedures which determined the conditions of admission, stay, and eventually release of the mentally ill. As superintendents, they also often had economic and financial responsibilities, being in charge of the material as well as the medical aspects of the functioning of their institutions.

Despite the fact that the laws now strictly differentiated the nature of the limitations of liberty in asylums and in prisons, the participation of the alienist in a form of social control was eventually perceived negatively by the public, and often by other physicians, and contributed to accentuating the specificity of psychiatry inside medicine. During the third and the fourth decades of the 19th century, which saw the birth of the asylum system, the psychiatrists became really conscious of their identity as a professional group. In England, France, Germany, and the United States they founded societies and began to publish journals with specialized scientific goals. Such a description oversimplifies an evolution which was progressive and in some cases took different directions. The creation and the extension of the asylum system took many years; it did not reach its classical form until the last part of the century, as testified by the famous campaign conducted in the United States during the 1840s by Dorothea Dix who complained that many of the mentally ill were still incarcerated in almshouses and prisons. The moral treatment practized in the institutions was eventually used to justify brutal measures, alleged to be therapeutic, and the behaviour of the attendants, who were not usually medically trained (significantly, they were known as surveillants in France), was too often of a purely repressive character. It was a long time before the proposals made in 1856 by the British psychiatrist John Conolly in his book, The Treatment of the Insane without Mechanical Restraints were put into practice everywhere.

The clinical orientation of Pinel, Esquirol, and their followers was basically empirical. By concentrating on describing observable symptoms and abnormal behaviours, it avoided theoretical controversies. However, many believed that if psychiatry was to become a branch of the medical sciences and to progress, it had to adopt models similar to those accepted by the rest of medicine. According to the anatomoclinical perspective, which was now dominant, diseases were distinct entities. Each disease was defined by a characteristic pattern of symptoms provoked by a lesion or eventually, a dysfunction of an organ to be discovered at autopsy. In 1821, Bayle, following this scheme, described the typical clinical symptoms and lesions of the brain in the general paralysis of the insane. Despite the disappointing results of the further anatomopathological studies (brain lesions were observed in only a small proportion of cases), there was increasing conviction that, with better investigation methods, mental disorders, like other diseases, could be explained by somatic causes. The degeneration theory, proposed in 1857 by Morel, which attributed many forms of insanity to the hereditary transmission of dysfunction of the nervous system produced by the noxious effects of environmental factors, and whose influence lasted until Kraepelin, is another expression of this biological orientation whose aim was to give psychiatry an undisputed medical status.

The biological and the purely clinical approaches were concerned with different conceptual levels—the discovery of the causes of insanity and the description of its manifestations respectively. Therefore, they could easily coexist. Even when the followers of Pinel and Esquirol expressed reservations about the applicability of the biological model to every type of mental disorder, they still believed in the medical nature of psychiatry. The situation created in the German-speaking countries by the school of the ‘mentalists’ (the term Psychiker by which they were known means ‘psychologically oriented’), who were predominant during the first half of the 19th century, was very different. Influenced by philosophical, religious, and romantic trends, these psychiatrists took a radical dualistic position, postulating the absolute difference between the physical body and the spiritual soul. The soul was the source of the whole psychic life and hence eventually of its abnormal aspect— insanity. A term such as disease, appropriate for the somatic illness,
could only be used metaphorically in psychiatry. The sins of the patients were the origin of the mental disorders, and psychiatry belonged more to moral philosophy than to medicine. These ideas were developed in various related forms by the majority of the German psychiatrists of the period (Heinroth, Ideler, Langerman, and many others). Their ideological position had two consequences: scientific relations with other schools, such as the French and the English who saw in the publications of the mentalists obscure philosophical theories devoid of medical character, were largely cut off, and they provoked a violent reaction in Germany itself. The most extreme representatives of the contending group of ‘somatists’ (Somatiker), such as Jakobi and Friedreich, saw the mental disorders as symptoms of somatic diseases, not necessarily of the brain. In fact for them mental diseases as such did not exist. They defended aggressively their biological and sometimes bizarre hypotheses, such as the aetiological role of intestinal worms, against the mentalists. Finally, around 1850, they gained the upper hand. The publication in 1845 of Pathology and Therapy of the Nervous Diseases by Wilhelm Griesinger, an heir to their school who was also influenced by the French alienists, is a landmark in the history of the German psychiatry. With his appointment in 1865 as professor of psychiatry in Berlin, where he succeeded the mentalist Ideler, medical psychiatry was definitely established in Germany as a branch of the natural sciences.

Romberg’s Lehrbuch der Nervenkrankheiten symbolizes the birth of neurology as an autonomous medical specialty studying and treating the diseases of the nervous system. It was published 5 years after Griesinger’s Textbook in which, adopting and expanding Bayle’s anatomoclinical model he had affirmed: ‘Mental diseases are diseases of the brain’. If both psychiatric and neurological symptoms originated in the nervous system, some form of association between the two specialties was a logical step, at least at the conceptual level. One aspect of their complex relationship was the creation of neuropsychiatry which developed its most characteristic aspects in the German-speaking countries.

The universities acquired considerable power and influence in the second half of the 19th century. From the 1850s on, chairs were created for the teaching of the new common discipline and special institutions, the university clinics, were built with hospital beds for psychiatric patients (if their disorders became chronic they were sent to the nearest asylum), laboratories for research on neurophysiology and neuroanatomy, and special wards for the neurological cases were developed. Griesinger’s first move when he took over the chair of psychiatry at Berlin was the creation of neurological wards at the Charité. The leading neuropsychiatrists in charge of these institutions often performed research in both fields with equal competence, as shown by the work of Wernicke and Westphal, and later of Kleist and Bonhöffer, in Germany and of Meynert in Austria.

The concept of neuropsychiatry, appearing at a period during which the German school was progressively gaining influence, had a deep impact on psychiatric thought and on the psychiatric profession, even if its institutional driving force, the university clinic system, was not developed everywhere to the same extent as in Germany. For example, it was conspicuously absent in England, despite the fact that the theoretical position taken by the most important psychiatrist of the time, Henry Maudsley, was very close to that of Griesinger. The National Hospital in Queen’s Square, London, founded in 1860, retained a virtual monopoly on the teaching of neurology for many decades, and psychiatry, taught essentially in hospitals, was not represented at university level until the 1930s. However, in most countries, neuropsychiatric institutions coexisted with the asylums where the alienists had the unenviable task of caring for chronic mental patients, often with inadequate means. The concept of neuropsychiatry reflected a basically biological perspective on the aetiology of the mental illnesses, expressed in the creation of a new specialty associating competence in the two previously separated domains of medicine. However, it provoked ideological and professional tension between the ‘pure’ psychiatrists, mainly those in charge of asylums, and the neuropsychiatrists, predominantly involved in teaching and research. In the long term, this conflict was one of the factors which finally led, in the 1960s, to the almost complete administrative and institutional separation of the two specialties in countries such as France where they had been, at least formally, associated. But many traces of the old situation remain. The most influential scientific journal published in German, Nervenarzt, still deals equally with neurology and psychiatry, and the term ‘neuropsychiatric’ survives in the titles of many teaching and research institutions.