Guided by rules not always identifiable from theperspective of the present [2], most human cultures[3] have gone through periods of classificatory zealand produced more than their fair share of ‘classes’out of the objects, real and ideal, populating their uni-verse. Western culture and its medicine have not beenan exception and since Classical times, all manner ofhuman ailments, including those pertaining to behav-

Ordinary article OA 555 EN

Classifications in psychiatry: a conceptualhistory*

German E. Berrios

Background: Historical accounts of psychiatric classifications have hitherto beenwritten in terms of a ‘received view’. This contains two assumptions, that: (i) the activ-ity of classifying is inherent to the human mind; and (ii) psychiatric ‘phenomena’ a r estable natural objects. O b j e c t i v e s : The aim of this article is to provide an outline of the evolution of psy-chiatric classifications from the perspective of conceptual history. This is defined asa theoretical and empirical inquiry into the principles, sortal techniques and contextsin which alienists carried out their task. It assumes that all psychiatric classificationsare cultural products, and endeavours to answer the question of whether classifica-tory models imported from the natural sciences can be applied to man-made con-structs (such as mental illness) definitionally based on ‘personalised semantics’. M e t h o d s : Exemplars of classificatory activity are first mapped and contextualised.Then, it is suggested that in each historical period crafting classifications has beenlike playing a game of chess with each move being governed by rules. This is illus-trated by offering an analysis of the 1860–1861 French debate on classification. Results and Conclusions: (1) Medicine is not a contemplative but a modificatoryactivity and hence classifications are only valuable if they can release new informa-tion about the object classified. (2) It should not be inferred from the fact that psy-chiatric classifications are not working well (i.e. that they only behave as actuarialdevices) that they must be given up. Conceptual work needs to continue to identify‘ i n v a r i a n t s ’ (i.e. stable elements that anchor classifications to ‘nature’. (3) Becausemental disorders are more than unstable behavioural epiphenomena wrappedaround stable molecular changes, ‘neurobiological’ invariants may not do. Stabilitydepends upon time frames. Furthermore, it is unlikely that gene-based classifica-tions will ever be considered as classifications of mental disorders. For once, theywould have low predictive power because of their lack of information about the defin-ing codes of mental illness. ‘Social’ and ‘psychological’ invariants have problems oftheir own.Key words: classification, diagnosis, natural kinds, psychiatry, taxonomy.

Australian and New Zealand Journal of Psychiatry 1999; 33:145–160

*This article is dedicated to Dr Mikulás̆Teich, one of the great histori-ans of science of the 20th century, on his 80th birthday. I have had theprivilege of enjoying, first at Oxford and then at Cambridge, the plea-sures of his teaching and friendship.German E. Berrios, University Lecturer in Psychiatry and ConsultantNeuropsychiatrist [1]D e p a rtment of Psychiatry, University of Cambridge,Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ, UnitedKingdom. Email: <geb11@cam.ac.uk>Received 8 January 1999; accepted 15 January 1999.

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iour and/or the mind, have been assiduously classi-fied [4].

One such classificatory drive, mainly concerningplants, animals and languages, appeared in the Westduring the 17th century [5]. By the end of the 18thcentury [6], it had been generalised to all Creationand crucially imbued with the belief that ‘classify-ing’ was inherent to man [7], who carried it outaccording to cognitive rules written either into hisbrain [8], mind [9] or language [10]. From then on,the debate was no longer about whether one shouldclassify, but how [11]. It has remained so to this day.According to the majority, groupings have to beformed in terms of ‘privileged’features [12] (e.g. thereproductive organs of plants). Linné and other 18thcentury botanists applied this method to diseases[13]. Towards the end of the 18th century, Adanson[14] dared to suggest that all features should be takeninto account; his insight is now considered as a pre-cursor of numerical taxonomy [15].

It is currently accepted that all classificatory actsmust assume a ‘theory of concepts’ [16]. Eighteenthcentury classificators did likewise sharing the beliefthat concepts were ‘sortal’ instruments (i.e. devicesto create classes by comparing candidate items witha paragon). The latter, in turn, was conceived aseither a list of features (menu approach) or an image(a prototype) with sufficient discriminatory power tosort out all denizens of a finite universe into membersand non-members of the given class [17]. The nature,origins and construction rules for the paragon wereno longer discussed, for, by then, Locke’s account ofthe meaning of terms (central to his theory of class-ification) had been widely accepted [18].

A second important 18th century assumption wasthat the ‘natural’ classificatory drive exhibited byman was innate (i.e. God-given). However, as evolu-tionary principles became established during the 19thcentury, the competing belief emerged that classify-ing was an ‘adaptative’function (i.e. that it had been‘selected in’ by nature for it conferred a cognitiveadvantage). All of these earlier assumptions are stillembedded in current classificatory ideas, includingthose reigning in psychiatry.

In such Zeitgeist, classifying mental illness (or itsphenomena) is mandatory, and as it was in 1798, in1998 the mandate remains unchallenged. In roughand ready summary, views since the 19th century(which is the historical period to be dealt with in thispaper) can be grouped according to whether theyassume that the principles of ‘scientific’ c l a s s-ification are universal and: (i) apply to psychiatry

tout court [19]; (ii) apply to psychiatry mutatismutandi [20]; or (iii) they do not apply at all, for sodoing would be an instance of ignoratio elenchi[21,22].

To the question, how it is to be decided which ofthese three views is the correct one, the conventionalanswer has been ‘by interrogating nature’ (i.e. by‘empirical research’). However, this answer makestwo unwarranted assumptions: that nature is a trea-sure of ready-made ‘knowledge’ [23], and thatempirical research is ‘theory-free’. It is more likely,however, that at the moment the question has noanswer for, so far, no science (including physics) hasbeen able to develop a ‘crucial empirical test’ thatcan decide between rival conceptual systems. Thereis the additional complication that ‘empiricalresearch’is wedded to a view of nature according towhich nature and her objects are fully independentfrom the mind, have a ‘mathematical structure’, etc.,and hence it cannot be used to compare two different‘epistemes’, particularly when one of them may actu-ally reject that particular view of nature. In view ofall this, to expect psychiatry to develop a crucial testis utopian (i.e. by empirical research alone it will notbe able to identify, now or ever, a ‘real’classificationof mental disorders) [24].

A more realistic solution might, therefore, be forempirical work only to start once an agreement orconvention has been reached between the variousparties on matters such as: (i) the nature of the phe-nomena to be classified; (ii) the type of ‘concept’and‘class’ to be used; and (iii) a ‘sorting’ methodology.Because such agreement also requires that the con-ceptual analysis [25] be focused on a specific timeand space frame (i.e. region of the world), it becomesobvious that a ‘conceptual history’ of psychiatricclassifications is needed on which to base the agree-ment [26]. As far as I know, the latter has not yetbeen written. It is not that writings on ‘psychiatricclassifications’ or their history do not abound, forsince the 19th century the literature in this field hasgrown at much pace. It is that this material is sur-prisingly repetitious and parochial, and oftenintended to serve too many masters (e.g. clinical,administrative, didactic and propagandistic).Furthermore, they are based on inappropriate histori-ographical techniques and are not able to tell us aboutthe history of concepts.

Nonetheless, these writings offer rich pickings. Inaddition to containing ‘facts’about earlier classifica-tions (in the manner of good catalogues), they tellsomething about the scientific and social world in

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which classifications were born. For example, duringthe 19th century, it was part of professional growthand success that alienists developed a personalclassification [27]. These writings also tell about thedeeper forces (social and otherwise) that have alwayscontrolled the methodology and implementation ofclassifications. Depending upon façon de parler, his-torians may say that such forces originate from a‘paradigm’, ‘cognitive style’, ‘episteme’or ‘fashion’.The advantage of the last term is that it, in oppositionto the others, refers to a resistible social process, andhence removes the alibi that all alienists were con-trolled by ineluctable ‘cognitive rules’[28].

By providing an outline for a future history of psy-chiatric classifications, this paper aims at helpingreaders escape from the conceptual myth that psychi-atrists are obliged to classify mental disordersbecause that is the way in which the brain or lan-guage works. Because of its non-specificity (i.e. itcan be marshalled in favour of any cause), this typeof argument is unhelpful. Nonetheless, it is fair to saythat classifications may serve a number of house-keeping and actuarial functions (e.g. providing anomenclature, furnishing a basis for informationretrieval, and description) [29]. In view of what willbe discussed in this paper, it is less clear that they canalso help with prediction and theory formulation.Little will be said here about the sortal act itself (forone, this raises the ugly problem of symptom anddisease recognition) [30] or about the current prod-ucts of classification.

Definitions now and in history

‘Classification’is an ambiguous term in that it mayrefer to: (i) the creation of principles and rules interms of which items, referents, features, and futuregroupings are to be constituted (what is called taxon-omy when related to animals, plants and otherobjects of the tangible world) [31]; (ii) the act ofgrouping itself (sortal act; what in the case of psychiatry partially corresponds to diagnosis); and(iii) the products of activities (i) and/or (ii) (ICD-10and other classificatory systems can be considered asan exemplar of this). There is no space in this papereven to start discussing the implications and func-tionalities attached to each of these meanings.

Let us start with a 20th century definition:‘Classification is the identification of the category orgroup to which an individual or object belongs on thebasis of its observed characteristics. When the char-acteristics are a number of numerical measurements,

the assignment to groups is called by some statisti-cians discrimination, and the combination of mea-surements used is called a discriminant function’[32].

There is little difference between the above and a19th century definition: ‘In every act of class-ification, two steps must be taken; certain marks areto be selected, the possession of which is to be thetitle to admission into classes, and then all the objectsthat possess them are to be ascertained. When themarks selected are really important and connectedclosely with the nature and functions of the thing, theclassification is said to be natural; where they aresuch as do not affect the nature of the objects materi-ally, and belong in common to things the most differ-ent in their main properties, it is artificial ... theadvantages of classification are to give a convenientform to our acquirements, and to enlarge our knowl-edge of the relations in which different objects standto one another...’[33].

There now follows an 18th century view: ‘All[beings] are nuanced and change by degrees in nature.There is no one being that does not have either aboveor below it another that shares with him some featuresand that differs from him in other features’[34]; and a17th century one: ‘Nature, in the production ofdisease, is uniform and consistent; so much so, that forthe same disease in different persons the symptoms arefor the most part the same; and the selfsame phenom-ena that you would observe in the sickness of aSocrates you would observe in the sickness of a sim-pleton. Just so the universal characters of a plant areextended to every individual of the species; andwhoever (I speak in the way of illustration) shouldaccurately describe the colour, the taste, the smell, thefigure, &c. of one single violet, would find that hisdescription held good, there or thereabouts, for all theviolets of that particular species upon the face of thee a r t h ’ [35]. The common points shown by these defin-itions reflect their common origin and hence thesharing of assumptions about both the entities to beclassified and the rules for their classification.

Nomenclature

Any metalanguage (i.e. a second-order language)must include a minimum set of conceptual tools toallow the examination of the first-order languageitself, in this case taxonomy (as opposed to theobjects in the world to which the theory applies). Ametalanguage for classificatory theory is graduallybeing constituted. The first distinction to be made

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concerns the classificatory system and its domain:the former refers to a frame, the set of rules and thedefinition of the basic units of analysis; the ‘domain’concerns the population or universe of entities to beclassified. These elements interact with one anotherbut of particular relevance is the interaction betweenthe definition of the units of analysis and its domain.This because many might say that the former helps toconstitute the latter.

The metalanguage of classification has also beenexpressed in terms of a number of dichotomies: ‘cat -egorical versus dimensional’; ‘monothetic versuspolythetic’; ‘natural versus artificial’, ‘top-to-bottomversus bottom-up’, ‘structured versus listing’, ‘hier-archical versus non-hierarchical’, ‘exhaustive versuspartial’, ‘idiographic versus nomothetic’, etc. Thesepairs of concepts criss-cross one another and it is noteasy to deal with them independently. Some concernfeatures or dimensions, others the compass of classi-fications, yet others relate to the methodology of tax-onomy. Hence, only some may apply to psychiatry.

Ambiguity abounds within dichotomies. Forexample, in the dichotomy ‘categorical versusdimensional’, the first term can be interpreted asreferring to the status of features or properties (afeature is either present or absent or 0 or 1) or to thestyle of sorting (i.e. an entity is or is not a member ofa class); likewise the second term has a two-foldinterpretation: that a feature is present as a continuumor that the entity (as defined as a cluster of dimen-sions) is only partially the member of a class.Categorical classifications (e.g. species and classes)are popular in biology [36], and seem to require thatits exemplars be in steady state (at least within agiven time frame).

Psychiatric phenomena, whether features (i.e.symptoms) or entities (i.e. diseases) do not meet thisrequirement and hence can be considered as ‘dimen-sional’. An important issue here concerns theproblem of variations in either the quantity and/or thequality of the dimensions. If change occurred withina human time frame or range then it can be handledstatistically. However, if it were to occur in anexpanded time frame (say 100 000 years if due to agenetic mutation), then the change may be missedout altogether. This would be noticed after a recali-bration is found not to tally the original classi-fication. But then one would be confronted with theinteresting situation that there are two ‘natural’clas-sifications of the same domain.

The ‘monothetic versus polythetic’dichotomy con-cerns the number and predominance of the traits used

to effect the sorting: monothetic definitions are basedon the principle that classes consist of all the objectsthat take the same set of attributes. Polythetic defini-tions are based on the idea of ‘family resemblance’and hence list many attributes or characters all ofwhich are possessed by some members of the class,but none of which is possessed by all members of theclass (i.e. each member just having some of the char-acters in question) [37].

Since the 18th century, classifications have beensaid to be ‘natural’or ‘artificial’, but even this seem-ingly straightforward classification is ambiguous.According to a weak version, the terms characterisethe old observation that objects can be classified interms of either essential or man-made features (e.g.flowers can be grouped according to their sexualorgans or simply in terms of their use, such as infunerals, weddings, etc.). According to the strongerversion, however, the first horn of the dichotomyactually assumes the existence of ‘natural kinds’[38]. ‘Natural classifications’ would thus be dictatedby ‘reality’itself whilst artificial ones would be man-made [39]. It goes without saying that those chal-lenging the existence of natural kinds may want toargue that all classifications are, in fact, artificial.

‘Top-to-bottom’ and ‘bottom-up’ purportedly referto the manner in which classifications are con-structed. In practice, these terms overlap with thenatural versus artificial dichotomy for they go backto whether classifications (as sets of categories)should be deduced from some high level theory orwhether the furniture of the world should bepainstakingly organised into groups which hopefullymight become stable classes.

The ‘structured versus listing’dichotomy concernsthe internal organisation of the components of classi-fications. Good examples of pure ‘listings’ are theICD-10 and DSM-IV glossaries which are bestdefined as partial inventories. Furthermore, the inclu-sion rules for these inventories are heterogeneousand originate from scientific and social sources. Forexample, some of the ‘clinical’ categories of DSM-IV are said to owe their inclusion more to pressuresfrom the USA pharmaceutical or medical insuranceindustry than to ‘science’. Since social factors arealways present in psychiatric classifications, this mayor may not be a problem for DSM-IV and USA psy-chiatrists and it is nobody else’s business. However,it becomes a problem when the glossary is exportedlock-stock and barrel to other countries with an insur-ance industry structure totally different to that of theUSA. ‘Structured’ classifications, in turn, are those

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whose categories together purport to offer a completemapping of the universe to be classified (e.g. like thetable of chemical elements). Although there weresome during the 19th century, structured psychiatricclassifications have not been seriously put forwardduring the 20th century.

The hierarchical versus one-level dichotomy alsoconcerns the structure of classifications. Hierarchicalclassifications are decisional trees with higherclasses embedding lower level ones. For example,Kraepelin’s division of neurosis and psychosis, andthe latter into schizophrenia and manic depressiveinsanity, is an example of a hierarchical dichotomousclassification (said to have been suggested by KarlKraepelin, Emil’s older brother and distinguishedclassificator of molluscs) [40].

The ‘exhaustive versus partial’dichotomy concernsthe coverage or compass of a classification.Exhaustive classifications purport to cover all theentities in a given universe, hence, they tend to bedeductive. For example, some 19th century classifica-tions of mental disorders started by assuming that theentire realm of mental phenomena can be classifiedwithout residuum into intellectual, emotional andvolitional. Then it was further assumed that any ofthese mental functions were independently aff e c t e dby disease and it was thence inferred that there mustbe intellectual, emotional and volitional mental disor-ders. In fact, this is the basis for our current classifi-cations leading to schizophrenia and paranoia (firstgroup); mania, depression, anxiety, phobias, etc.(second group); and character and personality disor-ders (third group). Such classifications purported tocover all possibilities and anyone with a mental dis-order had to fall into one of the groups. To deal withcases where more than one function was involved,rules of preference or hierarchies had to be created todecide on which ‘disease was primary’[ 4 1 ] .

Last, there is the occasionally mentioned idiographicversus nomothetic dichotomy whose historical originhas little to do with psychology or psychiatry althoughmuch to do with the classification of the sciences. T h i sdichotomy is rich in meaning and hides a complex setof assumptions as to the nature of the natural andsocial sciences, as it was at the turn of the century. In1894, in his inaugural lecture as Vice-Chancellor ofS t r a s s b u rg University, Wilhelm Windelband offered asummary of his views and focused on the diff e r e n c ebetween two types of sciences: ‘We can therefore saythat in approaching reality the empirical sciencessearch for either of two things: the general in the formof natural laws or the special, as a specific event of

h i s t o r y. They thus contemplate the permanent andimmutable or the transitory as contained into real lifehappenings. The former sciences concern laws, thelatter events; the former teach what has always been,the latter what has happened once. In the first case, sci-entific thinking is (if we were allowed to coin newtechnical terms) nomothetic, in the second case idio-g r a p h i c ’ [42]. This distinction carries too much theo-retical baggage to be applied s i m p l i c i t e r to the issue ofgroup versus single case studies which are raging atthe moment particularly in regards to classificationand analysis in neuropsychology and neuroimagingstudies. A study of Wi n d e l b a n d ’s original reasoning,h o w e v e r, may throw some light on current confusions.

Concepts

It has been mentioned above that at the core of anytaxonomy there is always a theory of concepts. Thisclaim needs unpacking. Classifying can be made intoa simple or a complex activity. According to theformer, classifying is the act of sorting the entities ofa given universe into pigeonholes provided by natureor invented by man. When analysed from a logicalperspective pigeonholes have been called ‘classes’,and when studied as cognitive categories ‘concepts’.Now, while it is possible for anyone to create a classi-fication without needing to explicitly sponsor atheory of ‘concepts’(ICD-10 and DSM-IV are goodexamples of this), it is also true that a theory of con-cepts is always implicitly assumed. In the latter case,the classificator will find that, because he has notworked out the theory of concepts he subscribes to, itmight not be easy to understand some aspects of hisown classification (e.g. its ‘truth-value’, internalstructure, coverage, predictive capacity, etc.) [43].

However, good classifications must be more thanconcepts that are able to pigeonhole without error. Ofall the potential benefits of a classification, the mostimportant is its predictive power (i.e. its capacity torelease additional knowledge about the entity at thevery moment of its classification). The fact that thisepistemological fruitfulness is rarely apparent in psy-chiatry needs to be accounted for. In this regard, oneexplanation may be that to be informative classifica-tory systems need to be structured, encompassing,and based on a general theory (like the table of chem-ical elements). For reasons which are discussed inother sections of this paper, there is little hope thatthis can be achieved in psychiatry.

The realisation that structured classifications andfull categorical discrimination may be unachievable in

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psychiatry has led some to resort to other definitions of‘ c l a s s ’ and ‘concept’ (e.g. ‘prototypes’) [44]. In thisregard, Hampton has written: ‘it is claimed that uncer-tainty about classification is a result of people’s inade-quate knowledge of the categories that exist in the realworld. The prototype view is directed, however, at acharacterisation of exactly this inadequate knowledge— it is a model of the beliefs people have. Whether ornot the real world is best described with a classicalconceptual framework is an interesting and importantquestion, but irrelevant to this psychological goal ofthe prototype model’ [ 4 5 ] .

Is this relevant to psychiatry? Are the notions of‘clearest case’, ‘best example’, and ‘procedural cri-teria’ applicable to this field? Can prototypes for allmental disorders be generated? What is their source?A plausible answer to the last question is that thereare two sources: on the one hand, there is history (i.e.the received view of the disease), and on the other,there is ongoing clinical practice (i.e. the ‘livedexperience’ of the maker of the prototype). Howthese two sources interact is one of the problems ofpsychiatry. For it is no good saying simpliciter thatthe latter provides the criteria to trim the former. Itmust not be forgotten that what history now gives usas ‘past’ was once upon the time the ‘lived experi-ence’of the creators of the first ‘prototype’. Now, aseach successive generation trim and recalibrate the‘ r e c e i v e d ’ prototype new ones are being added.Faced with the historical series, we do not yet haverules to decide on which one should predominate.

Now, this problem has been dealt with by assumingthat there is a linear progress in science and that perforce the current prototype is best. Unfortunately, thisassumption is untenable for in the specific case ofmental disorders it is not right to say that all currenttrimmings and readjustments do is improve uponsome ‘received’prototype. The alternative view is tosay that because they reflected exactly ‘lived clinicalexperience’, all prototypes are as valid as currentones. The problem here is caused by the fact that it ishighly likely that through genetic mutation, medica-tion, social pressures upon the language of descrip-tion, fashions in the expression and formatting ofsubjective feelings, etc., the goal posts are moving allthe time. In other words, the biological invariant (andits behavioural expression) are no more stable or reli-able than a social invariant. Hence, it cannot be saidthat the latest prototype is necessarily the best in thetemporal series.

The problems with prototypes, therefore, is thatthey do not really advance our knowledge about

disease. They represent periodic recalibrations whichremain valid within a given period of time, and thereis no Platonic model to which they ineluctably takeus. They simple capture, as Hampton put it, theextension of our ‘current beliefs’ about the object(disease) in question. In this regard, the hope thatgenetics will help psychiatry to fix the boundaries ofmental disorders forever seems misplaced.

Assumptions

A number of assumptions are also made in regardsto the feasibility of classifications. For example, asmentioned above, writers start from the assumptionthat classifying is the expression of an adaptativecognitive function. This assumption is expressed invarious ways: for example, by using Kantian episte-mology and affirming that man cannot stop classify-ing. In this sense, J.S. Mill also believed thatclassifying was built into grammar and that predi-cates are natural sortal mechanisms [46]. A ‘sortalconcept’ is a ‘concept which conveys a criterion ofidentity and thus determines a type of object forwhich it makes sense to ask whether objects of thetype are the same or different’[47]. But not everyonein the 19th century agreed. For example, Durkheimbelieved that the human mind was not, in fact, verygood at generating classifications and that it bor-rowed models from the symbolism available insociety and culture. Hence, the so-called ‘logical’categories were, in fact, social categories [48]. In thissense, classifying mental illness was more like clas-sifying symbols than natural kinds.

But the same idea can also be approached from apsychological perspective, in relation to the role ofboth mental functions in general or to the role ofhuman subjectivity. Thus, often a classificatory rolehas been attributed to ‘memory’ and considered:‘essential to adaptive behaviour because it is orga-nized in ways that make information gained frompast experience applicable to present situations. Andthe essence of memory organization is classification.Although we experience only individual events, weremember them and identify occurrences as instancesof classes or categories’ [49]. Others have proposedthat there are at least two types of category learning:classification-based and inference-based [50]. Soingrained is this view, that it has been said that if lan-guage did not automatically perform a classificatoryfunction, man’s perception of the world would becompromised and he would live in a confused andconfusing Jamesian mess.

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Towards a history of psychiatricclassifications

Foucault’s suggestion that a new drive to cataloguenature started in the West during the 17th century isfundamentally correct. He further believed that thishad to do with a new way of dealing with representa-tion: namely, with the question of linking words tothings (so that at a later stage one would only dealwith words). For example, the crucial differencebetween 17th century animal histories and themedieval and Chinese bestiaries is that in the latter‘everything was said about each animal’ whereas inhistories all the old semantic content was cleaned outand systems of representation were created whichapplied to a variety of objects. The same changesaffected history itself which from being a narrativebecame a technique to capture the truth of things.This forced history to catalogue and deal with theobserved in a different way [51]. This is why duringthe 18th century, the issue of classifying becamelinked with the Condillacean concept of science as a‘perfect language’ [52] and also with the debate onhow sciences related to each other (the problem ofthe classification of the sciences) [53].

At the very end of the 18th century, the young Pinel[54] placed himself at the junction of two traditions.As one of the French translators of Cullen (who hadadmirably summarised the work of the continentalnosographers) [55], Pinel declared himself a child ofthe 18th century; but in writing his NosographiePhilosophique [56] and challenging John Locke, helooked resolutely towards the new century. It wasonly by the division of the 19th century thatBouillaud, still influenced by Condillac, started toemphasise the value of creating a ‘perfect language’for science, and the need for a stable nomenclature;in this latter regard he criticised Pinel for not havingdefined any of his key terms [57].

In his own definition of classification, however,Bouillaud remained an 18th century man: ‘a class-ification of diseases that is truly philosophical andrational must be based on knowledge on the nature ofdisease. All nosological buildings erected on anyother foundations will remain fragile and lead to ruin’[58]. (For a general criticism of this view see Riese[59].) In this short paper, there will only be space forsetting the principles of a conceptual history. To thispurpose, a specific historical event has been chosenfor analysis, namely the 1860–1861 debate on classi-fication at the Société Médico Psychologique. Thiscase study will show that the said debate was a con-

ceptual microcosm where all the main 19th centuryissues on psychiatric classification were ventilated.

Matters historiographical

There are at least three modes of writing on thehistory of psychiatric classifications: chronologicalcatalogue [60], and social [61] and conceptualhistory. The last approach, to be followed in thispaper, is based on the view that the history of words,concepts and the associated behaviours must be con-sidered separately, and that for each mental symptomor disease a ‘convergence’point can be found wherethe three elements come together. Conceptual historyis based on the idea that mental symptoms are speechor communication acts conveying a biological signalwhich is heavily formatted by personal, social andcultural codes, and that upon being uttered these actsare additionally conceptualised by professional inter-preters. Hence, the nature of psychiatric ‘reality’ isneither pure biology nor an empty social constructbut a complex combination of the two. This generalhistoriographical approach requires some modifica-tion to deal with psychiatric classifications. Forexample, the purpose, objective, conceptual assump-tions, and social and temporal frames of classifica-tions, what Lanteri-Laura has called ‘les référencesnon-cliniques’ [62], need also to be identified.

The 1860–1861 SMPdebate

In 1934, Desruelles et al.o ffered the official view onthe origin of French psychiatric classifications: ‘In1843, the year when Annales Médico-Psychologiquesstarted their publication, the classification of mentaldisorders generally accepted included mania, lypema-nia, monomania, dementia, paralytic insanity, andidiocy; to which some added stupidity. [In fact] this isthe classification first put forward by Cullen in 1872(mania, melancholia and dementia) to which Pineladded idiocy, Esquirol added monomania, andG e o rget added stupidity (i.e. states of confusional,demented and melancholic stupor which Esquirol hadrefused to consider as a separate entity). Lastly,Parchappe added paralytic insanity’ [ 6 3 ] .

The view proposed by Desruelles et al. is factually[64] and historically telling. First, the saliency ofC u l l e n ’s work has also been noticed by others (i.e. thatby blending and streamlining 18th century diseaseclassifications, the great Scotsman became a de factoculture carrier) [65]. Second, because 20th centurymedicine can be considered as sharing the same classi-

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fication principles as the previous two centuries, itcould be said that Cullen’s taxonomic ideas have moreimportance than what has hitherto been considered.Third, the fact that all leading European psychiatricnosologies (e.g. German, French and Italian) seem tohave the same origin (i.e. Cullen’s nosology) suggeststhat later divergences may have resulted more fromthe growth of European nationalisms than from anylogical or empirical developments within psychiatryitself [66].

While during the 19th century most alienistshappily accepted the view that classifying was anessential aspect of their work, writers with a deepersocial understanding were more ambivalent. A goodexample is Philippe Buchez [67], who satirised:‘Upon believing that they have completed theirstudies, rhetoricians will compose a tragedy andalienists a classification’ [68]. However, he alsowrote: ‘in addition to facilitating teaching andhelping to remember — by themselves importantfunctions [classifications] have as their most impor-tant objective to carry out a diagnosis, now calleddifferential diagnosis. Now since diagnosis is at thebasis of treatment, then it can be said that in the lastanalysis the objective of classifications is treatment’[69]. This feeling of confusion about psychiatricclassifications continued till the end of the century.Thus, Féré wrote: ‘those who debate on psychiatricclassifications sound like the workers at the Tower ofBabel: the more they talk the less one understandsthem. If the terms do not mean the same for everyonethen they run the risk of being applied to differentclinical states’ [70]. This trouble with definitions ledB a i l l a rger to suggest that the Société Médico-Psychologique should ‘fix the meaning of the mainforms of mental disorder so that their scientific pathcould, so to speak, be controlled’[71].

Desruelles et al. also reported that 19th centuryFrench alienists used at least eight criteria to classifymental disorders: the cause of the disorder (aetiolog-ical), the substratum of the disorder (e.g. anatomy),the clinical outcome (whether curable or incurable),actuarial (according to what was observed in the sta-tistics of the main asylums in France), phenomeno-logical (according to whether or not the disorderincluded delusions), ‘natural’ (i.e. whether it corre-sponded to ‘real types’ as given in nature), psycho-logical (i.e. what mental faculty was assumed to beimpaired), and disease course.

With all these approaches vying for power, it is notsurprising that the Société Médico Psychologiqueresorted to a debate [72] on psychiatric classifications.

The debate

The debate was started on 12 November 1860 byDelasiauve [73] who, on the excuse of dealing withBuchez’s positive review of a book recently pub-lished by Morel [74], launched forth into an analysisof the classificatory ideas of Esquirol, Ferrus, Falret,Girard de Cailleux, Lasègue and Baillarg e r. OfMorel’s aetiological classification, Delasiauve wrote:‘Morel is evidently intoxicated by his views. Whatseems to have seduced him and to a certain extentBuchez is the disorders caused by alcohol, lead andepilepsy where the cause is tangible and its effectsunderstandable. Not so with other states where thereare multiple factors and influences’ [75]. Buchezreplied briefly: ‘Mental illness is characterized bysigns and symptoms and these have served always asclassificatory principles. Are they sufficient? Theanswer is not ... it is necessary to search for thepathogenesis of mental disorder ... to describe mentalillness is not to classify it’[76].

The debate on the Session of 26 November 1860was started by Jules Falret [77], who offered to iden-tify ‘the principles that govern, in all sciences, thedevelopment of natural classifications’: ‘1) A classshould be defined in terms of a set of features presentin all the objects to be encompassed and not in termsof one character that might artificially bring togetherobjects which would be different if other featureswere to be considered; 2) the said feature-set shoulditself be organized in a hierarchy so that its essentialcomponents are clearly identified; 3) the objects thatcome under one class should not only share thefeature set at a given moment in time but show thatthey have evolved in a similar manner [acquired thefeatures in an order that can be predicted]’[78]. It canbe clearly seen that criterion 3) reflects the influenceof evolution theory and sets a task that remains unful-filled to this day: few psychiatrists will consider theorder in which the symptoms appear as a classifica-tory criterion [79].

Falret then proceeded to criticise all available clas-sifications for they rely on one feature or characteralone, for example the involvement of: ‘1) an intel-lectual faculty or 2) a predominant idea or emotion or3) act or 4) the features and extension of a delusion’[80]. Based on this, he went on to conclude that‘mania, monomania, melancholia and dementia arebut provisional symptomatic clusters and not truenatural species of mental disorders’ [81].

Morel had attended the session of 26 Novemberand ‘although [he] was not planning to talk ... he felt

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the need to intervene as his ideas had been ques-tioned by Delasiauve and Falret’. Not having beenprepared, his speech was rambly and concentrated onjustifying his view that hereditary mental disordersexisted although ‘three elements converge to createthem: predisposition, a cause, and a series of trans-formations of pathological phenomena that ... deter-mine the place that a given disorder will occupy inthe nosological classification’[82].

The session of 10 December was taken by thedebate between Adolphe Garnier [83] and AlfredMaury [84]. Garnier started by suggesting that thedichotomy ‘natural–artificial’ should be replaced by‘essential–superficial’. Since it was impossible totake all the features of the objects to be classified intoaccount, groupings based on a limited number ofcharacters always led to blurred boundaries andhence ‘there were always patients who floatedbetween two classes’. Geoffrey Saint-Hilaire andCuvier had had a clash on this very issue a long timeago and ‘there was no solution to it’. This was thereason why alienists tried to complement their classi-fications with speculation about aetiology but thelatter should not be considered as a feature of theobjects in question. Garnier finished by suggestingan ‘essential classification of mental disorders basedon mental faculties’[85].

Maury rose to say that since science had notadvanced sufficiently, only artificial classificationswere possible, particularly in the area of psycho-logical medicine where little was known aboutcauses. He attacked Garnier for sponsoring a‘psychological view’ of mental illness, for consider-ing that ‘it is a consequence of an emotional turmoilalready present in the heart of man, and which in theevent enslaves him and takes his freedom away’.While strong emotions might on occasions causeinsanity, there were many cases where the symptomsovercame the patient (e.g. those resulting from braindiseases forced changes in his behaviour). The ques-tion ‘was not to classify mental disorders from aphilosophical viewpoint in terms of which mentalfaculty seemed involved but in terms of its patholog-ical origins ... otherwise it will not be possible to dif-ferentiate mental illness from normal behaviour (e.g.monomania from dreaming)’. ‘We must not forgetthat we are not here in the world of metaphysics butin psychological medicine. We classify mental disor-ders to cure them and this is why we must try andfind out their aetiology’[86].

The next session, on 24 December, was taken byGarnier’s rejoinder. After iterating his view that

‘looking for efficient causes according to Bacon’sprinciples’[87] was the best way to achieve a classi-fication, he explained why Delasiauve had feltunable to classify insanity according to the receivedview on the psychology of the intellectual functions:‘it is not possible to create a classification of insanitybased on a conventional division of intelligence intojudgement, reasoning, etc. because the latter modesare not independent but blend with each other andwith attention and memory ... Hence, it might bebetter to divide intelligence according to the objectsit deals with’[88].

Garnier then turned on Maury: ‘He tells me, you donot take into account physical causes but are onlypreoccupied with psychological ones ... I reply,although a spiritualist I am not afraid of matter butwhen I look for it I cannot find it ... insanity is a dis-turbance of the intellectual faculties and requires aspecific method of observation ... there is as littlepoint in listing insanities due to saturnism, alco-holism, etc. as there is listing others due to diseasesof the liver. Changes in this organ do not cause theinsanity. It is in the brain where the cause must besought. If that part of the brain that produces halluci-nations is lesioned in any way, including by thetouching with a finger, it will lead to the samesymptom’[89].

The following session took place on 29 January1861, and its protagonists were Buchez and Garnier.The former started by producing a summary of whathad gone on so far: ‘on the one hand, papers havebeen read here suggesting that insanity would be justthe one disease with diverse manifestations’ [90]from which follows that descriptive and classifica-tory publications only scratch its surface and ‘on theother hand, a paper has been read trying to identifyo rganic aetiology, pathogenesis’... ‘the Baconianmethod is used in medicine under the name of“method of exclusion” but has had little influence onnatural history’; ‘Diseases are not independent enti-ties, existing by themselves, with a life of their own,like plants or animals. They fully depend upon aliving organism and exist only in it’ [91]. Because ‘aclassification must be above all a faithful reflectionof the science of its time’, Buchez felt that he neededto explain to the audience what was the ongoing stateof the philosophy of science and proceeded to do so.He concluded by, once again, giving support toMorel and his organic classification [92].

Garnier was surprisingly conciliatory in his inter-vention: ‘The question then is to know whether thereare various insanities or only one. Buchez seems

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inclined towards the latter.To determine this we mustuse the Baconian method ... But he is right in sayingthat the latter is not relevant to natural history’ [93].The session was closed by the blunt (and correct)observation of Dr. Archambault’s [94]: ‘Garnier andBuchez seem to be employing the words madness(folie), mental alienation, mental illness etc. as if theymeant the same. As far as I am concerned they havedifferent meaning’. Stung by the comment Buchezrose to his feet: ‘madness and mental alienation donot mean the same; mental alienation has however amuch wider meaning’[95].

The debate went on for three more sessions: 25F e b r u a r y, 25 March and 29 April. By then it was repe-titious and although new speakers appeared (Parchappeand Lisle) no new conceptual point was made.

In summary, the 1860–1861 French debate on psy-chiatric classifications is important for it was amicrocosm where all the important issues of the con-ceptual and empirical difficulties involved in thisfield were made. Desruelles et al. saw it as reflectinga clash between the traditionalists (defenders ofE s q u i r o l ’s monomania concept) and innovators(those who followed Morel) [96].

Although historically correct, on hindsight thisinterpretation is found too narrow, and its widerimplications need teasing out. Salient is the fact thatthe debate, although taking place in a Medico-Psychological Society founded by alienists, andapparently starting from a practical problem, wassoon taken over by philosophers of mind. This meantthat there was the need to sort out principles andrules, and to reach the agreement that empiricalresearch alone could not solve the problem. Notablealso is the fact that all participants at the time soonrealised that classifying diseases was not like classi-fying plants or animals and that the conceptualproblem involved was completely different. Thus,and in terms of the classification of points of viewsuggested at the beginning of this paper, Frenchalienists believed that general taxonomic principlesonly applied mutatis mutandi. They also realised thatthe question of whether there was only one or manyforms of mental disorder (i.e. the ‘unitary psychosis’issue) was of central import to the classificationdebate and that this question was not necessarilyempirical in nature. Last, no clear decision was takenas to whether psychological (descriptive) or organic(aetiological) criteria should be used. In general,although lip service was paid to organic classifica-tions, it was agreed that so little was known aboutaetiology that such approach remained utopian.

The 19th century French alienists were well awarethat confusion about classification was an obstacle toresearch, and in 1889 a second debate took place atthe Société Médico-Psychologique [97]. At theEuropean level, there were also two meetings. In1885, the Congress of Mental Medicine at Antwerpappointed a Commission to consider all existing clas-sifications. This was discussed at the Paris Congressof 1889 and a classification drawn by a Dr. Morelfrom Ghent was adopted. Rather ruefully, DanielHack Tuke wrote in 1892: ‘it has yet to be seenwhether asylum physicians will adopt it in theirtables’[98].

Conclusions

For the conceptual historian, there are basicallytwo ways of approaching psychiatric classifications.One is to write from within the episteme and acceptboth the ‘received view’that classifying is inherent tothe human mind and the inference (yet to be tested)that this means that psychiatrists are compelled toexercise this function in their field of interest.According to this first approach, all the historian cando is catalogue (once again) the products of earlierclassificatory enterprises. As shown above, this typeof work has been done ad nauseam.

The second approach is to study psychiatric classi-fications from outside the episteme, not to take anyviews for granted, and consider psychiatric classifi-cations as cultural products. This should also includeexamining the scientific evidence that brains, mindsor languages actually possess built-in classificatoryalgorithms. In practice, however, it does not matterwhether or not they do for even if their existence isgranted, it does not follow that their possessionshould drive men to classify any and all objects theycome across. In fact, it can be assumed that the clas-sificatory capability was ‘selected in’by evolution toallow for the rapid classification of plants, animals,stones, and other objects relevant to man’s survival.It remains to be proven: (i) whether this capabilityextends to all objects in man’s new environments;and (ii) if it does, whether it is in his best interest (andcreating science is considered as one of them) to clas-sify ideal objects, hypothetical constructs and otherentities whose real management and understandingmay require the use of a personalised semantics.

This paper has been written from the perspective ofthe second approach. This is the reason why its firstlong section was dedicated to mapping the concep-tual structure of the various components of the clas-

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sificatory activity and to linking them, as far as it waspossible in terms of the available scholarship, to thecontext in which they were first thought out. The firstconclusion here is that there are major gaps in the lit-erature and that much work needs to be done beforea coherent picture emerges. The second conclusion isthat conceptual history and straight analytical philos-ophy work well together in this field. A third conclu-sion is that even after showing that there are weightyconceptual reasons why psychiatric classificationsare not working, there is no reason to infer from thatthat classifying in psychiatry is a useless exercise. Allthat follows is that much more conceptual workneeds to be done if we are going to develop classifi-cations which have more than an actuarial function.

Since medicine is not a contemplative but a modi-ficatory activity, a fourth conclusion is that what isrequired is classifications that can release new infor-mation about the object just classified. The receivedmodel of mental (a variant of the old anatomo-clini-cal hypothesis) still enjoins us to anchor all ‘essen-tial’ classificatory criteria in neurobiology. Lookingfor a ‘biological invariant’ responsible for surfaceevents (symptoms) seems a task worth pursuing. Butit also looks as if, in order to really understand therole of the biological invariant, some naive beliefs asto the stability, duration and reliability of biologicalsubstrata will have to be given up. History seems tosuggest that the biological substratum is ‘invariant’only within a given time frame. We know little aboutthe latter, particularly in regards to the genes relatedto the main mental disorders.

Nonetheless, the view that mental disorders arebehavioural epiphenomena wrapped around molecu-lar changes is rapidly developing in some quarters.According to this view, a ‘natural’ classificationshould develop once all responsible genes have beenidentified. What is more, it is also expected that suchclassification might even help with the characterisa-tion of stable phenotypes. The question here iswhether such a molecularly based classificationwould actually be a classification of mental disor-ders. Many may feel that it would not for molecularchanges are not yet a mental disorder, and becausethe latter is intrinsically a complex construct thatmust include the pertinent formatting codes.

But the fact that genetics alone will not do, shouldnot stampede psychiatrists into searching for a socialinvariant. The belief that all mental disorders aremerely social constructs is not threatening to psychi-atry because it undermines the professional existenceof psychiatrists; it is threatening for it does not offer

the steadiness required to create a predictive system,which is what medicine is all about.

Taxonomy and its associated classificatory activi-ties constitute a self-contained and more or lessexhaustive conceptual system. This means thatwithin a given historical period, thinking about andcrafting classifications is like playing a game ofchess in that everything will occur within strictboundaries and according to explicit or implicit rules.For example, not all possible moves will be made:some because they are forbidden by the rules, othersbecause they are patently suicidal, and yet othersbecause they are not fashionable. The same withclassifications. For example, the concept of class wehave inherited from 18th century botany still encour-ages psychiatrists in the 20th century to dream ofclassifying per genus et differentia , even if this doesnot apply to mental disorders at all. It was preciselyto illustrate this point, namely, the constrained con-ceptual environment in which all talk on classi-fication takes place, that a detailed analysis of the1860–1861 French debate is offered in this paper.Noticeable was the fact that whether psychologist,historian, philosopher or alienist, the participants inthe debate agreed on fundamentals such as that thereis a need to classify, that mental disorders are sus-ceptible to classification, that classes must have clearcut boundaries, etc.

The same can be said of the current literature onpsychiatric classifications. Although increasinglyvoluminous and on occasions imaginative, it is stillpostulated by ‘unsaids’and with very rare exceptionsdoes not allow itself to think the unthinkable; that is,psychiatric classifications may be called into ques-tion because not enough is known about aetiology, orbecause mental illness is so complex and mysteriousthat it cannot be classified, or because not enoughempirical research is being done, or because one isnot being scientific enough and allows social factorsto contaminate what should be a purely surgicalenterprise (carving nature at the joints). But rarely ifever the literature challenges the validity of the clas-sificatory act itself, irrespective of whether mentaldisorders are or are not susceptible to classification.It is one of the contentions of this paper that that con-ceptual (chess) move needs to be explored.

Endnotes and References

1. Reprint requests to G.E. Berrios, Department of PsychiatryUniversity of Cambridge, Addenbrooke’s Hospital, HillsRoad, CB2 2QQ, UK. Email: <geb11@cam.ac.uk>

2. See, for example, Viejo JL. El Hombre como Animal: el

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Antropocentrismo en la Zoologia. Asclepio 1996; 48:53–71;and Foucault M. Les Mots et les Choses . Paris: Gallimard,1966.

3. Durkheim E, Mauss M. Primitive classification. (Translatedfrom the French by R. Needham.) London: Cohen & West,1963 (first published in 1901–1903).

4. See, for example: Temkin O. The history of classification inmedical sciences. In: Katz MM, Cole JO, Barton WE, (eds).The role and methodology of classification in psychiatry andp s y c h o p a t h o l o g y. Washington, DC: US Department ofHealth, Education and Welfare, 1965:11–25; Chapter 10, inLorr M, et al. Syndromes of psychosis. Oxford: Perg a m o nPress, 1963; Fischer- H o m b e rger E. Eighteenth century nosol-ogy and its survivors. Medical History 1970; 14:397–403.

5. Slaughter MM. Universal languages and scientific taxon -omy in the seventeenth century. Cambridge: CambridgeUniversity Press, 1982.

6. See Flint R. A history of classification of the sciences.Edinburgh: William Blackwood, 1904; Larson JL. Reasonand experience. The representation of natural order in thework of Carl von Linné. Los Angeles: University ofCalifornia Press, 1904. Berg F. Linné et Sauvages. Lychnos1956; 16:31–54.

7. Even great men gave way to the new ideas. For example, in1749 Buffon was very sceptical about classifying livingbeings but by 1761 he had been converted (p.566, in RogerJ. Les Sciences de la Vie dans la Pensée Française du XVIIISiècle. Paris: Albin Michel, 1993; first edition 1963). For amagisterial treatment of this topic see Chapter VI: ‘TheProblem of Classifying and Systemizing Natural Forms’(pp.118–136) in Cassirer E. The problem of knowledge.Philosophy, science, and history since Hegel. New Haven:Yale University Press, 1950; and Riese W. History and prin-ciples of classification of nervous diseases. Bulletin of theHistory of Medicine 1945; 18:465–512.

8. Whether such beliefs concern classification or categorisationremains unclear. At any rate, the underlying rules and mech-anisms are far from being understood (on this see the bril-liant: Estes WK. Classification and cognition. Oxford:Oxford University Press, 1994).

9. The ‘Kantian revolution’was partially about the identifica-tion of general categories in terms of which knowledgemight be organised.

10. For example, Mill stated that naming something as X isalready classifying for two classes follow: X and not X(p.76, Mill JS. A system of logic. London: Longmans,Green, and Co., 1898).

11. Such was the belief in the ‘naturalness’of classifying that atthe 1860–1861 SMPdebate on classification Jules Fairetstated with incredulity: ‘even in the present, some peopleare still inclined to deny the importance of classification inthe sciences and consider them as sterile … to think like thisis to deny the essential nature of the human mind and itsinstinctive tendency to group objects by analogy, and sepa-rate them by differences and to search for the general lawsthat allow the organization of multiplicity … This tendencyis so totally inherent to the human mind and its nature soabsolute that it shows itself both in the child and in theprimitive man …’(pp.145–146, in Reports. Meeting of 26November 1860, Annales Médico-Psychologiques 1861;7:143–177. For a recent review of classification as a ‘cogni-tive activity’see Jablensky A. Methodological issues in psy-chiatric classification. British Journal of Psychiatry 1988;152(Suppl. 1):15–20.

12. During the 18th century classifications were also caught up

in the issue of whether the mind was capable of penetratingnature or whether divisions were only in the mind of man(see Jordanova LJ. Lamark. Oxford: Oxford UniversityPress, 1984). In regards to the origin of the concept of ‘priv-ileged features’, it is likely that this originated from Locke’sview that: ‘because nature contains only many particularsresembling each other in many ways we must decide whichdifferences between individuals objects, whether grosslysalient or barely noticeable, to include in our abstract ideasof them and thus in our definitions of general terms’(p.145,Guyer P. Locke’s philosophy of language’in Chappell V, ed.The Cambridge companion to Locke. Cambridge:Cambridge University Press, 1994:115–145.

13. See Larson JL. (1971) ibid. 14. Adanson M. Preface Istorike sur l’état ancien et actuel de la

Botanike, et une Téorie de cette science. In: Familles desPlantes, First Part. Paris: Vincent, 1763:i–cccxxv.

15. Vernon K. The founding of numerical taxonomy. BritishJournal for the History of Science 1988; 21:143–159.

16. Mechelen I van, Hampton J, Muchalski RS, Theuns P, eds.Categories and concepts. London: Academic Press, 1993.On the role of concepts in classifications see the excellent:Malmgren H. Psychiatric classification and empiricist theo-ries of meaning. Acta Psychiatrica Scandinavica 1993;373(Suppl.):48–64; and on the cultural contextualisation ofpsychiatric classifications see: Gaines AD. From DSM I toIII-R: voices of self, mastery and the other: a cultural con-structivist reading of US psychiatric classification. SocialScience and Medicine 1992; 35:3–24.

17. On a strong criticism of such a view and of the cognitivescience that has developed out of it see: Fodor JA.Concepts. Where cognitive science went wrong. Oxford:Clarendon Press, 1998; and his recent simplified version in:Fodor J. When is a dog a DOG. Nature 1998; 396:325–327.

18. On this see Landesman C. Locke’s theory of meaning.Journal of the History of Philosophy 1976; 14:23–35.

19. On this see the full debate at the Société Médico-Psychologique (Annales Médico-Psychologiques 7:128–143;145–171; 316–326, etc.). Because the idea of directly apply-ing the scientific ‘principles of classification’to medicineand psychiatry is old, it is the more surprising that its itera-tion at the New York meeting (February 1959) of theAmerican Psychopathological Association by Carl Hempel(Zubin J, ed. Field studies in the mental disorders. NewYork; Grune and Stratton, 1961; and Chapter 6 in HempelCG. Aspects of scientific explanation and other essays in thephilosophy of science. New York: The Free Press,1965:137–154) left most psychiatrists mesmerised and manyto this day seem to believe that it was a portentous discov-ery (e.g. p.2 in ‘Introduction’to Sadler JZ, Wiggins OP,Schwartz MA, eds. Philosophical perspectives on psychi -atric diagnostic classification. Baltimore: The JohnsHopkins University Press, 1994; p.25 in Kendell RE. Therole of diagnosis in psychiatry. Oxford: Blackwell Science,1994. It is a pity that this error has not been corrected inrecent books, e.g. Tischler GL, ed. Diagnosis and class -ification in psychiatry. Cambridge: Cambridge UniversityPress, 1987; Mezzich JE et al., eds. International class -ification in psychiatry. Cambridge: Cambridge UniversityPress, 1987; Sartorius N et al., eds. Sources and traditionsof classification in psychiatry. Toronto: Hogrefe and Huber,1990. For an excellent critical analysis of the tout courtposition see: Schwartz MA, Wiggins OP. Logical empiri-cism and psychiatric classification. ComprehensivePsychiatry 1986; 27:101–114.

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20. Modification of the ‘general taxonomic principles’ofscience is required for they were extracted from formal clas-sifications of static objects and hence cannot apply to classi-fications of fluent and less stable ideal objects such asmental disorders, social mores, etc. On occasions, an escapeclause might be used that ‘medical classifications are eclec-tic and pragmatic’(e.g. Jablenski A. Current trends in themethodology of classification. Acta Psychiatrica Belga1986; 86:556–567.

21. Ellenberger H. Les illusions de la classification psychia-trique. L’Evolution Psychiatrique 1963; 28:221–248.

22. Psychoanalysis has inspired various members of this group;e.g. ‘But as we came to better understanding of its nature[mental illness] we have been able to discard most of thefictions which we have used during the long reaches ofmore incomplete knowledge’(p.419, in Menninger K. Thevital balance. New York: The Viking Press, 1964). Also seeEllenberger (1963) ibid.

23. To this level of the debate, the pragmatic or empirical argu-ment that we ‘need to classify’in order to organise hospi-tals, finances or clinical care is not very relevant.

24. This view underlies papers providing methodologicalrecipes (e.g. Pfohl B, Andreasen NC. Development of clas-sifications systems in psychiatry. Comprehensive Psychiatry1978; 19:197–207; for a criticism of this approach see:Katschnig H, Simhandl C. New developments in the classi-fication and diagnosis of functional mental disorders.Psychopathology 1986; 19:219–235).

25. For modern approaches to the philosophy of classificationthat go beyond Hempel see: Douglas M, Hull D, eds. Howclassification works. Nelson Goodman among the social sci -ences. Edinburgh: Edinburgh University Press, 1992;Blashfield RK. The classification of psychopathology. NewYork: Plenum Press, 1992; Rorsch E, Lloyd BB, eds.Cognition and categorization. New Jersey: LawrenceErlbaum, 1978. For a revealing analysis of classifications ascompared with tests see: Blashfield RK, Livesley WJ.Metaphorical analysis of psychiatric classification as apsychological test. Journal of Abnormal Psychology 1991;100:262–270.

26. Surprisingly, not many exist. It is important here to separate‘catalogues’from conceptual histories which contextualiseideas and classification rules. Examples of catalogues are:Menninger (1964) ibid.: Sartorius N et al., eds. 1990, ibid.;de Boor W. Psychiatrische systematik. Berlin: Springer,1954. More difficult to characterise, due to their linearityand decontextualised nature, are works such as Mack AH,Forman L, Brown R, Frances A. A brief history of psychi-atric classification. From the ancients to DSM IV.Psychiatric Clinics of North America 1994; 17:515–523.

27. In the same way as 20th century national psychiatric institu-tions and countries have felt obliged to provide theirs.

28. ‘Fashion’plays a central role in theories of social change.There are two main accounts of its mechanisms: psycho -logical, which seeks them inside people’s heads (e.g.fashion is seen as something which satisfies the individual’sneed to integrate himself into a group, etc.), and sociologi -cal, which sees fashion as a social mechanism dedicated tofacilitating change. Georg Simmel (1858–1918), one of itssponsors, believed that one of the objectives of fashion wasto maintain the identity of social classes in the midst ofchange. Thomas Kuhn’s notion of ‘paradigm shift’mightthus be regarded as the application of the sociologicaltheory of fashion to scientific change.

When applied to psychiatry, ‘fashion’invites to search

for social mechanisms. These are not hard to find as it isincreasingly clear that the pharmaceutical and medicalinsurance industry may play a role in the ‘choice’of clinicalclasses (as in the case of DSM-IIV). It can also be predictedthat the neuroimaging and genetic industry will soon play asimilar role: new ‘diseases’will be defined in terms of thesetechniques and the pressure will be on to include them inthe classifications of the future. Although prima facie this isto benefit patients, there is little doubt that the medicolegalobligation to diagnose what is in the official classificationswill force psychiatric centres in the world to buy therequired equipment.

The crucial question is how fashion controls the behav-iour of those who follow it. While a mechanism of cognitiveor perceptual control seems attached to concepts such as‘mentalité’, ‘episteme’and ‘paradigm’(e.g. people con-trolled by a paradigm will ‘see’the world in a particularway), fashion requires subjects to become ‘aware’that achange in belief or action is desirable and in the event‘choose’to proceed. Both the strong and weak versions canbe applied to psychiatric classification. If the former, writ-ings are platitudinous and repetitive because that is the onlyway they can see it (and also because there are only a fewways in which it can be said). If the latter, then psychiatristschoose to talk about PC in a particular way but it is possiblefor them to ‘see’it differently. I suspect that latter is a moreconstructive approach to take than the former.

29. Blashfield (1984) ibid.30. On this see: Berrios GE, Chen E. Symptom-recognition and

neural-networks. British Journal of Psychiatry 1993;163:308–314.

31. Raven PH, Berlin B, Breedlove DE. The origins of taxon-omy. Science 1971; 174:1210–1213.

32. Anderson TW. Classification and discrimination. In: SillsDL, ed. International encyclopaedia of the social sciences.London: Macmillan 1968:553–559.

33. Fleming W. Vocabulary of philosophy. London: RicardGriffin and Company, 1857:91–92.

34. Bonnet Ch. Œuvres d’histoire naturelle et de philosophie.Vol 17. Neuchatel: Samuel Fauche, 1783:320.

35. Sydenham T. The works of Thomas Sydenham MD. 2Vols.London: Printed for the Sydenham Society, 1848:15.Sydenham’s approach has been called more botanico, i.e. ‘inthe fashion of botany’and was firmly held by 18th centurynosologists (see: López Piñero JJ. Historical origins of theconcept of neuroses. Cambridge: Cambridge UniversityPress, 1983). In this regard, Linneé’s epigram is also wellknown: ‘Symptomata se habent ad morbum ut folia et fulcraad plantam’. At the beginning of the 19th century, Pinel wasstill stating: ‘The revolution brought about by Linneé innatural history, together with the introduction of a method tooffer descriptions that be short and exact, could not butgreatly influence medicine’. (see p.ixxxiv,Vol 1, Pinel Ph.Nosographie Philosophique. 3 Vols. 5th Edition. Paris: JABrosson, 1813.

36. The issue of the ‘reality’of the concept of species remainsunresolved. Darwin himself looked: ‘at the term species, asone arbitrarily given for the sake of convenience to a set ofindividuals closely resembling each other.’(p.108, DarwinC. The origin of species. Harmonsworth: Penguin, 1970, 1stedition 1859). For a discussion of the current state of sys-tematics see: Sober E. Philosophy of biology. Oxford:Oxford University Press, 1993.

37. For a recent proposal for a polythetic classification see:Corning WC, Steffy RA. Taximetric strategies applied to

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psychiatric classification. Schizophrenic Bulletin 1979;5:294–305.

38. But unfortunately problems exist as to the definition of‘natural kinds’. See: Granger H. The scala naturae and thecontinuity of kinds. Phronesis 1985; 30:181–200; Dupré J.Natural kinds and biological taxa. Philosophical Review1981; 90:66–90; Wilkerson T. Species, essences, and thenames of natural kinds. Philosophical Quarterly 1993;43:1–19.

39. Dagognet F. Le catalogue de la vie. Paris: PressesUniversitaires de France, 1970. For a recent example of aproposal for an artificial classification, i.e. one that empha-sises certain features of ‘questions’, see: Mellergård M.Psychiatric classifications as a reflection of uncertainties.Acta Psychiatrica Scandinavica 1987; 76:106–111.

40. See: Berrios GE, Hauser R. The early development ofK r a e p e l i n ’s ideas on classification. Aconceptual history.Psychological Medicine 1988; 18:813–821. For a retrospec-tive diagnostic ascertainment of a selected cluster ofK r a e p e l i n ’s patients see: Jablensky A, Hugler H, von CranachM, Kalinov K. Kraepelin revisited: a reassessment and statis-tical analysis of dementia praecox and manic depressiveinsanity in 1908. Psychological Medicine 1993; 23:843–858.On the origin of the categories themselves and the small roleplayed by empirical research in Kraepelin’s classification see:Weber MM, Engstrom EJ. Kraepelin’s ‘diagnostic cards’: theconfluence of clinical research and preconceived categories.H i s t o ry of Psychiatry 1997; 8:375–385.

41. In this regard, Jaspers’views are well known: ‘The principleof medical diagnosis is that all the disease phenomenashould be characterized within a single diagnosis. Where anumber of different phenomena co-exist the question ariseswhich of them should be preferred for diagnostic purposesso that the remaining phenomena can be considered sec-ondary or accidental.’(pp.611–612, in Jaspers K. Generalpsychopathology. Translated by J Hoenig and MWHamilton. Manchester: Manchester University Press, 1963).

42. p.317 in Windelband W. Historia y Ciencia de la Naturaleza.In Preludios filosóficos. Translation of Wenceslao Roces.Buenos Aires: Santiago Rueda, 1949:311–328 (originalGerman edition 1903).

43. The literature on the philosophical and psychological natureof ‘concepts’is enormous. This should not dissuade would-be classificators from undertaking the arduous task of learn-ing about them (see: Mechelen et al. (1993), ibid; Fodor(1988), ibid; Peacocke C. A study of concepts. Cambridge:MITPress, 1998; Palmer A. Concept and object. London:Routledge, 1988; Weitz M. Theories of concepts: a histor yof the major philosophical tradition. London: Routledge1988; Rickert H. The limits of concept formation in naturalscience. Cambridge: Cambridge University Press, 1986; firstpublished in 1902).

44. Prototypes (see: Rosch E. Principles of categorization. In:Rosch E, Lloyd B, eds. Cognition and categorization.Hillsdate, NJ:Erlbaum, 1978:27–47) in the field of psychia-try have also been called ‘ideal types’(see: Schartz MA,Wiggins OP. Diagnosis and ideal types: a contribution topsychiatric classification. Comprehensive Psychiatry 1987;28:277–291); and ‘hypothetical construct’(see: Morey LC.Classification of mental disorder as a collection of hypo-thetical constructs. Journal of Abnormal Psychology 1991;100:289–293).

45. Hampton J. Prototype models of concept representation. In:Van Mechelen et al., eds 1993, ibid. 1993:70.

46. See Mill JS (1898) ibid.

47. p.685, Hale B, Wright C. A companion to the philosophy oflanguage. Oxford: Blackwell, 1997.

48. p.xi, Durkheim and Mauss (1963) ibid.49. p.4, Estes WK (1994) ibid.50. Markman AB, Yamauchi T, Makin VS. The creation of new

concepts: a multifaceted approach to category learning. In:Ward TB, Smith SM, Vaid J, eds Creative thought. An inves -tigation of conceptual structures and processes. WashingtonDC: American Psychological Association, 1997:179–208.

51. Foucault (1966) ibid.52. Rousseau N. Connaissance et langage chez Condillac.

Geneva: Droz, 1986.53. Speziale P. Classification of the sciences. In: Wiener PP, ed.

Dictionary of the history of ideas,Vol 1. New York: CharlesScribner’s Sons, 1973:462–467.

54. Pinel requires no introduction. See: Riese W. The legacy ofPhilipe Pinel. New York: Springer, 1969; Postel J. Genésede la Psychiatrie. Paris: Le Sycomore, 1981; Garrabé J, ed.Philipe Pinel. Paris: Les Empêcheurs de Penser en Rond,1994.

55. W. Cullen (1710–1790): born in Scotland, trained inGlasgow, and eventually professor at Edinburgh, Cullen wasone of the most important clinicians, classificators andmedical philosophers of the 18th century. His emphasis onthe role of the central nervous system in the development ofall diseases led to his neural-pathology hypothesis. Hisconcept of ‘neurosis’(word he coined) is therefore over-inclusive and caused much difficulty during the followingcentury.

56. Pinel (1813) ibid.57. p.xxiii Bouillaud J. Traité de nosographie médicale. 5Vols.

Paris: Baillière, 1846.58. p.xcii, Bouillaud (1846) ibid.59. Riese W. History and principles of classification of nervous

diseases. Bulletin of the History of Medicine 1945;25:465–512.

60. This is by far the most popular method and most historicalaccounts of classification consist of chronological lists: agood illustration is Menninger (1964) ibid; or Faber K.Nosography in modern medicine. London: OxfordUniversity Press, 1923.

61. According to this approach, medical classifications wouldbe a super-structure, epiphenomenon, or reflection of deepsocial and economic structures, and hence would tell moreabout the social frames, people and times when theyappeared than about the biology of disease. Although thereare excellent social histories of psychiatry, rather surpris -ingly, no good social history of psychiatric classificationshas yet been written.

62. Lanteri-Laura G. Classification et Sémiologie.Confrontations Psychiatriques 1984; 24:57–77.

63. p.638, in Desruelles et al. (1934) ibid.64. Surprisingly, it is not mentioned in Pichot PJ. The French

approach to psychiatric classification. British Journal ofPsychiatry 1984; 144:113–118.

65. See López Piñero (1983) ibid.66. It is often not mentioned that even great men such as

Kraepelin and Chaslin went through nationalistic periodsand gratuitously attacked psychiatric developments in therival countries. For example, Kraepelin was a Bismarkian àoutrance and even wrote a paper comparing his own person-ality to Bismark’s! (see: Kraepelin E. Bismarck’sPersönlichkeit. Ungedruckte persönliche Erinnerungen.Süddetische Monatshefte 1921; 19:105–122). Likewise,Chaslin attacked the use of German nosological categories

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in France and enjoined his fellow country men to developtheir own nosology (see: Berrios GE, Fuentenebro F.Introduction to, and translation of, Chaslin’s ‘Is psychiatry awell-made language?’ History of Psychiatry 1995;6:387–406). But there were also objective efforts tocompare French and German psychiatric classifications. Asuperb example is Roubinovitch J. Des variétés cliniques dela folie en France et en Allemagne. Paris: Doin, 1896.

67. Phillipe Buchez (1796–1866) physician, publicist and socialreformer, for a time associated with the Carbonari and theSaint-Simoniens, he eventually developed a form ofChristian socialism on which he lectured widely. He wroteon history, psychology and psychiatry. His parliamentarycareer came to an abrupt halt in 1848 when as President ofthe Constituent Assembly he showed much indecisivenessvis-à-vis the disorderly conduct of those who protested infavour of Poland (see: Biéder J. Un précurseur de la démoc-ratie chrétienne et de l’Europe à la Société Médico-Psychologique: Phillipe-Joseph-Benjamin Buchez. AnnalesMédico-Psychologiques 1986; 144:109–115; and Robaux(no initial). La vie de Buchez. Annales de ThérapeutiquePsychiatrique 1965; 4:220–234.

68. Quoted in Desruelles et al. (1934) ibid.69. p.328 Buchez P. Reports, Annales Médico-Psychologique

1861; 7:326–33070. Féré, Traité de Pathologie Générale (quoted in p.41,

Desruelles M. Les Classifications des Maladies Mentalesdans l’Enseignement Contemporain. Annales Médico-Psychologiques 1934; 92:41–58.

71. Baillarger, quoted in Desruelles et al. (1934) ibid.72. The debates of theSociété Médico Psychologique are famous

for they brought together the great alienists of the day and onoccasions led to some conclusions. Topics such as Halluci-nations and Classifications were debated more than once.

73. Louis Jean Françoise Delasiauve (1804–1893) was a physi-cian with political and literary interests turned alienist. Heresearched and wrote widely on epilepsy, mental retardationand education.

74. Bénédict-Augustin Morel (1809–1873) is well known toAnglo-Saxon psychiatrists for his writings on degenerationand démence précoce. However, his output and interestswere much wider. Morel and Buchez were close friends.Morel attacked all psychiatric classifications based onsymptoms and surface phenomena and proposed instead an‘aetiological’criterion. Buchez’s favourable reviewappeared as ‘Rapport sur le Traité des Maladies Mentales deM. Morel. Annales Médico-Psychologiques 1860;6:613–635. Morel’s classification included six (purportedlyaetiological) groups: ‘1) Hereditary insanity, 2) Toxic insan-ity, 3) Insanity produced by the transformations of other dis-eases, 4) Ideopathic insanity, 5) Sympathetic insanity, 6)Dementia’. (pp.258–272, Morel BA. Traité des MaladiesMentales. Paris: Masson, 1860.

75. p.131, Reports. Séance of 12 November 1860, in 1861,Annales Médico-Psychologiques 1861; 7:128–143.

76. p.143, Reports, 1861, ibid77. Jules Falret (1824–1902), son of the alienist Jean Pierre

Falret (1794–1870) was a bright and shy academic whogrew in the shadow of his authoritarian father.A friend ofLasègue and Morel, he researched into general paralysis ofthe insane, delusions, epilepsy and folie a deux.

78. p.147, Reports, 1861, ibid.79. However, see Fava GA, Kellner R. Staging: a neglected

dimension in psychiatric classification. Acta PsychiatricaScandinavica 1993; 87:225–230.

80. p.148, Reports, 1861, ibid.81. p.171, Reports, 1861, ibid.82. p.176, Reports, 1861, ibid.83. Adolphe Garnier (1802–1864), distinguished philosopher of

mind, died (it is said of grief after the death of his only son)four years after his intervention at the SMPmeeting.Trained under Jouffroy, Garnier wrote a thesis on ThomasReid and can be considered as one of main expositors inFrance of the Scottish philosophy of common sense. Adefender of a version of faculty psychology (this is analysedin a crystal-clear fashion in his La Psychologie et laPhénologie Comparées. Paris: Hachette, 1839), Garnier pro-posed a new classification of the mental faculties in hissuperb Traité des Facultés de l’ame (Paris: Hachette, 1852).His intervention in the SMPdebate is thus important for itfirst underlies the interdisciplinary nature of the SMPat thetime, and second, the fact that he was able to bring into thedebate the central tenets of French philosophy of mind: acombination of faculty psychology and spiritualist eclecti-cism (for an account of Garnier’s philosophy see Charles, É.Garnier. In: Franck A, ed. Dictionnaire des SciencesPhilosophiques. 2nd Ed. Paris: Hachette, 1875:593–594.

84. Alfred Maury (1817–1892) was a polymath who trained inmathematics, the law, archaeology and medicine andthrough his friendship with Baillarger and Moreau de Toursbecame interested in psychological medicine. A Republican,he took an anti-Catholic stance and argued always in favourof an organicist approach to mental illness (on Mauryhimself see: Bowman FP. Du romanticisme au positivisme:Alfred Maury Romanticisme (no volume) 1978:21–22;35–53). In the famous debate on the nature of hallucinations(particularly as experienced by some Roman Catholic saints,Pascal and Socrates) he was on the side of Lélut in believ-ing that these experiences were the result of a disease of thebrain (see his Des hallucinations. Paris: Paris, Bourgogneand Martinet; 1845; for an account of the hallucinationdebate see: Dowbiggin I. Alfred Maury and the politics ofthe unconscious in nineteenth century France. History ofPsychiatry 1990; 1:255–287; James T. Dream, creativity andmadness in nineteenth century France. Oxford: ClarendonPress, 1995). It is difficult to imagine a wider ideologicalgap than that separating Maury and Garnier. Hence theirdebate on psychiatric classification on 10 December 1860 isparticularly important.

85. pp.316–320, Report, 1861, ibid.86. pp.320–322, Report, 1861, ibid.87. Francis Bacon (1561–1626): Cambridge-trained English

statesman and philosopher of science whose work under-went a revival during the 19th century. Bacon’s principlesare contained in the Instauratio Magna (Great Instauration),his grand plan to help man to regain control upon thenatural world: a classification of the sciences; new princi-ples to interpret nature (Novum Organon); a guide and cata -logue of the phenomena of the universe, i.e. a veritablecorpus of empirical data and research methodologies; theLadder of the intellect; anticipations of the new philosophy;and the new philosophy or active science (see p.248, in: Thephilosophical works of Francis Bacon . Ed. John M.Robertson. London: George Routledge and Sons, 1905).)For a study of Bacon’s classification methodology see:Chapter 1, 2 and 3 of Peltonen M, ed. The Cambridge com -panion to Bacon. Cambridge: Cambridge University Press,1996. Bacon tried to persuade James I to found ‘science’chairs at Oxford and Cambridge. His advice went unheededin his lifetime but there is agreement among historians that

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the later foundation by Charles II of the Royal Society is alate reflection of Baconianism.

88. pp.323–326, Reports, 1861, ibid.89. p.325, Reports, 1861, ibid.90. This concept is currently discussed as the ‘unitary psy-

chosis’hypothesis (see: Berrios GE, Beer D. The notion ofunitary psychosis: a conceptual history. History ofPsychiatry 1994; 5:13–36).

91. Buchez was here criticising remnants in the 19th century ofthe old ‘ontological’model of disease (see: Riese W. Theconception of disease. Its history, its versions and its nature.New York: Philosophical Library, 1991; also Vié J. Sur l’ex-istence d’entités morbides en psychiatrie, l’utilité et l’orien-tation de l’effort nosologique. Annales Médico-Psychologiques 1940; 98:347–358).

92. pp.326–330, Reports, 1861, ibid.93. pp.330–332, Reports, 1861, ibid.94. Théophile Archambault (1806–1863) was then a senior

alienist and secretary general of the SMP. He died withintwo years of this intervention. He was a disciple of Esquiroland knew English well. In 1840, he translated Ellis’s‘Treatise on the Nature, Causes, Symptoms and Treatmentof Insanity’(1838) into French. He did classical work onurinary incontinence in the insane.

95. p.332, Reports, 1861, ibid.96. p.648, Desruelles et al. 1934, ibid.97. There is no space in this paper to even touch upon this impor-

tant debate (which stretched from the meeting of July 1888 tothat of June 1889 [Annales Médico-Psychologiques]) where anew generation of French psychiatrists had a second go at theproblem. Aconceptual analysis of this debate and a compari-son with the 1860–1861 debate must be part of any futurehistory of psychiatric classifications.

98. p.233, Tuke DH. Classifications. In: Tuke DH. (ed)Dictionary of psychological medicine 2Vols. London:Churchill, 1882:229–233.