The birth of the bipolar disorder

Eur Psychiatry
(1995)
0 Elsevier, Paris
1
10, l-10
Historical
The birth
of the bipolar
review
disorder
P Pichot
24, rue des Foss~s-Saint-Jacques,
(Received
17 May
75005
1994; accepted
Paris,
18 May
France
1994)
Summary
- The history of the description
by Jean-Pierre
Falret of circular insanity, the origin of our present day bipolar disorder, is
presented as well as the claims of priority
raised by his colleague Jules Baillarger.
A detailed account is given of the long-lasting
controversy
which has often given rise to biased judgments
about the respective
roles of the two psychiatrists.
It is shown that the
clinical concept was an expression of Falret’s views about the nature of mental disorders and that, through the influence these views had
on future nosological
systems, the apparently
purely picturesque episode corresponds
to a landmark in the history of psychiatry.
depression
/ bipolar
REBIRTH
disorder/history
/ Falret
INTRODUCTION
OF THE BIPOLAR
I Baillarger
:
DISORDER
The year 1966 saw the publication of two books
which were to change profoundly the views held
until then on the nosology of the depressive illness. One was entitled About Aetiology and Nosology of the Endogenous
Depressive
Psychoses
and
Psychoses (Penis,
(Angst, 1966), the second A Study of Bipolar
Unipolar
Recurrent
Depressive
1966). The two authors, who worked independently, one in Zurich, Switzerland, the other in
UmeB, Sweden, demonstrated, mainly by genetic
arguments, the need for a revision of the unitary
concept of manic depressive insanity established
by Kraepehn at the end of the preceding century.
The classic view of the German author (Kraepelin,
1909-1915) postulated the existence of a single
disease, later named manic depressive psychosis,
whose aetiology and pathogeny, although not yet
demonstrated, was considered to be a biological
process probably of genetic origin, hence, the term
endogenous borrowed by Kraepelin from Moebius.
The disease expressed itself in various clinical
manifestations, in one or several exclusively manic
or depressive episodes or in a combination of both,
but, whatever the variety of expressions, the basic
unity of the nosological category was absolute.
Endogenous manic depressive psychosis was the
core of the mood disorders and stood in contrast to
the other affective entities, especially to depression
considered to be of psychogenic origin, which had
names such as reactive or neurotic depressions.
Kraepelin’s
system did not escape opposition,
however. There existed in Germany a tradition
hostile to his tendency to describe extremely broad
categories, as expressed in the division of the psychoses in only three entities, manic depressive psychosis, dementia praecox - renamed schizophrenia
by Bleuler - and paranoia, a trend accentuated by
one of his successors, Kurt Schneider (1987), who
incorporated
paranoia into schizophrenia.
The
school of the “dividers” began with a contemporary of Kraepelin, Wemicke, continued with his
pupil Kleist, and was carried on in the middle of
the present century by Karl Leonhard, professor of
psychiatry at the East Berlin University,
who
expanded the views of his former teacher in a
series of publications (Leonhard, 1972). For the
basic dichotomy of the psychoses, he substituted a
large number of independent
diseases, within
schizophrenia as well as within manic depressive
psychosis. Leonhard’s work provided the inspiration to Angst and Perris. The results of their independent research rapidly convinced psychiatrists
of the existence, within manic depressive psychosis, of three separate entities: two unipolar forms
exclusively depressive or manic, and one bipolar
2
P Pichot
in which both types of episodes occurred in the
same patient. Subsequently, it was shown that unipolar manic patients could not be genetically distinguished from bipolars and therefore manic
depressive psychosis was simply dichotomized. In
1980, the third edition of the Diagnostic and Statistical Man& of Mental Disorders (DSMIII) was
published (American Psychiatric Association,
1980). DSMIII
introduced
many innovative
changes such as the use of diagnostic criteria and
multi-axial
diagnosis. However, the most important was the so-called a-theorism, which was conceived as a refusal to define a category by its aetiology when the causal relationship was obscure or
not empirically demonstrated. Since this was the
case in most traditional categories, DSMIII used
purely symptomatic definitions, and the categories
became syndromes. Manic depressive psychosis,
now termed major affective disorder, was subdivided into bipolar disorder and major depression.
The authors left the possibility of using, as a subsidiary notation, the obsolete term melancholia for
cases of depression exhibiting the symptoms classically associated with endogeneity but, in their
purism, they stressed that “since the term endogenous implies to many, the absence of precipitating
stress... it... is not used in DSMIII.”
The principles
of DSMIII have been adopted by the World Health
Organization in the tenth revision of the Zntemational Classification of Diseases (ICD 10) (Organi-sation mondiale de la Sante, 1993). ICD 10 takes
an even more extreme position than DSMIII. Schematically, it opposes the bipolar affective disorders
to all other depressive states. The latter are subdivided in a simple - not to say simplistic - way
according to their evolution in single episodes,
recurrent episodes, or persistent states and according to their intensity: light, moderate, severe, and
severe with psychotic features. Although some of
these possible combinations are not used (persistent depressive disorders are always described as
of light intensity), one retains the impression that,
within the mood disorders, only one well-defined
category exists, namely, bipolar disorder, and that
cases of depression which do not belong to it are
not susceptible of a “scientific” subclassification,
hence, the appeal to the elementary criteria of evolution and intensity. The authors recognize in their
foreword that “the relations between aetiology,
symptoms, underlying
biochemical
processes,
response to treatment and outcome are not yet sufficiently understood to allow their classification”
and conclude that “(the classification) presented
here is put forward in the hope that it will at least
be acceptable”. We now return to the period, more
than 150 years ago, for the birth of the bipolar disorder, when Jean-Pierre Falret considered that,
outside of this well-defined category, the depressive states were waiting for a satisfactory classification.
THE DRAMA: STAGE, ACTORS, SITUATION
AT THE BEGINNING
OF THE PLAY
Before recounting the drama of this birth, we
will set the stage, present the main actors, and
summarize the situation at the beginning of the
play.
Two locations in Paris constitute the stage: the
Hospice of La Salp&ribre and the Imperial Academy of Medicine. The mental patients of Paris, Zes
ali&% as they were called, were confined in three
public institutions: the Hospices of La SalpCtribre,
Bicetre, and Charenton. The latter, originally
a
religious foundation, had a peripheral position, both
geographically - located relatively far from Paris and administratively
- managed directly by the
Ministry of Health - whereas La Salp&ribre and
Bicetre, which had been created by Louis XIV in
the middle of the 17th century, were an integral part
of the Parisian hospital system. La Salpkiere was
reserved for women, Bicetre for men and they were
primarily hospices for the senile paupers, but served
also as asylums for the mentally ill who were confined to special wards (or sections). In addition, they
included small general medical and surgicaJ departments, some of which were later to become famous:
Charcot studied hysteria in a nonpsychiatric medical
department of La SalpCtribre and Broca gave the
first description of aphasia in the surgical department of Bic&re. Probably because La Salpttriere
was closer to the center of the city than BicCtre, its
prestige was greater and the position of “alienist of
La Salp&riere” was the most sought after. The rules
for their selection varied during the 19th century,
but were most of the time based, following the
French custom, on competitive examinations (concows). Many of these alienists supplemented their
income by owning and directing private psychiatric
clinics. Since the French Revolution had suppressed
all the medical societies under royal patronage,
Ring Louis XVIII decided in 1820 to found the
Royal Academy of Medicine. It was a selected body
of the best medical and surgical specialists who
advised the government in matters of public health
and who presented in appropriate surroundings their
latest discoveries. The offkial denomination varied
according to the vicissitudes of French political life:
originally Royale, it became Nationale in 1849 during the Second Republic, Zmperiale in 1853 with
Bipolar
Napoleon III, simply Acade’mie de Medecine in
1871 after the fall of the emperor, and is now again
Nationale since 1948. The number of members
elected by their peers (the nomination being confirmed by the Head of State) was about 80 in 1850.
They met every Tuesday afternoon to discuss
administrative matters and to hear lectures given by
the members, the proceeding of the meetings being
published in a bulletin.
The Dramatis Personae of our story are two alienists of La Salpetribre, Jean-Pierre Falret and
Jules Baillarger, whose parallel lives can be told in
a Plutarchian manner. Falret was born in 1794 in
the south of France, Baillarger 15 years later in the
Loire Valley. Both came to Paris to study medicine and became pupils of Pinel’s successor,
Esquirol. Esquirol, who began his career in 1811 at
La SalpCtri&re, had become in 1825 head physician
of Charenton which he reorganized and directed
until his death in 1840. By his informal clinical
teaching and by his publications, the most important being his epoch-making book Of Mental Diseases Treated With Respect to Medicine, Public
Health and Forensics (1938), he had trained prac-
tically all the psychiatrists of the following generation. Both Falret and Baillarger served as residents
under him, Falret at La SalpCtribre in 1813, Baillarger at Charenton in 1832. In 1818, Falret
defended his inaugural thesis, in which he criticized Pinel’s concept of “manic suns de’lire” in a
way already evoking his later criticism
of
Esquirol’s nosography. Baillarger’s
thesis, presented 18 years later, on the pathological basis of
cerebral hemorrage, testified to the precision of his
observations but also to his interest in biological
topics which later reappeared in his research on
general paralysis. After becoming medical doctors,
both earned their living in private practice. Falret
founded with his colleague and friend, Felix Voisin, a private clinic in Vanves, near Paris. Baillarger who, during his residency,
had been
employed as secretary to the aging Esquirol and
had been his assistant at the private clinic he
owned at Ivry, became, after the death of his
teacher, co-director with Moreau de Tours of the
institution
now owned by Esquirol’s
nephew,
Methivier. In 183 1, at the age of 35 years, F&et
was nominated physician to the psychiatric “section” of La SalpCtriere reserved for the feebleminded but, in 1841, took over the psychiatric
admission unit - “First Section of the Division of
the Insanes”. In 1840, Baillarger also became head
of a psychiatric section of the hospice. Four such
positions had been filled by competitive examinations and he had won the first place. Both psychi-
disorder
3
atrists had been extremely active scientifically
since the beginning of their medical career. By
1822, Falret had written a book On Hypochondriasis and Suicide and Baillarger had published studies on the structure of the brain (1840, 1847).
Their merits had been recognized by their election
to the Academy of Medicine, in 1828 and in 1847,
respectively.
Moreover,
Baillarger
rapidly
acquired a powerful position among the French
alienists through the foundation in 1843 of the
journal Annales medico-psychologiques,
for many
years the leading French psychiatric publication.
He was also the driving force in the creation, a few
years later, of the Societe medico-psychologique.
We shall now turn to the situation at the beginning of our story, as far as it concerns the reigning
ideas about the nosology of mental diseases, and
especially of the depressive illnesses. Since antiquity, insanity was seen psychopathologically
in a
mainly intellectual perspective. The mental disorders were “disturbances of understanding” (troubles
de l’entendement).
All the faculties of the mind
could be simultaneously affected in the “general
delirium” (d&ire general) or mania. Alternatively,
the disorder could be restricted to a part of the cognition, consisting as Pine1 still formulated it, in a
“delirium directed exclusively upon one object or a
particular series of objects”, the rest functioning
normally (Pinel, 1801). This was his “partial delirium” (delire partiel) or melancholia. (The French
language uses a single word, delire, the English and
the German, two: delirium and delusion or Wahn. In
the older literature, it was customary to use only the
term delirium. Whereas delire g&z&-al corresponds
more to the present English delirium, delire par-tie1
has to be seen as a delusional syndrome restricted to
a limited number of themes.) In practice, de’lire
gffneral or mania included all the acute states with
agitation, whatever their nature - not only our
present manias, but also schizophrenic excitement
and organic confusional
states, at that time
extremely common. The diagnostic d&ire partiel or
melancholia applied to delusional depressive syndromes, but also to any nonexcited, relatively
chronic state with delusional ideas, such as found in
our present day schizophrenia and paranoid disorders. It was known that in melancholia the delusional ideas were often associated with “dejection,
gloom and a tendency to despair” as Pine1 formulated it, but the quality of mood was of no real
importance, and Pine1 himself described cases of
“melancholia
with exaltation and/or happiness”
(mdlancolie avec contentement).
Esquirol introduced a change of perspective. He disregarded the
primary intellectual basis of classification and gave
4
P Pichot
an important role to “affectivity”
(les passions).
Melancholia appeared to him as a conglomerate of
heterogenous entities. He proposed to divide it into
two main groups: the first was the “partial delirium
provoked by a sad, debilitating or oppressive passion”; the second included all the remaining dklires
purtiels defined, as the old melancholia, by the existence of primary delusions. He proposed to abandon
the term melancholia because of its ambiguity and
to introduce two neologisms: lypemunie (from the
Greek lupeb, I am sad) for the first category and
monomanie for the second category. Esquirol’s conception amounted for a complete reversal of psychopathological
theory: in lypemanie “le dflire
prend sa source dans le dhordre
des affections
morales qui rt?agissent sur l’entendement”
or, in
modem terms, in depression the mood disorder is
the primary phenomenon, the delusional ideas are
secondary effects. Although the term lypemunie met
with little success, Esquirol’s
framework
was
adopted and henceforth served as a definition for
melancholia. The evolution of the concept of mania
has been less clear, but there has also been a tendency to eliminate progressively from it the febrile
confusional states and the acute delusional states,
and to restrict it to its present limits.
Act one: 1850-1851. The “forme
circulaire”
The first, short act of the play begins on Wednesday 15 May 1850 at La Salp&iere. With an introductory conference
on the clinical approach in
psychiatry,
Falret begins a series of weekly lectures on “the general symptomatology
of mental
diseases”. Psychiatry was not officially taught at
the medical school - such teaching was first done
in 1862 by F&et’s pupil, Lasbgue - but Falret was
following
the example of Esquirol. Since there
were ten weekly lectures, it can be surmised (with
high probability) that the tenth lecture was delivered on 24 July, just before the August vacation.
The lectures were published, in irregular installments, by the Gazette des Hfipitaux, beginning 21
May and ending on 29 January 185 1. This issue
contained the tenth lesson (Falret, 1851), which
included twelve lines on “a special form (of insanity) we call circular”, described as “the alternation
of a period of excitement with a period, usually
longer, of depression (uffaissement)“.
Act two : 1854-1890. “Folie
“Folie a double forme”
circulaire”
versus
The second act, much longer, takes place four
years later, in 1854. “At the request of friends and
pupils”, as F&et explained, the texts printed in the
gazette were reprinted in book form by the publisher Baillibre (Falret, 1854). Falret had revised,
corrected, and expanded the original lessons. The
previous twelve lines had become one and a half
pages beginning with the statement: “The transformation of mania into melancholia, and vice versu,
has always been mentioned as an accidental fact,
but it has not until now been realized that there is a
category of insanity in which the succession of
mania and melancholia manifests itself in a nearly
regular manner. We have considered this fact to be
of sufficient importance to become the basis of a
special form of mental disease we call circular
madness (folie circulaire)
because the course of
this type of insanity runs in a repetitive circle of
pathological
states... separated only by rational
intervals of fairly short duration.” The expression
folie circulaire
was printed in italics. The book
appeared in the bookstores in January 1854. The
exact day cannot be ascertained;
it is given by
Baillarger as 25 (Baillarger, 1853-54b, p 401) and
as 20 (Baillarger, 1854, p 387). On 31 January, the
Academy of Medicine, which had recently been
styled Imperiale, held its weekly session, during
which Baillarger presented a lecture (Baillarger,
1853-54a) entitled “A note on a type of madness
whose attacks (a&s)
are characterized by regular
periods of depression and excitement”. In the text,
which ran for 12 pages of the bulletin, he briefly
quoted Esquirol and Guislain, described six cases
at length, and proposed the “provisional
name” of
“folie ci double fonne” for “a type of madness different from monomania, melancholia and mania”.
The typical phase consists of two periods, one of
depression, the other of excitement, in immediate
succession, the switch being either sudden or more
gradual. But the so-called free interval between the
two periods does not exist, as demonstrated by a
careful observation.
For Baillarger
the manic
period is a “reaction” to the preceding depression
and is proportional to it. F&et is not recorded as
having joined the discussion of Baillarger’s
lecture, as was his right. But, at the next session, on
7 February, he presented officially to the library of
the Academy a copy of his recently published
book and, after the secretary had read the proceedings of the preceding session, he requested to
speak. This scene was described in the bulletin
(Anonymous,
1853-54)
as follows:
“Mr Falret
requests to speak about the Proceedings and about
the work of Mr Baillarger, in order to establish his
claim to priority in the description of similar facts,
under the name offolie circulaire, and he begins to
read a text on this subject. But on the objections of
Bipolar disorder
several members, Mr Falret is requested to continue his lecture at the following
session, the
agenda not allowing time for a discussion”.
Another and more picturesque description, written
the following day (Latour, 1854) tells that it was
the size of the manuscript in the hands of Falret
which motivated the Academy to postpone the lecture. The real confrontation between Falret and
Baillarger, therefore, took place on 14 February.
Falret continued his lecture (1853-54a) entitled
“On circular madness, a form of mental disease
characterized by the successive and regular reproduction of the manic state, the melancholic state,
and a more or less prolonged lucid interval”. He
began by ascertaining that Baillarger’s new variety
of illness corresponded to facts which he, Falret,
had already described in his teaching and to which
he had given the name of&lie circulaire. He mentioned the publication by the Gazette des H6pitaux
of his lessons in 1850-51 and quoted in extenso
the passage of the book he offered to the Academy
the week before. He then gave a clinical description of circular madness, reproduced on 17 pages
of the bulletin. As soon as he had finished speaking, Baillarger answered. His reply, nearly as long
as Falret’s lecture (14 pages), was made in a
highly aggressive tone. Two versions of the reply
exist. One is the official one, published in the bulletin (Baillarger, 1853-54b), and the second, never
quoted, appeared in the journal Union Mkdicale
(Anonymous, 1854) 2 days after the session, on 16
February. The Union Mkdicale regularly published
detailed reports of the sessions of the Academy
and, in this case, after giving an extended summary of Falret’s lecture, reproduced, I%obably verbatim, Baillarger’s answer, which seems to have
been highly insulting. Baillarger
undertook to
demonstrate that Falret’s claim was unfounded,
that the core of his description had already been
given “in a clearer and less timid way” by their
common teacher, Esquirol. The lesson published in
book form, quoted by Falret, is completely different from the first version published in the Gazette.
In any case, Falret’s description dealt with a limited asect of his, Baillarger’s, folie h double forme
and, for that reason, Falret’s only justifiable claim,
the invention of the term folie circulaire, was
without interest, since “it does not apply to three
quarters of the cases I have described”. Baillarger
then tried to demonstrate that everything that was
good in Falret’s description had been borrowed
from him, Baillarger. He perfidiously said that “he
will not deal with his (Falret’s)‘Lecture
nor with
the similarities he may have with my work” but, at
the same time, reminded the Academy that “the
5
short LeGon of Falret and his present Lecture have
been written at an interval of two weeks and that,
during those two weeks, Mr. Falret had access to
my own Lecture”. If, therefore, important facts not
included in the LeGon appear in the Lecture, the
conclusion is obvious. Baillarger went even further. He cast doubt on Falret’s assertion that he
had used the concept of folie circulaire for years in
his clinical teaching and stressed its importance to
his pupils. Morel “the most devoted and the most
distinguished pupil of Mr. Falret” had just published a textbook on psychiatry in which he quoted
his teacher repeatedly, but he never mentioned this
allegedly extremely important type of mental disease. The final note was struck by the concluding
paragraph - which was deleted from the bulletin “Mr. Falret has written a hundred pages on hallucinations, and especially on the theory of this phenomenon. In more than ten passages he has discussed, without quoting it a single time, my work
on the same phenomenon, which the Academy has
honoured in 1845 and published in its Memoirs.
I never complained about the silence of my Colleague, being convinced of the necessity of tolerance in such matters”. To such an acrimonious
attack, Falret gave only a short answer (Falret,
1853-54b). To refuse to become involved in a personal discussion is a “duty to the dignity of the
sessions of the Academy as well as to my own dignity” and he concluded that the publication of his
Lecture would give alienists the opportunity to
verify, by their own observation, the accuracy of
its clinical content.
Falret kept his word until his death. In 1864, he
published a book (Falret, 1864) in which he collected among his publications those he considered
of special interest and wrote a foreword of 68
pages, his scientific testament, in which he gave an
impressive description of the evolution of his convictions about the nature of mental illness. The
LeFons at La Salp&riere in 1850 and the Lecture at
the Academy in 1854 were considered by him
worthy of a reprint. But the only reference to the
quarrel with Baillarger was a short footnote which
gives a concise and objective enumeration of the
events ending with the sentence: “I do not want to
embark on a controversy and content myself by
reproducing my Lecture at the Academy”.
Very different was the attitude of Baillarger. He
had, like Falret, begun to give informal clinical
conferences at La Salp&rii?re. During the “summer
semester”, 3 months after the sessions at the Academy, he took as subject “De la folie ci double
forme “. As chief editor of the Annales mkdico-psychologiques, he could publish it immediately
6
P Pichot
(Baillarger, 1854) in the journal. The paper ran to
32 pages and ended with a remark that it would be
followed in the next issue by a second part on the
“description
of the disease”, which, in fact,
appeared 26 years later. What remains of
Baillarger’s lesson is an extended attack on Falret.
Half of the paper is of historical nature and aims at
demonstrating
that what is correct in Falret’s
description had already been said, and what is new
is largely incorrect. Baillarger quotes extensively
Willis, Esquirol, interpretations of Esquirol’s ideas
by his pupil Anceaume, and, for the first time, the
“classic textbook”
of Griesinger
which had
appeared in German in 1845. He noted that Griesinger wrote that “the whole disease may often
consist in a cycle of the two forms (melancholia
and mania) which quite often alternate regularly”
and added that Griesinger’s comparison to a circle
- although he actually used the word cycle - is
perfectly
correct, and must “have greatly
impressed Falret” who had, for that reason, coined
the expression folk circulaire
- an indirect way of
denying Falret even the paternity of the name.
After having described, in the second part of the
lesson, the basic differences between Falret’s and
his own conceptions, Baillarger ended with a new
and virulent accusation of plagiarism against his
colleague. He stressed “the complete reversal of
opinion” of Falret between the Lecon “published
on 20 January 1854, that is, a few days before the
presentation of my Memoir to the Academy” and
the “ideas he immediately hastened to adopt”. He
expressed his satisfaction about Falret’s sudden
acceptance of some of his own ideas, but concluded in a retorical vein with a venomous sentence “Whether Mr. Falret’s attendance of my Lecture two weeks before had any influence on the
change I have mentioned, I cannot say”.
The conflict between F&et and Baillarger was
watched with passionated interest by their collegues. One of Falret’s pupils, Morel, tried to find
a compromise. Morel was already well known for
his Etudes cliniques, the book which, as pointed
out by Baillarger,
did not mention the circular
madness, and he would later gain considerable
international influence with his theory of Degeneracy (Morel, 1857). On 21 September 1854, he
published in the Union Mkdicule a detailed analysis of Falret’s book which had appeared in January
(Morel, 1854). After discussing Falret’s general
ideas, and full of praise for Falret’s clinical
method for the study of psychological symptoms,
but regretting his relative lack of interest in biological aspects, he wrote about the relation between
folie circulaire and folie & double forme and con-
cluded: “We have read with the greatest attention
the discussions which the subject has provoked at
the Academy and in the medical Press, and we are
convinced that the differences between the doctrines of these two eminent physicians are more
apparent than real, and depend more on the particular form of their genius than on a radical difference in the interpretation
of the facts”. Morel’s
hopes of a compromise were not realized. Baillarger wrote immediately
an “Open letter to Mr.
Morel” which he sent to the Union M&dicale where it never appeared - and which he published
in his Annales mkdico-psychologiques (Baillarger,
1855). After beginning his letter with the modest
but unfortunate sentence: “The ‘folie b double
for-me’ will probably never occupy an important
place in mental pathology”,
he added that he
wanted to prove that the idea was his own and that
Morel’s contention about the absence of differences between Falret’s and his views was completely false. The letter rehearsed the usual arguments but, this time, the role of Griesinger was
given more emphasis, the sentence of the German
being now translated: “The whole disease consists
of this circle of two forms...“, whole and circle
being printed in italics. The accusation of plagiarism was now no longer masked by retorical formulas, “I agree with you that Mr. Falret’s opinion has
close links with my own, but even that they are
completely identical. It was my opinion that was
developed in his Lecture... there is only one difference - the date”, with the word date being also
printed in italics.
During the following years, the new entity progressively gained acceptance in France. But
although both Falret and Baillarger were quoted,
the latter was generally credited with the discovery. Falret died in 1870 and Baillarger took a leading position in the medical and psychiatric world.
In 1878, he was elected president of the Academy,
one of the very few psychiatrists ever to have been
so honoured. The brillant clinical teaching he had
continued at La SalpCtriere attracted a large public,
not only of physicians like Broca and Charcot, but
also of philosophers like Ribot and of historians
like Tame. “Every French and foreign alienist who
came to Paris went to La SalpCtrZre to hear Baillarger”, wrote Magnan (1906) who described vividly in his address to the Academy the atmosphere
of those lessons. Under such circumstances, it was
difficult for contemporary French authors not to
favour Baillarger. Typical of this situation is the
extended chapter written in the Dictionnaire
Encyclopkdique des Sciences Me’dicales (Ritti,
1879) which is significantly entitled “Folie ci dou-
Bipolar
ble forme “. The author, Ritti, despite an obvious
effort to achieve historical objectivity, described in
the historical part of his monograph how Falret
“on Februray 14 of the same year (1854) came to
the Academy and read a memoir which on many
points completed the memoir presented 15 days
before by Baillarger”, an indirect way of proclaiming the latter’s priority.
But Baillarger was still not satisfied. In 1880, the
Annales midico-psychologiques,
which he continued to control as editor, published a paper entitled
“Pathologie
de la folie ci double forme”
(Baillarger, 1880). In its 36 pages Baillarger reproduced
the clinical observations illustrating his Lecture of
1854, and reiterated in the same tone as before his
claims to priority. Now, as proof of the rightness of
his position, he added selected quotations from
authors who in the meantime had discussed the
problem. Marc6 in his Textbook of Psychiatry
(1862), the second edition of Griesinger’s Treatise,
the translation of which he had promoted and axmotated (1865), Meyer (1874) and Foville (1872), and
peremptorily concluded: “Falret has been wrong in
pretending to have discovered the folie circulaire”.
Ten years later, he collected some of the works he
had published during his life in two volumes
Recherches sur les Maladies Mentales (1890), the
third chapter of the first volume being entitled:
“Folie ci Double Forme, History and Problems of
Priority”. Time had not softened his aggressive attitude. The attack on Falret made use of the old arguments but he was now able to quote at length Ritti
and to add, as a last arrow directed at his adversary,
his hommage to Griesinger who “although he has
been the first author to fur his attention on the alternations of mania and melancholia, has never raised
any claim to priority”. Baillarger, now 89 years old,
died on 3 1 December of the same year.
Act three : 1894. Happy
end
The last act of the play takes place on Saturday,
7 July 1894 and brings us back to La SalpQtribre
(AM, 1894; AR, 1894). The gardens extending
from the entrance portal to the magnificent main
building are the stage. “From the flowers and the
green bushes”, to quote a contemporary lyrical
description, emerge now two white marble busts.
On the podium of the left-hand statue is written “A
Baillarger
(1809-1890),
la SocitW M.&dico-Psychologique de Paris, ses amis, ses &ves”
and on
the other “J-P. Falret (1794-1870)“.
Behind a
small tribune for the speakers stands a pavilion
under which many people have congregated members of the Acad&mie de Mkdecine led by its
disorder
7
president and secretary, the professor of psychiatry
at the Paris Medical School, Raymond, and his
retired predecessor, Jeoffroy, the members of the
SocitW mkdico-psychologique,
the residents and
head nurses of the psychiatric ‘sections’, the families, pupils, and friends of the two psychiatrists
and representatives of the administrative
authorities led by Mr. Poubelle,
the Prdfet of the
Dkpartement
Seine, whose name will later be
given to the Parisian dustbins he introduced. The
mental patients of the Hospice - euphemistically
called in the description “hosts of the House” - are
the audience. They are standing on both sides of
the scene and, during the whole ceremony, showed
“an impressive calm”. The musical accompaniment is provided by the “Harmonie de Bicgtre”, a
patients’ brass band organized by Bourneville,
then head physician of the Section for FeebleMinded in the Bic&tre hospital. After the rendering
of the Marseillaise, played with everyone standing
to attention, the speeches began. The first speaker,
Jules Falret, the son of Jean-Pierre, had been since
1867 alienist of the BicEtre Asylum and succeeded
Moreau de Tours in 1884 at La SalpCtri&re. He was
known by his work on the folie raisonnate and by
his introduction with Lasbgue of the concept of
folie ci deux (J. Falret, 1890). In 1878-79, he published a long study on “La folie circulaire ou folie
h formes altemes ” whose brief historical introduction abstains from any controversy: “The discovery of folie circulaire or folie ci double for-me, diseases first described by my father and by Mr.
Baillarger in 1854...“. His conciliatory attitude was
further shown by the fact that he had accepted the
chairmanship of the committee which collected
funds for Baillarger’s bust; he had himself given
the bust of his father. In his speech he drew a parallel between the “two direct pupils of Pine1 and
Esquirol”. He was tactfully brief on the 40-yearold controversy between the “two masters of mental pathology... separated during all their lives by
the deep differences of their personalities
and
of their scientific
orientations”.
He praised
Baillarger’s many achievements and, “as the son
of a father for whom (he) has kept the most profound veneration” he restrained from any judgement on him, mentioning only that “he has discovered the folie circulaire”.
The next speaker was
Magnan, who presented his teacher Baillarger. He
evoked in a lyrical vein the controversy, “a battle
between giants”, and concluded: “You can both be
satisfied, dear teachers, you have both won the victory”. After these relatively brief speaches, Ritti,
then secretary of the Socie’te’ m&dico-psychologique, endeavoured to compare in great detail the
8
P Pichot
scientific works of the two psychiatrists. His analysis of their philosophies, of great thoroughness
and understanding, allowed him to introduce the
controversy as an example. He abstained from any
discussion on priorities,
contrasting
only the
“broadness” of Falret “synthetic” conceptions with
the “analytic faculties” of Baillarger, which had
led him to “accumulate clinical facts”. The other
five speakers, the last of whom was Mr. Poubelle,
remained on safe ground by praising the general
medical, personal, and humanitarian qualities of
the two physicians. The curtain falls on all the
actors and audience taking part in an “admirably
served lunch”.
Aftermath:
International
reception
What was the aftermath of this happy end? In
France, most books mention the two contestants
without dwelling on their respective roles. The
manual of H. Ey et al (1974) is typical. It mentions
only “that in 1854 J.P. Falret and Baillarger
described, at nearly the same time, a single disease...“. Quite recently, for the first time, Hautsgen, in an excellent study (1993) discussed the role
of Falret as founder of the modern clinical
approach in psychiatry. Since his purpose was to
present the medical philosophy of the psychiatrist
- he published by way of illustration large extracts
from the introductory
LeGon Falret given on
15 May 1850 at La Salp&triBre - he was understandably concise on the history of the controversy, stressing that in 1854 “Falret brought
together in a single disease Esquirol’s mania and
melancholia under the name (offoEie circuluire). If
his description appeared a few days later than the
description by Baillarger offolie h double forme, it
represents a clear progression in relation to the latter insisting rightly on the lack of comprehension
in France of the originality of Falret’s work. He is
more explicit on the reception of foZie circuluire in
Germany, Great Britain, and the United States than
on the factual details of the controversy. It is true
that, contrary to what has happened in France, psychiatrists in other countries consider Fah-et as the
real discoverer of the new entity, usually quoting
only the namefolie circuluire. In Germany, Kahlbaum in his book on catatonia (1874) proclaimed
that his research is based on the “clinical method”,
writing: “Only the French, who discovered this
first form (general paralysis) have been the only
ones to make further progress in the clinical direction: folie circuluire”.
Although he did not mention Falret by name, it is obvious that he considered him as the father of the second of the two
“clinical
forms” which are his models in the
description of catatonia. In the first editions of his
textbook (1887), before he had adopted the allencompassing concept of manic-depressive insanity, Kraepelin mentioned Falret’s “circu&.res Irresein” as one of the best established types of mental
diseases. In Great Britain, in his classical historical
review of melancholia (1934), Sir Aubrey Lewis
wrote: “In France, Jean-Pierre Falret draws attention to the differences between ordinary melancholia and the periodic variety. Then, in 1854, Baillarger described to the Academy of Medicine his
folie a double forme; there was a brief controversy
as to priority, and Falret, at the following session,
read his paper De la Folie Circulaire. “Sir Aubrey
then made an analysis of Falret’s lecture which
occupies more than one page of the journal, without ever again mentioning Baillarger on the subject. In the United States, a paper appeared 10
years ago on “Falret’s Discovery: The Origin of
the Concept of Bipolar Affective Illness” (Sedler,
1983). Regreting that “today there is little appreciation for the magnitude of Falret’s contributions”,
the author attributes such a situation to the fact that
“Falret’s landmark essay had never before been
published in English translation”. For that reason,
a translation of the 1854 Lecture is appended to
the article. The text of the paper, which praises the
originality
of Falret’s approach by which “he
ensured for the first time a study population with
pure bipolar affective illness”, ends with the following lines: “Credit for the discovery of bipolar
illness is typically shared by Falret with his colleague at the SalpCtribre, J. Baillarger, who published his essay De la Folie a Double Forme a few
months after Falret published his memoir. At that
time, their dispute over priority was acrimonious,
and both papers reflect no little concern about the
issue”. Although the paragraph is historically inaccurate - it refers to Baillarger’s
paper in the
Annules which appeared a few months after
Falret’s Lecture, but not to Baillarger’s own Lecture, which antidated Falret’s - the author’s appreciation of Falret who “would have been delighted
to know that his pioneering efforts have not been
forgotten” is basically correct.
CONCLUSION
:
ATTEMPTING
A FAIR JUDGEMENT
To make a fair judgement, one has to look at the
whole story at different levels. The chronology is
clear. The two versions of the 1850 Legon of Falret, the first published in the Gazette in 1851, and
the second, slightly extended, which appeared in
Bipolar
book form in January 18.54, antidate Baillarger’s
lecture of January 31. Falret’s Lecture, which he
tried without success to present on 7 February,
took place on the 14 February. The basic contention of Baillarger
is that Falret’s opinion, as
expressed in the 1850 “Le9on”, differs from his
1854 Lecture because, having in the meantime
heard his (Baillarger’s) Lecture, he modified his
point of view. It is not necessary to discuss at
length this accusation, which rests mainly on the
fact that in the &con, Falret mentioned that the
two pathological states “are separated by an interval of normality
of relatively
short duration”
whereas in the Lecture, he mentions that, in the
sequence mania-interval-melancholia-interval
the
first interval between mania and melancholia, may
be completely lacking. The important point lies at
another level. As has been well stressed by Ritti in
1894, the orientations of the two psychiatrists were
fundamentally different. Baillarger appears in his
numerous publications, dealing with the most various subjects, as a describer of clinical phenomena.
His best work is his study on hallucinations
especially hypnagogic - and of “pseudo-hallucinations” which, linked with his concept of “mental
automatism”, makes him a forerunner of De Clerambault. When he trespassed on more theoretical
ground, as in his studies of the nature of general
paralysis - a problem he discussed all his life - his
opinions were of much lower quality. In this
respect, he was the direct follower of Esquirol. The
attitude of Falret was completely
different.
Although he was also a good observer, his main
preoccupations were, as Ritti expresses it, of a
more “synthetic” bent. In his medical autobiography, the foreword of his collected works (1864),
he explains how after having put his faith in the
anatomy of the brain, then in the psychology of his
time, he had, although of the opinion that mental
disorders were ultimately biological, become convinced that for the time being, advances could only
come from the clinical approach: “The most serious progress which can be realized today in our
special domain”, he wrote, “will consist in the discovery of disease entities (espsces naturelies),
characterized by a set of physical and psychological symptoms, and by a special evolution”. This
sentence resumes his program. The purpose of
psychiatry is the discovery of “natural species”,
and he used natural in the meaning given to the
word by botanists and zoologists since Linnaeus: it
postulates the existence in mental pathology of
distinct categories,
the description
of which
implies knowledge of the cause and suggests the
treatment. But it is essential to select the “real”
9
disorder
symptoms. Falret criticized his teacher Esquirol
for having based his classification on a single or a
few superficial manifestations. He distinguished
between the basic symptoms (symptames de fond)
which, being permanent, are the only ones to be
considered, and the superficial ones constituting
the surface (reZieJ) symptomatology,
easy to
observe - such as the theme of the delusions - but
of no use for a classification. The same opinion
was expressed nearly half a century later by Eugen
Bleuler when, in his description of schizophrenia
(191 l), he opposed the basic symptoms (Grundsymptome) - the German word is the exact translation of Falret’s sympdmes de fond - and the accessory symptoms
(akzessorische Symptome).
However, a cluster of such basic symptoms does
not suffice to specify a for-me naturelle: “A classification of the ‘formes naturelles’ of madness”
insisted FaIret, “must rest on the clinical study of
the physical and mental symptoms, but also and
mainly on a deep study of the evolution of the disease”. This emphasis on evolution, already noted
by Ritti, had a deep influence, first on Kahlbaum,
and through him on Kraepelin. The folie circulaire
was for Falret a prototype of such a for-me naturelle. He regreted that, in his time, only general
paralysis answers, such as circular insanity, to the
necessary criteria, and wrote that the rest of psychopathology
was “awaiting its Jussieu”. In a
famous paper (1864) he had already destroyed the
concept of monomania proposed by his teacher
Esquirol, and he saw in the melancholic states,
apart from the folie circulaire, an amorphous
group probably made of many different formes
naturelles which remain to be isolated. Seen in this
perspective, the birth of bipolar disorder is more
than a picturesque episode illustrating the occasional smallmindedness
of brilliant scientists. It
can be considered as a decisive episode in the history of psychiatry.
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