1. The summer of 1925 at Mas Potou
In the summer of 1925 Henri Ey (1900–1977) took his holiday and withdrew to the ancestral land of his family in Roussillon, at a place called Mas Potou in the foothills of the Pyrénées-Orientales. Clervoy’s biography records that the house was empty and furnished with the barest minimum. His provisions were rice and bacon, onions and garlic, and every day he cooked a Spanish rice in a large frying pan. He set a table and a chair facing the mountains, put his books, his notebooks and his pencils in front of him, and worked in deliberate isolation. What Ey worked at, in this hermit’s life, was a translation of the great book Bleuler had published in German fourteen years earlier.[1]
Eugen Bleuler (1857–1939) and his Dementia praecox oder Gruppe der Schizophrenien (1911) were, for all that it is among the most important works in the history of psychiatry, almost unknown in the French-speaking world.[4] At the point when Ey began his translation in 1925, the French learned journals had carried a total of three items bearing on Bleuler: a short summary by Trénel in the Revue de Neurologie in 1912; an analysis by Hesnard in the Journal de Psychologie in 1914 — Hesnard testified in later years that it was he who had first introduced Bleuler’s ideas to France, at the Le Puy congress of 1913; and a commentary by Eugène Minkowski in L’Encéphale in 1924. The severing of academic contact with the German-speaking world during the First World War had certainly slowed the diffusion. More important, however, is that French psychiatry harboured a fundamental reservation about Bleuler’s conceptual framework itself.
Ey studied the book with his teacher Paul Guiraud, copying summaries of it into a blue university notebook. “That is how I learned psychiatry,” he testified later. And in the course of the translation one phrase troubled him deeply and, in his own words, left a deep mark on his psychiatric training:
The cradle of many delusional ideas is the acute states. [T1]
Why this short sentence should have gripped Ey so hard can only be understood through the analysis that follows. But a point of accuracy must be entered here at the outset. Bleuler’s vieler — “many” — is not aller, “all.” Bleuler said that the cradle of many delusional ideas lies in the acute states; he did not claim that all delusions arise in that way. He acknowledged the existence of delusions formed chronically and insidiously, and his interest lay rather, under Freud’s influence, in the content and structure of delusion — complexes, wish-fulfilment, symbolic expression. What Ey drew out of the sentence was a reading of his own, in which Bleuler’s restricted description was systematized within the framework of Jacksonian dissolution. The meaning of that reading is taken up again in §10 below. The French translation of Bleuler was not published until 1993, and Ey’s abridged version circulated among a limited readership only in the mimeograph printed in 1945, with the collaboration of S. Follin, for the Cercle d’Études Psychiatriques.[1][2]
One further point is indispensable if Ey’s reasoning is to be followed. The sentence does not stand alone as an aphorism. It is the opening declaration of a section entitled “Genesis and fates of delusional ideas” (Entstehung und Schicksale der Wahnideen, S. 106), and over the eight pages that follow Bleuler produces case after case in its support. The theoretical keystone comes at once. Having distinguished two routes — delusions answering to affect in melancholic and manic states of mood, and the apparently mad welter of false representations thrown up in properly schizophrenic confusion — he adds that ideas of both kinds can outlive the state in which they arose, persisting thereafter, stripped of affective and intellectual connection, as “residual delusion” (Residualwahn, Neisser) in the “secondary” states.[T13] The very event Ey needed — a delusion born in the acute phase and carried over into the chronic one — is here given a name.
The cases fall into recognizable kinds. Four concern delusions formed within a dream and held after waking. An educated patient, capable of work and of society, built her delusional fable only in dreams, knew that she did so, and believed it all the same: one morning she complained that Bleuler had made her a child while she slept and cut it out of her arm, and when he protested that he could not be answerable for what she dreamt, not having in fact been with her, she replied “But then why do you come in my dreams?” — against which, he records, his powers of persuasion were exhausted (S. 111). A schoolmaster in financial difficulty woke one night wholly happy and related that he had dreamt his salary raised; the delusional idea persisted, and formed the prelude to a severe illness (S. 111). A catatonic patient “has dreams, and when she wakes the things stay as she has dreamt them” (S. 111). A paranoid patient who had met with something disagreeable — the rejection of her erotic aspirations, for instance — dreamt the opposite the following night and then held it fast as a delusion (S. 111). Beside these stand dreams passing over into twilight states: a catatonic woman dreamt on two successive nights that she was quarrelling with her husband, in reality a brutal man, speaking aloud with rigid, wide-open eyes; the same attacks then came on when she went to bed, and afterwards in the course of the day (S. 112). A footnote records the gradient in its purest form — a schizophrenic may for years hallucinate only in dreams, then equivalently in half-sleep, and only after further years in waking life (S. 356 n.).
A second group concerns persistence across episodes. Ideas formed in an earlier attack are as a rule taken up again in later exacerbations as though nothing had intervened, and not seldom prove on reappearance to have developed further, so that they must have gone on living, and growing, in the unconscious (S. 113). A patient who in her first attack had made a preacher a present of a Bible sent him, in her second attack twenty years later, a bill for fifty francs for it (S. 113–114). A third group bears on duration: ideas formed in acute attacks commonly fade with the excitement, but a mildly ill woman who at twenty had heard the promise that if she remained a virgin for thirty years more she would receive twenty thousand francs went, when the thirty years were up, to the bank to collect it (S. 112). A fourth bears on speed. It is nothing unusual, Bleuler writes, for a woman to be deluded first that she is loved, then that she is married, then that she is pregnant — and “this development takes a few weeks in a twilight state, in lucid patients often years” (S. 110). The acute state, on this account, is the place where the same content crystallizes at an altogether different rate.
This is the body of material Ey was summarizing into his blue notebook, and it explains why a single metaphor could trouble him for a lifetime. It should be said in the same breath that none of it establishes that all delusions arise so. Bleuler expressly declines to lay down the development of delusion out of indefinite “feelings” as a rule (S. 110), and notes that sharply formulated ideas may be the first symptoms of the illness, and that delusions may rise “primordially,” ready-made, out of the unconscious in wholly lucid people (S. 110–111).
2. Geneva–Lausanne, 1926: Bleuler against Claude
From 2 to 7 August 1926 the thirtieth session of the Congress of Alienist and Neurological Physicians of France and the French-Speaking Countries met at Geneva and Lausanne. The subject set for the psychiatric report was precisely “Schizophrenia.” Bleuler himself came from Zurich to deliver the principal report, and Henri Claude gave the French counter-report, “Dementia Praecox and Schizophrenia.” The proceedings were published the same year by Masson et Cie in Paris. What the present study has consulted and translated directly is the reprint published by L’Harmattan in Paris in 2001 — La schizophrénie en débat — which is in three parts, includes the discussion, remains readily available, and reproduces the text of the Masson original of 1926 in full.[11][12]
The opening words of Bleuler’s report are a candid measure of how deeply he understood himself to have been misunderstood in France:
When I read the French work on schizophrenia I have the impression of being a legendary personage, to whom words he never spoke and deeds he never performed are frequently attributed. [T2]
The core of the report is a declaration of the organic reality of schizophrenia:
In all pronounced cases of schizophrenia one finds anatomo-pathological modifications in the brain […]. Schizophrenia is thus not only a clinical entity but at the same time an anatomo-pathological entity. [T3]
Schizophrenia is a physiogenic affection, that is to say one with an organic basis. […] The organic origin of schizophrenia can today be demonstrated with all the evidence one could wish. [T4]
These declarations are the official confirmation of the position Ey had been reading out of Bleuler through the labour of translation in the Pyrenees. Of the occasion Ey remarked in later years that the French psychiatrists appear to have heard this from Bleuler’s own mouth to no purpose.
Bleuler added a piece of warm irony at French psychiatry’s expense. The French, he said, are certainly the best psychologists in the world — and we are the worst. He went on: the clinical tables French psychiatry had produced — catatonia, confusion, delusion of interpretation — are admirable as units of a different order, but must be distinguished in their principle of classification from a “group of schizophrenias” founded on anatomo-pathological and hereditary-biological grounds.
The discussion was lively. Minkowski spoke from the position of developing Bleuler’s concept of autism psychopathologically, as a loss of vital contact with reality. Anglade attacked Bleuler’s conception, calling it a vast territory occupied by a vast schizophrenic confederation. Laignel-Lavastine supported Bleuler from the anatomo-pathological side. Courbon’s objection to the “Congo example” is discussed at length in the companion paper, where its conceptual stakes belong; in brief, it questions whether an odd geographical association really demonstrates a loosening of associations at all, and the answer requires the intellectual-historical context set out there. Claude’s counter-report argued the need to distinguish “dementia praecox” from “schizophrenia,” and in its denial of an “acute schizophrenia” and its defence of the French classical tradition of diagnosis by course, it was in sympathy with Ey.[9]
The joint paper Ey and Guiraud had published in March of the same year — “Critical remarks on Bleuler’s schizophrenia,” in the Annales Médico-psychologiques — belongs to the same intellectual context as the Lausanne congress.[1][3] The core of their criticism had two points. First, the denial of “acute schizophrenia” and the defence of the tradition of diagnosis by course. Second — and here they were explicit in their support — the organic character of affectivity, that is, an organic aetiology of the affective disturbance. This doubleness is the signature of Ey’s reading of Bleuler.
The Lausanne congress was thus the historical moment at which the two axes of contrast that run through this whole study became publicly manifest. The first axis is the divergence between Ey’s organo-dynamic position and Minkowski’s phenomenological one. Against Minkowski’s rereading, at that congress, of Bleuler’s autism as a Bergsonian loss of lived time, Ey held to a reading that placed the organic basis of the loosening of associations at the centre. The divergence is not merely a question of how a text is interpreted; it must be understood as a difference over the epistemological foundation of psychiatry itself — whether mental phenomena are to be grasped organogenetically or described phenomenologically. The second axis is the contrast between the French dissolutional tradition and the phenomenological psychopathology of the German-speaking world. Karl Jaspers established the echte Wahnwahrnehmung, genuine delusional perception, as a primary phenomenon refusing causal explanation, and Schneider and Conrad developed that tradition into operational diagnosis.[14] Ey, by contrast, made the acute confusional state the fundamental manifestation of dissolution and grasped delusion as its fixation and crystallization. It is at the point where these two axes intersect that the specific problem of the French reception of Bleuler is concentrated, and the reader is asked to keep both in view through what follows.
3. The divergence from Minkowski
In the single year 1926, two readings that had set out from the same book of Bleuler’s diverged sharply. On the one side was the organogenetic reading of Ey and Guiraud; on the other the phenomenological reading of Eugène Minkowski (1885–1972). Minkowski reread Bleuler’s concept of autism (autisme) in the phenomenological direction of a loss of Bergson’s lived time (temps vécu), in La schizophrénie (1927).[10] In Ey’s eyes this hollowed out the very organogenetic framework Bleuler had valued most.
Ey’s later papers point out repeatedly how far Minkowski’s reading distorted Bleuler’s intention. His conviction that Bleuler’s doctrine is above all organogenetic and not psychogenetic did not waver across his life. Clervoy records that Ey, from the standpoint of organo-dynamism, directly criticized Minkowski’s treatment of the unconscious as a case governed by consciousness. And yet, by Clervoy’s account, on his weekly journeys to Paris on Tuesdays Ey would call on Eugène Minkowski, discreetly, every month. A sharp theoretical opposition did not amount to a human rupture. At the Foucault debate of 1971, too, where Ey criticized Foucault sharply, Minkowski behaved as a conciliator — a difference of bearing that lies on the extension of the divergence of 1926. This configuration, of a relation between teacher and pupil that is at the same time a head-on theoretical opposition, would divide the French reception of Bleuler in two.[1][2][3]
4. From mimeograph to essay: the lecture of 1940
The translation work of 1925 in the Pyrenees came out into public debate immediately afterwards, in 1926, and then for a time fell away from the centre of Ey’s concerns. With that accumulated reflection behind him, Ey gave in September and October 1940 a series of lectures under the title “Contemporary tendencies in psychiatry,” of which the last, “The conception of Eugen Bleuler,” was printed as a mimeograph in 1945. The text of Ey’s used in the present study is the one later included as an appendix to Viallard’s French translation of Bleuler in 1993.
A word about the existing Japanese scholarship. Ey’s essay has been published in complete Japanese translation, with detailed annotations by Prof. Ninsa Kageyama, as “Document 2” of Henri Ey’s Les hallucinations, vol. 5, Organo-dynamism 2 (trans. N. Kageyama and T. Abe, 2017).[13] Prof. Kageyama’s annotations constitute an extremely precise piece of documentary work, including collation against the German originals, notice of Ey’s free renderings, and identification of the paper of 1934 in which Ey first used the term “organo-clinical gap.” That paper does not, however, extend its examination to the contents of Clervoy’s biography of 1997; and the essay of Ey’s on which Prof. Kageyama’s annotations rest itself states, in Ey’s own note 8, that he has not touched on Bleuler’s Lehrbuch. The present study attempts a consideration whose field of view differs from that of these predecessors, by adding Clervoy’s biographical context, a detailed analysis of the Lehrbuch (carried out in the companion paper), direct quotation from the primary text of the Lausanne proceedings, an intellectual-historical and theoretical examination of the concept of the loosening of associations, and the testimony of Kapsambelis’s contemporary French textbook.
5. Ey’s reading: the group, the gap, the autism
5.1 A nosological concept: not an entity but a group of reaction-forms
The first of Bleuler’s achievements as Ey names them in the lecture of 1940 is a renovation of the nosological concept. Ey quotes Bleuler’s own words: “For convenience I use the word in the singular, but the group probably includes several diseases” (1911, p. 5). Viallard’s French renders the definition thus:
It is a matter of a group of psychoses evolving either chronically or in outbreaks, in such a way that no restitutio ad integrum can result. It is characterized by the dissociation of the psychic functions, by associative disturbances, by affective disturbances and by disturbances of contact with the world. [T5]
On Ey’s interpretation, the group of schizophrenias should be grasped as a genus rather than a species — a genus analogous to that other genus, the organic psychoses. A determinate structural form of psychopathological reaction: that is the proper sense of what Bleuler calls schizophrenia. Behind this recognition stands the principle of quantitative continuity argued in chapter A of the Lehrbuch:[5] schizophrenia is grasped not as a break with health but as the collapse, in a specific manner, of the organization of normal mental function.
5.2 Primary and secondary symptoms: the principle of the organo-clinical gap
The conceptual contribution of Bleuler’s that Ey regarded as most important is the distinction between primary symptoms (symptômes primaires) and secondary symptoms (symptômes secondaires). Bleuler explained the distinction by an analogy with osteomalacia (ostéomalacie): in the softening of bone, the direct sign corresponding to the process of decalcification is the failure of the bone’s resistance; the fractures and deformities are secondary signs, and for them to occur the intervention of an external factor is required. The formulation quoted in Ey’s mimeographed text may be verified in the French:
There are symptoms which correspond directly to the morbid process, others which are secondary […]. The primary symptoms are the necessary manifestations of a disease. The secondary ones may be absent or vary without the morbid process itself being modified at the same time. [T6]
Bleuler stressed that this primary/secondary distinction is compatible with an organic aetiology. From it Ey extracts the principle of the organo-clinical gap (le principe de l’écart organo-clinique). Between the primary, direct, “negative” action of the organic process and the indirect, mediated, “positive” symptomatology, there intervenes the whole thickness of the surviving mental activity. “The merit of this conception,” Ey wrote, “belongs in the first place to Bleuler.”
5.3 Autism: the deployment of an underlying mental activity
On Bleuler’s third principal concept, autism, Ey argues as follows. Autism is, so to speak, a secondary consequence of the splitting (Spaltung) of the personality. When the primary disturbance of association loosens logical constraint, and complexes come to be satisfied without difficulty, a mechanism operates on a pathological scale which is the same as the need common to all human beings — to seek in imagination the compensation for an impoverished reality. Bleuler himself had stressed the analogy between autistic thinking and dreaming: dream thought and autistic thought are, with our present means of investigation, essentially identical. The loosening of associations in the acute phase — the primary disturbance of cerebral process — prepares the cradle of delusion. And autistic mental activity nurses the delusion within that cradle.
6. Jackson, and the completion of organo-dynamism
6.1 Ey’s declaration
The meaning of Ey’s decision to put the discussion of Bleuler at the end of “Contemporary tendencies in psychiatry” is by now clear. For Ey, Bleuler was the purest embodiment of a third way — the pursuit of organogenesis (organogenèse) — that was neither mechanistic psychiatry nor pure psychogenism. The lecture closes with a single long paragraph. It is given here entire, since in one movement it delivers the verdict on Bleuler, states the programme Ey was about to undertake on his own account, and names the philosophical reason for both.
It is obviously not by chance that we end this survey of the present tendencies of psychopathology with Bleuler’s conception. We have followed in this exposition the path which seemed to us to lead from the less probable to the more probable, marking thereby our opposition to the mechanicist theories and our preference, among the anti-mechanicist doctrines, for the organo-dynamist theories as against the psychodynamist conceptions. Before undertaking on our own account the elaboration of a general psychopathology, the exposition of Bleuler’s work will serve as the model of our enterprise. His position, in particular before the problem of the relations of the physical and the moral, will become ours — as indeed it is implied in every biodynamist conception.
For if Cartesianism as it is generally understood posits the radical separation of thought and extension, of soul and body, and thereby permits many spiritualists to show themselves resolutely mechanicist in their psychiatric pathology, and materialists to regard the psyche as an epiphenomenon, it belongs to all anti-mechanicist conceptions to give themselves soul and body in a substantial unity which strips mechanicism of all meaning. In a monist doctrine of the relations of soul and body — as Bleuler saw very well in inclining, under cover of “mnemism,” toward vitalism — it is essential to regard the body as penetrated, vivified, organized, formed by a vital principle of direction, the very principle that comes to flower in the finality of psychic activity. This philosophical position is the only one that permits the establishment of a psychopathology which does not collide at every step with the relations of the physical and the moral posed in the form of the alternative “the organic” or “the psychic.” Bleuler’s organicism is, to our mind, the true one, equally distant from mechanicism and from pure psychogenism. We shall endeavour to turn it to our profit. [T7]
The two poles Ey was criticizing were, on the one hand, mechanistic organicism (organicisme mécaniciste), which would connect the anatomical localization of a lesion directly to a symptom, and on the other psychogenism (psychogénisme), which would explain every symptom from a mental cause. The common position of Bleuler and Ey lies in a doubleness: to admit the organic processes of the brain and yet to interpose, between their action and the symptom, the whole thickness of the surviving mental activity (toute l’épaisseur de l’activité psychique subsistante). Against Schneider’s operational turn, Ey held on to that doubleness as the epistemological core of psychiatry.
6.2 The Jacksonian frame
To complete theoretically the principle of the organo-clinical gap he had taken over from Bleuler, Ey summoned the neurological theory of dissolution of John Hughlings Jackson (1835–1911). Jackson’s basic principle rests on the recognition that the nervous system possesses a hierarchical structure built up, in the course of evolution, from lower levels to higher. A lesion dissolves that hierarchy from above and liberates the automatic functions of the lower levels. By transplanting the Jacksonian scheme into psychiatry, Ey gave a neurobiological foundation to Bleuler’s distinction between primary (negative) and secondary (positive) symptoms. He expressed it in the formula that consciousness is the organ of freedom occupying the summit of the pyramid of mind, and treated mental illnesses systematically as diseases of consciousness (maladies de la conscience). Clervoy calls him the French Jackson. For the organic basis of the loosening of associations too, the Jacksonian scheme supplies a coherent theoretical framework: the dissolution of higher executive control, the disintegration of frontal–temporal networks.[1][2]
7. Bonneval, Lacan, and chlorpromazine
The greatest stage on which Ey’s organo-dynamism was publicly interrogated within French psychiatry was the Bonneval colloquium of 1946. Its proceedings have been translated and published in Japanese in five volumes, and the details may be left to them. What should be recorded here is the state of the relation between Ey and Lacan, which Clervoy’s biography was the first to establish clearly. At the time of the split in the S.F.P., Lacan, having been refused the use of the lecture hall at Sainte-Anne, came directly to Ey’s home in the rue Delambre in Paris and asked him to join the new school. Ey listened for a long time, and declined. His words, preserved in a draft, run:
The friendship that binds us, to which you know I have always been faithful, rests precisely on the entire freedom of movement by which each of us has sought to become what we in fact are — that is, someone. And so we shall maintain our relation only at the level of our mutual affection and esteem.[1]
The organogenetic conviction was reflected directly in Ey’s clinical conduct as well. Among the facts Clervoy’s biography brought to light for the first time is Ey’s early introduction of chlorpromazine into psychiatry. Paraire, a Catalan by origin and a friend of Ey’s of long standing, was introduced to chlorpromazine by Laborit, and it was through Paraire that Ey used it experimentally at Bonneval — as two papers Ey himself published in L’Encéphale in 1955 and 1956 attest. The honour of the systematic study, and of the naming (neuroleptics), fell in the end to Delay and Deniker. The episode connects directly with the organicism of the loosening of associations: the pharmacological asymmetry by which chlorpromazine is effective above all against positive symptoms and insufficient against negative ones came, unintentionally, to endorse Bleuler’s distinction between primary and secondary symptoms on the pharmacological plane.
8. The legacy: from the Manuel to Kapsambelis
The two readings that diverged in 1926 led the French understanding of schizophrenia in two directions thereafter. Minkowski’s phenomenological direction made possible connections with Jaspers and Binswanger within the tradition of phenomenological psychopathology, and yielded rich results in the description of the patient’s subjective experience. Ey’s organo-dynamic direction, by way of the confrontation with Lacan, crystallized in the institutional tradition of French psychiatry: the centrality of the concept of disintegration (désintégration).
Between the divergence of Ey and Minkowski and the contemporary textbook of Kapsambelis there stands a decisive mediating link, in which Ey formulated for the world his own theoretical relation to Bleuler: the Manuel de Psychiatrie of Ey, Bernard and Brisset (1st ed. 1960; 5th ed. 1989, Masson). By Clervoy’s account the book went through a new edition roughly every four years to meet demand, and became so standard a text that in common parlance the authors' names stood for the title itself. Having spread throughout the French-speaking world, it was translated into Italian, Spanish, Portuguese and Japanese, and has been read particularly widely in Latin America and the Far East.[1] In it Ey places Bleuler’s theory of schizophrenia explicitly within the framework of Jacksonian dissolution. Three passages from the fifth edition (1989) may be quoted.[22]
Eugen Bleuler likewise, in his conception of schizophrenia, with his distinction between primary disturbances — negative on the whole — and secondary disturbances — positive on the whole, in Jackson’s sense — and in his later works of psychobiology (Die Psychoïde, 1925, and Mechanismus, Vitalismus, Mnemismus, 1931, etc.), forged a theory of mental illness which integrates itself into this movement. [T8]
The late psychobiological works Ey invokes there — Die Psychoïde and Mechanismus, Vitalismus, Mnemismus, and behind them the Naturgeschichte der Seele — are analysed in the companion paper.[6][7][8]
Such a process is more or less slow, progressive and deep; it is characterized, as E. Bleuler would have it, by a deficit syndrome [of dissociation, negative] — and by a secondary [positive] syndrome of the production of ideas, feelings and delusional activity, to which M. Bleuler attributes still greater importance. [T9]
The older authors discussed this point at length: it is inaffectivity, said Kraepelin; the disturbance of associations, said E. Bleuler; for Berze it was the hypotonia of consciousness; for E. Minkowski, the loss of vital contact with reality; and so on. [T10]
What this flat assertion has hitherto lacked is demonstration. That Bleuler’s tradition is in fact carried on by way of Ey in the contemporary French textbook can be established documentarily from chapter 27 of Kapsambelis.
In chapter 27 of the manual of clinical and psychopathological psychiatry edited by Vassilis Kapsambelis, “Schizophrenias of the active period,” the definition of the core symptoms of schizophrenia runs as follows:
These different terms derive from Bleuler’s conception (1911) of schizophrenia, as it was taken up by Henri Ey (1996) and the French school, incorporating the work of Chaslin (1912). In this conception they constitute a pathognomonic sign of this pathology, separating it from the systematized chronic delusional psychoses. […] these clinical manifestations are fundamental to all descriptions of schizophrenia, whatever its definition. They designate a defect of integration of mental, emotional and behavioural manifestations. [T11]
And on dissociation at the level of thought, the chapter continues:
At the level of thought, dissociation manifests itself as a disorder of thinking which realizes a loosening or a rupture of the associations of ideas. [T12]
The definition is decisive. Relâchement des associations d’idées is nothing other than the French expression of Bleuler’s Lockerung der Assoziationen. Kapsambelis names the source of the conceptual family — disintegration, dissociation, ambivalence, discordance — explicitly as Bleuler (1911), and records the route of its transmission as “Henri Ey (1996) and the French school.” Which is to say that the lineage Bleuler → Ey → contemporary French psychiatry can be confirmed as primary evidence within a current standard French textbook of psychiatry.
To a Japanese psychiatrist accustomed to the Schneiderian tradition, “disintegration” certainly appears a difficult concept. Where the operational criteria adopted by the DSM strongly reflect Schneiderian first-rank symptoms, the French concepts of disintegration and dissociation are underwritten by the logic of Bleuler’s two-layer structure — loosening of associations, then autism, then delusion. Kapsambelis also writes that continuity of care is what opposes the disintegration and collapse which are the principle of schizophrenia, and is a crucial condition of a good outcome (chapter 27, §6): “disintegration” functions, in other words, not as a merely descriptive term but as a central concept with therapeutic implications. This is the substance of the claim that Bleuler’s tradition has been institutionally preserved within French psychiatry.[19]
9. DSM-5, ICD-11, and a partial return
What the theoretical transmission from Bleuler to Ey means for contemporary psychiatry can no longer be captured by the modest formulation that it exerts an influence. It bears on the methodological foundations of contemporary psychiatric research and practice.
There is first the question of the diagnostic concept. Bleuler’s original insight that the group probably contains several diseases anticipated by a century the movement, from DSM-5 onward, toward the schizophrenia spectrum and dimensional diagnosis. While Schneider’s operational turn came to fruition in the institutional authority of the DSM, the legitimacy of Bleuler’s grasp of schizophrenia as a group of reaction-forms rather than a disease entity is today supported by independent evidence from molecular genetics — the identification, by genome-wide association studies, of genetic risk loci shared across schizophrenia, bipolar disorder, autism spectrum disorder, attention-deficit/hyperactivity disorder and major depression.[24]
Second is the junction between the loosening of associations and contemporary neuroscience, argued at length, and with its limits, in the companion paper: the concept Schneider dismissed as impossible to operationalize has re-entered the sciences by three distinguishable doors. There is a documented lineage, in the dysconnection hypothesis, which names Bleuler as the psychopathological ancestor of its own central idea; a partial operationalization, in the computational analysis of speech, which measures the semantic coherence Bleuler’s concept describes; and a structural analogy with the predictive-coding theory of Fletcher and Frith and the aberrant-salience theory of Kapur, whose own empirical foundations remain contested within neuroscience.[18][17][25] The third door, taken alone, licenses the word analogy and not the word demonstration.
Third, and this is the most important point, Ey’s organo-dynamism — the Jacksonian dissolutional theory in which the dissolving of higher neural function brings about the liberation of lower — finds a suggestive structural counterpart in contemporary neuroimaging. Functional MRI studies show an asymmetrical pattern in schizophrenia: prefrontal dysfunction, correlating with negative symptoms and cognitive impairment, and overactivity of the temporal lobe and limbic system, correlating with hallucinations and delusions.[23] (Whether prefrontal activity is uniformly reduced is task-dependent, and the finding is more accurately characterized as a dysfunction of higher cognitive control networks.) This is the neuroimaging counterpart of Bleuler’s distinction between primary (negative) and secondary (positive) symptoms; together with the pharmacological asymmetry by which chlorpromazine is effective against positive symptoms and insufficient against negative ones, it forms a pattern consistent with the Bleuler–Ey system — and a pattern consistent with a theory is corroboration of its shape, not proof of its mechanism. With that measure kept, the re-evaluation of Ey’s organo-dynamism is proceeding quietly, but steadily, at the front line of today’s neuroscience.
9.1 ICD-11
The foregoing has taken DSM-5 as its principal axis of reference. ICD-11 requires separate treatment, and the conclusion may be stated at once: ICD-11 embodies, by a route different from the DSM’s, a partial return to Bleuler’s tradition. The fact is not sufficiently recognized in Japan.
The first piece of evidence is the explicit survival, among the ICD-11 diagnostic requirements, of the loosened association. The evidence is best taken at first hand, from the World Health Organization’s own text: the third of the essential features of schizophrenia reads “disorganized thinking (formal thought disorder) (e.g. tangentiality and loose associations, irrelevant speech, neologisms) – when severe, the person’s speech may be so incoherent as to be incomprehensible (‘word salad’).”[26] Set against DSM-5’s replacement of formal thought disorder with the behavioural description “disorganized speech,” the ICD-11 formulation keeps the psychopathological term, and with it Bleuler’s concept. The German commentaries make the same observation.[21]
The second is ICD-11’s relativization of Schneider’s first-rank symptoms, which is legible in the architecture of the requirements themselves and needs no commentator to certify it. ICD-11 asks that “at least two of the following symptoms must be present ... most of the time for a period of 1 month or more,” and that “at least one of the qualifying symptoms should be from items a) to d)” — the four being persistent delusions, persistent hallucinations, disorganized thinking, and experiences of influence, passivity or control.[26] The Schneiderian phenomena are thus gathered into item d), where they stand as one qualifying class among four and can never by themselves carry a diagnosis; whereas ICD-10 had allowed a single clearly present symptom from its corresponding groups (a) to (d), which were precisely the Schneiderian ones, to suffice.[27] Neither the term first-rank nor Schneider’s name occurs anywhere in the ICD-11 clinical descriptions. Ey’s position — rejecting Schneider’s operational turn and asserting throughout his life the significance of the pathogenetic distinction between primary and secondary symptoms — may be said to have received no small confirmation from this change; the German commentaries draw the same conclusion.[21]
The third is the abolition of the classical subtypes and the introduction of a dimensional approach. ICD-11 abolishes the classical subtypes — paranoid, hebephrenic, catatonic — and introduces instead codes for the symptomatic manifestations of primary psychotic disorders — positive symptoms 6A25.0, negative symptoms 6A25.1, depressive mood symptoms 6A25.2, manic mood symptoms 6A25.3, psychomotor symptoms 6A25.4, cognitive symptoms 6A25.5 — each of which may be qualified by an extension code for severity: none (XS8H), mild (XS5W), moderate (XS0T), severe (XS25).[26] The abolition of the subtypes is a return to Bleuler’s concept of a group — the group probably contains several diseases — and the dimensional rating of severity can be read as the implementation, as a diagnostic operation, of Bleuler’s principle of quantitative continuity: the difference between patient and healthy person is only quantitative. The independent coding of positive and negative symptoms embodies at the classificatory level Bleuler’s distinction between secondary (positive) and primary (negative) symptoms, and the principle of the organo-clinical gap Ey extracted from it.
The comparison of DSM-5 and ICD-11 yields a clear picture. DSM-5 retains a functional-impairment criterion (criterion B) and a six-month criterion of long course (criterion C), and in giving priority to operational reliability stands closer to the Schneiderian tradition. ICD-11 retains a one-month criterion, abolishes the privilege of Schneider’s first-rank symptoms, and preserves the psychopathological language of loosened associations, thereby standing closer to Bleuler’s tradition. The French concept of disintegration — which Kapsambelis describes explicitly as a lineage running through Bleuler and Ey — may be said to have gained, under the new language of ICD-11’s symptom specifiers and dimensional severity, a more congenial institutional environment than before. The spirit of the proposition Bleuler declared at Lausanne in 1926, that schizophrenia is not only a clinical entity but at the same time an anatomo-pathological entity, is rising, a century later, to the level of the international classifications, by way of ICD-11’s dimensional and spectrum approach. The chapters on schizophrenia in the German ICD-11 commentaries of van der Broek and Hölzel offer Japanese-language psychiatry a convenient route into this material;[20][21] but every claim made in this section rests on the World Health Organization’s own diagnostic requirements, quoted above at first hand, and the reader who wishes to check them need go no further than that text.[26]
10. Conclusion: a double creative transformation
Ey’s essay on Bleuler — distributed as a mimeograph to a few psychiatrists in 1945, introduced to Japan in Prof. Kageyama’s annotated complete translation, yet unexplored from the standpoint of the textbook — has here been confirmed genealogically, along with the primary sources of the Lausanne congress, by a contemporary witness in Kapsambelis. But what this study finally establishes is that the French reception of Bleuler was not a faithful transmission but a double creative transformation.
Return, at the end, to the problem announced in §1: Ey’s reading-in of the sentence about the cradle. In Ey’s organo-dynamism, psychosis is the hierarchical dissolution of consciousness (dissolution progressive de la conscience), and the acute confusional or oneiric state (état onirique/confusionnel) is the essential manifestation of that dissolution. Delusion in the chronic phase is understood as the fixation and crystallization of this acute dissolution. For Ey, in other words, the sentence about the cradle was an intuitive statement of Bleuler’s in perfect accord with Jacksonian dissolution.
But this must be recognized as an interpretation of Ey’s own, systematically reinforcing along Jacksonian lines a restricted description of Bleuler’s — many delusional ideas. The phenomenological psychopathology of the German-speaking world does not share it. Jaspers, in the Allgemeine Psychopathologie (1913),[15] described genuine delusional perception: the experience in which an abnormal meaning is suddenly conferred upon a normal perception is not a product of a clouded consciousness but a primary phenomenon (Primärphänomen) refusing causal explanation. Schneider’s Wahnwahrnehmung stands in the same tradition,[14] arising primarily in its own right rather than deriving from acute confusion. Klaus Conrad’s Apophänie, described in Die beginnende Schizophrenie (1958)[16] — the stage at which a pathological self-reference (Bezugserlebnis) arises in ordinary perception — is likewise understood as a transformation of the meaning of perception against a background of tension and anxiety, not of acute confusion.
How deliberate Bleuler’s restriction was can be established from a wholly separate place in the same book. In the section “Relations of schizophrenia to dream” he states the analogy between dream and schizophrenia in its strongest form — “the analogy becomes identity in the cases where the patients treat their dream hallucinations as real ones, form their delusional ideas in the dream and hold to them when awake” (S. 356). And then, in the very next breath, he enters the same qualification a second time.
[…] all that is certain is that delusional ideas — but not all of them — are formed in dreams, and that dreamlike and schizophrenic-autistic thinking are, for our present means of investigation, essentially identical. [T14]
Vieler at S. 106; aber nicht alle at S. 357. Two hundred and fifty pages apart, Bleuler enters precisely the same restriction. Once might be an oversight; twice must be a deliberate reserve. Even in the place where he presses the kinship of dream and delusion hardest, he forecloses the generalization to “all.” That Ey’s reading is a reading-in is thereby put beyond doubt.
There is an irony to add. In that same section Bleuler turns to the French, who had erected “oneiric deliria” into a class of their own and wished to treat it as an aetiological group among the intoxication psychoses; the prototype of that class, delirium tremens, he judges on closer inspection not to admit of comparison with a dream at all (S. 357). Yet the framework through which Ey would later read Bleuler — the acute confusional or oneiric state as the essential manifestation of the dissolution of consciousness — belongs precisely to the French tradition from which Bleuler is here taking his distance. Ey read Bleuler with the instrument Bleuler had set aside. The thesis of this study is compressed into that single fact.
The configuration of Bleuler’s reception in France is thereby fully visible. Minkowski read Bleuler’s concept of autism in the phenomenological direction of Bergson’s lived time. Ey read Bleuler’s sentence about the cradle in the direction of Jackson’s theory of dissolution. Both these readings-in took the organogenetic core of Bleuler as their point of departure, and developed it in wholly different directions — the one phenomenological and existential, the other neurological and dissolutional. The phenomenological category of primary delusion, which the German-speaking world preserved, was in effect discarded by Ey’s Jacksonian reading. It is in these two hermeneutic conversions that the French reception of Bleuler underwent its own transformation.
To describe accurately the price and the yield of that conversion is the condition of a fair verdict in the history of psychiatry. And what must be stressed in the end is that Ey’s organo-dynamism, having passed through this transformation, gave psychiatry the theoretical framework that resonates most deeply with the results of contemporary neuroscience. Bleuler’s insight — that the definition of man as the being possessed of logos, held since Aristotle, is supported by the cognitive foundation of contextual control over association — was never stated by him in those terms; but by way of the mediation of Ey’s organo-dynamism it lives on in the clinical practice of French psychiatry today, and independent lines of contemporary work — measurement of the incoherence of speech, the dysconnection literature that names Bleuler for itself — have come near enough to it to make its neurobiological legitimacy an open question rather than a closed one. The era of a diagnostic psychiatry that dismissed Bleuler’s theory as impossible to operationalize is, at this moment, under pressure to think again.
Texts
Originals of the passages quoted in translation. Bleuler, Dementia praecox oder Gruppe der Schizophrenien, Leipzig/Wien: Franz Deuticke, 1911; French translation by A. Viallard, Paris: E.P.E.L./G.R.E.C., 1993. Bleuler, “La Schizophrénie,” Rapport de psychiatrie, XXXe Session, Genève–Lausanne, 1926 (repr. Paris: L’Harmattan, 2001). Ey, “La conception d’Eugen Bleuler,” in Bleuler (Viallard trans.), 1993. Ey, Bernard & Brisset, Manuel de Psychiatrie, 5e éd., Paris: Masson, 1989. Kapsambelis (dir.), Manuel de psychiatrie clinique et psychopathologique de l’adulte, Paris: PUF, 2012, chap. 27.