Assen Jablensky
email: assen@cyllene.uwa.edu.au

Living in a Kraepelinian world: Kraepelin's impact on modern psychiatry

Keywords: DSM, Emil Kraepelin, neo-Kraepelinian, psychiatric nosology, psychiatry

5-volume book of reprints of original translations. Together with his

and the translations of several of his papers published in History of Psychiatry, they present a fair, though still incomplete picture of Kraepelin's lifetime work. This paper draws on those publications to assess Kraepelin's legacy and his influence on contemporary psychiatric theory and practice..

It is hard to imagine a debate taking place today among practising physicians on the evidence base for Virchow's description of leukemia, or on the prognostic implications of the diagnosis of Osler-Vaquez disease. Yet Emil Kraepelin's views on the typology of mental disorders -often quoted, occasionally misquoted and at times hotly debated -continue to frame much of the present-day psychiatric discourse. It looks indeed as if 'psychiatry still lives in a Kraepelinian world' [START_REF] Berrios | The early development of Kraepelin's ideas on classifi cation: a conceptual history[END_REF], but the exact contours of its map are still disputed and often get blurred. While European psychiatry rarely departed in a signifi cant way from the nosological concepts formulated by Kraepelin and his followers, decades of psychodynamic psychiatry in North America were followed by a 'neo-Kraepelinian revolution' [START_REF] Compton | The neo-Kraepelinian revolution in psychiatric diagnosis[END_REF][START_REF] Klerman | The evolution of a scientifi c nosology[END_REF] and the development of operational diagnostic criteria [START_REF] Apa | Diagnostic and Statistical Manual of Mental Disorders, Third Edition[END_REF][START_REF] Apa | Diagnostic and Statistical Manual of Mental Disorders, Third Edition -Revised[END_REF][START_REF] Apa | Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition[END_REF][START_REF] Feighner | Diagnostic criteria for use in psychiatric research[END_REF][START_REF] Spitzer | Research diagnostic criteria: rationale and reliability[END_REF], which were presumed to incorporate Kraepelinian diagnostic conventions. Among other things, the American rediscovery of Kraepelin in the 1970s has raised the question, what exactly were Kraepelin's views on the defi ning features and boundaries of the major psychiatric disorders? What did Kraepelin actually say?

English language readers will now fi nd it easier to search for answers to these recurring questions thanks to the exquisitely produced fi ve-volume edition of reprints from the original translations of Kraepelin's seminal texts, Lifetime Editions of Kraepelin in English (2002). Together with his Memoirs [START_REF] Kraepelin | Memoirs[END_REF] and the translations of several of his papers published in this journal, they present a fair, though still incomplete picture of Kraepelin's lifetime work.

Although Kraepelin's legacy is best known for the set of ideas about the nature and classifi cation of psychiatric disorders, an exclusive focus on the disease entity concept and the nosology of psychoses may detract from a proper appreciation of the extraordinary breadth and depth of his achievement. Kraepelin's many and varied research pursuits were often well ahead of his time, laying some of the enduring cornerstones for scientifi c psychiatry as a medical discipline. In one of the early papers, based on his 1886 inaugural lecture at the University of Dorpat (now Tartu, Estonia), Kraepelin, then only 30 years of age, outlined the 'research programme' that was to become a driving preoccupation for the rest of his life [START_REF] Kraepelin | The directions of psychiatric research[END_REF]. Five key themes, articulated with great clarity, illustrate his critical insights into the actual state and future prospects of the discipline, as well as what many would consider a strong pro-'medical model' bias: (i) psychiatry needs a 'profound and deep union with general medicine'; it is 'above all the medical, somatic side of our science' that provides the 'point of departure for psychiatric research'; (ii) the task of psychiatry is the clinical study of mental disorders, i.e. 'the empirical determination of individual forms' of illness according to their cause, course and outcome by applying 'impartial observation and tireless pursuit of individual psychiatric cases', rather than 'medicospeculative' theory which 'strives to be more than it really is'; (iii) the existing nomenclature subsumes 'all those small variations and intermediate forms … under excessively large and therefore meaningless and blurred categories'; (iv) 'as long as it is impossible to relate a simple and unequivocal patho-anatomic observation to an equally simple and unequivocal psychopathological observation', scientifi c psychiatry will not have reached the goal it should be capable of reaching; (v) among psychiatry's auxiliary sciences, the 'strictly empirical research methods' of experimental psychology 'hold out the most promise' of 'validity and scientifi c utility'. Which of the goals of his 'research programme' did Kraepelin achieve and where did he fail?

Elaborating on ideas first enunciated by Griesinger and Kahlbaum, Kraepelin reinforced greatly the primacy of the clinical method as the fi rma terra of psychiatry but went beyond its confi nes by actively seeking and building alliances with the 'auxiliary sciences' of psychology [START_REF] Kraepelin | Psychologische Arbeiten, Erster Band[END_REF], neuropathology, pharmacology and genetics. By attracting as co-workers a number of brilliant clinicians and researchers, including Nissl, Spielmeyer, Alzheimer, Brodmann, Plaut, Aschaffenburg and Gaupp, among others, Kraepelin created an ethos of scientifi c innovation and discovery, which earned for psychiatry a respectable place among the medical disciplines. The German Research Institute of Psychiatry (Deutsche Forschungsanstalt für Psychiatrie, now Max-Planck Institute of Psychiatry in Munich), established in 1917 after a decade of Kraepelin's tireless campaigning, was the world's fi rst centre specifi cally planned and designed for multidisciplinary studies of the mental disorders. Kraepelin's team pioneered the staining and microphotography of neurons and glia; produced contiguous microphotographic maps of the cortex; developed a technique for determining the specifi c weight of particular brain structures; formulated the principles of pedigree analysis in psychiatric genetics; and were the fi rst to use cinematography as a documentation tool in psychiatry. Kraepelin himself carried out original work in experimental psychology and pharmacology (the performance curve; manipulation of time perception; measurement of the effects of alcohol and caffeine on cognition) and much of his characterization of dementia praecox has defi nite neuropsychological underpinnings. Although not directly involved in population studies, Kraepelin stimulated others to conduct community surveys. Following a trip to south-east Asia, he outlined in 1904 the rationale for cross-cultural clinical and population research in his programmatic paper on comparative psychiatry (Kraepelin, 1974a). Last but not least, Kraepelin's advocacy of a population-based reduction in alcohol consumption and of a screening programme for the early treatment of syphilis, revealed his sound judgement on targeting the state's public health priorities towards the top two preventable causes of mental morbidity at the time.

Two components of Kraepelin's legacy continue to infl uence profoundly the theory and practice of psychiatry: the idea of the disease entity in psychiatry and the conceptual map of the psychiatric disorders with the distinction between dementia praecox (re-named schizophrenia in 1911 by Bleuler; see [START_REF] Bleuler | Dementia Praecox or the Group of Schizophrenias[END_REF] and manic-depressive insanity. As pointed out by Janzarik (1978), Kraepelin's principal merit was the articulation of the 'multitude of pathogenetically unclarifi ed psychoses' into those leading to a 'state of weakness' (Schwächezustand) and those spared such outcome. The ultimate validation of the proposed disease entities, Kraepelin believed, would come from neuropathology, physiology and biological chemistry of the brain, whereas the specifi c contribution of clinical research to their delineation consisted in identifying replicable patterns of intercorrelations between symptoms, course and outcome.

Kraepelin's approach to the problem of defi nition and classifi cation of psychiatric disorders was, essentially, a nosographic one, i.e., based on comprehensive clinical observations and naturalistic descriptions of a large number of individual cases. However, in contrast to earlier nosographers, Kraepelin was the fi rst to apply explicitly and systematically a longitudinal, lifetime approach to the description of individual illness, which resulted in 'a concrete living picture … with the help of ordinary language and no conceptual elaboration' [START_REF] Jaspers | General Psychopathology[END_REF]. Kraepelin never issued a defi nitive list of diagnostic criteria for dementia praecox and manic-depressive insanity, and was particularly careful to avoid claims about any 'pathognomonic' symptoms. Considering the whole of the clinical picture, as well as the characteristics of the individual personality invaded by the illness, was the rule he taught his students (see the 'Lectures on Clinical Psychiatry' in Kraepelin, 2002, Vol. 1).

Kraepelin's main research tool was the database provided by the 'counting cards' (Zählkarten) -annual collections of case summaries in a semi-standardized format [START_REF] Weber | Kraepelin's 'diagnostic cards': the confl uence of clinical research and preconceived categories[END_REF], which he used in a kind of 'pattern recognition' process involving iterative permutation-recombination to detect differences and similarities among cases. Thus, hierarchically ordered groups and subgroups emerged for a refi ned description of prototypes of disorders that included only rudimentary statistics. These prototypes, presented as categories of mental disorder, were not cast in stone and underwent numerous modifi cations. For example, the initial formulation of dementia praecox was fairly narrow, heavily weighted for features characterizing Hecker's hebephrenia (Kraepelin, 2002, Vol. 2, based on the seventh German edition of Psychiatrie). The later version (Kraepelin, 2002, Vol. 5), translated into English from the eighth edition and published in 1919 under the title Dementia Praecox and Paraphrenia, is considerably richer in descriptive detail and wider in scope, comprising nine quite different 'clinical forms', including several that today might be classifi ed as schizoaffective or acute transient schizophrenia-like disorder. Therefore, the widely held notion that Kraepelin's dementia praecox was a narrowly constrained, severe psychotic illness of an invariably poor outcome in a 'defect state' is only partially correct -insofar as it applies to the early version of the concept.

It is arguable by what kind of mental operation Kraepelin arrived at the primordial idea about the two major categories of schizophrenic and affective psychoses, but one thing is certain: they were not 'atheoretical' products of a mechanical accumulation of empirical facts [START_REF] Weber | Kraepelin's 'diagnostic cards': the confl uence of clinical research and preconceived categories[END_REF]. As Kraepelin himself wrote in his Memoirs, the idea of dementia praecox gradually 'dawned' on him when observing that many patients, who initially present with mania melancholia or amentia, develop progressive dementia and, in spite of individual differences, begin to resemble one another. This led him to the insight that: (a) one uniform disease process must be affecting them all; and (b) the process might be slow or quick, sometimes accompanied by delusions, hallucinations and excitement, but always leading to a loss of 'intellectual' capacity.

Kraepelin's goal of developing a consistent 'natural' classifi cation of the major mental disorders was never attained, and the system he created contained internal contradictions that necessitated frequent revisions and adjustments. The initial hope that neuropathology would reveal brain abnormalities unique to dementia praecox had to be dashed; the use of the longterm outcome criterion as a validity check on the diagnosis was unreliable and impractical, requiring prolonged monitoring of the patients; and varying proportions of the cases initially classifi ed as dementia praecox actually recovered. As regards the differentiation between schizophrenia and manicdepressive psychoses, there were too many cases where a clear distinction was impossible to make on purely clinical grounds. Kraepelin was fully aware of these diffi and, in a seminal paper from his late period (published in 1920; see Kraepelin, 1974b), he not only acknowledged 'the suspicion that our formulation of the problem may be incorrect', but went as far as to propose that 'the affective and schizophrenic forms of mental disorder do not represent the expression of particular pathological processes, but rather indicate the areas of our personality in which these processes unfold'.

Notwithstanding such diffi culties and doubts, as well as many attempts at alternative formulations of the diagnostic classifi cation of the psychoses, the categorical nosology constructed by Kraepelin gained more or less general acceptance and its essential features are still clearly present in ICD-10 (WHO, 1992) and DSM-IV [START_REF] Apa | Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition[END_REF]. This occurred in spite of criticisms and challenges that have accompanied the Kraepelinian nosology since its inception to the present day. The various objections raised by its critics fall into several groups: (i) Searching for disease entities in psychiatry on the basis of clinical data on subjective symptoms is like the 'chasing of a phantom' [START_REF] Hoche | Die Bedeutung des Symptomenkomplexes in der Psychiatrie[END_REF]; it is impossible to infer anything about the aetiology and cerebral localization from the symptoms and course of the illness. (ii) Similarity in outcomes does not necessarily imply that the same disease is present; the same illness may result in deterioration in some cases and in recovery in other cases. (iii) A categorical distinction within the group of major psychoses is impossible to sustain as there are many inter-forms and transitions in symptomatology, as well as in the individual course of illness over time. (iv) The diagnostic categories of schizophrenia and manic-depressive disorder do not defi ne genetically distinct biological entities. (v) Kraepelin's nosology is not based on a scientifi c methodology, has no empirical support and represents an arbitrary grouping of heterogeneous cases.

Most of these objections are essentially valid, but the last one appears to be simply ill-informed. The extensive documentation that Kraepelin left on his clinical research allows original material to be re-examined or re-analysed using modern statistical methods. Having been granted access to the entire set of 721 Zählkarten from the year 1908, we [START_REF] Jablensky | Kraepelin revisited: a reassessment and statistical analysis of dementia praecox and manic-depressive insanity in 1908[END_REF] extracted and coded the symptoms and other recorded clinical features of all the 53 cases of dementia praecox and 134 cases of manic-depressive insanity admitted to the Munich clinic during that year, using the syndrome checklist and glossary defi nitions of the Present State Examination (PSE; Wing, Cooper and Sartorius, 1973). After processing the data with the CATEGO computer classifi cation algorithm, we found an overall concordance of 80.2% between Kraepelin's original diagnoses and the computer-assigned ICD-9 diagnoses. At a next step [START_REF] Jablensky | Dementia praecox and manic-depressive insanity in 1908: a Grade of Membership analysis of the Kraepelinian dichotomy[END_REF], we applied grade of membership analysis (a form of latent structure analysis) to obtain a statistical grouping of Kraepelin's patients based solely on their symptom profi les, disregarding the original diagnoses. This independent taxonomic analysis reconstituted three 'pure types' of disorder, clearly corresponding to bipolar affective disorder, recurrent unipolar depression, and dementia praecox, thus suggesting high content validity for Kraepelin's typology and a consistent 'goodness of fi t' between the categories and the actual clinical data on which the typology was based.

The relevance of the Kraepelinian classifi cation to genetic research is more diffi cult to evaluate. Long before the advent of molecular genetics, Robert Gaupp, a close collaborator of Kraepelin, wrote: 'We are, of course, clearly aware of the fact, which we don't deny even for a second, that the greatest part of all genetic work in psychiatry would immediately collapse like a house of cards if Kraepelin's theory was shown to be altogether mistaken' [START_REF] Gaupp | Die Lehren Kraepelins in ihrer Bedeutung für die heutige Psychiatrie[END_REF]. The lack of spectacular advances in unravelling the genetic causes of schizophrenia and the major mood disorders during the last 15 years leads researchers to question whether the current diagnostic criteria of DSM-IV (or ICD-10), incorporating Kraepelinian concepts, define phenotypes suitable for genetic research [START_REF] Jablensky | Subtyping schizophrenia: implications for genetic research[END_REF]. Recent genetic linkage and association fi ndings, pointing to shared genetic risks and the existence of sets of genes with overlapping effects on both schizophrenia and bipolar disorder, e.g., dysbindin, neuregulin, DISC1, BDNF [START_REF] Craddock | The beginning of the end for the Kraepelinian dichotomy[END_REF], suggest that the nosological boundaries, on which a whole generation of molecular genetic studies was predicated, do not 'carve nature at its joints'. It is, however, premature to draw radical conclusions about the overall validity and utility of the distinction between schizophrenia and mood disorders, as there is still an 'explanatory gap' between the fi ndings of a statistical association and the demonstration of causality with regard to specifi c illness phenomena. This gap might be easier to bridge by employing intermediate (or endo-) phenotypes in the domains of cognitive function, neurophysiology or neuroanatomy. As objectively measurable quantitative traits, endophenotypes are better anchored in brain biology than clinical symptoms and can help delineate subtypes of disorder with likely distinct genetic basis [START_REF] Hallmayer | Genetic evidence for a distinct subtype of schizophrenia characterized by pervasive cognitive defi cit[END_REF]. Parsing the major clinical syndromes into 'modular' endophenotypes with specifi c neurocognitive or neurophysiological underpinnings is likely to cut across the conventional diagnostic boundaries and may prove a promising approach in the genetics of psychotic disorders. The current evidence is neither fi nal nor static, and will need to be re-examined as new concepts and technologies coming from molecular genetics and genomics, cognitive science or brain imaging bring forth new perspectives on disease causation and brain function. With the rapid advances in molecular neuroscience, genetics and genomics, the role of clinicians in defi ning and evaluating refi ned, reliable and valid phenotypes will be critical to the success of the discovery enterprise -and will be entirely along the lines of Kraepelin's envisaged 'research programme'.


Florian Mildenberger
email: mildenberger1973@gmx.de

Munich Historian

Kraepelin and the 'urnings': male homosexuality in psychiatric discourse

Keywords: Emil Kraepelin, homosexuality, Magnus Hirschfeld, National Socialism, racial hygiene

The discourse on male homosexuality -whether it deserved punishment or possible therapies for homosexuals -was significantly shaped by the physician Magnus Hirschfeld between 1900 and 1933. He fought passionately against §175 of the Penal Code (Reichsstrafgesetzbuch), which made homosexual acts between men punishable by law. Initially, Emil Kraepelin, the doyen of German psychiatry, and his students did not join in this discourse and only gradually developed their own ideas about homosexuality. The radicalization of German physicians in World War I led to a complete break between Hirschfeld and Kraepelinian psychiatry. But instead of developing his own theoretical model, Kraepelin adopted the arguments of his rival Alfred Hoche, who regarded homosexuality as a disease contracted through 'seduction'. Consequently, Kraepelin contributed to what, like the Nazis, he called 'popular sentiment', but neither he nor his followers influenced research on the aetiology and spread of homosexuality, and Kraepelin left no legacy in this field.

The eclipse of sexology in Kraepelin's research On 29 January 1918, Emil Kraepelin (1856[START_REF] Boeters | Lex Zwickau[END_REF] published an essay on 'sexual confusions' in the Münchener medizinische Wochenschrift. His research had been conducted under the auspices of the Munich Physicians' Association and its Commission on the Preservation and Enhancement of National Vigour (Kraepelin, 1918a). The essay dealt mainly with male homosexuality, discussing the studies of Berlin's pioneer campaigner for homosexual emancipation Magnus Hirschfeld (1868Hirschfeld ( -1935) ) and drawing important and far-reaching conclusions. Kraepelin argued that homosexuality had to be fought prophylactically and the age of consent raised to protect young people from homosexuals (Kraepelin, 1918a: 120).

The struggle against sexual confusions will have to work primarily against masturbation, including and especially mutual masturbation. This can be achieved through education, a hardening and toughening of the will through gymnastics, checks on premature sexual stimulation, avoiding seduction, and careful sex education at the right time. Containing homosexuality thus serves not only to foster comradely relations between the two sexes and to promote early marriage, but also to keep the seduction of young people at bay and to eradicate male prostitution.

Kraepelin called for a ban on every form of information about homosexual intercourse that did not condemn it.

This implied nothing less than radical censorship and a rejection of the movement for homosexual emancipation. Kraepelin's aim was to enhance the growth of the German population, and his article indicates a radical attempt to draw a clear line between 'German psychiatry' and the 'homosexual emancipation movement'. Although Kraepelin's utopian vision should be seen in the context of intellectual currents and conditions of the time, we can safely assume that the doyen of German psychiatry had reason to distance himself especially strongly from Hirschfeld and his ideas. In fact, Kraepelin's statements of January 1918 represent a complete change in the views he held before World War I.

When and why the debate began

Until about 1900, the discourse on homosexuality was dominated by forensic doctors and psychiatrists who were completely convinced of the pathological character of 'contrary sexual feeling' (Krafft-Ebing, 1901a: 309). The aetiology and therapeutic possibilities remained unclear. In their differentiation between healthy heterosexuals and 'pathological contrary sexuals', researchers referred to the studies of the jurist Karl Heinrich Ulrichs (1825-95), who made no secret of his own homosexual disposition and who published a number of works, from the 1860s onwards [START_REF] Ulrichs | Forschungen über das Räthsel der mannmännlichen Liebe[END_REF]. Ulrichs gave homosexuals the name 'urnings', referring to the god Uranus of ancient Greek mythology (Numantius, Numa [Ulrichs], 1864: 1, 4-5). 1 The writer Karl Maria Kertbeny (1824-82) coined the term homosexuality in 1869, but it did not enter medical discourse until 1900 (Lautmann, 1993: 15).

The debate was transformed by the work of the Berlin physician Hirschfeld. In 1897, with like-minded advocates, he founded the 'scientifi c-humanitarian committee' which sought to amend the part of the Penal Code dealing with sexual matters, in particular the part ( §175) that criminalized homosexual intercourse. Hirschfeld hoped that scientifi c arguments would change how physicians, the public and lawmakers viewed homosexuality. Psychiatrists and criminologists initially rejected his ideas. But this prejudice soon made way for a deeper examination of Hirschfeld's research, which involved extensive observations on the development of homosexuality. Unlike his colleagues, Hirschfeld did not examine patients in insane asylums or individuals who defi ned themselves as being 'sick'. Instead, he carried out broad surveys using a standardized 'psychobiological questionnaire' (psychobiologischer Fragebogen) among students and metal-workers in Berlin [START_REF] Hirschfeld | Fragebogen[END_REF]. He argued that male homosexuals should be regarded as 'sexual intermediate stages' as they had physiological and psychological traits recognizably characteristic of the opposite sex (Herzer, 2001: 105-7). Hirschfeld asserted that homosexuality was congenital, and that its punishment was therefore unjustifi able. At the turn of the century, his broad and -by the standards of the time -scientifi cally objective studies enabled him to convince the two psychiatrists most interested in sexual psychology, Richard von Krafft-Ebing (1840-1902) and Paul Näcke (1851Näcke ( -1913)); see Krafft-Ebing (1901b: 5); Näcke (1903/04: 312).

Friends and students of Kraepelin soon addressed Hirschfeld's theses. First, Gustav Aschaffenburg (1866Aschaffenburg ( -1944)), one of Kraepelin's assistants and a key fi gure in the newly emerging fi eld of criminal psychology, published an article in the fi rst volume of Monatsschrift für Kriminalpsychologie und Strafrechtsreform [START_REF] Aschaffenburg | Zur Abänderung des §175 RStGB[END_REF], a journal that he had founded. Ashaffenburg did not so much dispute Hirschfeld's fi gures as question his positing a constitutional disposition for homosexuality; at the same time, he conceded that Hirschfeld's methods were scientifi c (Aschaffenburg, 1904: 124). Kraepelin's assistants Karl Wilmanns (1873-1946) and Robert Gaupp (1870Gaupp ( -1953) ) even signed Hirschfeld's petition to abolish §175probably refl ecting the views of their more reticent teacher (Herzer, 2005: 30, 44). A series of debates, often involving Kraepelin's favourite student of eugenics, Ernst Rüdin (1874Rüdin ( -1952)), took place in the journal Archiv für Rassen-und Gesellschaftsbiologie. For example, Rüdin (1904: 106-8) declared that Hirschfeld's attempts to depathologize homosexuality were unscientifi c and even said that homosexuals always damaged their 'race', whether by refusing to reproduce or, if they did, by passing on their sexual disposition to their children. But at the same time, Rüdin (p. 108) explained: 'We are in complete agreement with them when they demand the abolition of §175. It is useless and cruel and breeds blackmail.' But even in this period (up to 1914), the same journal also published theories about homosexuality that, after 1918, would be adopted by Kraepelin. Otto Ammon (1879-1942), a doctor and self-appointed specialist in race anthropology, asserted that homosexuality was the product of modern urban life and masturbation. He added that it could be prevented by sports, 'respect for modesty ' and natural living (Ammon, 1909: 651-3).

Psychiatry and sexology

As early as 1883 Kraepelin had briefl y commented on 'contrary sexual feeling', classifying it as an expression of a degeneration (Kraepelin, 1883: 127). In the 6th edition of Psychiatrie, he thought homosexuality was a disease (Kraepelin, 1899: 223). And by the 8th edition, he had come to view homosexuality as a 'disturbance' based on 'degeneration' (Kraepelin, 1908: 403). In his remarks on the excesses of human sexual life, Kraepelin (1908: 154) emphasized the role of masturbation and the value of some psychoanalytic assessments. He found support for his views in the work of the neurologist Leopold Löwenfeld , whom Hirschfeld's adherents also admired (Bloch, 1908: 107;Burgmair, 2000: 141). Apparently, Kraepelin did not think male homosexuals should be punished. But adopting the terminology of Carl Westphal (1833-90), he always spoke of 'contrary sexual feeling', whereas his students generally used the term 'homosexuality', thus accepting the discursive norm laid down by Hirschfeld. There was only one personal encounter between Hirschfeld and Kraepelin: in 1906 they met coincidentally at an anti-alcoholism conference in Berlin (Burgmair, Engstrom and Weber, 2006: 69).

Thus, until World War I, several members of Kraepelin's school of German psychiatry took the view that homosexuality was a sign of degeneration and possibly a morbid condition, but also that it posed so little danger and was so unimportant that neither punishment nor a deeper analysis of its aetiology seemed necessary. At the same time, 'homosexual coitus' was deployed as an argument in debates on penal code reform, in an attempt to introduce the concept of 'diminished responsibility'. This was an important demand that united sexual reformers and clinically experienced criminal psychologists (Engstrom, 2000: 84; see also Weygandt, 1910: 146).

However, some of those involved in German psychiatry took a very different stance. Kraepelin's strongest critic, Alfred Hoche (1865-1943), and especially Hoche's student, Oswald Bumke (1877Bumke ( -1950)), held more radical views. In 1896 Hoche had already spoken out against the decriminalization of homosexuality, which in his view was caused by seduction and masturbation (Hoche, 1896: 61). He emphasized the danger inherent, for example, in dormitories in boarding schools; he was probably remembering his own youth (Hoche, 1934b: 69, 77). 2 Bumke also took part in the debates on homosexuality, and in 1904, just as the fi rst discussions in the Archiv für Rassenund Gesellschaftsbiologie appeared, he wrote: Every alcoholic, every morphinist tries to excuse his lack of resistance by accusing as high a percentage as possible of his acquaintances of the same weakness, thereby merely using the same principle of extenuation that is familiar to every child caught at mischief. [START_REF] Bumke | Zur Frage der Häufi gkeit homosexueller Vergehen[END_REF](Bumke, : 2333) ) Bumke also noted that a homosexual disposition alone did not incline one to practise 'pederasty', which instead involved a degree of 'aesthetic and ethical numbing'. He also called for Hirschfeld's exclusion from the medical discussion.

The question must therefore be asked: what lasting effects did World War I have on Kraepelin -effects that made him distance himself so completely from his own students who were open to emancipated ideas, and instead adopt the views of his antagonists, Hoche and Bumke? Advocates of racial hygiene initially welcomed the outbreak of World War I. Much earlier, Wilhelm Schallmayer (1857Schallmayer ( -1919)), for example, had hoped that a call to arms would eliminate inferior elements of the German populace [START_REF] Schallmayer | Der Krieg als Züchter[END_REF]. But Schallmayer and his colleagues had expected a short war, not the slaughter of trench warfare that was occurring on all fronts by 1915.

The consequences of trench warfare

The tremendous losses of soldiers on the Western front (Ypers) led to the fi rst change in Kraepelin's mood. In 1915 he wrote in the 8th edition of Psychiatrie that homosexuals were emotionally degenerate, barely amenable to therapy, and a serious danger to the German people [START_REF] Kraepelin | Psychiatrie. Ein Lehrbuch für Studierende und Ärzte[END_REF](Kraepelin, : 1961(Kraepelin, , 1965). To distinguish between heterosexuals and homosexuals, however, Kraepelin used Hirschfeld's language of 'intermediate stages ' (p. 1939). He went on to say that the seduction of urban youth had to be prevented; the most one should accord to homosexuals was pity (p. 1971).

With these remarks, Kraepelin anticipated the volte-face in his and his followers' views on the classifi cation of homosexuals. Nevertheless, the infl uence of Hirschfeld's work was obvious. Even his antagonists had to use the terms he chose when they wanted to confront him on his own grounds. Kraepelin sharpened his tone and stance towards homosexuals after the German defeat in the autumn of 1918: 'For Kraepelin, a whole sociocultural and political world collapsed with the German defeat in 1918 and the end of the monarchy. His science could not remain untouched by this.' (Engstrom, 2000: 85).

The same was true for many of Kraepelin's students and friends. In 1918 Schallmayer compared the situation in Germany with the decline of Ancient Greece and blamed homosexuality for the decay of both (Schallmayer, 1918: 216). And, he argued that because homosexuality played such a decisive role in the internal breakdown of the body politic, the punishment of homosexuality must be made more severe (p. 359). Kraepelin's former employee Mathilde von Kemnitz (1877Kemnitz ( -1966) ) warned against 'seduction', which invariably led to 'aberrations of the sex drive'. (Kemnitz, 1923: 117-19). Both Max Isserlin (1879Isserlin ( -1941) ) and Robert Gaupp feared the 'organized perversion' of German youth by sexual-reform concepts (Gaupp, 1919: 7;[START_REF] Isserlin | Die planmäßige Pervertierung unserer Jugend[END_REF]. Kraepelin, in contrast, concentrated on refuting Hirschfeld. After Hirschfeld appeared in the fi lm Anders als die Andern (Different from the Others) in 1919, stressing the harmlessness of homosexuality and calling for its depathologization, Kraepelin accused Hirschfeld of behaviour unworthy of his profession (Weber and Burgmair, 1997: 12). When the Physicians Disciplinary Committee of the province of Brandenburg and the City District of Berlin commissioned Kraepelin to analyse the fi lm in 1921, he judged it to be 'dishonest' and 'shameless', and it cast homosexuality in much too positive a light (Weber and Burgmair, 1997: 13-15; see also [START_REF] Steakley | Film und Zensur in der Weimarer Republik[END_REF]. At the same time, Kraepelin collaborated with the Bavarian Ministry of Culture, lecturing educators and physicians about the dangers posed by homosexuals (Weber and Burgmair, 1997: 17).

Kraepelin now adopted the position that, before World War I, had been advocated by Hoche and Bumke. Instead of arguing scientifi cally, he expressed prejudices taken from the repertoire of popular sentiment. This radicalization of his views was a consequence not just of the war, but also of Hirschfeld's apparent triumph in the debate. [START_REF] Hirschfeld | Ist die Homosexualität körperlich oder seelisch bedingt?[END_REF] made only a brief attempt to reconcile his views and Kraepelin's. He must have recognized the hopelessness of the attempt, as German psychiatrists were now hostile towards him. While most of the psychiatrists who taught at universities were drifting further to the right on the political spectrum, Hirschfeld was evolving into a pioneer of socialist sexual reform. And the arguments he advanced on the congenitality of homosexuality also seemed to be gaining ground. For example, the director of the Kaiser Wilhelm Institute for Biology, Richard B. Goldschmidt (1878Goldschmidt ( -1958)), thought his experiments with animals in 1916 had proved that the aetiology of homosexuality was a product of congenital intermediate disposition (Goldschmidt, 1916/18: 8). And a little later, after extensive animal experiments, the Austrian physiologist Eugen Steinach (1861Steinach ( -1944) ) claimed that he could correct the endogenous disposition to homosexuality by a testicle transplant [START_REF] Steinach | Histologische Beschaffenheit der Keimdrüse bei homosexuellen Männern[END_REF]. 3 Hirschfeld seized upon these ideas with enthusiasm, and felt he was triumphing over his psychiatric detractors, but this euphoria was short-lived. Just a year later, the new theories were subjected to massive criticism which would fi nally -in 1925-26culminate in the refutation of the so-called 'Steinach-Hirschfeld doctrine' (Bab, 1920: 9). 4 As a consequence, Kraepelin seems to have lost interest in any further engagement with Hirschfeld's ideas. Instead, he traced Hirschfeld's concept of homosexual desire back to his Jewish religion and 'race':

A preponderant infl uence of the Jewish spirit on German science, as is unfortunately wielded ever more intensely, appeared to me to be a very serious danger that should be countered above all by a deliberate fostering of the outstanding gifts of the German race. (Kraepelin, 2000: 43) 5 This dream of fostering German science came to fruition in the development of the Deutsche Forschungsanstalt für Psychiatrie (DFA; German Research Institute for Psychiatry) in Munich (Kraepelin, 1918b). But soon, and in spite of the considerable infl uence of the DFA, almost nothing of Kraepelin's views on homosexuality infused contemporary psychiatric research.

Kraepelin's heirs and homosexuality

In the 9th edition of Kraepelin's Psychiatrie, revised by Kraepelin's last assistant Johannes Lange (1891Lange ( -1938)), homosexuality was discussed only in passing. The book asserted that this sex drive begins early, but results from seduction (Lange, 1927: 564). Lange, who assumed Kraepelin's legacy in the DFA, found himself confronted with the fact that the term his mentor used, 'degeneration', was undergoing an increasing revival in the 1920s. Consequently, an extensive discussion of same-sex sexuality that arose on the foundations of a vaguely defi ned theory of 'degeneration' seemed counterproductive. At the same time, Lange had his own ideas on the aetiology of homosexuality. He conducted research on twins in order to explore the endogeneity of psychopathologies. In his infl uential study Verbrechen als Schicksal, he called homosexuality an exacerbating expression of criminal disposition (Lange, 1929: 67, 75). The contribution of seduction played no role here. And as early as 1923 Rüdin, Kraepelin's heir in the fi eld of racial hygiene, had concluded from the work of Goldschmidt that homosexuality was congenital (Rüdin, 1923: 472).

Both Lange and Rüdin wanted to legalize the prophylactic sterilization of both dangerous and mentally ill individuals. The possibility of adults seducing children ran counter to this goal. For if seduction were really a possible cause of homosexuality, and as frequent as Kraepelin and Bumke asserted, then even a broad sterilization campaign could not change this. Lange rejected outright the suggestion that prophylactic castration could be used to destroy the sex drive -a view that he believed was unproven and unfounded. 6 But by rejecting or ignoring Hirschfeld's sexual reform movement, Kraepelin's heirs remained faithful to their teacher. Their lack of interest in the complex themes of homosexuality in the 1920s was probably due to the fact that, during the 1920s, they only gradually and reluctantly came to accept the ideas of Ernst Kretschmer (1888Kretschmer ( -1964)). In his book Körperbau und Charakter, fi rst published in 1921, Kretschmer (1940: v) construed a differential diagnosis between manic depression (endomorphs) and schizophrenia (ectomorphs and aesthenics) on the basis of physical constitution. He posited an affi nity between homosexuality and schizophrenia and associated them with a tendency to the aesthenic body type: 'We often fi nd among them and their kin homosexual tendencies and, in addition, even without a stronger sexual drive, a contrary-sex disposition in emotional life, men-women and womanish men. ' (p. 94). Kretschmer came to this conclusion after fi nding a correlation between schizophrenia, the aesthenic (ectomorphic) body type and malfunctions of the gonads (p. 93). In his view, this corresponded with 'infantile emotional attitudes' and an 'emotional fi xation on the mother' (p. 95). Kretschmer thereby skilfully combined biological and psychological patterns of categorization that, overall, implied the endogeneity of homosexuality and made the seduction hypothesis unlikely. A broader discussion of the potentially negative role of mothers aroused little interest among racial hygienists. During the 1920s, Kretschmer's ideas captured the imaginations of forensic biologists, physicians, anthropologists and philosophers. His popularity quickly surpassed that of the Kraepelinians, who showed little inclination to welcome Kretschmer into their fold. In 1923 he had delivered a paper to the Ärztliche Gesellschaft für Sexualwissenschaft und Eugenik -an organization dominated by Hirschfeld -stressing the similarities between his and Hirschfeld's oeuvre (Hirschfeld, 1923: 5;[START_REF] Kretschmer | Keimdrüsenfunktion und Seelenstörung[END_REF]. It was not until the 1930 debates on reforming the criminal code that Kraepelin's followers and antagonists again took a public stand on homosexuality.

The debate on homosexuality in 1930

At the request of the penologist and Reichstag delegate Otto Kahl, several prominent psychiatrists stated their views on homosexuality in the Deutsche Medizinische Wochenschrift in 1930. A reform bill was to be discussed by the Reichstag's Penal Code Committee; it was proposed that simple homosexuality between adults should be decriminalized, but provisions on the 'protection of minors' should be tightened up. The Berlin professor Karl Bonhoeffer (1868-1948) initially rejected the hypothesis of homosexuality's endogeneity, claiming that homosexuals were psychopaths who became homosexual due to 'some kind of psychological constellative situations or other' [START_REF] Bonhoeffer | Stellungnahme zu einer Aufhebung des §175 Reichsstrafgesetzbuch[END_REF]. He said that §175 was not particularly effective, but useful as a deterrent, and that protecting minors should take precedence [START_REF] Bonhoeffer | Stellungnahme zu einer Aufhebung des §175 Reichsstrafgesetzbuch[END_REF]. Gaupp (1930: 87) wrote that he did not want to see private sexual matters included in the Penal Code, but agreed that protecting children must be given top priority. Like other contributors, he explicitly refuted Hirschfeld's views (Gaupp, 1930: 88). Hoche rejected the homosexuals' 'mushy apologetic literature', but favoured some liberalization of the Penal Code [START_REF] Hoche | Stellungnahme zu einer Aufhebung des §175 Reichsstrafgesetzbuch[END_REF]. Bumke (1930a) followed his mentor Hoche in completely rejecting Hirschfeld, but like Hoche conceded that the existing law was not sensible. Bumke hoped in particular that a reform would impose a harsher penalty for 'seduction'. In another article, he stressed that he would not treat homosexuals who wanted to be cured (Bumke, 1930b: 50). Two years later, Bumke identifi ed homosexuality as 'one of the gravest signs of degeneration … that we encounter with great regularity among the symptoms of a declining culture'. 7 If Kraepelin had still been alive at this time, he would have interpreted these statements as confi rmation of his own work. Homosexuality had been the only area in which he and his opponents (Hoche, Bumke) had worked together, although their agreement was based more on prejudice than on the results of scientifi c research -a fact that neither Kraepelin nor his admirers and opponents realized.

German university psychiatrists were unwarranted in their fear that the Coalition Government -whose parties quarrelled among themselves -could, in a last burst of strength, pass a reform of the Penal Code on sexual matters. For in the fi nal stages of the Weimar Republic, in an era of emergency government and rule by decree, such ideas were no longer on the parliamentary agenda.

National Socialism, homosexuality and Kraepelin's legacy

After the National Socialists came to power in 1933, the law on homosexuals was revised, but now as a crackdown intended to prevent the 'seduction of minors'. The revision saw the principles formulated by Kraepelin after 1915-18, and by his disciplinary adversaries, adopted into the Penal Code. Fortunately, as explained below, the National Socialists were too arrogant to accept that their understanding of homosexual life had been developed by 'researchers' other than themselves, so Kraepelin's legacy was adopted by the National Socialist government without recognizing him by name. It was easy to ignore Kraepelin because his supporters did not emphasize this aspect of his work; also the spectre of Germany's youth being 'seduced' had been common currency among anti-Semites and 'youth protectors' since the second half of the nineteenth century.

Although the impact of the German scientific community on law enforcement took on strong eugenic overtones, the case of homosexuality was something of an exception. Being homosexual was no reason for sterilization, as mentioned in the law on preventing congenitally ill offspring (Gesetz zur Verhütung erbkranken Nachwuchses or GVN), passed in 1933. Hermann F. Hoffmann (1891Hoffmann ( -1944)), a psychiatrist teaching in Tübingen and an admirer of Kraepelin, justifi ed this by claiming that insuffi cient research had been done on the relationship between homosexuality and heredity, and without a clear understanding of the aetiology of homosexuality, sterilization might be useless (Hoffmann, 1934: 205). Overall, Kraepelin's supporters believed that the GVN posthumously crowned his life's work. Gaupp (1941: 257) wrote that the 'Kraepelinian form groups' (Kraepelinsche Formenkreise) of mental illnesses were the foundation of the new legislation.

The law against habitual criminality also mentioned castrating only recidivist paedophiles, not homosexuals. But in 1935 provision was made for homosexuals to be 'voluntarily castrated' if they were deemed to be aware of their condition and in control of their sexuality. This established a legal distinction between homosexual men and 'youth-endangering' paedophiles -a distinction that contradicted Kraepelin's ideas and hopes after 1918.

The general view that homosexuals were seducers of young people was articulated outside scientifi c discourse by, among others, the all-powerful SS Leader and police chief, Heinrich Himmler. He strongly promoted the seduction hypothesis, not only in his 'secret speech ' in Bad Tölz in June 1937 (Smith andPeterson, 1974: 93-104), but also on the radio. 8 Himmler wanted to resocialize minors who had been seduced -he called them 'streetwalking lads' -and at the same time to conduct a campaign against what he regarded as an overly intense, homoerotic 'maleness' within the SS (Smith and Peterson, 1974: 99, 103). It would seem that, whatever other infl uence Kraepelin's work had on psychiatry as practised in National Socialist Germany, at least his views on homosexuality were not directly put into political practice. For those wont to salvage Kraepelin's legacy, in this case his 'non-legacy' will likely prove more useful than his outright legacy.

Kraepelin's views on homosexuality had little impact on the practice of psychiatric research. There was apparently a gap between his public pronouncements and pseudo-scientifi c prejudice against homosexuals on the one hand, and his research on homosexuality on the other. After Kraepelin died, his research was quickly overtaken and his students strayed from their mentor's line. Aschaffenburg and Lange willingly contributed to the Handbuch der gerichtlichen Psychiatrie (Handbook of Forensic Psychiatry), compiled by Hoche. Aschaffenburg (1934: 87-8) mentions seduction only briefl y and considers the endogeneity or exogeneity of homosexuality to be of secondary importance, although this issue had been highly signifi cant in the dispute with Hirschfeld (who had long since been driven into exile). Hoche (1934a: 338) used the term 'contrary sexual feeling', thus shifting the discourse back to Hirschfeld's time. Disposition seemed to him merely an expression of deeper psychopathology, and he no longer spoke of seduction as a prominent reason to prosecute. In his own textbook on psychiatry, Lange accorded only indirect recognition to Kraepelin and his ideas about homosexuality. Lange (1936: 237) maintained that every person was fundamentally bisexual, a view that echoed Hirschfeld's theories. Lange also used the term 'homosexuality' rather than Hoche's formulation 'contrary sexual feeling'. He mostly evaded the question of homosexuality's endogeneity or exogeneity, but stressed the existence of 'dispositionally same-sex-oriented men' (p. 238). He thought such men displayed physiological similarities to women and concluded that they threatened to seduce young people:

The fight against homosexuality is initially a prophylactic fight; in particular, the seduction of young people must be combated by all means. In addition, the onanistic tendencies of psychopaths with unclear aims must be guided, precisely because all sorts of abnormal drives can take root in masturbatory fantasies. (p. 238; original italics) After Lange died in Breslau on 11 August 1938, Bumke's favourite student August Bostroem (1886Bostroem ( -1944) ) became the editor of Lange's extremely successful textbook on psychiatry. Bostroem did not alter Lange's basic assessments, but did extend the discussion of homosexuality, remarking on issues of diminished responsibility in court proceedings and the possibility of therapeutic castration (Bostroem, 1941: 244-5). After 1933, Rüdin's student Theobald Lang (1898Lang ( -1957) ) was a prominent researcher on aetiology. He openly professed his agreement with Goldschmidt's ideas on homosexuality, which Hirschfeld had previously used as confi rmation of his own work (Lang, 1936: 713). As a result, Lang assumed the endogeneity of homosexuality; in his studies, seduction played no part. Instead, after years of investigation he arrived at conclusions diametrically opposed to Rüdin's and Kraepelin's. He believed that the persecution of homosexuals effectively forced them into deleterious marriages that were racially unhygienic: 'Perhaps a humane approach to pitiable abnormals here would bring a certain reward in the racial-hygienic area' (Lang, 1939: 412).

Nor did Lange's colleagues, Rudolf Lemke (1906-57) andHans Bürger-Prinz (1904-78), enter into the seduction debate to the extent that Kraepelin had demanded. Such discussions remained the province of forensic biology, located between jurisprudence and medicine, where experts were constrained by the Penal Code and hoped to support their elucidations with psychiatric diagnoses (Mildenberger, 2002: 260-5). But the forensic biologists themselves had to concede that their judgements, based as they were on 'objective scientifi c methods', were wrong in about 25% of the cases (Schiedt, 1936: 68). In addition, the staff of bioforensic research facilities preferred to use Kretschmer's body-type teaching, rather than Kraepelin's complicated 'form groups' (Mildenberger, 2002: 262-3). Only one academic racial hygienist took Schallmayer's ideas about the degeneration of the German nation and the analogous decay of the ancient Hellenic world seriously, and he also picked up on Kraepelin's ideas about seduction: Lothar Gottlieb Tirala (1886Tirala ( -1974)), who worked in Munich from 1933 to 1936. He had obtained his position solely through political cronyism and would lose it again in 1936 because of his incompetence. But in his book Rasse, Geist und Seele (Tirala, 1935: 62-3), he reiterated Schallmayer's and Kraepelin's assessments, without characterizing them as such. Instead, he presented Kraepelin's ideas as his own. Initially he mixed these ideas with a crude anti-Semitism by attributing the role of seducer to the Jews. He was probably thinking of Hirschfeld, whom the Nazi party periodicals sometimes presented as a prime example of a seducer (Rodenfels, 1939: 19). However, his remarks were criticized; for example, Julius Bauer (1887Bauer ( -1979)), the critic of National Socialist racial hygiene who taught in Vienna, wrote: 'The racial doctrines of people such as H. Günther 9 or L. Tirala cannot in any way claim to be scientifi cally grounded.' (Bauer, 1935: 634). When Tirala's university career ended in 1936, the ideas he professed were thoroughly discredited and so, indirectly, Kraepelin's ideas were dropped from the medical debate on homosexuality.

Acknowledgement

This paper was translated from German by Mitch Cohen, Berlin.

Notes

No way back for Kraepelin in sexology

After 1945, when Bürger-Prinz and his colleague Hans Giese (1920-70) set out to inaugurate a new sexual reform movement, they avoided any direct reference to Kraepelin. Even after the psychiatrist Detlev von [START_REF] Zerssen | Biometrische Studien über Körperbau und Charakter[END_REF][START_REF] Zerssen | Körperbau, Psychose und Persönlichkeit[END_REF] banished Ernst Kretschmer's body-type theory from scientifi c discourse in the mid-1960s, a reorientation of sex research towards Kraepelin's ideas was no longer possible. His research, which had evolved in confrontation with Hirschfeld (whose views had likewise long since been abandoned) was regarded as outmoded and too ideological. It remained for historical research at the end of the twentieth century to identify and explain the different concepts of these physicians in their contemporary context [START_REF] Weber | Anders als die Andern". Kraepelins Gutachten über Hirschfelds Aufklärungsfi lm[END_REF].

We note in conclusion that until 1914-15 Kraepelin's assessment of homosexuality was remarkably progressive and that, together with his students, he was contributing to a reformulation of the Penal Code and of psychiatric research in order to provide a better explanation for sexuality. His pessimistic re-orientation after the war and his subsequent move to negative eugenics brought this development to an end. If Kraepelin had brought the objective scientifi c methodology that he always demanded of himself and others to bear on his own psychosexual studies, he might have achieved lasting signifi cance in this fi eld as well as in clinical psychiatry. Instead, within his own lifetime he found himself on the defensive and his name disappeared from the discourse on homosexuality soon after his death. The legacy of Kraepelin's theories on homosexuality remained a blank slate.


Jean-Etienne-Dominique Esquirol

Rafael Huertas
email: huertas@ih.csic.es

D Esquirol

Between doctrine and clinical practice: nosography and semiology in the work of

Keywords: Esquirol, France, hallucinations, nosography, semiology, 19th century

This paper makes a fresh analysis of the work of the French alienist J. E

Introduction

Jean-Etienne-Dominique Esquirol (1772Esquirol ( -1840) ) was an outstanding reformer of asylum institutions in post-revolutionary France. His effort in introducing the Law on Alienated Persons of 1838 is, unquestionably, one of his major contributions to the history of psychiatric care [START_REF] Castel | L'Ordre psychiatrique[END_REF]Gourevitch, 1983a;[START_REF] Quetel | La vote de la loi de 1838[END_REF]. However, from a clinical perspective, he is considered to have merely continued and extended the paradigm imposed by his mentor Pinel (1745Pinel ( -1826)). Esquirol has often been hailed as a great clinician, capable of describing 'admirable pictures' 1 but hampered by a diffi culty in systematization and with little concern for 'doctrinal unity'. Indeed, this was the tone of the graveside oration by Jean-Pierre Falret (1794Falret ( -1870) ) in homage to his deceased colleague: Undoubtedly Esquirol's writings contain many lacunae, and we must in particular regret that the various parts were not closely tied by a more philosophical bond; we do however … acknowledge that Esquirol must, like the venerable Pinel, have been thinking above all about the ills it was urgent to alleviate and the good that Providence had called upon him to perform. (Falret, 1841: 7) Esquirol had less nosographical originality than Pinel and always moved within the theoretical and methodological framework established by his mentor. However, his work includes original contributions of great importance for understanding the subsequent development of alienism in the course of the nineteenth century. The purpose of this paper is to examine a number of the elements of Esquirol's psychiatric thinking, in order to gain a better understanding of the general focus of his investigations, his methodological approach and his real signifi cance in nineteenth-century French alienism.

A body of doctrine?

The French researchers Marcel Gauchet and Gladys Swain (1980) have identifi ed two stages in Esquirol's scientifi c output. Initially, the young alienist of Des Passions … [START_REF] Esquirol | Des Passions considerées comme causes, symptômes et moyens curatifs de l'aliénation mentales[END_REF], with little clinical experience and totally faithful to his mentor, was an ardent enthusiast of the potential of moral treatment. A more mature Esquirol, improving in clinical virtuosity, became increasingly sceptical from a therapeutic standpoint.

As will be shown below, Esquirol's nosography is closely tied to his enormous capacity for semiology and clinical practice. It is generally accepted that Esquirol's most important and most quoted work is Des Maladies mentales considérées sous les rapports médical, hygiénique et médico-legal (1838). However, this work is a compilation of monographs -somewhat amended -that had been previously published either separately or as articles in Panckoucke's Dictionnaire de sciences médicales … 2 So this compendium cannot be considered to be a suffi ciently complete and polished theoretical corpus. For this reason, and because Esquirol's activities were predominantly practical, Karl Ludwig Kahlbaum (1828-99), years later, thought that this 'hero of psychiatry, who appeared to be called to establish the undisputable fundamentals of this science', did not go beyond the reproduction in 1838 of a classifi cation outlined as early as 1816 (Kahlbaum, 1863: 35). But Esquirol does not, in fact, claim dogmatic pretensions. In the Preface to Des Maladies mentales …, he clearly acknowledges that the book 'lacks the advantages of a work drafted systematically' and admits that 'my book would no doubt be read with greater interest if a general idea dominated all its parts. But that would have involved me in a project which is incompatible with my many occupations' 3 (Esquirol, 1838: vi).

This absence of a 'general idea' does not necessarily imply renunciation of all doctrinal aspirations. However, if we propose to analyse such a body of doctrine, we cannot limit this to Esquirol's proposed classifi cation alone, and to make a thorough assessment we must examine other aspects of his work.

The chapters of the clinical part of Des maladies mentales … lack a coherent and orderly sequence, and descriptions of specifi c diseases are mixed with sections on symptomatology or general pathology. The following is the order of subjects given by Esquirol, in his table of contents:

Heir to l'idéologie: clinical practice and nosography

We know that the medicophilosophical project, inspired by the idéologie and developed through application of Condillac's (1714-1780) sensualism and the analytical method, played a fundamental role in the renewal of medicine in the transition from the eighteenth to the nineteenth century. 5 Pinel -and later Esquirol -undertook this task in the fi eld of psychiatry. The new alienists were followers of Cabanis (1757Cabanis ( -1808) ) and they embraced his criticism of the classifi cations more botanico: 6 Nosologists such as Sauvages, Linné, Sagar and Cullen, referring all diseases to certain principal divisions, ordering them into families the way botanists order plants, have, it is true, created classifi cations more suitable to rescue the memory of a student defending his thesis than to demonstrate to the practitioner the order in which their knowledge and plans for cure must be linked. When they have sought to do so, they have become lost in the details and have multiplied families and species to infi nity: and the more they have perfected this plan, the closer they have come to individual descriptions. (Cabanis, 1798: 74) In fact, the nosographical proposals of the fi rst French alienists move in this same direction. Pinel explains that 'the arbitrary and incomplete distributions by Sauvages and Cullen diverge more from the objective rather than simplifying the work' (Pinel, 1800: 83), 7 and he makes a 'new classifi cation of insanities' based on a reading and careful selection of observations in medical literature, confi rmed or corrected by his own clinical experience.

Esquirol follows the example of his mentor Pinel -and the line marked by the idéologues -by choosing a small group of morbid clinical pictures [START_REF] Codet | La nosographie d'Esquirol[END_REF]Gourevitch, 1983b), overcoming the excesses of the more botanico with its interminable lists of individual forms. To implement the proposal, he resorts to a strict application of Condillac's analytical method, also learned from Pinel, which provides him with the keys necessary for developing his nosography. Elvira Arquiola and Luis Montiel (1993: 57) expressed it well:

For Condillac, the analytical method consisted of resolving the objects of study into their simple constituents and reconstructing them according to their natural order of generation and development. Thus, the fi rst step is to decompose complex ideas into the simple ideas or sensations which make them up, and then to synthesize the latter.

These methodological principles can be identifi ed in Esquirol's nosographical work and are synthesized by him when he writes: 'After having reduced delirium to its primary elements, all we need to do is to bring these elements together in order to obtain the general forms of madness' (Esquirol, 1838, I: 22). Esquirol describes fi ve 'general forms of madness', which are defi ned as follows (p. 22):

1. Lypemania (melancholia of the classical authors): delirium with respect to one or a small number of objects with predominance of a sorrowful or depressing passion. 2. Monomania: delirium limited to a single object or a small number of objects, with excitation and a predominance of a joyful and expansive passion. 3. Mania: delirium extending to all sorts of objects, accompanied by excitation. 4. Dementia: incapacitation of the organs of thought because they have lost the energy and force required to perform their functions. 5. Imbecility or Idiotism: the organs have never been suffi ciently wellconstituted to enable proper reasoning. 8

As can be observed, Esquirol's system is based on two elements: delirium, whether limited or not, and passion, in the sense of 'thymia' but with a nuance of 'dominant idea'. The most signifi cant novelties in comparison with Pinel's system are undoubtedly the distinction between dementia and idiotism, by identifying the latter with a primary mental defi ciency, and the attempt to defi ne the idea of 'mania without delirium', by replacing it with monomania. Pinel's 'mania without delirium' created a terminological and conceptual problem. The description 'mania without delirium with specifi c delirium' was very confusing. So, in 1819 Esquirol proposed the term 'monomania' in order to characterize the main feature of the disease: a fi xed idea which takes over the patient's mind (Esquirol, 1819: 114). This 'fi xed idea' provides the basis for the position of monomania in Esquirol's classifi cation. The form and contents of delirium -eminently clinical criteria -are the key to the establishment of the relevant subcategories. Thus, on the one hand, Esquirol describes the monomania derived from 'mania without delirium' and characterized by a 'partial delirium and an exciting joyful passion' and, on the other hand, the so-called 'lypemania', initially considered 'an affective and sorrowful monomania' and, later, as a differentiated entity. 9 Esquirol (1838, II: 2) considers that 'monomania and lypemania are chronic cerebral disorders, without fever, characterized by a partial lesion of the intelligence, of affections and of will', but ends up by giving lypemania a specifi c, defi ned place among the other forms of madness: 'Monomania is an intermediate type, between lypemania and mania; it shares with lypemania (melancholy) the fi xedness and concentration of ideas and, with mania, the exaltation of ideas and physical and moral activity.' This differentiation is based, on the one hand, on clinical and evolutionary criteria: 'the course of monomania is more acute, its duration shorter, its termination easier unless complications arise, while lypemania is quite the contrary'. And, on the other hand, it responds to anatomical criteria: in lypemania, 'the delirium appears to come from certain abdominal injuries', while in monomania 'the delirium appears to be caused most immediately by the abnormal state of the brain' (Esquirol, 1838, II: 3).

Esquirol defi nes three varieties of monomania: intellectual monomania (if the partial 'injury' is in the intelligence, affective monomania (if it is in the affections) and instinctive monomania (if in the will). In intellectual monomania, the thematic delirium is very evident, and very specifi c: outside that partial delirium, they feel, reason and act like everyone else. The diagnosis of madness is obvious, since 'the illusions, hallucinations, faulty associations of ideas, false, erroneous, strange convictions, are the basis of the delirium' (Esquirol, 1838, II: 1-2). However, in affective monomania (Pinel's reasoning mania), the patients, 'with well-reasoned explanations, justify the present state of their feelings and excuse the extravagance and unsuitability of their conduct' (Esquirol, 1838, II: 2). Finally, instinctive monomania is defi ned as an alteration of the will, producing 'involuntary, instinctive, irreversible actions' (Esquirol, 1838, II: 2).

The French alienism of the time consistently maintained that there was no form of madness devoid of delirium. In England, on the contrary, the concept of moral insanity, proposed by James Cowles Prichard (1789Prichard ( -1848)), was widely accepted. The confrontation between moral insanity and monomania is of particular interest from a conceptual standpoint and is an element of the debate on the external manifestations of madness and the diffi culties in diagnosing 'madmen who do not appear so' 10 [START_REF] Esquerdo | Locos que no lo parecen[END_REF]. The existence of 'moral anomalies' without alterations to the intelligence, the basis of moral insanity, recaptured the idea of the absence of delirium and moved away from the notion of monomania. For Prichard:

Moral insanity is a disorder manifested only in the state of feelings, affections, mood, and in the individual's habits and conduct, or in the use of those mental faculties described as the active and moral powers of the mind. There is no perceptible illusion or hallucination in this order, or the lack of conviction impressed upon judgement similar to the deceptive or erroneous impressions which characterise monomania. [START_REF] Prichard | On the Different Forms of Insanity[END_REF]: 30-1, quoted by Augstein, 1966;original italics) Prichard uses terms from Esquirol and establishes a clear distinction between monomania and moral insanity, particularly after Esquirol had suggested that, in the moral insanity of this writer [Prichard], 11 in Pinel's reasoning mania, in mania without delirium, the intelligence is more or less damaged. Otherwise, those alienated would allow themselves to be carried along by reasoning and would recognize that their principles are false, their actions unusual, strange. Their intelligence is more or less imperfect, has lost its infl uence over the will and is not in harmony with the other faculties. (Esquirol, 1838, II: 5) The concept of monomania had caused a scientifi c and social debate of signifi cant interest [START_REF] Fontana | Les intermittences de la raison[END_REF][START_REF] Goldstein | Console and Classify.The French Psychiatric Profession in the Nineteenth Century[END_REF][START_REF] Saussure | The infl uence of the concept of monomania on French médico-legal psychiatry (from 1825-1840)[END_REF], although this is beyond the scope of the present essay. It is not relevant here to analyse the specifi c features of each concept described, but rather the fundamental principles governing the whole of this proposed systematization.

An initial aspect worth highlighting in this regard relates to the different interpretations which Esquirol's work attracted in the debate on the concept of 'unitary psychosis'. In a celebrated article published in Archivos de Neurobiología, the Spanish psychiatrist Bartolomé Llopis (1905-66) considers Esquirol as 'one of the fi rst representatives in modern times of the theory of unitary psychosis' (Llopis, 1954: 6). Llopis quotes the French writer, stating that 'madness can, successively and alternately affect all these forms; monomania, mania, dementia all replace each other, alternate and complicate each other during a single disease, in a single individual' (Esquirol, 1838, I: 23). Such a statement would place Esquirol as a follower of unitary doctrine. However, immediately following that sentence, in the same paragraph, the text continues:

This has led some physicians to reject any distinction and not to admit in madness any more than a single disease, presented in varied forms. I do not share this way of seeing things, and consider the genera … to be suffi ciently different so as not to be confused. (emphasis added) Furthermore, Esquirol's nosography has even been interpreted from precisely the opposite extreme. Paul [START_REF] Guiraud | Psychiatrie général[END_REF] also criticized the multiplicity and extent of Esquirol's idea of monomania, indicating that 'from the nosographical standpoint, this tendency runs the risk of leading Psychiatry to describe one disease for each patient: an individual who sets fi res is a pyromaniac; one who steals, a kleptomaniac, and the like'. However, Esquirol did not at any time propose attributing to symptoms the nature of independent diseases. Under the infl uence of Cabanis, as mentioned above, Esquirol sought to avoid the excesses of the botanical systematization and to establish subdivisions of eminently clinical utility.

In this way, Esquirol characterizes as genera the forms which Pinel calls species. The terminological difference is by no means casual, and shows Esquirol's attempt firmly to establish the broad nature of the notion of mental alienation, which would encompass specifi c and differentiated nosological entities. In short, Esquirol does not appear to have shared the idea that mental alienation is a single process which may take on variable clinical aspects.

The genera proposed by Esquirol were entities 'suffi ciently different so as not to be confused' (Esquirol, 1838, I: 23).

Mania, melancholy, dementia and idiotism were, for Pinel, suffi ciently similar forms in terms of their external features to be considered species -a fundamental taxonomic category -of mental alienation. These species would not constitute four individual diseases but rather four different aspects of a single disease: the aforesaid mental alienation. On the contrary, Esquirol's genera make it possible to group together different species of very similar characters within each genus and, as I have already noted, to establish subdivisions useful for clinical diagnosis.

Thus, for example, the genus of 'idiocy' would include two species, depending on the degree of intellectual defi ciency: 'imbecility', in which intelligence is unable to develop more than 'to a certain point', and 'idiocy' proper, where the intellect does not even manifest itself. In turn, these species admit varieties, distinguishing 'fatuity' (as a variety of imbecility), where some faculties of understanding are devoid of affectation, and 'cretinism' or 'alpine idiocy', already considered by Pinel and particularly by E. F. Fodéré (1764Fodéré ( -1835) ) in his Traité de goître et du crétinisme (1800). Similarly, the 'monomania' genus would group together species and varieties according to different criteria. Among these criteria, the object of the delirium is particularly signifi cant: homicidal, erotic, incendiary, kleptomaniac monomania, and the like. Therefore, in no case would they be different diseases but rather different manifestations of monomania.

Moreover, we cannot overlook the fact that Des maladies mentales … introduces the term maladies (illnesses) in its title, rather than alienation, emphasizing that in mood disorders not only are the psychic characteristics and symptoms important but those of an organic nature are also. Nevertheless, Esquirol -despite his efforts to overcome the old more botanico approach, and although he had implemented new concepts representing unquestionable novelties in clinical practice and psychiatric nosography -remained faithful to the naturalist nomenclature. Esquirol, in much the same way as Pinel, attempted to compose a natural history of diseases (as we have already seen, the clinical pictures continued to be grouped into genera, species, etc.). The criticism of the eighteenth-century nosographers by the early alienists is evident, yet they remained incapable of incorporating the new classifi cation criteria which the Paris School was applying to internal medicine (Arquiola and Montiel, 1993: 256).

However, this apparent lack of alignment with the Paris School should not be seen as an insuperable difference between Esquirol's thinking and the anatomoclinical approach. As I have noted earlier, Pinel stood halfway between enlightened and positivist medicine. Although in his Nosographie philosophique (1807) he does use 'orders', 'genera' and 'species' in a way similar to the earlier nosologistical systems, he does so by 'using a different criterion: the distribution of the internal diseases in their anatomical structure' (López Piñero, 1973: 256). It is true that here Pinel's discourse is to a degree undefi ned, but there can be no doubt that some of his specifi c applications, such as in the so-called 'phlegmasiae', are an immediate antecedent of the work of Marie François Xavier Bichat (1771Bichat ( -1802)). In Esquirol's work, however, the adoption of the anatomoclinical method is far more evident. Although he, too, resorts to the genus and species denomination, the anatomoclinical criterion begins to appear in some cases, such as in epilepsy, divided exclusively by using localization criteria (Esquirol, 1838, II: 398;Peset, 1993: 177). However, this caution in Esquirol as a nosographer is not refl ected in his activity as a clinician. As we shall see below, Esquirol initiated the construction of a psychiatric semiology according to the principles advocated by the Charité group.

A new semiology: trapped sensation

The construction of a strictly anatomoclinical psychiatric semiology is a clear aim in Esquirol's work. His most outstanding contribution in this respect is unquestionably the reformulation of the concept of hallucination [START_REF] Álvarez | Las alucinaciones: historia y clínica[END_REF][START_REF] Lantéri-Laura | Les Hallucinations[END_REF]. The French alienist notes the conceptual confusion up to that time, with respect to the use of the term 'hallucination' and its place in the old nosographies:

Sagar gives the name of hallucinations to the false perceptions forming the fi rst order of rages in his nosology. Linné includes them in the order of diseases of the imagination (imaginarii). Cullen catalogues them among local diseases. Darwin, and later, the English physicians, gave the name hallucination to the partial delirium which affects just one of the senses and used it indistinctly as synonymous with delirium. (Esquirol, 1838, I: 159-60) Esquirol's great merit in relation to hallucinations was not only to formulate their defi nitive meaning and establish a differential diagnosis with respect to illusions, but also to remove their clinical descriptions from their nosographical category and to present them as genuine physical signs. Esquirol incorporated the hallucinations and the illusions into a semiology described in the framework of the anatomoclinical thinking which was becoming established in France during the fi rst half of the nineteenth century [START_REF] Huertas | L'alienismo e la mentalità anatomoclinica: l'opera di J. E. D. Esquirol[END_REF][START_REF] Lantéri-Laura | Le problème de la sémiologie dans l'oeuvre d'Esquirol[END_REF].

Esquirol discusses the clinical history of a patient who had gone blind but suffered visual hallucinations, thereby corroborating the existence of 'a certain form of delirium in which individuals are able to perceive sensations, whether through one sense or another or several at the same time, without any external object to excite such sensations' (Esquirol, 1838, I: 188). This fact proves particularly relevant because it makes it possible not only to conclude that a 'perception without an object' exists, but also to reject the localization of the problem in one of the sense organs, the factor on which the distinction between hallucination and illusion is based:

Hallucinations are not false sensations, nor are they illusions of the senses, nor erroneous perceptions, nor errors of organic sensitivity, as occurs in hypochondria. They may be confused with illusions of the senses or with the false perceptions of hypochondriacs, but here there are always external objects whereas, with those who hallucinate, not only is there no stimulation of the senses but rather, at times, these organs do not even function. (Esquirol, 1838, I: 195) The signifi cance given to anatomical pathology must also be emphasized. In the preceding clinical case and in others described by Esquirol, the detailed necropsy following the clinical history is a good example of the extent to which postmortem dissection had become one more area of the alienist's routine work. The search for an injury defi ning the disease -in the very strictest anatomoclinical tradition -was in fact a priority objective of a good part of nineteenth-century alienism. This objective to determine the anatomical basis of mental disorders, already present in Pinel's work, was the fundamental starting point for understanding the complete assimilation of madness by an individual's corporeality and, above all, its localization in the brain, particularly following the anatomical studies of Bayle (1799-1858) (Brown, 1994) and the prolifi c and active phrenology movement [START_REF] Lantéri-Laura | Histoire de la phrénologie. L'homme et son cerveau selon F. J. Gall[END_REF][START_REF] Renneville | Le Langage des crânes. Une histoire de la phrenologie[END_REF].

Hallucination thus becomes a physical sign referring to an anatomical localization of the disease: the brain. For Laënnec (1781-1826) a physical sign is 'any sensorial observation enabling a physician to obtain, with a well-founded pretension of certainty, a partial image of the anatomical state of a patient's body at the time of the examination' (Laín, 1950: 296). However, a physical sign is not necessarily an item of information obtained from the somatic examination of a patient. Certain symptoms may fi t the defi nition of a 'sign': Broca's aphasia, for example, and hallucinations in Esquirol's conception.

This novel approach to the problem of hallucinations enabled Esquirol to arrive at a spectacular redefi nition of Cabanis' (1805) notion of 'internal sensitivity' and adapt it to the new theoretical premises. This concept was used almost exclusively to ascertain the causes of madness. From Esquirol onwards, hallucinations and illusions would succeed in supplanting the old visceral aetiologies in the alienists' area of interest [START_REF] Azouvi | Des sensacions internes aux hallucinations corporelles: de Cabanis à Lélut[END_REF].

Cabanis' criteria, a mixture of old and new theories, led to two ways of interpreting madness. On the one hand, the internal sensations of a visceral origin were invoked by some alienists to support their idea of mental disorders originating in the abdomen. On the other hand, this same thesis was updated. What was understood in eighteenth-century medicine as the conveyance to the brain of animal spirits or humours was now interpreted as pathogenic sensations which elude the consciousness. With Esquirol, however, 'cerebral sensations' were the object of a far more fecund and innovative approach. Now termed hallucinations, these sensations would not be considered exclusively as causes of madness, but would begin to as one of its most salient symptoms: 'A man with the intimate conviction of a perceived sensation, even in the absence of an external object causing him this sensation, is at the mercy of his senses, in a state of hallucination: he is a visionary.' (Esquirol, 1838, I: 159;original italics). As can be seen, this defi nition points to the psychic nature of hallucinations, clearly delimiting them from sensorial phenomena. Esquirol insists that: 'Hallucination is a cerebral or psychic phenomenon which operates independently of the senses. It persists, even though the delirium ceases, and reciprocally.' It appears evident that, from then on, the so-called 'internal sensitivity' would no longer be considered as 'disturbing', but instead would begin to be examined as 'disturbed'.

The process is, nevertheless, lengthy and complicated. Cabanis related the arrangements of the internal organs, particularly those in the lower abdomen, with the capacity to feel and, above all, their infl uence in the genesis of bulimia, hysteria, hypochondria and the like. [START_REF] Bichat | Anatomie générale appliqué à la physiologie et à la médecine[END_REF] emphasized the function of the ganglia, traditionally considered 'little brains' endowed with a specifi c sensitivity. Thus, what for Cabanis was only a specifi c division of the nervous system into parts became for Bichat a clear separation between the functions and the properties of the central nervous system and those of the ganglionic nervous system. The fi rst would be responsible for 'neuroses' such as paralysis, tetanus, catalepsy or epilepsy. The so-called 'vapours' would be attributed to the latter: hysteria, hypochondria, melancholy, 'and a whole numerous class of affections in which the abdomen and chest, but particularly the former, appear to be the fi re where all ills are rooted' [START_REF] Bichat | Anatomie générale appliqué à la physiologie et à la médecine[END_REF], I: 227-8, quoted by Laín, 1948).

It can thus be seen how the visceral aetiology of madness was refi ned, little by little. It is still included by Pinel, whose Traité médico-philosophique sur l'aliénation mentale ou la manie mentions the precordial localization of the passions and affi rms that the origin of mania is 'almost always in the epigastric region' (Pinel, 1800: 16). Esquirol tried to have it both ways: although the passions might originate in the peripheral organs, he had already suggested in his work on the passions that the sensitive stimuli registered in the viscera are picked up by the nerves and carried to and integrated into the 'centre of sensitivity' [START_REF] Esquirol | Des Passions considerées comme causes, symptômes et moyens curatifs de l'aliénation mentales[END_REF]. This is substantially the basis for the aforementioned nosographical and pathogenic distinction between hallucination and illusion. In hallucination, 'everything happens in the brain' (his 'centre of sensitivity'), while in illusion 'the sensitivity of the nervous extremities is altered, exalted, weakened or perverted' (Esquirol, 1838, I: 203). Esquirol (1838, I: 204-5) affi rms from a pathogenic standpoint that, if the sensitivity and activity of the senses are altered, it is evident that the impression produced on them by external objects will be modifi ed; if the transmission nerves are damaged and, at the same time, the brain is in a pathological state, the latter will be incapable of remedying the error of the senses: hence the illusions.

Clearly this distinction between hallucinations and illusions must be circumscribed within the delimitation established by [START_REF] Cabanis | Rapports du physique et du moral de l'homme[END_REF] between 'visceral sensations' and 'cerebral impressions'. However, this differentiation no longer serves to establish an aetiology, but merely a symptomatology.

In the rigorous anatomoclinical method, the physical sign made it possible to establish diagnoses through more or less sophisticated exploratory techniques -particularly effective in cardiac and respiratory conditions. However, its application to mental pathology required relatively signifi cant methodological modifi cations, for a number of reasons -fi rst, because of the ambiguity with which the earliest alienists confronted the problem of injuries. Even when the corporeal localization of mental illness was accepted, the morphological alteration was not always evident. This is why there was a tendency to treat the presence of non-morphological lesions in the nervous system as a consequence of remote and more general disorders.

Second, physical examinations were unable to offer adequate diagnostic keys and had to be replaced by a meticulous anamnesis. The patient had to provide a suffi ciently exact description of his mental sensations and experiences, and the physician then had to rule out or confi rm the existence of external objects which might have stimulated the patient's false perceptions. In the case of hallucinations, according to Esquirol's defi nition, the clinician also had to discover what the patient's 'intimate conviction' was, with respect to the visions or sensations perceived. Introspection thus became a primary semiological method.

The distinction between hallucinations and illusions made it possible to establish the localization of the disorders: in the brain, in the sense organs or in the sensorial tracts. Therefore, once a symptom was identifi ed, the diagnostic possibilities became entirely clear. Having identifi ed hallucination, the clinician could, in most cases, consider this a mental alienation, but had to rule out certain clinical pictures, such as hysteria or catalepsy, which, strictly speaking, were not considered mental diseases, as well as the so-called febrile delirium. Following Esquirol's contribution, interest in hallucinations grew. Some of his more outstanding disciples, such as J. G. F. Baillarger (1809-90) and Falret examined the subject in greater depth. In 1855-56, the concept and the clinical practice relevant to hallucinations were discussed by the Société médico-psychologique [START_REF] Ey | La discussion de 1855 à la Société médico-psychologique sur l'hallucination et l'état actuel du problème hallucinatoire[END_REF].

Studies of hallucinations multiplied during the twentieth century, showing this to be a central problem of psychiatric clinical practice, subject to innumerable points of view and methodological approaches. Bayle's thesis of 'General Progressive Paralysis', despite its decisive contribution to the foundation of anatomoclinical thinking in psychiatry, remained a solitary landmark. In contrast, the concept of hallucination, which arose in that same area of thought, remains valid today in a way comparable to the rhonchus and wheezing described by Laënnec, which continue to be explained in clinical propaedeutic and semiology texts. That was the understanding of [START_REF] Assard | Hallucinations: theoretical and clinical overview[END_REF] when they reviewed Esquirol's concept of hallucination in the American Journal of Psychiatry.

The anatomoclinical model thus served to explain the origin of certain diseases and generated descriptive demands leading to new semiological languages. This model was also used in the fi eld of alienism, thereby paving the way for the 'somatization' of mental illness which, a few years later, in the second half of the nineteenth century, would become consolidated, thanks to degeneration theory [START_REF] Huertas | Madness and degeneration. From 'fallen angel' to mentally ill[END_REF][START_REF] Pick | Faces of Degeneration: A European Disorder, c.1848-1918[END_REF] and criminal anthropology [START_REF] Peset | Lombroso y la escuela positivista italiana[END_REF].

Conclusion

It can be concluded from the foregoing that the medicalization of madness began with Esquirol. In Pinel's work, alienation had appeared as a medical concept placed in the perspective of an ontological theory of disease. In early alienism, moreover, such ontologism was particularly useful in the development and understanding of the bases of moral treatment [START_REF] Widlöcher | Psychiatrie morale et théorie ontologique de la maladie[END_REF]).

Esquirol's role in the development of the alienist movement was of prime importance. He was able to create a wide circle of disciples and collaborators, who eventually took up the main institutional and professional posts in French psychiatry in the middle of nineteenth century. Furthermore, his contributions to psychiatric practice -or, if preferred, to the theory of the practice -proved genuinely transcendental.

Highly authoritative writers such as Georges Lantéri-Laura (1998) and José María Álvarez (1999) have found in Falret's work the turning point which signifi ed the break with the more traditional and orthodox alienism, as represented by Pinel and Esquirol, and the birth of a new paradigm -that of the mental diseases -closer to internal medicine and with a pluralist conception of psychic disorders. There can be no doubt that a reading of Falret himself can contribute to this interpretation where he indicates that:

The idea was to study madness as a single disease, rather than investigating this group, so broad and so badly delimited, of truly different species, characterized by a set of symptoms and a given course. This fundamental error has, to our way of thinking, been the most disastrous in the progress of science … In fact, we cannot fail to repeat yet again that madness is not a single disease but that it may take the most diverse forms, infi nitely variable according to different individualities and circumstances, depending on the education received or on the environment in which the individuals affected have lived … The most serious progress that can be made in our speciality will involve the discovery of truly natural species characterized by a set of physical and moral symptoms and by a special evolution. Unfortunately, we are still very far from attaining such a desirable result. All our efforts must however tend toward that objective! (Falret, 1864: xxx-xxxi) Falret's argument is irrefutable and, more importantly, programmatic. This text in fact launches a call for practical action that would end a unitary or antinosographical vision of madness. He places the accent on the need to erect large nosographical structures in which to include multiple diseases that needed to be delimited. Falret cast doubt on the existence of monomania 12 as such and described the folie circulaire in 1854, the very year in which his colleague Baillarger presented his folie à double forme. 13 It is therefore not surprising that the historians Lantéri-Laura (1998) and Álvarez (1999) placed Falret's work at the crossroads between two paradigms. However, we must not forget that Esquirol's contributions represented a major point of departure for this line of thinking, rendering his acceptance of alienation as a single disease more than dubious. In any event, Falret's text appears to be addressed less to Esquirol than to Joseph Guislain (1797-1860) and the German writers who were advocates of the Einheitpsychose (unitary psychosis) [START_REF] Berrios | The notion of unitary psychosis: a conceptual history[END_REF].

The great semiologists came later in time, and the distinction between hallucinations and illusions has been defi ned solely as an 'outline of a semiology'. However, I believe that, contrary to what has been asserted, Esquirol's effort in this sense laid the foundation for a clinical propaedeutics. Esquirol's contributions, despite their limitations and peculiarities, resemble the major reform of medicine undertaken by the Paris School -by Corvisart (1755-1821) and Laënnec among others -leading to the birth of a new semiology based on the anatomoclinical method.

6. Several nosographies more botanico were quoted by both Pinel and Esquirol in their works; however, the ones that they knew best, or at least that they used to a greater extent, were those by Johann Baptist Sagar (1702-78) and François Boissier de Sauvages (1706-1767).

The former was the author of Systema morborum symptomaticum secundum classes, ordines, genera et species, cum characteribus, differentiis et therapeiis, which ran to three editions in Vienna in 1771, 1776 and 1784. The major work by the latter was Nosologie méthodique, ou distribution des maladies en classes, en genres et en espèces, suivant l'esprit de Sydenham, et la méthode des Botanistes was published in 1772 -a French translation of the orginal Latin (1863). For an in-depth study of these systems see: [START_REF] Arquiola | La Corona de las ciencia naturales[END_REF][START_REF] López Piñero | Los sistemas nosológicos del siglo XVIII[END_REF]Martin, 1990. 7. In Pinelian bibliographies some controversy exists as to whether the date of this work was 1800 or 1801; I follow Weiner, 1999: 394. 8. Originally published in Esquirol (1816: 163); however, in this fi rst version no distinction between lypemania and monomania is made, and 'monomania or melancholy' is considered a single genus. 9. Esquirol never claimed that he was the fi rst to distinguish between these two forms of partial delusion. He quotes for instance the work of Benjamin [START_REF] Rush | Medical Inquiries and Observations upon the Diseases of the Mind[END_REF], who differentiates between 'tristemanie' and 'aménomanie'. Interestingly, while the term monomania was very successful, it never quite enjoyed the success of the term lypemania, despite Esquirol's hopes that it would become established through 'use'; see Esquirol, 1818: 150-1. 10. 'Locos que no lo parecen'; I borrow this expression from the Spanish alienist José María Esquerdo (1842Esquerdo ( -1912)), who at the turn of the century used it in his description of a well-known murder case. On this author, see Huertas, 2003. 11. Esquirol is referring to earlier publications of [START_REF] Prichard | A Treatise on Diseases of the Nervous System: Part the First, Comprising Convulsive and Maniacal Affections[END_REF][START_REF] Prichard | A Treatise on Insanity, and Other Disorders Affecting the Mind[END_REF]. 12. 'De la non-existence de la monomanie'; originally published in 1854 and then reproduced in Falret (1864: 425-48). 13. On the controversy regarding the original description of this clinical presentation, as well as its signifi cance and consequences in the setting of alienistic thought, see Álvarez, 1999: 80 ff.

Acknowledgement

This work was carried out under Proyecto de Investigación nº BHA2003-01664 fi nanced by the Ministerio de Educación y Ciencia (Spain).