Conceptual History of Endogenous Psychoses

History of Psychiatry
http://hpy.sagepub.com
The endogenous psychoses: a conceptual history

M. Dominic Beer
History of Psychiatry 1996; 7; 1
DOI: 10.1177/0957154X9600702501
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1996 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
001
The
endogenous psychoses:
conceptual history
M. DOMINIC BEER*
Introduction
Little has been written in English, or indeed in any other language, on the
history of how the terms endogenous and psychosis came together to be
known as the endogenous psychoses. Most accounts start with the premise
that the endogenous psychoses are schizophrenia and manic-depressive
insanity (Wyrsch 1956, Schneider 1959). This article attempts to rectify this
omission. The term endogenous on its own has been looked at by Lewis
(1971). The wider subject of the psychosis concept itself is being addressed
elsewhere (Beer 1993, 1995, in press). So, this article will specifically address
the term endogenous psychosis.
According to Schneider (1959), the yardstick for many English- and
German-speaking psychiatrists, the endogenous psychoses were Kraepelins
two disease entities schizophrenia and cyclothymia (manic-depressive
insanity) and no others. In the first place this article will show how, in the
late nineteenth and early twentieth centuries, there were many other mental
disorders, for instance psychopathy, which made up the category of the
endogenous psychoses. Secondly, I shall explain how this came to be the
case, namely because of the widespread influence of the theory of
degeneration. Thirdly, I will show how different attitudes to the theory of
degeneration in France and Germany led to two separate classifications of
the endogenous psychoses. Fourthly, I shall go on to show how the
endogenous psychoses were narrowed down to the present day position and
suggest how non-scientific (political) factors played their part in this process.
Finally, on the basis of the first four points, I shall discuss the
Some of the work on which this article is based was carried out, with the helpful advice of
Professor Bill Bynum (Wellcome Institute for the History of Medicine), when the author was
generously provided with a Research Fellowship by the Wellcome Trust to write an MD thesis.
Address for correspondence: Dr M. Domimc Beer, Department of Psychiatry, UMDS (Guys),
Guys Hospital, London SE1 9RT.

appropriateness of the
with.
The
term
today and conclude that it should be dispensed
endogenous was introduced by the German psychiatrist and

neuropathologist Paul Julius Moebius in 1886. Moebiuss views represented
the zenith of the influence of the prevailing theory of degeneration and were
in turn taken up by the great nosologist Emil Kraepelin. To understand the
way in which this theory became the conceptual framework of the psychiatric
profession from the 1860s until the First World War, it is necessary to trace
its genesis in its country of origin - France.
term
theory of degeneration in French psychiatry

French psychiatry was strongly influenced by the theory of degeneration,
itself the predominant philosophical and cultural concept of the time. It was
introduced into psychiatry by Benedict A. Morel (1809-1873). For Morel,
degeneration was the name given to the process whereby increasingly severe
mental disorders were transmitted - by a process called transformational
heredity or polymorphic heredity - in successive generations. In his Trait
des dgnrescences physiques, intellectuelles et morales de lespce humaine et de ses
causes qui produissent les varits maladives, Morel ( 1857) based his theory on
the biblical account of creation. Through original sin mankind deviated from
the type primitifand became subject to destructive influences. These in turn
made him prone to physical and mental disabilities, which could be acquired
or hereditary. Especially if they were hereditary, they would follow a
downward or degenerative path to further deterioration.I
Nowhere was this more the case than in the sphere of mental illness where
Morels classification (Morel 1860: xiv-xvi) ran as follows:
The
1. Alienations ou folies hereditaires.

2. Alienations mentales par intoxication.
3. Alienations determinees par la transformation de certaines nevroses.
Folies hyst6rique, epileptique, hypochondrique.
4. Folies sympathiques.
5. Alienations ou folies idiopathiques;
6. Demence. Formes terminatives.
So, within three years Morel had written his Trait des maladies mentales.
Here he had not only expanded his theorizing of degeneration vis--vis the
mental illnesses, but he proposed a totally new classification. This was based
not on symptoms, as had been earlier French nosologies, but on aetiology.
Thus the largest group (1) was hereditary. Groups two to six were acquired
Thus Morels theory of Degeneration

1859 in his Origin .
of Species
was in
contradistinction
to
Darwins
published in

theory of Evolution,
and caused
by such factors as poisoning (2); transformations of the major

hysteria, hypochondria, epilepsy (3); and the pathological
influence of other organs on the brain (4). And for the rest of the nineteenth
century in French mental hospitals the diagnosis sheets mostly read
degenerescence avec ...(Zilboorg and Henry 1941).
The hereditary insanities were divided into four categories, representing
increasing severity of degeneration. The first comprised people with normal
intellect but of nervous temperament, for instance the sensitive, irritable or
impetuous who were regarded as eccentrics, with idees fixes, such as
compulsive phenomena, phobias or paranoid beliefs/fantasies. The second
category comprised those with intellectual flaws which were hidden by
artistic abilities and whose main problem lay in their delirium of affects and
behaviour ( :154). Examples included kleptomania and moral insanity. The
third group had definite intellectual deficits, suffered from serious mental
illnesses in their youth and ended up with dementia. For these Morel coined
the term dmence prcoce, which Kraepelin was later to make famous in 1896.
These patients, according to Morel, often drifted into vagabondage and
criminality. The fourth category were the end of the line - those being
afflicted from birth - the cretins, imbeciles and idiots.
Morel was able - without full explanation - to hold to a double theory of
aetiology; both degeneration and lesions accounted for mental disorder, with
the modification that the lesion did not usually refer to a localized injury, but
to a functional problem which left no organic trace of its appearance.
neuroses -
It is in another order of functional cerebral lesions that it will be necessary

to search for the pathological element in the great number of circumstances.
This element is nothing else than the degeneracy with which hereditarily
tainted individuals are invariably stricken in the normal development of
their nervous systems. (Morel 1860: 585)
Thus Morels
polymorphic inheritance denoted the transmission from one

next of widely different symptoms in mental illness. It was
generation
in this - the application of the theory of degeneration to psychiatry - that he
was original.
to
Valentin
the
Magnan (1835-1916)
He was a
Magnan used Morels clinical ideas and developed them further.
pupil of Morels and an assistant under Moreau, and he retained Morels
emphasis on polymorphic inheritance. However, Magnan was a Darwinist
J. J. Moreau de Tours (1804-1884) attributed insanity to a hereditary condition of the nervous

system, or a neuropathy, in his work on the Neuropathic Family of 1852. This had influenced
Morel as he formulated his own theories.

and
religious, whereas Morel had been brought up in a monastery for ten

to his Christian beliefs. So Magnan could not agree with
Morels type primitif . Nevertheless the points in common between Morel
and Magnan were considerable regarding mental illnesses.
Magnan and his pupil Legrain constructed their theories with the
following building blocks:
1. Predisposition: the initial state of the degenerate in the absence of
complications.
2. Stigmata: the old idea that the body expressed the qualities of the soul; the
moral stigmata were intellectual or affective retardation, social
maladjustment; the physical ones were atrophies, hypertrophies and
dystrophies.
3. Imbalance (dsquilibri). The intellectual stigmata betrayed an imbalance
of the cerebrospinal axis according to Magnan. In fact he claimed that all
stigmata (moral, intellectual and physical) were a result of this imbalance.
4. Episodic syndromes: fits of delirium, obsessions, impulses.
In the conceptual sphere Magnan differed significantly from Morel:
Morels theory was based on the book of Genesis, Magnans on the theory of
evolution. This would at first sight seem to be contradictory. The fall from
grace fits in with degeneration, but how does evolution? Magnan explained
this by saying man was evolving towards a higher form but on the way some
people slipped back! So Magnan did not hold to the ideal and perfect
primitive type. For him the first humans had yet to reach an acceptable
intellectual level, but they were at least normal for their evolutionary stage.
Individuals who could not adapt to lifes demands slipped back and if they
were not fit enough to survive they were liable to be sterile and so their
generation would die out.
Magnans classification was to prove highly influential for French
psychiatry for years to come (Pichot 1982, Huertas 1992). He separated the
psychoses into two categories. Both were correlated with the type of
hereditary constitution in which they occurred. The basically healthy people
could suffer from affective psychoses and chronic delusional states of
systematic evolution. The former were Baillarger and Falrets illnesses; the
latter were Lasegue and Falrets delusions of persecution. The chronic
delusional state usually occurred in an adult with no previous history of
disordered mind, manner or mood. The course was up to fifty years with a
fixed deteriorating path. The four stages comprised:
(i) Prodrome: faulty judgement, illusions, fretfulness.
(ii) Persecutory: delusions of persecution, severe auditory hallucinations and
neurological signs.
(iii) Grandiose: grandiose delusions, fanciful hallucinations and more
neurological signs.
(iv) Dementia
not
years and held

The other large category

divided into three:
was
the delusional
states
of
degeneracy.
These
were
Delusional states of inferior degenerates: mainly idiots, morons.

(ii) Chronic delusional states: i.e. any which deviated from the typical
course of the systematic version.
(iii) Transitory delusional states of degeneracy of which the classical
description was given by Legrain in 1886. Bouffie dilirante was its
synonym, which implied suddenness of both onset - with no
precipitants - and resolution; other characteristics were: polymorphic
delusions sometimes impossible to define; clouded consciousness
associated with emotional instability; absence of physical signs; course
from a few days to a few months; return to premorbid functioning.
The other major condition which was of a degenerate nature was Morels
dmence prcoce (also known in France as hebephreno-catatonia). This
occurred in young people and was characterized by a sudden immobilization
of all the faculties with idiotism and dementia being the sad fate that will
(i)
terminate the course.

What then happened was,
as
Pichot (1982: 478) writes:
It soon became apparent that Magnans chronic delusional state of systematic

evolution was a misleading construct defining a disorder found more
readily in theory than in practice, the exception more than the rule.
Then, around 1910 the degenerate/non-degenerate criterion for distinguishing the types of the chronic delusional state was dispensed with.
Instead, the clinical approach of Esquirol was resurrected and imposed on
Magnans disease entities. Thus, the pathological mechanisms which
generated the delusional ideas was emphasized and three major forms of
chronic delusional
states were
described between 1909 and 1913:
1. Chronic
interpretative delusional state (dilire chronique dinterprtation) was

described in 1909 by Capgras and Serieux.
2. Chronic hallucinatory delusional state (psychose hallucinatoire chronique)
was proposed by Gilbert Ballet first in 1911 and developed in 1913.
3. Chronic imaginative delusional state (dlire chronique dimagination) was
described by Dupre and Logre in 1911.
These three, along with a much diminished form of dementia praecox,
have constituted the endogenous psychoses in France up until the present
day and demonstrate how the theory of degeneration strongly influenced
French psychiatry. I shall now turn to its influence on German psychiatry.
The
theory of degeneration in German psychiatry: Heinrich Schuele

With Richard von Krafft-Ebing, Schuele championed the degeneration
theory in German psychiatry. Moreover, he was important because his

textbook -
heavily influenced by Morel - was to be quoted for many years by

Kraepelin. It was Kraepelin who was largely responsible for establishing the
term endogenous in German psychiatry.
In his textbook Schuele (1880) addressed the individuals predisposition to
mental illness and specifically looked at heredity.
With this chapter on heredity our aetiology reaches its most important
aspect ... Our intellectual life is determined by those same laws which
pertain in the realm of biology. We are what we are, only marginally because
of ourselves, but mainly we are the product of our forefathers. This is the
momentous conclusion of Darwin that, through Moreau and above all
Morel, has been introduced into psychiatry. (Schuele 1880: 225)3
Schuele (1880: 228, 239) quoted Darwin on heredity and mental illness
and thus it can be seen that Schuele held to both Morelian and Darwinian
theories. He formulated two statements:
Not only are mental disorders hereditary, but diseases of the nerves, the
mind and the brain are all capable of forming transitional disease forms
on the ladder of degeneration. That is the first all-important statement
and by means of which the psychoses interrelate with the whole sphere of
the neuroses4 and more deep-seated cerebral illnesses.
neuroses were diseases of the nerves; psychoneuroses were the
diseases of the mind; cerebropsychoses were the diseases of the brain. His
second statement concerned:
Hereditary
progressive nature of the hereditary poison, that is the progressive

degeneration seen in the affected descendants ... Heredity can exert a
simple or a degenerative influence: simple insofar as the descendants are
affected by the same illness ... degenerative, insofar as prognostically more
serious forms and finally defect states arise. (Schuele 1880: 229)
the
So, Schueles classification of the mental disorders reflected his reliance
on
theory of degeneration. The mental disorders formed two groups; one

comprised those with degenerate (invalid) brains which he entitled the
neuropathic conditions (: 232). The other comprised those who had been
born with healthy (rustig), fully developed brains but had later acquired
psychoneuroses and cerebropsychoses.
The degenerate brain conditions involving intellectual degeneration were
divided into defective and degenerate states. The defective were microcephaly
and idiocy. The degenerate comprised hereditary insanity (impulsive and
the
3
It was actually incorrect to write that Morel was influenced by Darwins Origan of Species
,
because this works publication post-dated Morels (1857) Traité by two years. Leibbrand and
Wettley (1961) claimed that the same error was made by many other nineteenth-century
too.
psychiatrists
4
By neuroses he
).
b
1994
meant
the
movement neuroses
such
as
chorea, paralysis agitans (see Beer

moral), severe neuroses causing insanity (epileptic, hysterical and hypochondriacal) and periodic circular insanity (: 339).5
The second group (healthy brain) was divided into, firstly the psychoneuroses or the psychische Hirnneurosen and secondly the cerebropsychoses.6
These cerebropsychoses were serious conditions which were subject to a
disease process which Schuele referred to as a Psychosenprocess (: 568).
Schuele, then, was influenced by Morel and applied his aetiological way of
classifying - based on the theory of degeneration - to German psychiatry. He
divided mental disorders into two broad categories - those subject to
degeneration, and those which were not. He was also the originator of the
term cerebropsychosis, which he used in contradistinction to psychoneurosis;
the former affected motor systems of the body and was seen as more severe
than psychoneurosis. In this he was opening the way for psychoses to be
seen by later psychiatrists like Kraepelin as severer illnesses - indicating
insanity. Schuele also used the psychosis term in the sense of a process
whereby psychological symptoms gradually occurred in a mental illness and
thus was a forerunner of Jaspers. However, because of his aetiological
rather than symptomatological - way of classification, the categories
psychosis and neurosis were sometimes confusingly intermingled. This
confusion was further compounded by his interchangeable use of the terms
psychoneurosis and psychosis for disorders of the mind (see Beer 1995).
Paul Julius Moebius
(1853-1907): endogenous and exogenous

Six years later in 1886 saw an attempt by Moebius to simplify the mental
disorders directly into degenerate and non-degenerate. It heralded the
introduction to psychiatry of one of the professions most bewildering terms:
endogenous.
Magnans work Leons psychiatriques had been translated into German by
the brilliant but misanthropic neurologist Paul Julius Moebius. He took on
Magnans beliefs on the psychology of the degenerate personality and also his
classifications of the mental disorders. His innovation was the great division
of the mental disorders (Krankheiten in der speciellen Psychiatrie) into
endogenous and exogenous. He was the first to apply this division to psychiatry
in 1886, although as Scharfetter (1983) pointed out, Candolle had used it for
botany in 1813. Moebius (1892) published On the Classification of
5
Moral
1880:
338).
6
insanity
was seen as
partial idiocy and
as
such
was
transitional
to
full idiocy
(Schuele
groups differed can be seen by the explanation Schuele gave for

in both the psychoneurosis and the cerebropsychosis groups. Thus
the mania and melancholia of the cerebropsychoses was termed organic, whilst that adjective is
absent from the mania and melancholia of the psychoneuroses.
7
Thus the term endogenous was not first used by Moebius in 1893 as Sir Aubrey Lewis (1971)
claimed.
The ways in which these
two
having mania and melancholia

Diseases.
Neurological observations by P. J. Moebius. It is here that he

explained what he meant in detail.88
Moebius explained his division of the mental illnesses into endogenous
and exogenous:
[A] 11 recognized diseases fall into two classes depending on whether their
conditio sine qua non is an external (e.g. poisoning, trauma) or an
internal one (congenital debility).
In exogenous diseases the causes
lead, toxins, etc.). In endogenous
are
ones
qualitatively different (alcohol,

there is only one cause - the
predisposition.
He examined clinical evidence for his
theory:
proof of degeneration is seen in two areas. Firstly, and more

importantly, through an examination of the patient and his history.
Secondly, through his family history. (: 297)
The clinical
He then
proceeded to the classification, reiterating the impossibility of

delineation
within the endogenous diseases: We must always
sharp
the
fact
that
we are dealing with a continuum. He acknowledged
recognize
the need for some kind of order and found the only useful criterion for classification purposes to be
a
degree of degeneration. The highest degree is seen in idiots ... [Then

the feebleminded, and lastly the unstable persons.] This last group
is by far the most important; it encompasses many gradations but it is
the
came
difficult
He gave
to
attach
names to
them.
examples of how predisposition and circumstances interrelate, for
example:
Sudden loss of wealth ... can cause a hysterical attack in someone with a
hysterical predisposition ... The climacteric can lead to melancholia in
someone with a melancholic predisposition ... (: 298)
The endogenous diseases were hysteria and the other neuroses (diseases of
the nerves), such as Nervousness, Hypochondria, Epilepsy, Migraine,
Chronic chorea, tics, also the specific diseases of psychiatry - mania,
melancholia, stupor, confusion, paranoia, circular insanity, primary
dementia.
This article appeared in the Centralblatt für Nervenheilkunde und Psychiatrie. Internationale
Monatsschrift fur die gesamte Neurologie in Wissenschaft und Praxis mit besonderer Berucksichtigung der
. The journal had been founded by Erlenmeyer in 1878 and amongst its
Degenerations-Anthropologie
were Charcot (Paris), Lombroso (Turin), Gowers (London), Obersteiner
(Vienna), Kowalewskij (Krakov, Russia). The subtitle, as well as the fame of its editors, bear witness
to the influence of the theory of degeneration.
illustrious editors

Moebius divided mental illnesses into endogenous and exogenous, terms

which he introduced into psychiatry and were taken up by Kraepelin.
Unfortunately, the precise meaning of the word endogenous was hard to pin
down, because it was part of the theory of degeneration, which itself became
outdated and difficult to defend. His specific diseases of psychiatry, such as
mania, melancholia and confusion were similar to the psychoses and were
differentiated from his neurosis category, which included conditions such as
hysteria and epilepsy.
Although Moebius used the term neurosis, he did not refer to the
psychoses, unlike Schuele. He is nevertheless important because of his
influence on Kraepelin for his introduction into psychiatry of the term
endogenous, which was closely related to degeneracy.
Psychopathy and J. L. A. Koch (1841-1908)

Koch is significant for his development of a term that Schuele helped
introduce from French into German psychiatry. In the twentieth century it
was to refer to a disorder of personality, but in the nineteenth it was not
employed in such a restrictive sense. It was Koch - and also psychiatrists like
Krafft-Ebing (1886), with his Psychopathia Sexualis - who really began the
process whereby this occurred. Kraepelin and his successors were to
continue and complete this process.
Like Magnan, Schuele and Moebius, Koch was Morelian in his scientific
conceptual outlook. He became famous for his (1891) Psychopathic
Inferiorities which was an expanded version of one chapter of his Short
Textbook of Psychiatry.
Psychopathy had been introduced by Feuchtersleben (1845) as a
synonym for psychosis, to denote a disease of the personality as a whole. It
was taken up by Griesinger and was used in the general sense of a diseased
mind, for instance in his (1868-9) On a Virtually Unknown Psychopathic
Condition (by which he meant obsessional thoughts).
However, the connotations of the concept changed as the theory of
degeneration grew in influence. Psychopathic was often used by Schuele
(1880) as referring to the mental side of a usually degenerative disturbance,
whereas neuropathic referred to the nervous or neurological aspects.
Werlinder (1978: 87), in his history of the concept of psychopathy, has
pointed out that Moreaus older French term neuropathic was gradually
replaced by the German, and more circumscribed, psychopathy concept.
Koch was not original in his employment of term, but what was new
according to Koch (1891 : iii) was the juxtaposition of the two words:
The introduction of a
Inferiorities. That is a new name
because ... the concept of the Psychopathic
Inferiorities as something new and sui generis must be recognised within
the spheres of psychiatry and neurology.
Psychopathic
new
...
term was necessary

10
Koch then
explained the
rationale of his
new term:
Our inferiorities are psychopathic in the sense that their causes are organic
changes which lie outside the domain of the merely physiological. (: 2)
He classified the inferiorities into Permanent and Transitory; the former

divided into Congenital and Acquired and these both in turn into
Psychopathic Disposition, Taint (Belastung) and Degeneration (: 4).
Thus the psychopathic inferiorities had organic changes and some were
were
subject to degeneration.
I am classifying the abnormal
mental life into:
phenomena,
processes and conditions of
1.Elementary Mental Anomalies. These can be of a psychotic9 nature as

for example simple isolated hallucinations. They may be of a
psychopathic (inferior) nature as for example simple isolated
obsessional thoughts. These can occur in otherwise healthy people, the
physically ill, the psychopathically inferior, and also in the mentally ill.
2. The
Psychopathic Inferiorities. Inferiorities have been erroneously

classified with the psychoses and been variously termed: hereditary
temperament, hereditary neurosis, hereditary insanity, insanity with
obsessional thoughts.
3.
Psychoses and Psychotic States. In the two latter examples the persons
whole life [my emphasis, M. D. B.] is affected by the phenomena,
processes and conditions ... (Koch, 1891: iv-v).
Then Koch
explained that
diseases, and he used the
the
terms
psychoses were equivalent

interchangeably:
to
the mental
the
taints and degenerations merge with the mental diseases

(Geisteskrankheiten). Many predisposed - the least severe of the three
categories - persons have a stronger inclination ... to psychoses. Many
tainted and degenerates are even more pre-disposed to mental diseases;
frequently psychopathic taints and degenerations develop into a
psychosis. (: 4)
In both
psychoses and psychopathic inferiorities, then, Koch
wrote that the

affected. These two contrasted with the mental
anomalies - such as some of the neuroses like neurasthenia - which could
occur without the presence of a mental illness.
Moreover, despite his insistence on the need for a separate diagnostic
category of psychopathic inferiorities, Koch wrote:
persons whole life
that
This
was
[the psychopathic inferiorities]
was an
merge
gradually
and
completely with
early use of the adjectival form which Wernicke also favoured in the

1890s.
11
the mental diseases (Geisteskrankheiten)
people on the other. (: 3)
on
the
one
hand and with normal
Koch coined the term psychopathic inferiorities for those individuals

whom he termed as suffering from degenerative states and having organic
changes. He opened the way for a separate category of psychopathy
disorders of the personality, but in a more specific sense than
Feuchterslebens original sense, which was developed by Kraepelin and his
successors. Although the psychopathic inferiorities were not the same as the
psychoses - the mental disorders - they did merge with them.
Psychoses and their increasingly degenerationist aetiology in the first

three editions of Kraepelins Textbook
In Kochs and Schueles works there were the beginnings of a differentiation
between psychoses, psychoneuroses, neuroses and psychopathies. In the first
three editions of the Textbook Kraepelin (1883-1889) often wrote about
Psychosen in the sense of mental disorders in a general sense. Thus, in the
first edition, Kraepelin (1883: 187) began his section on The Specific
Pathology and Treatment of Insanity with three pages of introduction
entitled Die Klassifikation der Psychosen.
At this early stage of his career Kraepelins classification was mainly based
on that of Griesinger (1876), whose name Kraepelin quoted first in his list of
German psychiatric textbooks. Although Griesinger preferred the term
Geisteskrankheiten and Kraepelin used Psychosen, the fact that Kraepelin was
influenced by Griesinger is shown by the form of his classification in the first
edition of his Textbook. Kraepelins sections on aetiology, psychopathology,
prognosis and treatment were very similar to Griesingers. Moreover,
Kraepelin kept Griesingers three basic classificatory forms namely:
Mental depressions,
Mental exaltations, and
Mental debilities.
By the time of the third edition of Kraepelins Textbook (1889) he was

replacing the term psychosis by Seelenstrung. This may well have happened
because of a change of influence on Kraepelin. In this edition, although nine
psychiatric textbooks were recommended by Kraepelin in his bibliography,
only two were mentioned in the text itself: The sequence and classification
of the mental disorders is based on the system of Schuele and v. KrafftEbing (: 239). Much of his new material, compared with the 1883 edition,
concerned aetiology. The aetiology in question was that of the theory of
degeneration which Schuele and Krafft-Ebing had adopted. The influence of
this theory was to stay with Kraepelin for the rest of his life and was to dwell
uneasily alongside his clinical mode of classification.

12
In Kraepelins (1889) classification he divided his twelve disease categories
into four groups. The first, caused by external factors, were curable, acute,
or subacute disease processes with a typical course. They included deliria,
acute exhaustion states, mania, melancholia and insanity (Wahnsinn). The
second group arose from constitutional causes with incurable changes
accompanied by a chronic, stationary or periodic course. These included
periodic insanity, paranoia, general neuroses. The third group were cerebral
conditions caused by severe disturbances of cerebral nutrition and more
deep-seated organic changes. They were chronic, usually progressive and
included dementia paralytica, intoxications and states of debility. The
fourth category comprises congenital, stationary and incurable conditions
(or mental anomalies of development).
He claimed that the first and third categories could be described as
accidental psychoses, as against the constitutional and congenital
anomalies of the second and fourth groups (: 239). He conceded that the
distinction was not hard and fast, there being transitional states. This was
very much a concept Schuele had used. Indeed Kraepelin wrote exactly as
Schuele had, that Wahnsinn was such a transitional form - being the
transition to the constitutional psychoses.
Just as Schuele had used the words psychopathic and neuropathic, so did
Kraepelin. The latter explained why he ordered the first group according to
aetiology (Kraepelin 1889:239) - and why in my view aetiology
corresponds to the psychopathic predisposition (: 39-40). Earlier in the work
he wrote on Individual Predisposition - heredity:
the
the
psychopathic predisposition can be passed on to a child ... Where

hereditary influences accumulate - as seems to be the case in blood
marriages between neuropathically predisposed families - there develops
an organic handicap. In the descendants, the more serious forms of
mental degeneration occur, especially intellectual and moral disturbances.
(Kraepelin 1889: 62)
He actually then quoted Morel and gave the reader a synopsis of his four
stage degenerative process, going from one generation to the next. He listed
those disorders which were examples of this process, stating that congenital
states of debility were the end stage of hereditary degeneration. And like the
degeneration theorists he wrote:
The more the cause of the psychosis rests in the organism itself, the
smaller the external trigger needs to be in order to cause a lasting and
usually incurable change in the mental constitution as a whole. (Kraepelin
1889: 63)
Another concept which Kraepelin used from Schuele was that of the
healthy or robust brain. We have seen his use of the psychopathically
predisposed, but in this section he actually used Schueles word for the

13
healthy brain - rustig - which he put in quotation marks and explained as

not hereditarily handicapped (: 64).
Thus, Kraepelin began by using the term psychosis for mental disorders in
the first edition of the Textbook. In the third edition Seelenstdrung was
beginning to replace it. In these early editions Kraepelins views on classification and aetiology were strongly influenced by other psychiatrists such as
Griesinger and then by the degenerationist Schuele.
The
description of the endogenous psychoses in successive editions of

Kraepelins Textbook
Kraepelins disease entity of dementia praecox is crucial to an understanding
of the endogenous psychoses. Morel was actually the first to use the term as
early as 1852/53 (dmence pricoce) for a condition similar to Heckers
Hebephrenia. Zilboorg wrote that:
B. Rousseau spoke of a puberty disease in 1857, and so did Moreau in
1859. Gautier wrote his doctors thesis in 1883 on dmence prcoce.
Magnans pupils Saury and Legrain used the term dmence pricoce, and at
the first congress of French psychiatrists in Rouen in 1890 Charpentier
read a paper Dmence prcoce simple des enfants normaux.(Zilboorg and
Henry 1941:458)
I would add, more significantly perhaps for Kraepelin, the works of Schuele,
who actually used the term dementia praecox in his textbook (Schuele,
1880: 234 but not indexed):
there occurs quite unexpectedly a sudden standstill in development.
Pleasure and interest in previously enjoyable pursuits subsides. The
patient himself cannot work out why this has happened. There is no
recovery. This is the dementia praecox of many of these hereditary
problems. They reach a certain stage of development ... but then wither
away like a tree robbed of its sap. (Schuele 1880: 234)
Schuele did not include dementia praecox as a disease entity but merely as
part of the constitutional neuropathy. Kraepelin was steeped in Schuele; as
late as in the ninth edition of his own Textbook (Kraepelin and Lange 1927)
Schueles is still recommended. (This contrasts with his not mentioning any
of the Frenchmen listed after Morel by Zilboorg).
We should also take note of what Kraepelin himself wrote. He actually
attributed the name dementia praecox to Arnold Pick:
Dementia praecox is the name first applied by A. Pick in 1891 to a group
of cases including the hebephrenia of Hecker and Kahlbaum,
characterized by maniacal symptoms followed by melancholia and rapid
deterioration. Since then, the meaning of the term has been extended so
as to include a larger group of cases appearing in earlier life, characterized
by a progressively chronic course with certain fundamental symptoms, of

14
which
progressive
1904: 152)
mental deterioration is the
most
prominent. (Kraepelin
Dementia praetox was introduced by Kraepelin (1896) properly in the fifth

edition of the Textbook. In the crucial sixth edition Kraepelin (1899a) divided
mental disorders - now termed Seelenstdrungen and not psychoses - into
acquired and endogenous. Diseases I-VIII were examples of acquired
conditions and IX-XIII were caused by a morbid predisposition.
Kraepelins
1899
Classification
I Infectious insanity
II Exhaustion insanity
III Intoxications
IV
V
VI
VII
VIII
IX
X
XI
XII
XIII
Thyrogenous insanity
Dementia praecox
Dementia paralytica
Insanity with cerebral disease
Involutional insanity
Manic-depressive insanity
Paranoia
General neuroses
Psychopathic
(degenerative insanity)
development
It is clear that manic-depression was regarded as endogenous - whereas
dementia praecox was not. With regard to the former condition, the sixth
edition saw the conglomeration of mania, melancholia and periodic insanity
into one new, original Kraepelinian category: Manic-depressive insanity. In
this context it is significant that Kraepelin met, was impressed with and
probably influenced by, Magnan at the Berlin International Medical
Congress in 1890. The most interesting event for me was the Frenchman
Magnans paper on circular insanity. (Kraepelin 1987: 63-4). As regards
dementia praecox, Kraepelin ( 1899b) said that he had put all dementing
processes togetherlo and he then explained the aetiology of the term
dementia praecox:
states
Defective mental
In consideration of the close relationship with the age of puberty, the

presence of disturbances of menstruation, and the frequent appearance of
the disease for the first time during pregnancy and puerperium, the
further assumption is made that it is the result of auto-intoxication.
(Kraepelin 1904: 153)
This view
10
was a common one at
Interestingly,
the reaction from other
this time,
namely that
mental illness could
psychiatrists was generally unfavourable.

15
be caused
by a toxin, which came from inside the body.

putative organic factors of the disease:
He stressed the
It seems probable, judging from the clinical course, and especially in

those cases where there has been rapid deterioration, that there is a
definite disease process in the brain, involving the cortical neurones.
(Kraepelin 1904: 153 my emphasis, M. D. B.).
Thus dementia praecox was seen as an organic disease process and not as
endogenous so, at this stage, dementia praecox and manic depressive insanity
did not form an exclusive duo as the endogenous psychoses.
By the eighth edition of the Textbook Kraepelin (1909-1915) had
incorporated Bleulers ( 1911 ) better prognosis schizophrenia into his classification. To the three categories of dementia praecox - hebephrenia,
catatonia and dementia paranoides - Bleuler had added a simple form to
make the new disease schizophrenia.
It was in this edition Kraepelin first termed dementia praecox as
endogenous: 11
If
to, then
processes
classify thyrogenous insanity, endogenous

(including dementia praecox) and epilepsy as
metabolic diseases. (Kraepelin 1909: 17).
one wants
dementing
one can
In between the eighth and ninth editions of the Textbook (Kraepelin 1921 )
still classified dementia praecox and manic-depressive insanity in separate
general categories. The former was classified with arteriosclerosis, senile
mental disturbances, paraphrenia and epilepsy under the heading: Psychoses
as a result of internal physical pathological processes. Manic-depressive
insanity, by contrast, was an example of Constitutional mental disorders,
along with hysteria, paranoia, compulsive neurosis and sexual perversions.
In the ninth edition of the Textbook this had changed and dementia
praecox (endogenous dementia) and manic-depressive insanity were
classified together under the endogenous illnesses,. 12
Of the endogenous dementias Kraepelin wrote:
Here also we should be looking for the causes arising from processes
which come from the body itself, without our knowing the source for
certain. Certainly heredity and predisposition play a significant, if not a
decisive role ... When we examine manic-depressive insanity, then we
11
He also introduced a new category, as the other example of the Endogenous dementias Paraphrenia. However, later, Kraepelin (1927) returned to a unitary view of dementia praecox and
paraphrenia and rejected paraphrenias separate status, after Willy Mayer (1921) had found that of
Kraepelins 78 patients with paraphrenia, forty per cent developed signs of dementia praecox at
follow-up.
12
Other categories to belong to this group were: endocrine insanity, arteriosclerotic insanity,
presenile and senile insanity and epilepsy.

16
dealing with an illness in which the inherited predisposition

undoubtedly of great importance. (Kraepelin and Lange 1927: 22).
are
is
Both
manic-depressive insanity and schizophrenia were now regarded in the

group, with heredity being crucial for both.
So, by the time of the ninth edition, published one year posthumously in
1927, with Johannes Lange, the picture regarding the use of the term
psychosis had been clarified, even though there was still work to be done.
The mentions of psychosis as the general term mental disorder found in the
important explanatory Introduction to the eighth edition (Kraepelin 1909:
15) had been removed by the ninth.&dquo; The term psychosis was generally not
used except for serious mental disorders, which Kraepelin and Lange
referred to as the exogenous and endogenous psychoses. Nevertheless,
Kraepelin (1927: 23) still confusingly classified the traumatic neuroses and
psychogenic depression as examples of forms of insanity and put the prison
psychoses along with neurotic conditions under psychogenic illnesses.
Thus the definitive division between the psychoses and the neuroses had not
same
yet been finalized.

The relationship between
Textbook
psychosis and psychopathy in Kraepelins
Kraepelin was formative in his views here and was instrumental in

psychopathys eventual splitting off from the psychoses. Originally the two
terms had been synonymous when introduced by Feuchtersleben (1845) and
both meant mental disorder.
Influenced by the theory of degeneration, Kraepelin (1883) had put moral
insanity (the precursor of personality disorder) and mental retardation in the
same category. In the third edition of the Textbook he ( 1889) still saw moral
insanity as a special kind of mental retardation. In the fifth edition Kraepelin
(1896), influenced by Koch and Krafft-Ebings recent works, described the
psychopathic states as degenerative insanity, neurasthenia, anankastic and
impulsive insanity and homosexuality. With the influence of Langdon Down
(1866, 1887) and others, intellectual retardation was removed from this
group. 14
In the sixth edition Kraepelin (1899a) abandoned the heading moral
insanity. He still, however, claimed that patients with psychopathic states
suffered from degenerative insanity and were subject to the Morelian concept
of polymorphic heredity.
13
That it was Kraepelins own view, and not Langes, can be confirmed by the use of the same
classification in his Introduction to Psychiatry (Kraepelin 1921).
14
There was, however, a debate on whether mental handicap and insanity could co-exist (see
Turner 1989).

17
In the seventh edition Kraepelin (1918) made the crucial, though not
distinction between psychopathic personalities and original
disease states (originale Krankheitszustande). The former were static
conditions, that is personality disorders, whilst the latter were diseases - such
as nervousness, sexual deviations, periodic ill-humour and excitement,
compulsions and impulses - with a certain course. This distinction was
upheld in the eighth edition.
What is confusing in the eighth edition is that Kraepelin also saw hysteria,
paranoia and the preliminary stages of manic-depressive insanity as types of
psychopathy in a more general sense - which he referred to as the
degenerative disorders. This term found its parallel in the degenerative
insanities of Birnbaum (1923) and Kleist (1928). Nevertheless, Kraepelin
maintained his division of the specific type of psychopathy into original illness
states and psychopathic personalities.
There was some movement towards the position Kraepelin and Lange
(1927) were eventually to adopt - in the formers ( 1921 ) classification, where
constitutional disorders were distinguished from congenital disorders. The
former comprised: manic-depressive insanity, paranoia, hysteria, compulsive
neurosis and sexual perversions. The latter were psychopathy, oligophrenia
(mental handicap) and nervousness.
In the ninth edition Kraepelin and Lange (1927 :25) finally separated out
genuine psychopathy from the original illness states and other conditions,
although he recognized that the former - with their abnormal personalities
inadequate in the sphere of mood and will [but] which did not manifest other
signs of illness - were disorders belonging to the borderland between
mental illness and health which merge imperceptibly with the normal
variation in psychiatry.
Thus, in the first edition of the Textbook moral insanity and mental
retardation were in the same category and were seen as psychoses (mental
disorders). By the ninth a clear distinction had been made between
psychopathic personalities (the former moral insanity), oligophrenia (mental
retardation) and the endogenous psychoses (dementia praecox, manicdepressive insanity and epilepsy).
original,
Summary of Kraepelins view of the endogenous psychoses

In the third edition of the Textbook Kraepelin ( 1889) had relied on Schueles
classification with its division of diseases into those caused by external and
constitutional factors. The fifth edition (Kraepelin, 1896) had the clearest
delineation between acquired and predisposed conditions, and contained the
first description of dementia praecox. This was, however, not seen as an
endogenous illness, rather as an acquired condition. In the sixth edition
Kraepelin ( 1899a) first introduced manic-depressive insanity, which was
termed a constitutional mental disorder and an example of an endogenous

18
condition. Both these new illnesses were described by Kraepelin using the
clinical principles outlined by Kahlbaum. Nevertheless, the theory of
degeneration still influenced Kraepelin and so clinical and aetiological
principles had to be held in tension. Dementia praecox was not actually
classified exclusively as an endogenous psychosis, along with manicdepressive insanity and epilepsy, until the eighth edition of the Textbook.
In line with these changes, Kraepelins use of the word psychosis
developed throughout the course of the editions of his Textbook. In the first
three editions he wrote of Die Klassifikation der Psychosen as a main heading
that is, psychoses denoted all mental illnesses. Throughout the course of
the successive editions of his Textbook the loose employment of the term
psychosis was tightened up. By the fifth edition he did not refer to The
Classification of the Psychoses but to: The Classification of Mental
Disorders. However, as late as the eighth edition he occasionally referred to
Die Gruppirung der Psychosen. The reason for this general trend was because
psychosis was becoming more specialized and therefore not so suitable a
term to denote the whole gamut of mental disorders. By the ninth edition
psychosis was only employed when referring to specific diseases. The
psychoses no longer included mental handicap, the constitutional
psychopathies, psychopathic personalities or some of the modern neuroses.
Nevertheless, occasionally even in 1927 Kraepelin included examples of
neurotic conditions such as psychogenic depression and the traumatic
neuroses under forms of insanity or psychoses.
Kraepelins unclear legacy regarding the exact relationship of the neuroses
and the psychoses was to be developed and clarified by his followers,
especially Jaspers and Schneider.
-
Karl Jaspers:
psychosis versus personality; and the three endogenous
psychoses
With the great and wide-ranging intellect of Karl Jaspers came the definitive
delimitation of the psychoses from the psychopathies and neuroses. The
concept of the disease process as developed by men such as Schuele and
Kraepelin was crucial here.
The whole issue of distinguishing disease process and personality
interested Jaspers from early on in his career, as it was to do his protagonist
Ernst Kretschmer. Jaspers (1910) published a detailed analysis of the
Othello Syndrome (Eifersuchtswahn or Delusion of Jealousy). It was
subtitled A Contribution to the Question: &dquo;Development of the Personality&dquo;
or &dquo;Process&dquo;? Jaspers gave seven case histories from his clinical work, but
much of the article was devoted to discussion of issues such as the nature of a
process.
We must
state
here that
by process we do not mean everything that occurs

19
in
a mental illness, but only that which results in lasting incurable change.
Something heterogeneous has to happen to the personality which it
cannot shake off and which leads to the foundation of a new personality
(Jaspers 1910:607).
...
How then did Jasperss notion of process relate to the psychoses in this
article? Firstly he divided the processes into mental and physical-psychotic.
He thus went against much of the contemporary climate of psychiatric
opinion, for instance the views of Nissl (1899) and Wernicke (1900), who
proposed a physical basis for all mental illness:
If we call those mental phenomena resultant upon a definite cerebral
condition the physical-psychotic processes (e.g. general paralysis,
arteriosclerosis) then those processes which are characterized by the
psychological nature of their symptoms or course, we call mental
processes.
to him the mental processes result in a new unity and an
extensive rational and insightful coherence (: 613).
The physical-psychotic processes showed an irregularity of symptom and
course. All phenomena appear higgledy-piggledy, since they are dependent
on the physical brain process (: 613).
Jaspers strongly rejected an organic basis to the mental processes: Not a
single mental symptom (emotion, delusions, impulses) can be traced to a
particular location or site of the brain (: 609). But for the physical processes:
where definite cerebral processes have been ascertained all manner of
psychopathic&dquo;symptoms occur and the only constant one is the defect state
... (: 608-09). At this point he called the physically-caused mental illnesses
organic psychoses, and manic-depressive insanity and dementia praecox functional psychoses (: 606).
Thus at this stage in his career the distinction between personality and
process in mental illness was not as delineated as that between personality
and process in organic mental illness. Jaspers was later to make a much
greater differentiation in the former. It was after Kretschmers publications
that he was to change his views. For the present, he was at pains to point out
that mental illnesses did not have physical causes.
In 1913 Jaspers published his famous textbook on general psychopathology and it was in successive editions of this work that his ideas on the
issue of personality versus mental disease process developed. Rather than
being a rundown of all psychiatric diseases, as, say, Kraepelins textbooks had
According
...
15
Psychopathic here meant symptoms of
connotations of the theory of degeneration.
diseased mind in
general, and did

not
have
20
been, this concentrated
psychology of the
on
psychopathology or perhaps
Jaspers wrote:
more
helpfully the
diseased mind .16
The subjec*of psychopathology is the real mental occurrence. We want to

know what and how human beings experience life and to discover the
breadth of intellectual reality ... However, it is not the whole realm of the
mind that is our concern, but only the pathological. (Jaspers 1923: 2-3).
The 1923 edition of the textbook showed that Jaspers now differentiated
the psychopathies from the mental disease processes, which he limited to
dementia praecox.&dquo; It is important to state that at this juncture the term
psychosis still had a very general meaning in that it embraced all mental
conditions except the psychopath category. This was to change in future
editions.
For Jaspers, those suffering from processes were qualitatively different
from the psychopaths. However, it should be noted that manic-depressive
insanity was not regarded as a process by Jaspers at this stage. The
distinction that Jaspers drew between group two, Processes, and group
three, Degenerative Insanity, was that the latter should be seen as
variations of the [pre] disposition not as disease processes. The term
degenerative was not meant in the Morelian sense, but rather as a deviation
from normal character.
By the later editions of the textbook the picture with regard to the
psychoses became clearer, partly as a response to Kretschmers views. By
1963 his three groups were:
1. Known somatic illnesses with
systemic illnesses,
e.g.
psychic disturbances,
uraemia; toxic
states, e.g.
e.g. GPI;
morphine
addiction.
2. The three
3.
major psychoses: genuine epilepsy, schizophrenia;

manic-depressive illness.
Personality disorders: neuroses; abnormal personalities; abnormal
reactions.
Jaspers gave his explanation for the

endogenous as follows:
[T]hese three psychoses
Heredity is an important
16
17
second group, which he called
exogenous but endogenous psychoses.

The hereditary link is a concrete reality.
are not
cause.
For further discussion of the nature of psychopathology, see Berrios (1991).

The classification was divided into three categories:
1. Organic psychoses: brain processes, e.g. GPI; physical disease, e.g. uraemia;
2.
3.
poisoning,
e.g. morphine; some epilepsies.

Processes (schizophrenia).
Degenerative insanity: manic-depressive insanity;

personalities.
abnormal
reactions; abnormal

21
But these hereditary psychoses are not all clearly of the same order and
present us with a confusing manifold since we do not know what is
inherited - the specific gene and gene-combination. All we have for the
time being is the classificatory concept of hereditary psychoses. (Jaspers
1963:
608).
Kretschmer (1929) had favoured a continuum from normality to disease

and proposed that normal people with a cyclothymic termperament were
linked to those with manic-depression by a third group which he called
cycloid. Similarly, the (normal) schizothymic group were linked to
schizophrenic patients by the schizoid group. Jaspers criticized Kretschmer:
dimly defined relationship but a transition: he

exaggeration of a constitutional variant of
1963:
personality ... (Jaspers
653).
Kretschmer not only saw a
saw the psychosis as an
All the personality-changes brought about by a process have in

the limitation or disintegration of the personality ...
common
Among the personalities which are due to a process, those of the

schizophrenic group deserve special mention. (Jaspers 1963: 446).
Jaspers (1963: 654)
concluded:
Sometimes it appears that Kretschmer has lost his sense of the differences
that gape between personality and process-psychosis
We would have
to introduce a series of transitions from average schizothyme persons via
schizoid psychopaths to schizophrenics.
...
Jaspers differentiated the schizophrenic psychotic process much more

cogently than Kraepelin, from the psychopathic, about which he (1963: 421)
concluded: In psychosis there is no lasting or complete insight.&dquo; Where
insight persists we do not speak of psychosis but personality disorder
(psychopathy) .
Kurt Schneider and the two
endogenous psychoses
Schneider was described as the logical successor to Kraepelin (Hirsch and
Shepherd 1974: 31), and like Jaspers, he consolidated and developed
Kraepelins classification. He, too, was critical of Kretschmers multidimensional approach. Schneider did, however, concede in his (1920: 63)
article On the Question of the Sensitive Delusion of Reference, in response
to Kretschmers (1966) article on this topic:
Even if
18
Jasperss
one
criteria
doubts the sensitive delusion of reference
for insight
were awareness
of being ill and
to
appreciating
be first and
some
of the
illness.

reasons
for
22
foremost
reactive-psychopathic development [as Kretschmer claimed],

recognise in it a new type in the group of paranoid psychoses,
much in the vein of the erotic delusion of reference of older women.9 Its
characterogenic nature seems assured. One can learn from the exemplary
manner in which Kretschmer buries himself in the beings of his patients
and works out psychological connections, even if he is said to have gone
a
so one can
too
far in this.
So Schneider rejected this delusion being an example of a psychopathy or

neurosis (Erlebnisreaktion). However, he praised Kretschmer for his
contribution in helping to explain the way the patients character shaped the
paranoid psychosis. Schneider claimed character exerted a pathoplastic rather
than a pathogenic effect.
Schneider ( 1924: 203) further elucidated his understanding of the
psychoses. He claimed that in those psychoses which were not organic three
questions had to be asked:
a
1. Is a diagnosis in the circumscribed

2. What is the clinical type?
3. What is the clinical course?
organic
sense
possible?
With regard to the first issue he somewhat surprisingly stated that: Manicdepressive insanity and dementia praecox were not diagnoses; for these terms
do not refer to the somatic, but rather describe psychological conditions
(: 203). He was to revise this view by 1933. Secondly, with reference to the
type of the illness, he wrote: There is no question that all the clinical types
can exhibit schizophrenic and non-schizophrenic forms (: 204-5). Thirdly,
on the course of the illness he wrote, echoing Jaspers: The question is
always: Development/Reaction of the Personality or Psychosis. In a psychosis
one must also differentiate between a curable phase and an incurable
process (: 206).
Schneider also agreed with his teacher Kraepelin regarding psychopathic
personalities, which he viewed as static conditions, as had his mentor in the
seventh edition of the Textbook .20 By contrast the psychoses showed either
phasic or deteriorative courses.
This was clarified in Schneiders (1933) Psychopathie und Psychose:
We believe that there
are
no
transitions between psychopathies and
schizophrenias ...
The view that there is a fundamental difference between development and
process and therefore between psychopathy and schizophrenia, which
19
This is now known as De Clérambaults syndrome or Erotomania.

Schneider was to influence the way in which psychopathies (personality disorders) were
classified, in that to Kraepelins categories which caused distress to others he added those categories
in which the individual caused distress to himself (Schneider 1946).
20

23
Jaspers has always emphasized, is today represented by the Heidelberg

Clinic ...
By schizophrenias we understand psychotic processes which destroy the

personality, or at least turn it upside down - processes which are
fundamentally irreparable and whose aetiology and physical basis are
unknown ...
We concur with Reichardt, who warns against the terming of

understandable abnormal reactions as psychoses, which occurs not only
in everyday speech (war psychoses), but also frequently in clinical
conversation ... [T]his cannot affect the scientific concept of psychosis.
In
pathological
terms a
psychosis is
a matter
of illness...
could conclude that schizophrenia is an organic-constia primary cerebral disorder, a heredodegeneration

(Kleist), in which somatically speaking there are no transitions with
normality. (Schneider 1933: 343, 342, 339, 339, 341, 343).
In the end
one
tutional, perhaps
So, by 1933 Schneider was differentiating psychosis from psychopathy and

neurosis. He rejected the word psychosis being used as a synonym for
mental disorder. It was a scientific concept, a pathological condition, an
organic illness which did not exhibit any continuity with normality. In this
respect a psychosis could be viewed as an illness and it was quite clear who
was suffering from it and who was not.
In the socio-political context - with regard to who was erbkrank,
congenitally mentally ill, and therefore a candidate for euthanasia (Meyer, J-E
1988, Weindling 1992) - it was evident who fell into this category. In the
1930s it was common to read in the psychiatric literature of Nazi Germany
that the endogenous psychoses consisted only of dementia praecox and
manic-depressive insanity (e.g. Fluegel 1937-38).

Gaupp (1939: 47,54) expressed the situation thus:
It is
piece of good fortune [when it comes to diagnosis] that it is

question of schizophrenia or manic-depressive insanity, that is two hereditary diseases with the same eugenic significance ... Whom do
we thank today when the state can pass laws in order to counter
1933 saw the
effectively the growing degeneration in our people?
compulsion to fulfil the demands of the law which in its division of the
hereditary mental illnesses is founded completely on Kraepelinian
teaching.
a
only
great
...
In
his
definitive
endogenous psychoses
Kraepelin and Jaspers,
21
Schneider (1959:89) described the

as cyclothymia2 and schizophrenia. So, unlike
he excluded epilepsy. The meaning of endogenous
classification
Cyclothymia was Schneiders term for manic-depressive insanity.

24
had however
predisposed
which meant
known.
in the modified Morelian sense of

tainted had become for Schneider a purely negative word
a condition where no primary somatic cause is actually
changed. Endogenous
or
We call cyclothymia and schizophrenia endogenous psychoses. Everyone

knows what this signifies and therefore there is no need to abandon these
terms in everyday practice.
Schneiders negative view of endogenous psychoses has come to be

accepted, that is those where no primary somatic cause is known. We can,
however, thirty years on dispute the statement that we all know what it means.
Schneider (1959: 2) classified the mental illnesses:
I Abnormal variations
of psychic life
Abnormal intellectual endowment

Abnormal personality
Abnormal psychic reaction
II
Effects of illness (and defective structures)

Somatic etiology
Intoxications
G.P.I.
Other infections
Other internal disorders
Cerebral defect
Cerebral damage
Cerebral arteriosclerosis
Senile disorder
Other cerebral disorders
Idiopathic epilepsy
Condition of unknown
Condition of unknown
etiology causing schizophrenia

etiology causing cyclothymia.
Schneider stated that psychoses were all of the mental abnormalities in

the second group and no others. The essential prerequisite was that these
were all diseases (: 10-11). Schneider wrote:
In discussing them [cyclothymia and schizophrenia] we must try to
discriminate between the data they offer and what is normal in psychic
life, or abnormal but not psychotic, by which we mean abnormal
(psychopathic) personality and abnormal psychic reactions [neuroses],
which basically are but variations of the normal. (Schneider 1959: 89)
So, for Schneider, by 1959, the two endogenous psychoses had become
diseases. They had firmly separated from the neuroses and personality
disorders which were merely abnormal variations of psychic life. Schneider
thus carried to completion the process that his teacher Kraepelin established.
This process may also have been assisted by the social and political

25
conditions which demanded a cut-off point between normality and disease

something that the endogenous psychoses seemed to offer. The fact that
cyclothymia and schizophrenia were seen as the psychological sequelae of an
organic condition, and not as examples of the organic illness itself, however,
showed that Schneider still had his doubts as to the exact nature of these
conditions.
Discussion
The proponents of the theory of degeneration were to influence the
development of the concept of the psychoses and also the key figure in the
concepts development, Emil Kraepelin, in various ways. The intellectual
climate was dominated by degeneration theory, applied to psychiatry by
Morel and developed by Magnan. Moebiuss concept of endogenous,
arising from this theory, was to be introduced by Kraepelin at the same time as
his great division of manic-depressive insanity and dementia praecox and was
to prove a source of confusion. Morbid predisposition, a concept espoused
by Schuele, was to feature in Kraepelins works. Schueles category of severe
mental illness - the cerebropsychoses - assisted the process of psychoses
being regarded as serious conditions. By contrast, the psychoneuroses were
seen as less serious conditions. The concept of the psychopath, as outlined
by Koch, was taken on intact and developed by Kraepelin. As the influence
of the theory of degeneration began to wane, psychopathy came to be viewed
as a static disorder, rather than a stage in a deteriorating process. Because of
the aetiological approach to classification, based on the theory of
polymorphic heredity, a unitary model of mental disorder was favoured and
led to men like Schuele and Koch blurring the division between the
psychoses, the psychopathies and the neuroses. It was Kraepelin and his
successors who were to clarify these categories.
After Jaspers and Schneider, the endogenous psychoses have been limited
to the two major Kraepelinian diseases, schizophrenia and manic-depressive
insanity. But in the early part of the twentieth century there were other
examples of endogenous psychoses. These included the degenerative
insanities, some of which, e.g. hysteria, would now be termed neuroses. Of
the two Kraepelinian disease entities only manic-depressive insanity was
originally seen as endogenous; dementia praecox was not. It was only in the
1920s that it was referred to as endogenous. By the 1930s the endogenous
psychoses only comprised dementia praecox and manic-depressive insanity;
this process was influenced by the political climate of Nazi Germany, which
necessitated a clear division of the mental disorders on eugenic grounds.
After the collapse of the Nazi regime, why did the endogenous psychoses
survive? Mainly because of the continuing tide of research suggesting that the
two conditions are, at least partly, of genetic aetiology. Also, endogenous has
been linked to depression in a symptomatically specific way to refer to

26
patients with so-called biological signs (early morning waking, diurnal

variation of mood, appetite and weight loss) severe and persistent depressed
mood, delusions and no precipitants. There are many problems with this
approach, as Lewis (1971) outlined, not least: what is the opposite of
endogenous? Bonhoeffer (1909, 1917) originally separated the endogenous
conditions from those which had a cause which was exogenous (to the
brain). As Berrios (1987) has pointed out, Moebius had been vague in his
definition of exogenous. His engendered from without did not refer either
to the central nervous system or the skin as being the dividing line between
the endogenous and exogenous categories. Spechts (1913) criticism of the
terms lay in his refusal to accept that a mental condition had to be
exclusively either endogenous or exogenous. He cited the example of there
being a typical picture of melancholia in the early stages of dementia
paralytica.
If, on the other hand, we suggest that reactive should be the antonym for
endogenous, then it is clear that some reactive depressions can end up as
severe as a so-called endogenous depression. It is not surprising that the
International Classification of Diseases 10 (WHO 1992) classifies depression
according to its severity and not according to any supposed aetiology. If one
examines the two Schneiderian endogenous psychoses, then, on the one
hand we now have more evidence that genetic factors are indeed implicated
in their aetiology. On the other hand, there are additional conditions which
have entered the category of psychoses of unknown aetiology. In this
context, the rich tradition of the atypical psychoses is now being reevaluated. Many of these conditions have just as much right to be called
endogenous psychoses as the Kraepelinian duo. In the ICD 10 (WHO 1992)
these are known under such categories as acute psychotic disorders,
schizoaffective psychoses, persistent delusional disorders.
Another important consideration is that it is now agreed that, although
genetic factors are important in the psychoses, there are other influences
which
be borne in mind. Environmental factors - e.g. whether the

lives in the developing world - affect not only the clinical
manifestations of schizophrenia (Guinness 1992), but also its very course
and prognosis (Leff 1988).
For all these reasons - having its origins in the outdated conceptual
framework of degenerationism and also Nazi eugenics, as well as its lack of
reliable and valid meaning - it seems that the time has finally come to put the
must
patient
term
endogenous psychosis
to rest.
BIBLIOGRAPHY
Beer, M.D. (1993). Psychosis:
history
of the concept. M.D. Thesis
London

University of
27
Beer, M.D. (1995). Psychosis: from mental disorder to disease entity. History of
Psychiatry, vi, 177-200.
(in press). Psychosis and Neurosis: a historical perspective.
(in preparation). Psychosis: a history of the concept.

Berrios, G.E. (1987). Historical Issues of Psychoses: 19th century issues. British
Medical Bulletin
, xliii, 484-98.
— (1991). British psychopathology since the early 20th century. In G. E.
Berrios and H. Freeman (eds), 150 Years of British Psychiatry 1841-1991
(London: Gaskell and The Royal College of Psychiatrists), 232-44.
Birnbaum, K. (1923). Der Aufbau der Psychose. Grundzüge der psychiatrischen
Strukturanalyse (Berlin: Springer). Translated by H. Marshall as: The
Making of a Psychosis. The Principles of Structural Analysis in Psychiatry. In
S. R. Hirsch and M. Shepherd (eds), Themes and Variations in European
Psychiatry: an Anthology (Bristol: John Wright, 1974), 199-238.
Bleuler, E. (1911). Dementia Praecox oder Gruppe der Schizophrenien. In G.
Aschaffenburg (ed.), Handbuch der Psychiatrie, Spezieller Teil 4.Abt. 1. Hälfte.
(Leipzig und Wien: F.Deuticke). Reprinted in 1978 by Minerva Publications,
Munich.
Bonhoeffer, K. (1909). Zur Frage der exogenen Psychosen. Zentralblatt für

Nervenheilkunde und Psychiatrie, xxxii, 499-505.
— (1917). Die exogenen Reaktionstypen. Archiv für Psychiatrie und
Nervenkrankheiten, lviii, 58-70.
Down, J. L. H. (1886). Observations on an ethnic classification of idiots. In C.
Thompson (ed.), The Origins of Modern Psychiatry (Chichester: J. Wiley &
Sons), 15-23.
— (1887). Some of the mental affections of childhood and youth. British
Medical Journal, 49-50, 149-51, 256-59.
Feuchtersleben, E. von (1845). Lehrbuch der ärztlichen Seelenkunde (Wien: Carl
Gerold).
Fluegel, F. (1937-8). Über die Verteilung der endogenen Psychosen in Deutschland.
Zentralblatt für die gesamte Neurologie und Psychiatrie, lxxxvii, 709-10.
Gaupp, R. (1939). Die Lehren Kraepelins für die heutige Psychiatrie. Zentralblatt
für die gesamte Neurologie und Psychiatrie, clxv, 47-75.
Griesinger, W. (1868-9). Ueber einen wenig bekannten psychopathischen Zustand.
Archiv für Psychiatrie und Nervenkrankheiten, i, 626-35.
— (1876). Die Pathologie und Therapie der psychischen Krankheiten, 4th edition
(Braunschweig: F.Wreden).
Guinness, E. A. (1992). Patterns of mental illness in the early stages of urbanisation.
British Journal of Psychiatry, clx, Supplement 16.
Hirsch, S. R. and Shepherd, M. (eds) (1974). Themes and Variations in European
Psychiatry: An Anthology (Bristol: John Wright).
Huertas, R. (1992). Madness and degeneration, Part I. From "fallen angel" to
mentally ill. History of Psychiatry, iii, 391-411.
Jaspers, K. (1910). Eifersuchtswahn. Ein Beitrag zur Frage: "Entwicklung einer
Persoenlichkeit" oder "Prozess"?. Zeitschrift für die gesamte Neurologie und
, i, 402-52.
Psychiatrie
— (1923). Allgemeine Psychopathologie für Studirende, Ärzte und Psychologen.
(Berlin: Springer). 3rd edition. 7th edition published in German 1959 and

28
translated
by J. Hoenig and M. W.Hamilton (1963) (Manchester: Manchester

University Press).
Kleist, K. (1928). Cycloid, paranoid, and epileptoid psychoses and the problem of
the degenerative psychoses. In S. R. Hirsch and M. Shepherd (eds), Themes
and Variations in
European Psychiatry: an Anthology. Translated by: H. Marshall

(Bristol: John Wright), 297-331.
Koch, J. L. A. (1891). Die psychopathischen Minderwertigkeiten (Ravensburg: Dorn).
Kraepelin, E. (1883). Compendium der Psychiatrie (Leipzig: Abel). 1st edition
3rd edition (1889). Psychiatrie. Ein kurzes Lehrbuch für Studirende und Arzte
5th edition (1896). Psychiatrie. Ein Lehrbuch für Studirende und Ärzte (Leipzig:
Barth).
6th edition a
(1899
)
. Also: English edition edited and translated by A. R. Diefendorf
(1904) (New York: MacMillan).
7th edition (1918) translated from the German edition of 1903-4 by A. R.
Diefendorf. (New York: Macmillan).
8th edition (1909-1915). Vol.1 Allgemeine Psychiatrie (1909); vol.2 Klinische
Psychiatrie I (1910); vol.3 Klinische Psychiatrie II (1913); vol.4 Klinische
Psychiatrie III (1915).
9th edition (1927). Psychiatrie with Lange J., 2 vols.
(1899b). Zur Diagnose und Prognose der Dementia Praecox. Allgemeine
Zeitschrift für Psychiatrie, lvi, 254-63.
. 4th edition (Leipzig: Barth).
— (1921). Einführung in die psychiatrische Klinik
— (1987). Memoirs. Translated from the German by C. Wooding-Deane (Berlin-
Heidelberg : Springer).
Krafft-Ebing, R. von (1886). Psychopathia Sexualis (Stuttgart: Enke).
Kretschmer, E. (1929). Körperbau und Charakter. Untersuchungen
zum
Konstitutions-
problem und zur Lehre zu den Temperamenten. 7-8th edition (Berlin: Springer).
— (1966). Der sensitive Beziehungswahn (4th edition) translated by J. Candy as The
Sensitive Delusion of Reference. In: S. R. Hirsch and M. Shepherd (eds), Themes and
Variations in European Psychiatry. An Anthology (Bristol: John Wright, 1974).
Leff, J. (1988). Psychiatry Around the Globe. A Transcultural View (London: The
Royal College of Psychiatrists. Gaskell).
Leibbrand, W. and Wettley, A. (1961). Der Wahnsinn. Geschichte der abendländischen
Psychopathologie (Freiburg/München: Alber).
Lewis, Sir A. (1971). "Endogenous" and "exogenous": a useful dichotomy?
Psychological Medicine, i, 191-6.
Mayer, W. (1921). Über paraphrene Psychosen. Zeitschrift für die gesamte Neurologie
und Psychiatrie, lxxi, 187-206.
Meyer, J-E (1988). The fate of the mentally ill in Germany during the Third Reich.
Psychological Medicine, xviii, 575-81.
Moebius, P. J. (1892). Über die Einteilung der Krankheiten. Centralblatt für die
gesamte Neurologie in Wissenschaft und Praxis mit besonderer Berücksichtigung der
, xv, 289-301
Degenerations-Anthropologie
Morel, B. A. (1857). Traité des dégénérescences physiques, intellectuelles et morales de
lespèce humaine (Paris: J. B. Baillière).
— (1860). Traité des maladies mentales (Paris: Masson).
Nissl, F. (1899). Über die sogenannten functionellen Geisteskrankheiten. Allgemeine
Zeitschrift für Psychiatrie, lv, 67-68.

29
Pichot, P. J. (1982). The diagnosis and classification of mental disorders in French-
speaking countries: background, current views and comparison with other

nomenclatures. Psychological Medicine, xii, 475-92.
Scharfetter, C. (1983). Psychosis. In M. Shepherd and O. L. Zangwill (eds),
Handbook of Psychiatry, vol.I, General Psychopathology (Cambridge:
Cambridge University Press), 39-40.
Schneider, K. (1920). Zur Frage des sensitiven Beziehungswahn. Zeitschrift für die
gesamte Neurologie und Psychiatrie, lix, 51-63.
— (1924). Über die Notwendigkeit einer dreifachen Fragestellung bei der
systematischen Erfassung von Psychosen. Zentralblatt fuer die gesamte Neurologie
und Psychiatrie, xci, 200-8.
— (1933). Psychopathic und Psychose. Nervenarzt, vii, 337-44.
— (1946). Die Psychopathischen Persönlichkeiten. (8th edition) (Wien: F. Deuticke).
— (1959). Clinical Psychopathology. Translated by Hamilton M. W. from the 5th
German edition of 1958 (New York and London: Grune & Stratton).
Schuele, H. (1880). Handbuch der Geisteskrankheiten, 2nd edition in: H. von
Ziemssen (ed.), Handbuch der speciellen Pathologie und Therapie, vol. 16 (Leipzig:
F. C. W. Vogel).
Specht, G. (1913). Zur Frage der exogenen Schädigungstypen. Zeitschrift für die
gesamte Neurologie und Psychiatrie, xix, 104-16.
Turner, T. H. (1989). Schizophrenia and mental handicap: an historical review,
with implications for further research. Psychological Medicine, xix, 301-14.
Weindling, P. (1992). Psychiatry and the Holocaust. Psychological Medicine, xxii,
1-3.
a history of the concepts. Analysis of the origin
development of a family of concepts in psychopathology. Acta Universitatis
Upsaliensis. Uppsala Studies in Education, 6.
Wernicke, C. (1900). Grundriss der Psychiatrie in Klinischen Vorlesungen (Leipzig:
Thieme).
World Health Organisation, (1992). Tenth Revision of the International Classification of
Diseases Mental Disorders, Chapter V (Geneva: WHO).
Wyrsch, J. (1956). Zur Geschichte und Deutung der endogenen Psychosen (Stuttgart:
Thieme).
Zilboorg, G. and Henry, G. W. (1941).
A History of Medical Psychology (New York:
W. W. Norton).
Werlinder, H. (1978). Psychopathy:

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Conceptual History of Endogenous Psychoses

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Conceptual History of Endogenous Psychoses

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History of Psychiatry

The endogenous psychoses: a conceptual history

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today and conclude that it should be dispensed

endogenous was introduced by the German psychiatrist and

theory of degeneration in French psychiatry

1. Alienations ou folies hereditaires.

Thus Morels theory of Degeneration

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by such factors as poisoning (2); transformations of the major

It is in another order of functional cerebral lesions that it will be necessary

polymorphic inheritance denoted the transmission from one

J. J. Moreau de Tours (1804-1884) attributed insanity to a hereditary condition of the nervous

Downloaded from http://hpy.sagepub.com by Daniel Martinez on November 10, 2007

religious, whereas Morel had been brought up in a monastery for ten

years and held

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The other large category

Delusional states of inferior degenerates: mainly idiots, morons.

terminate the course.

Pichot (1982: 478) writes:

It soon became apparent that Magnans chronic delusional state of systematic

described between 1909 and 1913:

interpretative delusional state (dilire chronique dinterprtation) was

theory of degeneration in German psychiatry: Heinrich Schuele

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heavily influenced by Morel - was to be quoted for many years by

progressive nature of the hereditary poison, that is the progressive

So, Schueles classification of the mental disorders reflected his reliance

theory of degeneration. The mental disorders formed two groups; one

chorea, paralysis agitans (see Beer

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Paul Julius Moebius

(1853-1907): endogenous and exogenous

partial idiocy and

groups differed can be seen by the explanation Schuele gave for

The ways in which these

having mania and melancholia

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Neurological observations by P. J. Moebius. It is here that he

qualitatively different (alcohol,

proof of degeneration is seen in two areas. Firstly, and more

proceeded to the classification, reiterating the impossibility of

degree of degeneration. The highest degree is seen in idiots ... [Then

examples of how predisposition and circumstances interrelate, for

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Moebius divided mental illnesses into endogenous and exogenous, terms

Psychopathy and J. L. A. Koch (1841-1908)

term was necessary

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He classified the inferiorities into Permanent and Transitory; the former

processes and conditions of

1.Elementary Mental Anomalies. These can be of a psychotic9 nature as

Psychopathic Inferiorities. Inferiorities have been erroneously

diseases, and he used the

psychoses were equivalent

taints and degenerations merge with the mental diseases

psychoses and psychopathic inferiorities, then, Koch

wrote that the

persons whole life

[the psychopathic inferiorities]

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hand and with normal

This is now known as De Clérambaults syndrome or Erotomania.