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On the Origin of the Clinical Standpoint in Psychiatry: By Dr Ewald Hecker in

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History of Psychiatry, 15(2): 201–226 Copyright © 2004 SAGE Publications

(London, Thousand Oaks, CA and New Delhi) www.sagepublications.com
[200406] DOI: 00.1177/0957154X04044598

Classic Text No. 59

On the Origin of the Clinical Standpoint

in Psychiatry
by Dr Ewald Hecker in Görlitz

Introduction and translation by

ABDULLAH KRAAM*

Ewald Hecker (1843–1909), a friend and disciple of Karl Ludwig Kahlbaum

(1828–1899), was a relentless advocate of his teacher’s psychiatric nosology.
This paper is an early manifesto of their ideas and sets the context for the
following publications, namely Hecker’s seminal paper on hebephrenia to be
published in the same journal and in the same year (1871) and Kahlbaum’s
catatonia published in 1874. Their idea that age of onset and time course of an
illness, together with close clinical observation, helps to delineate disease forms
out of the mass of confusing psychiatric symptoms proved to be one of the most
important paradigm shifts in middle to late nineteenth century psychiatry. This
had a strong influence on Kraepelin’s dichotomy between dementia praecox and
manic depressive insanity, and thus on our modern notions of schizophrenia and
bipolar illness.

Keywords: Hecker; Kahlbaum; nosology; paradigm shift

Introduction
This paper by Hecker1 was published in 1871 in one of the most important
and widely read journals in nineteenth-century Germany: Archiv für
pathologische Anatomie und Physiologie und für klinische Medizin. It has to be
remembered that this journal, which was founded by Virchow2 in 1847, was
read far beyond the German-speaking world. Articles published here would

* Address for correspondence: Dr A. Kraam, The Bethel Child and Family Centre, Mary Chapman
House, Hotblack Road, Norwich NR2 4HN, UK. Email: abdullah.kraam@norfmhc-
tr.anglox.nhs.uk
15(3) Classic 59-Hecker 6/1/04 4:57 PM Page 2

000 HISTORY OF PSYCHIATRY 15(3)

have been discussed among clinicians and academics from virtually all
medical specialities on both sides of the Atlantic. The second factor to
consider is that many of them were multilingual – the dominance of the
English language was still in the future.
This 1871 volume of the Virchow’s Archiv is of particular relevance as it
contains two articles by Ewald Hecker: ‘On the Origin of the Clinical
Standpoint in Psychiatry’ and his famous ‘Die Hebephrenie’, in this order.
The order of the publication could not have been deliberate, but makes
sense. The former should be seen as a manifesto of Kahlbaum’s nosology,
setting the context for the seminal paper on hebephrenia, and three years
later for Kahlbaum’s on catatonia.
What were the most burning psychiatric issues of middle to late nineteenth-
century German psychiatry? Two important and influential psychiatric
concepts of that time, namely ‘degeneration theory’ and ‘unitary psychosis’
provided the framework for most discussions. It had become clear for Hecker
and his teacher and friend Kahlbaum3 that the rigidity of these concepts was
proving as an obstacle for advances in psychiatric classification. But powerful
and eminent psychiatrists like Schüle,4 who advocated Morel’s degeneration
theory, and Neumann5 and Griesinger,6 proponents of ‘unitary psychosis’,
were fiercely guarding these paradigms. Although Kahlbaum’s own classi-
fication (1863) was received with respect, it failed to have the impact it
should have had, partly because it was too revolutionary. The density of
Kahlbaum’s style, and the fact that he was at the fringe of academic life as a
director of a private asylum in Görlitz, undoubtedly contributed to his
isolation from the psychiatric élite of his time (Kraam and Berrios, 2002a).
Enter Ewald Hecker who in 1871 was working in Kahlbaum’s private
asylum in Görlitz as his deputy. A friend and disciple of Kahlbaum, Hecker
had qualities which the former lacked, namely the ability to convey complex
ideas in an accessable form. Later Hecker would use this talent to lecture and
publish widely on psychiatric issues for the public.
The mixed reception of Kahlbaum’s classification of psychiatric disorders
had left its author disappointed, and the managerial duties of his asylum did
not allow him, the perfectionist, to expand on his ideas. Hecker’s article ‘On
the Origin of the Clinical Standpoint in Psychiarty’ should be seen as an
exegesis of Kahlbaum’s central argument that mental disorder is a longitudinal
process and thus age of onset and natural history are central to diagnosis. It is
tempting to compare this paper with Kraepelin’s 1887 lecture in Dorpat on
‘The Direction of Psychiatric Research’. Both presentations evaluate critically
the current psychiatric notions and suggest alternative paradigms which will
form the basis of psychitric classification in years to come. It was not by chance
that Kraepelin acknowledged Kahlbaum’s contribution to empirical clinical
research as opposed to the speculative psychiatry of others.
Hecker identifies two main schools of psychiatry: those who believe that
most psychiatric presentations reflect as many disease entities, and those who
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CLASSIC TEXT NO. 59: INTRODUCTION 000

come to the opposite unitarian conclusion like Neumann, advocating a single

psychiatric disease which merely undergoes different stages. Hecker criticizes
both positions and advocates a middle ground which allows the existence of
disease forms in psychiatry by removing the condition that, unless the
pathological-anatomical basis of a disease is known, it should not be named
as such. Detailed and precise clinical observation are sufficient for Hecker to
identify psychiatric disorders and to differentiate them from symptoms.
Hecker regards melancholia, mania, confusion, etc., as symptoms, comparing
them with headache or cough, which need further investigation to be
correctly diagnosed. He introduces the idea that the time course of the illness
is an important factor in determining its nature. ‘Paralysis of the insane’
serves as prime example of a psychiatric disease which can be diagnosed by
its typical course and the grouping of the symptoms into a singular disease
entity.
Hecker acknowledes that he is presenting Kahlbaum’s ideas and describes
the current contribution as an introduction to a series of clinical essays by
Kahlbaum which unfortunately never materialized.
Hecker illustrates his point by presenting vignettes of two patients with
melancholic symptoms. He then demonstrates how the time course of the
illness helped to distinguish between the first case of general paresis of the
insane by revealing more differentiating features, while the second case
proved to be due to anaemia and responded to iron supplementation. Hecker
concedes that there is such an entity as true melancholia but he advocates a
new denomination for it and suggests Kahlbaum’s ‘dysthymia’ in order to
end ‘the unfortunate confusion’. Likewise, Hecker tries to introduce further
categories of Kahlbaum’s classification including vesania typica, catatonia
and the paraphrenias.
Hecker continued to defend and advocate Kahlbaum’s classification of
psychiatric disorders beyond this essay, and throughout his career, with the
same passion until the last official opportunity in his obituary of Kahlbaum
twenty-eight years later (Hecker, 1899). Only elements of Kahlbaum’s
grouping of psychologocal disorders were going to survive into the next
century (katatonia, hebphrenia) in a different form than either he or his pupil
Hecker had envisaged, incorporated (gridlocked?) into Kraepelin’s psychiatric
classification. The latter admitted that he got the idea – which led him to
regard dementia praecox as a distinct disease – from Hecker’s way of thinking.
He could have said Kahlbaum’s, but to differentiate between them in this
context would have been like distinguishing between Plato and Socrates.

Notes
1. Ewald Hecker (1843–1909): studied medicine in Königsberg; disciple and friend of
Kahlbaum and worked as his deputy in Görlitz until setting up his own private asylum in
Wiesbaden. For a detailed biography, see: Kraam and Berrios (2002b).
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000 HISTORY OF PSYCHIATRY 15(3)

2. Rudolph Virchow (1821–1902): German pathologist and a founder of cellular pathology;

professor at the University of Würzburg (1849) and professor and director of the
Pathological Institute, Berlin (1856); prolific contributor to almost all branches of
medicine including the introduction of sanitary reforms in Berlin; founder of the Archiv
für pathologische Anatomie und Physiologie und für klinische Medizin in 1847; published
widely – Die Cellularpathologie (1858, tr. 1860), etc.
3. Karl Ludwig Kahlbaum (1828–99): studied medicine in Königsberg, Würzburg, Leipzig
and Berlin; director and owner of the private asylum in Görlitz; proposed his own classi-
fication of psychiatric disorders; few, but important, publications such as Die Katatonie.
For a short biography in English, see Bräunig and Krüger (1999); see also Hecker (1899).
4. Heinrich Schüle (1840–1916): studied medicine in Freiburg and Vienna; director of the
asylum in Illenau; co-editor of Allgemeine Zeitschrift für Psychiatrie; the German theorist of
degeneration, wrote an important textbook of psychiatry and introduced the term
dementia praecox into German psychiatry.
5. Heinrich Neumann (1814–84): studied medicine in Breslau; various medical and
psychiatric positions until promotion to director of the asylum in Breslau (1874); wrote a
well known textbook of psychiatry; the most radical advocate of unitarism.
6. Wilhelm Griesinger (1817–68): studied medicine in Tübingen and Zürich; worked in
Paris; assistant for medicine at the clinic in Tübingen; Professor of Medicine at the same
clinic; later Professor of Psychiatry in Kiel, Cairo and Berlin; saw psychiatric disorders as
disorders of the brain.

References
Bräunig, P. and Krüger, S. (1999) Images in psychiatry: Karl Ludwig Kahlbaum, M.D.
1828–1899, American Journal of Psychiatry, 156: 989.
Hecker, E. (1899) Nekrolog über Kahlbaum. Psychiatrische Wochenschrift, No. 14, 125–8.
Kahlbaum, K. L. (1863) Die Gruppirung der psychischen Krankheiten (Danzig: A. W.
Kafemann).
Kraam, A. and Berrios, G. E. (2002) On Heboïdophrenia, by K. L. Kahlbaum. Classic Text No.
50 (translation, with an introduction). History of Psychiatry, 13 (2), 197–208.
Kraam, A. and Berrios, G. E. (2002) Ewald Hecker (1843–1909), by K. Wilmanns. Classic
Text No. 52 (translation, with an introduction). History of Psychiatry, 13 (4), 455–65.
Kraepelin, E. (1887) Die Richtungen der Psychiatrischen Forschung [Lecture at the University of
Dorpat] (Leipzig: Vogel).
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CLASSIC TEXT NO. 59: HECKER (1871) 000

Classic Text No. 59

On the Origin of the Clinical Standpoint

in Psychiatry
by Dr Ewald Hecker in Görlitz

There is possibly no medical specialty which is generally more remote from

the practising physician than psychiatry. Quite a few consider it as virtually
not belonging to the medical sciences, considering it, with a somewhat
haughty disregard, as pure philosophical speculation. However, anyone who
has penetrated deeper into our science and has acquainted himself with the
progress which psychiatry has made, particularly in the last decades, will
concede how unfair this verdict is. He will acknowledge that the drive, which
is gripping our psychiatrists nowadays, is definitely a rational one, carried
forward by the same seriously scientific dedication which created the most
beautiful achievements in the fields of somatic pathology. After suffering for
centuries from the admittedly correct accusation by other pathological
disciplines of losing its way in fruitless philosophical over-subtleties, psychiatry
has taken a strong stand in the field of science through the empirical method
in the last decades; and, in fact, one has to admire how quickly and greatly
this branch of the medical sciences (whose exploration is far more complicated
than any other discipline) has blossomed, considering the relatively small
number of doctors who choose psychiatry as their specialty and thus can
contribute to its advances. Psychiatry is not yet on a par in all aspects with
somatic pathology, but one should make allowances, considering that its
formal development is still stagnant. Precisely these circumstances lead to the
wrong conclusion, which underpins the view of those who take only
superficial note of psychiatry. Valuable and hard-earned experience has been
only slightly productive; large numbers of single observations still lack the
format to make them generally accessible and generally understandable.
This difficulty is demonstrated by the fact, well known to every psychiatrist,
that the commonly accepted names for psychiatric illnesses, i.e., melancholia,
mania, insanity, confusion and dementia [Blödsinn], are completely unsuitable
and insufficient, b e c a u s e t h e s e n a m e s d o n o t d e s i g n a t e t r u e

* Published in Archiv für pathologische Anatomie und Physiologie und für klinische Medizin, 52,
203–18 (1871). Hecker’s use of expanded letters for certain terms and names, and for emphasis,
has been followed.
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000 HISTORY OF PSYCHIATRY 15(3)

d i s e a s e f o r m s b u t t e m p o r a r y c o n d i t i o n s . Transferred to
somatic medicine, they would correspond to a classification of diseases of
headache, chest pain, abdominal pain, etc. Melancholia is a symptom like
headache, which can occur in a variety of different diseases, at times more
important, at other times less so, at times singular, at other times replaced
with chest pain, abdominal pain (corresponding to mania, insanity) or even
transformed into them. Just as constraining the somato-pathological symptom
groups into this classification must lead to great confusion, or prolixity and
awkwardness at the least, thus completely preventing a definite and general
statement about the prognosis and treatment, in psychiatry, too, the same
difficulty influences the generally used classification of psychological
disorders.
We do not have disease forms in psychiatry (apart from the only form, the
so called “progressive paralysis of the insane”, which I am going to talk about
below). In order to ascertain prognosis and treatment, every single case, after
being categorized with difficulty and quite often randomly and arbitrarily
under one of the following groups: melancholia, mania, etc., has to be re-
examined individually every time by the psychiatrist, who will obviously find
the categorization insufficient. A certain diagnosis requires an infinite
number of single case experiences, because other observations and experiences
of such a case have not been summarized in a suitable form in order to serve
as a comfortable starting point. Of course, in somatic pathology, too, we have
to examine every single case in its individuality despite the existing disease
forms. But here we have to consider each time a much narrower range of
facts, since a general ascertainment of prognosis and treatment of the case
has already been given to us by the diagnosis. We are on different ground
from the start when we are evaluating the headache, once we have recognized
it as part of typhoid compared to the evaluation of a headache which we have
diagnosed as frontal sinusitis.
Due to a lack of such a classification, the assessment of a single case is
greatly hampered in psychiatry, and one can achieve certainty only after a
detailed, lengthy observation. The practical physician, who has neither time
nor opportunity for these observations, will find it almost impossible to
penetrate deeper into psychiatry; should he, however, believe wrongly that all
psychiatry consists of is making the diagnosis of melancholia, mania, etc.
(hardly necessitating any medical knowledge), then it must appear to him as
if we were lagging further behind in our science than is actually the case.
Of course, much is lacking in psychiatry: namely, the foundation of clearly
delineated disease forms with pathological-anatomical basis giving us insight
into the relation between cause and effect. But the somato-pathologists
cannot blame us for this, since in a large number of empirically based disease
forms (cholera, typhoid, Morbus Basedow, etc.) they themselves cannot
prove the close connection between the primum mobile and the clinical
symptoms.
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CLASSIC TEXT NO. 59: HECKER (1871) 000

But psychiatry is lacking more: as already mentioned, it generally lacks

(apart from one form), the very foundation of empirical and clinical disease
forms. – There are, of course, special reasons for this, which are of general
interest and warrant further investigation and exploration.
Initially we encounter one opposing opinion, which is propounded by
N e u m a n n (Pöpelwitz) in his intelligent textbook of psychiatry1 and surely
has other followers. N e u m a n n disposes of the entire classification of
mental illness by stating: “There is only one type of mental disorder. We call
it madness [Irresein]. – Insanity does not possess different forms but different
stages; they are called: insanity [Wahnsinn], confusion [Verwirrtheit], and
dementia [Blödsinn].”
There is no doubt that this assumption, if it can really be sustained, would
mean the end of all uncertainty. But when we consider the psychiatric cases,
we soon arrive at the conclusion that only some of the mental disorders will
fit into that schema, and that this part in itself presents with such a quantity
of different diseases as to make it impossibe to try to lump everything
together. And even Neumann has contradicted his own statement quoted
above, from page 167 of his textbook, by declaring the general paralysis of
the insane as a special disease form (page 129), saying: “I have never seen
the mental condition described above without stated paralysis and vice versa
and I am therefore in the position to recognize a stable d i s e a s e f o r m in
this complex, which I call paralysis.” – Thus, we do not find a solution for
the problems of this opinion, and most psychiatrists would admit that
different forms of mental disorder do exist. “But, they say, we are not in a
position to propound any, since we do not know their anatomo-pathological
basis. The current state of our taxonomy and classification is indefensible
and provisory, we know that very well, but as long as the anatomico-
pathologic basis is missing, we do not have a choice but to create another
proviso and we do not see an advantage in this.”
I am far from denying that a completely correct and final foundation of
disease forms can only be based on anatomo-pathological facts. But we know
that the subtle anatomy and physiology of the brain are still in a dismal state
and that the pathological anatomy of the psychoses up to now has offered us
extremely few hard facts. We will have to gather material for a long time until
clarification and distinction become possible. But the longer we continue to
use the old classification and taxonomy of psychiatric material, the longer
this will be postponed. – No wonder we find in “mania” at times this and at
times that changes, a whole myriad of changes, in the brain. Would it be any
different if we were to trace the anatomo-pathological substrate of “abdominal
pain”?
The right path for psychiatry to follow has been paved by somatic
pathology: long before the changes of the organs could be demonstrated with
the knife in the hand, certain disease forms were propounded according to
empirical, clinical observation. One was already familiar with the clinical
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000 HISTORY OF PSYCHIATRY 15(3)

picture of typhoid, scarlet fever and cholera before their anatomo-patho-

logical substrate, the latter still partly unknown. One did not hesitate, despite
the risk of having to perform a separation and further distinction at a later
stage, to propound the disease forms according to empirical observation and
designate them, and no one is going to blame the pathologists, for example,
for once having declared consumption as a unitary disease, because
pathological anatomy teaches us now to discern two pictures (tuberculosis
and cheesy pneumonia). Why, then, in psychiatry do we want to wait until
we have found an anatomo-pathological basis instead of nominating and
propounding disease forms on the basis of detailed and precise clinical
observation? We will obviously achieve the nomination of these forms only
gradually; out of the general and large symptom complexes more restricted,
delineated and even more clearly identifiable fields crystallize, presenting
themselves as special forms. It is the lowest level of empirical observation,
where we, for example, choose cough as an apparently prominent symptom
followed by nomination and designation of a group of illnesses. A more
detailed observation considering other symptoms as well as the whole course
shows quickly that the group consists of completely different disease forms,
mixed at random, where in any one of them cough can be present or absent
without being of special significance; it so happens that it possibly occurs
only during a special stage in the whole course of the disease. To cut a long
sentence short, pathology makes a notable step forward by considering the
whole course of the disease and propounding the clinical forms of bronchitis,
pneumonia and, initially, consumption. – Considering the apparent adherence
of psychiatry to the classification into melancholia, mania, etc., it seems to be
in the stage where “cough” is designated as a special disease form, although
each psychiatrist will never really be content with this diagnosis. According
to the system it uses, psychiatry still occupies this position, and we have to
insist that it must be seen to leave this lower step and make a step forward.
Instead of forcing the case observations into frames of temporary psycho-
logical conditions (difficult enough for every psychiatrist), we have to
propound real disease forms and name them, and in order to do that we have
to keep an eye on the whole course of the disease when observing patients.
Furthermore we should not take a predefined classification principle as a
guideline or propound different forms according to presence or absence of a
single symptom, but we have to consider in our unbiased observation all
symptoms, psychological as well as somatic, and question all other aspects of
the aetiology in particular. This is the only way psychiatry can approach its
final destination, namely the definition of disease forms on an anatomo-
pathological basis. Even if a large number of disease forms, defined through
clinical observation, are split up further, we have temporarily made a major
step forward and gained practical advantages. Just as in somatic pathology
where prognosis and treatment became infinitely more secure after the
clinical disease forms fever, typhoid fever, etc., branched off from the general
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CLASSIC TEXT NO. 59: HECKER (1871) 000

symptom constellation fever, the definition of clearly demarcated

psychological disease forms, established according to the principles outlined
above, will greatly inform our diagnosis, prognosis and therapy, and help us
to shed the current uncertainty.
The only real disease form, which has gained entry into psychiatry,
provides the best evidence for this: the so-called progressive paralysis of the
insane. This form, which validates itself as a real clinical disease entity by
displaying a peculiar and special course, as well as the unification of a range
of psychological appearances, allows us to make an almost confident diagnosis.
It is not the single symptoms of grandiose delusion or the paralysis which allow
us to propound this disease form, but the grouping of these symptoms into a
clinical picture and the peculiar course which the disease runs as a whole. It is
possible – and I almost believe it – that a more concise and intensive clinical
observation teaches us to divide the hitherto single disease entity of “progressive
paralysis” further into different forms, something possibly supported by the low
congruence of the anatomo-pathological facts. I would happily say that this is a
clear advancement of our science. I know, however, that some voices will object
to this “splitting” of the material (as they are calling it). I would like to argue
against them, with V i r c h o w ’ s authority, by quoting from the lecture
“On Newer Developments in Pathology” held at the Frankfurt Natural
Scientists Meeting [Frankfurter Naturforscherversammlung]. It almost seems as if
V i r c h o w had said those words with psychiatry in his mind. By speaking of
the establishment of empirical disease forms (cholera, typhoid) where the
evidence of their aetiological unity is still missing and thus describiing this
establishment as provisory, he rejects the charges of the other branches of
science against pathology with the following words: “On the contrary, I
believe that there exists in every other natural science the same method of
initially assigning certain things to an empirical group and giving it a name
while reserving the search after the true origin, the interpretation of this
empirically discovered fact, for a later time. It certainly is an immense,
sometimes excessive, advance to reach the stage of defining these empirical
groups, and I believe it is right for the advancement of pathology to declare
publicly without letting a year pass by: this is a new disease; wherever we cut
segments from the large circle of facts and summarize them into a specific
body of knowledge, I say, as long as we can do that, one has to acknowledge
that we immediately target our aim like the others, that we ask more and
more questions, which should be solved through continuing observation by
our generation and the coming one.”
Psychiatry is further away from this aim than somatic pathology. We are
far from providing evidence of a new disease every year. On the contrary, this
endeavour meets a certain resistance because on the one hand one gets
caught in the paradox: there are no different types of mental disorders, and
on the other hand one remains passively content with the old nomenclature
because of lack of anatomo-pathological forms. To expose this resistance as
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000 HISTORY OF PSYCHIATRY 15(3)

unjustified and even as damaging to the advancements of science was the aim
of the lecture, which will be followed by our next objective, namely the
proposition of c l i n i c a l disease forms. There is hardly any psychiatrist who
has not clearly felt this claim to be a pium desiderium; that the latter
does not have to remain unfulfilled has already been demonstrated by
K a h l b a u m ’ s attempt in 18632 (in his publication: “The Grouping of the
Psychological Disorders, etc.” framework for an empirical-scientific basis of
psychiatry as a clinical subject) to gather the existing psychopathological
material and to group it into clinical disease forms according to the features
stated above. In his lectures at the University of Königsberg, K a h l b a u m
has further elaborated on the diseases, which are only briefly demonstrated
here, and I have to acknowledge with gratitude that he left part of the
material gathered for me to work on and to publish. This paper, which is
something like an introduction, will be linked to a series of publications of
clinical essays by him.3
Finally, however, with particular reference to non-specialist colleagues, it
seems important to deliver a short overview of the psychiatric material,
relying on the old classification, in order to characterize exactly the differ-
entiation between the old and the newly desired standpoint.
The notion of melancholia has been conceptualized in completely different
ways by different authors and is not easy to outline (1).
Generally, the main complaint is said to consist of “the pathological
dominance of a painful, depressive, negative affect in a psychologically
painful state” (G r i e s i n g e r ). It is known to all psychiatrists that such a
depressive mood can occur in a variety of, well, one can almost say in all
psychological disorders, and a comparison with fever comes to mind, which
accompanies all sorts of somatic disease forms, too.
Without doubt fever is a very important and notable symptom, allowing
occasionally a quite certain conclusion to be drawn from the characteristics
of its occurrence regarding the origin of the underlying disorder. However, it
is not so much the current picture of the fever which allows us to draw this
conclusion, but its course, its sequential raise and fall and its exchange with
fever-free times. – The case is very similar in melancholia. This can occur as
a primary or end stage (disorder), as anintermittent symptom and lastly as
the definitely obvious and chronic sign of the disturbed psychological
functions in various disease forms, and it is not so much the special character
of the melancholic delirium which gives us the accurate picture of the
existing disorder, but rather the type and mode as well as the timing and

(1) N a s s e ,4 for example, defines melancholia as a constraint of the soul particularly in the
faculty of imagination [Vorstellungsvermöge] and identifies it with insanity [Wahnsinn].
N a s s e ’ s Zeitschr. f. psych. Aerzte. 1818. S. 46.
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CLASSIC TEXT NO. 59: HECKER (1871) 000

modification of its occurrence in connection with the other psychological and

somatic symptoms.
The general paresis of the insane, which we have already mentioned as a
disease form, very often shows a melancholic aspect that is without doubt of
significance, leaving us, however, with complete uncertainty regarding the
true disease process if considered in isolation. The importance of this insight
is shown in an example where we compare two apparently quite similar
pictures of melancholia with clearly different underlying disease process, and
thus an unfavourable prognosis in one case and a favourable one in the other.
Case 1. The patient, assessor v.G., is sitting around, staring with an
anxious expression into space, only from time to time looking up shyly; after
a brief greeting he excuses himself with a whiney voice, saying that “he has
been acting irresponsibly towards us, being responsible for the demise of the
whole asylum, having committed a serious injustice, having swapped keys,
etc.” He would know that I have already made arrangements regarding him;
I would behave completely different towards him—his coffee had been
brought to him much later than usual.—The next day a similar behaviour:
“All sorts of signs emitting from the train; the trains would travel back and
forth only because of him; he has been accused of stealing, two civil servants
from town are already here to arrest him—he is constantly hearing (voices)
outside the door: ‘he has to go, he has to go!’ etc.”
There is no doubt that we have here a complete picture of a melancholic
state, quite similar to the following one, which, like the above, has been
literally extracted from our records.
Case 2. The patient (Mrs K) is sitting still, her face distorted with pain
(prominent nasolabial folds), not responding to greetings. Only after
prolonged prompting she starts speaking in a quiet moaning voice: “She has
been excluded from eternal bliss, she once stole a pair of gloves from a shop,
which did not belong to her, now she has been accused of having stolen
money, too—the gossip about this would go round outside. She is
responsible for all misfortune; she is responsible for the ladies in the garden
being without a coat, etc.”
The similarity of the melancholic state between the example just reported
and the first one is quite astonishing but, nevertheless, how different are the
disease forms these two cases belong to!
The history in the first case reveals that he became suddenly ill with an
anxiety state of sudden onset three months ago, displaying conspicuous signs
of so-called grandiose delusion (unspeakable feelings of bliss, shopping
addiction, etc.); he was admitted to the asylum, where he suffered severe
bouts of rage, the euphoric exaltations expressing themselves in excessive
joyous gayness, project-planning and utter over-estimation of self. He claims
to have experienced the manifestation of God, thinks he is a reformer, chosen
by God, wants to become an opera singer; he destroys his belongings and
anything else, which he gets hold of “in order to process it”. He wants to
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000 HISTORY OF PSYCHIATRY 15(3)

turn one frock into three, build a whole cardboard ceiling out of a quarter
sheet of newspaper. To cut a long story short, he is relentless in producing
proper so-called grandiose delusional ideas while displaying excess over-
activity. Examination reveals obvious difference of the pupils, both appearing
abnormally constricted, and fibrillary twitching and trembling of the
outstretched tongue; speech has a strangely buzzing quality, the apparent
lisping resulting in frequent fragmentation of single letters and syllables;
wobbly, somewhat heaving walk, unsteadiness while standing with eyes
closed. – Thus, there could not be any doubts about the diagnosis “general
paresis of the insane with grandiose delusion”. The same was ascertained
even more following a sudden apoplectic incident with severe one-sided
cramps of the right side of the body in complete unconsciousness. – The
paralysis of the whole right side of the body, which had remained following
the incident, resolved after only three days; the patient woke up gradually
after only 24 hours, even achieving a state of cognitive clarity. The latter
lasted for approximately 14 days and was followed by the melancholic state
described above, which persisted with some interludes for two months, being
terminated by yet another apoplectic incident and superseded by the old
raging behaviour with exquisite grandiose delusions. Following various
fluctuations and single, rather pure remissions, another apoplectic incident
resulted in sudden death (2 years after the onset of the disease).
The s e c o n d c a s e shows a different course. The patient, being very
anaemic, nervous and irritable some time before the outbreak of the illness,
was displaying ill temper after various incidences and began exhibiting an
increasing amount of sadness accompanied with inner restlessness and anxiety.
She withdrew completely from housework, lost all interest, neglected her
husband and children, whom she had loved with tenderness so far, and kept
saying that she had made everybody unhappy. When admitted to the asylum
she produced the delusional ideas described already, which had the character
of melancholic dysphoria [Verstimmung] throughout. The examination did
not reveal any abnormality apart from noticeable signs of anaemia and
slightly disturbed digestion. The use of ferrum, amaris and opium as well as
a nourishing diet led to a gradual reduction of the inner restlessness; the
patient expressed her delusional ideas less often, became more aware of her
environment, her physical condition improved and now, after 8 month, she is
approaching recovery.
So, despite the nearly identical melancholic state, what a difference not
only in course and outcome but certainly in the actual nature of the disease,
too! – Of course, the psychiatrist as specialist is well able to differentiate
between these cases; but the non-specialist will be easily confused by the
diagnosis, which he initially has to make after his observation of melancholia
as the dominating symptom. B r o s i u s 5 has described this relationship
in detail in a very remarkable essay “The Melancholic Element in
Insanity” (Der Irrenfreund, Year XI, 1869.N. 8 ff.). He says among other
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CLASSIC TEXT NO. 59: HECKER (1871) 000

things: “Encountering a case of melancholia in an individual whose

antecedents are unknown will prevent the immediate recognition of its
significance, its nosological character. It could be a simple, primary self-
directed melancholia, it can be the precursor of rage [Tobsucht], of paralysis
of the insane, the symptom of another brain disease ending in dementia
[Blödsinn], it can be melancholia on an imbecile basis, part of the
presentation in hysteria, epilepsy, etc., or the element of circular insanity”.
“My question is, what does it actually mean, when a doctor makes the
diagnosis of “melancholia”, and most patients are sent with this diagnosis to
the asylum.
This diagnosis is justified and warranted in only one case. B r o s i u s
speaks in the quotation above of the “simple, primary self-directed
melancholia”, where the dysphoria of the affect [trübe Verstimmung des
Gemüths] has to be regarded as the only existing psychological and generally
essential symptom permeating the whole course of the disease. This
melancholia χατ εξοχην6 (a later essay will deal with its diagnosis) is
characterized mainly by its very favourable prognosis and furthermore never
transforms into other types, just as typhoid never transforms into measles,
thus remaining melancholia until the end of life or leading towards
remission.
Considering the general connotation of melancholia for a (certain)
condition, and in order to avoid the continuous confusions and doubts I
would regard it as advisable to give the “simple primary self-directed
melancholia” a special name, thereby particularly favouring the older
denomination “d y s t h y m i a ” for this d i s e a s e f o r m , which has been
revived by K a h l b a u m .
Some people will ridicule this denomination in psychiatry by obviously
ignoring its importance. It is sufficient to point out how central and
important the new term of cheesy inflammation (in contrast to tuberculosis)
introduced by V i r c h o w has been for somatic pathology. It is only the new
nomenclature that has brought to an end the unfortunate confusion in this
field. – There is an urgent need in psychiatry for a new nomenclature, which
allows differentiation between the m a n i f e s t a t i o n s [Zustandsformen] so
far, remaining under the old name, and the true clinical d i s e a s e f o r m s .
But, after this short diversion, lets turn to another manifestation, i.e.,
mania. – Everything said about melancholia is even more accurate for mania.
Mania is understood as a condition of enduring excitement and exaltation of
the will, “which is easily associated with an increased sense of self-assurance
[Selbstempfindung] and self-confidence”; it is meant to split into two
directions, rage [Tobsucht] and insanity (G r i e s i n g e r ).
Whoever has lived in an asylum, even for a short time, knows that almost
any mentally ill person can develop fits of rage regardless of the disease form
(this is not the right place for a discussion of disease forms that are
exceptions to the above). A sizable number of those with fits of rage suffer
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000 HISTORY OF PSYCHIATRY 15(3)

from general paresis of the insane, and the majority of the cases of mania
mentioned in textbooks belong to this disease form. A form of mental illness
regarded by N e u m a n n as the only one that exists provides another
contingent of rage or mania, as important as the former, a form undergoing
the typical consecutive stages of melancholia, mania, confusion [Verwirrtheit]
and dementia [Blödsinn] unless remission is achieved beforehand, which is
rather likely considering the not completely unfavourable prognosis in this
form. This has been called vesania typica by K a h l b a u m because of its
typical course, and it displays certain aberrations relating to the more or less
complete existence of the stages or the interchange between those
distinguished as typica praeceps, simplex and recurrens.
Another form of mental illness, which is accompanied by peculiar tensions
in the muscular system as well as some cataleptiform conditions, exhibits a
stage of mania besides a more or less sharply defined melancholic stage (the
presence of the latter leading to the proposition of melancholia attonita
without f u r t h e r c o n s i d e r a t i o n o f t h e c o u r s e ). This disease form,
called c a t a t o n i a by K a h l b a u m and briefly described in Innsbruck at
the meeting of Natural Scientists, is associated with a middling prognosis and
a peculiar characteristic course including a series of nosologically important
symptoms leading to a clear delineation as a disease entity.
Mania is also a very common symptom in the large group of mental
diseases called “d y s p h r e n i a s ” by K a h l b a u m , where following and in
connection with extra-cerebral processes a particular course and a peculiar
symptom complex can be observed. The fits of rage of epilepsy sufferers,
mania puerperalis, alcoholism, etc., belong here.
Finally, we observe the intermittent occurrence of fits of rage in disease
forms, which develop following a transitional period in the biological
development, in forms, called by K a h l b a u m neophrenia (idiocy),
hebephrenia (a disease form associated with the development of puberty),
paraphrenia senilis (the specific mental disorder occurring as a result of the
involution of the brain in old age) and, last, the paraphrenia hypnotica
originating in sleep. After what has been said, what, then, can the common
diagnosis “mania” mean?
The situation is not much different in the case of “insanity” [Verrücktheit],
a condition, whose definition is as yet even more uncertain than for those
described. The majority of the disease forms mentioned under mania can
undergo a stage of insanity. Sander(2) has been quite right in delineating
recently a so-called “original insanity” (originäre Verrücktheit),7 which matches
Kahlbaum’s “paranoia”. It will be obvious from the preceding explanations

(2) Arch. f. Psych. Vol. I. P. 387 “On a Special Form of Primary Insanity, by Dr. W i l h e l m
S a n d e r .”
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CLASSIC TEXT NO. 59: HECKER (1871) 000

that we need here a special name in order to differentiate between disease

form (Krankheitsform) and manifestations (Zustandsform).
C o n f u s i o n [Verwirrtheit] is, like insanity [Verrücktheit], a temporary
stage between mania and dementia [Blödsinn], being part of those conditions
with psychological weakness [psychische Schwächezustände] and observed in a
large number of diseases, which transform into idiocy.
The forms insanity [Verrücktheit], confusion [Verwirrtheit] and dementia
[Blödsinn] as manifestations [Zustandsform] have themselves been hardly
noticed so far and described only in general terms despite offering a rich
source of characteristic symptoms, which would allow a diagnosis of a
disease form from those end stages that have led to them.
For a long time, inborn dementia, idiocy, has been described as a special
form; but even the dementia forms that follow various psychological diseases
differ from each other. The dementia of “paralysis” is different from the one
of vesania typica, and again the latter can be distinguished from the one in
hebephrenia by its distinct symptoms, just as it is often possible to draw
conclusions from the type of scar on a wound and say whether the wound
resulted from a cut or from burning, etc. The evidence for this claim is going
to be delivered by the following essays, which are intended, as this one is, to
justify the clinical standpoint in psychiatry as defined by Kahlbaum’s
grouping.

Translator’s notes
1. Hecker refers here to Neumann, 1859.
2. Kahlbaum, 1863. For an introduction and an English translation of excerpts, see Berrios,
1996.
3. Sadly this did not turn out to be the case. It is not clear why. Was Kahlbaum too tied up
with the managerial tasks of his private asylum in Görlitz? Was he embittered about the
lack of recognition of his classification and the fact that he was never appointed a
university professor of psychiatry? Hecker (1899) states in his obituary how he repeatedly
encouraged Kahlbaum to publish his material or at least allow him (Hecker) to submit it.
Had Hecker not overcome Kahlbaum’s resistance to publication in the case of “Die
Hebephrenie” the latter concept would possibly be of mere historical interest rather than
part of DSM and ICD.
4. Christian Friedrich Nasse (1778–1851): studied medicine in Halle and was Reil’s
favourite student; editor of the Zeitschrift für psychische Aerzte, which was published from
1818 to 1822; Professor of Medicine and director of the Medizinische Klinik Bonn; had
four sons who all became professors except one who was President of the Province Rhein
(Rheinprovinz); coined the term “Irresein” (insanity). For a detailed discussion, see:
Leibbrand and Wettley, 1961; Nasse, 1818.
5. Caspar Max Brosius (1825–1910): studied medicine in Greifswald, Bonn and Prague;
founded a private asylum in Bendorf in 1857; initially co-editor and from 1878 sole editor
of the psychiatric journal Der Irrenfreund (1859–98); his translation of Connolly’s “The
Treatment of the Insane without Mechanical Restraint” in 1859 led to a debate between
traditionalists and advocates of a more humane treatment of the mentally ill. See also
Brosius, 1869.
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000 HISTORY OF PSYCHIATRY 15(3)

6. Greek, meaning par excellence.

7. Wilhelm Sander (1838–1922): studied medicine in Breslau and Berlin; assistant physician
at the Charité in Berlin under Horn, Griesinger and Westphal; Habilitation in psychiatry
and forensic medicine; 1887 director of the asylum in Dalldorf. ‘Primäre Verrücktheit’ was
later called primary paranoia if its origins could be traced to childhood. See Sander,
1868/69.

Translator’s references
Berrios, G. E. (1996). Die Gruppirung der psychischen Krankheiten, by K. L. Kahlbaum,
Part III. Classic Text No. 25 (translation, with an introduction). History of Psychiatry, 7,
167–81.
Brosius, C. M. (1869) Das melancholische Element im Irresein. Irrenfreund, 11, 113–21,
129–38, 145–56, 161–7.
Hecker, E. (1899) Nekrolog über Kahlbaum. Psychiatrische Wochenschrift, No. 14, 125–8.
Kahlbaum, K. L. (1863) Die Gruppirung der psychischen Krankheiten und die Eintheilung der
Seelenstörungen. Entwurf einer kritisch-historischen Darstellung der bisherigen Eintheilungen und
Versuch zur Anbahnung einer empirisch-wissenschaftlichen Grundlage der Psychiatrie als
klinischer Disziplin (Danzig: A. W. Kafemann).
Leibbrand, W. and Wettley, A. (1961) Geschichte der abendländischen Psychopathologie,
Vererbung und Entartung (Freiburg, München: Verlag Karl Alber), ‘Der Wahnsinn’ (pp.
399–402).
Nasse, C. F. (1818) Über die Benennung und die vorläufige Eintheilung des psychischen
Krankseyns. Zeitschrift für psychische Aerzte, 1, 17–47.
Neumann, H. (1859) Lehrbuch der Psychiatrie (Erlangen: Ferdinand Enke).
Sander, W. (1868/69) Ueber eine spezielle Form der primären Verrücktheit. Archiv für
Psychiatrie und Nervenkrankheiten, 1, 706–29.

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