Editorial Commentary

I. Lecture-by-Lecture Synopses end of the lecture, he provides his classifi cation of symptoms in a three-by-three table: The columns Synopsis of L1: This, the very fi rst lecture, is one are: ‘Psychosensory’, ‘Psychomotor’, and of eight comprising the fi rst main section of ‘Intrapsychic’; the rows are: ‘loss of’, ‘excessive’, Grundriss, outlining Wernicke’s overall under- or ‘aberrant’ excitability (e.g. ‘anaesthesia’, standing of normal human brain processes in rela- ‘hyperaesthesia’, and ‘paraesthesia’ in the tion to subjective awareness. However, he starts Psychosensory column). This classifi cation gains with his basic credo, that mental illnesses are brain prominence in the clinical lectures. diseases. He expresses the view that psychiatry, compared to other specialties, is backward in its Synopsis of L3: The main topic of this lecture is development (although he suggests later that he Memory Images (Erinnerungsbilder ) sometimes has something better to offer). The rest ‘sets the rendered here as ‘remembered images’. Much of scene’ in relation to clinical concepts, clinical the lecture is devoted to separating perceptual/ practice, and neuroscience of the day. sensory images from ‘memory images’. In mod- ern terms this is the distinction between sensation Synopsis of L2: In this lecture, the point of depar- and perception. The former implies ‘awareness’ ture and the topic he understood best is the cere- arising directly from sensory input, the latter has bral representation of language—but this is added implications of a degree of interpretation merely a device to move into other territory. He or analysis of that input, to be given lasting repre- moves quickly at the start of the lecture to clarify sentation in memory. the notion of the ‘supposed’ Conceptualization Centre mentioned in L1. Although he was a pio- Synopsis of L4: The main topic of this lecture is neer for the notion of cerebral localization of the way in which remembered images, acquired function, by the time Grundriss was written he separately, come together to create a coordi- had moved beyond simple localization. Soon nated picture of the external world. In describ- other issues arise, raising several philosophical ing how remembered images of objects are questions. Much of the emphasis is that all symp- assimilated to become representations of con- toms in psychiatry can be reduced ultimately to a cepts, Wernicke sees an exact analogy with for- patient’s movements, which are all a physician mation of memory images from sensations, sees directly. This strongly materialist tone was represented in the primary visual areas by link- common in Germany, after Griesinger, a leading ing various active ‘perceptual elements’ (primary ‘Somatiker’ of an earlier generation. Towards the visual cortical cells).

© Springer International Publishing Switzerland 2015 331 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9 332 Editorial Commentary

Synopsis of L5: This lecture focuses on how the hood consist of three components. These are the brain represents our body (using interchangeably sense of one’s own body (corporeality), one’s ‘physicality’ and ‘corporeality’). A conceptual sense of the outer environment, and personal distinction is made between sensory content and memories or beliefs acquired in one’s own life tone of sensation, a near-synonym for the latter experiences. An additional topic introduced here being ‘organ sensation’, a term whose meaning is is not so much the ‘contents’ of consciousness discussed in section XVI: ‘Terminology’). (upon which earlier lectures focused) but the ‘Corporeality’ includes what we now call visceral ‘processes’ by which such contents are laid down, sensation, notably that from the large intestine. and are subsequently manipulated and retrieved. Wernicke knew the importance of this topic, Synopsis of L6: The main topic of this lecture is although current understanding in the nascent representation of movement. Amongst evidence discipline of neuropsychology was quite limited. referred to is that obtained by electrical stimula- tion of muscles: This procedure, well known at Synopsis of L8: Much of this lecture is psycho- the time, was pioneered earlier in the century by logical theory, about psychological processes, Duchenne de Boulogne, who used it to study rather than content, such as might have been actions of individual muscles and muscle groups. found in writings of his American contemporary, Later, Wernicke discusses how full perceptual William James. This includes the phenomena of awareness depends on combining passive sen- attentiveness, and of ‘narrowness of conscious- sory awareness with exploratory movements. ness’ (i.e. selectiveness of attention), the process The latter notion builds on ideas fi rst mentioned by which memory is acquired, and the role played in L3, on elaboration of tactile perception by by Affective states. Much of the lecture consists combining immediate sensation with exploration of shrewd refl ections based on introspection, (especially manual exploration), an idea now which was easier before psychology became well understood by somatosensory physiologists. ‘objective’ when behaviourism came centre- Wernicke draws exact parallels here between tac- stage. The lecture also brings to the fore the sci- tile and visual perception/exploration. entifi c tradition in which Wernicke is best placed—not so much that of most biomedicine of Synopsis of L7: The subject matter of this lecture his day, but that of natural philosophy (which is how our brains construct for each of us an became physics). This conclusion can be reached image of ourselves as a (somewhat) unifi ed per- not only from his use of analogies from physics son. In English, the word ‘personality’ refers to for processes envisaged to occur in the brain. the unique quality or ‘essence’ of each person. More important are methodological features such Another word—‘personhood’—is used in legal as his balance between experiment and theory, discourse, signifying ‘status as a legal person’. In typical of natural philosophy (but seldom found this lecture, and later, ‘personality’ will be used in biomedicine); his freedom in postulating hid- as just defi ned, while ‘personhood’ is used in a den variables which could not be directly demon- more generic, abstract sense, referring to our strated (as were many concepts in the history of sense of ‘being (to a degree) a unifi ed person’, physics); and notably his close reasoning from whatever the detail of each individual’s personal fundamental principles, based on sensory and quality. Sometimes the phrase ‘personalized con- motor processes. This allowed them to be traced sciousness’ seems to capture Wernicke’s meaning back to the core language of the natural sciences. better than a literal translation. The word ‘indi- vidual’ refers to a single human, without imply- Synopsis of L9: Lectures 9–17 make up the sec- ing that he/she approximates to any sort of unifi ed ond main section of Grundriss, dealing with entity. A central notion, to be developed in later chronic states of ‘paranoia’, and dealing mainly clinical lectures, is that memories from which with long-stay patients in his institution. One each individual constructs his sense of person- such patient is described in vivid detail. In this fi rst Editorial Commentary 333 lecture dealing with clinical matters, Wernicke for delusions not mainly as an abnormality in the outlines basic concepts. First he distinguishes process of interpreting experience, but rather as a ‘real mental illness’ from ‘mental disturbance’: more-or-less rational attempt to explain other In lectures so far, when ‘illness’ has been men- subjective experiences, which he sees as primary tioned, the German word was Geisteskrankheit. abnormalities. His concepts appear to be impre- Here he uses Geistesstörungen. Wernicke also cise or over-inclusive. This is perhaps inevitable enunciates a principle, that one should start one’s when there are major gaps in background knowl- analysis with the simplest situations, before mov- edge, and when the most useful way to defi ne ing to more complex ones. He points out (as he concepts is unclear. Sejunction is the obvious often does in later lectures) the similarity between example here, making this one of the more con- normal mental processes and mental processes he tentious of his lectures. This lays him open to a sees in his patients, an emphasis no doubt sceptic’s charge of ‘neuromythology’, especially intended to dispel as far as possible the idea that when components drawn from his analogies are patients were somehow ‘alien’ to the rest of used subsequently as premises for further steps in humanity. It is already clear here that psychiatric supposed scientifi c reasoning. Much of the sec- symptoms are to be the major focus of Grundriss. ond half of the lecture is vividly descriptive, but also attempts to systematize, even to explain. Synopsis of L10: This lecture is a succession of case presentations, continuing those in L9, and Synopsis of L13: The fi rst part of this lecture is referred to in later lectures. It gives insight into about hallucinations (identifi ed as ‘sensory medical practice and institutional life in the asy- deceptions’), recognized then, as today, as most lums of the day, Wernicke’s clinical style, his often of the verbal auditory variety (‘phonemes’ approach to symptoms, as well as initial ideas in his terminology). These are taken as primary about his approach to classifi cation. abnormalities, a consequence at the symptom level of the hypothetical ‘sejunction’ process at Synopsis of L11: The focus here is on separating the neuronal level. Later parts of the lecture deal chronic cases from residual ones where the disease with explanatory delusions, envisaged to arise by process has apparently run its course, and patients quasi-rational processes, as patients’ accounts of have recovered, without their gaining insight into primary abnormalities they experience. their illness. Wernicke outlines his classifi cation, based on which of the three components of mem- Synopsis of L14: The preceding lecture examined ory is falsifi ed—a patient’s sense of corporeality explanatory delusions occurring immediately to (somatopsychic), of the outer world (allopsychic), account for unusual primary experiences. This and life experiences from which personhood is lecture explores delusions distorting earlier built (autopsychic component). Falsifi cation in events, held in memory, as ‘retrospective delu- each of these is seen as secondary, a normal attempt sional explanation’ and ‘falsehoods of memory’, to explain other experiences, whose abnormality is to match current abnormal experiences. primary. Two such primary areas are identifi ed: ‘autochthonous ideas’ (not ‘created by usual Synopsis of L15: Wernicke’s idea that each processes of association’), and hallucinations. patient’s symptomatology arises from a single ‘elementary symptom’ was mentioned in L14. Synopsis of L12: The fi rst half of this lecture Such symptoms, by virtue of a range of internal attempts to defi ne what for Wernicke is a key interactions, lead secondarily to other symptoms. concept, which he calls ‘sejunction’, purportedly The concept of an ‘elementary symptom’ is part a neuropathological process occurring at the level of the title of L15, yet is not well explained. A of nerve cells by which associative links are bro- review by Krahl and Schifferdecker, (1998) [1 ] ken, and through which primary abnormal symp- suggests that he developed the idea in relation to toms are to be explained. As in L11, he accounts ‘anxiety psychosis’ and ‘hallucinosis’, to which 334 Editorial Commentary can be added ‘autochthonous ideas’, plus ‘over- more primary abnormalities, and he suggests valued ideas’ dealt with in this lecture. additional ways in which this may occur.

Synopsis of L16: This lecture is important for Synopsis of L19: The fi rst two-thirds of this lec- both clinical science, and hospital administra- ture give details of the phenomenology of hallu- tion, and Wernicke sketches out systems of clas- cinations in major sensory modalities, and when sifi cation to cover both. Much of the chapter modalities are combined. Later, he discusses the attempts to decipher what might be the core theory of hallucinations, starting with the history pathological processes, by excluding other dis- of attempts to provide such theory. Curiously, turbances, seen as normal, albeit working to that presented here is different from, and based resolve tension set up by primary abnormalities, on assumptions different from those relating hal- especially sejunction. lucinations to sejunction (in L13).

Synopsis of L17: A major part of this lecture is Synopsis of L20: This lecture continues discus- devoted to Wernicke’s views on classifi cation of sion of the theory of hallucinations, and in pass- mental disorders. He also introduces the term ing, expands on issues discussed earlier on ‘chronic hallucinosis’. Towards the end, an inter- underlying neuroscience, notably the cohesive- esting section delves into recent history of psy- ness of acquired organization across widely sepa- chiatry, as he saw it. In opening his fi rst lecture, rated cortical regions. Wernicke goes on to he already expressed his scepticism about discuss other symptoms, including motor disor- contemporary categorization of mental disorders. ders of speech, hyperaesthesia, and what he calls Here his critique is expanded, more sharply, and ‘hypermetamorphosis’, ‘an organically produced in greater detail. He appears to reject most cate- compulsion to take note of sense impressions, gories currently in use, favouring something sim- and to fi xate attention on them’. This is presented pler. Following a statement in his fi rst lecture, he as occurring mainly in neurological conditions, prefers to take as a starting point symptoms and this being a precursor to subsequent lectures, the processes by which they arise, rather than where such symptoms arise in the context of supposed disease entities. Terms are introduced mental disorders. referring back to an earlier analogy, where inten- sity and extent of symptoms over time are plotted Synopsis of L21: This lecture deals with overrid- graphically. These are aszendierend (ascending) ing features of any psychotic state, namely dis- and deszendierend (descending), but henceforth, orientation, and ‘disarray’. The latter is an for clarity (since these words have other senses), Affective state or reaction, and presents problems we use the terms ‘worsening’ and ‘improving’, in translation, (section VIII(g) ‘Wernicke’s unless they clearly refer to anatomical relation- Distinctive Clinical Concepts in Psychiatry’, ships (such as in the gut), or refer directly to the Affective Impact of Mental Illnesses ). These con- original graphical analogy. cepts divide according to the three-way split of contents of consciousness discussed earlier (allo- Synopsis of L18: The remaining lectures in psychic, somatopsychic, and autopsychic), to Grundriss (more than half the series) cover acute which, for the fi rst time, a fourth subdivision— syndromes of mental illness and defect states, as motor abnormality—is added. seen in Wernicke’s practice. In this lecture he introduces the topic of acute mental illness, a Synopsis of L22: This lecture starts by enlarging topic he has already declared as more complex on the concept of an overvalued idea, fi rst dis- than that of chronic disorders. He also explores a cussed in L15, and leads to discussion of illu- topic touched on in L17, the separation between sions. As already discussed for hallucinations, acute and chronic disorders. Later parts expand illusions originate as bias or distortion of percep- on the theme of delusions constructed to explain tion resulting from a prevailing Affective state. Editorial Commentary 335

Illusions and hallucinations thus become hard to The clinical description is vivid, and raises separate, but generally, the former are triggered important scientifi c questions about the nature of mainly by concurrent events and their Affective the abnormal mental state in such patients. impact, the latter arising more in the context of underlying illness. Synopsis of L27: This lecture follows from the previous one, amplifying the description of Synopsis of L23: In this lecture, the style changes. Delirium tremens , but moving on to ‘polyneuritic It deals with identifi ed disorders—‘anxiety psy- psychosis’ (otherwise known as Korsakoff’s psy- choses’, including ‘hypochondriacal anxiety psy- chosis), common in people who have seriously chosis’—and for the fi rst time gives direct advice abused alcohol. We now know this to result from to students about treatment. The immediate symp- nutritional inadequacy leading to thiamine defi - tom clusters, other than anxiety, are recognizably ciency, affecting both peripheral and central ner- psychotic in modern terms, but may rapidly vous systems. Wernicke did not know this, but worsen to produce quasi-neurological symptoms, hints that two pathologies may exist which can- sensory abnormalities or akinesia, perhaps equat- not yet be adequately separated. Later parts deal ing to classic conversion symptoms. with ‘presbyophrenia’, a mental disorder of the elderly. Synopsis of L24: This lecture, using Wernicke’s terms, deals with ‘hypochondriacal psychosis’ Synopsis of L28: This long and complex lecture and ‘somatopsychosis’. The interest for today’s deals with disorders of personal identity (‘acute reader is how concepts of mental disorder which autopsychosis’ for Wernicke). The lecture does today are considered separate, were then brought mention hysteria, but goes into most detail in into relation with each other. They include soma- describing a patient with a ‘second state’. This tisation, eating disorders, and a case of probable had recently been described in France, but the shell-shock from the Franco-Prussian war. Often emphasis here is different, with little stress on these arise in conjunction with abnormal psychic trauma, and more on other ways in which sensations arising from the intestines. A modern such states might arise, including forms of epi- slant is given, attributing these to genuine abnor- lepsy, or episodic binge drinking. Towards the mality of sensations from the body, perhaps end, discussion shifts to forensic topics, as exaggerated and distorted by patient’s inaccurate ‘acquired moral insanity’, a term on which he is lay knowledge about their internal organs. rather sceptical, and which he uses in a more restricted sense than some of his colleagues. Synopsis of L25: The focus of this lecture is ‘Acute Hallucinosis’, regarded by Wernicke as Synopsis of L29: Here Wernicke continues his ‘one of the best -defi ned forms of acute psychosis’. account of ‘acute autopsychosis’, starting with Usually this is the result of chronic excesses of two cases dominated by limited delusional ideas drinking, probably mainly of hard liquor (cognac which distort personal identity, accompanied by is mentioned), rather than beer or wine. The syn- prominent vasomotor symptoms, with acute drome occurs rarely in other circumstances. onset and good prognosis. He gives them a provi- Apart from description of symptoms, detail is sional term ‘acute expansive autopsychosis medi- provided on common patterns of recovery, aetiol- ated by autochthonous ideas ’ . He draws a parallel ogy, and danger of relapse. between disorders arising at the time when autochthonous ideas appear , and those arising on Synopsis of L26: This lecture focuses on a spe- disappearance of thoughts. Later, he deals with cifi c diagnosis, Delirium tremens, starting with a obsessive neuroses and psychoses, commenting case presentation, followed by discussion of on differences between neurosis and psychosis. symptoms, aetiology, diagnosis, differential Finally he deals with the symptom of ‘audible diagnosis, treatment, and post-mortem fi ndings. thoughts’ (‘thought echo’). 336 Editorial Commentary

Synopsis of L30: This important lecture starts by Synopsis of L34: This lecture, one of Wernicke’s presenting two contrasting cases, one of severe longest , complements L32, and deals with what he melancholia (a variety of what is now called calls ‘akinetic motility psychosis’. Early parts deal ‘depression’), the other of fl orid mania. It contin- with symptoms such as ‘waxy fl exibility’, muscle ues with a fascinating account, with cogent rea- rigidity and catalepsy, and also with abnormal soning to suggest that melancholia is primarily a (that is para kinetic) movements. Much of the lec- disorder of ‘will’ (inability to resolve competing ture, while dealing with psychiatric symptoms, claims for action, leading to failure in taking reveals a world-class neurologist at work. decisions). Only when a person grasps their inca- pacity in daily activities, does it become a sec- Synopsis of L35: This continues analysis of motil- ondary disorder of lowered mood, along with ity disorders, by exploring syndromes combining symptoms such as ‘delusions of belittlement’. hyper- and a-kinetic symptoms (that is, compound The importance of accurately diagnosing the dis- psychoses). It also considers akinesia based on order is stressed, as well as the risk of suicide, disorder of intrapsychic processes (including what and the good response to treatment in hospital (if Wernicke refers to as ‘depressive melancholia’), it can be arranged). and that based on psychsensory processes. It ends by considering the theory of motility psychoses Synopsis of L31: This complements L30, with an (which started with Wernicke, and was retained in analysis of processes occurring in mania. the Wernicke–Kleist–Leonhard tradition). Fundamentally mania is seen as ‘pathological facilitation of acts of association’ and, with it, an Synopsis of L36: This lecture is the fi rst in which overall increase in activity levels in the cortex. It Wernicke starts ‘winding up’ the series of 41 lec- includes ‘levelling of ideas’ (as the level of acti- tures. As an overview, he discusses more compli- vation of every idea is pushed to a similar ‘ceil- cated syndromes, in which different acute ing’), course of illness, mania in progressive psychotic syndromes might be combined either paralysis, combinations of mania and melancho- simultaneously (‘mixed psychoses’), or as separate lia, and chronic forms of mania. phases (‘compound psychoses’). Four components in such combinations are ones he defi ned earlier: Synopsis of L32: This lecture starts with presen- allopsychosis, somatopsychosis, autopsychosis tations of cases which Wernicke calls ‘hyperki- and motility psychosis. In turn combinations dealt netic motility psychosis’, occurring either in the with are: auto-somato-psychoses; allo-somato- puerperium, or in relation to menstruation. psychoses; motility-allo-psychoses; motility- Symptomatology is then extended from motor somato-psychoses; motility-allo- psychoses; and manifestations to speech pathology, and to com- lastly, auto-allo-psychoses. pulsive choreatic movements; and there is discus- sion of what might today be called either akathisia Synopsis of L37: This lecture, another long one, or restless legs syndrome, and other syndromes deals with the disorder mentioned many times driven by unusual sensations. earlier in passing, Progressive Paralysis. While he recognizes that it has some relation to syphilis, Synopsis of L33: This continues from L31, deal- perhaps caused by a transmissible agent (not nec- ing with situations when ‘intrapsychic hyper- essarily the same as that for syphilis), he is function’, described in L31, escalates further. He ambivalent about the relation between the two. thus deals with more severe grades of mania This is understandable, since in 1900, when the (‘confused mania’ and ‘agitated confusion’), lecture was written, the spirochete had not been leading to discussion of ‘amentia’, a term origi- discovered, nor had the Wasserman test to iden- nating with William Cullen and used by Meynert, tify it been developed. Given this, Progressive but which Wernicke believes to be too broad to be Paralysis was of central importance to Wernicke, helpful. because its clinical manifestations overlapped Editorial Commentary 337 with other forms of psychosis, and yet could be Synopsis of L41: Wernicke’s fi nal lecture covers a linked to identifi able neuropathological change, number of general topics, dissimulation (dis- which could be correlated with specifi c clinical guise) of mental illness, the opposite—simula- syndromes. It was thus an important basis upon tion (or exaggeration) of it in healthy persons, which he could conceive a neuropathological and the proper role of mental institutions (and, in basis for a wider range of psychotic syndromes. his view, the inadequacy of alternatives). His fi nal section deals with his hopes for the future, Synopsis of L38: This lecture, spanning all earlier especially the possibility of basing understanding ones, is about aetiology of mental illnesses. of mental disorders on a secure pathological Aetiology had already been discussed in the con- anatomy. Although Progressive Paralysis is an text of Progressive Paralysis (L37), with neuro- important pointer, he is clear that most ‘func- pathological evidence. Here, there is no tional psychoses’ are unlikely to reveal any ana- neuropathology, the focus being on pathological tomical fi ndings, were cases to come to autopsy. processes inferred from symptoms, and ‘proxi- He nevertheless expresses in a closing section his mate causes’, that is the circumstance in which optimism, in the face of numerous nay-sayers, for particular syndromes most often arise. Topics a future when there is a secure scientifi c basis for include psychoses linked to alcoholism, cocaine the subject of his major life’s work. A century (then as now), poisoning by heavy metals (lead, later, his hopes are still to be realized. arsenic compounds), infection diseases (tubercu- losis, syphilis), the hereditary basis for mental ill- ness, and links between epilepsy and psychosis. I I . Unnamed Acknowledgment

Synopsis of L39: This lecture continues the aetio- In Wernicke’s Foreword to the 1894 edition, he logical grouping of psychoses, covering a variety mentions an ‘advocate of theoretical natural sci- of topics, especially disorders occurring at transi- ence’ who provided ‘stimulation and guidance’, tional periods of life. Topics dealt with include and may have been a critical supporter, without hysterical absences, psychoses of adolescence whose encouragement this work would never and puberty (including hebephrenia), senile psy- have seen the light of day. Who was this? It can- choses, menopausal and menstrual psychoses, not be discovered from Wernicke’s correspon- and puerperal psychoses. In addition, following dence, since most of it is lost. Was he a recent new concepts in general medicine, he con- neuroscientist, neurologist or psychiatrist of the siders the separation of general and special aeti- time? The most likely such candidate would then ology (the latter originating in specifi c body be Theodor Meynert, his own mentor, whose por- systems or organs). This leads him to consider trait hung on the wall of his consulting room (see delirium due to inanition, and psychoses arising L26); but Meynert died in 1892, 2 years before during other bodily disorders. the 1894 edition. Moreover, Wernicke gives thanks to the un-named person ‘for his stimula- Synopsis of L40: This lecture discusses how the tion and guidance over the hours and days of a overall course of mental disorders might be rep- chance encounter’—hardly the acknowledgment resented and reported, including measures of he would give to his own, recently deceased intensity and symptomatic extent across time. mentor. Was it Gustav Fritsch (1838–1927), 10 The second half deals with dementia, a topic years Wernicke’s senior, Professor of Physiology mentioned frequently in earlier lectures, and now at Berlin University, and who, with Edouard in more detail. Wernicke considers this under Hitzig, fi rst showed, by electrical stimulation, the heading both ‘congenital’ and ‘acquired’ demen- orderly layout of motor representation in the tia, and discusses terms for grades of dementia, cerebral cortex? Was it Paul Flechsig, foremost ways of assessing it, and dementia occurring in German neuroanatomist of the day, also infl u- several clinical contexts. enced by Meynert, and director of the Clinical 338 Editorial Commentary

Institute of Psychiatry and Neurology at Leipzig took the symptoms he found in his patients as the (an easy journey from Breslau)? In his fi rst primary facts. As discussed later, Wernicke’s Lecture, while praising such predecessors, nota- whole approach, and especially his emphasis on bly Meynart, Wernicke sees signifi cant weak- scientifi c reasoning, appears to be that of a natu- nesses in their approach to scientifi c psychiatry, ral philosopher, not that of a typical biomedical and he had little time for some of them (for scientist. In the fi rst eight lectures, many topics instance Hitzig). This suggests that he intended are referred to which correspond exactly to those to attempt something better. In several places in with which Mach dealt. In his obituary Ziehen Grundriss, Wernicke makes it clear that he describes Grundriss as having being written attempts to supersede Meynert’s teachings. ‘almost as if a science of psychiatry did not yet It is noteworthy that he identifi ed this unnamed exist’ [4 ]. Of course it did exist, and had done so person as ‘an advocate of theoretical natural sci- for a century; but Wernicke was independent of ence’, possibly hinting at a theoretical physicist. it. The fi nal sentence of L41 reads as follows: ‘I In the German-speaking world before Einstein, want to draw your attention to one point, and that the foremost theoretical physicist was Ernst is that these, my last comments, should serve to Mach (1838–1916), who, between 1867 and remind you of the need for those theoretical con- 1895 held a chair in physics at the Charles siderations which occupied us in the fi rst half of University, Prague, an easy journey from Breslau. our clinical studies, but, for you, perhaps often Mach is best known for his philosophical and quite diffi cult to understand.’ Clearly, in his fi rst theoretical work. The main way in which this eight lectures, Wernicke was informed by insights might have fulfi lled his role of chair of right outside the fi eld of study of his very able Experimental Physics, was that his philosophy students, which he knew they might struggle to was that of a thorough-going empiricist. Theodor comprehend, and yet which he took to be of criti- Ziehen, who together with Wernicke, founded cal importance. In conclusion, we believe that it Monatschrift für Psychiatrie und Neurologie, and was Ernst Mach to whom this anonymous was much cited by Wernicke in Grundriss , was acknowledgment refers; but we have been unable himself much infl uenced by Mach [ 2 ], and is to fi nd any direct evidence of that ‘chance likely to have met Mach. That it was indeed encounter’. Mach who inspired Wernicke is made plausible In preparing the index for our translation by several other facts: Mach himself made con- (based on a translation of Wernicke’s own index, tributions to both sensory physiology and phi- plus items referring to this Editorial Commentary) losophy of science (both of which pervade we gained another insight into this matter. We Grundriss , especially in early lectures). Mach realized that items which Wernicke chose to himself gained his inspiration in both areas from index were based on fairly orthodox concepts, Gustav Fechner (1801–1887), who spent most of while his most distinctive theoretical ideas, such his life in Leipzig, and was also a major infl uence as sejunction were under-represented. We con- on Wernicke. The three of them worked in clude that, in indexing, he was playing to ortho- neighbouring university cities. Uniquely, Mach dox medical expectations of the time. However, as a natural philosopher did not take variables careful reading of his text leaves us in no doubt such as mass and force as primary concepts, as that he thought the fi rst eight lectures, and his did Isaac Newton. They were derivations, not more distinctive theoretical concepts were a cru- ones related directly to empirical facts. Rather, cial foundation for his clinical ideas; and also that his primary concept was ‘sensation’ ([3 ], p. 82). they were likely to be beyond his audience, Corresponding to this, Wernicke never took dis- despite their being advanced students. Perhaps he ease concepts as the primary facts to be explained, was reticent, shy, possibly even a little embar- these inevitably being indirect derivations and rassed about his theoretical contributions. This is therefore of questionable validity, to which relevant to the 1894 foreword, and the acknowl- symptoms would then be secondary. Rather he edgment to the anonymous person—who we Editorial Commentary 339 think was Ernst Mach. Wernicke probably real- dence of diseases, and precious few national sta- ized that the person to whom he addressed ‘these tistics. In L30 (pp. 210) Wernicke makes apologetic intentions’ really was a supreme sci- impressionistic comments on the high prevalence entifi c theoretician. In any case there is an enigma of melancholia; but only once (L40, p. 313) does about why he did not name this person: The sug- he give any quantitative data on incidence of par- gestion just made is not the only one possible. ticular conditions, when he cites statistics on mortality related to mental illnesses in asylums, probably the nearest anyone could get to accurate III. The Medical Scene at Breslau statistics at the time. In 1893, at a congress of the in Wernicke’s Day; Typical International Statistical Institute, a French physi- Psychiatric Practice cian, Jacques Bertillon, made a distinction, for purposes of epidemiology, between general dis- Breslau, located on the river Oder, was, at the eases and those localized to a particular organ or time of Wernicke’s fi rst edition of Grundriss, a anatomical site (the Bertillon Classifi cation of leading centre for medical research in the German Causes of Death). The fi rst conference to revise empire, with many now-famous names working the International Classifi cation of Causes of there; and a large proportion of contemporary Death took place in 1900, from which, eventually clinical and scientifi c researchers, to whom he the International Classifi cation of Diseases (ICD) refers, were working there, or had done so. It was emerged as an administrator’s instrument. The an exciting time in medical research. Recent dis- distinction made by Bertillon probably led coveries included the transmissible agents Wernicke to write (L1, p. 4): ‘Let us recall the responsible for tuberculosis, tetanus and diphthe- division of brain diseases into focal disease pro- ria (and the toxins produced by the latter two cesses and general diseases; mental illnesses will agents). The neurone theory was coming to be certainly not be subsumed under the former, but generally accepted; and, building on advances in possibly under the latter.’ the German chemical industry, new stains were By the time that Wernicke was revising the text available which led to exciting new work in neu- for the 1906 edition of Grundriss , he was work- rohistology and neuropathology. However, for ing in Halle, and the prestige of the Breslau medi- most disorders, whether in general medicine or cal centre had declined. In its heyday, bacteriology psychiatry, the best treatment that could be and dermatology had been prominent specialties achieved was excellent nursing care and symp- there. Sexually transmitted diseases, especially tomatic relief. In L39 (p. 307), Wernicke writes, syphilis, were major topics for research. Of inter- on psychoses occurring in the context of other est here, what was probably the fi rst effective stat- bodily disorders: ‘The prognosis of symptomatic ute law on medical ethics was passed in Prussia psychoses depends exclusively on the course of in 1900, following a research scandal in the the underlying disease, whose prospects, of dermatology department in Breslau, deriving course, can only be infl uenced unfavourably’. He from research on syphilis. At the time, evidence thus accepts that, for most diseases, there was no on fundamental aetiology for brain disorders was effective treatment, although good general care very limited (except for correlations between favoured natural healing. lesion location and symptoms), a shortcoming Through most of the nineteenth century, Paris refl ected throughout Grundriss. However, per- had been the leading centre for medical research, haps because of the paucity of techniques avail- but by Wernicke’s day, Vienna and several able, those that were used, were employed with German centres were worthy rivals, as French- great care and in meticulous detail. In psychiatry, and German-speaking worlds competed on sev- the one method that was available was docu- eral fronts. International conventions for defi ning menting and analyzing psychiatric symptoms. diagnoses had not yet appeared, so there were no Grundriss describes this in greater detail than cross-national statistics on prevalence or inci- one might fi nd anywhere today. 340 Editorial Commentary

The institution where Wernicke practised infl ammation of arterial adventitia. In L38 included many patients with what are now recog- (p. 294) he refers to ‘childhood cramps’, painful nized as neurological conditions, as we read in muscle spasms which may be provoked by exer- his clinical descriptions. Moreover, many inmates cise and various metabolic or hormonal changes, of asylums suffered from the ravages of tertiary not viewed today as having adverse long-term syphilis; and some of the phenomenology sequelae . In his day, cramps may have been a described by Wernicke (for instance in L20) is ‘proxy’ for some more serious problem, related the result of this disease, rather than what we now perhaps to poverty, poor nutrition, or some other recognize as mental disorder. Various syndromes, aspect of life’s hardships. In his discussion of notably ‘general paralysis of the insane’ (GPI: extended regimes of tube feeding of akinetic German—Paralyse der Irren), now known to be patients (L34, p. 258) he is well aware of the dan- syphilitic, would have been common in the asy- ger of ‘scorbutic’, that is ‘scurvy-like’ lesions. lum populations. In 1903, the causative agent The fact that scurvy could be cured by various was discovered, but the diagnostic test for the dietary supplements such as citrus fruits had long spirochete was not yet available, so the diversity been known. That the anti-scorbutic factor was of syndromes it caused was not yet clarifi ed. ‘hexuronic acid’ (‘Vitamin C’), was not proven Tuberculous meningitis, mentioned in L38 until 1932. Wernicke clearly retained his skill in (p. 294), is now rare in developed countries, but surgery, for instance when he writes L34 (p. 249) is the commonest form of chronic CNS infection of a patient with a syndrome of rigidity in jaw in developing countries, and probably was so in muscles: ‘I decided on “re-positioning” under Wernicke’s day. chloroform anaesthesia, and fi xed his jaw in a Alcohol abuse was also a major issue for psy- half-open position’. chiatric practice. We now know that many of the Public attitudes to psychiatry appear to have psychiatric sequelae of excess drinking are not been a mix very similar to those found today. In due directly to alcohol, but to poor nutrition, and L9 we hear Wernicke, echoed by other enlight- defi ciency of thiamine (vitamin B1). In L27 ened practitioners, expressing concern about the (p. 179) Wernicke refers to ‘alcoholic degenera- poor grasp by the general populace of the reali- tion’ in the context of Delirium tremens . That ties of mental disorder, along with calls for public state is, in itself, a withdrawal syndrome not education. There are hints of diffi cult public rela- linked with neuronal loss, but may become tionships, where he refers to ‘the familiar refor- linked, when combined with chronic alcoholism, matory idea of those philanthropists’. In L17 and thiamine defi ciency. Later in the same lecture (p. 101) he advises his students thus: ‘I cannot (p. 180), he mentions the poor general health and emphasize strongly enough, that you have the cachexia of such patients, an expected precursor right to declare a person mentally ill only when of impaired memory, now known as a sequel of you can produce evidence of this by establishing thiamine defi ciency. Later in L27 (p. 182) he defi nite psychotic symptoms; only then will you writes ‘restoration of function’ after a period in be spared the embarrassment of your opinion hospital. being exposed to justifi ed attacks by lay people’. Throughout the clinical lectures, Wernicke Then, as now, it seems, psychiatrists were targets refers to links between mental disorders and a of public suspicion, for which attitudes Wernicke wide variety of problems in general medicine; had some sympathy. Concern over custodial and clearly he was competent both as a general practices in mental hospitals in German princi- physician and as a surgeon. In the lecture on pro- palities went back to the early nineteenth century. gressive paralysis (L37, p. 286) he mentions By the 1890s this led to the fi rst genuine anti- gumma, a non-cancerous granuloma in tertiary psychiatry movement, and, by the turn of the cen- syphilis which may appear in various organs tury, to calls for tighter legal control [5 ]. Some (liver, brain, heart, etc.), and endarteritis, another diagnoses, especially the so-called ‘moral insan- pathology of tertiary syphilis starting with ity’ linked to the ‘second state’ (dual personality), Editorial Commentary 341 were contentious then, just as today. In L28 master carpenter and his overvalued idea. (p. 193), he writes: ‘You know that this is about Members of the public could initiate proceedings cases of illness, which lawyers, unfortunately against people suspected of being mentally ill, supported by clashing opinions, have been par- which could lead to the latter being detained in an ticularly reluctant to recognize, which, in our institution. There is no evidence of processes for own view, has diverted attention from much of legal scrutiny, or appeal against medical author- both the factual reality of these pathological con- ity. However, in L41 (p. 322), Wernicke writes: ditions and their theoretical basis’. In L41 (pp. 322, ‘After several weeks had elapsed the family then 323) he asks ‘… could not a healthy person imi- decided, much against my advice, to remove the tate the speech of a mentally ill person?’ This, of patient from hospital treatment’: Clearly legal course, has been carried out in an approximate provisions did not give doctors unassailable pow- way in recent times, to draw attention to the ers to detain patients. Medical and judicial sometimes arbitrary compulsory detention in authorities were probably not sharply separated, asylums. There is no suggestion of such activism as was the case in other jurisdictions at the time in Wernicke’s day. In any case, despite early and for some time to come. ‘anti-psychiatry’ rhetoric, public views, as might In some respects, legal provisions and out- be expected, were diverse and not always chari- reach of psychiatric services were far advanced. table. In L30 (p. 210), when arguing for hospital In L24 (p. 158), and again in L25 (p. 170) it is admission in cases of melancholia, we read ‘… clear that patients could admit themselves volun- the general view is that only the insane belong in tarily, a provision not possible in Britain until the institutions’. On public perception of links 1930 Mental Treatment Act. A comment in L25 between mental disorder and violence, the issue (p. 169) suggests that community follow-up was was not schizophrenia (a term not yet coined) but undertaken in the mental health system where epilepsy (which carried similar associations in Wernicke worked. In some places, then as today, the popular mind). In L38 (p. 298) he writes: the possibility of managing short-lived periods of ‘Mostly, there is no later recollection [of acts serious mental illness at home, with intensive committed during twilight states of epilepsy]; support, was given consideration (L25, p. 170). however, except for one—albeit cursory— In L34 (p. 247) we read: ‘Patient feels that he is reminder, we fi nd that violence was perpetrated very severely ill, and asks for reports’: This as defence against a threatening situation’. He should not be taken to imply that patients had the hints here at unnecessary stigmatizing attitudes at right to access their medical reports, a possibility the time towards epilepsy, just as people with in psychiatry which is rare even today. schizophrenia or bipolar disorder are targeted Decisions about whether (and on what crite- today, yet are more likely to be victims than per- ria) to discharge patients were of central impor- petrators of violence. tance, no doubt with fi nancial issues in the In L9, it is made clear that there were legal background, but also taking notice of a patient’s criteria controlling how and when patients might current mental state. In relation to the latter, we be admitted compulsorily to a mental hospital. read comments such as (L10) ‘… the patient’s L41 (p. 321), addressing his class, he states: behaviour is in no way normal but … requires so ‘Each of you will, at some time, be in a position much patience and forbearance … that she can of deciding on the placement of a patient in a exist only in the special confi nes of an institution’ mental hospital, or having to issue a certifi cate (p. 60), or ‘After recovery from actual mental ill- that health has been regained’. The laws were ness, they prove themselves incapable of living broadly the same across Germany, but with varia- anywhere else than in an institution, on account tions in different Länder [6 ]. There are clues to of their social incompatibility, their demanding the lack of rigour (as understood today) in mental and predominantly egotistical behaviour requir- health law, and, just as today, in criteria for com- ing constant supervision’ (p. 61). Of course, then mittal. In L15 (pp. 92, 93) a story is told about a as now, such criteria might apply to many people 342 Editorial Commentary who never had any mental illness, nor spent time ment called a Pfl egeanstalt. Such places, for in an institution. Overall the quality of care was mentally or physically disabled persons were half as good as could be expected. In L40 (p. 313) we way between an asylum and what in Britain, from read ‘Such patients, after repeated attempts at early nineteenth century, was called a ‘nursing discharge, fi nally remain permanently in the home’. In Britain and the USA, these were places institutions, where they fi nd necessary protection for care of the elderly, under less austere and and care, and also an opportunity for useful activ- unsavoury conditions than obtained in the alms- ity’. In administrative terms, it seems that patients houses of the time in the USA, or the workhouses fell into three categories: ‘Recovered’ (geheilt ), in Britain. In Germany, care of elderly or disabled ‘Residual’ (geheilt mit Defekt ), and ‘Unrecovered’ persons or recuperating patients had long been (ungeheilt ), a system of classifi cation which undertaken by nurses linked to religious orders, probably applied across Germany [6 ]. although in 1869 Rudolf Virchow had recom- In several places in Grundriss, Wernicke mended that nursing be secularized. By the turn emphasizes that the best place to treat and care of the century, a large variety of Pfl egeanstalten for patients with mental disorders is in institu- existed, some secular (e.g. under the Red Cross), tions specially designed for this. In L30 he rec- some religious [7 ]. Wernicke implies that such an ommends this in the case of melancholia, because environment might sometimes be more condu- of the high suicide risk; and later (p. 209), urges cive to recovery than the institution where he that discharge should not be too early: ‘After the worked. They were not free from compulsion, illness has ended, a phase of mild manic exalta- since, in L28 (p. 186) we read: ‘During the tion is seen quite regularly, lasting only a few unusually hot summer of 1886 she was detained days or weeks; and it is always ill-advised to dis- for 2 months in a charitable institution.’ In the charge the patient before this’. In L37 (p. 287) he Third Reich, they often became centres for makes a similar recommendation for progressive euthanasia. paralysis: ‘If you are in any doubt over whether Communities outside the institution might and when to bring the patient into a mental insti- accept or reject a patient after discharge, lead- tution, it is always safest to decide in favour of ing Wernicke to comment (L16; p. 99) this’: Such general advice might not be given ‘Unfortunately, however, it is often inevitable nowadays, in public hospitals at least, simply for that patients return to a life with no structure of fi nancial reasons. One wonders what the fi nancial regular activity nor any ordered social engage- tensions might have been for Wernicke. ment, conditions that are harmful both through In Breslau itself, there appears to have been a the lack of normal interests, and also even by well developed public health system. In L32 predisposing them to emergence of depressive (p. 229) reference is made to a ‘female patient, Affects. Their main interest may then remain previously healthy, had been in the public focused on experiences of injustice; an Affect- hospital’, presumably a public general hospital. laden state of mind sets in, and further delusion- It was, after all, in Bismarck’s Germany that a formation is inevitable’. These lines ring true version of what we now call the ‘welfare state’ over 120 years. Issues of discharge planning, was fi rst adopted. On alternatives to institutional and the social milieu in which a patient might care Wernicke writes (L41, p. 324): ‘there are fi nd him- or herself after discharge, applied then experienced alienists who adopt the view that by as much as now. properly setting up a private residence, the same The harsh realities of care in institutions also can be achieved as in institutional treatment. We seem to be similar then as they often are today. must realize immediately, when discussing the Ward staff are referred to not as nurses purposes of institutional treatment, that this is not (Krankenschwester ), but as ‘warders’ (Wärter, or entirely true’. Ideas circulating then were the Wärterin), although they were probably mainly same as today, facing all the same dilemmas. In skilled professionals (and in L34, [p. 250] L24 (p. 158), reference is made to an establish- Wernicke refers to the warder’s notes recording Editorial Commentary 343 rigid postures adopted by patients). Given the Beliefs shared amongst patients in a long-stay great vulnerability of patients, they are always ward are probably often not symptoms of active likely to be subject to demeaning behaviour and illness, nor (in the above case) of religious senti- attitudes (or worse) not only from the general ment, but social constructions by disturbed peo- public, but also sometimes from staff in the insti- ple confi ned within a very strange environment, tutions, and, as we read in L9, these can lead to one where ‘anything goes’ conceptually, however bitter complaints from patients. In L18 (p. 115) absurd, as part of the ‘organizational culture’ in we read of violence within the ward: ‘On inquiry the ward. Likewise, complaints from patients we learned that he was not suffering headaches may be driven by knowledge of—or resistance but experienced very unpleasant sensations in his to—the abnormal situation of institutional life. head, which he described as dull and dragging— We also read (L10, p. 59) ‘… she is persistently they were a result of mistreatment by the ward- submissive by nature; she rises at each salutation ers’. Then as now, it may be hard to avoid physical and bows, doing this to every fellow-patient, even coercion in restraining agitated patients; although to a very feeble-minded female paralytic patient’. nowadays, there may be guidelines on suitable Such ritualized behaviour speaks of strategies to minimize this, training in ways to do institutionalization. it safely, and routines for reporting diffi cult inci- Families of patients are mentioned a few dents. Although Wernicke is well aware of simi- times . In L22 (p. 140) there are two mentions of larities between normal mental processes and families. Again in L30 (p. 203), we read: ‘… those in his patients, in L9, he confi dently regards takes no notice of visits by her relatives’. Clearly complaints of patients or former patients as ‘false visiting was possible, perhaps into the main sec- readings of reality’. Recovery of insight is more tion of a ward, although, in L23 (p. 151), there is likely for the time of admission than for the fact of a reference to a ‘visitor’s room’, suggesting that, remaining in the institution. He describes the as in many psychiatric wards today, visitors do mental content of many patients as an amalgam of not see the main part of the ward. In the recent delusional and healthy material. memory of RM, this may be obstructed in psy- Some of Wernicke’s descriptions reveal what chiatric facilities, or visitors are shown only into might now be identifi ed as signs of institutional- a special ‘quarantined’ visitors’ room; and even ization, rather than intrinsic features of any ill- in general medicine, when charters for patient ness. In L41 (p. 325) he writes: ‘There are still rights have been enacted in various jurisdictions, many such phrases used similarly by mentally ill visiting rights are not necessarily included (for people in a remarkably similar ways’; and In L29 instance in the European Charter of Patients (p. 199), we read of patients’ words, ‘often heard Rights of 2002) [8 ], the NHS Patients’ Rights, in mental institutions, that thoughts were “drawn 2013 [9 ]). However, in 2011 in the USA, legisla- out of” them’. The specifi c experience described tion was passed about visitation rights [10 ]. How here would now be called ‘thought withdrawal’, that applies to psychiatric institutions is not clear, pathological not so much for the experience itself but is likely to be more restrictive than in general but for the delusional interpretation imposed on medicine. it. However, Wernicke implies that interpretation of ‘jargon’ used by patients requires experience of the ‘local scene’. In other words, linguistic use IV. Wernicke’s Personal Style by patients to describe their experiences is devel- in Psychiatric Practice, Teaching, oped collectively as much as individually in a Writing, and in Scholarly Disputes long-stay ward, as in any other community. Other signs of institutionalization include descriptions From the outset in L1 Wernicke shows that he is such as (L10, p. 60) ‘She regards her fellow- aware that psychiatry, perhaps because of its patients as men of the cloth, usually high-ranking intrinsic complexity, was backward, compared clerics who are here in part for repentance’. with other specialties. At the very end, in a closing 344 Editorial Commentary section of L41, he assures his students that atti- We cannot miss Wernicke’s careful and realis- tudes to the discipline from other physicians, had tic assessment of what might be possible for each improved over the preceding 20 years. He patient. In days when effective treatments were advises (L1) that a teacher in psychiatry ‘should few, assessment of prognosis loomed larger than proceed as in sister disciplines of medicine’. today. So, in L10 (p. 59) we read ‘Frau Reisewitz, Clearly he wanted to adopt standards and meth- whose illness developed gradually over the last 5 ods of general medicine, as did his contemporary years, from barely noticeable beginnings, and is Kraepelin, but in a very different way. In L1 he expected to develop further’; in L16 (p. 97) ‘… also accepts that there may be different types of cases where active illness is fully extinguished mental disease, but as we shall see, his approach …’: Clearly this bore implications for ‘progno- to classifi cation was quite different from that of sis’. The prognostic indicators he used are dis- Kraepelin. cussed later. Footnotes in Grundriss were often A critical aspect of the style of practice of added retrospectively, about the eventual out- any psychiatrist is whether, to what extent, and come for patients he has presented and how, reunifi cation of personhood can be discussed. achieved after it is fragmented by mental disor- A distinctive aspect of Wernicke’s approach ders. This is a core issue, more for psychiatry if appears to be that he did not distance himself practised well than for any other medical disci- unnecessarily from his patients. Although he pline. In L7 (p. 39) we read the following: ‘After refers to doctors working in mental institutions a person has recovered from a mental illness, it as Irrenärzten (literally ‘mad doctors’)—never is required that we ensure that he has achieved ‘alienists’—he often drew parallels between insight into the abnormality of the state he has normal psychological processes and those experienced; for the sum must necessarily be underlying symptom formation in his patients. inaccurate if it contains false elements’. These We see this initially in L9, where the emphasis is words reveal what a fi ne clinician he must have no doubt intended to dispel for his students any been, in his hope that his patients recover full idea that his patients were somehow ‘alien’ to health, and in defi ning his own role in helping the rest of humanity The emphasis is most strik- each patient to regain their sense of ‘personal ing when discussing delusions, seen mainly as wholeness’ to whatever extent this was possible. plausible—even rational—attempts to explain Nowadays, lack of such a holistic approach is more primary abnormalities of experience: In the sharpest criticism made of many of today’s L13 (p. 82) he addresses his audience thus: psychiatric practitioners by service user groups. ‘Should anyone experience a feeling of deliber- We get another clue his compassionate concern ate rudeness when a greeting is omitted etc., then in L18 (p. 113). Unlike many chronic patients this also is an echo of a delusional interpreta- presented in earlier lectures, whose surname is tion’. He skilfully points out similarities, where given, here a patient is referred to just by an ini- they can be found, between the psychology he tial, because he is of some standing in the local sees in his patients, and those in his audience. In community, and likely to remain so after dis- L8 (p. 45) he speaks of ‘herd consciousness’ as a charge (which is to occur soon). He thus wanted social phenomenon, in such a way as to make to avoid his publication—which gives much clear that this also applies to himself, accepting detail about the patient—making life more diffi - that he is not only a clinician and observant sci- cult for him after discharge. Likewise, in L27 entist, but also an object of study. Subject and (p. 180), he uses initials only, to hide not only the object, clinician and patient, appear not sharply identity, but also the former place of residence of separated. In discussing the role of language in a patient who is to be discharged; and in L30 L8, he writes (p. 45): ‘… the main way to acquire (p. 203), for the same reason, an initial is given a particular order to one’s perceptions is through for the place in which one of his patients worked articulated speech’; but later, he steps back from as a nurse. his ‘real self’—an articulate, supremely rational Editorial Commentary 345 clinician-scientist—to defend himself against for childhood or adolescence, almost as one with charges of over emphasizing language in defi ning little knowledge of psychological issues faced by human nature. young persons. Wernicke knew how, as a skilled clinician, he Wernicke’s teaching style is revealed from could use those faculties of a patient still assumed time to time. There was clearly a plan to cover to be normal, along with events occurring inci- the subject of psychiatry comprehensively (with dentally, or engineered by him, as a vehicle to a ‘course curriculum’ referred to in L24, p. 162). correct delusional explanations. So, in L24 In L32 (p. 226) he refers to details presented in a (p. 158) we read: ‘this patient, was discharged ‘past semester’, so, probably the lectures were from the nursing home after 6 weeks, allegedly given across a whole year over two semesters. In completely recovered, probably as a result of the the clinical lectures, he sometimes develops his powerful impression that transfer there must have arguments by referring to cases described by had on her.’ He also knew how, on occasion, he other psychiatrists or neurologists of the day in could use the vividness of a clinical presentation Germany or France (never Britain). Often how- for therapeutic purposes beyond any of the ses- ever, patients were present—even several in suc- sion’s didactic aims; that is, to exert on a patient cession—for at least some of the lecture, or an impact more powerful, albeit subtle, than is sometimes, it appears, in sessions prior to the lec- possible in normal clinical encounters. He writes ture (L24, p. 153). There are occasional hints (L15; p. 94): ‘Clinical presentation of such cases (from comments such as ‘To our great surprise, a has proved useful to me several times, as is the turn-around occurred from yesterday’ [L32, process of ‘internalization’ itself, that is, a con- p. 223], and ‘Chance has favoured us, in that I scious ability to recognize mental illness, and to can present another patient’ [L32, p. 225]) that constantly accept paternal guidance: These are choice of patients each day was sometimes quite powerful and salutary corrective experiences.’ opportunistic. In these clinical sessions he pre- Again in L41 (p. 321) he writes of mute patients: sumably demonstrated to the class his manner of ‘Amongst the best proven ways of bringing such interviewing each patient. Detail of such dialogue patients to speak, is a clinical presentation’. is seldom recorded, but in later lectures, verbatim It is also clear that he does not hide from his dialogue is sometimes reported, showing his own mistakes. In L34 (p. 257), he writes: ‘This interviewing style, including his modelling for happened to me once, and the tracheotomy which his students how to ask about suicide (L30, was carried out immediately could not avert a p. 202). In this situation, he states at one stage: fatal outcome.’ Again in L41 (p. 322) after ‘As you see, his appearance is quite appropriate describing how a patient’s family insisted on the to the situation’, (L9, 56). Clearly, Wernicke has patient being discharged, against his wishes, he his patient in the lecture theatre, seeing no incon- writes: ‘Apparently they were right, for there was gruity about such candid public description of the no further recurrence of the delusions he had patient’s characteristics to the assembled audi- expressed previously, and he resumed his earlier ence. There might be more constraints in today’s work in a business’. world! However, at times his comments leave it The one area where Wernicke seems to have a unclear whether they are the patient’s view or his less subtle approach is with young patients. There own. This ambiguity may sometimes have been are no descriptions of children in Grundriss; and necessary, when a patient about whom he is in L39 (p. 304), when describing hebephrenic speaking is in the lecture theatre; and usually it traits in adolescents, he writes: ‘They are not to does not matter. be found in the specifi c childhood form, in which, As a lecturer, he knew how to engage his audi- the resulting feeble-mindedness in silly and fool- ence, often with personal anecdotes, or references ish beings, would seem only natural’. This com- to typical life experiences which all could share. ment, like ones in L40, betray him, Nonetheless, the lectures are dense with ideas, uncharacteristically, as one with little sympathy arguments and evidence, suggesting that, as delivered, 346 Editorial Commentary they were each followed by extensive discussion, That his lectures were, in large part, research otherwise his students would have been left seminars is clear at the start of L21, when he behind. In L28 (p. 193), he more-or- less invites acknowledges that the patient he is about to dis- discussion: ‘This might be the place for me to cuss is a ‘very complex, and as yet little known respond to an objection that you could easily form of illness’. He conveys that the lectures make’. Indications that this took place can also be were research presentations more-or-less explic- found in the fact that some cross-references to itly, when he writes (L41, p. 329): ‘Hence pre- earlier lectures refer to material, or patients not liminary work is needed, in which you have actually present in the text of Grundriss. For participated in these lectures’. There may, how- instance in L18, where patient K. is fi rst intro- ever, have been other courses, especially for duced, there is no mention of his making a suicide future administrators of asylums. attempt, but this detail is mentioned in L21, when Details are available on several members of referring back to this lecture. In L22 (p. 139) he Wernicke’s class who went on to distinguish revisits the notion of an ‘overvalued idea’ fi rst themselves. Many of the following names pro- introduced in L15; yet specifi c points mentioned duced works cited in Grundriss. Hugo Liepmann in L22 are not mentioned in L15. In addition, (1863–1925), editor of the 1906 edition of sometimes two lectures (e.g. L9 and L10, L19 and Grundriss, was himself a noted psychiatrist and L20) appear so closely connected as to suggest neurologist, who had worked closely with that they were given close together in time, even Wernicke from 1895 to 1899. He was noted for on the same day. Sometimes we are left to infer studies of cerebral localization of function, the the occasions when patients, who are referred to, fi rst to describe several neurological syndromes, have been met in other situations, without know- later becoming director of the Herzberge asylum ing when or where this occurred. Later lectures in Berlin. Ernst Storch was Wernicke’s loyal often cite in-house reports (Krankenvorstellungen assistant, one of his fi rst co-workers. He was aus der psychiatrischen Klinik in Breslau). appointed privat-dozent in Psychiatry at Breslau His audience appears to have consisted of very in 1902, and had previously been fi rst-assistant in advanced students. They were quite familiar with the psychiatric clinic there. In 1901, he published routine neurological problems, since, in L37 Psychologische Untersuchungen über die (p. 286) he writes: ‘You are so often called to deal Funktionen der Hirnrinde, zugleich eine with a so-called “stroke” that your fi rst question Vorstudie zur Lehre von der Afasie [ 11 ], recently must be whether you are dealing with a possible republished. Biographical detail on Storch is paralytic attack’. In introducing L41, he begins: obscure. Karl Bonhöffer (1868–1948) was a psy- ‘These lectures can hardly be intended to intro- chiatrist who worked briefl y in Heidelberg duce you to the practical medical specialist (1903–1904), but moved to Breslau, where, training course for the asylums. Whoever wants under Wernicke, integration of neurology with to dedicate himself totally to our specialty is of psychiatry was possible. He gave detailed course expecting to spend a considerable part of descriptions of Delirium tremens (L26, p. 175), his life in mental institutions, and among men- and may have challenged Kraepelin’s view that tally ill people, a task that in some respects you categorical disorders were to be defi ned by symp- can imagine is not suffi ciently challenging, but tom clusters [ 12]. After Wernicke’s death he also not suffi ciently gratifying and interesting … defi ned the conceptual separation of endogenous it is therefore imperative to give you some orien- from exogenous psychoses. His son, Dietrich tation on practical issues, including the specifi c Bonhöffer was the celebrated theologian who, tasks of the asylum, and the simulation and dis- from within Germany, resisted the Nazi regime, simulation of mental illnesses’. Clearly members and was, imprisoned and executed in the last of his audience are likely to become researchers; days of World War II. Karl Heilbronner (1869– but here, he descends to mundane matters, likely 1914) worked at Wernicke’s clinic from 1894 to also to be important in their subsequent careers. 1898, and between 1897 and 1903 headed an Editorial Commentary 347 observation ward for mentally ill prisoners there. fellow physician, whose situation became pre- Karl Kleist (1879–1960) continued Wernicke’s carious in a local society, on account of his approach to description of symptoms, originated Jewish wife. Heinrich Lissauer (1861–1891) was the terms ‘unipolar’ and ‘bipolar’ for Affective a neurologist and neuropathologist at the psy- disorders, made detailed studies of many head- chiatric institute in Breslau. Despite his early injury cases from World War I, and is known death, his name is associated with several signifi - today as continuing what became the Wernicke– cant advances, making studies on the pathology Kleist–Leonhard tradition. Kurt Goldstein of Progressive paralysis, having a tract in the spi- (1878–1965) became an advocate of anti- nal cord is named after him, and the fi rst to localizationist neurology. When Hitler came to describe visual agnosia. Clearly Wernicke power, being Jewish, he was imprisoned for a thought highly of him; Paul Schroeder (1873– short time in Berlin, then expelled from Germany, 1941) worked with Wernicke in Breslau, with going fi rst to Amsterdam, then to the USA, where Kraepelin and later with Nissl in Heidelberg, and he founded Gestalt therapy. Heinrich Sachs with Bonhöffer in Berlin, to become professor of (1863–1928) was an early researcher on amyo- Psychiatry at the University of Griefswald in trophic lateral sclerosis. After working with 1913. In 1937, he became fi rst president of the Wernicke at Breslau, he became head of the divi- International Society of Pediatric Psychiatry, but sion of neurology and neurosurgery in the Jewish retired the following year. hospital there. Otfrid Foerster (1873–1941) stud- In the fi rst clinical lecture (L9) Wernicke ied under Babinski in Paris, returned to Breslau enunciates the maxim that one should start one’s to become a pioneer neurosurgeon, and spending analysis with the simplest situations, before mov- much time later in Russia. His most famous ing to more complex ones. In consequence, he patient was Vladimir Ilyich Lenin, and it was chose to deal fi rst (L9–L17) with stabilized men- Foerster who recommended that Oskar Vogt tal abnormalities seen long after acute stages of examine the latter’s brain, after his death from disturbance have subsided, before going on to stroke . Edmund Forster (1878–1933) was one of acute states. His maxim may be sound; and given Wernicke’s later students. During World War I, as the realities of practice in his day, was no doubt a military physician, one of his patients was applied correctly. Better this than trainees (then, Adolf Hitler, who was treated and hypnotized by and perhaps still today) being ‘thrown in at the him after a gas attack, and whom he described as deep end’, making it hard for them to reconstruct a ‘psychopath with hysterical symptoms’. He all the steps between normality and severe dys- committed suicide in 1933 under persecution ; function. In psychiatry, the implied alien status of Ludwig Mann (1866–1936) studied with inmates could then only be reinforced. Whether Wernicke and became professor at St this was true or not for Wernicke, it is likely that Georg- Krankenhaus, Breslau. In 1896, he pub- patients most commonly encountered in his insti- lished Klinische und anatomische Beiträge zur tution were those whose acute disturbance had Lehre von der spinalen hemiplegia [ 13 ]. Robert subsided to a stable state, however abnormal. Eugen Gaupp (1870–1953) was an assistant to However, in a number of areas of medical educa- Wernicke at Breslau, and afterwards worked with tion, there is tension between what is best from a Emil Kraepelin at Heidelberg and Munich, later didactic point of view, and what is possible prac- to become a professor of psychiatry at Tübingen tically. For instance, one of us (RM) has argued (1908–1938). He studied the relationship between [ 14 ] that, in teaching gross anatomy, spatial rela- psychosis and personality, advocated for ‘pasto- tionships in body cavities are grasped more eas- ral psychology’, and after World War II, headed ily by starting with, ‘empty’ cavities, and then the department of health and welfare in Stuttgart. adding organs one by one; which is exactly the In 1935, after passage by decree of the opposite of what is normally possible in a dis- ‘Nuremberg Laws’ (‘for protection of German secting room course. The way in which Wernicke’s Blood and Honour’), he came to the defence of a maxim might be applied could likewise be 348 Editorial Commentary questioned in today’s world: Mental states in acuity decreased to 30 cm on the left and 20 cm chronic stabilized cases may appear simple, but on the right.’…‘we discovered particularly poor to understand them fully depends on understand- bone conduction; against the skull or mastoid pro- ing processes leading to this ‘end state’, which cess the clock was not heard at all.’ In testing the are by no means simple. By L17 Wernicke pupillary light refl ex we read (L24; p. 159): ‘His reaches just this conclusion. In today’s psychia- pupils were fairly narrow, equidistant, and wid- try, where most patients recover from acute psy- ened only a little, when his eyes were shaded.’ In chosis, the best place to start education for trainee L34 (p. 397) we read ‘Refl ex excitability of cuta- specialists may be open discussion with people neous capillaries is normal’. Presumably this who are distant from acute episodes, but whose refers to the axon refl ex, producing the reddening memory for, and insight into those episodes is of the skin when scratched, a clinical test which, good enough to help such trainees grasp the we believe, is not routine today. In L8, we read of unfolding processes. Indeed, in L18, Wernicke Wernicke’s simple clinical test to assess ‘short- makes use of exactly such an insightful patient, term memory’, subsequently referred to as ‘reten- who has reached near-complete recovery. tion of memory’. Much as today, this involved In addition, in L17, the last dealing with testing recall of ‘a three-digit number, a foreign- chronic conditions, he writes as follows (p. 105): sounding word which she should have retained ‘… after many years of work I had to decide to after interposing a short question’ (L27, p. 180). reverse my strategy, and to start working from the In L30 (p. 203), we read of long-term memory ground upwards, placing acute mental illnesses, tested separately for recall and recognition. which are still the main source of paranoid condi- Attentiveness was apparently tested separately for tions, as the precursor of the latter [chronic con- each of the three domains of experience (L27, ditions]’: This sentence is important. In L9–L17, p. 285). For speech articulation Wernicke had his spe- Wernicke deals with chronic conditions, paying cial probe words (Zivilisation, Armeereorganisation, little attention to their relation to acute ones. Guiglelminetti, Exterritorialität [‘civilization’, Here, however, he feels the need to reverse the ‘army reorganization’, ‘Guiglelminetti’, ‘extra- emphasis; and later lectures fi ll out details of the territoriality’]). His test of cognitive capacity was shift in strategy. We comment here, that, in the to ask a patient to recognize, count, and make a sequence of 41 lectures we both had the clear tally of a number of coins. At various points he impression that Grundriss is not so much a com- uses the phrase ‘closed train of thought’, attrib- pletely pre-planned presentation of Wernicke’s uted to Meynert. In L20 (p. 130), it becomes clear ideas, but rather a progression of his developing that this phrase describes a method of testing ideas. In particular, in the transition from chronic higher cognitive functions, where he writes of to acute disorders, we felt that later clinical ‘absent-mindedness, that is, the intractable nature lectures were almost superseding earlier ones of thought processes, and inability to follow a (although at times in the later lectures his consis- closed train of thought.’ tency in use of terms defi ned earlier became Wernicke’s written style is hard to separate looser, perhaps because he was writing in haste). from his style of reasoning, discussed later; and At various points in Grundriss, we get glimpses we are ill-equipped to assess it in comparison of Wernicke’s methods of clinical examination. with that of contemporary German researchers. Basic assessment of sensory and refl ex motor Overall, Grundriss is closely reasoned, with capability probably differed little from today. For small phrases in early lectures being developed auditory acuity, a test familiar today is described later, in a meticulous way, and special terms used (L24, p. 158): ‘On admission she understood with great efforts at consistency. However, there speech whispered at 3–3½ m.’ …‘Over the fi rst 2 are many superfl uous words, academic niceties, months there was a clear decrease in her auditory unnecessary qualifying words, double negatives, acuity. This was noticeable even at ordinary con- and tautologies. Perhaps this refl ects how he versational levels; for whispered speech, auditory delivered the lectures. Sometimes there are Editorial Commentary 349 colourful idioms. For instance, in L13 (p. 83) a often underlie a very severe feeling of illness, as young man, embittered against his father, had the proven by occasional examples of rapid onset, intention of ‘setting him straight’, without mur- resolved by relief of muscle pain.’ We inferred dering him ( ihm etwas Ordentliches zu verset- the meaning here in respect of a single word we zen ); in L28 (p. 193), he writes: ‘However, this added, ‘resolved’. What was actually written assertion does not hold a candle’ ( Diese was: Muskelschmerzen liegen Häufi g einem sehr Behauptung hält aber vor den Tatsächen nicht schweren Krankheitsgefühl zugrunde wie ver- Stich ); in L35 (p. 290), he uses the phrase ‘ über einzelte Beispiele rascher Herstellung durch jahr und Tag’, familiar in English as ‘for a year Beseitigung der Muskelschmerzen beweisen. In and a day’; and in L24 (p. 162) he uses the meta- L28 he writes (p. 188): ‘the sensorium is appar- phorical term ‘burnt out’, which has been used in ently well- preserved; on the other hand, to some many ways. In medicine it might refer to the end- extent, there is a break in continuity in conscious- stage of an epidemic, or of an incurable disease ness of personhood, such that two personalities, such as leprosy (in Graham Greene’s novel A very different from each other, override each burnt out case), or to the end-stage of chronic other’; yet later (p. 191), again on the ‘second schizophrenia. In the nineteenth century, it led to state’ he writes: ‘Interrupted continuity in con- mythology about ‘spontaneous human combus- sciousness of personality is totally lacking here, tion’, a case of which is described in Charles and appears only temporarily during the recovery Dickens’ Bleak House; and today is revitalized as period.’ Probably he was pointing to a contrast ‘workplace burn-out’. found amongst ‘second state’ patients, but gives A few points need clarifying, where he is little sign that he is actually making a contrast. In over-concise. For instance, in L31 (p. 219) where L33 (p. 241), what he writes seems to be repeti- he writes ‘… the disorder is mainly one of form’ tious: ‘If … we must acknowledge confused he implies (we presume) but does not say ‘rather mania as an independent clinical picture, and fi nd than of content’; or, in L39 (p. 303) we read ‘the its essential sign as an increase of the intrapsy- familiar tendency for akinetic motility psychosis chic hyperfunction to the point of incoherent to be transformed into dementia might be based fl ight of ideas, we cannot consider it accidental, in part on this aetiological relationship’, probably that such conditions tend to occur especially after referring to (but not mentioning) Kahlbaum’s severe attacks of confused mania or agitated con- concept that transitional periods of life make aeti- fusion’. Occasionally sentences seem incorrectly ological contributions to some mental disorders. phrased, as in L19 (p. 119), where the German Sometimes, the line of reasoning becomes hard reads: ‘erfolgt das Abklingen der Phoneme in der to grasp when describing the ‘second state’ Weise, daß die Kranken nicht mehr deutlich spre- (L28). For instance, in L13 (p. 82), we read: chen, sondern nur ein Flüstern hören ’. We trans- ‘Therefore, it follows from this that, as abnormal late this literally as: ‘the phonemes fade out in excesses of activation continue, phonemes, which such a way that patients no longer speak clearly tend to appear only intermittently in such cases, but hear only a whisper.’ Surely what he meant require a special amplifi cation of activation was ‘the phonemes fade out in such a way that before they come to a standstill.’ We could not patients no longer hear clear speech but only a come to a conclusion of what was meant here. In whisper.’ L17, (p. 106) we read what seems to be a non There are also some signs of Wernicke’s haste sequitur: ‘So, the great mystery remains for in preparing Grundriss. In L6 (p. 34), his usual Griesinger: how such regularity of content can greeting to the class ‘Mein Herren!’ is abbrevi- arise—the occurrence of ideas of grandiosity and ated to ‘M.H.’; and in L39, the greeting is omit- persecution, in which “perhaps among ten ted. In the later lectures, some clinical descriptions patients, only fi ve throughout the whole duration are synoptic, even to the extent of not being fully of the disease, form the main content of the delir- formed sentences; and his index included a few ium.”’ In L24 (p. 162) we read ‘Muscle pains index items, but no corresponding page numbers. 350 Editorial Commentary

Probably this refl ected the pressured existence pioneer of an earlier generation (L19). It is not which he had to maintain, making perfection of clear that he knew of the work of Pierre Janet, written style a minor concern; and also a note- who, although working at Hôpital de la Salpêtrière format may have been habitual amongst busy cli- in Paris during the period when Grundriss was nicians, then, as now. In L32 (p. 228) much of the written, was not so well known, and was at this last paragraph is in note form, but we expand it, time no longer focusing on hysteria [16 ]. Some of to form full sentences. On p. 230 we render such Wernicke’s ideas, notably the division between a fragmentary section as accurately as possible in positive and negative symptoms, and on hierar- translation. Presumably he is reporting straight chical organization in the brain were similar to from Dr Kemmler’s notes. In Wernicke’s index, it those of his English contemporary, the neuropsy- seemed that some items did not refer to the page chiatrist, John Hughlings Jackson (L2; L11, p. 66; he had assigned for them. etc.). Both were fl uent practitioners in areas where Ambiguity about whether views expressed dur- psychiatry and neurology intersect. There is no ing clinical demonstrations were the patients’ evidence of direct infl uence of Jackson, and none views or his own has already been mentioned. of the sources he cites were in the English lan- Usually it does not matter; but a 100 years later a guage. A few are in French; one assumes that little clarifi cation may be needed. In L29 (p. 199), Wernicke could not read English papers. we read: ‘At times she showed a feeling of anxiety, Academic disputes are normal amongst which severely disturbed her sleep because of her researchers, and not always gentlemanly. thoughts’; and in L35 (p. 246) he writes: ‘Stress Wernicke’s style in controversy seems to have and many sleeping drugs were given as the cause been quite generous, sometimes with touches of of the illness’: Of course, sleeplessness, while no gentle humour. In L17 (note), after giving his doubt accompanied by vigorous thoughts, proba- views on his French rival, Dr Magnan, he adds: ‘I bly has its own causes, at the level of brain biol- am delighted to be able to state that in my critical ogy, rather than in the realm of thought content, or opinion of Magnan’s teaching I have encountered ‘stress’. In L34 (p. 246), our translation reads: heat. But furthermore, I believe that in the funda- ‘When she closes her eyes, she sees bright colours. mental ideas that he expresses in his important She must be watched, when she closes her eyes’. book on the delusion of querulousness, despite Here there is a sharp juxtaposition of a clinician’s all the polemic directed against me, I perceive identifi cation of a symptom (based on a patient’s that I detect a pleasing agreement.’ He also writes report), and the patients self-referential statement. ‘Works of an eminent French psychiatrist, Wernicke clearly kept abreast of contemporary Magnan, have drawn us, even here in Germany, developments in other centres: He was well aware in his direction, in the back-and-forth swirl of of developments in Vienna, where he had studied, public opinion’: The hint at enduring hostility as well as other German-speaking centres, includ- between Germany and France can be understood, ing Prague, mentioning Arnold Pick, who he met given that Wernicke had been a surgeon during in 1875 when they had both worked under the Franco-Prussian war. His generosity of spirit, Westphal in Berlin [15 ]. There appears to have does not prevent his making wry jokes over been on-going dialogue with Freud (section national difference. In L4 (p. 22), he writes: ‘Not VIII,(s) ‘Wernicke’s Distinctive Clinical Concepts everyone is a Shakespeare, but you will be sur- in Psychiatry’—Wernicke’s Links to the Emerging prised when we soon pass to the other extreme Dynamic Tradition in Psychiatry). His awareness (among civilized nations!): the vocabulary of an of developments in Paris include several mentions English seaman does not exceed a few hundred’. of Charcot, and L7 mentions a ‘recent case’ (The exclamation mark is Wernicke’s.) In L30 described by him. Since Charcot died in August (p. 207), he writes: ‘The consequence of self- 1893, this was unchanged from the 1894 edition. knowledge of this is a state of pathological indif- Other references to French researchers of the time ference and inner emptiness, whose prototype is include Magnan (L17) as well as a Esquirol, a the blasé attitude, the renowned ‘spleen’ of the Editorial Commentary 351

English.’ Metaphorical use of the word ‘spleen’ dealing with a well-known, and relatively simple has shifted over time—for Shakespeare, it was disease state which is given the accurate name of ‘irritable’; in eighteenth and nineteenth century Paranoia chronica simplex. Then it is easy to England, ‘hypochondriacal’ or ‘hysterical’, or ‘in arouse the impression of intentional deception, bad humour’; and today, ‘prone to outbursts of for both judges and lay people, thereby harming anger’. It is not quite clear what Wernicke thought the reputation of the entire alienist profession.’ to be typical English traits, but he seems not to be The anonymous acknowledgment in the paying any compliments! Foreword of Wernicke’s 1894 edition is some- In L17 Wernicke has sharply critical words times taken to refer to Theodor Meynert, his for- directed against the concept of Paranoia chron- mer mentor. It is thus interesting to see how ica simplex. This refers to one of four types of Meynert is cited. (See [19 ] for a recent appraisal paranoia proposed by Theodor Ziehen [ 17 ], then of Meynert’s scientifi c work.) Certainly Meynert about 30 years old, but who is not named. is the most cited of all researchers in Grundriss. Wernicke’s target may have been more senior, In L1 to L8, he is mentioned with non-specifi c perhaps Otto Binswanger at Jena, under whom praise. So, in L1 we read ‘Work of men like Ziehen was working at the time. In L33 (p. 236) Griesinger, H. Neumann, Kahlbaum, Meynert, there is milder criticism on a matter of terminol- Emminghaus and many others, has not been in ogy. Ziehen later became professor in Halle in vain’; ‘Psychiatry today enjoys more general rec- 1903, 1 year before being replaced by Wernicke. ognition, and this would have been welcomed as From 1897, they jointly edited Monatsschrift für progress by a thinker like Meynert in his time.’ In Psychiatrie und Neurologie, and Ziehen pub- L2 (note), the reader is referred to the collection lished an eloquent and generous obituary therein of Meynert’s ‘popular scientifi c treatises’. at the time of Wernicke’s death. Even with those Sometimes he is cited as having established what who took opposed positions on basic philosophy, by Wernicke’s time had become basic facts about he is generous. Heinrich Neumann preceded the nervous system: ‘We learned from Meynert Wernicke as director of the institution in Breslau that voluntary muscles and sense organs are (with Wernicke as his assistant) until the latter’s linked with the cerebral cortex by conducting death, and was one of the last Psychiker psychia- pathways that extend, in physiological continu- trists, and opponent of Griesinger [18 ]. Despite ity, through the brain, the spinal cord, and the their having opposed philosophies for mental dis- peripheral nervous system. Meynert named the order, Wernicke has no hesitation in citing and aggregate of these pathways, where the ‘law of commending his work, in preference to his own isolated conduction’ predominates, the projection mentor, Meynert (L19, p. 124). The gentlemanly system’ (L1). Meynert’s conceptualization of fac- approach to rival research personalities shifts to a ulties remaining after transection at the level of sharper tone, when dealing with issues , espe- the cerebral peduncle is mentioned in L5, and his cially in L17, those of classifi cation. Following classifi cation of movements, into ‘defence’ and his cautioning trainees against over-hasty diag- ‘attack’ is cited several times. Sometimes his nosis of mental illness without fi rm evidence of analogies are cited. (Meynert, polymath that he symptoms (beginning ‘I cannot emphasize was, included poetry amongst his talents, so nat- strongly enough …’) he continues (pp. 101–102): urally thought in terms of vivid metaphors [20 ]) ‘The “general impression” sometimes relied on The ‘enclosed pipe system’ (L4) as an analogy even by better-known representatives of our pro- for the entirety of associative processes is fession, when they fail to elicit defi nite psychotic Meynert’s, as is the analogy between human and symptoms, is no better than everyday parlance mollusc (L5). Occasionally Meynert’s hypothe- and must elicit the deepest suspicion, when used ses are mentioned, for instance, in L5 (p. 29), as the basis of diagnosis of a paranoid state. It that intestinal sensation might be represented in deserves to be rejected most strongly when, in ‘the ganglia of the striatum’, or that the thalamus cases of this kind, the claim is made that we are was a central station for all sensory pathways 352 Editorial Commentary

(L19, p. 123). A few distinctive phrases and con- elements which are not then called into play’ cepts originate with Meynert. For instance [ 22 ]. This highly metaphorical—and partly vital- Meynert used the metaphorical phrase ‘a train of istic—account by Meynert of the formation of thought’, which goes back centuries, into psychi- associations is an analogy with ‘attraction’, pos- atric vocabulary, describing his own thought pro- sibly magnetic, or of ‘animal magnetism’ (whose cesses (L19, p. 123). It was conceived to have a popularity was still remembered). It applied at clear physical basis in the cerebral cortex. In L31 both cellular (‘molecular’) and mass levels to (p. 215) Wernicke writes: ‘In my introduction, I account for strengthening of connections between developed the idea that a strictly terminated train co-active cortical sites. Wernicke’s version was of thought is the result of practice and training, more precise, and in the fullness of time, became that is, of functional acquisition’ (see also L33, a testable hypothesis. p. 236: ‘closed thought’). These lines probably In L33 Wernicke’s expresses his sincere, but refer to Meynert’s ‘enclosed pipe’ metaphor. nuanced appreciation of his former mentor as fol- The most distinctive concept Wernicke attri- lows (L33, p. 240): ‘I have repeatedly indicated butes to Meynert is ‘primary Ego’ (das ‘Ich’ ), how important I consider Meynert’s clinical lec- dependent especially on the sense of corporeality tures to be; in my opinion, they have provided the (L5, L17). In the fi rst few lectures on chronic foundation for better understanding of the symp- conditions, the only mention of Meynert is to this tomatology of acute mental illnesses. However, it concept (L17). In later lectures he is more ambiv- must be expressly stated that Meynert also suc- alent and nuanced in appreciation of Meynert, cumbed to the general fate of other authors, who certainly not seeing him as an irrefutable author- have laboured hard on their monographs in cer- ity. In L30 (p. 213) we read: ‘Even in the clinical tain provinces, in our discipline … Nevertheless, lectures of Meynert, to whom we owe so much, the chapter on amentia is of lasting value for all you will fi nd this clinical picture [melancholia] time, and indicates the greatest advance psychia- defi ned far too broadly’. In L33 Wernicke men- try has made clinically since Kahlbaum’s work tions Meynert several times, showing how his on catatonia, since it contains the fi rst real theory own associationism grew from similar, though of mental illnesses and especially of acute psy- less well-formulated views of Meynert. choses, founded on hypotheses derived entirely According to Meynert (L33, p. 236), there was a from the condition of the affected organ’. In L36, direct link between local cerebral blood fl ow and he is mentioned again in relation to the hypothe- associative activity in the brain. The more the sis about local blood fl ow, which Wernicke hardly cerebral arteries narrowed and restricted blood believes, and his ‘celebrated optic thalamus supply, the less associative activity could occur case’. In L37, an issue of classifi cation of pro- in regions supplied [21 ]. According to him, active gressive paralysis (acute vs. chronic) is men- brain tissue attracted higher blood fl ow to supply tioned where Wernicke does not quite agree with nutritional needs—an uncanny forerunner of Meynert. He also mentions Meynert’s system for principles on which functional imaging is based cortical lamination, and—with high praise—his today—as in the following quotation: ‘If we data on brain weight in various conditions. In accept Fechner’s theory, that the cortical images L38 he compliments Meynert on his fi ndings and their connections may be stimulated to one of about hydrocephalus internus. L40, on dementia, two variable degrees of intensity, and that in any he is sometimes critical, sometimes full of praise, particular mental act those images which are and in L41, Meynert’s hyperaemia notion is men- actively utilized stand above the threshold of tioned again. Overall, from this survey of consciousness while others remain below the Wernicke’s citations of Meynert, it is hard to level of consciousness, then accepting this the- believe that it was the latter to whom the anony- ory, we may interpret it to mean that elements mous acknowledgment was made, given the bearing processes standing above this level terms in which it was expressed. exhibit a greater nutritive attraction than those Editorial Commentary 353

What about Emil Kraepelin, his real rival? In Basic neuroscience: In1894 Wernicke would L34 (p. 256), dealing with akinetic motility psy- have known of the neurone theory, for which choses Wernicke writes: ‘… in Kraepelin’s text- Santiago Ramón y Cajal and Camille Golgi book, dementia is described as the regular were jointly awarded the Nobel Prize in 1906. outcome for such cases. Here, as well as else- Their conclusion, that nervous tissue consists of where, we come across little by way of thought, discrete cells, not a syncytium, was developed plus an ignorance of facts, which features are between 1887 (when Cajal learned Golgi’s arguably unsuited to a textbook. Moreover, the staining method) and 1894 (when Cajal gave the tendency to recurrence, emphasized by Croonian lecture, focusing on cortical pyrami- Kraepelin, is in no way greater than in most dal cells). Other staining methods in neurohis- other acute psychoses’. It was probably the text- tology were that of Nissl (mentioned in L41, book to which he refers (L28, p. 192) with the p. 323) which stains neuronal cell bodies (the words: ‘as I constantly regret, it is impossible ‘Nissl’ granules in their cytoplasm) but not for me to recommend to you one of the best- axons or dendrites, and that of Weigert to stain known textbooks of psychiatry for your private myelin deep blue, with degenerating portions studies’. Here for the only time, Wernicke ‘takes yellow, and another of his methods to stain neu- off his kid gloves’ in opposing a rival. This is roglial cells. The distinction between neurones the most specifi c and potent personal attack on and glial cells was well understood in Wernicke’s any of his colleagues or rivals to be found in day, as well as some of the subtypes of glial Grundriss . cells, since, in L37 (p. 291) he writes: ‘We have There is one other striking sentence (L31, observed the occurrence en masse, of giant p. 221): ‘When attacks of recurrent mania fi nally astrocytes; and indeed they correspond to the outweigh in duration the lucid intervals, they do more recent stage, seen temporarily soon after not turn into a chronic mania, at least not in the loss of neuronal tissue’. In L4 (p. 24) ‘fusiform’ strict meaning of the term, that I alone can (spindle-shaped) cells in the visual cortex are defend’. (Emphasis added here.) Clearly, mentioned. This probably refers to a classifi ca- Wernicke knew that in some of his views, he was tion of cell types by von Kölliker [23 ], long a lone voice. before the Golgi method was in use. Wernicke suggests that their existence ‘contradicts our intuition to accept nerve fi bres that cannot prove V. Contemporary Knowledge their origin from any nerve cell’, implying that in Neuroscience; Contemporary aspects of Cajal’s neurone doctrine were not yet Practice in General Medicine fully resolved. and Psychiatry in Wernicke’s Day In L16 (note) we also read ‘… we see only remnants of pathological change in the organ of Wernicke’s Grundriss contains much detailed association: That is, growth of glia. Of epoch- description in the clinical lectures, but, through- making importance in this regard is the work of out, he attempts to explain what he saw, on the C. Weigert [ 24] … We would hope that a patho- basis of neuroscience of the day. To understand logical anatomy of psychoses may be built from the strengths and weaknesses of his attempts, it is this.’ The role of glial cells in neuropathology, important to understand what he knew, and, just especially the proliferation of some types of glia, as important, what he did not know about struc- was not proven until the 1920s. However, it was ture and function of nerve cells, nervous tissue, shown by the Romanian, Georges Marinesco functional organization of the brain, and the state (1863–1938) that non-neuronal cells acted as of clinical knowledge at the time. In this section, phagocytes, removing remnants of injured or common knowledge, and prevalent misunder- dying cells [25 ]. This was published in 1900, but standings are described. Wernicke’s own contri- may have been known earlier; and Wernicke may butions come later. have been alluding to this. 354 Editorial Commentary

With regard to signals carried by nerve cells, nerves (long and short)—the visceral innervation there was some crucial knowledge, but many of the eye itself (as opposed to the retina)—most gaps. In L1 the law of isolated conduction (ini- of which knowledge went back to the eighteenth tially proposed for the peripheral nervous system, century [28 ]. L6 touches on the possibility that but implicitly applying to the central nervous there is position sense in the eyeball, transmitted system) is mentioned. This states that signals via the ciliary nerves. remain isolated in each axon, despite transmis- The laminar layout of the cerebral cortex was sion over long distances [26 ]. This extended fi rst described by Bailarger, with more detailed Johannes Peter Müller’s Law of Specifi c Energies , description provided by Meynert; but terminol- which stated that the function and subjective ogy was not settled. References to cortical lami- impact of activity in a nerve pathway depends on nae include: ‘the cortical layer (or layers) what it is connected to, rather than what initiated immediately adjacent to white matter would rep- the activity (be it a sensory stimulus, applied resent consciousness of corporeality’. (‘Die electrical or chemical stimulus, or whatever). schichtenweise Übereinanderlagerund der Conduction velocity in peripheral nerves had Ganglienzellen der Hirnrinde begünstigt eine been measured in 1850 by Helmholz, but nothing solche Annahme wonach die der Markleiste was known of conduction time in central axons. nächste Schicht (bzw die nächsten Schichten) das In L5 (p. 26), in developing a ‘thought experi- Bewusstsein der Körperlichkeit repräsentieren ment’ Wernicke writes ‘Sensations would, as würden )’ (L5, p. 30). We also read ‘the most before, reach consciousness, but with a slight superfi cial cortical lamina, that which Meynert delay caused by the longer pathway.’ He was thus identifi ed as the fi rst, purely grey lamina’ (L37, aware of conduction time in axons as a signifi - p. 290), presumably lamina II, in modern cant variable, but could not use this in explana- terminology. tory reasoning. Nothing was known of the The French edition of Cajal’s Histologie du physical basis of axonal conduction. The all-or- Système Nerveux de L’Homme et des Vertébrés none law was known to hold for cardiac contrac- was published in 1909–1911, and was already tion from work of Bowditch at Harvard Medical known in its Spanish version in 1905 (Textura del School in 1871, but that it applied to axonal con- sistema nervioso del hombre y de los vertebra- duction was accepted only in 1909, from results dos, vol. 1, published in Madrid in 1899; com- of Keith Lucas [ 27 ]. This indicates that signal plete in 1904). These works do not use the transmission in axons is independent of the ener- modern 6-layer terminology. Later in L37 getics for generating signals. Wernicke’s igno- (p. 290) we read ‘Cell loss in these cases did not rance of this was part of the context which extend continuously over the cortex, but came in enabled him to develop the imaginative (but irregularly distributed patches, and involved incorrect) sejunction hypothesis. Chemical trans- mainly layers of densely arranged, small pyra- mission was a completely unknown principle. mids, arranged in rows, and increasing in size Basic neuroanatomy of the brain had advanced inwards, in other words, Meynert’s second and in decades before Grundriss. In L1 a term used third layer’: This refers to laminae now known to by Wernicke (after Meynert) was the projection be major origins of cortico-cortical axons system, a metaphor derived from optics. We read (although some descending axons were identi- of ‘the fact of physiological continuity, if not fi ed). This point is relevant to Wernicke’s view of anatomical continuity’ in such pathways. This the cortex as the ‘organ of association’, and of refers to cytological fi ndings of Cajal. Knowledge mental disorder involving disruption in such about cranial nerves went back a long way, but connections. there were still uncertainties, even over their In 1905, it was unclear whether taste and smell exact number, and details such as the exact inner- had their own cortical projection area (L5, p. 26). vation of the tongue for touch and taste. At the Wernicke occasionally refers to the basal ganglia time of writing much was known about ciliary (although terms he uses leave doubt about which Editorial Commentary 355 structures he means). Karl Friedrich Burdach excitability of cutaneous capillaries’: This probably (1776–1847) provided the fi rst account of the refers to the cutaneous ‘fl are response’ or ‘axon anatomy of the basal ganglia [29 ]. Nothing was fl are refl ex’, responding to sharp mechanical stim- known of their function, but there were many uli such as scratching. That it was an involved ideas, including Meynert’s (L5, p. 29), that the local axonal conduction, but no central trans- ‘corpus striatum’ (Ganglien des Streifen ) repre- mission or integration was known since 1889, as sented intestinal sensation. It is unlikely that described by Sokovnin and Rozhansky, and appar- uncertain whether this refers either to ‘the stria- ently discovered as early as 1873 [34 ]. tum’ (part of the basal ganglia) or to the ‘nucleus Early in his career Wernicke made major con- basalis of Meynert’. Meynert was also the fi rst to tributions to the concept of cerebral localization suggest that Parkinson’s disease might arise due of function. Orderly representation of sensory to abnormality there [30 ]. In the 1880s, Hermann surfaces and motor control in the cerebral cortex Nothnagel (1841–1905) named the striatum (somatotopy, retinotopy’, etc) was well under- nodus cursorius, implying a role in locomotion. stood, although in a simpler way than today. Motor functions of the basal ganglia became Larger principles of organization linked basic known early in twentieth century, and wider neuroscience to clinical topics. In L5 (p. 27), aspects of their function were revealed later. writing on protective refl exes, he compares Wernicke refers to several issues about central humans to lower vertebrates: ‘Where a large nervous function. In L3, in analyzing the differ- cerebral hemisphere is present, as in mammals, ence between perceptual and memory images he and more so in humans, we see similar mecha- mentions visual after-images as a model of the nisms of movement transferred to central projec- former. His statement that after-images arise in tion fi elds of the cerebral cortex (as shown retinal ganglion cells is incorrect: Classical after- experimentally by Munk for eye movements)’ images, such as seeing an orange spot after star- This is similar to ideas of Hughlings Jackson ing at a blue light, or a black (sometimes white) (1835–1911), and before him, of Herbert Spencer, spot after staring at white light is due to satura- who, in 1855 had published ‘The Principles of tion of pigments in photoreceptors [31 ]. In L5 Psychology’ [35 ]. Their view, based on evolu- (p. 29) he assumes that the ability to locate the tionary doctrine, was that the central nervous sys- source of a sound refl ects processes in the inner tem has a hierarchy of levels, refl ex activity being ear (‘organ of Corti’), but we now know this to the lowest. Related ideas were promoted by depend on comparison in the brainstem of timing Meynert [22 ], for whom mental illness arose due of sounds from the two ears. to confl ict between cerebral cortex and sub-corti- Important principles of functional organization cal regions (a view still widely held today). were well known. The concept of refl ex action was important for both neuroscientists and clinicians, Bacteriology and Infectious Disease: Advances but the emphasis was different from today: in bacteriology in years immediately prior to Supposedly automatic refl ex action was easily publication of Grundriss provided a new model extended to include psychic processes, for instance of disease. Researchers in psychiatry saw a by Russian physiologists Ivan Sechenov, and potential cause for disorders in their own fi eld. I.P.Pavlov, and in Austria, by a young Sigmund ‘Phthisis’ is mentioned several times in Grundriss , Freud. This was easier then than now, because it a term implying no more than a ‘wasting disease’ was less clear that refl ex action was independent (as did ‘consumption’), qualifi ed, in English, as of conscious awareness (with support from the ‘pulmonary phthisis’. The name tuberculosis was philosophy of psycho-physical parallelism). In given by Schoenlein (1793–1864), based on psychiatry, Kahlbaum [ 32] formalized this with characteristic lesions—tubercles—seen in the terms such as ‘centripetal’, ‘intracentral’, and lungs post mortem. The term ‘phthisis’ was used ‘centrifugal’ for the stages of ‘psychic functions’ well into the twentieth century, and was used by [33 ]. In L34 (p. 236) Wernicke refers to ‘refl ex Wernicke (pp. 294, 296), but sometimes he used 356 Editorial Commentary the German term Lungenschwindsucht . Discovery Moritz Heinrich Romberg (1795–1873), to diag- by Robert Koch of the corresponding micro- nose Tabes dorsalis (L36, p. 280), an aspect of organism, Mycobacterium tuberculosis , dated neurosyphilis in which axons in the dorsal col- from 1882. umns of spinal cord are lost, leading to differen- Knowledge of the symptoms of tetanus after tial loss of discriminative somatic sensation. wounds went back to antiquity. That it was caused Tabes had been named as early as 1836 and given by a bacterial toxin was proven in 1884 by Arthur a full description by Duchenne in 1858 . It was Nicolaier (1862–1942). The bacterium responsible shown to be late-stage syphilis in 1885 by Jean ( Clostridium tetani ), its transmissibility, and its Alfred Fournier (1832–1914), who suggested role in producing symptoms of tetanus were dis- that GPI (‘Progressive Paralysis’ in Wernicke’s covered in the 1890s; and by 1897, an antitoxin had terms) was syphilitic in origin. However, when been produced, giving immunity. In L34 (p. 296) Wernicke was writing, this appears not to have catatonic rigidity is compared to tetanus. The diph- been fully accepted [ 38 ]. Another test involved theria toxin was discovered in 1890 by Emil Adolf pupillary refl exes and Wernicke refers (L37, von Behring (fi rst Nobel laureate for physiology p. 280), to ‘rigidity’ of pupillary refl exes, termed and medicine) working in Marburg [ 36]. The idea ‘Argyll Robertson pupil’ in the English-speaking that bacterial toxins could cause mental illnesses world [ 39]: The accommodation refl ex was appears often in writings of Wernicke and intact, while the light refl ex was lost. Argyll Kraepelin. Discovery of the spirochete in 1903, in Robertson, a Scottish-trained physician studied experiments on monkeys by Metchnikoff and in Prague and Berlin, and identifi ed the syndrome Roux, and the development of the Wassermann test in 1863, calling it ‘spinal miosis’. In fact, none of in 1906 clarifi ed the fact that syphilitic disease the pupillary refl exes (light refl ex, accommoda- could take many forms. Prior to this, diagnosis had tion refl ex, and papillary dilatation) involve spi- been based solely on clinical evidence, as in most nal pathways. Wernicke’s qualifying phrase—‘the of psychiatry to this day. Epidemics of ‘dengue so-called column disease’—suggests he was fever’, mentioned in L28 (p. 190) were long known referring to a named syndrome, rather than to to occur in tropical and subtropical regions. Its symptoms arising strictly in the spinal cord. Only transmission by mosquitoes was known from 1906, later was it found to be an early sign of general and its viral aetiology from 1907. CNS involvement in neurosyphilis. It is now rare in the developed world. Neurology : There are several references to A major issue, mentioned throughout advances in neurology in Grundriss. Wernicke Grundriss, was what was called ‘Progressive mentions ‘degenerative neuritis’. In L1 he refers Paralysis’ (‘of the Insane’: [ 40 ]). (Today to the fact, already known, that peripheral neu- ‘Progressive Paralysis’ has a different meaning, ropathies can lead to differential loss of sensory referring to several clearly defi ned neurological vs. motor function, or of specifi c types of somatic conditions.) Mainly, progressive paralysis is sensation. Many manifestations of syphilis were another manifestation of neurosyphilis. In 1894 well-known to neurologists; but at the time of Wernicke was unlikely to have known that it was revising Grundriss , it was not clear that GPI was part of a sexually transmitted disease, caused by syphilitic; it was seen as a mental rather than a an identifi able micro-organism. When revising neurological disorder (in so far as the two were the 1906 edition he could have known of the 1903 distinguished) [37 ]. Several clinical tests were fi nding, but detailed discussion of Progressive devised in the context of syphilis: In one, the Paralysis occurs in one of the last lectures (L37), Romberg test (L37, p. 229), a standing patient is so any revision he may have intended was fore- asked to close his or her eyes. Loss of balance stalled by his death. There is however no hint of indicates that the contribution of proprioception the fi nding in earlier lectures. Indeed, in L17 to balance is compromised. The test was devised (p. 103) he separates syphilis from Progressive as early as 1840 by the Berlin-based neurologist Paralysis, referring to ‘… disease of the posterior Editorial Commentary 357 columns [attacked] by alcoholism and syphilis Guillain–Barré–Stohl syndrome, after a publica- and, fi nally, the most famous type, of progressive tion in 1916 by Georges Guillain and Jean paralysis …’. In L36 (p. 280) he draws a contrast Alexande Barré. In modern defi nition it is an between Tabes and syphilis and in L37 (p. 286) autoimmune condition of myelin sheaths, limited discusses the differential diagnosis between to peripheral nerves, often triggered by infection. Progressive Paralysis and syphilis. However, he In Wernicke’s day, it was not separated from seems to have suspected some relationship, since other polyneuropathies; and those due to thia- this lecture, focusing on paralytic disorders, mine defi ciency could also affect the CNS. In makes reference to syphilis, and sometimes L27 (p. 182), he refers to fl accid paralysis, absent implies sexual transmission. Likewise, in L35 tendon refl exes, and muscles sensitized to pres- (p. 262) he writes ‘When a mild degree of somno- sure. These symptoms are found in polyneuritis lence is mixed in, a special subgroup among such due to in thiamine defi ciency. However, he writes: cases [of paralysis] seems to be defi ned, which, to ‘Oddly enough, I have never seen such severe judge by the results of specifi c therapy, should be cases of polyneuritis accompanied by polyneu- grouped among the luetic brain diseases’ ritic psychosis’. The latter term, refers to CNS (‘Luetic’: venereal—sexually transmitted). He involvement; he hints at his suspicion of differ- also mentions that paralytic attacks were some- ences between the two syndromes. times accompanied by fever (although that might Epileptic seizures are fi rst mentioned occa- have been due to another infection impacting on sionally in early lectures, and are dealt with in the CNS, or simply to the mental disorder itself— greater depth in L24 and L38. The full range of as mentioned in L41). In L36 (p. 280) he applies epileptic phenomena was not well documented in the word ‘bacterial’ to syphilis, implying perhaps the 1890s. Hughlings Jackson’s classifi cation sep- that symptoms were caused by a bacterial toxin. arated Petit-mal from Grand-mal, but included Despite his not understanding the origin of Vertigo [42 , 43]. In L37 (p. 284) we read ‘… a Progressive Paralysis from syphilitic infection, he specifi c muscle area such as the faciolingual clearly recognized that it was a chronic, progres- region is affected, the onslaught then spreading sive illness, with many mental symptoms (L36, further with familiar regularity’. This reminds one p. 285). He may have suspected it to have a bacte- of Jackson’s report of 1863, on the ‘march of epi- rial in origin, involving a different agent, but lepsy’, from which he inferred orderly representa- could not have known that overt syphilis, progres- tion of body parts in the brain; and the cortical sive paralysis, and other manifestations of syphi- region involved was known by 1875 [44 ]. Notably, lis had a common aetiology. After 1906, it might Wernicke, who inferred this principle from other have been too easy to dismiss unexplained symp- evidence, does not cite Jackson. He may have toms as syphilitic: Other neuropsychiatric syn- been unaware of his work, given that Jackson’s dromes are described in Grundriss which were most important papers on it were in journals not otherwise recognized for many decades, when which were probably inaccessible in Germany there could be no confusion with syphilis. [45 , 46 ]. The Asylum reports in which the later Reference to specifi c brain disorders includes publication appeared became the journal Brain. In Parkinson’s disease and its festinating gait (L34 European centres, differentiation of epilepsy from [p. 245]: ‘This movement accelerates in a manner hysteria was much-debated [16 ] and the word similar to propulsion in Paralysis agitans ’). ‘seizure’ was used for both. Charcot was the fi rst Dyskinesias—involuntary movements of mouth to attempt to distinguish the two, but differentia- and tongue—are described (L19, p. 120) although tion was not easy in Wernicke’s time. For instance, Wernicke attributes them to vivid taste hallucina- in L28, the so-called ‘second state’ could arise tions in patients with general paralysis. Landry’s equally from hysterical or epileptic attacks. paralysis (L27, p. 182) fi rst described in 1859 by Wernicke’s term ‘hystero-epileptics’ (L19, p. 122) the French physician, Jean Baptiste Octave presumably refers to what are now called ‘pseu- Landry de Thézillat [41 ], was known later as the doseizures’ or ‘psychogenic convulsions’. 358 Editorial Commentary

Wernicke mentions ‘general weakness of Separation of positive from negative symptoms in memory’ in L7 (p. 40; and in L8) where he psychiatry developed before Wernicke’s day, describes early stages of a disorder akin to what being fi rst proposed, in the context of childhood came to be called Alzheimer’s disease. In 1907, convulsions, by John Russell Reynolds in 1861 2 years after Wernicke’s death, Alois Alzheimer, [ 48], and extended by Hughlings Jackson in 1881 of Kraepelin’s institute in Munich, published the to apply to neurological symptoms more gener- fi rst description of the disorder, with details of ally. For Jackson, following the distinction was neuropathology, after the patient he had studied based on the hierarchical concept of brain organi- for 5 years had died, and been subjected to zation, so that positive symptoms refl ected autopsy. Clearly clinical aspects of Alzheimer’s release from inhibition coming from higher lev- disease were known at the time of Wernicke’s els. In psychiatry, the same concept goes back to death; and the ‘plaques’ had also been described Meynert: (L33, p. 240): ‘You can judge how far already by Marinesco [ 25 ], but not linked to Meynert approximates the standpoint that I have dementia. always advocated in these demonstrations, from In L14 (p. 87) Wernicke refers to confabula- the fact that he always places in the foreground tion as ‘… the positive form of falsifi cation of symptoms of functional defi cit, that is the differ- memory’, described as ‘incoherence in contents ent grades of weakening of associations, and he of consciousness’, linked to “memory distur- considers symptoms of irritation to be a conse- bance”’. A reference to Kraepelin is dated 1887, quence of these.’ These ideas appear as early as also the year of the doctoral thesis of L2, where we read: ‘absence of reactive move- S.S.Korsakoff in Moscow, defi ning what came to ments is often just as characteristic and as valu- be called ‘Korsakoff’s psychosis’. This is related able a symptom as their pathological to chronic alcoholism and vitamin defi ciency, modifi cation’; and in L11 (p. 67) ‘… all changes prominent features of which are loss of memory in content of consciousness can then be likened for recent events and confabulation, with intact to focal symptoms, and will behave just as do long-term memory. Since the vitamin defi ciency more familiar focal symptoms of brain diseases; caused both this and peripheral nerve problems, but these naturally, will have a different clinical the syndrome was also called Polyneuritic psy- “weighting” depending on whether they corre- chosis in Grundriss (e.g. L26, p. 174). Regardless spond with the stimulus state or the paralysis of whether Kraepelin or Korsakoff claims prior- state’; in L12 (p. 72) ‘defi cit symptoms’ are con- ity, Kraepelin’s major contribution to the concept trasted with ‘irritant symptoms’; in L14 positive came later (1913), when it was identifi ed as a and negative ‘falsifi cations of memory’ are sepa- feature of paraphrenia (see [47 ]). rated (confabulation, vs. ‘quasi-amnesia’). In L19 (p. 123) the idea is mentioned that the cere- Clinical Psychiatry: A phrase in L25 (p. 168); bral cortex can suppress subcortical activity, (‘… if you follow the practical advice for clinical notably in the basal ganglia; and symptoms arise analysis …’), may imply that guidelines were as release phenomena when such inhibition fails. taught in medical schools on ways to advance The idea has been used often since then in clinical knowledge. It is not clear whether this accounts of symptomatology; yet we now know refers to psychiatry or more widely. It implies that, with minor exceptions, long-axons cortical recognition that research and routine practice, for neurones projecting to the basal ganglia are many practitioners were inseparable endeavours, excitatory. unlike today. In any event, in Wernicke’s day psy- Another concept which Wernicke took from chiatry was seen as an advancing frontier. With the past was that there are ‘times of special vul- regard to then-current knowledge of clinical psy- nerability for development of various diseases of chiatry, we start with general concepts, moving consciousness’ (L5, p. 30). This derives from on to specifi c disease entities or prototype Kahlbaum, who proposed [49 ], in 1863 that cer- diagnoses. tain psychiatric disorders tend to occur during Editorial Commentary 359 transitional periods of life. The idea is developed p. 195; L31, p. 211), the exact meaning of which in most detail in L38 where we read (p. 294) that for him is unclear. ‘times of normal physical change, such as On genetics, clinicians routinely asked about puberty, menopause, and fi nally senescence, are family history. So, in L14 (p. 88) we read ‘… a particularly likely to predispose to onset of strong family predisposition to mental illness psychoses’. was established in this middle-aged man’. The concept of ‘degeneration’ loomed large in Founding principles of genetics based on Gregor social and psychiatric thought in late nineteenth Mendel’s work in the 1860s were not well known, century. The term (German: Entartete ) was intro- and systematic study of the inheritance of mental duced by Griesinger, but its persistence had sev- disorders was some way in the future. Wernicke eral origins; harmful effects of urbanization considered hereditary tendencies in most detail in during the industrial revolution, concepts of L38 (p. 297 seq. ). There is not so much as a hint social Darwinism and then biological evolution of eugenicist notions, although such ideas had more generally, greater awareness of historical roots going back some years earlier, at least in change of societies (as in Edward Gibbons’ Britain; and in Switzerland, Auguste Forel advo- Decline and Fall of the Roman Empire ), in psy- cated such ideas [ 50 ]. On one occasion (L38, chiatry Benedict Morel’s Treatise on p. 297) he ventures on the diffi cult area where Degeneration, and in forensic areas, Cesare genetics and (social) environmental infl uences Lombroso’s writings on criminality in relation to interact, and where the degeneration held sway anthropology. Valentin Mangan (1835–1916) (when he suggests that suicidal acts are attributed developed the degeneration concept in a sup- to effects of suggestion, even when they are posed evolutionary and genetic context, and pub- familial traits). In L38 he also seems to give way lished with Paul Sérieux, in 1892, Le délire to surrounding prejudices, when he makes pass- chronique a évolution systématique (‘Chronic ing comments on the social class of some patients delirium with systematic evolution’). The con- with familial mental disorders. cept was losing currency by the outbreak of Terms for classes of disorder, syndromes, and World War I, but can yet be seen as a precursor to symptoms, used in Wernicke’s day, are mentioned both Kraepelin’s Dementia praecox (for which here. Use of Latin terms, with upper case initial by defi nition, full recovery was not possible), and letter for the fi rst, was the style of Carl Linnaeus in later of eugenicist ideology adopted in Germany his eighteenth century botanical taxonomy, and in and elsewhere (with the word ‘degenerate’ the parallel taxonomy for diseases which he also [ entartete ] fi guring prominently in propaganda of developed in 1763 [ 51 ]. Named classes were then the Third Reich, especially in relation to art and taken to be ‘natural types’, an implicit assumption music). Wernicke is scathing about the glib way adopted for diseases in the nineteenth century. in which the concept was sometimes used, as in The old term ‘melancholy ’ appears fi rst in L1, L17 (p. 104) where we read of how other authors then in L17 (p. 81), and is discussed in detail in regarded ‘chronic paranoia … separate from all L30 as Affective melancholia . Two specifi c con- other mental illnesses, and the so-called degen- cepts come from Kahlbaum: Hebephrenia , was eration, acknowledging the latter to have only taken to be a form of adolescent insanity, men- one aetiology. He does sometimes use the term in tioned several times in Grundriss (L14 [p. 87]; a stricter sense, for instance in the context of L17 [p. 107], and in detail in L39 and L40). The alcoholism, or documented degeneration of nerve concept was elaborated by Ewald Hecker (1871) fi bres. Only once does he use the word in a more (assistant to Kahlbaum) as an offshoot from the prejudicial sense, when he hints that it occurs then-new idea that adolescence could be conceptu- across generations in families, for instance, in alized as a distinct developmental stage. The term L38 (p. 294): ‘Appearance of degeneration, rapidly gained acceptance, to be incorporated into which can be followed in many families …’ He Kraepelin’s concept of Dementia praecox (follow- also refers to ‘neurotic degeneration’ (L30, ing Heinrich Schüle [1880] and Arnold Pick 360 Editorial Commentary

[1891]) [52 , 53 ] . Today it survives as the ‘disorga- signifying voluntary muteness in mentally ill nized’ subtype of schizophrenia, or the ‘disorgani- people, often selective according to circum- zation’ dimension of symptoms (although such stance, especially in catatonia. sub-typing was abandoned in DSM-5). Kraam and In L23, under Anxiety psychosis , we are given a Phillips [ 54], who review the concept, never men- vivid description of what might also have been tion confabulation, although this was widely seen termed ‘conversion hysteria’ by Freud. Wernicke as characteristic of hebephrenic schizophrenia. does not use this term, although the phenomenol- Presbyophrenia (L14; p. 87), a type of ‘paraphre- ogy is described clearly—severe hysterical anxi- nia’ (psychosis with onset during a period of tran- ety leading to distinctive quasi-neurological sition in elderly people), a concept whose history symptoms (paralysis, sensory losses, etc.), whose is reviewed by Berrios [ 55], is long-abandoned, detail fi ts no known neurological pattern. ‘Blind but is mentioned several times by Wernicke. thrashing behaviour’ (L38, p. 164), seen in patients Paranoia is a very old concept, with a com- under extreme stress, is also discussed by plex history [56 , 57], complicated by popular Kretschmer [61 ] using the term ‘instinctive motor misunderstandings. While broadly signifying fl urry’, which removes an animal from a danger ‘delusional’, variants focus on whether it is zone only by chance. He hardly regarded it as ‘monodelusional’ as believed today for ‘delu- defensive, but likened it to behaviour of a cornered sional disorder’ and advocated by Kraepelin [58 ]; animal, as did Wernicke. In addition, in L24 and on the subject of delusions. Popular under- (p. 158 seq. ), Wernicke recalls a case from the late standing today stresses persecutory content. It 1870s, which—whatever else might have been was divided by Theodor Ziehen ( [ 17]; p. 210), present—included major components of delayed assistant to Otto Binswanger at Jena, Paranoia war neurosis (‘shell-shock’, as it came to be called chronica simplex being one of his four types, held in England), from the Franco-Prussian war. Images to be a distinct disease. Wernicke disliked the of bodily dismemberment probably derived from term as referring to any disorder, but defi ned par- what he saw as a soldier ( névrose traumatique and anoid states as ‘all those chronic mental disor- hystérie traumatique, according to Charcot). The ders where we encounter falsifi cation of content framework in which Wernicke understood such of consciousness’ (L11, p. 65). syndromes would have been quite different from The term neurasthenia originated in New that of clinicians such as Freud (who had debated England [ 59], to become part of medical vocabu- in 1886 in Vienna whether hysteria could occur in lary (as ‘nervous exhaustion’; L17, p. 106) in men.) History of the term ‘conversion hysteria’ Wernicke’s time, for instance in L37 (p. 280) when since then has been complex. DSM-III abandoned he mentions that tendon refl exes may be increased ‘hysteria’ but kept ‘conversion’, which, in DSM 5, in neurasthenia. (This was reported by others, for became ‘Functional Neurological Symptom instance by Dejerine and Gauckler [60 ]). The term Disorder’. Three ideas may need to be defi ned is seldom used now in the West, but appears in (Conversion, Dissociation, Somatization), with some Western classifi cation systems, and has but two terms usually recognized in diagnostic greater currency in East Asian medicine. systems. DSM- III and DSM-IV separate dissocia- Two terms appear in Wernicke’s footnote (L1, tion from the others; ICD-10 splits somatization p. 6), and later. Verbigeration —the monotonous, from dissociation/conversion. usually rhythmical, repetition of one or several words—and Mutism: ‘By mutism we defi ne the temporary speechlessness of the mentally ill.’ VI. Wernicke’s Underlying These two were subsequently classed as cata- Philosophical Views tonic symptoms, aspects of Kraepelin’s Dementia praecox . However, Kretschmer, [61 ] argued that We come now to unique aspects of Wernicke’s catatonic symptoms—or at least some of them— thought. In Grundriss, our eventual focus, of may be aspects of conversion hysteria. course, is on clinical issues for psychiatry, which Mutacismus is also mentioned in L24 (p. 164), have their own philosophical underpinnings; but Editorial Commentary 361 underlying these are Wernicke’s unique ideas on ally mathematical; but it need not be mathemati- brain theory, and deeper than this his singular cal, as in Wernicke’s case. The contrast with approach to methods and philosophy of science biomedicine is that (with notable exceptions) itself. To give a good account of his system of relations between variables is established by sta- thought it is necessary to start with the latter top- tistical inference, which eventually becomes a ics fi rst, and then work towards his special proxy for causality. approach in psychiatry. Second, Wernicke is more willing than most biomedical scientists to base arguments on hypotheses about hidden variables, which, at the VI,(a). Wernicke’s Adoption time, cannot be directly validated, and thus lack of the European Style of Natural direct empirical proof. This is typical of physics, Philosophy where many hypotheses or variables arose from their value in providing explanations, rather than Throughout Grundriss, we see a distinct contrast from direct proof that the variables existed with to pre-existing medical traditions. Wernicke’s properties ascribed to them. The archetype for approach as a psychiatrist probably was unique, the die-hard medical empiricism is the apostle St. but as a scientist, it seems he drew lessons from Thomas—a physician—who could not believe in outside medicine, from the most fundamental sci- the Resurrection without feeling the holes in ence, namely physics, or, to give it its original Christ’s hands. In contrast, Wernicke writes often name, natural philosophy. Similarities in both of ‘internal connections’ in the brain (informa- content and method are to be found between tion connections, not anatomical ones), which he much of Wernicke’s thought and prevailing tradi- could never observe directly, but inferred from tions of natural philosophy. Striking similarity is their effects. So, in L11 (p. 66), we read of the also evident, especially in L1–8, with the thought ‘indisputable connection’, between active mental of Ernst Mach, placing Wernicke clearly within disturbance and chronic mental disorder in which European traditions going back to Leibniz, rather the active process has subsided; and in L12 than English ones tracing back to Newton. How (p. 73) we read of ‘internal relationship between the similarities with Mach were conveyed to hallucinations and autochthonous ideas.’ In both Wernicke we do not know. In any case they sup- cases, plausible inferences are made, as a physi- port the view that if psychiatry is to be rational, it cist might argue without directly observing the must be based on concepts as fundamental as process, or intervening variables. Likewise in those from which natural philosophy itself arose; L20 (p. 127), he writes: ‘Gentlemen! You can see and psychiatry then differs from most medical that just by getting to know all the internally con- disciplines, whose basic concepts are ‘givens’, nected symptoms puts the signifi cance of the fi rst derived from elsewhere, requiring no original left temporal convolution in the right light, as the philosophical or metaphysical thought. (A caveat site of ‘phonemes’, the most common—and you is needed here: Ernst Mach was avowedly anti- could almost say, the most important—of all the metaphysical; but this may have been in reaction psychotic symptoms’. The same phrase is used in to the emptiness of German idealist philosophy L29 (p. 198) for the relation between autochtho- of the time, rather than a denial of centuries of nous ideas and phonemes; and in L30 (p. 208) for metaphysical debate preceding and accompany- Affective melancholia and a variety of symp- ing the birth of the natural sciences.) toms; and similarly elsewhere. Occasionally, the At the methodological level, there are four inference of hidden connections with explanatory striking features about Wernicke’s thought. First, power is applied to individual symptomatology, the author was a fi rm advocate of reasoning in rather than a generic process, as in L38 (p. 283), science, as much in psychiatry as elsewhere. where we read ‘… the entire clinical picture Systematically, he sought reasons for relation- could be understood only as a circumscribed ships between observations. This is typical of autopsychosis based on an overvalued idea’: physics from its outset, where reasoning was usu- Reliance on unobserved internal processes is 362 Editorial Commentary linked to his important concept of ‘elementary be deduced from familiar features of the diseased symptoms’ (see below), since links between organ’. By aiming to deduce symptoms from such symptoms and secondary ones involve more basic knowledge (the only occasion on internal links. which the word abzug is used in Grundriss ) he A third related feature, is Wernicke’s willing- clearly sought explanations as understood in tra- ness to postulate ideal situations, far removed from ditions of natural philosophy. There are of course any empirical demonstration as ‘thought experi- many ways in which subjective experiences can ments’, which aid clarity of thought. This way of be grouped as named symptoms. His statement thinking connects Wernicke directly to Mach. It appears to state that the groupings he recognized was a concept gaining currency in the Germanic were those which could be deduced from actual world at the time, as Gedankenexperiment , about or potential brain mechanisms, the neurosciences which Mach wrote (‘On thought experiments’) in of his day, a procedure closer to that of physicists 1905 [62 ]. It is different from medical traditions than of typical medical researchers. This makes where strict empiricism tends to rule, and is espe- him different from most psychiatrists, before or cially different from modern insistence that every since, and possibly unique. Examples follow statement be ‘evidence-based’. As an example, in later; but as a general statement, he states (L11; L2 he writes: ‘If we do not expect a speaker to p. 69) that ‘only as an exception do you fi nd an lead us astray, then we must recognize that in this “objective” observer who experiences just the case, in a normal person, answers will arise in a “foreignness” of emerging thoughts without totally determined manner, to be predicted with attaching to them any far-fetched interpretation’. approximate accuracy.’ He acknowledges that One may ask if, even in principle, description ‘total determination’ is not reality, but uses the (and therefore classifi cation) of experience can conjecture to advance an argument, just as a ever be wholly separated from interpretation, as physicist postulates a ‘frictionless surface’. In Kraepelin wanted: All description uses pre- L5, to bring to life the idea that a person’s body existing forms, analogies, or vocabulary. (and brain) are also part of the observable exter- We can now recognize what were the found- nal world, he invites the reader to join in such a ing clinical concepts for Wernicke. The state- ‘thought experiment’, and in L6 to compare ment just quoted indicates that primary concepts humans with molluscs. Other examples are evoc- for him were not any supposed disease entity ative analogies. (defi ned by a range of symptoms, accepted with The Fourth, and perhaps most fundamental little deeper analysis, as in Kraepelin’s system), similarity to the natural philosophy tradition is but symptoms themselves, as primary experi- Wernicke’s approach to validating concepts: ences, from which any disease entity is derived When pioneers of the sixteenth and seventeenth secondarily. However, with symptoms taken as century struggled to make rational the study of the starting point, one should rely not on surface Nature, their struggle was, in part, to defi ne con- appearance, but on deeper understanding, to cepts in a way which supported precise reasoning reveal commonalities, despite surface differ- [ 63 ]. Defi nition and explanation are then interde- ences. Here we see interdependence of defi nition pendent. Proto-scientifi c pioneers in psychiatry, (or descriptive form) and explanation, allowing such as Pinel and Esquirol saw their role as being symptoms to be grouped together and named. We to describe what they saw, not to explain it. see striking parallels here with the thought of Gradually the emphasis shifted: For Kraepelin, Ernst Mach. Mach’s fi rst university experience classifi cation (that is defi nition of concepts) had was teaching medical students (in which he to come fi rst, presumably on the basis of some excelled), and he was to make major contribu- sort of authority, and only then could explanation tions to analysis of sensory systems, especially be attempted. Wernicke’s approach was different the visual system. In important ways, he antici- from both. Rather than laying claim to personal pated ideas which blossomed in the twentieth authority, he states, early in L1: ‘symptoms must century as Gestalt psychology [64 ]. For Mach the Editorial Commentary 363 foundation for natural philosophy could not be necessary to relate the position of each point of a derived concepts—mass or force—but primary sensory surface such as the retina, to a frame of experience, that is sensation . His integration of reference such as the visual axis. However, the physics with perceptual psychology is made clear term was used in various ways, sometimes incor- in the title of his book fi rst published in 1886, and porating practical actions which helped defi ne a extensively revised in 1905: ‘The analysis of sen- position with respect to a frame of reference, and sations and the relation of the physical to the psy- for Wernicke incorporating both ‘emotional’ chical’ [65 ]. His maxim was: ‘The world consists quality of sensation at each sensitive point, and of sensations, for the scientist and for the com- motor behaviour such as defensive movements mon man’ ([3 ]; p. 126). He knew well that, when associated with the ‘emotion’. In discussing the sensory systems register reality they impose their spatial sense in the retina, with fi xed orientation, own biases and distortions of that reality, an arguments used are nevertheless reminiscent of insight stated centuries earlier by Francis Bacon, those of Lotze, Helmholtz and Mach. There are who wrote: ‘It is a false assertion that the sense of many further similarities between Wernicke and man is the measure of things. On the contrary, all Mach in their respective treatment of sensory perceptions as well of the sense as of the mind are systems, such as the role of motor systems in according to the measure of the individual and elaborating perception (L3, L6) ([65 ]; p. 127), not according to the measure of the universe. And terms such as ‘sensation of movement’ (L6) human understanding is like a false mirror, ([65 ]; p. 137), the importance for perception of which, receiving rays irregularly, distorts and constantly dealing with solid bodies (L4, L6, discolours the nature of things by mingling its etc.) ([65 ]; p. 232), and even highly technical own nature with it’ [ 66 ]. Cohen ([3 ]; p. 131) detail such as retinal after-images (L3) ([3 ]; comments that ‘Mach’s theory of science is a p. 131). new and better version of Bacon’s counsel of Not only did Wernicke recognize distortion modesty, and warning against hubris.’ It is in any imposed by sensory systems on our perception of case striking that Mach and Wernicke both based space, he also hints at distortion in perception of their science on primary experience rather than time. In L4, he suggests that two percepts are derived concepts. never experienced simultaneously: ‘… simulta- Given that our sensory systems are akin to a neity of sensory perception is not possible, on distorting mirror, it follow that notions of abso- account of the property designated as the “one- lute space, assumed in Newtonian physics, might ness” or perhaps as the “unity of consciousness”. be part of the distortion. Here again, we see strik- In truth, we always experience only one sensory ing kinship between Wernicke and Mach. In L5, percept at once; any second, apparently simulta- when discussing the brain’s representation of neous percept happens either earlier or later. corporeality and the ‘tone of a sensation’, Association by simultaneity therefore appears to Wernicke bases our concept of space as having be but a special case of generic association been acquired from association between adjacent through succession.’ Simultaneity may be sub- points on a sensory surface, which are then cap- jectively valid, yet, as Wernicke appears to tured within cortical connectivity. This principle accept, a unitary subjective percept arises objec- is straightforward for the retina, more complex tively by association of more elementary compo- for cutaneous sensation, albeit similar in princi- nents (although for elementary perception this is ple. The phrase ‘local sign’ is used already in L3. scarcely available to consciousness). These state- The phrase was not Wernicke’s, but originated ments are not very precise indicators of with Hermann Lotze in 1852 [67 ], and was later Wernicke’s thoughts, but later, in dealing with used by Hermann Helmholtz, Mach, and William clinical matters he refers to defi nite distortions of James (who probably took it from Mach, whom sense of time in some of his patients. Thus, in he had visited in Prague). For Lotze and L14 (p. 89), he describes how, normally ‘… Helmholtz, local signs were learned associations, memories are strung so close together that alien 364 Editorial Commentary elements fi nd no place between them. This tem- premise of Spinoza’s was that entities with noth- poral association must therefore be broken if the ing in common, could not engage in causal inter- pseudo-experiences of confabulation are to be action [69 ]. So, things which are extended in taken as true.’ Again, in L18 (p. 219), he describes space might engage in their form of causal inter- a patient who ‘on one occasion … expressed his action, and things in the realm of thought (ideas) astonishment that the head warder had disap- followed their own sequences; but since there is peared through one door of the hospital and nothing in common between extension and simultaneously entered through another door. On thought, neither could there be causal interaction another, food suddenly stood before him without in either direction between ‘body’ and ‘mind’. any delay … Both events seemed supernatural Instead, there was continual parallelism between and magical to him at the time. Now the patient the two, necessarily so, since the two were differ- gives us the explanation that he made errors of ent aspects of a single entity. observation due to a lapses in attention.’ Such Mach adapted this parallelism to physical distortions are no cause for surprise if our con- ‘causality’ as a whole, and wrote: ‘the old- cepts of space and time arise from the associa- fashioned idea of causality, is a little clumsy: A tions of spatial or temporal data points, rather dose of cause is followed by a dose of effect. This than the geometric absoluteness of space and represents a kind of primitive, pharmaceutical time; and they match contemporary views: Weltanschauung, like in the doctrine of the four Subjective time is not a geometrically regular elements … connections in nature are rarely ever dimension. These ideas also appear to connect so simple that one can identify one cause and one Grundriss with debates about distortion of space effect. Consequently, I have tried for a long time and time occurring in physics in the same era: to replace the concept of cause by the mathemati- Even before Einstein’s special theory of relativity cal concept of the functional relation: depen- cast doubt that absolute simultaneity could ever dency of the appearances from each other’ [65 , exist, simultaneity was being discussed by Henri 70]. Such reasoning is likely to be a source which Poincaré and Hendrik Lorentz. was to lead the physicist, Niels Bohr [71 ] to ques- Beyond such parallels with physics, in one sec- tion the validity of any ‘claim of causality’. In tion, Wernicke questions the validity of the con- L4, Wernicke sometimes uses the word ‘function’ cept of causality, replacing it with something akin unmistakably in a mathematical sense, implying to a ‘mathematical function’ relating variables. no causal relationships, merely a systematic Thus, in L4 (p. 23), he refers to ‘causality’, as an description of events (albeit non-quantitative). inbuilt error or bias in how we view the world. For instance he writes (p. 23): ‘Perhaps by now it Admittedly he is not consistent, because in L5 is obvious that consciousness of the outside (p. 30), now fully convinced of the validity of cau- world has defi nite dependence on the outside sality, he writes: ‘Movement without any kind of world, or, we might say, is a function of it.’ In the cause, is inconceivable’. Nonetheless, we see same lecture he writes: ‘Always, when a certain echoed what David Hume had written in 1740 sequence of events recurs without exception, we [68 ]: ‘’Tis not therefore reason which is the guide believe that a law is operating, and are particu- of life but custom. That alone determines the larly encouraged in this belief when we succeed mind in all instances to suppose the future con- in arbitrarily evoking the initial event, and then formable to the past. However easy this step may observe the subsequent one. Such an experiment seem, reason would never, to all eternity, be able has an irresistible persuasive power over us. to make it’. In a more recent precedent, when However, clearly, this reveals no deeper connec- Fechner developed his strict psychophysical par- tion between the two events—it proves merely allelism, he denied causation between mind and the presence of that pathway which was claimed brain in either direction. In this, he followed a line earlier in the same processes. Our need to infer taken two centuries earlier by another proponent causality, in short, is an inborn error or a bias of of parallelism, Baruch Spinoza. A fundamental our brain.’ Editorial Commentary 365

These ideas come in early sections of insights into reality) is central to Western philos- Grundriss. In clinical sections, Wernicke does ophy, and can be traced back to Plato, even to not follow through on these ideas, and happily Pythagoras. Wernicke’s ‘credo’ announced in L1, uses ‘aetiology’ as a synonym for biomedical that mental disorders are diseases of the brain, cause. In L38 (p. 293), we read ‘Every specialist was adopted by most psychiatrists in Germany is forced to some general notion: Very often we since Wilhelm Griesinger, this being central to fi nd some debilitating event being specifi ed as a debates between ‘Psychikers’ and ‘Somatikers’. proximate cause’. In L26 (p. 174) he uses the The Somatikers were clear about the materialism phrase ‘an unconditional cause-and-effect rela- on which they based their views, although they tionship’. It is possible that he was hinting here at often had sympathy for some views of the a defi nition of ‘cause’ provided by John Stuart Psychikers, while rejecting less helpful notions, Mill a few years earlier [72 ]: ‘the antecedent or such as remaining ideas of demon possession and combination of antecedents upon which an effect various types of quackery. Wernicke is caught is invariably and unconditionally consequent’. between two opposed infl uences, the materialism ‘Cause’ itself is very hard, perhaps impossible, to of the ‘Somatiker’ ascendency in psychiatry, and defi ne rigorously. the more metaphysical tendencies of Gustav A view made clear in Mach’s writings, prob- Fechner and followers. It would be a mistake to ably shared by Fechner, possibly also by take Wernicke’s materialism as implying lack of Wernicke, is that a scientist’s task is to provide subtlety or sensitivity to subjective realities (a the most economical description of nature, not charge often made later against behaviourists). to explain it (if that implies ‘fi nding its cause’; We read, for instance in discussing cerebral rep- although ‘explain’ could encompass exact quan- resentation of language (L2, p. 10): ‘We need not titative descriptions, and the reasoning leading assume that the entire process normally follows a to them). Here Mach’s views probably coin- set pattern, virtually in preformed pathways, so cided with those of Newton two centuries ear- that the result is predictable.’ Far from the deter- lier, but defi nitely differ from ones prevailing in minism, which might be implied by refl ex con- biomedicine, then and now. cepts of Wernicke’s times, here he anticipates Overall, there are numerous similarities Chomsky on the creative aspects of language. between Fechner, Mach and Wernicke, on under- Overall his stance became a curious mix, avoid- lying methodology, the primacy of subjective ing many implications of Fechner’s strict psycho- experience, the conditional nature of reality con- physical parallelism. Thus, for Wernicke, veyed by such experience, and the concept of parallelism applies to some brain structures but causality. The similarities give strong support to not others, and not consistently. His ambivalence the idea that it was Mach to whom Wernicke surfaces in L19 (p. 124) in terms of opinions of made his cryptic acknowledgement in the his former colleagues: He discusses the views of Foreword to the 1894 edition of Grundriss; and Meynert and Neumann that hallucinations might they connect this work with Einstein’s approach- arise due to release from inhibition. The former, ing revolutionary ideas, where mass, length and his earlier mentor, was clearly of the Somatiker time were all subject to distortion. persuasion, the latter, one of the few remaining Psychikers. The logic of their respective posi- tions is similar—only the words differ—and VI,(b). Wernicke on Mind/Brain while Wernicke suggests that Meynert’s version Relationships might be strengthened by experiments on local- ized function, he prefers the impartiality of The debate about the relationship between mind Neumann’s views. and brain (otherwise expressed as that between In more detail, in L2 (p. 11) we encounter the mind and body, mind and matter, meaning versus phrase ‘the organ of consciousness, in other mechanism, or subjective versus objective words, the organ of association’. The important 366 Editorial Commentary point is that consciousness is defi ned by the act of Fechner. His parallelism is sometimes expansive, association. This equation comes more easily in sometimes more restrictive. German than in English, since the German word Nonetheless, the infl uence of parallelism has a for consciousness, Bewusstsein , contains the past major impact on his whole approach to psychia- participle of wissen , the verb ‘to know’, which try. Wernicke, like Meynert, had no qualms about knowledge, is, in some sense acquired by associa- using subjective intuitions about how his own tion. The phrase sich bewusst sein , could then be mind worked, in order to draw inferences about translated as ‘to be aware of’ or ‘to be conscious how the brain operated. Examples are his subtle, of’. In L3 it becomes clear that Wernicke departs yet consistent distinction between ‘feeling’ from classical ‘two substance’ dualism, suggest- ( Gefühl ), ‘sensation’ (Sinnes ), and ‘perception’ ing instead the inseparable union of two different ( Wahrnehmung), and his grasp of Plato’s point aspects of cerebral activity. However, this seems (see next) of the subjective difference between mainly limited to the cerebral cortex, when he our perception of an object, and that of the gener- writes (p. 17): ‘Consciousness is a function of the ality or idea of the class of objects. Such intu- central projection fi elds. If the assumption—that itions are of course fallible, yet nonetheless a projection fi elds occupy the entire cortical man- fruitful source of ideas for exploration. tle—is confi rmed, then the corollary follows: Consciousness is a function of the cortical man- tle.’ His argument for the role of the cerebral cor- VI,(c). Wernicke on Theory tex is based partly on comparison with animals, of Knowledge where both cortical structure and apparent percep- tual capacity (as inferred from behaviour) differ Just as old as the debate about the relation from humans in corresponding ways. In L3 it is between mind and body is Plato’s theory of ideas, also implied that consciousness depends on neu- central to epistemology. In L4 (and note, L2), ronal perikarya in the cortex (the presumed site of Wernicke considers the relation between repre- association), not on axons or glial cells, when he sentation of immediate perception of an object writes (p. 16): ‘… when a memory … reaches a and that of the generalized concept of the object. person’s awareness via nerve pathways, it occurs He recognizes the distinction made by Plato 2000 specifi cally in nerve cell bodies.’ Wernicke is thus years earlier. Subjectively, it arises from the far short of the fully fl edged parallelism of Spinoza everyday fact that we generalize from individual or Fechner, essentially more materialistic in tone. cases of an object to its generic form, which latter Inconsistency in his proposed matching may have some vividness in our minds. The dis- between mind and brain comes again in L6 tinction was implicit, 50 years later, when Donald (p. 33), where we read: ‘The fi rst spontaneous Hebb [73 ] formulated the ‘neural assembly’ con- movements a child makes are apparently under cept. In Wernicke’s original, letter-spacing of his control of organ sensations’, in the newborn, with preferred term is widened—k o n k r e t e n B e g no continuity of retrievable memory with child or r i f f e—(‘concrete concepts’), clearly his own adult. Where he uses phrases such as ‘sensations special term. However, the conclusion implied by of movement’ or ‘representations of movement’, Wernicke, and made explicit by Hebb was very the inference is that, even for simple refl exes in different from that of Plato: In contemporary molluscs, sensory stimuli produce sensations. In thinking, we ascribe the origin of generalized L8 he writes (p. 49): ‘Feelings of pleasure and concepts, as distinct from objects themselves not pain in the spinal cord also seem to confer Affect to the other-worldly realm of Plato’s ideas, but to to the organ of consciousness, except that here their manner of representation in the cerebral we cannot specify the grey matter as the sole cortex, as captured by associative processes. bearer of the phenomenon’. He thus appears to be On other aspects of the theory of knowledge guided by Fechner’s parallelism, although his there are frequent indications of the infl uence of views are not worked out so consistently as by Immanuel Kant, and hints at that of John Locke. Editorial Commentary 367

The main debt to Kant is separation of ‘form’ In Wernicke’s clinical lectures, notably when from ‘content’ of experience. This appears fi rst in writing on delusions, he makes further assump- L2 (p. 13): ‘If the presenting symptom is an urge tions on epistemology. In L9, the fi rst clinical lec- to talk, then by the same token this is a circum- ture, he explicitly identifi es symptoms, which we scribed form of hyperkinesia. If, on the other call ‘delusions’, as ‘falsifi cation of contents of hand, his response is nonsensical speech, we consciousness’. This raises the unanswerable could rightly regard this as a symptom of paraki- question, attributed in the Gospels to Pontius nesia. Here, however, one would need a more Pilate ‘What is truth?’, a question which is tau- detailed account for each of these, because mis- tologous, since any answer has to be framed in understanding is to be expected. We will always terms of an assumption about the very matter at be forced, on practical grounds, to distinguish issue. Baruch Spinoza grasped the tautology two totally different aspects of speech: active well, when he wrote ‘He who would distinguish movement as such, and the content of the spoken the true from the false must have an adequate words.’ (emphasis added). In psychiatry, this sep- idea of what is true and false’ [69 ]. aration became central to writings of both Karl The notion that delusions refl ect error in think- Jaspers and Kurt Schneider. In L3, Wernicke ana- ing has a long history [76 , 77 ]. Modern psychiatric lyzes the difference between sensation and per- thought usually identifi es a delusion (as far as pos- ception, perception involving coordination of sible) by the manner in which a belief is held and many items of sensation, which conferred ‘form’ expressed, and by how it was formed (if evidence on them. This had been emphasized by Ernst on this is available). Wernicke, no doubt aware of Mach [64 ], and later was central to Gestalt psy- diffi cult issues in epistemology raised by delu- chology. The hint at John Locke comes in L4 sions, has prepared the ground well: In earlier lec- (p. 22), when Wernicke distinguishes essential tures he emphasized how, based on current and non-essential features of a concept. Locke knowledge, the brain comes to represent individual [74 ] had separated ‘primary’ from ‘secondary’ stimuli, and their integral, refl ecting the outside qualities (a split which, while not identical to world in its entirety. In L4 (p. 22), he is quite Wernicke’s, has some relation to it). explicit: ‘We can also identify the sum of such con- A different debt to Kant comes in L8 (p. 44), cepts as consciousness of the outside world , for in where he writes: ‘Sensory perception that has these concepts we in fact possess a true picture of never occurred previously … remains not only the outer world’ (ein getreues Bild der Außenwelt ). misunderstood, but also very-imprecisely per- The brain also acquires consciousness of the ceived’. This is supported by modern realization person’s own body, and the updated sum, of all that, even for the most basic visual perception, his/her life experiences so far. Altogether these we ‘learn, by experience, how to see’. However, three comprise, to a degree, an individual’s con- this sentence is followed by: ‘… complex thought cept of themselves as an integrated person. processes usually take place along prescribed However, the brain’s representation is not abso- paths’, and ‘Overall, mental activity shows itself lute, just an approximation, as Francis Bacon to depend on a long history of acquiring ideas, asserted. Given that the brain’s representation is and arranging them in special ways’. This appears potentially fallible, it may become more seri- to be a close parallel (albeit a special case) to ously deceptive. Nevertheless, Wernicke’s strong ideas presented in the opening of Kant’s Critique defi nition of truth and its separation from false- of Pure Reason , [ 75 ] where it is argued that syl- hood, based on understanding brain mechanisms logistic logic, as previously conceived is always implies that philosophical notions of truth depend incomplete, strictly a non sequitur, because it on, and in a sense, ‘bend the knee to’ what is relies on unstated, background notions (‘syn- known, or inferred about brain processes. This thetic a priori’ statements, for Kant). Wernicke reasoning also links with Mach’s view, that our (but not Kant) implies that such knowledge is not view of external reality is a distortion, although a priori, but acquired. sensation is primary. 368 Editorial Commentary

One specifi c aspect of distortion is introduced early lectures as in later clinical ones. Wernicke in L15 (p. 96), where Wernicke writes about is not entirely consistent in his treatment of them. ‘overvalued ideas’: ‘In this lady there was no In L7 (also L12), following Meynert, the view is psychopathic basis from which the overvalued expressed that an individual’s unchanging sense idea would have grown. However, you will not of ‘corporeality’ gives him his ‘primary Ego’, go far wrong if you take note of the “critical” age which also assimilates his knowledge of the out- she had reached, combined with an excess of side world, and personal life story. However, by mental energy, and resulting improper lifestyle, L14 (p. 86) he writes: ‘Normally, in a complex as suffi cient reason for occurrence of a sexually brain mechanism, there should not exist the coloured, overvalued idea’. These sentences sum remotest corner that is in discord with all other up his notions of ‘overvalued ideas’, and spell parts, and which does not function under their out with crystal clarity, a profound problem. Our infl uence’: This view of normality is perhaps the evaluation of ideas, persons or events inevitably dream of a philosopher, for whom rationality recruits basic functions of association, imple- comes easily, who does try systematically to mented by the cerebral cortex. Any mechanism erase all inconsistency in his thought, and who designed to detect and register associations, must (incorrectly) takes this as a universal norm. Such contain a ‘set point’ or ‘threshold’ above which a philosopher may be over-infl uenced by Western the link becomes credible, and below which it is religious thought which took rationality as the rejected as coincidental, and then forgotten. As in norm for human nature. However, deduction, and any statistical inference, conclusions are reached the quest to eliminate logical inconsistencies are ‘to degrees of probability’, not as certainties. not universal human endowments (whatever phi- Thus, without any inference of psychopathology , losophers of earlier centuries had said): They are we are all prone to error. Depending on where the products of education, training honed by experi- threshold is set—which varies from person to ence, and practice. The example given in L14, of person—we may be more, or less error-prone. a patient with a doctoral degree, is exactly the Overvaluation of ideas then refl ects normal cere- sort of person to have acquired this facility; but bral mechanisms in persons who are intrinsically most unlettered people, however effi cient and error-prone, as are we all. For some of us, cul- agile their minds, lack this facility, and operate tural traditions have given us an alternative fac- on the basis of memory and inductive inference ulty, that of deduction, which, when deployed (which are universal cerebral processes) rather systematically, can at least correct inconsistency, than by deduction. In L16, Wernicke, in effect, if not preventing error. L15 (also L14) deals with accepts this, when he compares recovery in two such corrective strategies. However, deduction is patients. In one, completely lacking insight when not a natural ability, but an artifi ce developed in ill, and complaining about his illegal detention, some cultures. Even in the most sophisticated recovered in an uneventful way; in another hypo- cultures, only a minority of the populace has suf- thetical but plausible patient, with extensive legal fi cient ability and faith in the method for it to training, there is a persisting focus on legal injus- overrule their associationist instincts. Therein tice, with continued accretion of far-fetched lies our problem! explanatory delusions. However, subsequent helpful corrective explanations might also develop in those who have acquired a facility in VI,(d). Wernicke on Personhood, reasoning. Unity of a Person, and The insight that the supposedly ‘indivisible’ ‘Self-Consciousness’ Ego has a complex, ever-shifting structure, and can become overtly fragmented, is clear in some The concept of personhood, the ‘unity of a per- of Wernicke’s lectures. In L12 (where he intro- son’, and—‘mystery-of-all-mysteries’—‘self- duces the sejunction concept) he discusses patient consciousness’, are topics which arise as much in Rother, and writes (p. 72): ‘This individual Editorial Commentary 369 consists simultaneously, as it were, of a number defi nition of fugue—a rare condition, usually of different personalities’, and that there is ‘a dis- related to psychic stress—has as exclusion crite- integration of individuality’. Likewise in L28 ria physical trauma, other medical conditions, (p. 193) he uses the phrase ‘split personality’ and various psychiatric diagnoses. The case (Spaltung der Persönlichkeit). The composite reported by Max Naef [79 ] (a doctoral thesis pro- nature of personhood is also found in writings of duced while working under Auguste Forel) which Ernst Mach who wrote that, although ‘psychol- Wernicke describes in detail (L28, p. 190 seq. ) ogy and psycho-pathology teach us that the Ego would be excluded according to such criteria: is the bond which holds all my experience This patient’s problems probably combined con- together, and the source of all my activity’, it can sequences of hyperthermia-heat stroke and den- ‘grow and be enriched, can be impoverished and gue fever, given the high air temperature in inland shrink, can become alien to itself, and can split Australia, and railway carriages with no air con- up—in a word can change in important respects, ditioning in the 1890s (see [ 80 ]; on neuropsychi- in the course of its life’ ([65 ]; p. 356). Quotations atric effects of hyperthermia). like this show that Mach—polymath that he In L7, the topic of ‘ self- consciousness’— was—could offer deep insights into psychiatry, ‘riddle of all riddles’ is Wernicke’s phrase—is from which Wernicke may have benefi ted. When discussed, and Wernicke’s scepticism about phi- we get to L28, and discussion of the ‘second losophy is interesting. He does not dismiss it out state’ in some of his patients, the fragmentation of hand, which would have been simplistic, given of personality is explicit. A vivid personal account that the natural science tradition grew out of hard is given by a patient, of her experience of this debates in past centuries on essentially philo- state, its authenticity ensured by apparent lack of sophical issues; and Wernicke was clearly distortion by her awareness of any popularized indebted to philosophers, especially Kant. concepts of ‘multiple personality’. Wernicke However, he ends by pointing out that the seem- clearly regarded the topic as very signifi cant, ingly ‘indivisible unchanging ego’ (implied by because, after describing this case, he starts his much of our language, culture and history), is comments with the words: ‘To leave no doubt actually a complex dynamic structure. This point about the importance of this case …’ The so- can be made from many perspectives, suggesting called ‘multiple personality’ had occasionally that different parts, with different functions can been described in the previous century, in France ‘cast their eye’ over other parts, by looking back especially by Charcot, who described a transient in time (Wernicke’s point), or by looking around condition with disorder of consciousness: There at the other parts of this complex entity. Such was dissociation between automatic activities ideas were becoming accepted by clinicians, (which were coordinated, if sometimes outland- from work of Pierre Janet in Paris. By the time of ish or bizarre) and personality, to which these the 1906 edition of Grundriss , more sophisti- activities were foreign, or contrasted with educa- cated views on this had been formulated across tion received. Pierre Janet described splitting of the Atlantic, by J. Royce and J.M.Baldwin (see identity, in relation to psychic trauma. Wernicke’s ref [16 ]), whose work Wernicke is unlikely to emphasis is different, with little stress on psychic have read. The line of thought was developed in trauma, and more on other ways in which such the 1930s by George Herbert Mead [81 ] and a states might be precipitated, including epileptic modern addition is found in a section of the doc- seizures, and alcoholic binge drinking. Hysteria toral thesis of Kate L. Ball [ 82]. The non -unifi ed is mentioned in this context, and it is clear that nature of the Ego was accepted by Mach, who Wernicke accepted it as a condition not limited to writes of ‘the instinctive, but untenable splitting women. Some states of dissociation described by up of the Ego into an object experienced and an Wernicke fi t the defi nition of ‘fugue’, a condition active or observing subject—a problem which which, according to Ian Hacking [78 ] was, in has tormented everybody long enough’ ([ 65 ]; part, a male equivalent of hysteria. The modern p. 332). Again: ‘Whoever cannot get rid of the 370 Editorial Commentary conception of the Ego as a reality which underlies visible. Here, rather than seeing personhood as everything, will also not be able to avoid drawing the integral of many parts of consciousness, we a fundamental distinction between my sensation fall back on older notions, perhaps related to an and your sensation’ ([65 ]; p. 356). Apart from ‘indivisible soul’. K.L.Ball, in her doctoral thesis anything else, this shows continuity between the [82 ] suggests that personhood is twofold, the thorough parallelism of Spinoza and Fechner, right hemisphere characterized as ‘the self expe- and the thought of Mach. riencing, and acting now ’; the left, as ‘conceptu- alizing the self, the will, and controlling at least some thoughts’. VI,(e). Wernicke on ‘Will’, Hegel’s concept of ‘will’ is pure teleology. In and on Teleology L8, Wernicke apologetically admits that his defi - nition of Affect is also teleological. Teleological In L30 (p. 204), we read: ‘For anyone to “will” a reasoning has a long history. The birth of the natu- certain action presumes making a decision, ral sciences depended (inter alia) on abandoning unquestionably an action of pure thought … In Aristotle’s notion of ‘fi nal cause’ (a cosmic form content, this implies that two or more possibilities of teleology) in favour of ‘antecedent cause’. For have been weighed against each other’. The Freud teleological arguments were used widely, German word for ‘will’—Das Wille— resonates in without restraint, this being a major criticism of German history. In combining ‘ Das Wille’ with his work. However, the behaviour of living things ‘pure thought’ a link is made to earlier idealist phi- clearly often does work towards an end goal, and losophers such as G.F.W.Hegel (1770–1831) Ernst Mach himself argued that teleology was which belies the materialist tone with which sometimes a valid account of nature, although not Grundriss began. For Hegel, ‘Will’ is not ‘free’ as Aristotle’s ‘fi nal purpose’, or with any overall until it is actualized, apparently unlimited by purpose for living things. (Here he might be at physical realities in the brain. Later, the monthly odds with Richard Dawkins, and his concept of magazine of the Hitler Youth was to be entitled the ‘selfi sh gene’). Today, no apology is needed Wille und Macht (‘Will and Power’). In discussion for teleology, if a correct approach is adopted: of freedom (or otherwise) of will by philosophers, Rigorous ways were devised to establish the teleo- the process of ‘getting out of bed’ is a widely used logical nature of behaviour, in work of ethologists metaphor, as here (L30, p. 207). It appears in such as Nikolaas Tinbergen and Konrad Lorenz, William James’ ( The Will to Believe; and other work that is highly relevant to psychiatry. essays in popular philosophy , published in 1897 [83 ]), and may have started its life there. Wernicke side-steps the challenge to determinism-in-princi- VII. Wernicke’s Contribution ple, based on overemphasizing ‘Das Wille’ , when to Neuroscience, Psychology he writes (L30, p. 207) ‘… of the error … that a and Overall Medical Knowledge person can control his thoughts and feelings, whereas actually the thoughts control the person’. In the English-speaking world, Wernicke’s name Possibly neither of these is right. Perhaps a is linked with two ideas: cerebral localization of person (or at least ‘one side’ of a person) is his or function, and—almost as strongly—a supposed her thoughts. Descartes, after all, asserted ‘I think ‘associationist school’ of thought. Less well therefore I am’. Referring back to the ‘unity of known, yet fundamental to Grundriss, are his personhood’, Wernicke is not consistent in dis- ideas on basic brain science. Here we deal with cussion of ‘will’. He writes (L35, p. 267) ‘To his additions to science and medical knowledge, assume a unilateral condition of the will would and with important gaps in his understanding, be nonsense’: Why nonsense, to assume that ‘the which shaped some of his mistakes. His major will’ resides in one hemisphere? Many clinical contributions to thought about mental disorders fi ndings have shown that personhood is not indi- come later. Editorial Commentary 371

VII,(a). Basic Neuroscience transfers to such intercortical pathways, and then seems very well suited, just as in the speech area, At least in early lectures, Wernicke assumes that to produce the paraphasia’. interactions between nerve cells were solely Sherrington is acknowledged as the fi rst to excitatory. In L8 (p. 43) he writes: ‘We can demonstrate neural inhibition clearly, inferred demand no more from it [the brain] than the rather than proven, in the spinal cord. There were sequence of certain excitatory processes’. Later, however a number of forerunners, such as the he contradicts this, implying that inhibitory inter- Edinburgh-based physiologists Charles and John actions might occur between cortical neurones. Bell early in the nineteenth century, and others in Sometimes this is ambiguous, when he mixes Russia and Germany in the nineteenth century, psychological and biological language. Thus, in cited by Sherrington in his Nobel Lecture of L8 (p. 48), when introducing the topic of emo- 1932. It is therefore interesting that the work of tions he writes of ‘a set of phenomena … which Hering in 1897, apparently denying the existence very often have effects of slowing down [hem- of inhibitory effects, and which Wernicke cites, menden] the course of mental activity, which are has, as its co-author CS Sherrrington, who had both decisive and disruptive, in equal measure.’ travelled in Germany (where he met, and worked In L19 (p. 123) he attributes the idea of ‘mutual with Goltz [see biographic comments, below]). inhibition’ to Meynert, whom he quotes in L33 In Refl ex activity of the spinal cord of 1933, (p. 236): ‘The association intensity corresponds Sherrington and colleagues [84 ] often used the to the molecular tissue attraction as a source of phrase ‘reciprocal innervation’, and ‘reciprocal strength. The mass of arching fi bres, within inhibition’ is used occasionally, stating (p. 67) which two sources of force, that of the idea of an ‘There is as yet no experimental evidence for the “objective” and that of the initial idea, tend existence of inhibition with neurones other than towards each other, as it were, in the act of think- motoneurones’. Direct proof came in 1942, when ing, always attaining vital force for elevation spinal inhibition by the eponymously named above the threshold of consciousness from two Renshaw cell was discovered [85 ]. Overall ideally centralized cortical areas, but the second- Duchenne (and Meynert) were proved correct in ary association from only one of these areas: this debate. Hering was proven incorrect, but either that of the “objective” or that of the initial may have infl uenced Wernicke. idea, according to whether for example the rhyme Of great interest is that, as early as 1894, fi ts its word picture. The functional attraction is Wernicke had clear ideas for what is now called the weaker here, and is inhibited by the stronger’. ‘synaptic plasticity’ as the physical basis of mem- In L35 (p. 235) he uses the curious phrase ‘inhib- ory. This is mentioned in L3 (p. 16), where he itory thought’ [hemmende Gedanke ]. ‘Inhibition’ writes: ‘Pathways that are initially hard to access is mentioned again in L35 (p. 236) where we become more fi rmly trodden-in with each new read: ‘maintenance of certain abnormal positions training experience—you could say that they are may reveal only subjective sensations of changed “molded by experience”’. There are references to balance between the motor impulse and its col- early German experiments (dated 1880 [Ward], lateral and antagonistic activation of defi nite and 1882 [Jarisch and Schiff]), showing the con- muscle areas, which cooperate in the normal cept as a basis for memory to have been clear in position’. He adds (note): ‘This representation is his mind in 1894, and to be much older than its based on Duchenne’s theory. The more recent current reincarnation. (Other early references on works of Hering, Jr. have meanwhile proven that synaptic plasticity are found to be in John [[86 ]; the assumption of an antagonistic muscle coordi- p. 198]). What is more, in discussing ‘falsifi ca- nation is not tenable.’ However, shortly after tion of memory’ (L14, p. 89), he shows aware- (L35, p. 269), he explicitly refers to inhibition at ness that there must be a complementary process: a neuronal level ‘The same inhibition [Hemmung ], ‘… memory falsifi cation requires a preceding which is responsible for immobility of the patient, break-up of associations.’ Today, dissipation of 372 Editorial Commentary associative memories is the subject of experi- More fundamentally, associations in the cortex mental study as ‘long-term synaptic depression’, are potentially so ambiguous, that they need a complement to ‘long-term potentiation’ which some sort of supervision or constraint to ‘disam- establishes them. Related to this, the temporal biguate’ them. A recent theory [88 ] attempts to precision of association at a neuronal level, is give an account of this process: By interplay mentioned in L3 (pp. 17, 18): ‘I agree entirely between hippocampus and cerebral neo-cortex, with Sachs and Goldscheider, that only by assum- the inherent ambiguity of associations in the lat- ing that functional links are acquired between ter structure could be resolved. It was also argued simultaneously excited perceptual elements using that such interplay sets up lasting confi gurations existing connections can one explain the specifi c which represent contexts for cortical operations memory for respective forms of retinal images, in specifi c situations, serving to disambiguate defi ned by patterned stimulation of retinal points’ activity circulating in the ‘organ of association’. (emphasis added). The modern slogan is ‘cells These contexts, it was proposed, correspond to which fi re together, wire together’. Kant’s ‘synthetic a priori notions’, which Wernicke describes as the ‘long history of acquir- ing ideas, and arranging them in special ways’ VII,(b). Wernicke (p. 44). There is one further major shortcoming in and ‘Associationism’ the view of the cortex as an ‘organ of associa- tion’: The motor region of the cortex, directly It is incorrect to regard ‘Associationism’ as a infl uencing lower motoneurones of brainstem ‘school of thought’. It is now fully accepted as a and spinal cord, and the decision-making pro- major bridge between neurobiology and psychol- cesses by which motor outfl ow is determined, do ogy. Wernicke’s view that the cerebral cortex was not fi t the concept. Wernicke gets near to this in (above all other brain regions), the organ of asso- L35 (p. 267): ‘From such arguments, it seems ciation, is basically correct, as a three-word syn- that in motility psychoses, consciousness of per- opsis. In L33 (p. 236) the assumption behind this sonality—in our sense, that “grand complex of is stated in simplest form: ‘If such functional dif- ideas” which makes up the Ego—is to a certain ferences of excitability are disregarded in the degree detached from motor mechanisms of the organ of association, the primordial condition of body, over which “the Ego” has become used to the childlike brain (Meynert’s “genetic confu- exert control. As a witness, the “Ego” is con- sion”), in which any given association is possible, fronted with motor processes, and also with the reappears to some extent, and may be retained for failure of this machine, and in turn, is initially a while, because anatomically preformed combi- affected by this’. By analysis at a psychological nations exist between any given two cortical level, this appears to reach a conclusion which areas’. Miller [87 ] developed a similar starting can now be put on a stronger footing: Operations point as a basic substrate for forming associa- of the motor system are not a natural component tions, that all neurones are connected with all oth- of the cortex, seen as the ‘organ of association’. ers in the organ of association—the The motor cortex is anomalous, having a place in ‘omniconnecton principle’—although, of course, the parcellation of the cerebral cortex only this does not—and cannot—occur in practice. because of other styles of processing imposed on One can of course point out that other princi- it by the basal ganglia, and elsewhere. ples of organization need to be added. As men- Many implications of the concept of associa- tioned above, for Wernicke, associations were tion are pursued in early lectures. Much of L3 is not only spatial (between data represented simul- devoted to distinguishing perceptual images from taneously), but to a degree, temporal. However, memory images. In the tactile sense, he separates he had no idea of the brain mechanisms by which sensitivity—‘ability to detect’ a tactile stimu- temporal associations might be formed, nor the lus—from what he terms Tastvermögen —using temporal limits within which they might apply. such stimuli for object recognition. In modern Editorial Commentary 373 terms this is the distinction between sensation as ‘positive feedback’: A ‘suspicion’ that ‘some- and perception, the former implying ‘awareness’ thing is the case’ leads to a ‘search backwards’ for arising direct from sensory input, the latter imply- relevant evidence, and if it is found, it is fed for- ing added processes of interpretation or analysis wards again, to strengthen the initial suspicion. In of that input. We translate this as ‘tactile percep- this way we arrive at sharp categorical judg- tion’. Likewise, later in L3, he often uses the ments—‘identifi cations’ in Wernicke’s terms— word optische and occasionally visuell . At one which go beyond objective assessment of the point he writes of ‘visual impressions that attract evidence. Wernicke is speaking of what we would our attention’ using the word Gesichtseindrücke. now call ‘pattern completion’, a process which In modern terms both this and visuell imply ‘per- Braitenberg [89 ] calls ‘ignition’—of representa- ception’ as distinct from ‘sensation’. Later (L20, tion of a whole, when only parts of are detected. p. 129) with a slightly different sense, he is at Wernicke’s associationism is based on ‘associ- pains to separate perceptual images from ation based on signal continuity’, a concept pur- ‘thoughts’ with no perceptual connotation (men- sued by Pavlov and others in somewhat different tal images devoid of perceptual imagery). The contexts. Not long after Wernicke’s death ideas German word Empfi ndungen implies sensation emerged that there was another major type of asso- itself rather than perception ( Wahrnehmung ) or ciation: North American psychologists developed remembered images of sensation, a subtle subjec- the idea of association between an item of emitted tive distinction, discussed in relation to both behaviour and the subsequent effect of that behav- visual and auditory sense. In translation we try to iour. From this so-called law of effect , the concept make the distinction as consistently as possible of reinforcement was developed, along with asso- (for instance using ‘visual’ as opposed to ‘visual ciated lines of theory and experiment. This con- perceptual’, and avoiding the word optische ). cept was mainly missing in Wernicke’s thought, as Despite separating perception from memory far as it infl uenced behaviour. images, Wernicke argues that similar associative processes apply at each level: He sees an exact parallel between formation of memory images in VII,(c). Cerebral Localization primary visual areas by linkage of ‘perceptual of Function elements’, and those higher in the hierarchy which generalize from percepts to concepts. The The concept of cerebral localisation followed arguments are another prescient forerunner of naturally from the ruling paradigm of general Hebb [73 ] in advancing the ‘neural assembly’ medicine, to relate symptoms to diseases in spe- concept: Most representation is via networks of cifi c organs or body systems, defi ned by anatomy widely distributed, but connected nerve cells. In and pathology. This was inevitable when, with L3 and L4 his arguments amount to setting up a few objective markers of disease, symptoms were ‘straw man’, such that ‘perception’ and ‘memory’ the prime source of evidence of disease processes are separate processes, represented in different in the living. The relation with general medicine groups of nerve cells; and he then proceeds to is seen in L24, where Wernicke employs the demolish the hypothesis, where he writes (p. 24): localization concept to refer to bodily symptoms, ‘But as soon as you go beyond this initial physi- bodily ‘localization of function’ being common ological unit, the memory image, and envisage clinical thinking at the time. Interestingly, just the next higher level of visual images or even throughout this lecture he refers to localization in association between visual images and remem- the body of feelings of anxiety. Just as much as bered images from another projection fi eld, the asking a patient ‘where does it hurt?’ he is at ease diffi culty of conceiving the process increases asking ‘where does your anxiety come from?’ enormously.’ This may seem strange today, but is logical, and In L4 (p. 22) he refers to ‘simple circuit opera- has precedents from classical times, when the tions’. He probably means what we now refer to heart rather than the brain was held to be the seat 374 Editorial Commentary of emotions. Similarly, a word root for ‘schizo- iour, carried out mainly on dogs, with some on phrenia’ (and other terms in psychiatry) is that for monkeys. The same principle assuredly applied the ‘phrenic nerve’ supplying the diaphragm. in humans. Wernicke writes ‘There can no longer Curiously, yet logically, the word ‘hypochondria’ be any doubt that each region represents the total (literally, ‘below the ribs’) is occasionally applied sensibility and motility of the designated body to unusual states of happiness as well as to those part, the arm region, which thus constitutes the of anxiety (p. 107; L29, p. 198). central projection fi eld for sensibility and motil- The concept of cerebral localization arose in ity or, in other words, the entire nervous system Wernicke’s earliest work defi ning the brain region of the arm.’ This comment would not be held representing speech sounds, but had become more valid today: A ‘second somatosensory area’ was nuanced by the time Grundriss was written, defi ned by Adrian in 1940 [90 ], spatially separate although missing some points we accept today. from the primary area, and now known to deal Sometimes he presents localization as a hypothe- with aspects of somatic sensation different from sis, without evidence, as in L1, when he suggests those dealt with by the primary area. In L1 he that semantic organization of speech uses brain refers to Broca’s area as the ‘motor speech path- regions different from those for phonetics. way’. Modern neuroanatomists would avoid such Sometimes he infers topographic mapping a statement, knowing the relation to motor out- between connected regions, in absence of evi- fl ow to be less direct. In one respect, however, his dence, simply because it seems necessary. localization is quite modern: In L36 (p. 274) he Sometimes his use of the concept is an analogy writes ‘Affi liation of motility symptoms with (‘For purposes of this analysis, all changes in con- changed body awareness is thus illustrated tent of consciousness can then be likened to focal again’: This view, iterated several times in this symptoms, and will behave just as do more famil- lecture, corresponds to a view which avoids sepa- iar focal symptoms of brain diseases’ [L11, rating functions of primary motor and somato- p. 66]). Sometimes he refers to the concept in a sensory areas of cortex (for instance in the notion quite metaphorical way. Sometimes he makes it of ‘active touch’: [91 ]). clear that it is no more than a hope for the future In L3, Wernicke discusses the difference that precise location can be found for symptoms between perceptual and memory images, and he describes, as when he writes (L33, p. 236): ‘the writes (p. 18): ‘only those elements in the cortical closed train of thought is a functional acquisition projection area serving perception should corre- pointing towards a most minute localization in spond to points in the retina’: He appears to defi nite anatomical elements’. In stricter scientifi c assume one-to-one relations between neural ele- vein, he concedes that much representation is dif- ments in the retina and those in the visual cortex, fuse, an insight closely connected to his ideas on a view which modern neuroanatomists would modifi able connections between members of question. Likewise, in L6, there is reference to a widely dispersed nerve cell networks. conjecture that there be orderly connections Nonetheless, in describing akinesia, hyperkinesia between points on the cortical map of the retina and parakinesia, which can occur independently and locations controlling activity of combina- in different muscle blocks (L35, p. 260), the infer- tions of eye muscles, corresponding to these ence that there is localized abnormality is strong, points; some empirical evidence for this is cited although the brain structure in which this exists from Munk’s experiments. However, empirical (cortex, or perhaps basal ganglia) is unclear. proof is lacking. This conjecture is intended to In early lectures (e.g. L2) the evidence he cites address a major problem for representation in the is clinical, either relating symptoms to identifi ed brain: How can object recognition generalize lesions, or studies in animals using lesions and over different sizes of retinal image, different electrical stimulation. In L5 he cites experiments directions of viewing etc. We read (p. 18): ‘An conducted by Munk, involving cortical lesions, equilateral triangle or a cross can be recognized with long-term follow-up, and study of behav- whether the triangle is standing on its base or its Editorial Commentary 375 apex, or whether the cross is standing, lying, or which neuropathological evidence was available, standing at an angle. How could the same mem- and other psychoses for which it was not, lent ory image be derived?’ The explanation proposed weight to localizationist views which he might seems far-fetched today. Moreover, given his have wanted to apply generally to psychoses more plausible account of concept formation in (L37, p. 274). We now know that pathological L4, which might also apply to percept generaliza- changes in progressive paralysis/tertiary syphilis tion, it is unnecessary. are greater than ever seen in endogenous psycho- Diffuse representation is raised as early as L1, ses, so the analogy may be false. Even so, in clos- when the supposed Conceptualization Centre is ing pages of L41 (p. 328), he rejects this hope: mentioned. ‘In truth, this supposed ‘Do the few cases I have in mind allow us to con- Conceptualization Centre is distributed to cortical clude that all acute psychoses, as well as the less sites far removed from one another’. In L2, any severe cases would reveal similar anatomical ambiguity is resolved, by asking whether this cen- fi ndings, were they to reach autopsy? . . In my tre has a defi nite physical location, or is it more opinion this question cannot be supported.’ diffusely localized, perhaps ‘localized’ more exactly but more abstractly in a logical structure? In L7, when discussing the cerebral basis of per- VII,(d). ‘Psychic Refl exes’ sonhood, he asks (p. 39): ‘What spatial sense can we make of a personalized consciousness?’ In The notion of ‘psychic refl exes’ was common talk answer, he refers to several types of disorder. at the time. Wernicke formalizes the concept, with Amongst those listed, it is unclear if they include distinctive italicized abbreviations: sAZm, signi- what is now call ‘mental illness’, to which cerebral fying the various stages in the ‘psychic refl ex arc’. localization seldom applies, or to neurological con- s and m are sensory and motor fi elds respectively, ditions, where it often does apply. Overall, while, presumably in the cortex, while A and Z , are as a neurologist, Wernicke’s name is rightly linked hypothetical staging posts where higher lever per- to the concept of cerebral localization of function, ceptual analysis and output planning are accom- this concept is not central to Grundriss. At times he plished. This model is fi rst described in L2 (p. 12), pulls away from localizationism in a fundamental for instance in the following lines: ‘Nervous exci- way. Thus, in L36 (p. 274), he writes: ‘There seems tation, which takes place along the pathway sAZm to be no compelling case for drawing an analogy can be likened to a refl ex process, and we can des- between the differentiation amongst these cases [of ignate this pathway as a “psychic refl ex arc”. The akinetic motility psychosis’] and the quite circum- movement activated from m then appears as the scribed nature of direct focal symptoms in brain result—a discernible consequence—of this acti- diseases’. Thus, he recognized that localizationist vation.’ The model is used throughout Grundriss , approaches, whatever their value in neurology, had for instance in L8 (p. 44), though expressed less limits as applied to realities of mental disorders. clearly than in L2 ‘… [mental] activity triggered At times cerebral localization is raised as a by the question as “registration”; and the result of possible basis for future classifi cation: ‘… I can- mental activity included in the answer as “execu- not emphasize strongly enough that the forth- tion”’. An example is the symptom of negativism coming principle of classifi cation must be that of ‘possibly having a signifi cance similar to that of a anatomical arrangement, giving a natural group- “modifi ed cortical refl ex”’ (L35, p. 266). ing and sequence of substantial changes’ (L17, Comparison with a monosynaptic ‘stretch refl ex’ p. 104). Here he is fl ying his favourite kite, that is hinted at, and the differential susceptibility he correlations will one day be found between the site describes, to rapid as opposed to slow stretch, of brain pathology and symptoms exhibited by implies selectivity to ‘phasic’ as opposed to ‘tonic’ patients, not only in neurology (where this was well stretch, a distinction well-known for stretch supported) but also in psychiatry. The relation refl exes. However, the two effects must have very between symptoms of progressive paralysis, for different mechanisms. 376 Editorial Commentary

Jackson’s hierarchical concept of brain orga- today) that the cerebral cortex has an inhibitory nization has already been mentioned. In L20, action on activity in the basal ganglia. He was Wernicke deals with levels of coordinated motor aware in a general way, of issues raised today behaviour, generated by the brain under different for understanding these structures. Thus, the conditions. These were to be explored later by fascinating lecture on melancholia (L30, Kretschmer [61 ] in Hysteria, Refl ex and Instinct. p. 204 seq. ), gives an incisive psychological Curiously, in L20 (p. 131), he accounts for com- account of decision- making, but referring to plex, but more-or-less automatic actions, as using the cerebral cortex. This is incompatible with a a ‘short-circuit’ within cortical networks, as view of the cortex as the ‘organ of association’, derived from the ‘psychic refl ex’ concept. He which can include neither ‘decision making’, uses the concept again in L24 (p. 157), to account nor competition between rival programs— for eruptions of ‘senseless rage’: ‘These motor implying inhibitory as well as excitatory pro- expressions bear the stamp of senseless rage, and cesses. However, mutatis mutandis, it is a fi ne would be correctly understood as a type of refl ex account of processes now thought to occur in response to violently increased organ sensations, the basal ganglia, where separate paths exist to and thus as hyperkinesia induced by psychosen- initiate and to veto any possible action, the so- sory means, via a short-circuit’. An alternative called ‘direct’ and ‘indirect’ pathways from view was possible, following Jackson’s claim, striatum to motor thalamus and motor cortex; that organization of motor responses shifts from and within each of these—under most circum- cortex to subcortex. Something like this is sug- stances—for resolution of competition between gested in L32 (p. 225): What appears to be ‘body rival courses of action [ 92]. In the process, language’ which is quite complex, is nonetheless Wernicke insists that at least one competitor instinctive, more-or-less automatic. should have access to motor outfl ow pathways. The psychic refl ex perspective leads to other Today, that condition is not needed: conclusions on voluntary actions, which are Competition can occur entirely between intra- strange for modern readers. Wernicke writes psychic ideas. He actually had evidence for (L35, p. 266): ‘… persisting contractions and this: Thus, in L29, where patients are discussed those independent of passive movements are so in whom the veto faculty is impaired, symp- invariably combined with states of unconscious- toms occur in one patient as unconstrained ness or marked stupor, that one might be com- motor outfl ow , and in another as unconstrained pelled to relate them to some form of volitional thoughts . action. I confi ne myself to suggesting that there Closely related to functions of the basal gan- are suffi cient clinical and experimental data to glia, Wernicke had little awareness of the rein- prove that central projection motor fi elds are the forcement principle, either (as soon to be defi ned) origin of tonic spasms and contractures’: There is in learning theory, or, following the Olds/Milner a disjunction here, in that evidence for involve- experiment of 1954 [93 ], at the biological level. ment of primary motor cortex is taken as equiva- He does imply a reinforcement process in L22 lent to voluntary action, even in patients who are (p. 140), when he writes: ‘we must attribute to unconscious or stuporous. Affective states the capacity to alter the normal value of ideas, in such a way that certain ideas are overvalued …’ This principle could clearly infl u- VII,(e). Wernicke on the Basal ence the representation of ideas and perceptions ; Ganglia its role in reinforcing behaviour is hard to fi nd in Grundriss. In any case, with no explicit knowl- Wernicke has little to say about the basal gan- edge, he sought elsewhere for processes by which glia. In L11 (p. 67) he does refer to a specifi c abnormal excessive (not epileptic) neural activa- structure, the lentiform nucleus (Linsenkern ); tion could occur. This was one aim of the ‘sejunc- and in L19 (p. 123) to the idea (still current tion theory’ (see below). Editorial Commentary 377

VII,(f). Higher Levels of Functional and dreams is so great that it breaks through, Organization even during apparent wakefulness. In this con- text, in L27 (p. 179), Wernicke refers to ‘falsifi - At a higher level of organization, Wernicke cation of consciousness, and [the] belief in the makes an important distinction as early as L8, lived reality of the dream experiences’, and thus between content of consciousness (produced by appears to imply this theory. It can now be based permanent change) and activity of consciousness on solid evidence—the so-called REM dissocia- (its ever-fl uctuating dynamics). This becomes a tion [94 ]—for which there is some EEG evidence recurring theme throughout Grundriss . In terms [95 ]. This idea is supported by a further similarity of activity, he compares ‘psychophysical motion’ reported in L14 (p. 87) ‘the total loss of memory between sleep and waking (L8, p. 46), and seems during epileptic twilight states, alleged experi- aware that sleep is an active process (an issue ence of Delirium tremens , or any other delirium resolved many years later). At times, he draws from severe intoxication, hysteria, or lastly, dur- parallels, as many have done, between distortions ing normal dreaming’. Amnesia for dreams is of reality in dreaming, and in mental illnesses. In well known, and normal. There are however two L9 (p. 55), he writes: ‘Lack of insight into illness differences between the state Wernicke describes is, in effect, the same as an increase in the sum of and normal REM sleep, that in the latter, there is a person’s memories by a body of data not cor- deep muscle relaxation, with no possibility of responding to reality, as we might gain from mental imagery infl uencing outward behaviour; experiences in a dream. If we were to string these and in the aftermath of delirium, after a period of often highly adventurous dream experiences onto sleep, imagery from the period of delirium is our store of memories, what incalculable conse- remembered for a while (L27, p. 179). quences for our actions, or our judgment of peo- ple might it lead to!’ More scientifi c issues about sleep are raised in L26, when discussing Delirium VIII. Wernicke’s Distinctive Clinical tremens , a severely abnormal state following Concepts in Psychiatry withdrawal, after prolonged excess of alcohol consumption. We now know that similar states VIII,(a). Is Clinical Science Even can be produced by withdrawal from other seda- Possible in Psychiatry? tive/hypnotic drugs, such a benzodiazepines. He writes (p. 172): ‘we are entitled to attribute Wernicke was aware of this as a signifi cant ques- another main symptom of Delirium tremens — tion. In the eighteenth century, when botanical total insomnia—to the stimulating effect of the classifi cation was high on the scientifi c agenda, dream-like hallucinations’. Today, insomnia is the acknowledged pioneer, Carl Linnaeus (1707– generally regarded as a sign of an impending or 1778), was a Platonist (philosophically speak- actual psychotic state (defi ned more narrowly ing), who believed in ‘natural types’. A rival than in Wernicke’s day), rather than being pre- Frenchman, George Buffon (1707–1788) cipitated by the hallucinations. Admittedly, hal- asserted, in contrast ‘Nature knows only the lucinations in other situations (effects of drugs, individual’. Just the same issue arose as psychia- their withdrawal, or toxicity, brain injuries, gen- try invented itself. In L8 Wernicke writes: eral medical crises), which are often visual rather ‘Despite all differences in social milieu, and the than auditory, may lead to, rather than follow epoch in which we live, all individuals in full insomnia. possession of their senses, have fi rmly laid down An alternative view of Delirium tremens is in their store of apperceptions, combinations of possible, now we know of a specifi c ‘pressure’ identical thoughts. In this regard therefore, we for dreaming (rapid eye-movement) sleep: must guard against overestimating the diversity Insomnia could be a precursor to dream-like hal- of individuals. This is defi nitely an advantage for lucinations, where the pressure for REM sleep psychiatry, making clinical observation possible’. 378 Editorial Commentary

This basic step moves the researcher from what ium, and soon of megalomania.’ Again (L35, seems endless variety and uniqueness of persons, p. 260) we read: ‘As we have seen above, it is in to their being somehow brought within a generic the nature of akinetic symptoms, that it is often scheme. After this step, he implies, psychiatrists totally impossible to decide how far they are may be within reach of scientifi c study, even of intermingled with other identifi cation disorders, diagnoses, rather than being limited to endless and at other times this is possible only after the unfocused description in the style of the natural akinetic stage is over. So we must then take into historian. Wernicke does this through a set of account the possibility that the above clinical pic- well-analyzed psychological processes, usually ture of akinetic motility psychosis, derived applicable as much to healthy as to disturbed entirely empirically, is too broad, and still con- individuals. Emil Kraepelin had the same basic tains cases in which the motor symptom complex objective, but approached it in a very different is merely grafted onto another syndrome, which way. is just as signifi cant, and encompasses it’: We see here his keen awareness of a methodological issue, that grouping of symptoms to form clinical VIII,(b). Role of Theory in Wernicke’s entities is sometimes guided by theory, but, in its Psychiatry absence, by empirical associations; and we see his discipline in separating the two. Less explic- Theory plays a crucial role in Grundriss, espe- itly, the same point is made in L34 (p. 256): cially in the fi rst eight lectures. This is empha- ‘Although this result is based on a statistical sized again in his closing sentence of L41: ‘In review of cases, it also confi rms what we might conclusion, I want to draw your attention to one already have expected’. point, and that is that these, my last comments, The balancing act between theory and empiri- should serve to remind you of the need for those cal data was crucial to the birth of the natural sci- theoretical considerations which occupied us in ences. The main difference from natural the fi rst half of our clinical studies, but, for you, philosophy is that psychiatry is much more com- perhaps often quite diffi cult to understand.’ At plex, and a would-be theoretician needs far more times he states explicitly that there are two roads facts at their fi nger tips before venturing an to scientifi c truth—theory and empirical data; explanation. This is hinted at in a comment on and that such truth is most secure when the two Kahlbaum (L34, p. 254) who ‘… has not escaped agree. In L28 (p. 188), commenting on the ‘sec- the fate of all authors who have laboured on ond state’, he writes: ‘Although I do not deny the monographs in a designated domain’: He implies theoretical interest in these most enigmatic states, that his own more comprehensive approach, cov- this should not affect their factual status’. This ering the whole fi eld of mental disorders, as well distinction is most clear in comments on melan- as their basis in neuroscience allows him to sug- cholia, a disorder defi ned by him most strongly in gest conceptualizations superior to those offered theoretical terms. So, in L35 (p. 261), we read: by those limited to single areas of psychological ‘Affective melancholia presented us with an abnormality. This also underpins his profoundly example where symptoms derived from a hypo- holistic approach to the brain and his understand- thetical scheme, and these alone, make up a clini- ing of each patient as an individual. cal picture which, in reality, is met very often’; In his fi nal lecture, Wernicke gives us some and yet shortly after, empirical demands prevail clues to his methods in analyzing and distilling (L35, p. 262): ‘sooner or later in their course, the wealth of clinical data at his disposal. ‘My they give further signs, in that delusions of relat- presentation is based on approximately 5,000 edness join in, this being entirely foreign to mel- carefully kept medical records that have been ancholia. Cessation of melancholia, which may prepared over the course of 15 years, under my last for a year or more, then usually gives way to direction and supervision’ (L41, p. 325), one pre- a further, worsening stage of persecutory delir- sumes between 1885 and 1900, his years at Editorial Commentary 379

Breslau. ‘Unceasing study of these case histories, In drawing attention to Wernicke’s strategy, their monitoring by continuous observation, the we should however be aware that conditions comparison of similar cases with one another, in which, to modern clinicians, are clearly neuro- addition to special study of individual symptoms logical, fell easily within his area of practice. The in these patients, required such an expenditure of fi rst example (L1) is a patient with abnormality in time that it was impossible for me also to evalu- semantic rather than phonetic organization of ate studies of other authors in the literature to the language. He draws an analogy between nonsen- extent that would have been necessary for my sical speech and transcortical aphasia, a concept purposes. The individual cases gave me the already defi ned. Other examples of ‘crossover’ advantage that they were very fully examined for are patients who turn continually in circles (L12, my purposes, especially since, through my p. 74), ones with impaired speech but intact sing- photographs, which form an integral part of our ing (L12, p. 75), or compulsive speech after a medical records, I usually managed to call to temporal lobe lesion (L20, p. 127). In L29 mind the entire personality’ (L41, p. 325). This (p. 199) his description corresponds well to mod- paragraph, and the preceding one, gives us insight ern descriptions of obsessive-compulsive disor- not only into his method, but also his into utter der (OCD, now a psychiatric disorder) or to the dedication to the task he had set himself. closely related Tourette’s syndrome (now a disor- der in neurology). Giles de la Tourette (1857– 1904) described the latter syndrome in 1884, VIII,(c). Relation Between Neurology while working under Charcot. In these two syn- and Psychiatry in Grundriss dromes, the balance between the ability to initiate and to veto actions is shifted to the former and Despite his opening assertion that mental disor- away from the latter. Wernicke’s comment about ders are brain disorders, Wernicke does under- actions being ‘softened by concomitant anxiety’ stand (L1) that they are generally different, a is interesting, since OCD is often co-morbid with different sort of brain disorder—Geistes- anxiety disorders, or occurs along with anxiety. krankheit as opposed to Hirnkrankheit. He also The specifi c symptom of Coprolalia [from sometimes makes a distinction between ‘psycho- kopros = faeces] (L32, p. 232), with inability to logical’ and ‘organic’ (i.e. neurological) drivers suppress undesirable speech is discussed in an of abnormality, for instance of abnormal move- apparent case of Tourette’s syndrome, as in L29 ments (L23, p. 148; L24, p. 154). Nonetheless, (p. 200). as a didactic method, he sometimes uses disor- Some disorders described by Wernicke strad- ders from neurology as a spring-board from dle with ease the divide between today’s neurol- which to understand psychiatric conditions, ogy and psychiatry: In stroke patients we see the when the two have similar symptoms. Examples symptom of confabulation, or a patient (L39, include the case of transcortical aphasia in L1; p. 200), who ‘believed the persecutor to be a man ‘hypermetamorphosis’ introduced in L20 in a who lay beside her in bed and had taken posses- neurological context, to be developed in L22 in a sion of the paralyzed half of her body’. The com- psychiatric context; and mania after temporal monality of processes of forming explanatory lobe lesions, to lead into mania with no such delusions between the latter case and many cases lesion. (The only basis upon which he could we now identify as mental disorders is striking. have made this comparison is to have seen mania In L37 (p. 305) he states that ‘… bouts of cortical in a patient whose brain was subsequently exam- epilepsy tend to leave focal symptoms in their ined post-mortem , referring to his own Lehrbuch wake, including, quite remarkably even those of der Gehirn Krankheiten [ 96]). Modern studies of a sensory nature, such as sensory aphasia or secondary mania after brain injury do attribute it hemiopia, and often also combined sensory most often to damage in temporal basal polar symptoms right up to the level of asymbolia’. regions [ 97]). Presumably he implies that areas of association 380 Editorial Commentary cortex as well as primary areas were affected. In easiest translation of the German word Krankheit, L20 (p. 131) a recognizable symptom is given an which was Wernicke’s usual word, used either accurate description—now called ‘akathisia’, a narrowly or broadly. In English it might be term introduced in 1902 by the Czech physician extended to include effects of injury (although Ladislav Haskovec (1866–1904), working in this is unusual). In L5 he does use the word to Prague [98 ]. Wernicke does not use the term, and refer to brain injury, which is odd to English may not have known the latter’s account. In L32 speakers. However, in English, there are several (p. 230) disturbing sensations are described by alternative words to chose from, with different two patients, with either akathisia or what might shades of meaning (‘disease’, ‘illness’, ‘ailment’ now be called ‘restless legs syndrome’, and ‘disorder’, ‘sickness’, ‘condition’, ‘syndrome’, which were driving their unusual movements. etc.), with fewer alternatives in German. Some The former is usually now seen as a side effect of physicians separate ‘disease’ (a generic concept) therapy with neuroleptic medicines; the latter, from ‘illness’ (that is, how a generic disease has mainly during sleep periods. The phenomenol- unique effects at an individual level). In German, ogy is nevertheless similar. Overall, it is refresh- Krankheit serves most purposes. In English, ing to see so many conditions described with so despite available alternatives, the restricted little awareness of today’s frontier between neu- vocabulary of German has tended to prevail. rology and psychiatry. Thus, one of the oldest anglophile psychiatry journals, founded in Wernicke’s lifetime, fol- lowed German tradition by calling itself Journal VIII,(d). Wernicke’s Concept for Nervous and Mental Disease . of Mental Illness/Disease Today, the debate is opening up again, part of a larger debate on use of medical models for In L1 Wernicke’s ‘credo’, that mental illnesses mental disorders. Medical terms for mental disor- are brain diseases, was in part a continuation of ders are now increasingly challenged by some of an ancient debate, between those who viewed today’s consumer activists. This is not new. One diseases as imbalances of factors intrinsic to each of Wernicke’s critics, Karl Jaspers, based his crit- organism (a view fi tting the doctrine of ‘four icism in part on exactly this—the use of medical- humours’), and those who proposed that there ized ‘disease’ terms for mental disorders [100 ], were essential concepts of disease, to be classi- this being the basis for his sharp line against fi ed in ways akin to botanical classifi cation [99 ]. Wernicke, as a purveyor of Hirnmythologie Essentialist notions grew, over the whole of med- [ 101]. It is therefore indeed ironic that Wernicke icine, as symptoms came to be correlated with never once uses the word Psychopathologie in pathology in specifi c organs or organ systems. Grundriss , while Jaspers is best known for his This was the tradition Wernicke grew up with, magnum opus entitled Allgemeine and in L5 (p. 28), he refers to cases in neurology Psychopathologie [ 102 ] . (The original 1913 ver- (presumably with lesions of known location) as sion of this work ran to only 332 pages; the ‘cortical diseases’. Such ideas reached their peak English translation which is now read, comes in the late nineteenth century when infectious from the 7th edition of 1959, with 748 pages.) diseases were identifi ed with specifi c micro- There are hints that Wernicke was aware of organisms. Extension to mental disorders was the alternative view, although he could not break (and still is) less convincing. free from medical terms. In L5 and later (L9), he Wernicke’s ambivalence on this large issue is uses the plural form, Krankheiten , when he has discussed later in this essay. Here we limit com- not yet mentioned any generic illness by name or ments to aspects which might have been ‘lost in given any diagnostic term. Sometimes he uses translation’. Psychiatry in the English-speaking Geistesstörungen, rather than Geisteskrankheiten world in the last century drew heavily on earlier (in L9, apparently introduced to Grundriss in the German work. The English term ‘disease’, is the 1900 revision of 1894 text [[ 52 ]; pp. 121]). In Editorial Commentary 381

L24 (p. 162) he applies the term to chronic men- sided, for which he prefers ‘chronic mental dis- tal disorders); and in L33 (p. 242) he uses the turbance’. The term also spans anxiety psychosis term Zustandsbild, literally, ‘picture of an exist- (L22, p. 143) alcoholic psychosis (L38, p. 295) ing condition’ He writes ‘To demarcate such and hysterical psychosis (L39, p. 301). A section cases it would be well to remember the old dif- in L24 (p. 162) gives important clues about how, ferentiation between habitual forms and actual operationally, he used the terms ‘psychosis’ and illnesses advocated especially by Kahlbaum. The ‘neurosis’, and, indeed what ‘mental illness’ was state of exhaustion described above is evidently for him. It reads: ‘For paralytic and hebephrenic not to be regarded as an actual illness, but shows somatopsychosis, severe organic loading is taken us asthenic confusion as a habitual form or, as to be prognostically unfavourable when the lim- recently termed, a disorder [ Zustandsbild ]’ . Such its of hypochondrial neurosis are exceeded and details might indicate that Wernicke intended to an undoubted mental illness is present’. convey the English concept of mental illness or ‘Psychosis’ becomes virtually synonymous with disturbance, as distinct from disease. However, ‘mental illness’, requiring obvious distortion of a in L9 and L16, he uses Geistesstörungen to make person’s sense of reality (in any of the three another precise distinction (also made by Miller domains of consciousness), while ‘neurosis’ is [[103 ]; p. 99]), between ‘active psychosis’ and separate from both these terms. Overall, the best ‘psychotic symptoms persisting as a hangover , or rendition of psychosis for Wernicke was proba- memory effect ’ from past episodes. bly ‘a state leading at least transiently to loss of It is worth summarizing the history of the insight (loss of the sense of personal wholeness)’. word ‘psychosis’ here, and what it meant for However, he was probably still formulating the Wernicke. According to Beer [52 ], Feuchtersleben concept at the time of his death. was the fi rst to use it in print, in 1847, but it may have been current for some time before that. He intended to stress mental concomitants of ner- VIII,(e). Wernicke’s Concept vous disorders, in contrast to the word ‘neurosis’ of Psychopathology which originally referred to objective signs of brain disorder. In any case, the word was not used Wernicke never uses the word Psychopathologie to differentiate classes of mental disorder in in Grundriss, although the word had been in com- Wernicke’s day. At the time of the 1906 edition of mon use in the Germanic world for some decades. Grundriss, Wernicke often used ‘psychosis’ as This is a fact of critical importance in deciding ‘falsifi cation of content of consciousness’, with how far he accepted the medical notion of mental ‘hallucinations’ and ‘delusions’ as the main illness. The words Pathologie or pathologische examples, a usage similar to today’s prevailing are used frequently, but refer almost entirely to meaning, but rather wider. (In today’s parlance, actual or potential fi ndings in the brain, while a ‘psychosis’ is often evidenced by limited forms different word, krankhafte, is used to describe of delusions and hallucinations. Thus, in today’s experiential or behavioural abnormality. Thus, in terms, falsifi cation of body perception in anorexia English, for the former (‘pathology’), we translate nervosa, or dissociation leading to falsifi cation of here with words which are directly equivalent, personal identity are not classed as psychotic.) and for the latter we use words such as ‘abnormal- However, Wernicke also used ‘psychosis’ with a ity’, ‘aberrant’ or occasionally ‘unhealthy’. His much wider range of meanings. Already in L1, he habitual usage might imply that, for him, experi- uses the phrase ‘motility psychosis’, and classes ential or behavioural features for which he used mutism and verbigeration as ‘psychotic symp- krankhafte might be statistically quite abnormal, toms’. Some clarifi cation is offered in the next but were not pathology sensu stricto. We identi- paragraph where he explains that ‘psychosis’ fi ed just two exceptions, where pathologie (not refers to an active mental illness, to distinguish it psychopathologie) is linked to behavioural or from residual states after an active phase has sub- experiential abnormality (see ‘Psychopathology’ 382 Editorial Commentary in section XVI. ‘Terminology’), and a third refer- cine’ in a strict sense. Sometimes the reasoning is ring to ‘sexual pathology’ (p. 326). We also found exact and prescient. For instance, in L20 (p. 129) two examples of tautology (such as krankhafte he discusses the idea that representation of some Symptome). The issue here is part of an older verbal thoughts—those ‘which are mainly con- debate, on whether ‘symptoms’ of mental disor- crete, with a somewhat simplifi ed thought con- ders are in continuity with normal experiences, or tent’—does not involve the left temporal lobe. are qualitatively different in nature [104 ]. Clearly, This intriguing idea receives support from recent in his sejunction theory, and in symptoms he research on representation of language in Chinese thought to be derived from sejunction, he did have script. In this case, the sequence from visual rep- a clear concept of neuropathology underlying psy- resentation of symbols to that of their meaning chiatric symptoms; yet that theory could not with- can be direct, not (as in alphabetic script) medi- stand scrutiny (see below). For most other ated via initial acoustic coding [105 ]. symptoms, our impression is that Wernicke mainly Wernicke, defi ned and grouped symptoms in thought in terms of the ‘continuity’ alternative, so far as he understood them on the basis of more although he never explicitly addresses the issue. basic scientifi c principles. In contrast, Jaspers took the basic categories of Kant as irreducible qualities [106 , 107], but could not validate them VIII,(f). Wernicke’s Attitude in a fundamentally scientifi c way. His categories to ‘Symptoms’ therefore had no link to any possible physical basis, and were thus independent of the common Despite never using the term Psychopathologie, language of science. Wernicke like Jaspers, uses Wernicke often used the medical term Symptome. Kant’s philosophy in emphasizing the distinction We have already seen how, like Mach, he based between content and form, yet drew on Mach’s his reasoning on primary experiences. In L1–L8, philosophy of science, to take primary experi- this reasoning links neurobiology to psychology ence as the key to the language of the natural sci- quite directly. In psychiatry reasoning from pri- ences. In psychiatry, this meant that symptoms, mary experiences meant that symptoms as albeit linked only indirectly to their physical sub- reported by patients were the starting point. Like strate, were by no means independent of that sub- Jaspers, he tried to grasp the subjective experi- strate. Wernicke thus did succeed (in principle if ence of his patients, rather than relying only on not always in practice), in bringing the common objective manifestations. He rejected grouping language of science to bear on psychiatry. That by aetiology (by which he meant ‘proximate was a huge achievement. cause’), because any one aetiology could lead to For Wernicke symptoms were by no means a wide variety of syndromes. He preferred fi xed entities, as they may be in general medi- grouping based on reasoning from more imme- cine. In L15, he argues that the class of symptom diate data; and he suggested that analysis of which emerges can depend on immediate events each case may lead to conclusions at various in a person’s life: What starts as an overvalued levels of organization: as psychological formu- idea, may subside, or be amplifi ed to delusional lations, as specifi ed pathways or regions, and proportions, depending on whether immediate potentially as cellular or molecular pathology at events and the social environment are benign or such locations. malevolent. Likewise (L18; p. 114) the symptom- Much of his reasoning is about psychological picture in a patient (not just its content, but the mechanisms underlying symptoms. (Reasoning class of symptoms) depends on his pre-existing at other levels, if attempted, was usually hypo- intellectual endowment (namely his capacity for thetical.) Thus links between symptoms and neu- ‘well-ordered thinking’), whether it be intrinsic, robiology were indirect; but they did exist, or developed through education. In addition he plausible if indirect. Most of his psychiatric prac- recognized that the underlying driver of a symp- tice appears to have been ‘psychological medi- tom complex might show up as a variety of Editorial Commentary 383 symptoms, depending on individual characteris- the basis of Wernicke’s extant conference presen- tics of each patient. Thus, in L13 (p. 81), we read: tations. His analysis of melancholia exemplifi es ‘For a single form of illness (such as acute “anxi- the concept. According to this, disorder of mood ety psychosis”), which entails an essential mental is not primary; ‘disorder of will’ is primary. It is content, one individual might portray that con- only a patient’s awareness of how impaired he or tent itself, while another produces phonemes rep- she is that leads secondarily to lowered mood. resenting the same content’. Major symptoms Whether or not Wernicke’s reasoning is robust, such as hallucinations and delusions can occur in few other psychiatrists even made the attempt. It many conditions, and do not defi ne any such con- is however part and parcel of his essential holism: dition in absence of other contextual detail; they As each person constructs his sense of whole- are indications of signifi cant mental disorder— ness, all parts of the mind (approximately) might no more—whose true nature must then be be in interaction with every other, continually defi ned. changing their mutual relation in response to life The primary aim of Grundriss was to teach events. It follows that a single abnormal experi- about psychiatry and the abnormalities he called ence can infl uence all aspects of psychology, thus symptoms. There are just a few references to producing many secondary symptoms. what is now called ‘personality theory’. In L7 we ‘Symptoms’ are thus not isolated, documented read some of Wernicke’s ideas about human indi- one-by-one, regardless of concurrent abnormal viduality, the emphasis being on acquired rather experiences, individual context, personal facul- than innate personality traits. This emphasis also ties, and life events. Wernicke appears to use the features in the clinical lectures, sometimes in ref- same concept for somatic symptoms, for instance erence to habits of behaviour, but occasionally to when (L24, p. 156), he suggests that a variety of personality as formed by habit. For instance, in secondary symptoms can start with abnormal L20 (p. 128), the term ‘brain habits’ is used, laryngeal sensation. A later psychiatrist, Eugen implying emphasis on acquired personality Bleuler, was infl uenced by Wernicke, and did dis- traits, rather than ones built into a person’s brain tinguish primary from secondary symptoms of processes ab initio . His comments on how basic schizophrenia, apparently following Wernicke’s processes appear as different symptoms accord- lead. ing to each individual’s traits suggests that he A fl aw in this approach is that abnormality at was aware of more fundamental differences. the neuropathological level (such as decreased However, research studies on personality were myelination) might have impact on many path- not well developed at the time of writing. ways in the brain, giving rise to diverse psycho- logical changes. The correlation between concurrent symptoms is then due to their com- VIII,(g). Wernicke’s Concept mon biological origin, not to interactions at the of ‘Elementary’ Symptoms level of information. Moreover, at times Wernicke admits failure to derive all symptoms in a patient In L13 (note) and L14 (p. 87) Wernicke intro- from a single ‘elementary symptom’. Thus in duces the term ‘elementary symptom’, L21 (p. 135) he writes: ‘We will not be able to (Elementarsymptome ), an important concept in derive the fact of disorientation from experiences his attempt to bring reasoning to bear on psychia- that you have just heard about, and they must be try. It implied that, for each patient, a single viewed as independent phenomena’; or in L28 symptom was usually fundamental, one from (p. 149), in discussing a case of acute autopsy- which all others were derived. The concept is not chosis: ‘Manifold abnormal sensations of which well presented in Grundriss , but is implicit she complained belong here only in part; in other throughout. Krahl and Schifferdecker [1 ] explore ways their importance is probably that of inde- the idea, its origins, implications, and differences pendent, hysterical concomitants’. In other lec- from ideas of other psychiatrists of the time, on tures (e.g. L23, p. 149) he is at pains to point out 384 Editorial Commentary that in the disorder he describes, symptoms occur symptoms. He states ‘… more complex circum- ‘in isolation’, these being exceptions to his usual stances underlie pathological processes of activa- thesis. tion, and in some way must be seen to depend on The logic of interaction between symptoms is symptoms of defi cit’ (L14, p. 85). In other words, usually ignored in today’s psychiatry in docu- defi cit (‘negative’) symptoms had more direct ments which operationalize detection of symp- explanations than symptoms of activation (‘posi- toms, as if they were independent entities. The tive’ ones), which were usually secondary to the concept of ‘elementary symptoms’ has much to former. This assumption may have grown from the recommend it in a fi eld where scientifi c reasoning fact that, as a neurologist, he was mainly concerned is rare. The history of the transition from with functional loss after discrete lesions. In his Wernicke’s style to today’s, moves inexorably sejunction hypothesis, he sees positive symptoms from Jasper’s fl exible approach to description as a bi- product of defi cits. However, this rule is by [108 ]; to Schneider’s fi rst rank symptoms of no means absolute. In L33, in introducing ‘con- schizophrenia, later codifi ed, probably against the fused mania’ (p. 236), he is clear that the picture of author’s intention [109 ]; to the emphasis of Erwin positive symptoms ‘as a symptom of stimulation— Stengel, working for the World Health Organization that is, one connected to fl ight of ideas and loquac- in the 1950s, on standardized nomenclature [110 ]; ity—is separated in principal from the and then to DSM III. This is largely the story of corresponding state of defi cit’. Moreover, in dis- tension between gifted and imaginative clinicians cussing states where hyperkinetic and akinetic who, above all, needed fl exibility, and administra- phases are combined (L35), ‘the hyperkinetic stage tors requiring precision and replicability, whatever always comes fi rst.’ This issue was addressed by the validity of the concepts used. Miller [111 ], suggesting that, at least for schizo- Krahl and Schifferdecker [1 ] suggest reasons phrenia, negative symptoms arise from activation (other than his premature death) why Wernicke underlying positive ones; repeated excess of ner- never developed the idea more fully. One such vous activity produces progressive cellular destruc- reason is that he preferred to focus on sejunction tion (However, the author no longer accepts this theory. However, in the opening paragraph of inference). Many views are viable here. L15, sejunction and supposed ‘elementary symp- toms’ are closely related, the former as a neuro- pathological process, generating the latter as VIII,(h). Affective Impact of Mental primary symptoms. So, in showing how one ele- Illnesses mentary symptom leads to others, he refers to: ‘the remaining content of consciousness, appear- As part of Wernicke’s thoroughly holistic ing, to a degree, to have disintegrated into frag- approach, he gives considerable thought to the ments, a fact to which we gave the name emotional impact of mental disorders. For this, he “sejunction”, in other words, detachment of indi- uses several terms—Affekt , Gefühl and Emotionen vidual components one from another. Such com- being the main ones—used carefully in different ponents initially form tight-knit structures, as senses, and often using the word Färbung (color- complete experiences, but their sejunction is ation). A fourth word used occasionally is shown by the fact that memories which fl atly Gemütsbewegungen (literally ‘movements of contradict each other can co-exist. The sejunction temper or disposition’). Affekt refers to an inner hypothesis then led us to a closer understanding experiential reaction or state, learned about of certain symptoms of activation, fi rst, of mani- mainly from a patient’s words. Gefühl is more of festations of disturbed conscious activity itself, a ‘visceral’ feeling, an ‘organ sensation’, but not and then of self-generated ideas and obsessions, identifi ed with any particular sensory modality, then of hallucinations.’ and closely linked to an automatic refl ex reaction Brief discussion is also needed on how Wernicke (often found in the compound noun Organgefühl ); saw the relationship between positive and negative while Emotionen refers to objective manifesta- Editorial Commentary 385 tions of Affekt , a state with visible, non-verbal, In all psychoses, abnormal mental content autonomic or somatic signs of emotion, typical of appears in the context of the Affective state hysteria (as becomes clear in L39). In L39 (p. 303) termed Ratlosigkeit , an insight probably based we also read an interesting line: ‘Almost always on Griesinger’s concept of ‘primordial delirium’ in these cases, phrenic nerve insuffi ciency can be (L18, p. 113). The word Ratlosigkeit requires demonstrated as the basis for the fear’. This some discussion. Its use predates Wernicke, for appears to refer to the theory of emotions pro- instance in writings of Kahlbaum [32 ], allied to posed independently by William James [112 ] in the term ‘confusion’. Wernicke knew it to be 1884 and Carl Lange [113 ] in 1887: Emotions as used sometimes by his patients to describe their experiential states originate as subjective state of mind; and he is also aware that it is dis- responses to automatic autonomic and other ste- tinctive to the German language (L21; p. 134). reotyped bodily reactions. How should it be rendered in English? The usual This is a diffi cult area for translation, where translation has been ‘perplexity’, or ‘helpless- there may be more words in German than in ness’. Neither word is a correct rendition. It is English. In English ‘emotion’ is the term used in different from ‘disorientation’, since, in L21 general speech, ‘Affect’ is a specialist term, (p. 134), we read that sensory deception alone although its use goes far back in history; and need not produce disorientation, but can lead to another word ‘passion’ is archaic, but with simi- Ratlosigkeit; and in L27, a patient is described lar meaning. In our translation we use ‘Affect’ or without Ratlosigkeit, but with prominent allo- ‘Affective state’ when Wernicke uses Affekt psychic disorientation, (p. 181), contrasted with (retaining the upper case ‘A’, to avoid confusion another in whom allopsychic disorientation is with the English verb—‘to affect’); and Emotion accompanied by Ratlosigkeit (p. 183). The dif- is used when he uses Emotionen. Gefühl is usu- ference appears to be that a person in a state of ally rendered as ‘feeling’. Ratlosigkeit knows that he/she is in this state; a In L25 (p. 169) Wernicke suggests that in disoriented person may lack such self-knowl- acute psychosis (Acute hallucinosis , in his edge (presumably of an Affective state). The terms) disturbed Affect recovers fi rst, followed relation between disorientation and Ratlosigkeit by hallucinations, while delusions persist lon- is not entirely clear, but may depend on whether gest. In addition, quite generally, he designates the disorientation is in the allo-, auto-, or the Affective impact of mental disorders in somato-psychic domains: Intense emotional acute mental illnesses, especially if they ‘irrupt reactions to auto- or somato-psychic symptoms acutely’ (p. 190), by the distinctive German may exist, while allopsychic orientation is word Ratlosigkeit. However, the impact is itself maintained. a product of another state, identifi ed as Ratlosigkeit, is itself an abstract noun indicat- Desorientierung (disorientation). Wernicke ing loss of Rat—a German noun most often used admits that he cannot defi ne the latter properly, as a ‘counsel’ or ‘advisory body’—a group of it being a matter for future work. It is presum- people, such as a city or regional government, ably not in the realm of Affect or emotion itself, ‘taking counsel’, or ‘providing advice’. Implicitly, but possibly a precursor of these at a cognitive then, Ratlosigkeit, suggests ‘loss of the inner level. Ratlosigkeit appears to be the Affective counsel’ or ‘deliberation amongst our various state produced by awareness of confl ict or faculties’, a meaning quite different from and incongruity between contents of the mind, pro- more specifi c than either ‘perplexity’, or ‘help- duced by mental illness, as in L28, where we lessness’ (the latter implying ‘loss of control’). read (p. 190): ‘It was only the newspaper article There appears to be no equivalent word with the [reminding a patient of a former place of work] same sense in English. Most discussion of it in that awakened in him the Affective state of psychopathology appears to have occurred well autopsychic disarray [Ratlosigkeit], and which after Wernicke’s days, for instance in a mono- caused him to seek medical help.’ graph from 1939 by G.E. Störring (see unsigned 386 Editorial Commentary review in Journal of Nervous and Mental Disease, dence. This theory also led him to view negative in 1940 [ 114 ]). The two English words we feel symptoms as primary, positive ones as second- get nearest to Ratlosigkeit are ‘confound’, usually ary: ‘I have represented sejunction as the funda- as a verb, and ‘disarray’, as a noun. The former mental process, and derived symptoms of has shifted in meaning but its older meaning is irritation from this’ (L33, p. 240). The German captured in a line from the English national word for ‘symptom of irritation’, Reizsymptome , anthem ‘confound their politics’; and in this older could also be translated as ‘stimulation meaning sometimes meant ‘to confuse, fail to dis- symptom’. tinguish, mix up’. While there is no satisfactory In no way does this theory stand the test of translation of this word, we choose ‘disarray’ to time, or could it ever have done so. It is a weak- render Ratlosigkeit. This word captures the sense ness, which in his day, fuelled the charge of ‘neu- of lost coordination, sometimes of a social group, romythology’. It is nevertheless instructive to but not that of coordination of separate faculties. examine the origins of the theory, the clinical The usage should be read in conjunction with this facts which it purported to explain, and the facts explanatory paragraph. Occasionally we do use he did not know, which had he known, might the word ‘perplex’ in a non-technical sense, and have held him back from this notion. In Grundriss, when we use ‘helplessness’, it is to translate a it is presented in L9 in connection with a patient word other than Ratlosigkeit. Occasionally, our named Rother (who is representative of many word ‘disarray’ is used to translate another long-stay patients in his institution). There were German word (e.g. Unordnung : p. 86). also various accessory notions, to deal with other clinical facts. Here we deal with the core concept. Other detail, especially on the second aim of the VIII,(i). Wernicke’s Sejunction theory, follows later in relation to specifi c Theory symptoms. Details of Rother, a gardener by trade, are as A central conjecture in Wernicke’s account of follows: Wernicke has known him since 1871, mental disorder, apparently a process at the cel- only one year after he graduated in medicine. He lular level, is his Sejunction Theory, supposed to has been a stable, reliable member of the institu- account for two striking observations. The fi rst is tion for many years, with little outward sign of the apparent illogical nature of utterances in abnormality, coherent in carrying out many daily many patients, blind to logical inconsistencies tasks, interested in current affairs, capable of all between different expressed beliefs. The second, normal courtesies, with a seemingly rational atti- as stated in the summary heading to L12 is ‘to tude to his being in the institution. However, explain pathological excitatory symptoms’. when questioned, his answers are astonishing. Already in L2 he has given a breakdown of pos- Once we gain complete trust , in the chatting sible neuropathological bases for mental disor- stage, he regales us unreservedly with his experi- ders: Three things could go wrong at a cellular ences. At fi rst we are struck by the fact that he level: Reduced, increased, or aberrant excitabil- knows nothing about having overcome a mental ity. In this context, he refers to ‘pathways’ and to illness; for his part he might have come into hos- ‘conduction’ therein. His inclusion of causes pital only because of an acute febrile illness, and other than frank lesions sounds modern, but gives he actually considers it wrong—a mistake—that no detail. The chief experiences which made him he has been held for so long, even though he raise the topic of pathological excitation were admits that the doctors had always been kind to probably symptoms of progressive paralysis, him. Then he tells of a confl ict with one of his some of which he interpreted as abnormal exces- gardener’s boys shortly before his admission to sive excitation at specifi c locations; his explana- the institution. During the struggle he had been tion of hallucinations in terms of the sejunction thrown down the stairs by this man, and had bro- theory may have grown directly from such evi- ken his neck. Editorial Commentary 387

I ask : “Who?” confi ned in an abnormal situation, a semblance of “Well, me”. normality as a ‘reconstructed persona’. A fourth, Question: “But aren’t you alive and sitting here?” and most likely possibility, recently expounded “Well, yes, but the other one is probably still by Ball [82 ] is that, in a chronic stage of schizo- there.” phrenia, there is failure to unite two aspects of the Question : “What other one?” ‘self’—the ‘self experiencing now’, and the “Well, Rother.” ‘conceptualized objectivized self’, normally rep- Question: “So, once you have been dead; is this resented (respectively) in right and left hemi- possible?” spheres. If the two are poorly integrated, a strong “Of course, everyone has a double.” conceptualized self may see a weak ‘self experi- encing now’ as an alter ego, sometimes referred He then recounts how he had experienced to in the third person (see: L21, p. 135; L22, other quite different things that no-one would p. 143; L24, p. 159)—or here, using the patient’s believe: he had once been a bull and, as such, had own surname. This is different from ‘dissociative been tortured in a quite inhumane manner and identity’, where each identity, while to a degree then been slaughtered. He describes how they separate, itself remains coherent. had drawn a ring through his nose and dragged Succinct statements of the core of the sejunc- him along. He had also been crucifi ed once, tion idea come in L14 (‘the uncoupling of asso- together with two robbers. ciations’) and early in L15 ‘… “sejunction”, in other words, detachment of individual compo- Question : “Like Jesus Christ?” nents one from another’: This phrase is reminis- “Yes, exactly like that.” cent of that to be used by Eugen Bleuler in his Question : “Then you are probably Jesus Christ?” 1911 work ‘ Dementia praecox or the group of “Yes, I am Jesus Christ.” schizophrenias ’ [115 ] who wrote: ‘In this malady the associations lose their continuity. Of the thou- In L12 (p. 72) where the term ‘sejunction’ is sands of associative threads which guide our fi rst introduced, Wernicke discusses Rother’s thinking, this disease seems to interrupt, quite state of mind. This section is more controversial haphazardly, sometimes such single threads, than most of his writing in Grundriss ; yet his sometimes a whole group, and sometimes even insight, to our mind accurate, is that there is large segments of them. In this way, thinking something important to be explained. In part, becomes illogical and often bizarre’. The similar- ‘sejunction’ is intended to account for suppos- ity is no coincidence: Wernicke’s Grundriss, and edly abnormal co-existence of incompatible specifi cally the sejunction concept, did infl uence notions. Different interpretations of such distor- Bleuler [116 ]. ‘Sejunction’ (literally a breaking tions of personal identity are possible. Literally, of associations, or a state of broken associations) Rother’s words refer to the Doppelgänger (in is a better term than ‘disjunction’, or ‘dissocia- English: ‘alter ego’), a familiar concept through tion’, both of which imply separation of inter- most of the nineteenth century. A second inter- nally coherent entities. There may also have been pretation is a true multiple (as opposed to double) older origins to the concept, coming from personality, a concept recognized after work of Meynert, since Wernicke writes (L33, p. 241): ‘I Pierre Janet in France, and today given the name might assign such cases to the highest grade of Dissociative Identity Disorder in DSM-IV (still weakened association [in confused mania] controversial). This may be revealed as multiple described by Meynert, which he compares to voices in conversation (three are referred to in genetic confusion.’ Meynert’s concept was that L29, p. 198), a symptom now known to be more in the childlike brain, associative connections common in Dissociative Identity Disorder than in are already very weak, which was probably what is called schizophrenia. A third possibility is linked to Kahlbaum’s idea current in Meynert’s that an attempt is made to recreate for a person day that adolescence was a time of vulnerability 388 Editorial Commentary to psychosis. Implicitly, Wernicke believed the such interplay sets up lasting confi gurations rep- ‘breaking’ to have a clear basis, at a micro-ana- resenting contexts for operating in specifi c situa- tomical level, rather than any gross lesion. As tions. In those humans who operate via deduction such, sejunction laid claim to be a fundamental and logical consistency, such contexts encom- and new neuropathological process underlying pass the operations needed for deduction, setting most major mental disorders. However, it lacked up hidden assumptions as the ‘framework’ any supporting evidence at the neuronal level. needed for the system to operate. In those who do Part of the context for ‘sejunction’ is what not operate in this way, likely to be those with Wernicke did not know, but which we know now. little education such as patient Rother, contexts He had no idea, or did not use, the idea that active can still be established by interplay between neo- inhibition existed in the brain at neuronal levels, cortex and hippocampus, but serve other roles in which, at psychological levels, could suppress the day-to-day lives of such people. In expres- one or more of a set of incompatible notions. sions of belief, inconsistencies may then exist, Failure of inhibition might then give a better but since these are between relatively unremark- account of Rother’s state. Even given his igno- able notions, they attract little attention, although rance of neuronal inhibition, a major fl aw in his it may be hard to get such persons to grasp the reasoning is apparent: He confuses statistical incompatibility of co-existing beliefs. If how- incompatibility (‘negative association’) which ever, such persons experience periods of active could recruit inhibitory processes now under- illness which introduce bizarre notions into their stood, with logical incompatibility (whose physi- beliefs, there is again no way in which the incom- cal basis would be quite different). Further gaps patibility can be resolved; yet the bizarreness of in Wernicke’s knowledge which made possible their beliefs now makes it clear in social settings the sejunction theory are mentioned below. that they have been mentally ill. The more bizarre However, one might ask what could be the the beliefs acquired during periods of active ill- basis of the apparent loss of logical consistency ness, the more outlandish is the residue of strange in patient Rother? As pointed out in section beliefs outlasting the active phase; yet, with no VI,(c). “Wernicke, on Theory of Knowledge”, ability in rational analysis, resolution of confl icts the facility for deductive inference, and with it, of beliefs is diffi cult, and may be impossible. awareness of logical inconsistencies and the need For Wernicke, primary abnormalities could be to eliminate them, is not a natural human endow- defi ned at either a biological, cellular level, or at ment, but one in which some people excel, while a psychological level. Sejunction was supposed others think in more natural ways, dependent on to be the primary biological abnormality. At the memory and association. Wernicke’s assumption psychological level ‘elementary’ symptoms that personal identity is synonymous with logical emerge, as in patient Rother. Some such symp- consistency of information within an individual’s toms are distorted perceptions (hallucinations); mind is unrealistic, and would not separate nor- others are beliefs whose abnormality falls short mal persons from his patients. Regardless of this, of being delusional. With regard to beliefs, he to operate via deduction in the quest for consis- introduced two terms, autochthonous ideas (L11, tency requires that ‘ground rules’ for a system of p. 68) and overvalued ideas (L15, p. 92), both logic be in place, as a ‘framework’ for reasoning linked to delusions. within which premises and conclusions can be ‘located’. In terms of Immanuel Kant’s Critique of Pure Reason, these are the ‘synthetic a priori VIII,(j). Hallucinations and Related statements’, needed (for instance) for numerical Phenomena for Wernicke or spatial reasoning. In another work [88 ] a the- ory was developed to show how, by interplay For Wernicke, hallucinations are important symp- between hippocampus and neo-cortex, the inher- toms, more primary than delusions (which are seen ent ambiguity of associations in the latter struc- mainly as secondary attempts to explain), and, as ture could be resolved; and it was also argued that such, a major class of ‘elementary symptom’. This Editorial Commentary 389 theme, which went back to Griesinger, may understood in the sense that the patient recog- explain why, for Wernicke, a major subdivision nizes these as their own thoughts, sounded out of psychoses is ‘hallucinosis’ (with separate loud on certain occasions, such as, for example, acute and chronic subtypes) a term which proba- when the patient is reading or writing. Cramer bly originated with him, and not widely used himself, and all his successors, left the symptom until after his death. He recognized the heteroge- so broad, that it has lost its original value as an neity in both the clinical aspects of hallucina- elementary symptom, and now still requires an tions, and their origin. His views on hallucinations explanation of its various routes of development’ appear in L13, L19, and L20. Although covering (L13, p. 80, note): Here he probably refers to a hallucinations in all modalities, as well as multi- comment made in L6, that muscle sensation had modal ones, he clearly states that ‘… for all hal- previously been given undue emphasis for posi- lucinations—with few exceptions—hallucinated tion sense. speech sounds predominate’ (L13; p. 80). Visual hallucinations are discussed in L19 Exceptions included psychoses of intoxication. (p. 120) ‘… patients themselves refer to them as On the ‘incorrigibility’ of hallucinations, he “images”, and … as shadows, or even as “ghosts”, writes: ‘The reality of a sensory deception is a term implying some form of explanatory delu- maintained against the testimony of all other sion.’ Whatever the perceptual component of a senses and most fantastic attempts are made to hallucination, the words with which it is explain it, leaving no room for doubt, or the pos- described, such as ‘poison’, often imply explana- sibility of their sense being deceptive’ (L13, tion. Visual hallucinations, like auditory ones, p. 80). Such an emphatic statement might not be capture the full focus of attention, but have a made today, when many lay people know of the greater sense of unreality than phonemes, and are symptom, some of whom, when they themselves thus less compelling and ‘incorrigible’. Tactile experience it, know immediately the experience hallucinations, sometimes called ‘delusions of to be deceptive, not a faithful refl ection of exter- infestation’ today, leave open the idea that they nal reality. In L21 (p. 134) in discussing patient originate from genuine disturbance of sensory K., Wernicke appears to accept this possibility. input. A fi ne account is given (L19, p. 121) of Wernicke refers to the usual auditory halluci- multimodal (‘combined’) hallucinations, a topic nations, which are verbal, as ‘phonemes’ (L13; rarely discussed today. These often combine p. 80), although he mentions non-verbal auditory senses with natural kinship (such as taste and hallucinations, (L19) which merge or transform smell). For such combinations, Wernicke uses the into verbal ones. The word ‘phoneme’ came from term ‘dreamlike’, etymologically similar to Dufriche-Desgenettes in 1873. Use of the term today’s ‘hypnogogic’ but probably a separate for an abstract concept in linguistics started with experience. An issue of increasing relevance Polish researchers, Jan Niecislaw Baudoiuin de today, is whether these are re-enactments of past Courtenay and Mokiloj Kruszewski, working at trauma. the University of Kazan in Russia between 1875 Many suggestions are made on the origin of and 1895. Wernicke’s use of the term has a differ- hallucinations. In L19, the possibility of abnor- ent sense, indicating inner experiences of speech mal sensory input is implied in both auditory and sounds, which might be projected as external tactile sense. Somatization, a modern term, is not voices (including dialogues [L13, p. 81]), or pro- used, but the concept features prominently (L10, jected upon identifi ed people in the vicinity (L13, L24) especially in relation to intestinal sensa- p. 81), a manifestation with less favourable tion. Then (as today), patient complaints might implications. He is strict in what he identities as be based on lay conceptualizations of the body, hallucinated speech: ‘In my opinion there is no and current fads of the day. In L10 (p. 62) a reason to refer to hallucinations of the muscle patient is described for whom ‘the suspicion we sense, as Cramer (1889) does, in order to explain therefore had, that he was still suffering physical “hearing voices”. The symptom of “thought sensations, was confi rmed when we examined echo” should be as restricted as possible, and him; for it revealed that the patient still felt an 390 Editorial Commentary obstruction and constriction of the bowel imme- much of the description in L24 combines what diately proximal to the anus, complained about might now be called somatization disorders, extreme discomfort and all sorts of abnormal along with eating disorders, especially anorexia sensations during defaecation, albeit conveyed nervosa, which posed a threat to life, then as now with a sense of hopelessness, and requested med- (L24, p. 162). ical treatment for his actual suffering’. In L24 In so far as some hallucinations arise from (p. 162) we hear of ‘unbearable tickling sensation genuine amplifi cation of sensory input to the cor- in the intestine’. L24 also contains descriptions tex, with no change of stimulus parameters, they of what might now be called ‘Irritable Bowel may signify an unrecognized, but general class of Syndrome’ a ‘functional disorder’ not otherwise disorders, found in many, perhaps all sensory sys- recognized until the 1950s, and usually dealt with tems, dealt with sometimes in psychiatry as in gastroenterology. Prominence given to intesti- ‘somatization’, sometimes in various other spe- nal sensation (see also L5) may seem strange to a cialties, as functional disorders in corresponding modern reader. However, the idea that ‘autoin- body systems. Their brain mechanisms may be toxication’ from gut bacteria might cause mental the background for some types of hallucination— disturbance was becoming popular at the time. It indeed, also for some delusions. Today, such sen- built on the germ theory of disease, starting with sory abnormalities are an active area of research, a paper in 1868 by Hermann Senator (1835– not yet assimilated into broad generalizations (see 1911), professor in Berlin. It developed further, section IX,(d). “Wernicke’s Approach to especially after Wernicke’s time, in France, Classifi cation of Mental Disorders” on theoretical Germany and elsewhere [117 ]. Kraepelin validation of Wernicke’s symptoms groups). With regarded auto-intoxication as a possible cause of such advances nowhere in sight in Wernicke’s Dementia praecox [ 118 ]. In L24 (p. 161) we also day, it is no surprise that his concepts of halluci- read of ‘the old theory of positional changes in nations—and delusions—differ from today’s. the colon as the cause of mental illnesses’, a Apart from unusually amplifi ed sensory input belief whose origin we could not trace. to the cortex, Wernicke argues that sensory per- Another recently named syndrome Persistent ceptions with no external stimuli, must originate genital arousal disorder (L24, p. 156) is also in cortical regions for sensory perceptions; ‘the described. What is now called delusion of infes- difference from actual sensory perception is then tation is mentioned (L24, p. 163). Another pos- limited, in that the origin of the stimulus in one sible case of exaggerated sensory input comes in case lies in the periphery, while for hallucinations L13 (p. 83): ‘It often happened that the father it lies in central, transcortical sites, although the pounded the table which drove him into the most target location is the same in both situations’ powerful sexual arousal.’ ‘The very sight of his (p. 81). In part this statement may have arisen father was apparently associated with a morbid from his encounters with progressive paralysis feeling that in this case was linked to morbid patients in whom striking positive psychotic physical sensations about which he was uncom- symptoms, as well as those of defi cit were seen. fortable. Such examples would probably have On the exact means by which this occurs two been called refl ex hallucinations by Kahlbaum’. quite different accounts are offered. The most Wernicke likens it to what Kahlbaum called ‘sen- plausible account comes towards the end of L19. sory delirium’. In either case it is an exaggerated Starting from early ideas of Müller, that there is sensation, rather than a quasi-perceptual image genuine disturbance of sensory input or process- arising from (or distorted by) meaning con- ing in sensory pathways, he excludes, step by structed at higher levels (as are many of today’s step, each suggestion. As part of this, he rejects ‘psychotic hallucinations’). Alternatively, it may Meynert’s view that hallucinations arise from be a case of what, in psychoanalytic theory, is over-activation of subcortical nuclei (L19; called the ‘electra complex’, unusual only in its p. 123). This is based on the fact that hallucina- being directed from son to father. In any case, tions often convey complex meaningful images, Editorial Commentary 391 along with the anatomical fact that, intrinsic to ual’, and again (L13, p. 79) ‘projection fi elds the cerebral cortex is a massive system of long themselves, regardless of whether these fi elds are and short association connections, while the thal- directly affected by a pathological stimulus, or amus and basal ganglia have no counterparts. are affected only indirectly as a result of a sejunc- Modern evidence supports the argument, in that tion process and the hypothetical backfl ow of ner- principal neurons of the thalamus have no local vous current from complex associative structures’ axon collaterals, and the principal neurones of (emphasis added). the striatum (caudate/putamen in humans), main What is implied is that, when pathways for nucleus of the basal ganglia, are inhibitory, not associative links are somehow broken, nervous excitatory; so neither structure can support mas- activity in pathways lacking onward connection sive associative operations. In the end, he is can build up, like a blocked stream, and propa- forced to conclude that ‘the essence of a halluci- gate backwards (‘hypothetical backfl ow’) to irri- nation [occurs when an] aberrant stimulus tate the site of origin, namely primary sensory extends via the memory image to these carriers of areas. Pent-up nervous energy, so to speak, pro- the organ sensation; and a memory image duces spurious retrograde activation of sensory becomes a visual image, and next, becomes a hal- regions. A specifi c example appears in L35 lucination, as soon as it is makes contact with the (p. 268): ‘For primary auditory hallucinations, associated organ sensation—by excitation of hearing is indeed to be regarded as a stimulation those perception cells.’ This view can incorporate process that arouses not only acoustic patterns, a comment made in L11 (p. 69) of ‘thought but also related organ sensation; and, beyond the becoming sound’: the so-called ‘audible intensity of the original stimulus, it is only the thoughts’, as a hypothesis for auditory verbal hal- presence of a well-worn pathway, which has lucinations, and (L12, p. 73) ‘the fi nding that always served for repetition, that explains irradi- patients themselves do not know exactly whether ation into the motor speech area’. The latter can they hear voices or only experience related only be the well known pathway from Wernicke’s thoughts, corresponds to a transitional state to Broca’s area, perhaps accounting for links between autochthonous thoughts and between verbal hallucinations and uttered speech. hallucinations’. A similar relation is implied in L34 (p. 251): This is Wernicke’s most coherent account of ‘Certain parakinetic symptoms, in hyperkinetic hallucinations. However, at an earlier stage (L12) motility psychosis, about which we have already he offers other views, deriving from the theory of had a chance to learn, give us a better hope of sejunction, which like the theory itself, is prone their being traced back to processes of to diverse criticism. In L12 (p. 74) he writes ‘hal- irritation’. lucinations may occur even without an actual Another statement, of how sejunction could process being in place, merely by accumulation account jointly for broken associations and aber- of nervous current at the point of sejunction’. rant excesses of excitation appears in L26: ‘We Here the ‘sejunction’ concept, based on observa- see in his allopsychic disorientation, a failure tions of haphazard disconnection of ideas, with corresponding with paralysis; and we may scant awareness of their logical incompatibility, assume that those complicated arrangements of has shifted to a different class of events, namely mutually associated memory images which allow subjective reports of hallucinations. The connec- recognition of the immediate situation have tion is not obvious until we read what follows become paralyzed or inexcitable. It is then per- (L12, p. 74) ‘the perceived magnitude of the haps not accidental that the irritant effect becomes stimulus is amplifi ed beyond the norm; conse- so clear, in that analogous arrays of memory quently, excitation of sensory regions of the brain images, corresponding to whole situations and (s ) may be expected to occur, even without an experiences, emerge spontaneously, and with external stimulus, especially if the same process abnormal clarity’. In these two sentences we see, has occurred often, and therefore become habit- in essence the twin processes of the sejunction 392 Editorial Commentary concept—loss of habitual associations, and their probably correct for at least some types of hallu- replacement by spurious excesses. These words cination, the other based on the sejunction theory, are in the context of Delirium tremens . which is quite implausible. Three incorrect assumptions lie hidden here, all refuted by subsequent advances. First, at the anatomical level, it is assumed that primary sen- VIII,(k). Sejunction Used to Account sory regions of cortex receive major inputs only for Phenomena Better Explained from ascending sensory pathways, not from other in Other Ways cortical regions. This is incorrect: The over- whelming numerical majority of synapses on In L12 the sejunction theory is used over- pyramidal neurones in primary sensory cortical inclusively, to account for two clinical manifesta- regions are derived not from thalamic input but tions which we now know to have more plausible from other sources, mainly other cortical regions accounts. One of these (L12, p. 74) was a patient [119 ]. Thus, hallucinations could arise by abnor- turning continually in circles: Apart from explan- mal predominance of ‘top-down’ control, which atory beliefs which a patient might construct, this is usually overridden by sensory input. There are is not psychosis, by modern concepts: Such a precedents for this: When sensory input is greatly movement disorder is well known (and well- reduced, the balance shifts, so that visual halluci- studied in animal models), arising in the basal nations may occur in sight-impaired people ganglia from either asymmetrical damage or (Charles Bonnet syndrome), or when falling asymmetrical activation by drugs or internal pro- asleep. This is implied by Wernicke’s account of cesses. Description of the subjective impact of hallucinations (L12, p. 76): ‘… combined hallu- these motor symptoms is interesting and vivid, cinations are not uncommon in all situations of but the case put forward that these are examples reduced sensation.’ of ‘sejunction’ is implausible. The second patient The second, incorrect assumption is that the (L12, p. 75) is ‘… a female patient [who] began ‘hydraulic’ metaphor which Wernicke uses is to sing, and you may still remember how clearly misapplied to transmission along nervous path- she spoke about the fact that she did this against ways. The mistake arises because he did not her will, and did not feel like doing it … She typi- know that the all-or-none law applied to axonal cally showed a defective pattern of breathing … conduction, making information transmission by When singing however, she suddenly presented a axons largely independent of signal energetics. normal respiratory pattern.’ Wernicke writes: ‘I Without such knowledge, the two could be believe that I have demonstrated conclusively linked, so that the hydraulic metaphor might that the explanation of this phenomenon is pos- apply. sible only based on the sejunction hypothesis’. The third gap which sejunction attempted to This is unnecessary. The fi nding that motor dis- fi ll, is Wernicke’s lack of awareness of the con- ability disappears during singing is known else- cept of reinforcement. Much of L20 deals with a where in neurology, perhaps related to unusual supposed pathological process by which points motor control, subject to unusual emotional of excessive activation arise in the cerebral cor- infl uences. tex, leading to abnormal added experience (‘posi- tive symptoms’). However, today, we might attribute such excess to overactive neural rein- VIII,(l). Delusions and Related forcement, possibly arising directly in the stria- Phenomena for Wernicke tum, and relayed from there to specifi c cortical foci. Overactive reinforcement is now a major There has long been unresolved debate over hypothesis to explain psychotic symptoms. whether delusions arise by normal interpretation Overall, Wernicke offers two incompatible of experiences which are themselves abnormal, accounts of hallucinations, one plausible and or as interpretations which are themselves abnormal Editorial Commentary 393

(see Miller [120 ], while admitting that alternative time—for compulsive thoughts—we might be views apply for some aberrant beliefs). For dealing with an excitatory process whose conti- Wernicke delusions are ‘falsifi cation of contents nuity is preserved; and at another time—for of consciousness’, and, with few exceptions, he autochthonous ideas—with an excitatory pro- advocates the fi rst of these, mainly denying a role cess, where it is partially lost’. for abnormality of interpretation in forming delu- Wernicke assumes that the organ of conscious- sions. This idea can be traced back to John Locke ness is the organ of association, that association for whom delusions arise not from fl aws in rea- is based on excitatory processes, that it occurs in soning, but from faulty premises [ 77]. Thus in the full focus of consciousness, and is slow L11 (p. 67), he writes: ‘Suffi ce it to say that we enough for us to know of its operation. Therefore, can trace back explanatory delusional ideas to according to him, when a person is not aware every single one of the acute symptoms that we how an idea sprang to mind, that is evidence of a will encounter later’. primary abnormality, and perhaps a loss of excit- Later he clarifi es this in one area: ‘Patients dif- atory processes. However, the premises in the ferentiate quite well between their own thoughts, argument can be questioned: Normally, we often which, in the case of compulsive ideas compel do not know the precursors of ideas arising in our them against their will, and “foreign” thoughts, minds, although they are likely to be the result of in the case of autochthonous ideas ’ (emphasis continuous reverberation in our brains. Wernicke added). The word ‘autochthonous’ appears to be admits as much with the phrase ‘unconscious Wernicke’s special term, with no antecedents. mental activity’, in L12 (p. 73). The phrase ‘par- Outside psychiatry, it refers to something arising tially lost’ again admits this as a possibility. locally (for instance in an indigenous society), Closely related to autochthonous ideas is rather than having wider currency, and intro- Wernicke’s concept of ‘overvalued ideas’, a term duced to a locality from outside. In psychiatry, an similar to the then-popular phrase—‘idéé fi xe autochthonous idea is a strongly perceived (which Wernicke uses occasionally [L15, p. 94; notion, with no links to prior thought activity. It L41, p. 329]). This is developed in L15, where he may be perceived as coming from an external, writes that they ‘… are sharply distinguished alien, perhaps malevolent source. This is confus- from self-generated ideas in that they are evalu- ing in relation to its wider meaning. It might be ated within a patient’s consciousness, and thus, better rendered here as a ‘self-generated idea’ by no means are to be viewed as alien intruders.’ which preserves the wider meaning, but since it Overvalued ideas may remain as isolated symp- is a distinctive part of Wernicke’s vocabulary, we toms, as in a case he describes in L15 (p. 93) of retain ‘autochthonous’. He writes (L11, p. 68) an elderly gentleman who, when outside the ‘Patients notice the emergence of thoughts which institution continually feels harassed by other they consider alien to themselves, not perceived people, especially a certain master carpenter ‘… as normal, that is, probably not created by the everything always came back to the one master usual processes of association’. In L12 (note), we carpenter who, meanwhile, had served up the old read that patients ‘initially have no explanation’ story to other people, and notifi ed the police of for autochthonous ideas. Usually however an their observations of mental illness. Nowhere in explanation is immediately contrived, except the institution has anyone observed even a hint of occasionally (333) where he writes: ‘Nevertheless, a delusion or any other sign of mental illness in there are those like the patient who taught me this patient’. An overvalued idea may lead to only recently. In that particular case autochtho- delusional elaboration, but since this is not a nec- nous ideas were the sole psychotic symptom, and essary feature, the two symptoms are separate, an they subsided again without being related to any overvalued idea being classed as an ‘elementary explanatory delusions.’ In L12 (p. 73) we read: symptom’; yet Wernicke admits that ‘the mecha- ‘We might also be tempted to seek a distinguish- nism of its formation remains unexplained’ ing feature related to sejunction, so that at one (p. 90). 394 Editorial Commentary

Wernicke is clear that delusions themselves Beyond such origins of falsifi ed beliefs, are are acquired by a learning-like process, some- other sources for delusions which need not be times instantaneously, and can then persist as abnormal or pathological. Some involve changed enduring beliefs. In L10, (p. 61) he documents sensory input (L10, p. 61, p. 63), especially in the cases where ‘we have observed . .the time at sense of taste or smell (L11, p. 70), or for hear- which somatopsychic delusional ideas actually ing, symptoms such as tinnitus (L19, p. 117). originate, and can thus provide evidence of their Wernicke attributes some falsifi cations to bodily origin from abnormal physical sensations.’ From changes, including ones due to physical abuse this, the point he often makes in early clinical (L11, p. 67), which need have nothing to do with lectures, follows easily—that there is a differ- mental disorder. Likewise, manifest abnormality ence between active illness, and beliefs that of motor function or behaviour (L12, p. 74), itself endure when the active phase is over (‘stable perhaps due to neurological rather than psychiat- conditions and diseases actually in the process of ric disorders, or recovery of mobility (L12, p. 74) developing’: L9, p. 34). Thus, delusions differ can be the origin for an explanatory delusion. from hallucinations, which, while remembered, Lastly, he mentions instances where awareness of are immediate experiences. In L25 (p. 169) he sudden, loss of attention, not itself abnormal, makes this point for one patient, that ‘recovery becomes a source of delusional of explanation involves elimination of the hallucinations, (L19, p. 114). despite tenacious retention of the system of delu- The classes of delusion for which the above sions’. Recent research also shows that halluci- experiences are a trigger, include delusions of nations are usually eliminated more quickly than reference, grandiosity, persecution or hypochon- delusions during antipsychotic drug therapy. dria. The fi rst two of these are in the autopsychic Experiences which could be classed as abnor- domain, the third in the allopsychic domain, and mal, and from which, in Wernicke’s, view, the last in the somatopsychic domain. It follows delusions arise, have been mentioned already— that these four classes of delusion are not pri- hallucinations (which may be projected into the mary: They are subclasses of the two major types, external world as ‘delusions of relatedness’; L11, delusions of relatedness or explanatory delu- p. 69; L13, p. 80) and autochthonous ideas (often sions . So, for instance in L17 (note, p. 107), on projected on to a doctor; L11, p. 69). He also the subject of grandiosity, he writes: ‘Here, I suggests that lack of insight may itself be a pri- believe that I am in agreement with Snell, who mary abnormality (L9, p. 56), often based on the also denies the primary occurrence of overesti- fact of a patient’s detention in hospital (L10, mation ideas essentially’ [121 ]; and later in this p. 64; L14, p. 88). This is seen as a primary effect lecture he discusses, but rejects Griesinger’s idea of the sejunction process; but this is hard to that delusions of grandiosity or persecution might accept: For a patient with no education about be primary symptoms. psychiatry, what needs to be explained is not so Clarifi cation of the terms we use in translation much lack of insight, which is to be expected, but is needed here, especially with regard to ‘delu- that many patients do have, or do gain insight, sion of reference’. Wernicke often uses the term even, to some degree, when acutely disturbed. Beziehungswahn, which we usually translate in a Other origins are said to be other pre-existing generic, abstract sense as ‘delusion of related- symptoms, for instance when a persecutory delu- ness’. However, that relatedness often involves a sion leads to delusions of grandiosity (L9, patient interpreting an event, an idea, a coinci- p. 56), or when past abnormal experiences are dence, or something else, as referring specifi cally reinterpreted retrospectively (such as when to him- or her-self. For this we use the more spe- knowledge that a person has had some sort of cifi c, less abstract term ‘delusion of reference’, a ‘episode’ leads to the belief that she has acquired term already current, after Neisser [ 122 ] drew a new style of thinking, or expertise in a new attention to ‘morbid self-reference’ (krankhafte topic ; L11, 68). Eigenbeziehung ). It became more precise in 1918 Editorial Commentary 395 with the publication of Ernst Kretschmer’s mono- tion, see above) but often develop further in the graph Der Sensitive Beziehungswahn (‘The sen- most consistent manner, forever giving rise to sitive delusion of reference’). The term is as in new delusions’ (L11, p. 67). Such ‘spread’ is not Grundriss, but Kretschmer allied it to a specially typical of ‘normal’ explanations by healthy peo- sensitive personality type. Wernicke makes a ple. In L10 (p. 61) we read that ‘parables, simil- similar suggestion (L13, p. 170), referring to ies, or analogies are … forced up to conscious Raskolnikov, Dostoievsky’s sensitive hero from levels, in distinctive ways for each patient, and Crime and Punishment: ‘In a brutal habitual are then used as a means of description’, again criminal, the state of mind of a Raskolnikov seldom part of normal explanation. Wernicke would be impossible’. In Wernicke’s terms, such writes (L10, p. 60) of experiences ‘reconfi gured delusions have a strong autopsychic content. For … as is often the case, within just such a religious delusions in the other two domains (allopsychic framework.’ Why, one may ask, ‘often the case’? and somatopsychic) we retain the generic term An answer is provided, in that religious language, ‘delusion of relatedness’. There are other issues rich in parable, simile or metaphor, and necessar- for translation. The German word Wahn, can ily symbolic in nature, offers the best scope for mean either ‘delusion’ or ‘an abnormal state in elaboration by hyperactive association; but he which delusions can occur’ (i.e. ‘madness’). We does not make this point. In L12 he states (p. 77) indicate which meaning is intended, whenever ‘… a pre-existing tendency to delusional inter- Wahn appears. Likewise the terms ‘delusion’ and pretation is also supplied by abundant normal or ‘delirium’ can be confused (more in French than near-normal material for processing and evalua- in German), and we have stuck close to tion’. This admission shows that he felt a need to Wernicke’s words here. qualify his thesis, that delusions are quasi- rational Wernicke repeatedly stresses that the process explanations of abnormal experience, with hints of explanation of experience is usually not abnor- that some personality traits favour delusions. mal. So, ‘explanatory delusions may have no The phrase ‘delusion of relatedness’ itself independent signifi cance’ (L12, p. 77). This almost implies hyperactive association, although emphasis was common in the nineteenth century, Wernicke still attributes misinterpretation to when, for instance, delusions could be conceived faulty perception, in that raw sense impressions as ‘parasitic’ on more primary symptoms such as are given abnormal Affective overtones, often hallucinations [77 ]. If more than one explanatory self-referential. In L18 (p. 115), where he is writ- idea is conceived, a patient may be in honest ing of acute rather than chronic disorders, he is doubt which of several to prefer. He supports his more explicit: ‘I presented this to you as an view with the comment (L16, p. 99) that ‘indi- example of a somatopsychic delusion of related- vidual circumstances can decide the outcome— ness; however, we cannot doubt that here too it another argument supporting our view that the was based on a process of aberrant elaboration of formation of explanatory delusions cannot be new associations. In our patient still other exam- based on an ongoing disease process.’ ples showed up in this connection, with somato- ‘Explanation’ may also take the form of voices psychic delusions of relatedness forming via (‘phonemes’) or be built into ongoing experi- processes of aberrant association. ’ (emphasis ences of voices (L13, p. 81). So, we read: ‘The added; the same phrase—krankhafter Assoziation — content of the phonemes consists overwhelm- occurs in L19, p. 240). In addition, the concept of ingly of “delusions of reference”’ (L13, p. 82). an overvalued idea, which Wernicke admitted he In delusion formation, abnormality of associa- could not explain, is well accounted for as intrin- tion itself, that is the very process by which expe- sic hyperactivity of a kind of association— rience is interpreted, is given less emphasis. between matters of personal value, and Nonetheless, such abnormality is often implied. surrounding events. Beyond this, the list of For instance, ‘delusions only rarely stay limited sources from which explanatory delusions arise, to the initial delusional ideas (usually of persecu- such as abnormal sensations (of taste/smell, or 396 Editorial Commentary tinnitus), bodily change, or loss of attention, are processes, and thus with much elemental power; normal experiences for us all, yet we do not use subsequent corrections, on the other hand, take them to construct delusions. Events which occur place slowly, as real, conscious thought processes from time to time for any of us—unusual motor leading to a conclusion after long brooding.’ performance or behaviour, knowledge of past Likewise, he writes ‘a prerequisite of such delu- mental abnormality (common after excess alco- sions by analogy is a facility for relatively well- hol), the fact of detention (not limited to mentally ordered thinking’ (L18, p. 113). ill people)—are not very abnormal (though per- These determinants of the nature of delusions haps strange for people experiencing them de are in the immediate circumstances in which novo), and are not normally given delusional they form, the personality of the patient, or in interpretations. Thus, his emphasis seems their personal style of thinking. Today, there unconvincing. might be more awareness of how enduring traits, Despite what seem signifi cant shortcomings independent of anything driving a patient’s psy- in his exposition on delusions he makes shrewd chosis might shape a person’s ‘cognitive fl exibil- comments about other infl uences on delusion for- ity’ or ‘rigidity’, and therefore the ease with a mation. On whether delusions persist, we read, of they can change their beliefs. Rigidity would a malcontent with a delusionally overvalued idea tend to make delusional beliefs persist longer. (note, L14): ‘… the repetition of the incapacita- There may be a bias towards evidence which tion decision was rejected by an expert because confi rms rather than refutes beliefs, making the malcontent’s delusion was known to be incur- recovery more protracted. ‘Confi rmation bias’ is able! But the result of this provocation itself, was a topic of recent research, not least in relation to that the patient was actually cured!’ Later in this psychosis [123 ], but it is not yet clear how far it is lecture a lady teacher’s overvalued idea is related an enduring trait, regardless of psychosis. Given in part to her fastidious personality. Again, in that the balance between confi rmation and refuta- L16 (p. 99) we read: ‘If [a former patient] has to tion varies between people, and from time to deal with foolish people who offer support for his time, Wernicke’s sense that ‘logic’ is preserved in misconceptions …he will delve just as injudi- explanatory delusions should be qualifi ed by ciously into newspaper reports about his fellow examining that ‘logic’ (which is not a unitary victims; he will again be excited by these and can skill). hardly escape from delusions, which continue every day and week that passes after his dis- charge, unless he puts his allegations to the test, VIII,(m). Other Symptoms thinking this to be in his best interests, thus help- of Psychosis According to Wernicke ing the inherently false focus of his attention to fade away’. Today, such factors are rarely dis- Wernicke’s concept of psychosis is broader than cussed. In addition Wernicke offers some views the one usually used today. Hence symptoms on the different manifestations of delusions dealt with below may not be included in today’s according to a person’s habitual style of thinking. ‘psychosis’. In L23, he describes and analyzes In L14 (p. 89), when discussing post hoc correc- ‘anxiety psychosis’, an uncommon term today, tive adjustments to beliefs, he writes: ‘Turning yet clearly associated with delusions and hallu- fi rst to the subsequent correction, you will soon cinations, which may be auto-, allo-, or somato- notice how closely the phenomenon is related to psychic in content. Anxiety itself, he states explanatory delusions… However, the subse- (L36, p. 491), ‘can be regarded as a special quent correction possibly corresponds to a more somatopsychic form of disarray’. In L1 we are refi ned psychological need, while explanatory introduced to ‘motility psychosis’—one of his delusions are driven by a coarser motive. special concepts, a topic expanded in later lec- Explanatory delusions take advantage of con- tures. Many symptoms he describes started with sciousness, usually quickly, through unconscious Kalhbaum. After Wernicke such symptoms were Editorial Commentary 397 commonly incorporated by both Kraepelin and giving regional impairment, rather than impair- Jaspers into the diffuse concept of ‘catatonia’ ment of specifi c movements. (Kahlbaum’s term, meaning no more than Parakinetic symptoms include waxy fl exibility ‘movement’). He is thus ‘delivering the goods’ ( fl exibilitas cerea) described in detail, and what as announced in L2, following Meynert, that appears to be a milder form, sometimes called ‘there is nothing else to fi nd and observe than mitgehen (‘going along with’) in classic German movements, and that the whole pathology of the psychopathology, a symptom ‘… in which any mentally ill consists of nothing more than pecu- joint resistance is lacking’ (L34, p. 252). liarities of their motor behaviour.’ Much later Negativism (L34, p. 250) is motiveless resistance Karl Leonhard [124 ] adopted Wernicke’s term, to any imposed passive movement. In L34 for psychoses which were neither manic bipolar (p. 245) we read ‘akinesia gradually remitted but nor schizophrenic. stereotyped movements appeared’. Stereotypy is Motility symptoms are described in greatest a term used by Kahlbaum, and by Kraepelin from detail in L31–35. Symptoms, classed as ‘hyper- the 1890s. Today it is widely used to identify kinesia’, ‘akinesia’ and ‘parakinesia’, are behavioural pathologies in laboratory animals described. Hyperkinetic symptoms are partly given stimulants and other agents. features of mania (L31, L33); akinetic and para- Many of the movements described here— kinetic ones are described in L34 and L35. aimless, but identifi able as fragments of activity Hyperkinesia includes both motor and speech which in other circumstance might be purpose- excesses (the latter termed verbigeration ). ful—are common enough, though in less obvious Akinesia includes immobility which ‘…varies, as form, amongst most people who never get the our cases show, according to its severity, in that attention of a psychiatrist. We are thus reminded sometimes it is so marked that it leads to cessa- of the title of Freud’s book from 1901 The psy- tion of almost all reactions, and causes a condi- chopathology of everyday life [126 ]. However, if tion apparently similar to death’ (L34, p. 249). such manifestations—the ‘symptoms’ described Kretschmer, called this a ‘death feint’, likening it by Freud—are everyday occurrences, present to to responses in most mammalian species (widely a degree in any of us, this calls into question their studied, and referred to as ‘animal hypnosis’). It being designated as psycho pathology . Rather, could account for cases when people reach the they might be taken to be normal manifestations morgue, and are found still to be alive. Another of a motor system capable of acquiring complex akinetic symptom is rigidity . Akinesia for speech behaviours for specifi c purposes, manifest even is mutism (L34, p. 249; L1, note, and includes when those purposes are not engaged. reactive mutism (L34, p. 253). In L35, (p. 267), The clinical lectures in Grundriss deal with we are given a specifi c example: ‘…failure to psychiatry rather than neurology, yet reveal a answer questions put by a physician’. In L35 world-class pioneer neurologist at work. Today, it (p. 264) we hear of ‘the so-called hypochondria- is often asked why such symptoms are seen so cal palsies’, which ‘provide evidence that elimi- rarely in psychiatric practice. One might rather nation of will can be manifest in localized muscle ask whether such symptoms actually are so rare. areas… Of course they never amount to palsies An alternative view might be that, as psychiatry of individual muscle and nerve areas, but of split from neurology, symptoms which do exist, whole limbs, or at least of whole sections of today as in Wernicke’s day, are not now recog- limbs’. Hughlings Jackson’s had suggested that nized for what they are. So, in L35 (p. 267), we the motor cortex, despite its orderly representa- read: ‘When you encounter a new patient who tion of body parts, did not represent individual responds to your questions with striking silence, muscles, but rather organized movements [125 ]. and thus makes examination diffi cult, do not However, what is described appears to be differ- omit, gentlemen, to move his limbs and arrange ent, a shut-down of a defi nite region of motor them in certain positions’. This hints that symp- cortex (or a connected region of the striatum) toms are not found today, because physicians do 398 Editorial Commentary not know what to look for. However this would secondary, as are fear of the future, feelings of not apply to profound akinesia lasting for weeks, inadequacy, self-accusatory or guilt-ridden ideas, described in L34, which could hardly be missed. world-weariness and suicidal thoughts. This is In L15 we read of the relationship between plausible: A person who regularly experiences obsessions and two easily confused symptoms, periods of depression (in today’s term), and overvalued ideas, and autochthonous (self- learns that these have a predictable time course, generated) ideas. Wernicke (L2, note) writes: and therefore that he or she will soon recover, ‘Obsessions are only exceptionally an essential may ‘sit out the episode’, undoubtedly impaired element of paranoid states, if you consider cases in decision-making, yet without desperate fall in of inveterate habitual infl uence on actions by mood. Conversely, as Wernicke acknowledges, obsessional ideas bordering on mental distur- lowered mood can be brought about in other bance, where they belong in my opinion. On the ways (L28, p. 194), when he refers to a ‘transient other hand I do not deny that between self- fi t of melancholy mood, which could as well be generated ideas, overvalued ideas, and obses- really the impact of insights into [a different] ill- sions, transitions exist, in which it is diffi cult to ness.’ The description is of what Wernicke calls assign the symptom to its correct position. In ‘Affective melancholia’, a concept mainly sepa- general however, the three symptoms are easy to rate from a more severe, but less well-defi ned tell apart. When Friedmann [127 ], recently attrib- concept, ‘depressive melancholia’ (‘the so-called uted obsessional ideas to the overvalued ideas in depressive melancholia’: L34, p. 257), in which his perceptive work, and connected the latter to outward signs of changed mental state are pres- the principal element of delusions, he does me ent (patients stop talking, or doing anything). The too much honour, and moves beyond the bedrock modern word ‘depression’ does not capture this of clinical experience.’ This explores the differ- distinction. ence between paranoid states (with their com- The converse clinical picture, mania (L31) is plex, multifaceted, and at times fast-moving excessive facilitation and acceleration of activity delusions), and what was once ‘paranoia’, now (implicitly in the cortex), and with it, excessive renamed ‘delusional disorder’, in which abnor- ease in making associations. Initially this gives mal beliefs have a single theme, clung to with rise to improved performance in many tasks, and obsessive tenacity, with little wider infl uence on secondarily, to elevated mood. As ideas crowd the rest of mental life, and unaccompanied by for attention, all are pushed to maximum levels, hallucinations. Today there are growing hints that and there is a ‘levelling of ideas’ with excesses of some forms of delusional disorder may be similar association, which may lead at a later stage, to to some types of obsessive compulsive disorder, confusion and severe impairment. Wernicke yet the overlap is ill-defi ned, since both appear to makes interesting comments on the ‘levelling of be heterogeneous. ideas’ (L31, p. 218): ‘We can understand this lev- elling of ideas, which is one of the most impor- tant symptoms of mania, when we take VIII,(n). Melancholia and Mania intrapsychic hyperfunction to be a general increase in excitability of intrapsychic paths. On Wernicke’s brilliant analysis of melancholia the other hand, the normal overvaluation of ideas (L30, p. 206), exemplifi es his concept of an ‘ele- is to be explained by the physiological (function- mentary symptom’, from which all other symp- ally acquired) increase in excitability of specifi c , toms fl ow. Melancholia is not primarily a mood chosen paths’. On the basis of modern knowl- disorder, but a defi cit in ‘will’. Thus the patient edge, the following inferences might be drawn: described at the start of L30 states that ‘she could (a) Mania occurs due to generalized change in feel neither joy nor grief; her heart was turned to cortical neurones, making them more excitable; stone’. Any mood change (which he refers to as (b) Since mania is not permanent, but episodic or deprimierte Stimmung—‘depressed mood’) is transient, such change is also transient—probably Editorial Commentary 399 originating in neuronal biophysics, rather than ideas in mania is not limited to ideas with strong permanent change at the level of neuronal struc- motivational links; any recruitment of Affect- ture; (c) This is different from enhanced excit- laden ideas, with consequent classic delusions, is ability in specifi c pathways, brought about by then secondary. cellular learning mechanisms. A comment on motility disorders is made in The analysis of mania raises two interlocking (L35, p. 260), that ‘more often … the akinetic issues: First , hitherto Wernicke has regarded symptom is an expression of increased intensity’. loss—or breakage—of associations (mediated by In L35, Wernicke discusses the relations between sejunction) as different from hyperactivity of mania and Affective melancholia, including top- association (seen in mania). The fi rst is the direct ics such as ‘cyclic psychosis’, and the same idea forerunner of the ‘disorder of associations’, is raised, as he hints, when he writes (L31, regarded by Eugen Bleuler as a primary charac- p. 220): ‘A mild form of one illness generally teristic of the disorder for which he coined the tends to appear during convalescence from the term ‘schizophrenia’. The metaphor of a ‘knight’s others and signals its termination’. This has an move’ in thought (a modern phrase) has been equivalent in later paper by Court [128 ], advocat- used to describe that disorder. Interpreted liter- ing the view that mania and depression are not ally, this is a move along unorthodox pathways, polar opposites. Rather there is a transition from but still actually existing, if indirect, associative normal, to depressed, to mixed and then to a links. A commonly cited example is the link manic state. between ‘lion’ and ‘stripes’ (with ‘tiger’ as the hidden connecting link). However, the more the associative links become indirect, via hidden VIII,(o). Hebephrenia, Thought stages, the less likely is it that a clinician can Disorder, and Forerunners detect them. Therefore to claim that a sudden of Dementia Praecox shift of topic in a patient’s discourse is ‘incoher- ent’ rather than a case of ‘hyperactive associa- ‘Hebephrenia’ was a mental disorder defi ned by tion’ is a subjective judgment on the part of a Kalhbaum and Hecker, typical of adolescence, clinician, saying as much about his mental pro- characterized by ‘thought disorder’, that is disor- cesses as about those of his patient. Cases where dered cognition, revealed as silly, foolish, mean- Wernicke makes the strongest statements about ingless talk. Today, thought disorder is evidenced breakage of association are in early lectures, by disordered content of speech. In L25 (p. 170) dealing with patients with very chronic disorders. and L29 (p. 196) cases are mentioned in which This distinction might be made in error more any ‘formal thought disorder’ (formale often in such cases than in most acute cases con- Denkstörung) is absent, the fi rst times in sidered later. One can thus argue that Wernicke’s Grundriss this term is used. (It is to be distin- attempt to separate breakage of associations from guished from ‘thought defi cit’—Gedächtnisde- their hyperactivity is fl awed reasoning. In the dis- fekt —which appears occasionally [e.g.: L27, order we now call schizophrenia, there is evi- p. 180]). The clearest account of thought disorder dence of hyperactive associative processes, is in L40 (p. 325), in adolescents, although there including an excess of indirect associations; but it is called ‘hebephrenic dementia’ not ‘thought this is appears to be an enduring trait, not a tran- disorder’. ‘Hebephrenia’ became part of sient state, as it is in mania. There may however Kraepelin’s Dementia praecox (hebephrenic sub- be a more subtle distinction to be made here: type), and survives now as ‘disorganization’ in Apart from enduring traits leading to excessive the symptomatology of schizophrenia. Dementia ease in association, in the transient psychotic praecox , defi ned in the 1896 edition of phases of schizophrenia, delusions may arise Kraepelin’s textbook, had, by defi nition, a poor because of hyperactive associations based on outlook, ending in dementia, however it started. strong motivational drives. In contrast, fl ight of The most direct reference to this is in L39 400 Editorial Commentary

(p. 304): ‘Thus the unfavourable prediction that being similar to Kraepelin’s Dementia praecox , Kräpelin makes for such cases, does not always the intended meaning is quite different. apply to those during puberty’. This clearly refers In L32 (p. 227 seq.) there is also a long verba- to Dementia praecox; yet Wernicke never uses tim transcript of speech pathology. Such exam- the term, and distances himself from its major ples were used deliberately in literary productions implication, the inevitability of a poor long-term when surrealism took off after World War II, for outcome. instance in the incoherent ‘speech’ of Lucky, in Apart from this, there are statements in Beckett’s Waiting for Godot [ 129]. Such cross- Grundriss where motility disorders present simi- overs from psychiatry were intended to portray larities to what became the catatonic subtype of speech disorganization (‘formal thought disor- Dementia praecox . Thus, in L32, (p. 228) der’) in schizophrenia. Wernicke writes: ‘After a few weeks in this hyperkinetic state, which was sometimes replaced by akinetic phases of apparent exhaustion, he VIII,(p). Dementia became calm, but at the same time with rapid increase of feeble-mindedness, while his greatly Today, dementia is often seen as an end stage, reduced nutritional status gave way to a rapid with little to be done by way of either treatment increase in body weight. At present, you would or prevention, and, at least for Alzheimer’s dis- scarcely recognize this ruddy, apparently pro- ease, defi ned partly by adverse, irreversible foundly demented patient, instantly refusing and change in the brain. However, since Wernicke unbiddable towards any demand to think. The distances himself from Kraepelin’s Dementia contrast is provided by the evidently un inten- praecox, he has to defi ne dementia independent tional movements, reminiscent of the familiar of this. In L34 (p. 256), he maintains that demen- jactation of unconscious states. Common to both tia is not an irreversible end-stage; and he hints is only the monotonous recurrence of the same that at least some forms of dementia are a bi- form of movement’. Later in the same lecture, we product of severely disordered mental process- read: (L32, p. 234): ‘the special aetiology is thor- ing—mental chaos —as opposed to delusions oughly decisive for the prognosis, so that the which are systematized in some way. Likewise, paralytic form here leads to dementia, as it does much of L39 implies that psychoses occurring at in other paralytic psychoses. This is true in cases transitional periods of life refl ect in part the spe- of hyperkinetic motility psychoses, which occur cial stresses and confusion arising during those in the course of a real hebephrenia or other periods. If such suggestions are correct, some chronic, hebephrenic degenerative psychoses’. In forms of dementia represent the unravelling of L34 he writes that akinetic motility psychosis is acquired schemata for understanding the world, most prevalent in young persons, especially girls; the body, and the self, arising not so much from a and in L39 (p. 303) he writes: ‘Next most com- biological disorder, but from disorder of the mon might be motility psychoses of any kind, but ‘information economy’ associated with extreme particularly akinetic motility psychoses, which mental states. If so, the inevitability of transition fi nd their next occasion for occurrence at time of to dementia would be less absolute, and possibili- puberty’. He refers to ‘the familiar tendency for ties for prevention, even reconstitution, would be akinetic motility psychosis to be transformed into more favourable. Sometimes combination of dementia’. There are common points here coinciding stressors (in L39 [p. 306], of men- between Wernicke’s motility psychosis and strual diffi culties and hebephrenic symptoms) is Dementia praecox, yet what he describes does a prerequisite for transition to dementia. Pursuing not match Kraepelin’s concept. Likewise, in L31 this line of thought, L37 focuses on Progressive (p. 219) a phrase occurs which we translate as Paralysis, which, we note, commonly led to ‘early dementia’ (schon zeitig … Demenz: liter- dementia. His criterion of lost insight, supposed ally ‘early-onset dementia’). Despite the phrase to separate it from neurosyphilis (p. 286) raises Editorial Commentary 401 an interesting question, given that most cases of Most of his prognostic indicators refer to psy- progressive paralysis were forms of neurosyphi- chological processes or factors, which are sepa- lis. One might ask whether the loss of insight was rate from any illness. In L15 (p. 94) we a genuine consequence of underlying brain read ‘… when the extent of the disease is limited pathology, or rather of severe psychological reac- just to the fi rst psychotic elements, it is possible tions, including denial (=lack of insight) of for health to be restored through the gradual awareness of a slowly progressing disorder, appearance of more powerful countervailing which was widely feared, publicly stigmatized— arguments’. Whereas today, various forms of psy- more even than other mental disorders—and ulti- chotherapy or CBT might be sought to resolve mately fatal. confl icts of belief set up during periods of psycho- In L40 (p. 314) the more familiar side of sis, Wernicke appears to consider that unaided dementia is prominent. In the nineteenth cen- processes of natural healing will occur, simply by tury, terms for different grades of intellectual a patient’s awareness of contradictions existing defi ciency varied, but usually three grades were amongst his or her beliefs. Later he writes: ‘The recognized. The most severe was idiocy, and clinical presentation of such cases has proved use- terms for other grades varied from one country ful to me several times, as is the process of “inter- to another. Generally the three grades were nalization” itself, that is, a conscious ability to defi ned in terms of mental age (and, in the twen- recognize mental illness’. The notion that, by use tieth century, as I.Q.). The ‘theoretical’ basis was of a person’s powers of introspection, self- often in part racist (with more severe levels sup- knowledge can contribute to recovery, is a posedly correspond to ‘lesser races’), and also modern-sounding, and wise principle, but hard to had some basis in Haeckel’s recapitulation the- support on the basis of strictly biomedical ideas of ory (which was also closely linked to his own mental disorder as diagnosable diseases. Further racial ideas). hints of Wernicke’s approach come in L16 (p. 98) for a patient who ‘can hardly escape from delu- sions … unless he puts his allegations to the test, VIII,(q). Prognostic Indicators; thinking this to be in his best interests, thus help- Concepts of ‘Cure’, or ‘Return ing the inherently false focus of his attention to to Health’ fade away’. He acknowledges the role of social milieu in resurgence, progression or regression of Wernicke often writes of the degree to which symptoms: ‘Gradually, and in favourable cases, patients can recover from their illnesses, and we patients themselves notice that return of aware- get various clues in Grundriss to the prognostic ness of their period of illness is unhelpful’ (p. 99). indicators he used. The word he usually uses is Here he suggests what is now seen as good prac- Heilung , which might be translated as either tice in ‘early intervention’ programs for psychotic ‘healing’ or ‘curing’. Occasionally he uses disorders, that patients can be assisted to gain Besserung (strictly ‘improvement’; e.g. L23, insight into warning signs of an incipient break- p. 151). Back-translation of the German word down, which may help avert relapse. Sometimes ‘cure’ includes both Heilung , and Kur , while that Wernicke comments on the prognostic signifi - for ‘heal’ is limited to Heilung . We therefore pre- cance of different symptom profi les, for instance, fer to translate Heilung as ‘heal’, ‘restore to for anxiety psychosis in L23, and for psychoses health,’ or sometimes ‘recover’ as more accu- more generally in L40, where complete recovery rate, terms that are less strongly medical, similar can occur (he estimates) in about a third of cases. in implication to ‘recovery’, now widely The word ‘degeneration’ (Entartung ) when used, favoured amongst community mental health a concept already with a long history in the groups. Occasionally (L11, p. 67) the word Germanic world, as in other countries, refers to ‘cure’ is used, and then, in quotation marks, as if the supposed irreversible nature of mental disor- to signify that it is not a wholly valid concept. ders, often related to alcohol abuse. 402 Editorial Commentary

VIII,(r). Holism in Wernicke’s clinical topics in L9 (p. 54), he writes: ‘We can Thought defi ne acute mental illnesses as the process of altering the content of consciousness, which we When dealing with Wernicke’s clinical style (sec- see taking place in a defi ned time period. Such tion IV “Wernicke’s Personal Style in Psychiatric changes are often linked with Affects and emo- Practice, Teaching, Writing, and in Scholarly tions, just as they are under conditions of healthy Disputes”), the following sentence was quoted mental life.’ The latter idea is expanded greatly in (L7): ‘After a person has recovered from a mental L22, where Affective states are taken to be the illness, it is required that we ensure that he has driving force behind illusions, hallucinations and achieved insight into the abnormality of the state other symptoms. he has experienced; for the sum must necessarily In the clinical lectures, he incorporates into be inaccurate if it contains false elements’. We see his account of symptoms a person’s entire trove here an impressive aspect of Wernicke’s thought— of life experiences, their employment, training, his understanding of each individual striving to be and acquired habits of thought (if not so much a coherent whole. The individual’s search for this their intrinsic personality traits). He has little to sense of personal wholeness is found in other say on a topic thought important today, the impact giants of psychiatry in early twentieth century of psychic trauma as a cause of (or at least an (Jung, Kretschmer, and later Victor Frankl); but infl uence on) mental disorders: Nevertheless, in nowhere do we fi nd it rooted so fi rmly in brain L37 (p. 281) we read: ‘Whoever fi nds himself science as in Wernicke. We see the intrinsic holism forced to work beyond his individual strength, at many levels. When referring to fundamental under tight time pressure, taking on responsibili- neural processes, he is never far from the concept ties beyond his capacity, must struggle with of unifi ed personhood: In L3, in discussing the excitement, grief, and sorrow, that can easily relationship of perception to memory, we learn cause damage in purely intellectual work. that, though the two words are separate, the Undoubtedly all-pervading careerism encourages respective functions are inseparable; and on such damage. From this, and similarly from the ‘remembered images’ he writes of their ‘solid increased prevalence of syphilitic infection, we ownership ’ (German: Besitz ), implying that a per- can explain the signifi cant predominance of the son ‘owns’ them. Later, in L11 (p. 67) when com- male sex, particularly amongst educated classes’. menting on normal large-scale patterns of Surprisingly, this is in the lecture on Progressive association, he writes: ‘We would then not be too Paralysis. He alludes to a common myth (which bold were we to conclude that, in this sense, the one of the authors has met in a Chinese context), set of “specifi c energies” of sensory elements may that psychosis occurs ‘because a person thinks be transferred to the entire organ of association.’ too much’. We see here a habit of inference Even more remarkable, in L20 (p. 126) he mixes emerging in other situations, when the true cause this physical metaphor, with another, that of ‘reso- of an ailment is not clearly defi ned: All manner of nance’. The fi rst seems strange today, but the sec- supposed social factors are seen as ‘causes’, or ond is an astonishing forerunner of the modern contributory ones. A modern example is gastric idea (still debated), that the ‘binding problem’ of ulcers, once attributed to ‘stress’, now known to unifying percepts and concepts across dispersed be due to a bacterium which fl ourishes in acid cortical regions is solved by resonance of electro- environments. How far this applies to mental dis- graphic activity shared across regions [130 ]. orders as understood today is unsure. He is at home with the idea that cognitive and All this is underpinned by an account in L7 of Affective processes are in continual interaction how each person constructs their own sense of as parts of the unifi ed whole. We read (L8, p. 49): personhood, by assimilating the three compo- ‘It will not surprise you that the content of apper- nents of their trove of memories—the enduring ceptions in mental activity also exerts infl uence sense of their own bodies, experiences of the on accompanying Affect’; and in introducing external world, and their personal life story—into Editorial Commentary 403 a remarkably unifi ed whole (for most people). approach (for which today’s psychiatry is a better Wernicke had no access to insights we now have, target), is for specialists to over-pathologize such as one made by Geschwind [ 131 ] that in experiences (especially hallucinations and delu- sub-primate animals, where prefrontal areas are sions) which are part of normal human experi- small, multimodal convergence in areas occurs ence. One might mention the transition by mainly in limbic areas, notably the hippocampus; imperceptible steps from normal overvalued while in humans, it occurs extensively in the neo- ideas to frank delusions; or that in many cultures cortex itself. Geschwind suggests that this might ‘hearing voices’ is accepted as normal, even as a be a prerequisite for appearance of language; but ‘gift’. it also allows each of us to construct a sense of personal wholeness, however far this falls short of any ideal. In his grasp of the intrinsic holism of VIII,(s). Wernicke’s Links a human person, Wernicke, in our view, is ahead to the Emerging Dynamic Tradition of where many practitioners in mainstream psy- in Psychiatry chiatry are today, dominated by categorical diag- noses in which a patient’s search for inner unity At the time when Wernicke practised in Breslau, has no place; and where the profession rarely major changes were occurring in European cen- teaches trainees how, as doctors, they could fos- tres in the emerging profession of psychiatry. ter the rebuilding of the sense of wholeness in Three strands of mental health care were in inter- their patients. Other traditions however (such as action—care and administration in institutions; that of Carl Gustav Jung) do retain this emphasis, teaching, research, and practice by academic but are not mainstream. neurologists; and the gradual, uneasy incorpora- These issues are related to one discussed later, tion into orthodox medicine of what had been namely whether medical concepts of disease, folk medicine for centuries, but became the defi ned as disorders in specifi c organs or body dynamic tradition in psychiatry. The last of these systems are adequate as an analogy for mental is analyzed in detail by Henri Ellenberger [16 ]. disorders. In one sense Wernicke’s holism implies The point is that they were in fruitful interaction that personhood arises because of close interac- at the time, and leading physicians crossed from tion of all system (or at least of their cerebral rep- one to the other, apparently with no overwhelm- resentation), which is perhaps a less medical ing sense of ‘cognitive dissonance’ (although conceptualization. However, in another sense, he both Freud and Jung had periods of crisis— might be saying that the ‘system’ which is disor- referred to as ‘creative illness’). In addition there dered in conditions he describes, namely the were many interactions between this emerging brain as a whole, is precisely the system repre- discipline and experimental psychology of the senting, as far as possible, that personhood, uni- day. Key fi gures included Charcot, Freud, Janet, fi ed to whatever degree is possible. In that sense, and later Jung, Kretschmer and many others . he succeeds magnifi cently, and this can then be Meynert can also claim to have crossed some seen to fi t within medical paradigms, albeit ones frontiers. Many clinicians of the time, from which are signifi cantly stretched. respectable academic positions, had experi- Admittedly, our fulsome praise has to be qual- mented with hypnosis, either themselves being ifi ed, because Wernicke apparently entertained hypnotized, or by administering it as physicians; the idea that human beings are entirely ‘rational’ and Wernicke refers to it occasionally (e.g. L14, in their mental operations, this being not just an p. 90). Hypnosis was a ‘bridgehead’ by which ideal, but the expected norm. Departure from this dynamic psychiatry spread within orthodox norm is then, by defi nition, a form of pathology, practice. or mental disorder. This point became central in Wernicke himself was, it appears, also one of the critique of psychiatry by Michel Foucault those intrepid ‘frontiersmen’. Over many years, [132 ]. Another possible criticism of Wernicke’s he had sporadic contacts with Freud, whose fi rst 404 Editorial Commentary independent work, an 1891 monograph on aphasias, However, precisely for that reason, we have not was partly a response to Wernicke’s work. Freud the slightest inclination to examine it more had seven of Wernicke’s works in his library, and closely, for the time being.’ This shows his aware- in 1896 Wernicke referred a patient to Freud. ness of contemporary discussion on subconscious In 1898 Freud's fi rst truly psychoanalytical processing. In L8 (p. 47), he writes of ‘intense study (of the Signorelli parapraxis) appeared in pain, such as violent toothache, [which] immedi- Monatsschrift für Psychiatrie und Neurologie , ately signals to our subconscious to redirect edited by Wernicke and Ziehen [ 133 ]. Wernicke attention to our senses’. This is the fi rst time cites Charcot several times, whose work in Paris Wernicke uses the word ‘subconscious’ (German: started the acceptance of dynamic psychiatry. In Ohnmacht). In a later lecture (L24, p. 162) he any case, he indicates at the start of Grundriss his writes ‘When the functioning of organs which awareness of alternative models for mental disor- usually goes unnoticed, reaches perception…’, der: a footnote (L1, p. 4) to his statement that phraseology which clearly indicates his aware- ‘mental disorders are disorders of the brain’ ness of varying levels of consciousness. In L34 declares: ‘A difference of opinion prevails only (p. 251) he writes ‘… balance evidently cannot over how far they [that is mental illnesses] are of be maintained based on a particular level of men- a functional nature or are determined by palpable tal ability, the only possibility remaining is changes.’ This probably refers to the debate at the unconscious compensation, in other words, time, about psychogenic syndromes studied by adjustment acting exclusively within conscious- pioneers of dynamic psychiatry, such as Charcot, ness of corporeality’. The contradiction between Janet and Freud, where symptom patterns the two last phrases implies that Wernicke unknown in neurology occurred—later to be accepted that that component of ‘contents of con- called ‘conversion symptoms’. sciousness’ which was most familiar to each Apart from these links, much of Wernicke’s patient—consciousness of corporeality—had, by engagement with the emerging dynamic tradition its familiarity, sunk below usual levels for con- is captured by his use of key terms or concepts, scious awareness. usually ones featured in Freud’s works. Perhaps In Freud’s writings, the Ego (German: das the most telling words are unconscious and sub- Ich ) is a term of great importance. As a noun, it conscious. In L2 he writes that ultimately all had currency in German philosophy long before symptoms boil down to movements of one sort or Freud used it (around 1920) in his structural another, a view concordant with the materialism model of the human psyche. For instance, it of the Somatiker school. However, he then appeared in writings of Max Stirner (1806–1856) ‘exclude[s] … intentional movements of which and of Theodor Meynert—mentor to both Freud other people are aware before they reach the con- and Wernicke—who used the term ‘primary Ego’ sciousness of the patient him- or her-self’. In this, in his treatise Psychiatry : Diseases of the he hints at advances in France and Vienna, where Forebrain [134 ]. For Wernicke, like Meynert, but unconscious or subconscious processes (which unlike Freud in the 1920s, the concept was rooted control seemingly deliberate behaviour) were in what was known about sensory and motor sys- recognized. He acknowledges that symptoms tems. It is hard to fi nd in Freud’s extensive writ- arising in the autonomic nervous system may be ings a precise defi nition of what he meant by the relevant, although never in Grundriss , do they term ‘Ego’, and it was probably used in more have the importance implied by dynamic psychi- than one sense. Freud only occasionally cites atrists of his day. On the hinterland between con- Wernicke, although in New Introduction to scious and unconscious (L5; note) we read: ‘We Psychoanalysis [ 135 ], he acknowledges a point will be confronted again and again with the con- which Wernicke stressed, that the Ego (unlike trasts between functioning and latent conscious- Freud’s Id and Superego ) was at the interface ness; they correspond apparently to different with the external world. Wernicke’s usage con- states of one and the same anatomical substrate. trasts with religious or metaphysical ideas of an Editorial Commentary 405 entity defi ning a person’s essence (his/her ‘soul’ the late nineteenth century, with expansion of the in Western tradition) often taken to be immortal. rail network, railway accidents had become com- As the ‘essence’ of personal identity, this entity mon (see also L27, p. 182), and an issue for pub- may be held to be indivisible, but reasons put for- lic debate (depicted in closing sections of ward for quasi-indivisibility of personal identity Tolstoy’s Anna Karenina —published in serial by Wernicke are quite different, in no way sug- form between 1873 and 1878). Related to this gesting immortality. was the question of how far disability was genu- The phrase ‘symptom complex’ is usually inely injury-related, or exaggerated by conscious thought to be intrinsic to psychoanalytic thought, or subconscious processes to obtain insurance but its history is interesting. The noun ‘complex’ payouts, or other secondary benefi ts. (In the now- goes back to the seventeenth century. Wernicke’s unifi ed Germany, national health insurance had 1874 paper on aphasia was actually entitled Der been introduced under Bismarck in 1883.) This aphasische Symptomencomplex; Eine psycholo- debate lay behind one of Freud’s early public pre- gische studie auf anatomische basis . In Grundriss , sentations (in 1886) ([16 ]. Ellenberger, 1970, the phrase ‘symptom complex’ occurs a number p. 438). The term ‘railway neurosis’ could thus of times (pp. 17, 132, 150, 162), and on p. 72 we be used in a Freudian sense. Such a usage is have a reference to the ‘Ego complex’: ‘The fact found in L11 (p. 68), when discussing a patient that, in the brain, different ideas and idea-com- with somatopsychic delusions. Wernicke writes plexes are not merely juxtaposed, but are nor- ‘… with such a round-about description of the mally combined into larger groups, and fi nally change in content of his consciousness, he is seen into unity of the ego, can, in the fi nal analysis, be by many doctors as a hypochondriac, that is, suf- due only to associative processes.’ fering from neurosis’. The term ‘neurosis’ is Neurosis is a term much used by Freud. It orig- sometimes used with hints of the older sense of inated in the eighteenth century with the Scottish William Cullen. So, in L37 (p. 284) we read of physician, William Cullen, meaning an objective ‘epileptic neurosis’, a curious juxtaposition disturbance in the brain. By the time of Freud and which would not be written today, refl ecting the Wernicke its meaning had shifted completely undefi ned border between hysterical and epilep- [52 ]. As the ‘Somatikers’ gained ascendency, tic seizures; and in L41 (p. 329) we read of ‘… ‘psychosis’ took over from the earlier word, while neurosis in a subcortical vascular centre’. ‘neurosis’ became accepted as a term for disor- Conversion symptoms are closely linked to ders arising from emotional confl ict; and ‘psycho- severe anxiety. In L23 (p. 150) Wernicke intro- sis’ by Wernicke’s day was also becoming split duces the term ‘anxiety neurosis’, and asks how into ‘organic’ and ‘functional’ types, the respec- ‘anxiety psychosis’ (perhaps equivalent to con- tive home ground for neurology and psychiatry. version hysteria) differed from ‘anxiety neuro- Wernicke, no doubt aware of these shifts, sis’: ‘In no other area of mental illness are there sometimes ‘fl ags’ the areas of contention. In L29, so many points of contact with the functional dis- in dealing with the relation between obsessions orders of the nervous system.’ ‘Functional disor- and autochthonous ideas, he writes (p. 199): ‘In der’ implies a disorder with no clear structural no other area is it more diffi cult to separate psy- basis [136 ]. Wernicke uses the term only a few chosis from neurosis: Thus, to identify both the times, and not very consistently. In L16 (p. 99) he degenerative aetiology as well as the elementary writes ‘… for such cases one must concede the symptoms as lying within the range of mental possibility that these symptoms persist to some normality, it might be fi tting to speak solely of extent as a purely functional disorder’. In L32, obsessional neurosis. ’ Mainly he uses ‘neurosis’ (p. 231) it is applied to abnormal movements of in the new sense, but sometimes in the older way. chorea, a claim hardly made today. His fi rst use of the term (L8, p. 47), refers to ‘… Both ‘anxiety’ and ‘neurosis’ are terms with neuroses (following head injuries, railway acci- interesting histories, long predating Wernicke. dents and the like)’ has hints of both meanings. In Their combined use became prominent in 1894, 406 Editorial Commentary at a time when the concept of ‘neurasthenia’ was are “right back into” their life, and who are inde- introduced from North America. Freud stated that pendent enough to earn their own bread; yet they ‘anxiety neurosis’ should include: ‘general irrita- are very reluctant to talk about their periods of bility, anxious expectation, anxiety attacks, and illness, even setting up major barriers to clinical [somatic] equivalents such as cardiovascular and probing’. Likewise, in (L16, p. 99) we read: respiratory symptoms, sweating, tremor, shud- ‘Gradually, and in favourable cases, patients dering, ravenous hunger, diarrhoea, vertigo, con- themselves notice that return of awareness of gestion, paraesthesia, awakening in fright, their period illness is unhelpful’. Reticence obsessional symptoms, agoraphobia, and nausea’ about talking of periods of past illness may have [137 ]. Wernicke’s use of the phrase suggests that bases other than fear of reactivating psychosis it already had wide currency, if only in informal (as implied here). It might refl ect fear of some- use. Most specifi cally, he occasionally refers to thing that utterly defi es a patient’s comprehen- symptoms (notably psychogenic amnesia) which sion, for which they have no language or frame other clinicians were calling conversion hysteria . of reference, leading to avoidance of anything In L14 (p. 90) when referring to lapses of mem- linked to the experience, and possibly to genuine ory, he writes that ‘the close relationship between amnesia. These two may be the same, since the content of these memory lapses and the over- retrieval of memory depends on activating the valued idea points to the fact that the associative context or ‘framework’ in which a memory was link is not entirely missing, but is heavily biased embedded. towards and limited to the overvalued idea, with- out which insight the apparently conscious act could not be explained. So this probably repre- IX. Wernicke’s Approach sents a narrowing of consciousness, as it is known to Classifi cation of Mental Disorders otherwise only from states of high Affect … However, we cannot exploit this moment, IX,(a). Historical Introduction because it remains unexplained why only certain types of mental patient show this symptom’. The No system for classifying anything can be ratio- idea of loss of memory at times of high Affect is nal, until the purpose is specifi ed. Wernicke similar to ‘hysterical amnesia’ which Freud accepted prevailing traditions and concepts, yet attributed to repression; ‘narrowing of conscious- appears to struggle to break free from them. ness’ (also L39, p. 301) at such times was a theme Alternative approaches of Linnaeus and Buffon of Janet, in his exploration of automatism ([16 ]; in the eighteenth century have been mentioned, p. 224). Amnesia described by these writers was and Wernicke tried to reconcile competing claims often more extensive than in cases referred to by for mental disorders. From time to time it is clear Wernicke, whose explanation is quite different. that he, like Linnaeus, sought a ‘natural order’ in In L25 (p. 306), Wernicke does use the term what he saw in the clinic (and debates about the ‘defensive reaction’, but it is not clear that this word ‘nature’ were critical in the seventeenth referred to ‘psychological defence’ as understood century in emergence of the natural sciences— in the emerging dynamic tradition. Today, such not least in writings of Robert Boyle). We read amnesia might be attributed mainly to high selec- (p. 4): ‘However, since in Nature combinations tivity of ‘selective attention’, a concept not well of symptoms are far more diverse and complex, it formulated in Wernicke’s day. Nowadays its has been necessary to construct an artifi cial selectivity is known to vary between people as a framework, sometimes more widely, and some- trait, and (as a state variable), from time to time times more narrowly, accomplished by different in one person. Wernicke hints that he understands observers in very different ways’; and again both. Another hint at evidence from which others ‘Symptoms must be deduced from familiar fea- developed the concept of repression comes in tures of the diseased organ, in order to treat the L16 (p. 99). Wernicke refers to ‘… patients who illness—in our case from features of the brain. Editorial Commentary 407

Only in this way do we have the prospect of well preserved.’ In L17, he is sharply critical of obtaining a classifi cation and overview of symp- Ziehen (and others) for implying that there are toms which is both natural (i.e. based on the defi nite ‘disease conditions’ ( Krankheitszustand ). nature of things) and, at the same time, exhaus- The next step, that there are categorically sepa- tive.’ In L21 (p. 133) we read ‘Disorientation rate ‘diseases’ probably had little currency in disorders included in our schema represent only 1894, but the 1896 edition of Kraepelin’s text- the route by which nature brings about such dis- book promoted this notion, and took hold orientation; but every psychiatric patient is in increasingly, so that, by the time of Wernicke’s some way disoriented’. death it may have prevailed. Gradual emergence Despite his quest for ‘natural types’, he can of the disease concept for psychotic disorders is also focus on the uniqueness of each patient; and discussed by Beer [52 ]. in L20, stands back from any system he might Another issue for classifi cation, which hardly impose, with the following words (p. 131): ‘We applies today, comes in L9. Wernicke contrasts should always remember, simply, that any ‘internal’ and ‘external’ origins of mental disor- schema, ours included, has value merely of a ders, and the phrase ‘external cause’ is used in means of teaching and understanding, and L23 (p. 146), referring to an event in a patient’s becomes superfl uous as soon as a better, simpler, life. This followed Kraepelin’s early (1881) clas- or more correct grouping of the facts is found. sifi cation, separating endogenous from exoge- Rest assured, gentlemen, nobody is more aware nous origins to mental disorder. The latter of this than I, and that respect for the facts when included infectious causes: At the time, there searching for a way to represent mental illness as were several links between infectious disease and seen in the clinic is my primary consideration.’ mental disorder. Quarantine measures for patients Clearly, in his own fi eld, he was aware of coun- with dangerous infections were in places not terarguments, such as a contemporary Buffon unlike those for compulsory detention in psychi- might have urged. atric institutions. Early attempts to defi ne con- The 20-year period after 1890 in Germany cepts of medical ethics applied in both fi elds. At was critical for emergence of what we now take a time when unlettered people understood little for granted, that mental disorders are defi ned as of their own bodies, symptoms of infectious dis- categories; yet Wernicke was unhappy with the orders could be incorporated into psychotic delu- growing trend. He preferred to take as his start- sions (L10; p. 61); and of course, syphilis, whose ing point symptoms and the processes by which late stages include psychiatric syndromes, fi tted they arise, rather than supposed disease entities. Kraepelin’s scheme, especially after the spiro- There are several steps between his position and chete had been discovered (although today, when the notion of mental disorders as categorical syphilis is rare, the dichotomy is less relevant). A ‘diseases’: In his frequent use of the word bacterial toxin was seen as a potential cause of Krankheit he probably implied no more than a mental disorders. ‘process’ (such as sejunction); and occasionally he uses Geistesstörungen as a ‘catch-all’ term, rather than Krankheit (‘disturbance’ rather than IX,(b). Purposes of Taxonomy ‘illness’ or ‘disease’). As early as L11, he writes (p. 66): ‘… let us face the question of nomencla- Wernicke was aware that different systems of ture. According to current labels, all those classifi cation are needed for different purposes. patients would be examples of “chronic insan- In L10 he refers to the issue of how to separate ity” or “paranoia” … We can avoid this misun- ‘curable’ from ‘incurable’ cases, this being an derstanding if we talk of paranoid states , which administrator’s classifi cation. In L11 (p. 66) he include all those chronic mental disorders where sketches his classifi cation of psychoses, using we encounter falsifi cation of content of con- scientifi c-clinical principles—somatopsychic, sciousness, while conscious activity remains allopsychic, and autopsychic classes of psychosis. 408 Editorial Commentary

Clearly he saw the two purposes as separate, add- IX,(c). Broad Versus Narrow Criteria ing (p. 66): ‘… you could emphasize the impor- tance of that group of patients in whom the Wernicke’s critique of then-current categories disease process had apparently run its course, and was not a rejection of categorization of mental the patients have recovered, without their having disorders in principle, and he did have his own gained any insight into their illness’; and contin- distinctive categories: Most of his criticism was ues: ‘The necessity of the latter distinction can, targeted at over-inclusive defi nitions. We see this however, lead us to introduce other, somewhat- as early as L11 (p. 65): ‘… if we wanted to com- simplifi ed terms into the fi eld.’ This second, sim- prehend it in this way—that paranoia was a well- pler, more pragmatic classifi cation serves the characterized clinical form of illness then the interests of institutional administrators in identi- fl oodgates of greatest confusion of concepts fying patients who recovered or were improved would be opened, for the cases show very great suffi ciently to be discharged, and those needing differences one from another.’ In L38 (p. 294) we continued institutional care. A similar purpose also read: ‘Nevertheless, if, by way of example for classifi cation, dealt with in L40, is to defi ne you speak, hear, or read of “exhaustion psycho- severity. In L40 (p. 314), in discussing mental ses” as a specifi c clinical entity, this is the same defi ciency, he writes: ‘Separating these three misunderstanding to which I have already repeat- [types] one from another is of course quite artifi - edly drawn attention. Even more can one say, cial, and in many borderline cases cannot be with some justifi cation, that in the sense just dis- achieved; but otherwise, it is easily applied in cussed, by far the majority of acute psychoses are practice’: Here he accepts both the pragmatic “exhaustion psychoses”’. More broadly, he writes need for, and the limitations of categorical clas- (L17, pp. 101, 102): ‘The “general impression” sifi cation of persons. However, generally, he sometimes relied on even by better-known repre- separates the two purposes. sentatives of our profession, when they fail to In Kraepelin’s system, emerging at the same elicit defi nite psychotic symptoms, is no better time, classifi cation (at least to separate Dementia than everyday parlance and must elicit the deep- praecox from manic depressive illness ) was est suspicion, when used as the basis of diagnosis based jointly on patterns of symptom, and long- of a paranoid state’. Today, in much the same term evolution of each case, especially on way, the ‘cause of psychosis’ is often attributed whether a patient recovered suffi cient to be dis- to ‘trauma’, without either trauma or psychosis charged. The distinction between an administra- being defi ned precisely enough to specify the tor’s and a scientist/clinician’s purposes was thus nature of the relationship, except most vaguely as not so clear: The administrator’s classes became ‘proximate cause’. The positive side of this, part of a supposed scientifi c classifi cation. Wernicke’s preference for narrow defi nitions Granted, classifi cation based on long-term out- (which also applied to symptoms, such as verbal come does have a scientifi c side, and in L17 hallucinations) appears several times, for instance Wernicke does explore how acute syndromes in L34 (p. 254): ‘Only where [motility symp- progress to chronic ones. Merging of classifi ca- toms] constitute the clinical picture, solely or in tion systems, which should be kept separate, greater part … are we justifi ed in accepting a spe- because they serve different purposes still pre- cial illness whose essential symptoms are motor vails. Systems such as DSM-III, DSM-IV and in content. I would particularly emphasize that DSM 5, purportedly serving clinical purposes, “catatonic”—or, in our sense, specifi c motor— are widely used in USA and elsewhere for deci- symptoms, tend to appear in the majority of sions on fi nance, insurance, and medico-legal or chronic progressive psychoses at some phase of forensic matters. Likewise, ICD, though now the illness. We are thereby warned to confi ne our widely used for clinical purposes, started life as clinical picture of akinetic motility psychosis an administrator’s document for collected mor- within the narrowest possible limits.’ Again in tality statistics. L35 (p. 261), he cautions himself: ‘So we must Editorial Commentary 409 then take into account the possibility that the any symptom could occur in various disorders. above clinical picture of akinetic motility psy- Today, especially in DSM, it is habitual to list chosis, derived entirely empirically, is too broad’. collections of symptoms which jointly defi ne The same criterion could be said to apply to each condition. Inevitably, many patients fi t diag- another of his more specifi c entities—Affective nostic criteria for a number of disorders, which is melancholia. Here we get an important clue to almost certainly mainly an artefact of how diag- one of his criteria to determine when, if ever, he noses are defi ned. In an attempt to avoid such could think of specifi c illness or disease entities: high prevalence of co-morbidity, systems such as They should be defi ned as narrowly as possible in DSM often impose by fi a t exclusion as well as terms of symptoms, thus avoiding the conundrum inclusion criteria in their defi nitions; but this has of today’s nosologist—that entities overlap so been criticized. ‘… by defi ning some diagnoses much that spurious co-morbidity, is not just an in terms of exclusion as well as inclusion criteria, exception, but the norm. arbitrary separation is enforced between disor- Occasionally, however, when seeking to ders which are actually closely related, and a pos- defi ne and name ill-defi ned concepts, he recom- sibly arbitrary hierarchy between disorders is mends broader concepts as in L28 (p. 192), where generated’ [ 138]. However, Wernicke’s approach, he refers to ‘the concept of the second state, where, in each patient, one symptom is usually which is unambiguous in itself—yet currently fundamental, the others secondary, related to the always too narrowly defi ned’. fi rst by psychological reasoning, is a stronger way to avoid spurious co-morbidity arising from facile categorization. IX,(d). Psychiatric Taxonomy Separation of acute from chronic disease goes in Practice: Issues of Co-morbidity, back to the fi rst and second centuries CE, in writ- Illness Trajectory, and Severity ings (whose originals are lost) of Soranus of Ephesus [139 , 140 ]. By the nineteenth century, Concepts identifi ed in a scientifi c taxonomy of the distinction was accepted as important in med- disease need not be identical to those recognized ical descriptive writing. In psychiatry, the issue in offi cial systems of diagnosis, although the two was of widespread interest, and central to should be closely related. Whatever his critique Kraepelin’s systematization. Coming from a of categories current at the time, Wernicke did medical background, with all that goes along often make use of specifi c diagnoses. Sometimes with concepts of disease, Wernicke naturally he refers to established diagnosis (Delirium tre- wanted to make a similar separation; and as early mens, Progressive paralysis), which today would as L14 (p. 86) he writes: ‘We set out initially to hardly be seen as psychiatric diagnoses. In L23, study alterations in the content of consciousness. in relation to ‘anxiety psychosis’ we read (p. 148): We identifi ed acute and chronic mental illnesses ‘In diagnostic terms, the assumption is that the according to the processes by which they arose’. illness will often develop further, forming no This habit came partly from Meynert, since in more than the initial stage of a more complex dis- L37 (p. 284) he writes, on progressive paralysis: ease picture’. Here he refers to one of his own ‘Whenever actual psychoses appear during the concepts unambiguously as a diagnosis; but often course, the illness always shows an acute charac- his special terms, although presented as if they ter, at least temporarily, and Meynert explicitly are diagnoses, seem to be highly specifi c to one classed it with the acute psychoses’. In L17 and or a few cases, and say more about analysis of L18, the subject matter of Grundriss shifts from those cases than of disease entities (e.g. ‘acute chronic to acute conditions, and Wernicke dis- expansive autopsychosis mediated by autochtho- cusses ways to differentiate the two (L18; p. 111), nous ideas’; p. 199). partly on the basis of duration (up to a few weeks Wernicke did recognize that any disorder still being acute) but mainly on the basis of the might include a variety of symptoms, and that processes: Chronic mental disorder refl ects 410 Editorial Commentary changed content of consciousness; acute disorder nal course of individual illnesses. In this respect, refl ects changed activity of conscious processes his descriptions may be better than can be made (p. 111). Later (L40, p. 310), he refers to fi ner today, partly because, with better treatment, long- distinctions: ‘We must subdivide the acute psy- term evolution of severe illnesses is seldom seen, choses according to their time course into per- and partly because organization of mental health acute, acute, and subacute psychoses. This services today make longitudinal follow-up by a distinction is of practical importance; however, single clinician more diffi cult. we would only apply it when we are dealing with a clinical picture of acute coloration which has developed slowly over time, to distinguish it from IX,(e). Wernicke’s Prototype chronic psychosis’. Clearly he does think there Classifi catory System are distinctions to be made, which are practically important; yet he seems to struggle to separate Descriptive schemes, based on a researcher’s acute from chronic syndromes, and in the end intuitions may claim to be theoretically neutral, fi nds clinical realities scarcely permit this. Thus, but there are often implicit theoretical assump- in L17 (p. 105) we read ‘Each newly emerging tions, even if unintended or well-hidden. In L2, symptom of mental disorder may have an acute as mentioned, Wernicke gives his classifi cation character. Most chronic mental illnesses can even of all possible symptoms in a three-by-three be characterized by their acute episodes, with table, with columns identifi ed as ‘Psychosensory’, new symptoms which may occur at any period ‘Psychomotor’, and ‘Intrapsychic’, the rows as along their course. I have intentionally avoided ‘loss of’, ‘excessive’, or ‘aberrant’ excitability. describing these states wherever possible, Given the lack of reasoning underlying the because they belong with acute psychoses; but scheme, and that it encompasses all conceivable this was not wholly successful for separating possibilities, it probably has few hidden assump- such episodes from new-emerging individual tions. It probably is strictly descriptive. symptoms, because even there, just as every- Beyond this, in L1 to L8, a more signifi cant where else in nature, imperceptible transitions system for description is advanced, derived take place’. Likewise in L40 (p. 310) he writes: cogently from basic brain science. Contents of ‘We … differentiate chronic and acute psycho- consciousness fall into one of three domains: ses. However, closer examination of these differ- allo-, somato-, and auto-psychic. This provides a ences of the course over time soon showed that three-way classifi cation of phenomena he sees in acute clinical pictures are occasionally to be his patients. This is not the whole of Wernicke’s found as in chronic cases, somewhere along their scheme for classifying symptoms. Motility time-line’. symptoms and disorders are a special feature in In L40 (and several times earlier) Wernicke his thinking, although he often suggests that they writes of the practical need to chart the severity are linked closely with somatopsychic phenom- of each illness across its course. In L34 (p. 255) ena; and Affective reactions to other psychopa- he concludes that ‘range’ of symptoms is not thology, differing according to the nature of the independent of severity, and therefore the former latter are incorporated into his descriptions is not a secure criterion for classifi cation. In L40 throughout. In early clinical lectures, the three he again considers separate dimensions of ‘range’ fundamental terms are used to describe various and ‘intensity’ of symptoms, but fi nds consider- types of ‘falsifi cation of consciousness’—allo- able diffi culties in their use in practice: ‘We must psychic, somatopsychic, and autopsychic (L9). not hide from the diffi culties in the way of such Between L24 and L29 there are clinical presenta- an undertaking’ (L40, p. 111). A striking feature tions of acute disorders dominated by each symp- of cases presented in Grundriss is nevertheless tom domain—somatopsychic in L24, allopsychic his ability to recognize patterns in the longitudi- in L25 to L27, and autopsychic in L28 and L29. Editorial Commentary 411

Somatopsychosis Allopsychosis Autopsychosis Motility psychosis Anxiety psychosis Acute hallucinosis Acute autopsychosis Hyperkinetic motility (‘second state’) psychosis Hypochondriasis Delirium tremens Hysterical absences Akinetic motility psychosis (Eating disorders) Polyneuritic psychosis Acute expansive Combined hyperkinetic autopsychosis mediated by and akinetic disorders autochthonous ideas Obsessions Affective melancholia Mania Confused mania Compound and mixed psychoses Progressive paralysis Hebephrenia Dementia

The emphasis is nevertheless on symptoms three-way split to organize his descriptions. (rather than diagnoses), some of which, with Despite the clarity of reasoning behind this, one modern names, can be assigned to Wernicke’s can ask three questions: categories: Delusions of persecution are allo- psychic. Misperceived body image (in Anorexia 1. Is the implied symmetry scientifi cally valid? nervosa ) is somatopsychic. Delusions of refer- 2. Is the classifi cation clinically useful? ence, and usually overvalued ideas, are auto- 3. Are the three symptom groups statistically psychic. Only later does he use the three-way independent? split to defi ne disorders themselves, subdivi- sions of the all-encompassing term ‘psychosis’: The fi rst question is theoretical, to be answered somatopsychosis , allopsych osis, autopsychosis , on the basis of brain theory. The other two are and motility psychosis. Specifi c diagnoses then empirical matters, some of which were clearly fall under each of the latter terms. Some of beyond the methodology of his time. Empirical these are Wernicke’s own concepts, usually evaluation of this three-way split may be the most based on a deeper level of abstraction than most important way forward from what Wernicke diagnoses with we are familiar today, a few wrote in Grundriss , but it is a complex task. which we recognize and to which can assign However, he does provide a language, which modern terms. In the Table above are some of condenses many details he heard from his patients the diagnoses (mainly for acute disorders) into generic concepts. He uses that language, in appearing in Grundriss . part to describe individual cases, often in very Given the care with which he derives the sys- interesting ways, for instance: tem, there are bound to be theoretical implica- tions. For instance, Wernicke implies that there is L11 (p. 66): According to this classifi cation the some symmetry in the three (or four) components fi rst patient presented, the gardener Rother, of consciousness. Thus, in one area after would be classifi ed as an example of a total another—falsifi cation of contents of conscious- chronic psychosis; Frau Reisewitz, a chronic ness, explanatory delusions, delusions of related- auto-allopsychotic; the patient Tscheike, a ness, disarray and disorientation, other Affective chronic auto-somatopsychotic; the Biega, reactions, overvalued ideas—he uses the same case, a pure somatopsychotic; Frau Schmidt, a 412 Editorial Commentary

combined chronic allo-somatopsychotic; and for rating his three categories—allo-, somato-, Frau Reising, a chronic allopsychotic. and auto-psychic aspects of his several clinical L33 (p. 239): Previous attacks of the illness, variables. especially the fi rst, which appeared along with Using his language, Wernicke’s many gener- menstruation, were pure manias. Actual dis- alizations have no accompanying detail to docu- orientation in the allopsychic area never ment their veracity, as needed today; but it would occurred; in the autopsychic area it had char- be unwise to ignore statements from an observer acteristics of grandiose delusion, understand- and analytic thinker as shrewd as Wernicke, even able in the context of mania—this having if rigorous proof is lacking. Most of the roughly religious coloration, corresponding with the 5,000 careful clinical records from Breslau have patient’s personality; and in the somatic not survived, except for the around 150 published domain, disorientation consisted essentially of as Krankenvorstellungen aus der psychiatrischen abnormal sensations, perhaps linked with Klinik in Breslau. However, from his short period menstruation, and an explanatory delusion for in Halle records have survived, and Frank the pseudospontaneous movements, particu- Pillmann, who has access to them, has attempted larly of her trunk. to evaluate Wernicke’s system on the basis of 889 (p. 274): … somatopsychic disorientation may be cases so documented [18 ]. He seeks to validate limited to delusions of pregnancy, autopsychic Wernicke’s special diagnoses as mutually exclu- disorientation to accompanying ideas of hav- sive categories, as might be expected today. ing sinned, and allopsychic disorientation However, the core of Wernicke’s system was not restricted only to certain time periods and cer- diagnoses, but symptoms. Pillmann is therefore tain relationships, so that the prevailing situa- judging Wernicke based on today’s assumptions, tion can still be recognized correctly. which Wernicke may not have shared, rather than starting from a tabula rasa, as, in a sense, he him- Such comments are some way distant from self did, with no automatic assumption that there generalizations with which science usually deals; must be categorical diagnoses. In the paragraphs but there are also many general statements, ones below, we discuss the three questions just raised: with which research can deal. However, the sophisticated logic pervading Grundriss is neces- 1 . Theoretical validity . Several objections can be sarily a complex pattern. Moreover, because the raised against the implied symmetry of the 41 lectures were delivered as clinical presenta- three domains of psychopathology. First , tions, the merits of his language for describing memories involved in building our notion of symptoms is not at once apparent: generaliza- personal identity are of a different type from tions are scattered through the lectures in a seem- those giving us a sense of bodily integrity, ingly uncoordinated way. To clarify these and, quantitatively if not qualitatively, from dispersed statements, and to illustrate their poten- those which represent the outside world. The tial—were his system better known and under- difference can now be based on that between stood—a few of the clearest (and most ‘episodic memory’—a trove of memories of oft-repeated) generalizations in each area of unique events occurring throughout our life— symptomatology are given below. The analysis and ‘semantic’ memory—usually acquired by avoids conditions whose specifi c cause we now repetition of events, a distinction not yet for- know, especially alcoholism and syphilis. The mulated in Wernicke’s day. Episodic memory intention is then to focus, as far as possible, on is more important in constructing a person’s what we now recognize as endogenous mental sense of identity than in representing his body, disorders. These paragraphs might point to future and possibly also in representing’ the outside work; but, of course, if this line is to be followed, world. It is now thought to involve interaction the fi rst step would be to devise authenticated of neocortex with the hippocampus [88 ], in instruments, as mandated by modern standards, ways which apply less to the other contents of Editorial Commentary 413

consciousness. Second , the account of fi ndings most easily accounted for by some Delirium tremens (L26) emphasizes dramatic generic feature of the cortex as a whole. If so, allopsychic disorientation, while autopsychic it is at least plausible to incorporate Wernicke’s orientation is remarkably preserved. The somatopsychic disorders into the broader probable explanation, (section VII,(f). ‘Higher scheme, where other symptoms also arise in Levels of Functional Organization’), is that the cortex. The point he makes in later lec- the syndrome described is what is now called tures, about affi nity between somatopsychic ‘REM dissociation’ (a breakthrough of dream- and motility phenomena has support from ing, after prolonged insomnia, within a state modern neuroscience, in which primary areas more akin to wakefulness). This is such an for somatic sensation and motor function are abnormal state that any suggestion of symme- increasingly seen to be functionally interde- try with contents acquired in other ways can pendent. At the same time, it makes scientifi c be dismissed. Third , ‘autopsychosis’ as sense to separate somato-psychic functions described in L28 does not match psychosis in (depending on somato- and proprio- ceptive other domains (if cases of epilepsy, alcohol- inputs, whose patterned inputs stay fairly sta- ism or other obvious assaults are excluded): ble over long periods of time) from allo-psy- Regardless of the area in which content is chic ones (depending on ever-changing inputs described, there is nothing fi tting usual defi ni- from distance senses), the corresponding cor- tions of either hallucinations or delusions; and tical areas being some way distant from each these should occur in Wernicke’s scheme, other. The conceptual separation of auto- and since, in L30 (p. 204), the point is added that allo-psychosis was crucial in his differential ‘such a disorder of identifi cation [is] assumed diagnosis of Delirium tremens (L26). Lastly, to occur in psychosensory areas’. In any case, his distinctive ‘anxiety psychosis’ and ‘hypo- the ‘alternative personhoods’ described in chondriacal psychosis’ concepts do have fea- L28 are relatively coherent, not dominated by tures in common with today’s concept of any such symptoms. Fourth , if motility psy- psychosis—especially delusions and halluci- chosis is taken as a fourth component, we nations—although the content is quite should be reminded that brain mechanisms different. underlying movement differ vastly from most 2 . Predictive validity in the clinic . Is Wernicke’s of those of the cerebral cortex seen just as an system for describing symptoms useful in pre- ‘organ of association’. Despite presence of a dicting early signs, development, course, and motor cortical region, the important role of the eventual outcome of different conditions, and basal ganglia and cerebellum (amongst other possibly in predicting the relative effectiveness structures) make symmetry with other con- of different treatments? One of the broadest tents of consciousness most unlikely. The dif- generalizations based on his system is about ference between motility functions and the the sequence in which symptoms appear and other domains is implicitly recognized when disappear during acute syndromes: Autopsychic Wernicke refers to ‘independent development phenomena appear fi rst, and, during recovery, of akinetic and parakinetic mobility symp- disappear last. Thus, when discussing a young toms, separate from normal mechanisms of patient with a fl uctuating state of consciousness association’ (L12, p. 74). he writes (L18, p. 116): ‘We can discern, Given this, several positive things can be amongst the internal stimuli mixed together in said about Wernicke’s broadened concept of the centre of his radiant mind, abnormal sensa- psychosis. Many cases discussed in L23 and tions, self-generated ideas, and simple disori- L24 appear to arise from disordered sensory entating phonemes. Disorientation occurs processing. Modern research shows that sen- predominantly in the autopsychic area, fol- sory thresholds and sensitivities across sev- lowed by the allopsychic area.’ Many examples eral modalities often correlate (e.g. [141 – 143 ]) of this principle are reported in the context of 414 Editorial Commentary

anxiety states. In L23 (p. 146), for a patient Suggestions that autopsychic symptoms with anxiety psychosis, we read: ‘These auto- appear fi rst and disappear last, compared to psychic ideas of anxiety existed on their own in symptoms in the other domains makes theo- the initial period of illness, and only shortly retical sense. For Wernicke, autopsychic before his admission were they joined by those symptoms appear to have been more diffi cult of fantastic threats, and at the same time, there and complex than allo- or somato-psychic was an increase in the patient’s restlessness ones, since they are discussed from L26 which became so noticeable that it was inevi- onwards, after fi rst discussing the latter two. table that he be transferred to an institution’. In In L33 (p. 240) he offers this rationale: ‘The L23 (p. 147) he offers a view that ‘Such anxiety situation may arise that the fi rmest associative regularly leads to emergence of various ideas, links exist in the domain of consciousness of which therefore deserve to be called ‘anxiety the body, the next fi rmest in consciousness of ideas’. They show grades of intensity such that the environment, and the loosest—and like- the autopsychic ideas of anxiety correspond to wise the last to be acquired, with the greatest lower intensity, the allopsychic and somatopsy- individual differences—in consciousness of chic ones to more severe anxiety’. Then, as a personhood. Correspondingly, a similar mea- generalization, he writes (p. 147): ‘When the sure of severity of illness, or, according to disease starts, and as it subsides only autopsy- Meynert’s concept, of general weakness of chic ideas of anxiety are usually present. In association, was always manifested fi rst in the some cases anxiety persists, accompanied just autopsychic region, and second and third in by such ideas; far more often the ideas are allopsychic and somatopsychic domains.’ “dressed up” as phonemes. At the height of the Today, much stronger reasoning lends support anxiety state, hallucinations can also appear to this rationale: As already mentioned, the temporarily in other modalities, and in some of sense of personhood each of us constructs the most acute cases, as in the example of anxi- depends on a trove of unique memories of ety in a case of epilepsy described above, can individual events, while our sense of corpore- occur simultaneously in all senses, as com- ality and of the outside world, are usually bined hallucinations.’ On p. 253 we read: ‘it acquired by a degree of repetition of events. seems to be intrinsic to such cases of agitated Retrieving the former, acquired by episodic melancholia that autopsychic ideas of anxiety memory depends largely on reinstating the outweigh by far any others in their content, neural context which prevailed when they even though allopsychic ideas may never be were acquired. At the level of brain function, totally absent.’ Later, (L40, p. 311) he notes the contexts for each memory depend on that ‘most anxiety psychoses are examples of interaction between neocortex and hippocam- such a remitting course, in which anxiety, and pus, more so than do the other types of mem- the autopsychic disorientation based upon it, ory. These are the most sophisticated brain usually exist in a persistent fashion, but are mechanisms we have, the most vulnerable to increased in attacks that lead to allopsychic dis- failure, and likewise the last to be reinstated. array, and corresponding ideas of allopsychic Some of Wernicke’s generalizations are anxiety in the guise of phonemes.’ He also about grading the intensity of a mental disor- extends the generalization to exacerbations in der. The intensity of Affective reaction, chronic illness (p. 199): ‘We have concerned according to Wernicke, is important in deter- ourselves earlier with more sophisticated ideas; mining overall severity of an illness. So, we but if we consider just the time course to be the read (p. 161) ‘… the autopsychic area shows decisive factor, we often have to attribute new itself always to be involved, to varying stages of these to acute autopsychoses, occur- degrees, corresponding with the Affective ring during a chronic course of illness.’ state induced by anxiety or somatopsychic Editorial Commentary 415

disarray.’ In L40 (p. 310) we read: ‘… most somatopsychic and allopsychic domains, and acute psychoses, especially all subacute ones, between somatopsychic and motility disor- initially show a worsening course. An exam- ders. Whether psychosis (as defi ned by ple of this is given by acute hallucinosis … Wernicke) in different domains respond to The clinical picture, apparently rises rapidly today’s antipsychotic medicine in similar to full disease intensity according to its ways is an empirical question, which, at pres- Affective coloration …’ Again (p. 312): ent, cannot be given a defi nite answer. ‘There are essential variations in the degree of However, single case studies have reported orientation here, and these depend in a dis- remarkable benefi ts for body dysmorphic dis- tinctive way on the intensity of Affect. The order by treatment with antipsychotic medi- name we give—autopsychic anxiety ideas (we cines [144 – 146 ], a disorder which, as defi ned, might also call them “misfortune ideas”, may include delusions. Understandably, there undermining ideas of happiness)—shows have been no controlled studies, given the their derivation from an Affective state.’ vast conceptual divide between the disorder in However, the relation to intensity of the question and those for which antipsychotic Affective response may vary across the course medicines are usually prescribed. of an illness: In contrast to the above state- 3 . Statistical independence of the three domains ments, he writes (p. 281): ‘The most severe of psychopathology . To assess properly the hypochondriac presentations show themselves statistical relation between symptoms in with hardly any Affective component, such as Wernicke’s three domains, the fi rst require- having no head, no heart, no lungs, no stom- ment would be to have authenticated instru- ach, or being completely hollow, “only a ments for assessing each; and then, after tube”, as one educated patient put it so starkly collecting suitable data sets, deployment of … However, for weeks in an earlier acute methods such as factor analysis. This might be stage of his illness, the same patient had pre- possible with the data to which Pillman [ 18 ] sented the picture of most severe somatopsy- had access. As a beginning, we can search chic disarray, admittedly not as agitation, but among Wernicke’s general statements looking only as almost total inaccessibility and help- particularly for ones about association or dis- lessness, while only occasionally were there sociation across the different domains. isolated expressions and actions pointing to With regard to statements about associations , the total loss of bodily orientation.’ most abundant are between auto- and allo- There are also many straightforward gener- psychic domains: alizations about course of illness, prevalence L10 (p. 62): She had no abnormalities of sensa- at various ages, and prognostic signs of tion, nor did her general condition reveal any favourable and unfavourable outcomes, which disturbances. Nevertheless, more extensive need not be repeated here. In addition, there is examination showed other severe changes, nothing to predict which specifi c treatments noted as defects, which encroached princi- might be appropriate, and effective in differ- pally into allopsychic and autopsychic areas. ent disorders, since there were no specifi c L23 (p. 147): Often, only autopsychic ideas are treatments in his day. Nonetheless, questions present, at a moderate level; or there may even are raised for today: If it is true that there is be a combination of autopsychic and allopsy- some kinship between symptoms arising in chic ideas of anxiety, with added phonemes different domains, because of their origin in only at times when anxiety intensifi es. different areas of the one structure—the cere- L23 (p. 147): Common contents of autopsychic bral cortex—some treatments now used in one ideas of anxiety and matching phonemes class of disorders may be usefully applied in express concern for family members, for the others. The cases in point are kinship between fi nancial situation, challenges to personal 416 Editorial Commentary

honour, and there may be micromania, self- self-accusatory content—which at the same recrimination, with corresponding abusive time she rejected—insomnia, fear of silence at phonemes. The content of allopsychic ideas of night when the noise increased, and thoughts anxiety is usually a threat to life or of igno- of suicide. minious disciplinary actions, abuse, etc. L28 (p. 188): From our point of view the case is L25 (p. 166): The main symptoms we know also very clear, because it presents a typical about are phonemes, whose content, corre- example of autopsychic disarray and disorienta- sponding with his anxious state, is partly of a tion. The addition of somatopsychic disarray threatening nature, and partly expresses his and disorientation should not distract us from reduced personal status (that is, part allopsy- this view, but will, on the contrary, strengthen it. chic part autopsychic notions of anxiety). Associations between allo- and somato-psychic L25 (p. 170): A specifi c characteristic of acute domains are few, including: hallucinosis seems to be the occurrence of L10 (p. 63): The patient was apparently suffering phonemes on a grand scale, their content a slowly developing paranoia, the basis for being autopsychic and allopsychic delusions which could be found mainly in a series of of reference. morbid sensations and tactile hallucinations. L29 (p. 201): In addition, everything that people The patient notices changes in her body but, in in the neighborhood say or do is assessed as if contrast to the previous patient, attributes those people know the patient’s thoughts; and these to outside infl uences; and thus she so it reaches the point, symptomatically, of reaches allopsychic—in addition to somato- generalized autopsychic delusions of refer- psychic—falsifi cation of consciousness. ence, with corresponding reinterpretation of L36 (p. 272): Moreover, there exists an internal the outside world. Allopsychic orientation connection between somatopsychic symp- will then also be impaired. toms, and (in this case), allopsychic symp- L33 (p. 242): Cases of weakened association, toms, due partly to simple explanatory with autopsychic and allopsychic defi cit delusions, and in part to the elementary symp- symptoms but no motor excitatory symptoms tom of somatopsychic delusions of reference, (therefore: ‘asthenic autoallopsychoses’) which, at the time, we categorized as newly which I have often seen in very acutely ill formed associations. young girls. L39 (p. 306): Moreover there are some—mainly L36 (p. 278): Residual sequelae involved severe severe—clinical pictures of psychoses related confusion with autopsychic and allopsychic to the puerperium, especially when, apart from disorientation corresponding to previous hal- the puerperium, other harmful circumstances lucinations and a moderately irritatable mood. are present, such as excessive lactation, febrile Those for association of auto- and somatopsy- illness, or painful mastitis, that have reduced chic symptoms include: the levels of energy. In such circumstances the L10 (p. 61): We will talk later about the processes most severe hypochondriacal psychoses may by which such falsifi cations of conscious- occur, with allopsychic disorientation. ness—partly somatopsychic, partly autopsy- Associations of motility symptoms with other chic—actually arise. domains include: L24 (p. 154): However, the dolour and autopsy- L39 (p. 303): Almost always in these cases, chic focus of her anxiety remained, as did the phrenic nerve insuffi ciency can be demon- somatopsychic perception of anxiety about strated as the basis for the fear. Twilight states having small bowel movements. lasting several days sometimes occur in young L 24 (p. 158): When the noise was bad, restless- people in connection with major emotions, ness in her heart and anxiety also occurred. with total allopsychic disorientation almost to Also present were severe unhappiness, hope- the point of asymbolia, blended with episodes lessness, autopsychic ideas of anxiety with a of parakinetic symptoms. Editorial Commentary 417

L39 (p. 306): Of the mixed forms, a special intro- L30 (p. 210): Affective melancholia totally lacks duction is needed to manic allopsychosis and ideas of allopsychic anxiety so typical of most manic hyperkinetic allopsychosis. cases of anxiety psychosis. L39 (p. 307): To all these delirious states, apart L33 (p. 239): Recovery in this case was accom- from familiar symptoms of hallucinations (in plished, in that the last attacks acquired a form particular the dreamlike hallucinations), occa- more of pure mania, while the fi rst attack, sional ideas of anxiety, and a restlessness even more than the second just described, more-or-less reminiscent of jactation, an allo- bore an overwhelming stamp of hyperkinetic psychic disorientation appears always to be motility psychosis. Allopsychic orientation in distinctive, at least temporarily. this case was completely intact. Statements on dissociation between domains are L33 (p. 239): Previous attacks of the illness, also interesting. Ones where allo-psychic especially the fi rst, which appeared along with experience is normal, while symptoms abound menstruation, were pure manias. Actual dis- in other domains include: orientation in the allopsychic area never L10 (p. 60): You will observe the contrast occurred; in the autopsychic area it had char- between this case with such pronounced allo- acteristics of grandiose delirium, understand- psychic falsifi cation of consciousness and able in the context of mania. another patient, in whom consciousness of the L33 (p. 240): Preceding attacks had a form more outside world is in no way involved over the akin to hyperkinetic motility psychoses, while entire course of the illness right up to the pres- the following sixth attack and last attack was ent time, while the main alterations are in purely manic followed by permanent restitu- awareness of physicality, and, in due course, tion, once a stage of exhaustion had passed. of personhood as well. We can take it as an This patient always remained perfectly orien- example of residual, mainly somatopsychic tated in the allopsychic domain. falsifi cation of consciousness. L35 (p. 261): At other times the fantastic menac- L23 (p. 149): … in acute hallucinosis, a charac- ing delusional state occurring within well- teristic paranoid stage develops very early, retained allopsychic orientation is to be seen which is not the case for simple anxiety psy- in the same paranoic stage, combined only chosis. In the latter condition, allopsychic ori- with hypochondriacal sensations mainly intes- entation remains intact, unlike the tinal in nature. anxiety-laden state found in Delirium L36 (p. 274): Nonetheless, I want to emphasize tremens . explicitly that a defi nite combination, specifi - L25 (p. 170): The rapid, comprehensive, and cally that with hypochondriacal symptoms, indeed allopsychic falsifi cation of content, makes up an almost normal picture; again this and the emergence of a manner of being perse- indicates that motility psychoses should be cuted physically, and usually soon directed included with the broader concept of somato- against specifi c persons of groups of persons, psychoses. On the other hand, in many cases, is highly characteristic acute hallucinosis; the fact that complete allopsychic orientation while in acute anxiety psychosis, except for is retained, has been established with reason- certain less common cases with chronic pro- able certainty. gression, this is absent. In other situations allopsychic symptoms alone L25 (p. 170): … the predominant features of predominate (often as exceptions to the idea acute hallucinosis, the preserved allopsychic that autopsychic symptoms are the fi rst to orientation, and the absence of any formal appear and the last to disappear): thought disorder, can persist for weeks, until L33 (p. 240): Confused mania, in the sense we an increase in defensive emotions and the give to the name, does not by any means occurrence of new symptoms mark the pro- embrace all cases of the so-called periodic gression of the illness. mania. Quite often, attacks of periodic mania 418 Editorial Commentary

do indeed correspond to the clinical picture Normality of somatopsychic experience while outlined, yet allopsychic disorientation is also symptoms appear elsewhere is seldom present, manifested as ignorance—or mistak- mentioned. ing the place—of the situation and persons, L36 (p. 274): I want to emphasize explicitly that often even of objects …We will therefore pro- a defi nite combination, specifi cally that with ceed correctly, if we regard such cases not as hypochondriacal symptoms, makes up an confused mania, but as periodic manic allo- almost normal picture; again this indicates psychosis —and they are often also totally sen- that motility psychoses should be included sory psychoses. with the broader concept of somatopsychoses L33 (p. 242): In one case of this kind, the principal … In one such case, there was complete characteristics of the state of exhaustion were somatopsychic orientation, but complicated found as previously described, namely a certain by fantastic micromania, and in general by a defect in spontaneity; failure of ideation in picture of Affective melancholia. more complex demands; attentiveness retained Occasionally, Wernicke’s three-way split allows just through excitement; but very poor memory him to make differential diagnoses: retention and simultaneous allopsychic disori- L25 (p. 170): The illness [acute hallucinosis] is entation, accompanied by symptoms of motor easily differentiated from Delirium tremens and sensory irritation of moderate nature. because of the point of difference from the A few statements mention dissociation between former—the fundamental symptom of allo- different abnormalities in the same domain: psychic disorientation in its strict sense. L27 (p. 181): Nevertheless, the existing [mem- L25 (p. 170): The differential diagnosis [of ory] defi cit will explain the fact that no trace Delirium tremens ] from acute anxiety psycho- of disarray was present, in obvious contrast to sis can easily lead to confusion, because of the the severe allopsychic disorientation. main point in common between the two, L36 (p. 275): The combination of allopsychotic which we should acknowledge: the abusive symptoms with mania is important practically, and fantastically threatening character of pho- and deserves special mention. The clinical nemes, and that they arise out of ideas of anxi- picture of choleric mania, found quite often as ety of an autopsychic and allopsychic nature is an independent illness, consists essentially of undoubtedly common to both. But with anxi- a combination of mania with ideas of anxiety ety psychoses, ideas of autopsychic anxiety and corresponding phonemes, but without any namely those of belittlement, quite often pre- necessary allopsychic disorientation. Usually dominate, these being grouped not so often however, allopsychic delusions of relatedness into phonemes, as here. and hypermetamorphosis are present. To the best of our knowledge, no one has ever Normal autopsychic experience with symptoms developed Wernicke’s language for symptoms appearing in other domains is mentioned along the lines of modern research. Admittedly, occasionally: his language has theoretical fl aws, yet they are no L26 (p. 230): Results of the clinical examination worse than those of instruments in use today. It is so far can be summarized, that we are dealing nevertheless an interesting language, and if with a patient who, in contrast to near- untried, seems useful at least as a descriptive completely preserved autopsychic orienta- scheme. The above section, where some associa- tion—up to the last 2 days—presents severe tions and dissociations appear frequently, others allopsychic disorientation. rarely, suggests that there is structure yet to be L26 (p. 176): the contrast between well-preserved discovered, with important developments yet to autopsychic orientation and severe allopsy- come, were this to be attempted. A case in point chic disorientation which provides a decisive is that the association of allo- and somato-psy- criterion. No other illness that I know provides chic abnormalities is relatively rarely reported. such a striking contrast. The three (or four) broad domains for symptoms Editorial Commentary 419 may correspond well to large regions of cerebral In the preceding section, we saw how cortex, which are some way distant from each Wernicke struggled to adapt the traditional dis- other; and if so, these broad concepts seem well tinction between chronic and acute disorders to suited for modern studies with functional imagin- realities in his clinic. Likewise, in L11, he has ing, seeking excesses or defi cits in cerebral activ- diffi culty separating illnesses which have ‘run ity in large cortical regions corresponding to the their course’ from those that are still active. The predominant symptom domains. fact that these decisions proved largely beyond him may indicate that his model of mental disor- ders based on medical precedents required major X. Wernicke’s Struggle to Adapt amendment to match clinical realities. In particu- Medical Concepts to Clinical Reality lar, if his essentially holistic view of human nature, including each person’s never-ending The 20 years from 1885 during which Wernicke quest to integrate past with present experience, is practiced psychiatry were of critical importance correct, it might make sharp separation between for the emerging discipline in continental acute and chronic illnesses impossible in princi- Europe. This is partly because interactions often ple, except by administrative fi a t . This appears to occurred between the three components of psy- be the conclusion to which he is forced in L17. chiatry, which came together to form the modern Wernicke’s struggle is similarly evident in his profession, arguably more fruitful than in later attempts to defi ne prognosis. In L16 (p. 150) he years. In addition, it was during this period that writes of ‘… cases where active illness is fully the idea took root that mental disorders could be extinguished …’ Clearly he uses medical termi- subdivided (as elsewhere in medicine) as named nology, with implications about ‘prognosis’. To categories. Wernicke’s medical training, and the speak of ‘fully extinguished cases’ appears to assumption that mental disorders were diseases imply a physical disease process with its natural like those being defi ned elsewhere in medicine course, rather than a rift in a person’s sense of inevitably led him to apply medical concepts to ‘wholeness’, which might be healed during that what he saw in his clinics. However, there are person’s later journey through life. In any case, signs that he struggled in this attempt. We have the prognostic indicators to which he does refer already seen his scorn for many categories of are of a quite different nature: the natural healing mental disorder gaining currency in his day, a patient might derive from his awareness of although he did not deny that valid categories inherent contradictions in belief, the impact of might be revealed by later research, and he malign social environments which provoke defi ned a few such himself. His psychological return of symptoms, dangers of undue rumination reasoning, guided by general principles and for resurgence of symptoms, and the difference acute awareness of cerebral functioning, is often between unlettered people and educated rational- highly individualized based on immediate or dis- ists in coming to terms with past episodes of ill- tant events in each patient’s life, and on individ- ness. Again we see unresolved tension between ual habits of thought acquired during education medical training and clinical experience. or employment. This personalized approach An aspect of mental disorders on which we might have been more familiar in the newly have more appreciation today, and which casts emerging dynamic psychiatry, rather than within doubt on medical conceptualization of such disor- medical paradigms, and does not easily fi t into ders, is that these disorders are by no means diagnostic concepts, applied in a generic man- purely negative in their impact, but an inseparable ner. His three-way split of symptom domains amalgam of negative and positive features, was of value to him in describing what he saw, although the latter are given little weight by doc- but by no means were they separate disease enti- tors trained to detect psychopathology . This does ties, or even separate pathological processes, not easily fi t medical concepts of disease. with separate causes, courses, and treatments. Wernicke shows some awareness of the principle. 420 Editorial Commentary

He is aware that in some acute conditions, patients basis for classifi cation. Admittedly, he knew little may have sharper attentional focus than normal. of fundamental causes, and usually replaced this A patient ‘on one occasion … expressed his with ‘proximate causes’, substituting correlation astonishment that the head warder had disap- for causation. Even so, he fi rmly rejects aetiol- peared through one door of the hospital and ogy, defying principles established elsewhere in simultaneously entered through another door. On medicine (notably for infectious diseases). So, in another, food suddenly stood before him without L39 (p. 307) he writes of ‘… the maxim that, so any delay, a process that reminded him of the fairy often, I sought to instil, that aetiological consid- tale “wishing table”’ (L18: p. 114): Both events eration offers a benefi t only if we separate it indicate a break in temporal continuity, due to sharply from clinical defi nition of the various total lapses of attention to the outside world. (See psychoses, making no claims to artifi cial con- section XV. ‘Allusions Requiring Clarifi cation’ struction, or certain clinical forms defi ned exclu- for clarifi cation of ‘wishing table’). He comments sively by aetiology’. Similar statements occur (L18, p. 116): ‘The state of distraction is reminis- throughout Grundriss . Clinical pictures of cent of delirium, and appears to be associated diverse kinds arise from any one aetiology; the with a dream-like clouding of consciousness. We two are in no specifi c relation to each other. can conceive of no sharper contrast than the atten- What, one might then ask, could determine which tive, razor-sharp consciousness, which follows clinical picture emerges in each patient? For immediately afterwards’. However, from brain Wernicke, we have some hints: Stage of life, theory, or psychological theory, we realize that accumulation of past experiences of mental dis- these two states, apparently dramatically differ- order, education, employment, sophistication of ent, are closely related: If attention has an exces- baseline mental processes, and other life experi- sively sharp focus, it can focus either on internal ences in the recent or remote past—mainly social information, or on the external world, in either factors not medical ones. A modern writer might case excluding anything else. Since both are rep- add baseline personality. resented in the cerebral cortex, a state of sharp- Perhaps the most fundamental source of ten- ened attention to one may apply to the other. sion evident in Grundriss , perhaps intrinsic to Wernicke also suggests that in acutely disordered psychiatry as a whole, is between mechanism and states, patients may have a better-than-normal meaning , or alternatively between physical disor- sense of sound localization (L5, p. 29). In L19 der and informational discord . Wernicke ‘cut his (p. 118) he elaborates thus: ‘Usually the direction teeth’ as a neurologist on clinico-anatomical cor- from which voices appear to come can be pre- relations; as a psychiatrist, he naturally sought cisely specifi ed; and patients often develop, in this neuronal pathology as a basis for mental disor- regard, quite striking ability to localize, found ders he studied. The sejunction theory was sup- only in cases of illness. The source of the voices is posed to provide this basis. While quite indicated not only by the direction, but even by hypothetical, it showed him striving to fi t mental the very precise location and distance from the disorder into medical concepts; yet, even in his ear.’ What is missing in Grundriss is an awareness day, it failed. In L14 (p. 74), in an account of ret- of how enduring personality traits combine an rospective delusional explanations, he writes that inextricable mix of both impairment (even severe ‘modifi ed contents of consciousness must be rec- disability), and, in other faculties, major strengths, onciled, according to our prevailing notions of which may amount to outstanding talent. That is causality, with old, as yet unchanged domains’; also missing in much of today’s psychiatry, and yet he clarifi es this as occurring ‘according to although it is now a possible development, with strict standards of logic’. However, causality and our greater awareness of the intrinsic diversity of logic are not the same! In L20 (p. 125) he con- personality types. fronts the ambiguous status of mental disorders A major sign of Wernicke’s struggle to apply as diseases akin to those of general medicine. medical concepts is his rejection of aetiology as a Pathologies along these lines, he argues, like Editorial Commentary 421

cortical lesions in neurology, should be random clinical science in psychiatry even possible? The (‘subject to chance’). We fi nd this echoed later in answers of the two were quite different, and Bleuler’s words on schizophrenia: ‘This disease hinged around their respective approach to clas- seems to interrupt, quite haphazardly, sometimes sifi cation. For Kraepelin, classifi cation had to such single threads, sometimes a whole group, come before explanation. Wherever possible, it and sometimes even large segments of them’. In should be based on pathology or aetiology. contrast, Wernicke suggests that hallucinations However, Kraepelin accepted by the mid-1890s are not random, not haphazard; not so much a that for key concepts this was no more possible deranged mechanism, but rather a disturbance in than in Wernicke’s system. He therefore focused processing meaning . on symptom clusters and long-term outcome; but Overall, throughout Grundriss, he gives little the ways in which complexities of symptoms direct evidence of a neuro pathological basis for were to be assimilated could not be strictly ratio- any mental disorder, apart from disorders now nal, but, based on ‘long experience’, ultimately clearly part of neurology. Perhaps there is no reliant on personal authority—especially his such qualitative pathology, at a cellular level, own. Kraepelin was under the infl uence (as was such as would be understood by a competent neu- Wernicke) of the neo-Kantian revival, led by ropathologist. Abnormalities at this level which Hermann Cohen (1848–1918), dating back to the are now evident, are more likely to be subtle 1870s. Kraepelin took basic categories of Kant— quantitative departures from the norm in cellular especially ‘cognition’ and ‘emotion’ as separate make-up, which do not amount to pathology; and and irreducible faculties [106 ]—as the basis for these can then combine to produce unstable distinct disease types; but Wernicke gets closer to vicious circles in large-scale functioning of the the core of Kant’s philosophy, in emphasizing the brain. ‘Pathology’ (if that is the right word), is distinction between content and form (as did then at the level of whole-person functioning, Jaspers), but also took primary experience as the especially in social functioning, which is beyond key to the language of the natural sciences. In a person’s normal capacity for reintegration. The psychiatry, this meant symptoms, albeit used implicit defi nition of Wernicke’s term indirectly via their sensory and motor representa- Geisteskrankheit, thus becomes ‘loss of sense of tion in the brain, and supported by reasoning personal wholeness’—a non-medical concept, from neuroscience. In contrast, Kraepelin’s dis- which does not fi t within system-based ideas of orders of cognition and affect (respectively disease. The fundamental question posed is then: Dementia praecox, with its supposed characteris- Can medical paradigms assimilate disorders tic of ‘thought disorder’, and Manic-Depressive whose essence is the brain’s handling of informa- psychosis), were rooted directly in Kant’s phi- tion, and therefore in its apprehension of mean- losophy and his psychological categories, with ing? There is another huge imponderable: Had he no link to their physical basis, and thus separated lived longer, would he ever have resolved the from the common language of science. tension? … and if so, how would he have done it? Kraepelin—at least in separating Dementia prae- At this point, it is appropriate to mention dif- cox from manic depressive psychosis, and with ferences between the clinical style of Wernicke, long term outcome as a criterion—fused clinico- and that of his contemporary, Emil Kraepelin, scientifi c and administrative requirements giving who outlived him, and whose infl uence continues supposed scientifi c disease categories, while to this day. Most of the points summarized here Wernicke acknowledging that the two required have already been mentioned in other contexts, different, co-existing systems of classifi cation, and are brought together here to show the sharp criticized over-use of terms such as degeneration, contrast between the two researchers. Both and never uses the Dementia praecox concept. wanted to adopt standards and methods of gen- The categorical typology of Kraepelin, and eral medicine, to give psychiatry the status they especially the implied gloomy prognosis of thought it deserved. In L8, Wernicke asks: Is Dementia praecox undermined any attempt to 422 Editorial Commentary see mental disorders as dysfunctions at the level ened now by vocal contributions from service of personal wholeness, and any implications this users. The defi nitive answer still escapes us. might have for a clinician trying to rebuild that sense in his patients. Wernicke’s system of thought was altogether more holistic, and more XI. Wernicke’s Reasoning optimistic, not only in his approach to classifi ca- tion, but also in his ability to make explanations XI,(a). Style of Reasoning at an individual level. We see this in his neuroscience- based concept of personal whole- Already in his fi rst lecture we sense the great care ness, where the three components of memory are with which Wernicke constructs his arguments: brought together to form a single larger entity. His word Begriffszentrum, translated as We also see it in his accepting that emotional and ‘Conceptualization Centre’, is qualifi ed as ‘sup- cognitive aspects of experience are parts of this posed’ (supponierten ), suggesting that he is set- same whole, always interacting, whether in ting up a hypothesis for later modifi cation; and health or in disorder. His holism is also seen in this is how it unfolds in L2. Sometimes he sets up his search, wherever possible for ways by which a ‘straw man’, with the intention, later, of show- different symptoms interact, one symptom often ing it up for what it is. In L3, in relation to visual taken as ‘elementary’, the root of all others, a after-images, he sets up a hypothesis, in order to style not found in Kraepelin. For him, Dementia present counter-arguments, and so gain better praecox was a disorder primarily of cognition, understanding, almost a classic reductio ad manic depressive psychosis one of mood; his absurdum argument. In addition, he often uses a work on Dementia praecox , seldom mentions style common in natural philosophy (and impor- abnormal emotions. tant for Ernst Mach), of putting forward a sce- In terms of overall style, Wernicke is impres- nario, which is not realistic, just to clarify an sive in that he attempts to bring scientifi c reason- argument. Overall, the more we have worked on ing—albeit of an unusual style—to bear on his German text, in our attempt to get the most psychiatry. He believed that neurology and psy- accurate rendition in English, the more are we chiatry were different parts of a single discipline, impressed by his attempts to use terms in his very or at least natural partners, unlike Kraepelin, who complex system of thought in a consistent way, want psychiatry to be an independent discipline. which does not blur his essential concepts. His By his faith in reasoning—and in other ways— reasoning is often subtle, but, especially in later Wernicke tried to distance himself from any per- lectures, complex, and at times hard to follow. sonal authority he might have had; nor did he For example, in L36 (p. 271), he writes of the easily accept the authority of others. Kraepelin, relationship between three concepts of melan- by contrast, both accepted authority (such as psy- cholia—hypochondriacal, depressive and chological categories of Kant), and expected that Affective. We view this as a contrast between he himself should wield such authority. Wernicke, hypochondriacal and depressive melancholia, of course did have power conferred on him by while Affective melancholia, referred to in pass- virtue of his position, but appears to have been ing, provides further explanation—but it is hard aware of his need constantly to earn it, in daily to be certain. interactions with many people. It is perhaps no In the fi rst eight lectures , Wernicke’s reasoning coincidence that, in this period, when militarism is mainly ‘psychobiological’, that is ‘cross-level was growing in Germany, involving many psy- reasoning’ as found elsewhere in the natural sci- chiatrists, Kraepelin was actively involved in ences. Specifi cally, he establishes rational links military research [5 ], while Wernicke, who cer- between, on the one hand, facts from neuroanat- tainly knew about military matters, ‘stood some- omy (the abundant long and short cortico- cortical what apart from the main stream and military connections) and from putative physiological roads of science’, according to Theodor Ziehen’s principles (modifi ability of these connections), obituary. The debate continues to this day, enliv- and on the other hand psychological facts of Editorial Commentary 423 memory, that memories of quite different types imperative that such inconsistencies should be and acquired at different times are assimilated to eradicated, all fail. He is keenly aware of the provide a somewhat integrated sense of person- anomaly in many patients, when ‘The very fact hood. In the clinical lectures, a more special and that this patient is unaware of contradictions distinctive form of reasoning becomes prominent, between his various misconceptions, suggests by which symptoms are related to each other that the combination of all higher associations (usually from ‘elementary’ to secondary symp- into a single unit, the ego, has ceased’ (L12; toms), to events in a person’s life, to habits of p. 72). However, he also suggests that use of thought acquired during education or training and explanatory delusions in a ‘corrective’ sense is employment, or to immediate social circum- important in retrospective review of psychotic stances in which a person might fi nd himself, such beliefs, especially in educated in people with as after discharge. The relationships are not mere habits of logical thought. So, in L14, we read: correlations; nor are they ‘causal’ in the sense that ‘The more that discernment can be regained or they employ known causal principles from else- has been retained during chronic psychoses, the where in science; nor are they strictly logical rela- more mental activity takes place according to tions in the usual deductive sense. The relation strict standards of logic, and the more imperative between elementary symptoms and explanatory it is to restore some semblance of order in struc- delusions is formally the reverse of normal deduc- tures brought into disarray by illness’. Again, tion, a word which Wernicke uses seldom (the when discussing mania: ‘As long as this “circum- exception in L1 being: ‘Symptoms must be spect collectedness” is not lost, secondary asso- deduced’). Thus the premise for an argument (e.g. ciations may be noticed to an intensifi ed degree, the fact of an explanatory delusional belief) fol- and yet the main association is retained. This pos- lows rather than precedes (in the patient’s mind) sibility exists particularly in highly trained minds’ the thing to be explained—an experience which is (L31, p. 216). These are good examples where primarily abnormal. So (L10, p. 60) ‘… every- life experience, work experience, or education thing is identifi ed in a reconfi gured manner to provides skills which counteract ‘mental illness’. match certain prevailing notions’. A preformed However, sometimes, a facility in reasoning hin- conclusion suggests ‘how the evidence is to seen’. ders resolution of confl icts of belief acquired dur- This style is of course common in everyday life, ing psychosis, as in the case suggested in L16, of sometimes adopted deliberately when expedient, a patient with a highly trained legal mind, who for instance when a person needs to defend them- applies his training to provide ever-more elabo- selves against charges of wrong-doing. For those rate accretions to his sense of injustice about with little experience in reasoning, and no alterna- involuntary detention. A rational habit which tive model of inference, it is quite instinctive. benefi ts one person can be devastating in another. Provision of an explanation for a new experience Some would argue that the highly individual- is initially then an exercise in imagination, only ized style of Wernicke’s reasoning reduces its later checked deductively for consistency. As scientifi c status; but it is hard to uphold such such it is similar to a creative scientist seeking an objections in the face of Wernicke’s skilled argu- explanation, a process far more complex than syl- ments, where a patient’s education, professional logistic deduction. This, of course, is the patient ’s activity, and social milieu after discharge are style. Wernicke’s reconstruction of this style is built into his understanding of how delusional genuine scientifi c reasoning, albeit of a form material arises, declines, or is subject to progres- unusual in science. sive increment or decrement. The way Wernicke formulates patients’ Wernicke occasionally uses the word ‘experi- thought process includes some fascinating elabo- ment’, but usually as Mach’s ‘thought experiment’, rations. Mainly he sees the process of delusion or as experiments conducted in animals by formation as near-normal in terms of rationality, researchers in other fi elds. In L20 (p. 129) he but, with sejunction, that rationality, that aware- describes what he actually did, to establish hyper- ness of the existence of inconsistencies, and the metamorphosis: ‘by bringing favourite sensory 424 Editorial Commentary stimuli into the vicinity of the patient: for example, eloquently, three centuries earlier, and for exactly pulling out a watch, a handkerchief, the stock mar- the same reason, in Francis Bacon’s Novum ket report, or noting how objects are casually Organum [ 66] a founding text for the natural sci- played with, to give a sense of sight …’ In L13 ences as a whole. For Wernicke, the ‘conceptual (p. 81) he writes ‘In this example, in one case only gap’, which forced him to adopt this strategy, was ideas full of anxiety, or “anxiety ideas”, as I call his ignorance of basic processes, especially the them, in the other, frightening and threatening pho- physical basis of nervous signals. nemes, that is the same ideas, but put into words. Many examples of analogies have already We can assess such experience …’ He appears to been given, some predating Wernicke, such as refer to tests which may have been carried out on those from Meynert. He refers to Meynert’s his patients, possibly word association tests. Such image of an ‘enclosed pipe system’, and in L4 tests were fi rst used by Francis Galton, and, devel- (p. 23) and L8 (p. 46) extends this to a ‘wave of oped further by Wilhelm Wundt, with reaction psychophysical motion’, citing Fechner, but time as the dependent measure. Theodor Ziehen referring to his earlier work on aphasia, in which was the fi rst to explore the method thoroughly in a succession of associations is described as ‘a 1898 [147 ], and it was from him that C.G. Jung wave motion in an enclosed pipe system’. learned the method to use on his patients at the Sometimes analogies are drawn from his earlier Burghölzli Mental Asylum in early years of the works, as when (LI) he draws the analogy twentieth century [148 ]. It is thus plausible to between nonsensical speech in psychiatric suggest that Wernicke also used the method in patients, and transcortical aphasia, a concept some form. In any case the idea of innocuous already defi ned; and when in (L4) he points out experiments to test hypotheses about motives or the similarity in forming perceptions from sen- cognitive strategies used by individuals was elab- sation, as for concepts from percepts. Sometimes orated further in later years by ethologists and analogies come by broadening the meaning of child psychologists such as Jean Piaget, and accepted terms, as when he clarifi es the notion of Nikolaas Tinbergen. the Conceptualization Centre (L2): He refers to Wernicke cites exact quantitative data only inputs to it, using the word versinnlich , usually once (L37, p. 288 seq. ), Meynert’s rather than his translated as ‘sensual’, although the situation is own, on brain weights in various patient groups. strictly neither sensual, nor sensory. He implies He claims that the data for progressive paralysis that a person’s understanding (of a question just show greater proportionate loss in frontal com- posed) becomes a quasi-‘sensory’ input to subse- pared to other regions. The values presented hardly quent stages of processing, where formulation of prove this in males, where the percentage losses in the answer occurs. frontal, temporal, and occipital lobes are 16 %, The boldest and most far-reaching analogies 14 %, and 11 %, respectively; and in females do so are usually based on recent advances in other only in so far as the temporal lobe in paralytics areas of science, a recurring feature in Grundriss . loses 5 % of the weight of the comparison group, The fi rst example is in L1, when, to clarify the compared to 20 % and 15 % losses in frontal and indirectness of relay between cortical regions, he occipital lobes. Variance is not reported, this being refers, to telegraphy. Presumably he referred to before the days of statistical analysis. cables and Morse code, not radio-telegraphy— ‘wireless’—since it was only in 1894 that Nicola Tesla fi rst demonstrated the ‘wireless’ principle, XI,(b). Reasoning by Analogy and the fi rst commercial system of radio transmis- sion, patented by Guglielmo Marconi, was not in It has been pointed out already that, when trying use until 1906. Electrical metaphors (‘resistance’ to understand a new fi eld, reasoning by analogy, in L19 and L30; ‘short-circuit’ in L20, p. 131) despite its shortcomings, is often the only way occur periodically. In L4 and L8, and often there- forwards. Exactly the same style is found, most after, he refers to a physicist’s graphical display Editorial Commentary 425 on rectangular coordinates, to depict interaction physics (‘energy per unit mass’ or ‘energy den- of two interdependent psychological variables. In sity’). In developing the sejunction hypothesis in L4 these are ‘strength’ (or ‘intensity’) and ‘extent’ L12, he mixes several analogies, in part mechani- (or ‘circumference’). In L8, they are the ‘level’ cal, hydraulic and electrical, including reference and ‘extension’ of consciousness, the former also to ‘resistance’ (L20, p. 126). He invokes localiza- expressed as intensity of excitation or activation tion of function far beyond any empirical evi- by a stimulus. The word ‘extent’ is often replaced dence; and uses the concept of energy less in our translation by ‘range’. precisely than as the robust physical variable we The most prevalent physical analogy is the now know. In phrases such as ‘build up of ner- concept of energy (Kraft ). Originally this term vous energy’ he seems to draw on the concept of was akin to ‘life force’, a metaphor often used by conservation of energy. He may also have drawn scientists or philosophers (J.F.Herbart, Fechner, on the fact that novel events force themselves on Helmholtz) in nineteenth century German us with unusual vigour if suppressed (as he psychology, and by Sigmund Freud in psychia- argues in L8, p. 46, when describing how a miller try. The scientifi c concept of energy emerged is awakened from sleep when machinery in his slowly from this, and in mid-nineteenth century, mill stops its steady grind). Inevitably, inferences various forms of physical energy were unifi ed in are made about underlying physical processes, the fi eld of thermodynamics. The fi rst use of which lacked any empirical support. Kraft in Grundriss is in L2, where the word iden- Sometimes analogies lead to serious errors, tifi es potentialities latent in any stored memory and, from today’s perspective it is easy to see (and again in L8). In L30 (p. 206) we read of mistakes from undue reliance on analogies. ‘necessary expenditure of energy’. ‘Potential Memories are not ‘stores of energy’; discharge of energy’ is specifi c term, coined in the nineteenth nervous activity along associative links does not century by the Scottish physicist William ‘drain away’ anything; failure of such discharge Rankine. Its use in L8, draws a conscious anal- does not lead to ‘build up’ of energy (the sup- ogy with the physicist’s concept, where Wernicke posed ‘irritant’ for symptoms such as hallucina- refers (p. 46) to there being ‘only a certain store tions). Often he draws analogies between of “life force” available in the brain for psycho- neurology and psychiatry, which turn out to be physical movement’; and in L32 (p. 223) his false. So, in L11 (p. 67) he writes: ‘We can fairly words (our translation) are: ‘all her energy has equate residual alteration in content as a local- been quite used up’. These phrases hint at a con- ized process, with changes in content when psy- servation law for (psychic) energy, as did Freud’s choses progress slowly’, implying that changed hydraulic metaphor. Conservation of energy is a content of consciousness (like focal brain injury) concept with a long history, but had been formu- is irreversible, an error based on his choice of lated concisely within living memory by analogy. In his analogy between progressive Helmholtz. It is no coincidence that Ernst Mach paralysis and other psychoses (L37, p. 280), we had also published in 1872 a book entitled now know that the pathological change in the for- History and Roots of the Principle of Conservation mer is greater than ever documented in endoge- of Energy [149 ] (strictly ‘conservation of work’: nous psychoses. Sometimes, in use of analogy, Erhaltung der Arbeit ). Modern concepts of fi xed close juxtaposition of error and visionary fore- limits to ‘processing resources’ for attention have sight is startling. In L20 (p. 126) the ‘specifi c similar implications. energy’ metaphor is used to point to the intrinsic Sometimes Wernicke takes physical analogies holism of the entire associative machine, a meta- too far: In L11 (p. 66) the term ‘specifi c ener- phor which may seem strange to us today; but gies’, like ‘potential energy’, is adopted from then he mixes this with the metaphor of ‘reso- thermodynamics, but its meaning—‘specifi c’ in nance’. Use of this analogy is astonishing because so far as it is linked with specifi c patterns of it was 30 years before any reliable method of information—is quite different from its use in recording the EEG was available. 426 Editorial Commentary

Errors in inference by analogy are not fl aws in rea- Unidentifi ed assumptions ; inconsistency in using soning: They are expected in this style of inference, assumptions: In L4, Wernicke discusses the num- to be recognized and, in due course, corrected. ber of concepts we might have in our heads, and However, conclusions based on analogies should writes ‘The number of words gives us a clue to the never be given credence greater than at the time of number of concepts’: Of course there is a fl aw: Any their origin. The concept of ‘mental illness’, as analo- word (perhaps more so in English than German) gous to illnesses of general medicine is a case in has a variety of uses: Many words are ambiguous point. Is it an appropriate? Is it given greater credence until the context is specifi ed. The claim that than it deserves? Does it survive just on the basis of Shakespeare used an unmatched variety of differ- habitual use? These questions need to be posed. ent words is commonly made, but has been ques- Throughout Grundriss , we see Wernicke tioned. Studies using modern methods do not fi nd searching for simplicity and symmetry, but Shakespeare’s vocabulary exceptional, compared sometimes, in hindsight it is simplistic. As already to many other eminent writers. In developing the argued, the implied symmetry of the three-way sejunction theory, an assumption is implied which split of contents of consciousness, is inexact. He is inconsistent with one made later in Grundriss. also implies symmetry between melancholia and Thus, in L13, ‘sejunction’ is seen to involve build- mania, opposite sides of the same coin, namely up and ‘back- propagation’ of energy along for- excessive ease or impairment in exercising ‘will’. wardly projecting pathways from primary sensory However, the underlying mechanisms, even as areas to higher areas, as if there are no direct path- analyzed by Wernicke, are not opposites of one ways in the opposite direction; but as early as L6 another, and modern research would show this (and in L19; p. 124), it is clear that concepts (espe- more clearly; so, there is no true symmetry. cially that of ‘corporeality’) are elaborated through associative interconnections with ‘perception cells’, implying (as we now know) that primary XI,(c). Flaws in Wernicke’s Reasoning sensory areas receive inputs from higher cortical areas, distant in forward-projecting connectional Hindsight, it is said, is a wonderful thing. With terms from primary sensory areas. The inconsis- the benefi t of 120 years’ hindsight, it is easy to tency reveals the struggle in Wernicke’s mind to fi nd fl aws in Wernicke’s reasoning. The same can explain hallucinations, and the incompleteness of be said of those intrepid pioneers, the fi rst who his system. Another inconsistency is his assump- had the temerity to venture into terra incognita , tion about inhibitory interactions in the ‘organ of by attempting to bring Reason to bear on Nature. association’ (implicitly the cerebral cortex). In L8 Johannes Kepler, for instance, was one such pio- he states his belief that there are only excitatory neer, and, despite great achievements, could interactions between neurones, but very soon, and resort to ‘mystical numerology’, supposing there in later lectures implies inhibitory interaction (see to be simple whole-number ratios between dis- section VII,(a). ‘Wernicke’s Contribution to tances of different planets from the sun. Here he Neuroscience, Psychology and Overall Medical followed the precedent of Pythagoras, who found Knowledge’, Basic neuroscience ). that simple whole-number ratios of lengths of vibrating strings produced harmonious musical Confusion of neuronal with psychological lan- intervals; and he was followed by John Dalton, guage: Wernicke often jumps too easily between whose successful hunch along similar lines was biological (neuronal) statements and psychological critical in the reasoning supporting his atomic ones, as if they were the same. Philosophers might hypothesis; yet in this Kepler was incorrect. The call this a ‘category error’: It is also another way in following comments are therefore offered, with which analogies lead to errors. An example is where full awareness that, with Wernicke, we deal with he writes (L14, p. 85) that ‘… breakdown of ner- another intrepid pioneer. Some fl aws we identify vous structure, a change occurring at a defi nite loca- are small details, others more profound and far tion, leads to signs of defi cit, with no possibility of reaching, and some quite subtle. recovery …It seems that dissolution of associations Editorial Commentary 427 in some circumstances is equivalent to destruction care, and restoring proper nutrition. There is no of certain psychological units’: This paragraph has indication that Wernicke adopted treatments obvious ambiguity, over whether defi cits referred to which were innovative, beyond high quality in are primarily in physical (nervous) structure or in this area, and his personal attention. Some sup- psychological (information) structure. Nevertheless, posedly specifi c treatments were hang-overs in his comparison of the views of Meynert and from days when medicine had no pretentions to a Neumann on hallucinations (p. 123) and the way he scientifi c basis. The few available medicines uses the word ‘pathology’ (never ‘psychopathol- aimed to alleviate immediate symptoms and ogy’) he shows a keen awareness of this very issue. ensure good sleep rather than address fundamen- tal issues. The history of medicines in psychiatry Overinclusiveness : Sometimes Wernicke’s argu- in this period is reviewed by Healy [150 ]. ments are based on supposed areas with specifi ed Of the few medicines used in mental hospitals, functions, supposed pathways, or supposed lesions, several were herbal. Most often mentioned in without anatomical or pathological proof. This Grundriss is opium, used in various contexts, style is common in today’s clinical neuroscience, without prescription, and not mainly for pain and is criticized by purists. In truth, it is hard to relief. It appears to have been widely used in late avoid, but best taken as ‘hypotheses to be explored’ nineteenth century Germany for disorders of not as known facts or conclusions based on secure mood, anxiety, or the two combined [ 150 , 151 ], deduction. Imaginative construction of explanatory and in L23 (p. 149) its use in anxiety psychosis is hypothesis is part of Wernicke’s style, as it is in the mentioned. Such treatment may not have been natural philosophy tradition. The concept of ‘motil- complication-free: Thus, in L25 (p. 305) we read ity’, an abstract noun related to ‘movement’, is also ‘A strict bed regime must then be imposed, to extended in ways some might call overinclusive ensure adequate sleep and nutrition, and to combat (such as the pressure to speak), although his ratio- occasional fi ts of anxiety induced by opium’. nale is made clear in suitable places. Again, in L35 (p. 262), in a case of ‘severe loss of intrapsychic function along with hypochondriacal Failure to Separate Deductive from Inductive symptoms’, we read: ‘At times of remission, or Inference: This has been referred to several times with a favourable response to a medication such as already, along with the idea that what Wernicke opium, you may hear from patients that they feel claims to be missing in some of his patients is a too ill to think, or speak or to do anything.’ In L32 faculty which—in truth—most people never had. (p. 234) we read: ‘Use of narcotics in hyperkinetic The supposed lost ability is closely related to one motility psychoses is generally contraindicated’. of the classical ‘laws of thought’—the Principle of Modern support for this statement is that, in Non-contradiction—going back as far as Aristotle, Tourette’s syndrome, opioid agonists, far from and formalized in Russell and Whitehead’s alleviating symptoms, may exacerbate them [152 ] Principia Mathematica , published 4 years after the and opiate antagonists may be effective treatment 1906 edition of Grundriss. Wernicke—logician [ 153]. For ‘restless legs syndrome’, a condition to that he was—may have regarded this principle as which some patients in L32 may correspond, they more of a universal human norm than it actually is. may be effective treatment [154 ]. Another product originally extracted from plants (now manufactured synthetically) was XII. Treatments and Medical camphor. Its medicinal use was mainly by exter- Technology of the Day nal application to the skin, but it was used in small doses orally to strengthen the heart, during Specifi c treatments for any disorder were very heart failure (L26, p. 173). Hyoscine (scopol- limited in Wernicke’s day; rational chemotherapy amine), an alkaloid extracted from henbane, and of any disorder was some way in the future. For a muscarinic antagonist, was used from mid- mental disorders the best that could be offered nineteenth century, with both sedative and eupho- was often little more than high quality nursing riant properties. It is mentioned in L23 (p. 149) 428 Editorial Commentary for treating anxiety psychosis (in combination Kast (1856–1903), worked at Breslau from 1892. with opium), and recommended doses are given. It is now known to have neuronal inhibitory In L32 (pp. 223, 225) it is recommended for actions, related to GABA. There is no mention of treating hyperkinetic disorders, and as a sedative any overall drug treatment for psychoses as in patients with such disorders. It is not men- understood either by Wernicke or in today’s con- tioned as treatment for melancholia (nor is any cept, but a combination of opium and hyoscine medication recommended for this condition). was probably used widely, since we also read in This is noteworthy, since one of today’s hypoth- L23 (p. 150): ‘Incidentally, treatment of anxiety eses for depression is based on overactivity of psychoses gives outcomes just the same as those muscarininc cholinergic systems, and anticholin- for psychoses generally’. ergics are effective in some cases of depression. Treatment of syphilis is mentioned in L37 Amongst synthetic products, bromide , intro- (p. 287). For centuries this had made use of mer- duced in the 1860s, was used as a sedative and cury, applied externally to lesions. From 1843 sleeping draught (L28, p. 192) [155 ]. Bromide potassium iodide by mouth was introduced, com- overdose has toxic effects, but there is no mention bined with mercury. That Wernicke recom- of this in Grundriss . However, in L34 (p. 246) we mended it for paralytic psychoses, which he read: ‘Stress and many sleeping drugs were given differentiated from cerebral syphilis, indicates as the cause of the illness’. Then as now, hazards the unresolved relationship between the two dis- of regular use of sleeping pills seem to have been orders in his thinking. No other treatment was well known. Amyl hydrate is a product mentioned available until salvarsan was introduced in 1910, in L20 (p. 134), as having an ‘immediate calming which also was relatively ineffective. effect’ in relation to psychosis with epilepsy. This Other biological or physical treatments are may have been amyl alcohol, which, although a mentioned. Magnetic cures, mentioned in L29 natural product of fermentation, was being pro- (p. 199) had a long history, and a century earlier duced industrially at the time, and was used as a in Europe had been popularized by Anton sedative and anaesthetic between 1880 and 1950. Mesmer (1734–1815). They were still recom- Amyl hydrate also has properties as a vasodilator. mended in some medical textbooks in Wernicke’s Paraldehyde was fi rst synthesized in 1829 by day for mental disorders, convulsions, insomnia, Wildenbusch and introduced into medical prac- migraine, fatigue or arthritis [ 157 ]. In L10 (p. 60) tice in 1882, by Vincenzo Cervello, as a central we hear of ‘“vaporization” of chloroform and the depressant. It was found to be anticonvulsant as “electrical treatment”’: Chloroform and various well as sedative, and is administered in various means of electrical stimulation were used in asy- ways. It is mentioned in L25 (p. 167); and in L26 lums in many countries in the late nineteenth cen- (p. 176) recommendations on dose as a hypnotic tury. Electrical stimulation in neurology clinics is are given which correspond well to modern rec- also mentioned in L27 (p. 182), it being used ommendations, according to Medsafe, New widely in both Europe and Britain in the second Zealand [156 ]. In L25 (p. 166) there is mention of half of the nineteenth century [158 ]. Use of Phenacetin , fi rst synthesized in the USA, and leeches to initiate menstruation went back long chemically related to paracetamol (its metabo- before Wernicke’s day, but was still apparently in lite). It was introduced clinically in 1887, as a use (L32, p. 234). non-opioid analgesic, and fever-reducing drug, Medical technology was very basic. ‘Infusion’ but was banned by the FDA in the USA in 1983, is mentioned in L24 (p. 155), but it is not clear because of evidence of serious side effects. what is meant. Intravenous injection was a diffi - Trional , mentioned in L29 (p. 197) was fi rst pre- cult procedure at the time, being favoured just for pared in 1888, and introduced clinically in the some medicines, and into the fi rst decade of the same year, as a sedative and hypnotic. The chem- twentieth century, at which time it was still a sur- ist behind this was Eugen Baumann (1846–1896), gical procedure. In L32, (p. 223) we read of and the specialist in internal medicine, Alfred ‘injection of hyoscine and morphine’ as a sleeping Editorial Commentary 429 draught for a hyperkinetic patient who would not loss of fi bres [in progressive paralysis] has now stop singing. This was a subcutaneous injection been proved to be a systematic loss, correspond- (L23, p. 150; L32, p. 235), which was easier ing to secondary degeneration; and Lissauer also [159 ]. In L26 (p. 174) Papilla nervi optici is men- succeeded in demonstrating the source of this tioned, no doubt visualized by ophthalmoscopy. secondary generation in the destruction of entire The ophthalmoscope was invented in 1851 by cell layers, in certain cases’. A later examination von Helmholtz (although some say primacy goes of neuropathology in cases of progressive paraly- to Charles Babbage, 4 years earlier). Its design sis [ 161 ], discusses the original fi ndings and sub- underwent improvement after Wernicke’s death. sequent ones, concluding that the pathology can There is little on any psychological approach be attributed to a variety of factors, not directly to treatment in Grundriss , and nothing compara- related to the spirochete. ble to any form of psychotherapy. However, in L30, there is detailed guidance, on the sort of Defi ned neurological disorders: ‘Visual agnosia’ nursing care most conductive to recovery from (fi rst mentioned in L3, p. 16) was originally Affective melancholia, along lines which follow defi ned by Lissauer. Wernicke mentions it in easily from the concept of this disorder Wernicke cases of polyneuritic psychosis (Wernicke- describes. Likewise in L32 (p. 233; also L20, Korsakoff syndrome) (L38, p. 295). Modern evi- p. 130) he writes ‘If sources of hypermetamor- dence shows that visual problems can occur in phosis are removed by seclusion of patients, such thiamine defi ciency, albeit rarely (e.g. [162 ]), and motor impulses subside quite predictably’: Today, that this is also associated with widespread corti- in good mental health facilities, the corresponding cal damage [163 ]. strategy is to use rooms specially designed to limit In L30 (p. 208) Wernicke comments on the all kinds of sensory stimulation. Wernicke also high prevalence of seizures in cases of melancho- gives his views on indications and contraindica- lia. This is echoed in today’s research literature tions for using seclusion (L41, p. 324). [164 – 169] the likelihood being that there are causal components in common between the two disorders rather than seizures being either cause XIII. Update on Scientifi c Issues Raised or consequence of melancholia or depression. There may be atypical features to depression In preceding sections there has already been dis- when the two occur together. The relationship is cussion of some scientifi c issues raised by hard to defi ne precisely because ‘seizures’ may Wernicke, in the light of modern research fi nd- be non-epileptic, and when they are epileptic, it ings. Here we summarize modern views on fur- is at present unclear which, of many types of epi- ther issues raised in Grundriss . lepsy collected under the single term, is involved. Wernicke’s comment (L29, p. 200) that com- Neuroanatomy: The number of nerve cells in the pulsive acts are more common at time of men- cortex (L4, p. 22) was ‘about a milliarde , by struation has modern support: Both motor Meynert’s count’ (about one billion). Modern compulsions (‘tics’) and obsessive thoughts are estimates put the fi gure much higher—19 and 23 known to increase in the premenstrual period in billion (mean fi gures for female and male respec- some patients with OCD or Tourette’s syndrome tively, with large individual variation: [160 ]). [ 170 , 171 ]. Neuropathology is mentioned occasionally in Grundriss. The neuropathology of progressive Symptomatology: Although Wernicke knew little paralysis is mentioned in several places, and of the principle of psychological reinforcement, Wernicke makes very bold conjectures in L7, he makes an interesting point in this context (L8, where he suggests that there is pathology in an p. 49) that ‘all more complex processes of associ- outer lamina of the cerebral cortex. In L41 ation—“mental processes” as we called them— (p. 326) we read: ‘As Lissauer has shown, this are accompanied by a moderate degree of Affect’, 430 Editorial Commentary and again ‘mental activity is usually associated mechanism is a general lowering of neuronal with a slight degree of Affect.’ He writes: activation threshold, so increasing the ease with ‘Whatever is conducive to consciousness of per- which threshold is reached, this being a dynamic sonhood—the Ego—evokes a pleasant state of shift, spread across the whole of the cortex, but mind; whatever is harmful to it, evokes an unpleas- without new learning. That for the second style of ant state of mind.’ This might be questioned, delusion formation may be dopaminergic excess, since unpleasant emotion—such as ‘shame’— acting in the basal ganglia to shape beliefs in a may involve intense consciousness of personhood. more fundamental way. Nonetheless, the notion conveyed, especially in In L30 (p. 208) Wernicke takes failure of the fi rst quotation, is that the very act of associa- imagery, or of imagination, as equivalent to a tion is itself subjectively attractive, perhaps wider failure of association, possibly a subjective because ‘things start to make sense’. This idea has manifestation of the very process of sejunction. a long history, from St Augustine’s ‘Eros of the However, imagery and association are not identi- Mind’, through Alfred North Whitehead’s [ 172 ] cal. Modern literature, based on ‘semantic prim- fi rst stage of learning (‘Romantic emotion is ing’ methods fail to fi nd any abnormality in the essentially the excitement consequent on the tran- process of association in major depressive disor- sition from the bare facts to the fi rst realizations of der [ 173 – 175 ]. A non-tachistoscopic method the import of their unexplored relationships’). (‘spreading activation’) suggests that students In terms of symptoms, Wernicke also writes scoring high on a depression scale have freer the following on mania (L31, p. 216): ‘… every- access to a wider range of associated words than thing seems just as easy for a person who is controls [176 ]. However, with regard to reduced manic as it is hard for one who is melancholic’. imagery in depressed patients, Wernicke is sup- An assumption here is that free association is ported by two modern studies [ 177 , 178 ]. rewarding (reinforcing); but the implication is Curiously, in modern literature, it is in schizo- that overactive reward is a consequence , not the phrenia as diagnosed, where increased associa- cause of fl ight of ideas, a point of relevance to tion is found, at least with the semantic priming today’s dopamine hypothesis of schizophrenia method, along with reduced cognitive inhibition (or ‘of psychosis’). I also have used the idea, in documented in various ways [103 ] both of which that to construct an explanation is itself a rein- would lead to excesses of association. In euthy- forcement ([103 ]; p. 86). If, in addition, rein- mic bipolar disorder, there are few studies, but forcement itself can encourage some type of one shows no abnormality in the semantic prim- association, a positive feedback loop is closed, so ing task [179 ] and another shows reduced prim- that mania would then progressively accelerate. ing [180 ], while yet another [181 ] investigating In L31 (p. 216) Wernicke also writes ‘… such cognitive inhibition produced evidence of reduc- manifestations of grandiosity usually remain tion which was rather equivocal. In mania itself within limits not far removed from what is pos- there are no such studies, presumably because of sible, or which are manifest only conditionally, as the practical diffi culties of the experiment. opinions and expectations, or which are expressed ironically, as though the patient were joking, and Defi ned mental disorders: In L34 (p. 256) indulging in “make-believe”’. That is, the full Wernicke comments on the prevalence of motility veracity of belief is not recruited, suggesting its psychosis as a function of age and gender: The origin is not overactive reinforcement. Pierre comparison with Kraepelin’s Dementia praecox Janet, about the same time, thought that much has to be made, and clearly, the young age of onset psychotic thought was akin to ‘play acting’ ([16 ]; is a point of similarity; but from what we now p. 218). On the other hand, some delusions appear know about schizophrenia—the concept derived to be backed by the full force of belief. There is from Dementia praecox—it tends to occur more an important issue here, with implications for commonly in young males than females of similar diagnosis as well as treatment. Possibly the fi rst age, in contrast to Wernicke’s statement. Editorial Commentary 431

Modern research has rarely compared herita- of Emil Kraepelin. In 1906, a patient he had been bility of melancholia or depressive disorders studying died and her brain was subjected to between adolescent and adult illness, but when it analysis using the Nissl’s silver staining method. has [182 , 183 ] results confi rm Wernicke’s state- This was the fi rst documented case of what ment (L30, p. 213) that the childhood variety is became known as Alzheimer’s disease. Alzheimer more strongly heritable. Modern evidence also was appointed professor at the University of supports Wernicke’s view that bipolar disorder Breslau in 1912, but died 3 years later, probably has a stronger genetic basis than unipolar depres- as a result of rheumatic heart disease (L41, sion (L31, p. 219); and that obsessive disorders, p. 328). or at least some of their forms of it, are also Oskar Berger (1844–1885), studied at Breslau, strongly inherited, (L29, p. 201; L38, p. 297) in Berlin, and Vienna, a student of Griesinger, a common with Tourette’s syndrome [ 184 ]. neuropathologist, and an expert on electrotherapy Wernicke also makes a more general comment (L29, p. 200). (L38, p. 294): ‘I want to make just one point here, Jules Gabriel François Baillarger (1809– that I still do not fi nd suffi ciently emphasized: 1890), a French neurologist and psychiatrist, stu- that a strong hereditary predisposition may be dent of Esquirol, the fi rst to describe the layered present without its ever leading to acute or a structure of the cerebral cortex, and as a psychia- chronic psychosis’. This fact is fi rmly supported trist, continued Esquirol’s analysis of hallucina- today: Risk of psychotic disorders in those with tions (L31, p. 220). familial loading for psychosis, although elevated Otto Ludwig Binswanger (1852–1929), a compared to the general population, is still quite Swiss psychiatrist and neurologist. After studies small. Following through from this, eugenic mea- at Heidelberg, Strasburg, and Zurich, he worked sures such as were soon to be deployed were at a psychiatric clinic in Göttingen, and in 1880 unlikely to reduce the prevalence of such weakly worked under Karl Westphal in at Charité heritable disorders. Hospital Berlin (at which time Wernicke was also In L38 (p. 296) Wernicke refers to psychoses working in Berlin). From 1882 to 1919 he held a in users of cocaine and morphine. In modern lit- chair in psychology at the University of Jena. His erature, paranoid psychosis induced by cocaine is publications include studies of epilepsy (on well-known, but almost completely unknown for which he wrote a textbook), neurasthenia and morphine; and there is no evidence of any hysteria, and included research on neuropathol- enhancement of the psychotogenic effect when ogy (L37, p. 291). morphine is added to cocaine. Clearly, what he Paul Broca (1824–1880), a French physician, saw was cocaine-induced paranoid psychosis. surgeon, and anatomist, the fi rst, in 1861, to describe a relationship of a specifi c psychic func- tion and a specifi c cortical region (‘Broca’s area’ XIV. Historical Context in the left frontal lobe). As a neuroanatomist he contributed to defi ning what is now known as the XIV,(a). Identifi ed Researchers or ‘limbic lobe’ (L37, p. 291). Clinicians Jean Martin Charcot (1825–1893), a French pioneering neurologist and neuropathologist, stu- These profi les include most of the researchers dent of Duchenne, and founder of the neurology cited by Wernicke, but for some (usually doctoral clinic at Hôpital de la Salpêtrière, in Paris. Apart theses) details were unobtainable. To this list can from defi ning many neurological syndromes, he be added profi les of some of Wernicke’s own stu- was one of the fi rst academic physicians to take dents (included in section IV: Wernicke’s seriously the phenomenon of hypnotism, leading Personal Style etc). to the incorporation of dynamic psychiatry into Alois Alzheimer (1864–1915), a Bavarian mainstream medicine (L7, p. 40; L22, p. 142; psychiatrist and neuropathologist, and colleague L35, pp. 264, 265). 432 Editorial Commentary

Julius F Cohnheim (1838–1884), a patholo- and with a great infl uence, which spread far gist, fi rst to show that accumulation of pus was beyond psychology. Educated in what is now due to migration of white blood cells. He worked western Poland, he studied medicine in Dresden at Breslau from 1872 to 1878, later at Leipzig, and Leipzig (where he spent most of his life). At and would have been known to Wernicke (L7, an early stage in his career he held a professor- p. 41; L36, p. 273). ship in physics, but resigned this after he devel- August Cramer (1860–1912), published, in oped an eye disorder. His scientifi c contributions 1889, the fi rst description of proprioceptive and are many and varied, but he is perhaps best known kinesthetic hallucinations (L11, p. 69; L13, p. 83; for formulating what is now called the ‘Weber- L28, p. 201; L34, p. 251; L41, p. 326). Fechner law’, based on ‘just noticeable differ- Duchenne de Boulogne—often referred to as ences’ which allows subjective sensation to be ‘Duchenne’—Guillaume-Benjamin Amand studied quantitatively. In philosophical terms he Duchenne (de Boulogne) (1806–1875), a pio- espoused a rigorous version of psychophysical neer and, arguably, the founder of neurology parallelism (L8, p. 46). in post-revolutionary France (L5, p. 28; L6, Auguste Forel (1848–1931), a Swiss neuro- p. 33). anatomist and psychiatrist, acknowledged by Hermann Emminghaus (1845–1904), a Cajal as one of the contributors to the neurone German psychiatrist, studied at Göttingen and theory. As professor of psychiatry, he ran the Jena, and worked later at Würzburg, before tak- Burghölzli asylum (established in 1870) for 20 ing up in 1886 the chair in psychiatry at the years. His writings include works on sexology, University of Dorpat (then ‘East Prussia’; now and on the biology of ants. Attention has also Tartu, in Estonia), in which position he was to be recently been drawn to the fact that eugenic succeeded by Emil Kraepelin. He is best known ideas pervaded much of his work [ 50 ], but he for his writings on psychopathology (L1, p. 4; had abandoned such ideas, and, in 1920, became L28, p. 185; L40, p. 314; L41, p. 326). a member of the Bahá'í Faith (which originated Jean-Étienne Esquirol (1772–1840), a pioneer in mid-nineteenth century in Persia) (L28, of psychiatry in France, a pupil of and successor p. 190 seq. ). to Philippe Pinel, at Hôpital de la Salpêtrière , in Carl Samuel Freund (1862–1932), a German Paris (L19, p. 117). psychiatrist and neurologist, born in Breslau, and Sigismund Exner (1846–1926), an Austrian studied medicine there and in Zürich, and later physiologist, best known for work on compara- with Westphal in Berlin and Charcot in Paris. tive psychology, and on perceptual psychology Later, In Breslau, he became chair of the (especially of colour), and structure of the visual Psychiatrische-neurologische Vereinigung. cortex (L37, p. 289). Married the sister of Fitz Haber, Nobel laureate Jean Pierre Falret (1794–1870), a French psy- in Chemistry (L7, p. 40). chiatrist, a disciple of Pinel and Esquirol, is best Gustav Fritsch (1838–1927), a neuroanato- known for the concept of folie circulaire . A strict mist and physiologist, who studied natural sci- philosophical dualist, he believed that mental ill- ence and medicine at Berlin, Breslau, and ness rose from an abnormal interaction between Heidelberg. With Edouard Hitzig (see below) he body and soul. He was also the fi rst to suggest a is best known for pioneering use of electrical principle adopted by Kraepelin, that the course of stimulation of the exposed cortex of unanaesthe- an illness was useful in delineating psychiatric tized dogs, which helped establish the principle entities: ‘for… the idea of a natural course of ill- of cerebral localization of function. The publica- ness that can be foreseen presupposes the exis- tion on this in 1870 also included ablation of the tence of a natural kind of disease’ [185 ] (L31, same cortical regions, as mentioned in L40 p. 220). (p. 320). Gustav Fechner (1801–1887), a philosopher, Sigbert Josef Maria Ganser (1853–1931), a physicist, pioneer of experimental psychology, German psychiatrist, and a neuroanatomist who Editorial Commentary 433 assisted Bernhard von Gudden in Munich. He is frequent phenomena of sane life than they are. In best known for work on a hysterical disorder order to escape these diffi culties, Hagen refers to (Ganser syndrome, now seen as a dissociative ‘subcortical sensory centres’ as the seat of hallu- disorder, originally described in prisoners— cination [187 , 188]. Tamburini [ 189 ] writes: sometimes called ‘prison psychosis’) (L39, ‘according to Hagen all peripheral stimuli arriv- p. 301). ing at the sensory centres are immediately Friedrick Goltz (1834–1902). In the experi- diverted to two destinations: the ideational cen- ment referred to in L34, reported in 1869, Goltz tres (where they will generate images in con- took two frogs, decapitated one and blinded the sciousness) and back to the periphery (by the other to prevent any voluntary motions that principle of external projection). Stimuli gener- might arise from visual sense. He placed both ated in the brain sites themselves would suffer animals in a vessel of water and gradually raised the same fate, thereby giving rise to apparent per- the temperature. Both frogs kept quiet until the ceptions’ (L19, p. 123). temperature rose to 25 °C; at this point the frog Ewald Hecker (1843–1909), a German psy- whose brain was uninjured showed signs of dis- chiatrist, a student and collaborator of Kahlbaum. comfort; and as heat increased, tried to escape, Together they challenged the idea of a ‘unitary and died at 42 ° C. During this entire time the psychosis’, and constructed their own system for other frog sat perfectly still, and gave no evi- classifying mental disorders (L38, p. 303; L41, dences of distress or pain, and did not die until p. 320). temperature reached 50 °C. The experiment was Hermann Ludwig Ferdinand von Helmholtz purported to prove that the brain itself was (1821–1894): Born at Potsdam, near Berlin, he needed for conscious sensation, a conclusion initially trained in physiology (and might have which, needless to say, aroused much subsequent become a medical student). Later he held various debate (L34, p. 250). academic posts—at Königsberg, Bonn, William Richard Gowers (1845–1915), a Heidelberg, and then professor of physiology at British neurologist, the most outstanding of his the University of Berlin. His scientifi c contribu- time. He is the only British physician mentioned tions included both physical sciences (mechan- in Grundriss , for his method of measuring blood ics, conservation of energy, acoustics, haemoglobin (L27, p. 181). electromagnetism) and physiology and neurosci- Wilhelm Griesinger (1817–1868), born in ence (sensory physiology, nerve conduction, Stuttgart, studied medicine at Zürich. Later he ophthalmic optics) (L1, p. 6). was professor of medicine in Tübingen, helped in Heinrich Ewald Hering (1866–1948), best planning the Burghölzli Mental Asylum in Zürich. known for defi ning respiratory refl exes control- He was a reformer for asylums of the day, believed ling inspiration and expiration (L35, note). in integration of former patients back into society, Johann Otto Leonhard Heubner (1843–1926), supported the ‘Somatiker’ viewpoint and opposed a pioneer of paediatrics (and director of the chil- the ‘Psychiker’ school of thought (L1, p. 4; L8, dren’s clinic at the Charité Hospital in Berlin). p. 83; L17, pp. 103, 105 seq.; L18, p. 113; L28, He was also an expert on infectious disease, and p. 185; L30, p. 204; L38, p. 294; L41, p. 326). one of the fi rst to use the newly prepared diphthe- Friederich Wilhelm Hagen (1814–1888), a ria antitoxin in his practise. Co-author of German pioneer of psychopathology, who, Handbook of Acute Infections (1874). Referred amongst other achievements, developed the con- to, in context of ‘luetic infections’ in L37 (p. 262). cept of ‘delusional mood’. On hallucinations, in Hirth, CGLO. Biographical details not located. 1897s, Edmund Parish [186 ] wrote of Hagen’s A paper of his is cited (L20, p. 126) on older con- ideas, as follows: ‘If an energetic ideational stim- cept of ‘epigenesis’ (see section ‘Terminology’). ulus could arouse a corresponding activity in the Edouard Hitzig (1839–1907), a neurologist sensory centres, hallucinations, and especially and psychiatrist, studied medicine at Würzburg voluntary hallucinations, would be much more and Berlin. He is well known for experiments at 434 Editorial Commentary

Berlin with Gustav Fritsch (above) and later Emil Kraepelin (1856–1926) studied medi- became director of the Burghölzli asylum in cine at Leipzig (and neuropathology under Paul Zürich, and later became professor at Halle until Flechsig, and experimental psychology under he retired in 1903 (L40, p. 320). Wilhelm Wundt), and also at Würzburg. In 1883 Adolf Jarisch (1850–1902), an Austrian der- he published the fi rst edition of his textbook on matologist, and a specialist in syphilis, cited in psychiatry. In 1886, he was appointed to the chair L3 (p. 16) as an early researcher into modifi abil- of psychiatry at the University of Dorpat (Tartu, ity of spinal refl exes as a result of repetitive present-day Estonia), and was later head of psy- stimulation. chiatry in Heidelberg, and then Munich. His con- Friedrich Jolly (1844–1904), a neurologist cept of Dementia praecox was fi rst formulated in and psychiatrist from Heidelberg. His work the 1896 edition of his textbook, on the basis of includes studies of hypochondria, and pioneering his clinical studies; and this and related concepts electrophysiology on myasthenia gravis. He is formed the basis for a system of classifi cation cited in Grundriss as approving the naming of which is still the mainstay of the profession in ‘Korsakoff’s psychosis’ (L38, p. 296). many countries. After the First World War, he Karl Ludwig Kahlbaum (1828–1899), founded a German Institute for Psychiatric obtained training at Berlin University, and Research. Later he advocated social Darwinist worked fi rst at an asylum near Königsburg, then policies and eugenics (L14, p. 87; L30, p. 234 as a lecturer in that city, before buying a private L34, p. 256; L39, p. 304). asylum, of which he became director, at Görlitz, Richard Krafft-Ebing (1840–1902) was an a German city close to borders with present-day Austro-German psychiatrist, best known for his Poland and Czech Republic. He never had an work on sexual pathology, and his work on this academic position, but was a noted pioneer in entitled Psychopathia Sexualis (L32, p. 234; L41, psychiatry, challenging the idea of ‘unitary psy- p. 275). chosis’, introducing a focus on the long-term Jean Baptiste Octave Landry de Thézillat (1826– course of illness into psychiatry, with suggestions 1865), a French physician and researcher, who, in that different forms of mental disorder occurred 1859, discovered the paralytic disorder now known at different transitional periods of life. With as Guillain–Barré syndrome (L27, p. 182). Ewald Hecker he defi ned motor (‘catatonic’) Henri Le Grand du Saulle (1830–1886). His symptoms [190 ] (L1, 4; L13, p. 83; L19, pp. 118, book, from 1875, entitled La folie du doute (avec 119, 122, 124; L22, p. 141; L24, pp. 162, 163; délire du toucher) (Madness of doubt, with fear L28, p. 194; L31, p. 220; L34, pp. 253, 254; L37, of contact by external objects) is cited by p. 280; L39, p. 303; L40, p. 320). Wernicke (L29, p. 200). Jacobus Ludovicus Conradus Schroeder van Heinrich Lissauer (1861–1891), a neurologist der Kolk (1707–1862): a Dutch psychiatric and neuropathologist at the psychiatric institute in reformer, and a defender of vitalism against Breslau. Despite his early death, his name is asso- encroaching materialism in Germanic and French ciated with several important advances, being the thought (L19; pp. 123, 24). fi rst to describe visual agnosia, as well as studies Sergei Sergeevich Korsakoff (1854–1900), a on pathology of Progressive paralysis, and a tract pioneering Russian neuropsychiatrist, student of in the spinal cord being named after him. Cleary Meynert, later based at the Preobrazhenski men- Wernicke thought very highly of him (L20, tal hospital in Moscow, and founder of journal p. 128; L37, pp. 284–286, 289–291; L41, p. 326). which still bears his name. His work encom- Jules Bernard Luys (1828–1887), a French passed psychiatry, neuropathology, forensic med- neuroanatomist, and a neuropsychiatrist, who led icine, and alcoholism. He is best known for the the way in defi ning connections of the basal gan- syndrome of memory loss seen in chronic alco- glia, the fi rst to describe the subthalamic nucleus holism (L38, p. 296). (sometimes still called ‘corpus Luysii’), and the Editorial Commentary 435

fi rst to produce a photographic brain atlas. From ence is made to ‘Meynert’s celebrated optic thal- the late 1880s, he was fascinated by hypnotism amus case’. It is not clear what this case was. and hysteria, using extravagant experiments, and However, Meynert and his doctoral student at the sometimes public demonstrations. His enthusiasm time, Auguste Forel, are credited with defi ning in made him the most widely caricatured of those 1872 the anatomy of the optic thalamus (L1, p. 4; exploring such topics [191 ] (L19; p. 123). L2, p. 11; L4, pp. 22, 23; L5, pp. 26, 27, 29, 30; Valentin Magnan (1835–1916) studied medi- L6, p. 34; L17, p. 106; L19, pp. 123–124; L21, cine in Lyon and Paris, and became an infl uential p. 135; L26, p.172; L30, pp. 210, 211, 213; L33, psychiatrist. He focused on the concept of pp. 236, 237, 240; L34, pp. 243–252, 253; L36, ‘degeneration’ and also on the adverse effects of pp. 275, 277; L37, pp. 284, 285, 288, 290, 292; alcohol and street drugs. His system of classifi ca- L40, pp. 314, 315, 318, 319, L41, p. 326). tion, which was infl uential in France, but was Constantin Von Monakow (1853–1930), a superseded by Kraepelin’s system, held that men- Russian neuropathologist from the region north tal disorders were of just two types, which were of Moscow, spent much of his life in Switzerland, quite separate, one based on hereditary degener- as a student in, and then at the Burghölzli Mental acy, the other defi ned by presence of delusions. Asylum under Edouard Hitzig, subsequently ‘Magnan’s sign’ refers to parasthesias, which can becoming leader of the Brain Anatomy Institute arise in cocaine addict (L17, note; L38, p. 297). in Zürich. He made many contributions to neuro- Adolf Meyer (1866–1950), with a medical anatomy, and in conceptual terms recognized that degree from the University of Zürich, studied the different localized mental faculties needed to subsequently with Auguste Forel and Constantin be integrated, as were thalamus and cerebral cor- von Monakow. In 1892, he found that he could tex. In 1925, with Georg Koskinas, he published not secure a university position, emigrated to the the most detailed cytoarchitectonic map of the USA to become the fi rst chief psychiatrist at human cerebral cortex (L37, p. 290). Johns Hopkins Hospital. Subsequently he was to Johannes Peter Müller (1801–1858), a German challenge the idea that mental disorders were physiologist from Koblenz. In neuroscience he is natural types of disease, replacing the concept noted for formulating the ‘law of specifi c ener- with that of ‘reaction types’. The paper cited on gies’, from which Wundt could later derive the p. 291 (L37) was published 2 years before he ‘law of isolated conduction’ (L1, p. 4; L19, emigrated. p. 124). Ludwig Meyer (1827–1900), obtained a medi- Hermann Munk (1839–1912), a Professor of cal degree from the University of Berlin, and Physiology at the University of Berlin, from 1876 from 1866 to his death was professor of psychia- (L5, p. 26; L6, p. 36). try at the University of Göttingen. He studied Clemens Neisser (1861–1942), a German psy- infl ammatory changes in the brain in Progressive chiatrist, working in north Germany (today, paralysis, and, in 1867, with Wilhelm Griesinger, Poland). His ‘morbid self-reference’ ([112 ]. founded Archiv für Psychiatrie und Neisser, 1891) is mentioned as origin to delu- Nervenkrankheiten (L31, p. 221). sions of reference (L13, p. 82; L37 p. 208; L38, Theodor Hermann Meynert (1833–1892), pp. 285, 298). polymath and pioneer in neuroanatomy and neu- Heinrich Wilhelm Neumann (1814–1884), of ropsychiatry, amongst whose students are Breslau, one of the last German ‘Psychiker’ psy- included Carl Wernicke, Sigmund Freud, Auguste chiatrists, and therefore potentially an opponent Forel, Sergei Korsakoff, and Julius Wagner of Griesinger. He was director of the Breslau Jauregg. He gave the fi rst detailed description of Psychiatric Institute, with Wernicke as an assis- the laminar architecture of the cerebral cortex, tant, until his death, when Wernicke took over. In and various brain structures are named after him a footnote (L20, p. 130) Wernicke acknowledges (notable the nucleus basalis of Meynert ). He was him to be discoverer of the symptom of hyper- also a well-published poet. In L36 (p. 336), refer- metamorphosis. Despite his having an opposed 436 Editorial Commentary philosophy for mental disorder, Wernicke does Josef Starlinger (1862–1943), an Austrian not hesitate to cite, and commend his work. physician and psychiatrist, studied medicine in (L1, p. 4; L19, p. 124; L20, p. 130; L22, p. 141). Vienna, worked under Meynert and then under Franz Nissl (1860–1919), a neurohistologist Julius Wagner-Jauregg. Little details could be and pathologist, studied medicine at the found about him, but he was clearly abreast of University of Munich, with Bernard Gudden as developments in neurohistology, in using the one of his professors. He is best remembered for osmium-based method of Vittorio Marchi for the ‘Nissl’ stain for cytoplasmic granules within staining degenerating myelinated fi bres, with neuronal cell bodies. Later he became a collabo- potassium bi-chromate added to prevent normal rator with Alois Alzheimer, and joined Kraepelin myelinated fi bres being stained. (L41, p. 326). fi rst at Heidelberg, and later, as full-time profes- Franz Tuczek (1852–1925) studied medicine sor, in Munich (L37, p. 290; L41, p. 326). in Berlin with Westphal and in Munich with von Edouard Friedrich Wilhelm Pfl üger (1829– Gudden, and then ran a psychiatric facility in 1910), born at Hanau (near Frankfurt am Main), Marburg. His research work was mainly in neu- studied medicine at Marburg and Berlin, later ropathology, in relation to various conditions to become professor of physiology at the (ergot poisoning, progressive paralysis pellagra, University of Bonn. He contributed research in alcoholism) (L37, pp. 289–291). diverse areas of physiology, and, in 1868, Rodolf Virchow (1821–1902), a pioneer in the founded the journal Archiv für die gesammte discipline of pathology at a time when the Physiologie des Menschen und der Thiere doctrine of the humours still had infl uence. He (now: Pfl ügers Archiv: European Journal of studied under Johannes Peter Müller in Berlin, Physiology) (L5, p. 27). and later worked at the Charité Hospital there. Arnold Pick (1851–1924), a Czech neurolo- Later he became the foundation professor of gist and psychiatrist, trained under Karl Westphal Pathological Anatomy at Würzburg, and later in Berlin, and later headed the Prague institute returned to a chair in Berlin University. Apart for neuropathology. He was one of those to use from his prodigious scientifi c work he was politi- the term Dementia praecox before Kraepelin cally very active, including support for the revo- adopted the term (L19, p. 126). lution of 1848, a strong advocate for public health Wilhelm Sander (1838–1922), a German psy- measures, and a strong opponent of Darwin’s chiatrist and neurologist (L17; p. 107). theory of evolution (and of his own student Ernst Schütz H, Little details could be found about Haeckel). He declined the ennobling title ‘von this pathologist, but, his 1891 paper cited in L37 Virchow’ (L37, p. 289). came from the laboratory of Paul Flechsig in Carl von Voit (1831–1908), a German physi- Leipzig. He held the position of ‘Privatdozent’ ologist and dietician regarded by many as the and ‘erster Assistent der Klinik’. ‘father of dietetics’ (L34, p. 258). Ludwig Snell (1817–1892), a psychiatrist and James Ward (1843–1925), a British philoso- asylum director, who refuted the concept of ‘uni- pher and psychologist. From Kingston upon Hull, tary psychosis’, and is cited in Grundriss for the he originally trained as a congregational minister, concept of monomania (L17, pp. 105, 106), and but won a scholarship to Germany, where he (L17, note), for the view that grandiosity is not a worked under Hermann Lotze (section primary symptom. ‘Wernicke’s Underlying Philosophical Views’, Herbert Spencer (1820–1903), a wide-ranging Wernicke’s Adoption of the European Style of philosopher, and a social commentator, who was Natural Philosophy.) On return to Britain he writing about social evolution some years before entered Cambridge University, with a scholar- the publication of Darwin’s Origin of Species, ship to Trinity College, and published a paper and it was he, not Darwin, who coined the phrase entitled ‘An interpretation of Fechner’s Law’. ‘survival of the fi ttest’. His work ‘Principles of His two papers on physiology in 1879 and 1880 Psychology’ was published in 1855 (L7, p. 39). were in German language journals, and one is Editorial Commentary 437 cited in Grundriss (L3, p. 16). It is the only work L27 (p. 181): Blood haemoglobin measurement by a British scientist he cites. is mentioned ‘… haemoglobin content (Gowers) of Karl Weigert (1845–1904), a pathologist and only 55 %’. The crystalline form of the red pigment neurohistologist, who developed important meth- in erythrocytes had been seen as early as 1848, and ods for selective staining for myelin, and for glial Hoppe-Seyler identifi ed the constituent, now called cells. He had worked at Breslau, and held a chair haemoglobin in 1868. He devised a method of in pathological anatomy at Frankfurt am Main at measuring haemoglobin content, subsequently the time of the fi rst edition of Grundriss ) (L16, improved in various ways. The method of L41, etc.) (L37, p. 289; L41, p. 328). W.R. Gowers (1845–1915), who was primarily a Carl Friedrich Otto Westphal (1833–1890), a neurologist, is referred to by Wernicke [192 ]. neurologist and psychiatrist from Berlin, under L28 (p. 186): The description of railway jour- whom Wernicke worked in the late 1870s. He neys of the time (‘… the journey home in a rail- coined the term ‘agoraphobia’, and also showed way compartment was particularly terrible; she the relationship between Tabes dorsalis, and felt that she had to leap out of the compartment’) Progressive paralysis. In L37 (p. 283) he is cited seems to be a case of what had recently been as supporting Wernicke’s view—that paralysis called ‘claustrophobia’, fi rst documented in the almost always allows one to detect early signs of 1870s in France, when dense urban dwelling was dementia (L29, p. 200; L36, p. 283). common. H. Zacher. Few details could be found about L35 (p. 267): We read of ‘… “reactive mut- this pathologist, cited in L37 (pp. 291, 292). ism”; and the fact that it emerges when confront- Clearly he studied neuropathology of progres- ing a physician, is immediately understood, if I sive paralysis and also published on syringomy- remind you of the distinction favoured by a tem- elia (Fuestner and Zacher, 1883. Arch f peramental colleague, between a “super-” and a Psychiatrie band. XIV). “sub-consciousness”’: This is unlikely to have Theodor Ziehen (1862–1950), studied medi- been Sigmund Freud, but may have been Albert cine at Würzburg and Berlin, after which he Schäffl e, a Schwäbian sociologist, political theo- worked under Kahlbaum at Görlitz, and then as rist and journalist with roots in German idealist assistant to Binswanger at Jena (where one of his thought. His four-volume work Bau und Leben patients was Friedrich Nietzsche). After a brief des sozialen Körpers, appeared in its second edi- period at Halle he became an expert on mental tion in 1896 [193 ]. disorders of childhood, and from 1917 was a pro- L36 (p. 277): The idea that sexual abstinence fessor of philosophy, again at Halle. He retired in was a cause of psychopathology was made popu- 1930 (L3, p. 18; L4, p. 23; L33, p. 236; L36, lar by Freud, but had older roots. Freud for p. 276). instance cited Schoppenhauer in this context, and the idea can even be traced back to Galen, who had suggested that hysteria in women was the XIV,(b). Other Medical or Scientifi c result of sexual abstinence. Topics

L27 (p. 182): ‘Gastroenterostomosis’: This oper- XV. Allusions Requiring Clarifi cation ation for cancer in the lower part of the stomach, or pylorus, was very advanced for its day, and These allusions are usually made by Wernicke’s involved reconnecting the rest of the stomach to patients, but are occasionally ones by Wernicke the jejunum. It was fi rst accomplished by Theodor himself: Bilroth (1829–1894) in 1881, at which time he held a professorship in Vienna. Bilroth was a pio- L9 (p. 57): ‘Gottfried von Bouillon’: A medieval neer of surgery and a gifted amateur musician Frankish knight, leader of the fi rst crusade and friend of Johannes Brahms. from the year 1096, and in the successful siege 438 Editorial Commentary

of Jerusalem in 1099. By the nineteenth cen- represents no more than an aetiological reca- tury, he was a somewhat mythical fi gure, but pitulation of psychoses, which otherwise dif- several accounts of the crusades in the second fer widely from each other’: The phraseology half of that century would have made him a here again hints at Haeckel’s maxim. plausible theme for delusions. L10 (p. 61) ‘Since that time she had doubled L10 (p. 59) ‘Dalldorf’: presumably refers to one everything—double nerves, double heart beat, of the asylums in Berlin. even a double brain.’: Concepts of a ‘double L10 (p. 60) ‘Duchess of Arco’: probably refers to brain’ circulated widely in popular versions of ‘Duchess of Arcos, member of a long- neuroscience in the late nineteenth century established line in the Spanish nobility. [194 ], and in this case may have drawn on ‘Kaiser Friedrich’: who, in 1888, succeeded recent fi ndings—including Wernicke’s own— Kaiser William (King of Prussia, and German about cerebral asymmetry and language. Emperor), but who died from throat cancer L10 (p. 61) ‘According to her, a person has 27 after only 99 days. senses’: The reference is curious. The phrase L10 (p. 60) ‘… the patient, having now survived ‘27 senses’ is associated, especially in Norway, the examination period, to play the role of a with the name Kurt Schwitters, a German art- priest or prophetess’: The imagery is reminis- ist, one of the Dadaist movement, and refugee cent of the plot in Mozart’s Zauberfl öte. during WWII. Born in 1887, he can hardly L10 (p. 61) ‘… at the time that she felt that a pre- have been the inspiration for this patient’s historic man, or a bloodthirsty man, or a lance- imagery, but there may have been an earlier let … had entered her body’: This and the source for their use of the phrase. following description draws heavily on writ- L11 (p. 68) ‘Duke of Sagan’: Old title, in French ings of Ernst Haeckel (1834–1919) a biologist aristocracy, linked to the name Talleyrand, and popular science writer, who introduced a French diplomat from the Napoleonic area. version of Darwinism to German readers. L11 (p. 70) Patients’ explanation of auditory hal- ‘Primitive man’ (Urmensch ) and lancelet (a lucinations in terms of telephone transmis- species important in early arguments about sion: The telephone, and (just as important) evolution, also called amphioxus ), fi gured the telephone exchange, predated Wernicke’s prominently in his writings. From the late 1894 edition of Grundriss by 15–20 years. 1860s Haekel promoted the idea that ‘ontog- ‘Telephone’ also referred to in L25 (p. 166). eny recapitulates phylogeny’, illustrated with L12 (p. 74): ‘… movement makes an increasing drawings of dubious scientifi c authenticity. By contribution to the entire personality, as levels the time of Wernicke’s Grundriss these ideas of schooling increase’: This comment may were well-enough known to be distorted in refl ect the special emphasis in German schools imagery in psychotic illness, and here, appear on physical education, strongly present in to make use of the illustrations in Haeckel’s most of the nineteenth century. Increased books. Later: ‘She mentions the book Häckel bodily awareness to which it led may have Urmensch oder Lanzettfi sch, but believes that been one of the infl uences which led fi rst Häckel means something like binding, or Meynert, and then Wernicke to emphasize belonging together’ (derivation obscure). continuity of body awareness as the fi rst Sometimes Wernicke himself hints at source of personhood (the ‘Ego’). Haeckel’s concepts, but it is unclear whether L13 (p. 82) Raskolnikov: Principle character in he refers to phylogeny or ontogeny, as in L8 Fyodor Dostoievsky’s ‘Crime and (p. 49), where he writes: ‘we see a protective Punishment’, fi rst published in 1866 (also or defensive device that the brain may have p. 193). acquired during its development’. In L37 L14 (p. 87) ‘… their perceptions show every (p. 280) he writes ‘… we again need to hold nuance of referential delusions, which an out- onto our view that the progressive paralysis standing psychiatrist has described succinctly Editorial Commentary 439

with the words “tua res agitur”’: ‘It is a matter eastern religions. Wagner’s operas, not least that concerns you’, a quotation deriving from his Ring cycle make continual reference to this Horace Book I, epistle 18, line 84: ‘… you too belief [195 ]. are in danger when you neighbour’s house is L18 (p. 114) ‘Head warder’: Presumably this was on fi re’. a warder at the hospital, not a character from L14 (p. 88) ‘Götz’: A contraction of ‘Gottfried’. post-revolutionary France. The person referred to (Götz von Berlichingen, L18 (p. 114) Reference to a ‘wishing table’: This ‘of the Iron Hand’) was a stormy nobleman is based on a fairy tale of Brothers Grimm: from what is now southern Germany, involved ‘The Wishing-Table, the Gold-Ass, and the in many battles and feuds in the sixteenth cen- Cudgel in the Sack’. For English text see tury. This left him with an iron prosthesis, Taylor [196 ]. The key section reads—‘… a after losing an arm. A play based on his life little table … made of common wood … had by Goethe had appeared in 1799. The offend- one good property; if anyone set it out, and ing defi ant phrase and gesture, which said, “Little table, spread thyself,” the good Wernicke is too polite to specify, is found in little table was at once covered with a clean Wikipedia: ‘He can lick my arse’, with the little cloth, and a plate was there, and a knife universal accompanying gesture of a bared and fork beside it, and dishes with boiled backside. meats and roasted meats, as many as there was L15 (pp. note) Animosity between Wernicke and room for, and a great glass of red wine shone Hitzig: ‘These prejudices are related to what I so that it made the heart glad. The young jour- claim to be the often misunderstood partiality neyman thought, “With this thou hast enough of the disease in such cases. In what sense I for thy whole life:”’. conceive this partiality will become more L18 (p. 115) ‘He was both a Christian and a Jew, readily apparent from the presentation given and had a previous existence; and he refuted here, so that I shall probably refrain from a my doubt by pointing to the third article of detailed refutation of the attack directed Faith, that relates to the resurrection from the against me by Hitzig (1895)’. dead’: This statement presumably relates to L17 (p. 106) ‘animal delirium’: a literal transla- one of the Christian creeds, used in church tion, ‘delirium of being an animal’ (a.k.a. services, and often written as three para- lycanthropy). graphs, in the third of which comes the state- L18 (p. 113) ‘Wotan’, ‘Ahlbrecht the Bear’: ment about resurrection from the dead. There is a mixture of images here. ‘Wotan’ is L19 (p. 121) ‘… the spirits which he also heard from ancient Norse/Germanic mythology, wanted to conduct various procedures on him incorporated by Richard Wagner into Die on purpose, for the spectators, even the dream Walküre , the second part of his four-part cycle images that he described’: The patient’s imag- Der Ring des Nibelung, fi rst performed in ery is reminiscent of a clinical demonstration. 1870. ‘Ahlbrecht the Bear’, otherwise known L19 (p. 124) ‘… the vestiges of aural mobility, as Albert I (c 1100–1170) was the fi rst which humans still possess’: Vestigial Margrave of Brandenburg, from which ‘The organs—those similar to functioning organs in Bear’ became a symbol for the city of Berlin. other species, but themselves lacking any However, the allusion here may again be to obvious function—have been recognized Wagner’s Ring cycle , since the fi rst part of the since antiquity. They became objects of scien- cycle (Das Rheingold) includes a character tifi c study in the later part of the eighteenth with the name Alberich. As Wernicke notes, century, and after Darwin’s Origin of Species the patient appeared to believe in ‘transmigra- were widely seen to indicate a species’ ances- tion of souls’, a common belief in the try. Wernicke is well aware of this, an idea Germanic world in the nineteenth century, which was also prominent in writings of Ernst partly resulting from recent scholarship on Haeckel. 440 Editorial Commentary

L21 (p. 135) ‘Diaconate institution’: An institu- L25 (p. 169) ‘Sewn into a cow-hide’: Two tion for training deacons, a position in possible interpretations are offered Rudolph Christian churches which can be traced back IV, a Hapsburg ruler died in Milan in 1365; his to the Gospels, whose role is care of and min- body was carried back to Vienna, sewn into a istry to the poor. cowhide, to preserve the body. ‘According to L22 (p. 140) ‘Pleasure garden’: A concept going the directions of the medieval Passion plays back to antiquity, but which fl ourished in most from Donaueschingen and Freiburg, the young European cities from the eighteenth century. priest who played the role of Judas fi rst had to Pleasures gardens (or their modern equivalent, be sewn into a cowhide. Underneath, onto his ‘Theme parks’ or ‘Entertainment parks’) chest, were to be placed the intestines of a could provide various forms of entertainment, sheep together with a live blackbird, or even a but, in cities with overcrowded homes, were live black squirrel, symbolizing the damned also always places for romantic encounters. (i.e. black) soul. During the act of hanging, L22 (p. 146): ‘He would receive 50 lashes, which was performed rather realistically, the counted-out ’. We have interpolated the word cowhide had to burst from the priest’s chest ‘lashes’ as we understand his context. downwards in order to let out the blackbird or L25 (p. 166) ‘Several times the criminal bell had squirrel and to show the intestines’ [197 ]. rung, as if he were now going to his death’: In L25 (p. 169) ‘Wenceslas is coming’: King some jurisdictions in Europe, in the not too- Wenceslas, a Bohemian monarch, who died in distant past, bells were rung at the time of an the tenth century (but who is remembered in a execution. popular English Christmas Carol), was a L25 (p. 167) ‘Last prayer’: Presumably refers to potent symbolic fi gure in central Europe, Catholic ritual, this being (present-day) commemorated in Wenceslas Square, in cen- Poland, now a Catholic country. In Wernicke’s tral Prague. day Catholic faith, while not adhered to by the L26 (p. 172): ‘… He knows the key dates of the majority, was adhered to by a large minority last war; knows about Bismarck, Moltke, and (~35 % of the populace). the three Kaisers, his participation in the L25 (p. 169) ‘Lawyer of the right, lawyer of the election’: The German empire had full adult left’ (Rechtsanwalt, Linksanwalt , etc.): This male suffrage since the election in 1871. The satirical song is based around word-play, and reference here is probably to the election in double meanings, in German, as in English of 1887. the words ‘Rechts’ and ‘Links’ (‘right’ and L26 (p. 172): ‘Krupp’s cannon’: The Krupp fam- ‘left’). Rechtsanwalt means an attorney, whose ily, long-established as industrialists in the concerns is with legal rights; Linksanwalt, is a Ruhr district of Germany, started manufactur- term used in jest, a deceiver, a shyster, one ing cannons from 1840, under Alfred Krupp. who twists the law. By the late 1880s this amounted to about 50 % L25 (p. 169) ‘Into the well, and under the water of Krupp’s total output. with him; he should be pumped full and cut L26 (p. 173) ‘… the walls closing together or open; then into the puddle with him; put him to threatening to collapse’: Does this image refer death’: In medieval Europe, as in Scotland, to events in Edgar Allen Poe’s story, ‘The Pit drowning was a more common means of capital and the Pendulum’, published in 1843, based punishment than hanging, surviving there until loosely on torture during the Spanish the seventeenth, even the eighteenth century. Inquisition? (Poe himself had a lurid life-style, Dismemberment after execution (including dis- in which personal experience of Delirium tre- section in an anatomy school), was also possible mens may have inspired some of his writing). as an extreme measure, for instance in cases of L26 (p. 173) ‘When alcohol abuse deserves to be attempted regicide in eighteenth century France, punished, it is bestowed in abundance, which supposedly to prevent ‘resurrection of the body.’ leads to delirium’: Does this refer to the mari- Editorial Commentary 441

time legend (echoes of which are found in RL L29 (p. 196) ‘30,000 Marks’: A huge sum of Stevenson’s Treasure Island ), of Blackbeard, money. With Germany since 1876 using the a notorious English pirate, who abandoned 15 Gold standard, 1 kg pure gold exchanged for, crew members on Dead Chest Island for a at most, a few thousand Marks. month, leaving each with no more than a bot- L29 (p. 196): ‘Niederwald monument’: Located tle of rum, and a sword? at Rüdesheim, in the Rhine Gorge, commemo- L27 (p. 183): ‘Choleric’, indicating a fi ery tem- rated the founding of the German Empire, perament, excitable, extrovert, and egocentric after the Franco-Prussian war, in September (or, in terms of body fl uid, infl uenced by ‘yel- 1871. low bile’). It is interesting to see a term derived L29 (p. 196): ‘Julian tower’: Probably referring from the doctrine of the four humours appear- to a Romanesque church tower, of ancient ori- ing in Grundriss. gin, at Sankt Julian, not far south of L28 (p. 189): ‘… delusion of being President of Rüdesheim. France and of his being appointed to Warsaw L29 (p. 197): ‘… go into the Oder’: Colloquial by the Tsar fi rst’: Warsaw at this time was term for a suicide attempt by drowning, prob- under Russian suzerainty. ably a common method in northern Europe at L28 (p. 191): ‘if you want to validate the popular the time. Peter Tchaikovsky made such an expression ‘drunkard’, note simply that, attempt in 1877 in St. Petersburg. through external circumstances, the opportu- L29 (p. 198): ‘two witnesses’: Mentioned in nity to drink alcohol and seek out like-minded the New Testament Book of Revelation company, is repeated each quarter year for [Chapter 11 ]. The role of the two witnesses is certain social classes’: This may refer to the to decry the reign of the Antichrist-Beast. fact that, following a decree in July 1888, L29 (p. 198) ‘… handed over to anatomy’: In Kaiser Wilhelm had decreed a succession of many medical schools of the time, bodies for public holidays throughout the year across the dissection were those remaining unclaimed, German empire [198 ]. who died in asylums. L29 (p. 195): Staatsexamen : A university qualifi - L29 (p. 200): ‘Panel doctor’: Presumably a phy- cation, required for teaching. At this time, the sician charged with offi cial duties authorized bias in this state examination favoured the by government. nobility, but varied between länder and L29 (p. 201): ‘Journeyman’: Tradesman’s quali- according to the year; and, until some years fi cation from an apprenticeship, not yet quali- later, it excluded females. fi ed as a ‘master’ able to employ others. L29 (p. 196): ‘special providence’: Shakespeare Journeymen were often travelling tradesmen. uses the phrase (‘there is special providence in This system of qualifi cations still exists in the fall of a sparrow’; Hamlet, Act V, scene 2). parts of Europe. It refl ects Protestant rather than Catholic the- L30 (p. 204): ‘How did you fi nd me , Professor?’ ology, in that divine intervention was achieved We felt this lady may have been a bit seduc- not so much by dramatic miracles as objective tive, hence our added intalicization of ‘me’. public events, but by subtle workings of natu- L30 (p. 203): ‘even were war to be declared’. ral laws. In any case, this reference refl ects This lecture was presumably prepared in the very well the details of Wernicke’s approach late 1890s, at which time across Europe there as a clinician, exploring details of this patient’s were already forebodings of a major war to delusions, and how well he was attuned to the come. culture and popular imagery of his times. L32 (p. 225): ‘enforced exaggeration in the L29 (p. 196): ‘He could only regard his time here expressive movements of a minuet’: The min- as probation imposed upon him’: The imagery uet was really a dance (or rather an important is perhaps of purgatory, although this concept social occasion) of the seventeenth and eigh- is rejected in most Protestant traditions. teenth century, which was transformed into 442 Editorial Commentary

the Waltz by the nineteenth century. However, ‘a year and a day’. On the continent of Europe, the title ‘Waltz-minuet’ was well known in laws codifi ed as legal statutes had greater sig- central Europe in the nineteenth century. nifi cance than precedents in the English com- L32 (p. 226): ‘Occupational deliria’: Elaborate mon law tradition, especially after the French pantomimes, as if continuing a usual occupa- revolution. Nonetheless, in Europe, legal stat- tion in the hospital bed, possibly depicted as a utes were infl uenced by customary law, and caricature in Charlie Chaplin’s portrayal of the use of this phrase by Wernicke derives assembly line employment in his ‘ Modern from this fact. This is why his use of this Times ’ . phrase is interesting. Today, in English as in L32 (p. 232): ‘Dr. Sch’: This refers to ‘the patient’ German—it means ‘for an indefi nite period with a PhD, not a medical doctor. In any case into the future’. this patient seems to attribute his disruptive L37 (p. 288): ‘medullary strips of the gyri and the motor symptoms easily to divine common underlying white matter’ Die intervention. Markleisten der Windungen und das gemein- L32 (p. 233): ‘sight of … a slate … brings schaftliche Marklager zeigen sich ebenfalls patients … to write on the slate.’ presumably beträchtlich verschmärlert. We infer that this the ‘slate’ used in schools, in preference to refers to white matter between the walls of a paper, for handwriting. gyrus, and that lying deep to the gyrus. L33 (p. 240): ‘Chansonette’: Roughly a ‘cabaret L38 (p. 294): ‘The acquired predisposition to singer’. ‘Cabaret’ emerged in France from mental illness is based usually on adverse around 1881, and did not appear in Germany infl uences that are also expressed as organic until the turn of the century, to reach its defi ni- changes in the brain. These include tive German form during the years of the Hydrocephalus internus [W], even if this has Weimar republic. reached the stage of recovery, as we often see; L34 (p. 244) ‘… she crosses her legs in a totally but we also see it even where no conspicuous inappropriate manner’: Presumably a breach alteration of the head has been left behind’: of lady-like etiquette. Head- shape is referred to here: A bulbous L34 (p. 247): ‘Prince Bismarck came and gave skull, then being seen as a consequence of him a malicious look’: This patient, encoun- Hydrocephalus, presumably the only way this tered during Wernicke’s Berlin period, was condition might be identifi ed in vivo at the seen at a time when Bismarck was politically time. powerful. (He was removed from power in L40 (p. 314): ‘… if you challenge an elderly phy- 1890 by Kaiser Wilhelm I). sician, lawyer, or mathematician with a test of L34 (p. 249): ‘Sleeping uhlan’: A military meta- word form in ancient Greek’: This presumably phor. The Polish word ‘Uhlan’ (‘Ulan’ in refers to the classical education in ancient German) refers to Polish light cavalry, armed Greek, which educated people are likely to with lances. The metaphor is thus similar to have received at an early age in Wernicke’s that of a fi erce animal ‘lying doggo’. time. L37 (p. 284): ‘For a year and a day’: This curious L40 (p. 316): ‘Karlchen Mießnick’: Pseudonym phrase (über Jahr und Tag ), has its origin in for Friedrich Wilhelm Ernst Dohm (born, customary legal settings, both in England and Breslau, 1819; died Berlin, 1883), a translator, in Europe, for instance wherein a person who actor and editor (of, inter alia , a satirical mag- dies more than ‘a year and a day’ after some azine Kladderadatsch ). assault, can no longer be deemed to be a mur- L40 (p. 316) ‘Berliner Wespen’: ‘Berlin Wasps’, a der victim; or where a couple must be married satirical magazine, founded in 1868 by Julius ‘for a year and a day’ before a spouse can Stettenheim (of Hamburg) known as claim a share of inheritable property. In medi- ‘Wippchen’, which, amongst other campaigns, eval Europe, a runaway serf became free after fought against growing anti-Semitism. Editorial Commentary 443

XVI. Terminology sory perception, while here, a higher-level pro- cess is meant. When used in this sense, the ‘Abusus spirituosorum ’ (L25, p. 168): Alcohol English word ‘apperception’ will be used, whose abuse went under a variety of names, such as defi nitions (OED) is: ‘perception with recogni- Marcel’s Folie des ivrognes ; Kraepelin’s akuter tion or identifi cation by association with previous halluzinatorischer Alkoholwahnsinn, etc. ideas’. ‘Abulia’ (L35, p. 267): The 1906 German ‘Apoplexy’: ‘Stroke’ is the common English medical dictionary defi nes ‘Abulie’ as ‘want of term, Up to the end of the nineteenth century, will-power’. ‘apoplexy’ referred to any sudden death with sud- ‘Acousma’: This term, used in L19 (p. 207), is den loss of consciousness, today given the term scarcely known today, referring to simple acous- ‘stroke’. Literally it refers to bleeding of internal tic experiences, illusory non-verbal auditory organs. ‘Apoplectiform ’ implies as if leading to sensations. sudden death, usually describing what is now ‘Activation’ (e.g. ‘Nervous activation of mus- called ‘stroke’. (See also L28, p. 186; L37, cle’ [L6, p. 32]): Muskelinnervation). We do not p. 284). translate ‘innervation’ directly because, in ‘Arsenic green’ (L38, p. 296): This is proba- English, it refers to structure not function. bly the same as ‘Paris green’, a highly toxic com- ‘Aegophony’ (egophony) (L37, p. 280): pound of arsenic (copper acetate triarsenite), Changed vocal quality, with lower frequencies used in Paris as a rat poison (in sewers). From fi ltered out, resulting in high-pitched bleating or about 1900 it was used in America and elsewhere nasal timbre. in agriculture, as an insecticide. ‘Affect’: see section VIII,(h). ‘Wernicke’s ‘Ascending’ (aszendierend ’): Although Distinctive Clinical Concepts in Psychiatry’ Wernicke frequently uses the metaphorical (Affective impact of mental illness ). German word, we replace it by ‘worsening’, ‘Alcoholic psychosis’: ‘most acute form of except when the German word is used in another alcoholic psychosis’ (L26, p. 174) a.k.a: sense. ‘drunkenness’. ‘Asymbolia’ (Asymbolie ; also to be translated ‘Amentia’ (L33, p. 235), a term originally as asemia or asemasia) (L27, p. 183), a severe used by William Cullen (1777) to mean ‘mental form of aphasia, in which there is inability to retardation’. For Meynert in his 1890 clinical lec- understand (and for the latter terms, perhaps also tures, the meaning had shifted—a sudden-onset to use) symbols in communication. (See also state of confusion, as a disorder of thinking— L20, p. 128; L38, p. 295). contrasted with ‘dementia’, which for him was ‘Atonicity’ (L34, p. 253): Pathological lack of ‘deterioration of personality’ [199 ]. Symptoms muscle tone. of Meynert’s (p. 240) ‘amentia’ ranged from ‘Atrophy’ (Atrophie ) First appears on L38, excitement to stupor, occasionally ending in p. 295 Atrophie der Optici; then L38, p. 288 deterioration. Atrophie des Großhirnmantels; pp. 288, 289; ‘Anxiety’ ( Angst) (L23, p. 145): We almost L40, p. 317 Optikusatrophie. It invariably refers always render the German word as ‘anxiety’, to biological change. only occasionally as ‘fear’, since ‘anxiety’ is ‘Autochthonous’: We usually retain more familiar in psychiatry, and fear implies Wernicke’s word, although ‘self-generated’ may ‘fear of something’, which is often not the case be less ambiguous. (Section VIII,(i). ‘Wernicke’s for anxiety states. Distinctive Clinical Concepts in Psychiatry’, ‘Apperception’ (fi rst used in L2, p. 9: Delusions and Related Phenomena for Wernicke ). Vorstellung ). The German word has many shades ‘Brain-softening’ (Encephalomalacia ) (L11, of meaning. ‘Perception’ is one rendition in p. 67) was an accepted medical term in the late English, but, as becomes clear by L8 (p. 43), the nineteenth century, deriving from autopsy exami- English word ‘perception’ usually refers to sen- nations of the brain, and later entered popular 444 Editorial Commentary vocabulary. It referred to localized change in the that it captured a widely recognized concept for brain, due to haemorrhage or infl ammation. German-speakers [204 ]. Three varieties, distinguished by colour, repre- ‘Blasé’ (Blasiertheit ) (L30, p. 207): This does sented different stages of morbid processes, not have quite the meaning of the French ‘blasé’ known respectively as red, yellow, and white (‘indifferent to normal sources of interest because softening. In Wernicke’s day such changes were they are familiar’; or ‘indifferent as a result of commonly seen post-mortem in aged people and excessive earlier indulgence’). Wernicke implies in those dying from syphilis, as well as in cases ‘indifferent due to repeated failure to fi nd enjoy- of stroke. ment in usual source of interest.’ ‘Cause’: We take this to be a debated concept, ‘Catalepsy’, ‘cataleptic attack’ (L28, p. 191): and avoid using it except in special circum- This is the fi rst mention of the term ‘cataleptic’ stances. It meaning is different from ‘aetiology’ or ‘catalepsy’ . It is an old term, whose meaning which we translate directly from the German. has varied, and has included a variety of differ- ‘Channeling’ (Bahnung ), fi rst used in L22 ent conditions or states. According to Berrios (p. 139). The root word (Bahn ) is common [ 190 ], in its complete form, it is a state of overall (Bahnhof, Eisenbahn, etc.). Dictionary transla- motor paralysis, sometimes with normal muscle tion of Bahnung includes ‘canalization’ or ‘chan- tone, or increased tone, sensory disconnection neling’, terms originating in engineering at a time without anaesthesia or analgesia, passive postur- when major rivers in Europe were being made ing, and total amnesia for the period of its pres- navigable. We use ‘channeling’ as a more famil- ence. In early nineteenth century it was classed iar word than ‘canalization’. The meaning of amongst the ‘neuroses’ in the original sense of Bahnung is captured in Wernicke’s phrases such William Cullen (along with paralysis, tetanus, as ‘frequent repetition’ and ‘deliberate practice’, and epilepsy). It was important to Kahlbaum, is suggesting ‘a pathway created by frequent use’, referred to by Wernicke in L34 (p. 253), and is ‘stamping in’ or ‘blazing’ of a trail. In psychol- mentioned by Ernst Kretschmer [ 61 ], for whom ogy it means an ever-narrowing focus of attention it was very similar to the instinctive ‘death feint’ and of motives for behaviour—as a result of men- known in most mammalian species. Curiously it tal disturbance, education, or other life events. is not reported today in humans, although it is a This term ‘canalization’ appears to have origi- term widely used in animal studies of psycho- nated with Pierre Janet as early as 1889. It is pharmacology (e.g. ‘neuroleptic-induced cata- unlikely that it originated with Wernicke, to be lepsy’ in laboratory animals), which is probably adopted later by Janet, because Janet had little different from the condition described by ability to read German [200 ]. The term Bahnung Wernicke, even when one restricts the compari- was also known in France and translated as fray- son to motor signs. age , (‘facilitation associative par répétition’). ‘Chorea minor’ (L32, p. 231): Sydenham’s Freud used it in Entwurf einer Psychologie [ 201 ], chorea, occurring after streptococcal injection also named Erinnerungsspur (‘memory trace’). affecting the brain. ‘Canalization’ was used later by Gardner Murphy ‘Column disease’ (‘L37 (p. 274): [ 202], acknowledging Janet as the source. Its use Strangerkrankung. Strang is a somewhat out- in psychology has diversifi ed since Murphy’s dated German word for (spinal) column; monograph. Bahnung has been used metaphori- Erkrankung is a more general, less specifi c word cally in science in various other contexts, includ- than Krankheit, referring to the start of a disease ing genetics (after Waddington). In physiology it process. was fi rst used by Sigismund Exner [203 ] and was ‘Complex’: see section VIII,(s). ‘Wernicke’s explained through an electrotechnical analogy. Distinctive Clinical Concepts in Psychiatry’ The coincidence of dates of Exner’s Wernicke’s (Wernicke’s Links to the Emerging Dynamic and Freud’s publications using the term suggests Tradition in Psychiatry. ) Editorial Commentary 445

‘Conform’ ‘The requirement for intellectual German text often uses deliriant, but we avoid material to “conform”’ (L40, p. 313): The sense this term in our translation. here is of discourse to ‘conform’ to what is ‘Delusion’ ( Wahn ): The German word can accepted (for instance to church doctrine). refer either to a delusion or to a state where delu- ‘Confusion’ ( Verwirrtheit): We take this to sions can occur. We have attempted to indicate indicate a state when confl ict between mental which meaning is intended. contents becomes overwhelming. Likewise ‘Delusion of belittlement’ (Kleinheitswahn ) ‘bewilderment’. (L29, p. 200), a term with a slightly different ‘Consolidating’: ‘um so fester ’ (L4, p. 22). sense from ‘micromania’ (see below). ‘Consolidation’—of memory—is accepted ter- ‘Delusion of persecution’: Verfolgungswahn. minology for memory researchers today, intro- ‘Delusion of relatedness’, ‘delusion of refer- duced by Muller and Pilzecker [205 ] but ence’ see section VIII,(l). ‘Wernicke’s Distinctive Wernicke does not use Konsolidierung. Clinical Concepts in Psychiatry’ (Delusions and ‘Crests of the gyri’ (L37, p. 288): Related Phenomena for Wernicke ). Windungskuppen site where localized pathology ‘Depression’/‘Depressed’: see ‘Melancholia’. develops after brain injury. ‘Descending’ (Descendierend ). See above ‘Crime against morality’ (L25, p. 168): under ‘Ascending’. Presumably a sexual crime. ‘Disarray’: see section VIII,(h). ‘Wernicke’s ‘Cure’ see section III. ‘The Medical Scene at Distinctive Clinical Concepts in Psychiatry’ Breslau in Wernicke’s Day; Typical Psychiatric (Affective impact of mental illnesses ). Practice’, on criteria for discharge; and section ‘Disorientation’: see section VIII,(h). VIII,(q). ‘Wernicke’s Distinctive Clinical ‘Wernicke’s Distinctive Clinical Concepts in Concepts in Psychiatry’ (Prognostic Indicators; Psychiatry’ (Affective impact of mental illnesses). Concepts of ‘Cure’, or ‘Return to Health’ ). ‘Drive’: Wernicke’s usual word is Antrieb , ‘Curve’: This idea is used to characterize the usually implying a degree of voluntariness, but plot of illness extent or intensity over time. This sometimes, a response driven by a sensory stimu- word captures Wernicke’s meaning more exactly lus, sometimes a behavioural urge, occasionally than ‘plot’ or ‘graph’. ‘voluntary effort’. The word Zwang is used only ‘Daimonion’ (L29, p. 196): Roughly ‘a dae- once mon’; and, according to Merriam-Webster dic- ‘Dyspneic’ (L39, p. 307): Short of breath. tionary: ‘an inward mentor conceived as ‘Eburnisation’ (L37, p. 289): Degenerative partaking of the nature of a demon or inspired by process of bone occurring at sites of articular car- one’. The legendary Socrates also experienced an tilage erosion commonly found in patients with inner voice giving advice (now perhaps called osteoarthritis. ‘command hallucinations’). ‘Elementary symptom’: see section VIII, (g). ‘Deduce’ (Abzug ): Used only once in ‘Wernicke’s Distinctive Clinical Concepts in Grundriss (L1, p. 4). Psychiatry’ (Wernicke’s Concept of ‘Elementary’ ‘Defi cit’: We prefer this to ‘Defect’ to render symptoms ) the German Defekt. ‘Emotions’ (L8, p. 48): see section VIII,(h). ‘Degeneration’ (Entartete, or Degeneration ). ‘Wernicke’s Distinctive Clinical Concepts in See section V. ‘Contemporary Knowledge in Psychiatry’ (Affective Impact of Mental Illness ). Neuroscience; Contemporary Practice in General ‘Emotional incontinence’ (L40, p. 320): It is Medicine and Psychiatry in Wernicke’s Day’, not clear where this term originated in the paragraph on ‘degeneration’. English-speaking world. For many years it ‘Delirium’ (Delirien ) is almost always sepa- appears to have been little used, but recently, a rate from ‘Delusion’ ( Wahn ), but p. 211, where number of papers on stroke patients in East Asia Wernicke cites Meynert is an exception. The have used the term. 446 Editorial Commentary

‘Endowment’: Besitzstand. ‘Fear’: see ‘Anxiety’ above. ‘Energy’: Usually Wernicke’s word is Kraft, ‘Feeling tone’: see ‘Organ sensation’. but the word Energie occurs sometimes, espe- ‘Feudal estate’ (L27, p. 180): The German cially when used for a specifi cally physical meta- word is Herrschaft, indicating the fi efdom of a phor (p. 43: pontentiellen Energien; p. 66: feudal lord of earlier days. specifi sche Energie ; p. 73: ‘drained away ,’ ‘bal- ‘Fibrae propriae ’ (Meynert) (L37, p. 290): ancing up’, ‘build up’: Energie strom; p. 80: The coherent band of white matter lying immedi- ‘damming up of nerve energy;’ p. 81: nerven ately deep to the cortical grey matter. Energie; p. 86: ‘perpetual motion’; p. 89: ‘energy ‘Fixed idea’(fi xen Ideen ) (L41, p. 329), obvi- accumulated etc’; p. 126: ‘specifi c energy’; BUT ously a direct translation from the French idée p. 183: ‘verbal utterance, and their energy ’ fi xe. (enkraften ). p. 218: ‘unrestrained energy’). (See ‘Flexibilitas cerea’ (L34, p. 250): This is a section XI,(b). ‘Wernicke’s Reasoning’, latinized version of the term ‘waxy fl exibility’ Reasoning by analogy ). which Wernicke also used; but he appears to use ‘Envenomation’ (L26, p. 176): This word the two terms as though they have slightly differ- implies some toxin of exogenous origin; but the ent meanings. exact meaning is unclear. ‘Forgery’: ‘Forgery of consciousness’ (L40, ‘Ependymitis granulosus’ (L37, p. 25): p. 313): Whereas ‘falsifi cation’ of contents of Infl ammation of the ventricular lining, with accu- consciousness’ (Fälschung des mulation of granular tissue. Bewußtseinsinhaltes ) need be no more than a ‘Epigenetic’: Use of this term (L20, p. 125) is one-off error, ‘forgery of consciousness’ confusing to a modern reader. Today the noun (Bewußtseinsfälschung ) is a more systematic, form ‘epigenetics’, introduced by Waddington in comprehensive and fi nalized version of such 1942, refers to the fact that the genome does not error. unfold in a manner determined solely by its own ‘f.S. artery’ (L11, p. 67): Presumably the nature, but is subject to numerous infl uences dur- artery supplying the superior longitudinal fascic- ing development, including, indirectly, ones from ulus (major hemispheric white matter tract). the outer environment [206 ]. However, in adjec- ‘Ganglion cell’ (Ganglienzellen ), fi rst used in tival form (‘epigenetic’), the term is much older, L3 (p. 16): This was Wernicke’s word for a cell rooted in a theory of ‘epigenesis’, that the germ is body, or perikaryon of a neurone, However, the brought into existence (by successive accretions), term is used in various ways, often in L3 refer- and not merely developed, in the process of ring to a specifi c neuronal type in the retina, and reproduction [207 ]. elsewhere just to indicate ‘a central neurone’. In ‘Experiment’: see section XI,(a). ‘Style of the latter context, he usually referred to long- Reasoning’. axon (projection) neurones, although Cajal had ‘Extent’: This word is used to characterize the already distinguished these from the ‘local circuit extent of an illness. We use this word, except neurones’ (in the cerebral cortex). when the German refers to a collection of specifi c ‘Gastric catarrh’ (L26, p. 173); now ‘Gastritis’. symptoms, when we use the word ‘range’. ‘Genetic confusion’ (L33, p. 236): see section ‘Faradisation’ ( Faradisation) (e.g. ‘Faradic VII,(b). ‘Wernicke’s Contribution to excitability of a nerve’, L3, p. 16): This was a com- Neuroscience, Psychology and Overall Medical mon term at the time, although ‘electricity’, ‘elec- Knowledge’ (Wernicke and ‘Associationism’ ). trisation’, were also in common use. The sense of ‘Globus pharynges’ (L22, p. 143): This term terms such as ‘electricity’ or ‘electric’ has shifted can be traced back to Hippocrates, and refers to over the centuries, and was not precise in persistent, but benign sensations originating in Wernicke’s day. Strictly, ‘faradisation’ meant the pharynx or larynx, otherwise known as ‘glo- ‘alternating current’, which, by Wernicke’s time, bus sensation’, just ‘globus’, or in older terminol- had superseded direct current in clinical situations. ogy ‘globus hystericus’—in common parlance ‘a Editorial Commentary 447 lump in one’s throat’. As with many psychoso- sifi cation and for classifi cation of diseases, matic disorders there has been debate about appears here to be used here to designate a per- whether it has a physical origin in the throat or sonality type, rather than a disorder. related structures, or a psychological one [ 208]. ‘Hydrops ventriculorum ’ (L38, p. 296): Here Wernicke appears to use the term to refer Literally, ventricular oedema. to normal anatomical structures from where ‘Hypermetamorphosis’ ‘(L20, p. 125): This such sensations sometimes arise, rather than to term originated with Heinrich Neumann, the symptoms themselves. (See also L30, Wernicke’s predecessor at Breslau [209 ], but also p. 208). has a meaning in entomology. Today the term is ‘Grandiosity’ ( Grössenwahn ), fi rst used in L8 not used, but perhaps should be reintroduced. It (p. 200). We avoid ‘megalomania’ (which has too has similarities to syndromes seen after defi nite many connotations in English vernacular), and cortical lesions [210 ], including instinctive ‘grasp ‘delusions of grandeur’ (which are described reactions’, tactile ‘avoidance reactions’ or later); and we wish to avoid confusion with true ‘instinctive visual fi xation’. The term was to be ‘mania’ for which Wernicke has a precise used later by Klüver and Bucy [211 ] in descrip- conceptualization. tions of a syndrome produced in macaque mon- ‘Granular cell’ (L41, p. 326): This is some- keys after bilateral temporal lobectomy. However, what dated terminology, referring to some layers their use referred to an ‘excessive tendency to of the cerebral cortex as ‘granule cell layers’ or take notice of and to attend and react to every ‘granular layers’. Their main neuronal type is not visual stimulus’. Wernicke gives no indication sharply different from those in other layers, being that the syndrome he describes in psychiatric pyramidal cells (Ganglienzellen in Wernicke’s patients is related to any cortical lesion, and terminology); but they are smaller and more excess of attentional fi xation can occur in any densely packed than in the layers (notably layer sensory modality, but differing from one patient V) containing larger pyramidal cells, hence the to another. It appears to correspond to various term ‘granular’. Lissauer defi ned cell loss in lam- perceptual sensitivities (such as sensitivity to inae II and III, which were referred to as ‘granu- noise, or to visual movement), and can be seen as lar layers’. It is not clear what ‘laborious’ method aspects of selective attention specifi c to one (or was used by Lissauer to trace the degenerating more) sensory modalities. connecting of these cells. The Marchi method is ‘Idiocy’ (L37, p. 292); Blödsinn. based on detection of degenerating myelin, and ‘ Impotentia coeundi’ (L24 (p. 160): erectile Lissauer may have used an earlier version of this dysfunction. method. ‘Inhibition’: see section VII,(a). ‘Wernicke’s ‘Hallucination’: The usual German word is Contribution to Neuroscience, Psychology and Halluzination. An alternative word is Overall Medical Knowledge’ (Basic neuroscience ). Sinnestäuschungen (sensory deception, some- ‘Insane’, ‘Insanity’: In current English usage times including delusions as well as hallucina- these are legal rather than medical terms, although tions). Visual hallucinations are referred to as the two were not separated in Wernicke’s day. We Halluzination , but tactile ones as therefore avoid them unless they were already Sinnestäuschungen . ‘“Hallucinations of common historic, were a patient’s own words, or were sensation”, which we will deal with in more referring to words of another clinician. detail later.’ (L19, p. 121) We are not sure of the ‘Insolation’ (L41, p. 328): Exposure to solar exact meaning of this phrase. radiation, equivalent to ‘sunstroke’, which may ‘Helplessness’: see ‘Disarray’. be relevant to the case of the fugitive from ‘ Homo tardus’ (L31, p. 216): This may have Australia to Switzerland (see also L28). been one of Wernicke’s own terms. It is of inter- ‘Jactation’ (L20, p. 131): As used medically, est, because the latinate binomial nomenclature, this term (also ‘jactitation’) indicates abnormal, devised by Carl Linnaeus for both botanical clas- restless tossing or throwing about of the body. 448 Editorial Commentary

‘Lateral column symptoms’ (L39, p. 301): problems he encountered in his patients as a form Presumably differential loss of pain and tempera- of illness, for which medical terms were appropri- ture sense, while discriminative sensation ate. ‘Geisteskrankheiten’ or ‘Geistesstoerungen’: remains intact. Usually the fi rst of these is used by Wernicke. ‘Lunatics’ (Irrenwesen— fi rst used in L1, p. 4; Cases where the second is used include the fol- likewise: ‘Mad-doctor’: Irrenärzte; ‘Lunatic asy- lowing (with our rendition)—p. 54: ‘mental dis- lum’: Irrenhaus, L32, p. 229, literally ‘mad- turbance’; p. 65 ‘all chronic mental disorders’; house’). These terms are the contemporary p. 66 ‘be advisable to reserve the term ‘chronic English equivalents, according to Lang [212 ]. The mental disorder’ just for residual cases’; p. 71: term ‘lunatic’ was removed from British law in ‘residual chronic mental disturbance’; p. 72 the 1930 Mental Treatment Act, but not from US ‘equally for chronic and acute mental disorders’; Federal law, until 6th December 2012. We often p. 101 ‘right to declare a person mentally ill’; use alienist interchangeably for Irrenärzte, p. 102 ‘paranoid states are mental disorders’, ‘all although Wernicke does not use the equivalent chronic mental disorders’ p. 105 ‘each newly German term. German words for madness do not emerging symptom of mental disorder’ (and yet, refer to the moon. The German word Laune, has a on the same page we have ‘most chronic mental lunar origin, but is more benign than ‘Lunatic’ illnesses’ [Geisteskrankheit ]; p. 158 ‘or senile (indicating ‘mood’, ‘whim’ or ‘caprice’). mental disorder’; p. 161 ‘accessible to the lay ‘Manic aphasia’ (L20, p. 127): A term coined man’; p. 162 ‘chronic mental disorder’; p. 180: earlier by Wernicke, from which he now appears ‘We obtained a report of the exact time of onset to be distancing himself. of her acute mental disorder which was very ‘Manifestation’: The word Ereignis consis- inaccurate’, (but on the same page, tently refers to ‘outward signs’ of mental disor- Geisteskrankheit is used, referring to onset of der, while Erscheinung, sometimes refers to inner menstrual bleeding ); p. 220 ‘circular mental dis- experience, and is better rendered as order’; p. 275 ‘either chronic mental disorder or ‘phenomenon’. dementia’; p. 309: ‘chronic mental disorder ‘Marasmus’ (L24, p. 159): Signs of severe remains’; p. 313 ‘residual mental disorder’. In malnutrition. summary, Geistesstoerungen is usually used ‘Megalomania’ (L14, p. 95), a term that origi- when referring to mental disorders generically, or nated as the French megalomanie , used by Hecker in a less specialized way. [213 ] including the phrase ‘exalted megalomanic ‘Maceration’ (L37, p. 288): strictly, ‘softening lying’, and fi rst appearing in English in 1890. by soaking’, but used in a variety of situations. In Wernicke used the term occasionally, but to refer pathology, refers to tissue degeneration after to other physicians’ usage, not his own. In death (for instance in a still-borne infant). German, it could be straight from French, or it ‘Medulla oblongata’: Oblongata. could become ‘der Grössenwahn ’. However, the ‘Medullary degeneration’: Markdegeneration. latter term refers to delusions of grandiosity, or to ‘Medullary pyramid’: Markkagel. a state where such delusions can occur. ‘Melancholia’/‘melancholy’: This is almost ‘ Menstruatio nimia ’ (L32, p. 225): excessive always the equivalent word in German. We use menstrual bleeding. (Also L38, p. 294). Wernicke’s ‘melancholia’ in most cases except ‘Mental illness’: Despite his assertion at the when it is in adjectival form, or when it refers to start of L1 (following Griesinger) that mental ill- the history of the concept, when we use ‘melan- nesses are brain diseases, Wernicke uses separate choly’. Only occasionally do we use depressed words, respectively Geisteskrankheiten versus (p. 219), when the German word is deprimiert . Gehirnkrankheiten , and, from time to time points ‘Meteorism’ (L34, p. 247): Gaseous disten- out differences between psychiatry and neurol- sion of stomach or intestines. ogy. His word for mental illness— Geistesk- ‘Metritis’ (L24, p. 157): otherwise known as rankheiten—clearly shows that he identifi ed the ‘Pelvic infl ammatory disease’, an infl ammation Editorial Commentary 449 on the uterine wall, as opposed to ‘endometritis’, as sometimes in psychology. This contrasts ‘low- an infl ammation of the functional lining of the level details’ of individual elements, and ‘high- uterus. level properties’ emerging collectively from ‘Micromania’ (L23, p. 147): A modern dic- many such elements. Wernicke, in effect, tionary defi nition is ‘excessive or unbridled acknowledges that ‘cross-level’ explanations are enthusiasm for self-deprecation’, or ‘delusions of the cornerstone of the most important scientifi c littleness or belittlement’, (‘low self-esteem’ per- explanations. haps in modern terms; an autopsychic delusion in ‘Molimina alvi’: (L30, p. 208). Archaic term Wernicke’s terms). ‘Micromania’ in this sense is for premenstrual diarrhoea. the opposite of megalomania, and Wernicke term ‘Molimina uterina’ (L30, p. 208): Archaic is usually Kleinheitswahn . We almost always use term for premenstrual uterine symptoms. ‘belittlement’ rather than ‘micromania’, except ‘Motility psychosis’: Signifi cantly, this is a when citing Meynert. Pierre Janet [214 ] gave disorder for which Wernicke appears to have had ‘micromania’ a quite different meaning, when he a special affi nity, since he starts Grundriss by writes as follows: ‘Micromania deserves atten- mentioning this disorder (L1, p. 6) and also fi n- tion: It is evident that many of these patients ishes the series (L41, p. 329). grant more importance to that which is small than ‘Motor impulse’ (L6), and ‘Impulse’ (used that which is big, Chu…, a woman of 36 years, extensively in L31 and L32) to indicate a driver anxiously searches for the “small crumbs of of motor activity. ‘Impulsive’ is also used a num- grease, crumbs of dirt” but does not take care of ber of times in L32. It is not clear whether he was “big dirtinesses.” Bow… is afraid of “small using ‘impulse’ as a deliberate analogy drawn noises,” not of the “big ones”. A canon blow does from physical science (as he did with other terms, not do anything to me, but I want to kill the peo- such as ‘energy’). ple that chew, who pick their teeth, who cough… ‘Mytacism’ (L27, p. 180). Excessive use of Mr. Stadelmann of Würzburg relates a nice the letter ‘m’, or an equivalent sound. observation of a man of 30 years, bothered since ‘Negativity’ (L34, p. 243): Negativismus. puberty by the preoccupation of what various ‘Nerve’ (Nerven ) (e.g. L3, p. 16) leaves it insignifi cant objects will become in the future, a unclear whether it refers to a nucleus, a pathway, fl y that fl ies, a lifeless match, the ash of the cigar, or to peripheral versus central nervous system. the spots of candle fallen to earth, etc. Mr. Farez ‘Nervous’ (L29, p. 196): Apart from its use in also relates obsessions and disgust for very small neurology and neuroscience, this word has a ver- objects, match tips, candle stains. It is needless to nacular meaning in English. The German word emphasize the importance that patients attach to nervös is probably more stigmatizing than is the “little bugs.” Into this preoccupation with ‘nervous’ in English, approximate synonyms what is small enters, of course, the mania of being ‘edgy’, ‘irritable’ and ‘agitated’. attention and precision.’ [ 214]. This alternative ‘Neurosis’: see section VIII,(s). ‘Wernicke’s meaning does not refer to the patient’s self, but to Distinctive Clinical Concepts in Psychiatry’ how he/she experiences the outside world (allo- ( Wernicke’s links to the emerging dynamic tradi- psychic in Wernicke’s terms); and since there are tion in Psychiatry ). differences between right and left hemispheres in ‘Nucleus’ (L19, p. 123) has had a variety of perception of large versus small images (at least meanings in science. In biology, its fi rst use for in the visual sense), Janet may be referring to an the intracellular organ in each cell dates from abnormality of cerebral asymmetry. 1831 (Online etymological dictionary). The use ‘Milliarde’ (L4, p. 22): one thousand million, of the term in neuroanatomy for a collection of according to terminology of the period, ‘one bil- nerve cells, or discrete block of grey matter can lion’, in today’s terminology. be traced back as far as 1828, and was used in the ‘Molecular’ (L8, p. 43): This is implicitly con- 1875 edition of Encyclopedia Britannica (OED). trasted with the term ‘molar’, as in chemistry, and After that time it had become standard terminol- 450 Editorial Commentary ogy. Wernicke occasionally uses the German included sense organs such as the skin, eyes or equivalent—Kern —as in Linsenkern (Lentiform inner ear), and these were sensations which, he nucleus: L11, p. 67), but in another instance thought, had a defi nite emotional ‘colouration’. (L19, p. 123), as the sogenannten Kerne (‘the so- We resist the temptation to translate the term as called nucleus’—possibly what is now called the ‘organic sensation’: Wernicke does sometimes dorsal column nuclei). use the adjective organisch, which has a different ‘Nurses’/‘Warders’: Wernicke never uses meaning. We can see the difference in the follow- ‘Schwesterin’ only ‘Warter’ and ‘Warterin’ ing terms we translate: ‘the “organ of conscious- except on p. 180 ( Krankenschwester: ‘the atten- ness”’, or the ‘organ of association’, in contrast dant nurse’ as a delusion). We therefore use with ‘organic brain disease’ or ‘organic (versus warder’ rather than ‘nurse’. functional) psychosis’. There is also a relation to ‘Organ sensation’. In L5 (p. 25) our transla- a conceptual distinction published 2 years after tion reads ‘Feeling tone of sensations’: Grundriss, by Rivers and Head [217 ], who sepa- (Gefühlston der Emfi ndungen ). Wernicke con- rated ‘protopathic sensation’ (poorly localized, trasts the ‘tone’ of sensation, with its ‘sensory conveying sensations of heat, cold and pain), content’. (See also: L30, p. 207: ‘tone of feeling’ from ‘epicritic sensation’ (permitting better spa- vs. ‘quality of sensations’). The former might be tial localization of touch, pressure, etc.). These clarifi ed as ‘emotional tone’. However, two were also separated by their different rates of Gefühlston, is used in a sense different from both recovery (‘protopathic’ sooner than ‘epicritic’) Emotionen , and Affekt (section VIII,(h). after experimental severing of peripheral nerves ‘Wernicke’s Distinctive Clinical Concepts in in the hand (the experimental subject in this case Psychiatry’ [Affective Impact of Mental being Henry Head himself). Wernicke’s use of Illnesses ]). He refers here to aspects of a stimulus the term ‘organ sensation’ is broader in scope associated with some inner ‘drive’ or motive for than ‘protopathic sensation’, and does not appear action. The term then becomes synonymous with to imply vagueness of spatial localization, and, ‘organ sensation’ (again in L6 and later), usually unlike the latter term, includes sensory input from in the original as Organempfi ndung , or muscles and joints (‘proprioception’ in English Organgefühl . The unifying theme appears to be terms), and that controlling eye movements. that ‘organ sensations’ are ones whose primary ‘ Papilla optica’ (L26. p. 174): optic nerve role is related to near-automatic refl ex or behav- papilla, the slight swelling, where nerve axons ioural responses, rather than to detailed conscious originating in the retina head towards the optic awareness. This is not the same as ‘emotional nerve, and the brain. tone’ where the emphasis is on sensory quality ‘Parametrium’ (L24, p. 157): The fi brous layer which may be linked to behaviour, but not to between the bladder anteriorly, and the supravag- behaviour which may be disassociated from any inal cervix, posteriorly. necessary sensory quality. Organ sensations, with ‘Paranoia’: generically, for Wernicke this their implication for automatic refl exive behav- meant a state where there is falsifi cation of con- iour, may be linked with perception at entry to the tents of consciousness (not ‘persecution delu- cortex, but not with memory images elaborated sion’—which is a vernacular meaning today). from these perceptions in higher cortical regions. Wernicke preferred ‘paranoid state’. The term translated here as ‘organ sensation’ has ‘Pathological’/‘Pathology’ (pathologische / a complex history in nineteenth century German krankhafte; Pathologie ): Wernicke limits this scientifi c thought. They can be traced back to almost entirely to abnormal fi ndings at a biologi- Johannes Müller’s Elements of Physiology [215 ], cal level, rather than at an experiential, psycho- and, for him, had a relation to an unresolved issue logical or social level. For abnormality at the about vitalism [216 ]. They were also linked to later levels he is almost completely consistent in sensations arising in defi nite organs (which using Krankhafte . Editorial Commentary 451

‘ Pavor nocturnus ’ (L39, p. 301): night terrors. meaning separate from the English word ‘psy- ‘Peak of illness’: The German word chopath’). This is an important point in Krankheitshöhe can mean either ‘level’ or ‘peak’ contrasting Wernicke’s ideas with those of of illness. Jaspers. The only possible exceptions are on ‘Perception’ (Wahrnehmung ). See above for p. 67, where ‘pathological principles’ ( patholo- separation from ‘Apperception’. gischen Prinzipes) are seen to underlie explana- ‘Perplexity’: see ‘Disarray’ tory delusions; and on p. 111, where we read: ‘To ‘Personality’/‘Personhood’: see Synopsis, L7, show how symptoms of mental illness are derived for use of terms. See section VI,(d). ‘Wernicke’s from this schema, and to put their occurrence and Underlying Philosophical Views’ (Wernicke on importance in various mental illnesses in their Personhood, Unity of a Person, and proper perspective, would be a separate and inde- ‘Self-consciousness’ ) pendent teaching exercise; yet any such attempt ‘Perytyphlitis’ (L39, p. 307): Infl ammation of might take us too far from our real task, which is the connective tissue about the caecum and to become familiar with specifi c cases of illness. appendix: in other words ‘appendicitis’. I shall therefore restrict myself just to the most ‘Phenazismen’ (L19, p. 117) archaic, exact important problems of identifi cation from a theo- meaning unclear retical point of view: I shall discuss these sepa- ‘Phrenic nerve insuffi ciency’: (L12, p. 75; rately, in some detail, as ones which are quite L30, p. 211). This phrase—probably Wernicke’s essential for understanding the general pathology own—does not refer to actual pathology in the of mental illnesses. These are mainly symptoms phrenic nerve, but to a style of breathing, domi- falling in the domain of hallucinations or which nated by costal rather than diaphragmatic muscu- have internal links with such symptoms.’ (empha- lature, likely to be a symptom of hysteria rather sis added) than a disorder of the peripheral nervous system. ‘Psychophysical’: A signifi cant word, ‘Physiological’ (e.g. L13, p. 82): ‘… physi- invented by Fechner. (See pp. 46, 68, 73, 80). ological delusions of reference…’ This word is ‘Psychophysiology’ In L13 (p. 80) we read: contrasted with ‘pathological’, indicating, ‘When introducing psychophysiology, I com- ‘within the normal physiological range’, or mented …’ This is the only time he uses this ‘relatively normal, in the prevailing context’ word in his main text, but he appears to refer back (also L15, p. 33). However, the word is some- to the general heading for L1–8, where the word times used in a more general sense (e.g. L39; appears only at the start of his ‘Contents’ list. p. 307). ‘Psychosis ’: see section VIII,(d). ‘Wernicke’s ‘Politzer method’ (L24, p. 158): A manoeuvre Distinctive Clinical Concepts in Psychiatry’ devised by Adam Politzer in Vienna in 1863, ( Wernicke’s Concept of Mental Illness/Disease. ) using increased air pressure in the nasopharynx ‘Puerperium’ (L32, p. 224), more commonly during the act of swallowing in order to reopen called the ‘post-partum period’ of ~6 weeks. blocked Eustachian tubes, and to equalize pres- ‘Registration’ (fi rst used in L2, p. 13): In sures in the sinuses. accord with the sAZm sequence, Wernicke refers ‘Polyneuritic psychosis’ (L27, p. 179): a.k.a. to the result of the stage s to A as ‘Korsakoff syndrome’. Ausgangsvorstellung (literally ‘output presenta- ‘Psychiatry/Psychiatrie/Psychiater’ (L34, tion’, but sometimes rendered as ‘initial percep- p. 253). These terms came into used after term tion’). Here and subsequently (e.g. L8, L2, L29) Johanne Christien Reil in 1808 coined the term we use the term ‘registration’. Psychiatrie; and they were introduced in France, ‘Resistance’ (L34, p. 244): German: from 1846. They are rarely used in Grundriss Widerstand (Title of book; pp. 253, 326). ‘Seizure’ In Wernicke’s day this was not lim- ‘Psychopathology’: Wernicke never uses the ited to epileptic seizures, an ambiguity recog- word psychopathologie (although, on a single nized in Lang’s medical dictionary of [213 ]. instance, on p. 96, he uses ‘psychopathische’—a ‘Silly’: Dumm. 452 Editorial Commentary

‘Spiritual acquis ’ (‘endowment’) (L39, p. 301; lost. Thus, for Wernicke the meaning of the term L40, p. 314): geistigen Besitzstand. appears to be almost the opposite of that given it ‘Stimulation’/‘Stimuli’: The usual German by later writers. However, the later writers dis- word is ‘Reiz’. tinguish ‘true’ from ‘morbid’ transitivism, which ‘Strength’ (of a concept: Festigkeit ) fi rst used may reconcile these divergent views. in L4 (p. 22) implying ‘security’ or ‘robustness’. ‘Transitory psychosis’ (p. 240): the so-called ‘Substantial’: ehebliche or wesentlich. ‘twilight states’. ‘Substantive’: enhaltlich. ‘Trichinae’ (L24, p. 159): Small parasitic ‘Symptom’ ( Symptome): In English the word nematode worm. ‘symptom’ is sometimes restricted to what a ‘Trophic’ (p. 273) anatomical change due patient complains about, while ‘sign’ is some- mainly to nutritional defi ciency. thing a doctor observes for him- or her-self. This ‘Tuberculosis’/‘Phthisis’: usually German usage is not very consistent, but is a signifi cant is‘ Lungenschwindsucht ’. distinction. Wernicke does not make this distinc- ‘The urge to be active’ (L31, p. 217): The tion for the word Symptome (fi rst used, L1, p. 4, German word Tätigkeitsdrang has no exact see for example, L37, p. 280, where the word English equivalent. ‘Impulsiveness’ has a dif- includes objective evidence from neurological ferent meaning. The word ‘impulse’, or more examination, and subjective evidence—a often ‘impulsive’ has a long history of use to patient’s complaints.); so ‘grandiosity,’ for refer to a more specifi c psychological urge. Wernicke, is a Symptome, although observed by ‘Impulse’ was adapted in Newtonian mechanics him, rather than being a patient’s complaint. to have a more specifi c quantitative meaning Since the distinction is not made consistently in (integral of force over time). (See also ‘Motor English, we translate it as ‘symptom ’. impulse’). ‘Tangible’ (L41, p. 328), presumably a change ‘Vicarious melancholia’ (L30, p. 215), an at the level of gross, rather than microscopic attack of recurrent mania is replaced by one of anatomy. Affective melancholia (see also L33, p. 239). ‘Tenesmus’ (L24, p. 155): A feeling of con- ‘Visual’: In L6 Wernicke often uses optische , stantly needing to pass stools, or void urine, which, in English coveys more of a physics- than despite empty rectum or bladder. a brain-based notion. We render optische as either ‘Thought disorder’: Denkstoerung. ‘visual’ or ‘visual perception/perceptual’. ‘Transitivism’ (L21, p. 137): Wernicke intro- ‘Visual agnosia’ (Seelenblindheit ), literally duced the term, to describe patients who show no ‘blindness in the mind’, usually translated as sign of psychological malaise, but whose entire ‘visual agnosia’ (fi rst used in L3, p. 16), but way of thinking and feeling led him to abandon sometimes as ‘psychic blindness’. ‘Visual agno- any assumption of similarity in trains of thought, sia’ means literally ‘failure of visual knowledge’. behaviour and conduct, which he otherwise In the context of a person born blind ‘visual would apply. The word became part of psycho- agnosia’ is not exact . analytic vocabulary, discussed especially by Wernicke’s Latin and Greek expression child psychologists such as Charlotte Bühler (excluding medical terms): (1893–1974) and Jacques Lacan (1901–1981). For such writers, the concept is closely linked to L3, p. 19 Cum grano salis (‘with a grain of salt’) development of a sense of personal identity, and L7, p. 39: κατ ’ εζοχηv (‘to a prominent degree’) for Bühler, was revealed by the fact that very L13, p. 79: Causa effi ciens (‘effi cient cause’ young children often do not distinguish sharply [after Aristotle]) between their own experiences and those of oth- L13, p. 82: sit venia verbo (‘forgive the word’) ers. Transitivism as defi ned by Bühler is rela- L14, p. 87: tua res agitur (‘It is a matter that con- tively normal, the abnormality coming when it is cerns you ’) Editorial Commentary 453

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A Allopsychoses , 183, 337, 407, 410, 411, 415 Absent-mindedness , 130 , 348 asymbolic , 183 Abulia , 266 , 443 chronic , 65 Acousma , 117 , 443 hyperkinetic 274 Acoustic patterns , 6 manic , 239, 274 Adaptability (to environment) , 39 paralytic , 281 Administration of mental hospitals , 334, 346 Allosomatopsychoses three categories of patient for , 342 acute , 272 Adolescence, as developmental stage , 359, 388, 399 chronic , 65 Aegophony , 443 Alzheimer, Alois , 358, 431 Aetiology , 335, 337, 364, 400 Alzheimer’s disease , 358, 431, 435 general vs. special , 337 Amentia (Meynert) , 240, 336, 352, 443 inferred from symptoms , 337 Amnesia , 358, 377, 405 internal vs. external , 407 psychogenic (hysterical) , 405 as ‘proximate cause’ , 337, 364, 408, 420 retroactive , 48, 180, 183, 190 ‘psychological’ vs. ‘organic’ , 379 Amyl hydrate , 428 of psychoses , 104, 307 Anaesthesia (symptom) , 331 rejection of by Wernicke, for classifi cation , 420 psychosensory , 65 transitional periods of life and , 337, 434 Analogies, use of by Wernicke , 331 Affect , 48 electrical , 424, 444 exhaustion of , 100 ‘enclosed pipe’ , 351, 424 integration with cognition , 421 energy , 424, 425 Affective reactions , 385, 410 errors due to , 425, 426 Affective states , 332, 334, 385, 406 graphical , 334, 424 abnormal mental states and , 385 hydraulic , 391, 424, 425 reinforcement principle and , 376 from medical to mental disorders , 403, 425 After-images , 16, 355 magnetic , 352 Agoraphobia , 436 from neurology to psychiatry , 374, 379, 424, 425 Akathisia , 336, 379 reasoning by , 424–425 Akinesia , 335, 374, 378, 384, 396, 397, 399, 400, 413 resonance , 402, 425 intrapsychic , 13, 208, 257, 262, 336 from syphilis/progressive paralysis to mental illness , partial , 76 375, 425 psychosensory , 336 Analysis (clinical) tube feeding in , 340 based on individual habits of patients’ thoughts , Alcohol 418–419 acute effects of , 442 based on life events , 418–419 chronic effects of , 335, 340, 356, 358, 359, 412, 434 levels of , 382 episodic binge drinking and , 169, 190, 335, 369 Anticonvulsants , 428 withdrawal syndrome , 340 (see also Delirium tremens ) Anti-psychiatry movements , 340 Alcoholic degeneration , 176 , 340 Anxiety , 335, 350, 379, 415, 443 epilepsy and , 176 allopsychic , 413, 415, 417, 418 restoration, after period in hospital , 340 autopsychic , 413, 414, 415, 418 psychoses and , 294 hysterical , 360

© Springer International Publishing Switzerland 2015 459 R. Miller, K.J. Dennison (eds.), An Outline of Psychiatry in Clinical Lectures, DOI 10.1007/978-3-319-18051-9 460 Index

Anxiety (cont.) arguments for , 342 localized feelings of , 135, 373 family visits to , 343 somatopsychic , 373, 405, 413 (see also Symptoms functions of , 323–324, 342, 345–346 (specifi c), consion) life within , 333, 342 states , 413 ‘only for the insane’ , 340 Anxiety ideas , 81, 142, 413, 414, 415 tertiary syphilis patients in , 339 with anxiety psychoses , 146 neurological patients in , 339 Anxiety neurosis , 149, 211, 405 staff (‘warders’) , 342, 439, 449 Anxiety psychosis , 333, 335, 360, 381, 396, 401, 409, violence within , 342 410, 413, 416, 418 voluntary patients in , 341 acute , 145 Atrophy , 443 aetiology , 147, 281 Asymbolia , 128, 183, 379, 416, 443 combined with Affective melancholia , 148 Atonicity , 443 combined with motility psychoses , 276 Attentiveness , 47, 79, 332, 348 course , 147 distraction of, as source of delusions , 114 diagnosis , 148 excessive fi xation by , 447 hypochondriacal , 150, 153, 161, 281, 304 lapses of , 419 prognosis , 149 measurement of , 47 symptoms , 146 paradoxical sudden shifts of , 419 treatment , 149 processing resources and , 424–425 Aphasia , 6, 379, 404, 424, 443 selectivity of , 332, 406, 417, 419, 443–444 manic , 127, 448 Autoallopsychosis, chronic , 65 schema for , 6 Autochthonous (‘self-generated’) ideas , 68, 73, 74, 113, transcortical , 379, 424 130, 361, 390, 392–393, 397, 404, 409, 410, 443 ‘Apoplectiform’ attack , 443 as primary abnormalities , 333, 334, 335, 388 in senescence , 320 Automatism , 406 Apoplexy. See Stroke Autonomic nervous system , 384, 404 Argyll-Robertson pupil (Pupillary rigidity) , 280, 356 Autopsychoses Aristotle , 370 acute , 185, 195, 335, 336, 361, 383, 407, 410, 412, ‘Arsenic green’ , 443 414, 416 Arsenic poisoning, psychosis following , 296 circumscribed , 93 ‘Associated-signs’ (Griesinger) , 106 expansive due to autochthonous ideas , 195 , 336, Association pathways , 5, 18 409, 410 aberrant , 115, 395 in paralysis , 219, 277, 280 binding, fi rmness of , 66, 125, 370, 371, 387, 414 hebephrenic , 303 cells , 23 Autosomatopsychoses cerebral cortex, as organ of , 365, 372, 393, 412, 426 acute , 272 dissolution/breakage of , 333, 371, 387, 398–399 chronic , 65 ( see also Sejunction) Avoidance (of recall) , 406 structure of , 21, 22, 23 Axons transcortical , 23 ‘all-or-none- law’ , 353, 391–392 Association (psychological) conduction time in , 353 across time , 363, 371 cortico-cortical , 354 (see also Association pathways) Affect accompanying process of , 429 ‘law of isolated conduction’ , 4, 353 ambiguity of , 388 signal information independent of energetics in , concept formation and , 331, 366, 373, 374 353, 392 delusion formation and , 195 Ego complex and , 404 hallucinations and , 390 B indirect , 398–399 B acon, Francis , 362, 367, 424 intrinsically error prone , 367–368 Bacteriology , 355, 380 motivational drives and , 399 Baillarger, Jules , 354, 431 overvalued ideas and , 395–396 Basal ganglia , 354, 358, 373, 376, 390, 412–413 pathological facilitation in mania , 336 functions of , 354 processes of , 333, 393 inhibition of by cortex , 376 semantic priming and , 430 intestinal sensation and , 354 word association tests and , 423 lentiform nucleus , 376, 449 ‘Associationist school’ , 370, 371–373 symptoms arising in , 153 Asylums (mental hospitals) Wernicke’s account of melancholia and , 376 alternatives to , 337, 341 Behaviourism , 332 Index 461

Beliefs (normal) , 388 Cerebral cortex , 415, 418. See also Sensory cortical areas bizarreness of , 369, 387, 388 activity level in , 335, 352, 398, 418 as components of personhood , 332 ‘association’ areas in , 378, 391 contradictions within , 388, 401 atrophy of , 287, 319 developed socially in institutions , 343 cytoarchitectonic map of , 435 explanatory , 392 excitation vs. inhibition in , 358, 370–371, 376, 426 fl exibility of , 396 integration across regions , 334, 402 overvalued ideas and , 388 interaction with hippocampus , 372, 388, 412, 414 persistence of , 393, 398 laminar structure of , 352, 354, 429, 435, 446–447 psychotic (see Delusions) lesions of , 374, 420 Benzodiazepines , 377 motor region of , 372, 374, 376, 397, 413 Berger, Oskar , 431 multimodal convergence in , 402 Bertillon, Jacques , 339 number of neurones in , 429 Beziehungswahn . See Delusions, of relatedness; projection areas for taste/smell , 354 Delusions, of reference pyramidal cells in , 354, 446, 447 Bilroth, Theodor , 437 as ‘organ of association’ , 354, 372, 376, 393, Bipolar disorder. See Manic-depressive illness 412–413, 426 Binswanger, Otto , 350, 359, 431, 436 sensory thresholds and , 413 Bismarck, Otto von , 342, 440, 442 sharpened attention and , 419–420 Bladder hypochondria , 156 suppressing subcortical activity , 358 Bleuler, Eugen , 383, 398, 420 Cerebral hemispheres, size of, encephalization , 355 debt to Wernicke , 387 Cerebral localization. See ‘Localization’ ‘Blind thrashing behaviour’ , 360 ‘Channeling’. See Attentiveness, selectivity of Body position (posture) , 371 Character /‘Personality’ , 49, 332, 420, 450 Body weight, behaviour of, in acute psychoses , alteration of, in mania , 217 100, 311 alteration of in progressive paralysis , 318 Bohr, Niels , 364 ‘brain habits’ and , 382–383, 396 Bonhöffer, Karl , 346 choleric personality , 216, 299 Brain-softening , 444 theory of , 383–383 Brain weight table in psychoses , 297–288 , 424 Charcot, Jean-Martin , 350, 357, 360, 369, 379, 403, Breslau , 338, 339, 342, 346–347, 351 431, 432 bacteriology and dermatology at , 339 Charité hospital, Berlin , 431, 432, 436 medical scene in 1890s , 339 Chloroform anaesthesia , 340 Wernicke’s institute in , 339, 412 treatment , 428 Broca, Paul , 431 Chorea , 230, 336, 405, 444 Broca’s convolution , 5, 40, 374, 391 Circular mental illness , 220 Bromide , 427 Classifi cation of mental disorders , 343, 407–419, 433 Buffon, Georges , 377, 406 based on administrative requirements , 333, 383–384, Burghölzli Mental Asylum , 423, 432, 433, 435 407, 421 Burdach, Karl Friedrich , 354 based on aetiology/pathology , 382, 421 based on clinical science , 333, 407, 421 based on illness course/outcome , 409, 421, 432 C based on likelihood of recovery , 407 C achexia , 340 based on severity , 407, 409 Cajal, Santiago Ramón y , 353, 354, 446 based on symptom clusters , 421 Histologie du Système Nerveux de L’Homme et des broad vs. narrow criteria , 408–409 Vertébrés , 354 categorical , 334, 407–408, 409, 412, 418–419 Camphor , 427 comorbidity and , 408–409 Catalepsy , 253, 336, 444 exclusion criteria and , 409 Catatonia , 352, 355, 360, 396, 408, history of , 406–407 433–434 ‘natural order’/‘natural types’ and , 406 ‘Cause’/Causality , 363–365, 443 over-inclusive defi nitions and , 408–409 John Stuart Mill and , 364 personal authority and , 421, 422 falsely equated with ‘logic’ , 420 purposes of , 406, 407–408 need for , 23, 85 rejection of aetiology as principle for sense of, as inbuilt bias , 364 (Wernicke) , 420 substituted by correlation , 361, 420 standardization of , 383–384 substituted by mathematical ‘function’ , 364 theory of (see Taxonomy) Cerebellum , 413 Wernicke’s critique of , 334, 406, 418–419 Cerebral asymmetry , 370, 438, 449 Claustrophobia , 437 462 Index

Clinical case presentations in Grundriss , 332, 335, neuronal cell bodies and , 365–366 345, 410 of one’s own body (corporeality) , 25, 28, 267, 332, complicating presentation of ideas in Grundriss , 412 334, 368, 404 deliberate ambiguity in Wernicke’s wording in , 350 of outside world , 22, 332, 334, 97 neurological as introduction to psychiatric, 334, 378–379 of personhood , 37, 54, 332, 334, 367 opportunistic choice of patients , 345 processes of , 332, 377 use for therapeutic ends , 344, 401 retrospective correction of contents of , 86, 87 use of insightful recovered patients , 347–348 self-consciousness , 368, 369 Clinical examination, methods of , 348 states of , 404 attentiveness , 348 three-way split of contents of , 332, 334 auditory acuity , 348 threshold of , 44, 352 axon fl are refl ex , 348 translation issues and , 365 cognitive capacity , 348 ‘unity’ (narrowness) of , 23, 46, 363 long-term memory , 348 Consciousness, activity of , 43, 54 pupillary refl exes , 348 vs. contents of , 376, 409 short-term memory , 348 Consumer activism , 380 Cocaine , 336-337, 434 Contemplative obsession , 199 psychosis , 296, 431 Contracture position after motility psychoses , 265 Coercion, means of , 325, 342–343 Conversion hysteria , 360, 405–406 Cohnheim, Julius , 431 Conversion symptoms and , 335, 360, 403–404, 405–406 Coma , 48 Coprolalia , 379 Committal, to asylum Corporeality, consciousness of , 332, 351–352, 354, 363, appeal against , 341 404, 414 procedures, initiated by public , 341 Course (of mental illnesses) , 310, 333, 407–408, legal criteria for , 341 409–410, 432, 434 Common sensation, disturbances of , 163, 447 depiction/graphical plot of , 311, 334, 337, 410 Community mental health care , 341 improving vs. worsening , 334, 378, 414, 443, 445 Compulsive speech , 13, 379 intensity vs. extent (range) of symptoms , 337, 410 in mania , 217 ‘natural course’ for disease entities , 419 in motility psychosis , 263 processes leading to chronic disorder , 347 in paralytics , 282 Cramer, August , 431 paraphasic , 127 Cramps, childhood , 340 psychomotor , 227 Cranial nerves , 354 Concepts, abstract , 45 Cranial vault, changes, in paralysis , 288 concrete , 22 Criminality , 39 loss of , 316 Critic , 123 ‘ Conceptualization centre’ , 6, 331, 374, 424 Cullen, William , 336, 404, 405, 443, 444 Conductivity, change in , 13 Confabulation , 87, 180, 183, 357, 359, 379 as memory of dream , 87 D Confusion , 385, 400, 415, 418, 443, 445 D alton, John , 426 acute (see Amentia) Darwinism , 436, 438, 439 agitated , 235, 336, 349 recapitulation theory and , 400, 438 asthenic , 240, 380 social , 358, 434, 436, 142 genetic , 234, 372, 387, 446 Deceptive appearances, legitimate content of , 142. See fl ight of ideas , 216 also Hallucinations and Illusions manic , 398 Decision making, by brain , 372 primary asthenic , 241, 274 impairment in , 207 primary (dissociative) , 235, 240 increased facility of , 217 substantive , 103, 313 melancholia and , 376 Consciousness , 16 Decortication , 288 alternating , 188 ‘Deduce’ (abzug )/deduction , 362, 368, 406, 422, 423, 445 in animals , 366 confused with inductive inference , 387–388, 427 cerebral cortex and , 365 ‘context’ needed for deduction , 388 contents of , 16, 21, 43, 66, 332, 334, 404, 410 deduction not a natural skill , 368 defi ned by process of association , 365–366 Defaecation hypochondria , 145 frontier with unconscious processes , 404 Defi cit symptoms. See Symptoms, negative grades of , 46, 48, 404 Degeneration , 358–359, 401, 426, 445 ‘herd’ , 344 alcoholic , 176, 340 narrowing of , 406 cross-generational, in families , 358–359, 434–435 Index 463

evolutionary theory and , 358–359 relation to hallucinations , 395 hysteric , 302 retrospective explanatory , 334, 394 neurotic , 219 somatopsychic , 394, 395, 396, 410, 416 Délire chronique à evolution systématique , 104 stable vs. developing , 393 Delirium , 349, 394–395, 416, 419, 445 systematization of , 67, 87, 400 acute , 273 ways to attenuate , 395–396 clouding of consciousness in , 419 ways to exacerbate , 395–396 grandiosity in , 417 Delusions of belittlement (micromania) hysteric , 301 in affective melancholia , 142, 207 occupational , 173, 441 in anxiety psychoses , 147 paralytic , 281 fantastic , 209 ‘primordial’ (Griesinger) , 105, 113, 385 in obsession psychosis , 200 sensory , 390 Delusions of persecution , 360, 378, 379, 394, 410, 445 Delirium tremens , 173, 335, 340, 346, 377, 391, 490 in acute hallucinosis , 170 aetiology , 175 altruistic , 170 chronic , 179 based on need for explanation , 56 chronic, protracted , 294 hypochondriacal , 83 combination with epilepsy , 183 physical , 70, 75 diagnosis , 176, 409, 413, 418 primary , 106 fi rst-person description of , 440 Delusions of reference, 394–395, 410, 416, 435, 438, 445 insomnia in , 377, 412 Delusions of relatedness , 378, 394, 395, 411, 418, 445 pathological fi ndings in , 177 in acute psychoses , 82 symptoms in , 173, 412, 418 allopsychic , 83 treatment of , 176 autopsychic , 82 Delusional disorder (‘monomania’) , 105, 360, 398, 436 in healthy people , 82 Delusional mood , 433 retrospective , 87 Delusions (general), 55 et seq ,113 et seq. , 392–396, somatopsychic , 83 412, 445 Delusions, specifi c content Affective concomitants , 395 belittling , 336, 445, 448–449 allopsychic , 394, 396, 410 fantastic hypochondriacal , 272, 282 by analogy , 114 grandiose , 378, 394, 412, 446, 448 associative spread of , 395 hypochondriac , 394 autopsychic , 394, 396, 410, 448 of infestation , 389, 390 belief in reality of , 377, 430 lycanthropic , 439 bizarreness of , 388 of pregnancy , 411 belief in reality of , 377, 430 religious , 76, 395, 411 bizarreness of , 388 Dementedness . See Paranoia changed sensory input and , 394 Dementia , 72, 314, 337, 352, 357, 399–400, 411, 443 confi rmation bias and , 396 acquired , 314, 337 corrective explanations and , 368, 423 aetiologies of , 317 defi nitions of , 367 alcoholic , 319 diagnostic non-specifi c nature of , 382 combination of stressors and , 400 differentiation from delirium , 394–395 congenital , 314, 337 empirical testing of , 401 context of occurrence , 337 epistemological assumptions in , 367 diagnosis of , 314 explanatory , 333, 345, 379, 395, 396, 416 epileptic , 319 as ‘falsifi cation of consciousness’ , 332, 360, 367, grades of , 337, 400–401 381, 392 hebephrenic , 303, 319 formed by learning-like process , 393, 430 mentally chaotic rather than systematised , 400 habitual style of thinking and , 396 not irreversible , 400 as half-serious ‘make believe’ , 430 paralytic , 284, 318 history of understanding of , 367 post-apoplectic , 519 impact of social milieu on , 342 processes leading to , 349 as interpretations of motor abnormality , 394 senile , 320 as interpretations of symptoms of medical disorders, 407 Dementia praecox , 399, 436 lapses of attention and , 394 Bleuler and , 387 parable, metaphor, analogy and , 395 hebephrenia and , 399–400 ‘physiological’ , 451 Kraepelin and , 359, 360, 389–390, 399, 408, 421, as rational interpretations , 333, 343, 344, 392–393, 430, 434 395, 423 Dengue fever , 356, 369 464 Index

Depression/depressive disorder , 335, 430, 445, 448 E Description in psychiatry , 362 E ating disorders , 335, 410 inseparable from interpretation , 362 anorexia nervosa , 381, 390, 410 interdependent with explanation , 362 ‘Eburnisation’ , 445 Determinism , 361, 370 Echolalia , 282 Diagnosis , 335, 409 Education level (of patients) , 368, 382, 394, 419, conventions for, lack of in Wernicke’s day , 339 420, 423 critique of , 350–351, 408 ‘Ego’, the, (das Ich ) , 404 differential , 333, 356, 412, 418 Affective overlay of , 429 Diagnostic and Statistical Manual (American Psychiatric complex dynamic structure of , 368–370 Association), 383, 408, 409 ‘Ego complex’ , 404–405 Didactic principles , 332, 347 fragmentation of , 368 tension with practical realities in teaching , 347 held together by logical coherence , 423 Diphtheria , 339, 355 history of concept , 404–405 toxin , 355 motor mechanisms and , 372 Discharge (from hospital) origin in sense of corporeality , 351, 414, 438 criteria for , 341 ‘primary’ (Meynert) , 351, 368, 404 obstacles to , 56, 60, 98 ‘shame’ and , 429 planning , 342 ‘soul’ and , 370, 404 Disarray , 134, 275, 334, 410, 418, 423, 445, 451 Einstein, Albert , 364, 365 allopsychic , 135, 414 Electra complex , 390 autopsychic , 135, 385, 416 Electrical treatment , 428 motor , 137 Electroencephalography , 425 non-appearance of , 137 Emminghaus, Hermann , 351, 432 somatopsychic , 135, 396, 414, 416 Emotions , 370, 445 translation issues (Ratlosigkeit ) , 385–386 ‘emotional incontinence’ , 319, 445 treatments of , 136 James/Lange theory of , 384 Disease use of terms in Grundriss , 384–385 clinico-pathological correlations and , 380, 420 Empiricism , 338, 361, 362, 382 ‘cortical’ , 380 evidence-based medicine and , 361 ‘entities’ , 334, 419 Encephalitis (a.k.a. ‘Phrenesia’) , 75 general vs. localised , 338 Energy , 424, 445 history of debate over concept of , 380, 406–407 conservation of , 425, 445 infectious , 336, 355–356, 380 history of concept , 425 diseases not primary concepts for Wernicke, specifi c, of sensory elements , 338, 362 66, 125 translation issues , 380 Ependymitis granulosa , 288 Disease curve . See Course (of mental illness), ‘Epigenetic’ , 445 depiction/graphical plot of Epilepsy , 335, 341, 412–413, 431, 444 Disorientation , 133, 334, 385, 406, 411, 418, 445 differentiation from hysteria , 357 allopsychic , 391, 411, 413, 416, 418 focal symptoms and , 379 autopsychic , 411, 413, 416 pseudo-seizures , 357 somatopsychic , 411, 416 psychoses in , 297, 337 Dissimulation , 321 seizures in , 357, 429 Dissociation , 360, 369, 381 stigmatization of , 341 Dissociative Identity Disorder , 387 twilight states of , 341, 376, 452 Dizziness , 48 Esquirol, Jean-Étienne , 350, 363, 431, 432 Doppelgänger , 387 Ethology , 370 Dorsal column disease in paralysis , 281 Eugenics , 359, 431, 432 Duchenne (de Boulogne) , 332, 356, 431 Euthanasia , 342 inhibition and , 371 Exner, Sigismund , 432, 444 Dynamic tradition (in psychiatry) , 403–406 Experiment , 423, 446 ‘Ego’ , 404 thought (Mach) , 354, 361 individual analysis in , 419 vs. theory , 332 neurosis and , 405 Explanation in science subconscious/unconscious mental activity , 393, and defi nition, as interdependent , 362 403–404, 405 and patients’ explanatory delusions , 422 ‘symptom complex’ in , 404 relation to classifi cation , 421 Dyskinesias , 356 Eye movements , 18, 28, 35 Index 465

F Geisteskrankheit , 333, 379, 380, 448 Facial expression , 11 Geistesstörung , 333, 379, 380, 407, 448 Falret, Jean-Pierre , 432 General Paralysis of the Insane (GPI). See Progressive Falsifi cation of consciousness/memory , 53, 333, 357, paralysis 371, 411, 450 Genetics , 358–359 allopsychic , 59, 333, 410, 416 interaction with social factors , 359 autopsychic (personal identity) , 333, 381, 410 pre-disposition without overt psychotic illness , 430 chronic worsening , 64 Gestalt psychology , 362, 367 residual , 54, 87 Glial cells , 353, 436 secondary , 333 astrocytes , 291, 353 somatopsychic (bodily awareness) , 60, 62, 333, phagocytic role of , 353 381, 410, 416 proliferation of, after neuronal damage , 291, ‘Faradisation’ , 446 328, 353 Fechner, Gustav , 338, 352, 364, 365, 366, 369, 424, 432 ‘Globus pharynges’ , 446 Feeblemindedness . See Dementia Goldstein, Kurt , 346 ‘Fibrae propriae ’ (Meynert) , 446 Golgi, Camille , 353 Fit of rage, epileptic , 298 Goltz, Friedrick , 371, 432 Flechsig, Paul , 337, 434 Gowers, William , 432 Flight of ideas , 215, 236, 237, 349, 384, 399, 430 Grandiosity, ideas of , 349, 394, 417, 430, 436, 446 Focal symptoms , 4, 66 , 358, 374, 375, 379 consecutive , 56, 102 in progressive paralysis , 7, 290 emergence of , 106 Foerster, Otfrid , 347 maniacal , 219 Food refusal, paralytic , 219 in akinetic conditions , 76, 249 religious , 76 in melancholia , 209 Granule cell , 447 in somatopsychoses , 154 Griesinger, Wilhelm , 332, 349, 351, 359, 365, 385, 388, Forel, Auguste , 359, 369, 432, 435 394, 431, 434, 435, 448 Forensic psychiatry , 335 Grundriss, as a lecture series , 345, 412 Forster, Edmund , 347 accompanying class discussions , 345 Foucault, Michel , 403 clinical generalizations within , 412–419 Franco-German rivalry , 339, 350 lectures in tandem , 345–346 Franco-Prussian war , 335, 360, 441 profi les of class members , 346–347 Frankl, Victor , 402 progression of ideas developed in , 348 Freud, Sigmund , 350, 355, 360, 397, 425, 435, 437, 444 as research presentations , 346 the ‘Ego’ and , 404 Gudden, Berhard von , 432, 436 interactions with Wernicke , 403, 404 Guillain–Barré (–Strohl) syndrome , 357, 434 neurosis and , 405 repression and , 406 teleology and , 370 H Freund, Carl , 432 Habitual forms of mental illnesses , 242 Fritsch, Gustav , 337, 432, 433 Haeckel, Ernst , 401, 436, 438, 439 Functional change Haemoglobin , 433, 437 abnormality of , 13 Hagen, Friederich , 433 excess of , 13 Halle , 339, 351, 412 loss of function , 13 Hallucinations , 72, 73, 117, 333, 334, 361, 381, 384, Fundamental concepts , 333 388–392, 393, 396, 412–413, 426, 446. See also mass, force (physics, Newton) , 338, 362 Illusions sensation (Mach) , 338, 362 abnormal sensory input and , 390 symptoms (Wernicke) , 332, 412, 421 changed in disorders of the projection fi elds , 126 Charles Bonnet syndrome and , 392 combining sensory modalities , 121 , 334 G dependence on affect , 142, 402 G anglion cells. See Cerebral cortex, pyramidal cells in diagnostic non-specifi c nature of , 382 Ganser, Sigbert , 432 differentiation from illusions , 334 Gastric feeding tube, use of , 257 dreamlike , 114, 122, 125, 167 , 377, 390, 416 Gastroenterology , 389–390 (see also Twilight states) Gastroenterostomosis , 437 ‘elementary’ , 127 Gaupp, Robert Eugen , 347 Esquirol and , 431 Gehirnkrankheit , 379, 448 explanatory delusions for , 69 466 Index

Hallucinations (cont.) Holism , 343, 378, 401–403, 421 functional , 119 based on brain science , 401 genuine in content, deceptive in appearance , 142 ‘binding problem’ and , 401–402 incorrigibility of , 79, 119 , 389 incompatibility with medical concepts of mental kinaesthetic , 431 illness, 419 localization of (in brain) , 126 integration of mental faculties and , 402 as major elementary symptom , 388 ‘personal wholeness’ and , 344, 402, 403, 419, 421 meaningful images in , 390, 420 relation of elementary to secondary symptoms and , 422 ‘memory image becomes a visual image’ , 391 ‘resonance’ metaphor and , 402 multimodal , 389 unifi cation of Affect and cognition , 402, 421 non-verbal auditory , 389 unifi cation of percepts and concepts , 402 progressive paralysis and , 390 Wernicke’s clinical style and , 402 reduced sensory input and , 391 Hôpital de la Salpêtrière , 350, 431, 433 re-enactments of past trauma and , 389 Hume, David , 364 refl ex (Kahlbaum) , 390 Hydraulic metaphors , 392, 425 release from inhibition and , 365 Hydrocephalus , 422 as sensory deceptions , 333, 388 externus , 288 sejunction theory and , 72, 123, 386, 388, 391–392 internus , 288, 294, 295, 352, 422 by suggestion in Delirium tremens , 172 Hyoscine , 234, 427, 428 tactile , 69, 121, 389, 416 Hyperaesthesia of the sense organs , 130, 332, 334 of taste and smell , 119, 389 psychosensory , 13, 117, 162 theory of , 122, 334, 389–392, 433 Hyperkinesia , 366, 374, 384, 397, 400, 410, 427 by ‘top-down’ control of sensory regions , 390, 392 intrapsychic , 13, 216 unimodal , 334 psychosensory , 13, 376 verbal auditory (see ‘Phonemes’) Hypermetamorphosis , 128, 227, 334, 379, 418, 423, visual (see Visions) 429, 435, 447 when falling asleep , 391 Hyperthermia , 369 Hallucinosis , 333, 388 Hypnosis , 403, 431, 434 acute , 166, 294, 335, 385, 410, 417 animal , 397 acute progressive , 170 bridgehead for dynamic psychiatry , 403, 431 aetiology , 169, 281 Hypochondria , 374, 405, 410, 416, 417 418 422, 434. course , 170, 310 See also Somatopsychosis chronic , 106, 268, 334 abnormal sensations in , 416 diagnosis of , 169 hypochondriacal anxiety , 335 prognosis , 170 palsies of , 397 residual , 74, 82, 99 without Affective component , 416 treatment , 170 Hypoglossal paresis in Delirium tremens , 174 Happiness, unusual feeling of , 373 Hysteria , 187, 335, 350, 357, 361, 370, 377, 385, 431, hypochondriacal , 107, 142, 198 435, 437 perceptions of , 316 abnormal sensations in , 383 Head shape , 442 absences and , 337, 410 Heavy metal poisoning , 336 fugue, as male equivalent of , 369 Hebb, Donald , 366 hystérie traumatique (Charcot) , 360 neural assembly concept , 366, 373 ‘hystero-epileptics’ , 357 Hebephrenia , 107, 303, 337, 345, 359, 381, 399–400, 411 in men , 360, 369 Heboid , 193, 303 psychosis in , 301 Heboidophrenia , 193, 303 Hysterical paralysis , 264 Hecker, Ewald , 359, 399, 434, 448 Hegel, Georg Friedrich Wilhelm , 370 Heilbronner, Karl , 346 I Helmholz, Hermann von , 354, 363, 425, 430, 433 Identifi cation , 7, 22, 373 Helplessness. See Disarray (Ratlosigkeit ) disturbance of , 7, 12, 128, 173, 378, 413 Hemiplegia in paralysis , 286 Idiocy , 314, 447 hypochondriacal , 264 ‘Illness’ (as an individual affl iction) , 380, 411, 419 Hering, Heinrich , 433 Illusions , 69, 117, 140, 334 Heubner, Johann , 433 Affective states and , 402 Hidden variables , 332 Imagery, mental , 377, 430 Hippocampus , 373, 389, 403, 412 Imaging, functional , 352, 418 Hitler, Adolf , 347 Imbecility , 314 Hitzig, Edouard , 337, 432, 433, 435, 439 Imitation, drive to , 44 Index 467

Impulsive action , 143, 231 Jactation , 230, 401, 418, 447 Inanition delirium , 307, 337 James, William , 332, 369–370 Inanition psychoses , 293 Janet, Pierre , 350, 370, 388, 403, 406, 431, 445, 449 Incapacitation in paralysis , 287 Jaspers, Karl , 367, 380, 383, 397, 421, 450, 451 Incurability , 54, 67 Allgemeine Psychopathologie , 380 Indecisiveness , 315 Jealousy, drinker’s delusion of , 295 ‘Individual’ (translation issue) , 332 Jolly, Friedrich , 434 Individuality . See Personhood ‘Jumpiness’ in epileptics , 130 Inductive inference , 368 Jung, Carl Gustav , 402, 403, 424 Infl uenza , 293 Inhibition , 447 cognitive , 430 K mutual (reciprocal), in CNS , 371 K ahlbaum, Karl Ludwig , 349, 351, 352, 356, 358, 359, release from and positive symptoms , 358, 365 378, 382, 385, 387, 390, 397, 433, 434, 437, 444 neuronal , 371, 388, 390, 426 Kant, Immanuel , 369, 422 spinal , 371 Critique of Pure Reason , 366, 388 thought, and , 371 form vs. content , 348–349, 366, 382, 421 Initial perception , 1 neo-Kantian revival , 421 Insight into illness , 38, 333, 348, 377 psychological concepts , 382, 421 lack of , 55 , 394 synthetic a priori statements , 367, 372 loss of, as psychological reaction , 400 Kepler, Johannes , 426 recovery of , 343, 408 Kinaesthetic word images , 6 Instinctive behaviour , 376 Kleist, Karl , 336 Institutionalisation , 343 Kleptomania , 260 ‘Insuffi ciency’, subjective feeling of (melancholia) , 207 Koch, Robert , 356 Insurance (health) , 405 Kolk, Jacobus van der , 434 Interactions, internal (psychological) , 343, 383, 402, 403 Korsakoff, Sergei , 335, 358, 434, 435, 451 ‘Interest’ , 207 Kraepelin, Emil , 344, 348, 353, 356, 358, 359, 360, 362, Intermissions (in illness course) , 310 390, 397, 430, 431, 433, 435 International Classifi cation of Causes of Death (ICD) , approach to classifi cation , 362, 378, 408, 409, 421, 422 339, 408 military research and , 422 International Statistics Institute , 339 paraphrenia and , 358 Intestine, large , 332, 335, 390 textbook of , 399, 407 Intestinal sensations (‘gut feelings’) , 29 Wernicke’s attitude to , 353, 399 Intoxication , 377 Krafft-Ebing, Richard , 435 delirious states in , 175 Krankenvorstellungen aus der psychiatrischen Klinik in pathological state of, 175, 29, 184 Breslau , 346, 412 Intrapsychic function Krankheit (translation issues) , 380, 407 excess of , 18, 205 Kretschmer, Ernst , 360, 376, 402, 403 loss of , 13, 205, 261 ‘death feint’ and , 397, 444 Intrapsychic pathway , 13 delusions of reference and , 394 Introspection (‘internalization’) , 332, 345 recovery and , 401 used to develop hypotheses about brain , 366 L Involution, senile , 304 L andry’s paralysis. See Guillain–Barré (–Strohl) syndrome Irradiation Language , 332, 345 of refl exes , 31 Chinese script and , 382 of stimuli , 126 not the only way to organize consciousness , 345 of ‘will impulse’ , 263 semantic vs. phonetic organization in , 379 Irritable Bowel Syndrome , 390 Lateral column disorder in paralysis , 280 Isolation of mental patients , 324 Lateral column symptoms , 448 ‘Law of Effect’ , 373 ‘Law of Isolated Conduction’ , 435 J ‘ Law of Specifi c Energies ’ (Müller) , 354, 435 J ackson, John Hughlings , 350, 355, 398 Laws, on mental health classifi cation of epilepsies , 357 across Bundesländer , 341 hierarchy of functions in brain , 351, 355, 358, 336 British Mental Treatment Act (1930) , 341 his work not known to Wernicke , 357 Lead poisoning, subsequent psychosis , 296 ‘march of epilepsy’ , 357 Learning (acquisition of memory) , 332 separation of positive from negative symptoms , 358 synaptic plasticity and , 371–372 468 Index

Leeches , 428 course , 218 Leonhard, Karl , 397 diagnosis , 219 Liepmann, Hugo , 346 differentiation from schizophrenia , 399 Linnaeus, Carl , 359, 377, 406 excessive association in , 336, 399 style of nomenclature , 359 expatiating , 196 taxonomy of diseases , 359 heredity , 430 Lissauer, Heinrich , 347, 429, 434, 447 as intrapsychic hyperfunction , 13, 205 , 336, 349 Load, inherited , 219, 293 as intrapsychic loss of function , 13, 205, 243 Local signs of retina , 18, 27 ‘levelling of ideas’ in , 336, 398 Localization (of function in brain) , 127, 331, 370, neural basis of , 398 373–375, 425 periodic , 191, 236, 239, 417 classifi cation of mental disorders and , 375 prognosis , 230 electrical stimulation and , 432, 374 progressive paralysis and , 336 lesion location and symptoms , 339, 373–374, 379, 432 puerperal , 233, 306 mental illness and , 375 pure , 215 motor symptoms and , 374 recurrent , 353, 452 orderly connectivity and , 374 relation to Affective melancholia , 399, 426 orderly topographic representation and , 355, 398 secondary , 379 relation to general clinical concepts , 357 symptoms , 215 Localization of sounds , 355, 420 temporal lobe lesions and , 379 Locke, John , 366, 393 treatment , 221 Lombroso, Cesare , 359 Manic-depressive illness , 408, 421 Lorentz, Hendrik , 364 Mann, Ludwig , 347 Lorenz, Konrad , 370 Marasmus , 448 Lotze, Hermann , 363, 436 Medical concepts and terminology for mental disorders , Lucid intervals in mania , 218 381, 403, 419–422 ‘Lunatic’/’lunacy’ , 448 incongruent with holistic concepts , 419 Luys, Jules , 434 prognosis and , 419 tension between mechanism and meaning , 420–421 Medical ethics statutes , 339, 407 M Medical practice in Wernicke’s day , 331 M ach, Ernst , 338, 339, 362–364, 365, 367, 422 emphasis on longitudinal course , 410 anti-metaphysical , 361 international developments , 339 ‘causality’ and , 364 military implications , 422 conservation of energy , 425 statistics on prevalence, lack of , 339, 408 Fechner and , 338 Medical records (at Breslau, Halle) , 378, 412 form vs. content in , 366–367 Medical technology , 427, 428 ‘local sign’ and , 363 infusion , 428 natural philosophy and , 338, 361, 362 intravenous injection , 428 personhood, complexity of , 368–369 ophthalmoscopy , 428 primary experience as foundation , 363, 382 Medulla oblongata , 448 psycho-physical parallelism and , 364 Medullary pyramid , 448 rejecting ‘absolute space’ concept , 363 ‘Medullary strips’/‘Medullary degeneration’. sensory physiology and , 338, 364 See White matter teleology and , 370 Megalomania , 448. See also Grandiosity, ideas of; thought experiments and , 362, 423 Delusions (specifi c content), grandiose Magnan, Valentin , 350, 435 Melancholia , 335, 383, 398, 445, 448 Magnetic treatment , 428 agitated , 148, 414 Magnetism, animal , 352 attonita , 254 (see cum stupore ) Maladie du doute , 199 combined with mania , 336 Mania , 335, 336, 379, 397, 398–399, 411, 416, 417, depressive , 103, 208, 261, 336, 398, 422 430, 447 heritability , 431 aetiology , 219 hypochondriacal , 162, 422 agitated confusion, and , 336, 349 rebound of mania in , 342 choleric , 274, 278, 306, 418 recurrent (proxy) 213 , 220 chronic , 221 , 336, 353 seizures in , 429 combination with melancholia , 220, 336 vicarious , 452 compulsive activity in , 217 Melancholia, Affective , 207 , 359, 361, 378, 398, 408, confused , 236, 336, 349, 384, 387, 411, 417, 418 410, 417, 418, 422, 428 cortical overactivity in , 336, 398 aetiology , 210, 281 Index 469

decision making in , 376 residual , 333, 448 diagnosis , 211 sensory processing and , 413 hospital admission for , 340–341 separation of acute from chronic , 334, 354, as impairment of ‘will’ , 336, 398, 426 409–410, 419 mood change in , 335, 398 simulation of , 337, 346 prevalence of , 339 terminology for , 380 prognosis , 210 transitional periods of life and , 337, 349, 358, 400, 434 relation to mania , 399, 426 ‘unusual experiences’ and , 381 secondary changes in , 336, 398 Mental processes , 333 suicide risk in , 342 similarities to normality in psychiatric patients , 334, symptoms , 207 343, 344 treatment , 212, 427, 428 Metaphysics , 361 Memory Meyer, Adolf , 435 cells , 17 Meynert, Theodor , 336, 338, 348, 351, 352, 354, 355, consolidation of , 444 358, 365, 366, 368, 403, 409, 414, 424, 427, 434, continuity of , 366 435, 436, 438, 443, 446, 449 episodic , 412, 414 analogies, metaphors of , 351, 424 long-term , 348, 358 attitude of Wernicke to , 337, 351–352 loss of , 46, 180, 182, 283 , 340, 357 cerebral blood fl ow and associative processes , 352 ‘manipulation’ within , 332 hallucinations and , 390 of one’s own body , 332, 333, 412 inhibition and , 370, 371 of outer environment , 332, 333, 412 Parkinson’s disease and , 354 of personal life experiences , 332, 333, 412 primary Ego and , 352, 368, 404 as ‘remembered images’ , 331 Micromania , 415, 418, 445, 448–449. See also retention , 48, 348, 417 ‘Delusions of belittlement’ retrieval of , 332, 406 Mill, John Stuart , 365 semantic , 412 Mitgehen , 397 Mendel, Gregor , 359 Monakow, Constantin von , 435 Meningitis , 293 Monatsschrift für Psychiatrie und Neurologie , 3338, delirious states in , 176 351, 404 Meningoencephalitis , 288 Monomania , 105. See also Delusional disorder Menopause , 305 Moral insanity , 39, 193, 335, 340 Menstrual psychoses , 219, 305 Morbid self-reference (Neisser) , 394, 435 Menstruation , 336, 400, 412, 417, 428, 429, 448 Morphine . See Opium Mental illnesses Mortality in acute psychoses (asylum statistics) , acute syndromes of , 334, 409 313, 339 Affective impact of , 384–386 Motility psychoses , 336, 372, 381, 396, 399, 410, 413, bacteriological toxins and , 356, 389–390, 407 415, 430, 449 ‘brain diseases’, compared with , 331, 379 aetiology , 256 chronic , 334, 347–348, 381, 408 akinetic , 243, 336, 348–349, 352, 378, 400, 408, 411 combining impairments with advantages , 419 catatonic symptoms in , 399–400 confl ict between cortex and subcortex , 355 combination with other psychoses , 274 content vs. activity of consciousness in , 409 complete , 260 continuity vs. separateness from normal composite , 275, 276 psychology , 381 course , 255 criteria for declaring a person mentally ill , 340 cyclic , 259 defi nitions of , 381 diagnosis , 256 disease process , 407 as form of somatopsychosis , 418 as ‘diseases’ , 407, 419 hyperkinetic , 336, 366, 391, 400, 410, 417 disruption of associations in , 354 prognosis , 257, 260 dissimulation of , 337 relation to Dementia praecox , 400 distinguished from ‘mental disturbance’ , 334 symptoms , 249 dreaming and , 376 theory of , 268, 336 family history of , 359 therapy , 257 general vs. focal , 339 Motility psychoses, hyperkinetic , 224 internal vs. external causes , 407 aetiology , 226, 233 loss of sense of personal wholeness in , 344, 381, akinetic phases in , 259 402–403, 421–422 combination with other psychoses , 274 relapse prevention, principles of , 401 course , 233 relation to problems of general medicine , 340 diagnosis , 233 470 Index

Motility psychoses, hyperkinetic (cont.) ‘Nature’ , 362, 377, 406–407 prognosis , 234 Negativism , 249, 265 , 397, 449 symptoms , 226, 227 Neisser, Clemens , 394, 435 treatment , 233 Nerve current (nerve ‘stream’), 73, 79 Motionlessness , 249 ‘Nervous exhaustion’. See Neurasthenia Motor impulse , 449 Neumann, Heinrich , 352, 365, 427, 435, 447 Motor (motility) symptoms. See Names for specifi c Neurasthenia , 360, 431 symptoms Neuroglial cells , 353, 436 rarity of, today , 397 phagocytic role of , 353 Movement (motility) disorders , 411 astrocytes , 291, 353 compound , 336 proliferation of, after neuronal damage , 353 driven by abnormal sensations (hypermetamorphic) , Neurohistology , 339, 353 378, 336 Nissl method , 353, 431, 435 fragments of purposeful actions , 397 staining methods , 339, 353 heredity and , 337 Weigert methods , 353, 436 parakinetic , 336, 366 Neuroleptic (antipsychotic) medicines , 379, 393–394, of speech , 334, 336, 366 415, 444 Movement sensation , 32 Neurology , 356, 420 absence of (see Akinesia) disorders of , 379 restless , 233 relation to psychiatry , 379, 397, 422 stereotypical , 251 used to explicate mental disorders , 334, 379 Movements ‘Neuromythology’ (Jaspers) , 334 attack , 11, 33 Neurone classifi cation of (Meynert) , 11, 351 activation threshold , 430 defensive , 11, 33 theory , 339, 353, 432 disturbances of , 12 Neuropathology , 339, 375, 381, 383, 420, 429 exploratory , 332 correlation with clinical syndromes , 336, 358 expressive , 11, 12 neurone loss and , 384 eye , 374 processes of, in mental illnesses , 334, 337 385, 420 initiative , 11, 12, 75 random vs. constrained by meaning , 420 pseudospontaneous , 136, 226. 251 Neuropsychology , 334 reactive , 11 Neuroscience , 331 rhythmic , 268 as foundation for Grundriss , 338, 378 signifi cance of, for psychoses , 10 Neurosis , 405, 449 spontaneous , 33 compared to psychosis , 381, 444 Müller, _Johannes Peter , 354, 435, 436, 450 ‘epileptic’ , 405 Multiple (‘split’) personality, 369. See also ‘Second state’ history of use of term , 405, 444 Muscle hypochondriacal , 161, 381, 405 activation sensation , 32 obsessive , 199, 297 , 335, 405 coordination , 33 ‘railway neurosis’ , 405 electrical stimulation of , 332 Newton, Isaac , 338, 361, 365 pains , 349 Nietzsche, Friedrich , 437 relaxation , 377 Nissl, Franz , 347, 353, 435, 436 sensation , 29, 31, 389 Nothnagel, Hermann , 355 sensitization to pressure , 377 Nursing spasms , 340 care in institutions , 339, 427, 429 Mutacismus . See Mutism homes, advantages for recovery , 342 Mutism , 6, 321, 360, 381, 397, 437 nurses (see Asylum, staff (warders)) in akinesia , 246 religious or secular basis , 342 in hyperkinesia , 226 Nutrition , 400, 427 initiative , 263 reactive , 267 Myelin , 353, 357, 383, 436, 437, 447 O Obsession , 68, 73, 91, 384, 397, 405, 411 Obsessive-compulsive disorder , 379, 398, 429, 431 N Obsessive psychosis , 199, 297 N atural history , 378 Occipital lobes, diseases of , 28 Natural philosophy , 332, 361–362, 378, 427 Opinion, psychiatric , 105 European vs. English style , 361–364 Opium/morphine , 427, 428 Natural sciences , 334, 337, 406, 421, 424 in movement disorders , 427 Index 471

psychosis due to , 296 hallucinatoria , 101 Organ of Corti , 355 originaria (‘original craziness’) , 107 Organ sensations , 331, 365, 376, 384, 390–391, 446, primaria (‘ primordial delirium’) , 105 449–450 querulous , 87, 94 hyperaesthesia of , 130 Paranoid states , 54, 65, 333, 348, 360, 398, 407, 448 abnormal infl uence of on motility , 131 after acute psychoses , 102 Overvalued idea , 87, 92, 334, 361, 367, 393, 395, 397, after motility psychoses , 256 398, 410 classifi cation , 104 amnesia and , 406 course , 102 as basis of illusions , 140 mono-delusional variety (see Delusional disorder) delusional elaboration of , 393, 403 nomenclature , 65 infl uence of , 87 Paraphasia , 127, 269 in melancholia , 94, 212 Paraplegia, hypochondriacal , 264 as primary abnormalities , 334, 388 Paraphrenia , 358 Parietal lobe, disorders of , 28 Paris, as medical centre , 339, 350 P Parkinson’s disease , 355 Pachymeningitis haemorrhagica , 288 Pathology Pain sensation , 48, 340, 349, 404, 448, 450 correlation with symptoms , 379 Parabadie [in Wernicke’s index, but not in his text, in mental illness, limited to ‘whole person’ level , 421 defi nition uncertain, probably a form of Wernicke’s use of the term , 381, 426, 450 paraphasia; Ed] 269 Patients Paraesthesia, psychosensory , 13, 181, 269 complaints by , 343, 389 Paragraphia jargon of , 343 in Delirium tremens , 174 long-stay in-patients , 333, 343 in paralysis , 286 mental content of , 343 Parakinesia , 13, 251 , 367, 374, 397 violence by , 341 Paraldehyde , 428 Pattern completion , 373 Paralexia [misreading of printed words; Ed], in Pavlov, Ivan Petrovich , 356, 373 Delirium tremens , 173 Perception Paralysis, progressive , 336, 340, 347, 352, 357, 381, ‘apperception’ and , 377, 443, 451 402, 409, 410, 424, 437 cells (‘perception elements’) , 17, 29, 30 abnormal excitation and , 386 compared to sensation , 331, 366, 373 advancing , 285 compared to thoughts , 373 aetiology , 279, 280, 281 , 336, 356 distortions of sense of space and time in , anatomical fi ndings in , 287, 288, 289 , 336, 434 363–364 anatomical fi ndings in, macroscopic , 287 elaborated by exploratory movements , 333, 363 anatomical fi ndings in, microscopic , 289, 429, 434 form vs. content of , 366 atypical , 285 generalization of , 374 clinical condition , 7 illusions, as distortion of , 334 dementia and , 400 ‘perceptual elements’ (cells) , 331, 391 diagnosis , 285 relation to memory images , 355, 372, 374, 391 disease concept , 279 solid bodies and , 363 fever in , 357 of space , 363 focal symptoms of , 285 tactile , 332, 363 372 galloping , 282 of time , 363 hypochondriacal , 265 visual , 331, 332, 372 hysterical , 264 Perceptions localization of degeneration process , 290 localization of , 1, 15 paranoid form of , 219 normal value of , 49 passive limb manoeuvrability, alteration of , 280 Perceptual image , 17 pointer to future of psychiatry , 336, 375 Periencephalitis , 288 prodromal symptoms , 280 Peripheral neuropathy , 357 remission , 284 fl accid paralysis and , 357 spinal symptoms in , 280 Perplexity (Ratlosigkeit ). See Disarray stereotypical movements in , 282 Persecution, ideas of , 349 syphilis, relation to, in Wernicke’s view , 356, 429 Perseverance in postures , 250 Paranoia , 65. See also Paranoid states Persistent genital arousal disorder , 390 chronica simplex , 101, 351, 360 Perseveration , 298, 495 complete , 104 Personality . See Individuality 472 Index

‘Personhood’ (‘Individuality’) , 37, 186, 332, 368–369, Polyneuritis , 181 431, 450 Positive feedback , 373 breakdown of , 57, 71, 87, 134 Potassium bromide in drunkards , 192 constructed by assimilating components of memory , Prague , 380 332, 402, 413, 422 Presbyophrenia , 182, 335, 359 contribution from physical education, 438 aetiology , 182, 281, 304 episodic memory and , 414 symptoms , 182 interaction of all body systems and , 402 Progressiva divergens , 219, 280 multimodal convergence as substrate for , 402 Prognosis , 339, 344 ‘personal identity’ , 335, 404 Dementia praecox and , 399, 421 re-integration after mental illness , 344, 402 determined by ‘natural course’ , 339, 419 two-fold nature of (Ball) , 370, 387 education level of patient and , 419 unique vs. common features , 377 importance given to , 344 unity of , 363, 369 indicators of , 401, 419 viewed as complete logical coherence , 388 psychological factors in , 401 Persons, failure to recognize , 141 social environment and , 341, 401, 419 Pfl egeanstalt (‘Nursing home’) , 342 specifi c syndromes and , 401, P fl üger, Edouard , 436 Projection fi bres of the retina , 36 Phenacetin , 428 Projection fi elds in the cortex , 2, 26 Phenazisms , 117, 141 of speech , 6 Philosophy of the viscera , 29 dualism of mind and brain , 365–366 Projection system (Meynert) , 4, 354 German idealist , 370 Pseudoapoplectic attacks in senescence , 320 materialism , 331, 365, 366, 370, 404, 434 Pseudofl exibility , 252, 266 of mind/brain relationships , 365–366 Pseudomelancholia , 262 psycho-physical parallelism , 364, 365, 371, 432 Pseudoparalysis, alcoholic , 295 of science , 338, 361 Psychiatry theory of knowledge (epistemology) , 366–368 backward compared to other specialties , 331, 343 Phonemes (auditory verbal hallucinations) , 80, 117 , criticism of by service users , 344, 422 361, 388–389, 391, 414, 415, 418 developed through precedents of general medicine , 344 compelled repetition of , 127 dynamic tradition in , 403–406 cultural acceptance of ‘hearing voices’ , 403 ethology and , 370 disorientating , 118 guidelines for training in , 347, 358 ‘explanatory’ , 395 history of , 334, 418, 451 localization of voices , 420 hopes for future of , 337 in mania , 218 legal control of , 340–341 in melancholia , 211 literary cross-overs with , 400 narrow defi nition of , 408 professional standing of , 331, 343, 351 as primary abnormalities , 334 public attitudes to , 340 projection of, on the surroundings , 81, 118 reasoning in , 422 relation to uttered speech , 391 relation to neurology , 379–380, 422 site of , 127 research and routine practice inseparable , 358 Phrenesia . See ‘Encephalitis’ role of theory in , 377–379 Phrenic nerve insuffi ciency of , 75, 374, 416, 450 ‘science of’ , 338, 412, 421 Physicality. See ‘Corporeality’ three traditions within , 403 Physics, theoretical , 337. See also Natural philosophy to be based on most fundamental premises , 361 hidden variables in , 361 ‘Psychiker’ , 350, 365, 433, 435 Pia mater, behaviour of in progressive paralysis , 288 Psychomotor pathway , 13 Piaget, Jean , 424 disturbance of , 226 Pick, Arnold , 350, 359, 436 Psychopathology , 368, 397 Pinel, Philippe , 362, 432 Wernicke’s rejection of term , 380, 381, 426, 451 Plato , 365 ‘Psychophysical’ , 451 theory of ideas , 366 Psychophysical movement , 46 Pleasurable sensation , 49 ‘Psychophysiology’ , 451 Poincaré, Henri , 364 Psychosensory pathway , 13 Politzer method , 451 Psychoses Polyneuritic psychosis , 180, 357, 411, 451 active vs. ‘residual’ or ‘memory effect’ , 380–381, 419 aetiology, 295, 296 acute , 111 prognosis , 182 aetiology , 293, 307 symptoms , 180 as consequence of sejunction , 85 Index 473

course , 309 etymology of , 386 ‘exhaustion’ , 408 meaning of word , 385–386 expiry of , 97 previously translated as , 386 as falsifi cation of contents of consciousness , 381, 407 term used by patients , 386 familial loading , 430–431 Rationality, as universal human norm , 368, 403 history of word/concept , 381, 405 Raving madness , 233 insomnia as a precursor to , 377 Reasoning Korsakoff (see, Psychosis, polyneuritic) by analogy , 332, 333, 424–426 manic-depressive (Kraepelin) , 421 from elementary to secondary symptoms , 422 outcome , 313 ‘framework’ (a priori context) needed for , 388 position of, in relation to organic brain diseases , 4 individualised clinical , 419, 421, 422, 423 possible neuropathology of , 336 from neurobiology to psychology , 382, 421, 423 relationship of the acute to chronic , 111 over-inclusiveness of , 333 separation from neurosis , 405 by psychiatric patients , 333, 423 social factors and , 402, 419 in psychiatry , 382, 421 as ‘too much thought’ , 402 in science , 361 ‘transitory’ , 452 (see also Epilepsy, twilight states in) by reductio ad absurdum , 422 treatment for , 428 reverse of deduction , 423 ‘unitary’ , 453–454 types of , 128 Psychoses, acute, basic forms of , 271 unstated premises in , 367 acute progressive sensory , 273 Wernicke’s , 422–427 acute total sensory , 272 Recovery (from mental illness) , 333, 401, 402 alcoholic , 336, 381 dependence on patients’ habits of thought , 368, 423 chronic , 65 of disturbed Affect , 385 circular/cyclic , 220, 399 natural ‘healing’ and , 401 compound , 275, 336, 411 sequence of, for different symptoms , 385, 393–394, 413 course , 102 translation issues , 401 epileptic , 297, 336 Recognition, process of , 16, 18 functional ( vs. organic) , 328, 337, 404–405 Refl ex(es), arc, psychic , 12 hebephrenic (of adolescence/puberty) , 303, 337, axon fl are refl ex , 334, 355 359, 387, 399 congenital refl ex movements , 27, 131 hereditary , 297 consciousness and , 376 hypochondriacal (see ‘Somatopsychosis’) hallucinations , 83, 119 hysterical , 301, 381 movements , 11, 31 menopausal , 305, 337, 358 ‘organ sensation’ and , 384, 450 menstrual , 305, 337, 411 protective , 355 mixed , 271, 336, 411 psychic , 355, 375–376 obsessive , 335 pupillary , 348 periodic , 309 ‘short-circuit’ through cortex, and , 376 polyneuritic , 335, 358, 429, 434 tendon , 357 ‘prison’ (Ganser) , 432 tendon refl exes, alterations of , 280 puerperal , 306, 337 Reinforcement (psychological) , 373, 376, 392, 429 senile , 304, 337, 358, 359, 449 as both consequence and cause of association , 430 symptomatic , 13 psychotic symptoms and , 392 total , 411 Reminiscence , 48 Psychotherapy , 428 Remission , 311 Public attitudes to mental illness in paralysis , 284 concern over custodial practices , 340 Renshaw cell , 371 diffi culties for psychiatrists , 340 Representation (by brain) disputes with lawyers , 340 assimilation of perceptions into concepts , 331, 424 diversity of views , 340 assimilation of sensory images into perception , 331, 424 need for public education , 340 of body , 331, 367, 414 (see also Corporeality) Public health system of the time , 342 of concepts , 331, 366 Puerperal disorders , 336 diffuse , 374 Pupillary rigidity . See Argyll-Robertson pupil of external world (allopsychic) , 331 Pursued persecutor , 95 of eye movements , 18 of goals (‘destination’, ‘execution’) , 10, 12, 44 of language , 331 R of movement , 332, 421 R askolnikov (Dostoievsky) , 395, 438 of personhood (autopsychic) , 332, 367, 374–375, Ratlosigkeit , 385 . See also ‘Disarray’ 402–403 474 Index

Representation (by brain) (cont.) Self-blame delirium . See Micromania potentially fallible , 367 Self-generated ideas. See Autochthonous ideas of sensation , 421 Self-reference, morbid , 81 of verbal thoughts , 382 Senescence , 304 Respiration type, defective , 75 Sensation Restless Legs Syndrome , 336, 380, 427 auditory , 373, 394 Restructuring of words , 102 biases imposed by brain , 363, 367 Retina , 363, 374 compared to perception , 331 images , 18 content vs. ‘tone’ of , 331, 363 ganglion cells in , 355 distinguished from ‘feeling’ , 366 stimulation, form of , 17 intestinal , 335, 351, 389, 417 visual after-images and , 422 localization of , 61 Rigidity (muscle) , 250 , 336, 340, 355–356, 397 of movement , 363, 366 Romberg test , 356 position sensation , 32 Rother (named patient) , 368, 386, 388, 411 sensory content of , 26 taste and smell , 394 threshold , 413 S visceral , 331, 384 S achs, Heinrich , 347 visual , 355, 363, 373 Schäffl e, Albert , 437 ‘Sense of self’. See also ‘Personhood’ Schizophrenia , 341, 349, 373, 383, 384, 387, 400, 421 exaggeration of , 59 associative processes in , 430 in manic patients , 216 disorganised (hebephrenic) subtype , 75, 399 ‘Senseless rage’ , 376 gender/age incidence , 430 Sensory cortical regions , 391 Schneider, Kurt , 367, 383 connections from other cortical areas , 391, 426 Schoppenhauer, Arthur , 437 somatosensory areas , 374 Schroeder, Paul , 347 Sensory perception , 29 Schüle, Heinrich , 359 Sequence of sensory impressions , 23 Science (natural) Severity (of illness) , 397, 408, 409, 410, 414 balance between experiment and theory , 377–378 Affective states and , 414 birth of , 378 grading of , 414 common language of , 381 graphical depiction of , 230 concise description rather than explanation , 365 Sexual abstinence , 437 Scopolamine. See Hyoscine Sexual pathology’ , 382, 435 Scurvy , 340 Sexually-transmitted diseases , 339, 356, 357 Sechenov, Ivan , 356 Shakespeare, William , 350 Seclusion , 429 ‘Shell shock’ , 335, 361 Sécond état (Second state/‘dual personality’) , 188, Sherrington, Charles Scott , 371 295, 299, 335, 340, 349, 357, 369, 378 409 410. Simulation , 322 See also Dissociative Identity Disorder Simultaneity , 363 ‘levelling’ of ideas in , 190, 193, 217 Skin sensation, disturbances of , 28 relation to epilepsy , 369 Sleep , 30 Sedative medicines , 377 as an active process , 377 ‘Seizures’/‘attacks’ , 451 disturbance of , 350, 377 diagnosis of , 286 insomnia and , 377, 416 paralytic , 284 pressure for dreaming sleep , 377 Sejunction theory , 71, 333, 334, 338, 368, 378, 382, REM dissociation and , 377, 412 386–388, 391–392, 393, 399, 425, 430 symptoms during , 380 autochthonous ideas and , 393 therapeutic role of , 427 backfl ow of nervous energy and , 391, 426 Sleeping drugs , 350, 428 fl aws in , 387, 391–392, 426 Snell, Ludwig , 394, 436 hallucinations and , 386 Social class , 359 illogical statements of patients and , 386, 391, 423 Social milieu ‘microanatomical’ basis for , 387 rejection of discharged patients by , 342 ‘mutually contradictory memories’ and , 384 ‘Somatikers’ , 331, 365, 404, 405, 433 negative vs. positive symptoms in , 384 Somatization , 335, 360, 390 origins in Meynert , 387 related to lay understanding of body/mind , 389 as primary pathological process , 386, 388, 407, 420 Somatopsychoses , 336, 381, 410, 417, 418 symptoms of activation and , 386 acute , 163 Self-awareness , 41 aetiology , 160 Index 475

body dysmorphic disorder and , 415 Symptoms. See also Delusions, Hallucinations, and circumscribed intestinal , 153, 156 specifi c named symptoms differentiation from hypochondriacal neuroses , 161 arising from aberrant excitability , 331 localization of pathological sensations in , 160 arising from excesses of excitability (see Symptoms, motor behaviour in , 154, 161 positive) paralytic , 162, 282 arising from loss of excitability (see Symptoms, prognosis , 161 negative) symptoms , 160, 162 allopsychic , 333, 334, 410, 414, 415, 417 worsening , 154, 304 autopsychic , 333, 334, 410, 414, 416, 417 Somnolence , 48 of breakdown, in brain diseases , 72 Space, concept of classifi cation of , 331 acquired rather than innate , 363 ‘symptom complex’ , 404–405, 444 Spatial sense ‘ deduced from features of diseased organ’ , 362, 406 of ear , 29 depend on person’s mental faculties , 382 of retina , 28 detailed analysis within Grundriss , 336, 358, 362, of skin , 35 382, 383, 397, 398, 408 Speech dimensions of, in schizophrenia , 359 articulation vs. content , 366 disappearance during singing (motor symptoms) , 392 centre, sensory , 80 elementary , 333, 362, 383–384, 388, 389, 393, 398, comprehension , 45 416, 446 development of , 33 entirely defi ned by motor behaviour , 396 disturbance, paralytic , 280 functional neurological , 360 excess of , 397 grouping of experiences as , 362, 378, 382 hallucinations , 80 internal connections between , 361, 382 importance for diagnosis , 323 intrapsychic , 331, 336, 410 pathology , 173, 424 as major focus in Grundriss , 333 pathways , 6 manner of expression depends on life event , 383 projection fi elds of , 6 motor abnormalities , 334, 336, 374, 379, 410 schema for , 10 negative , 331, 350, 358, 384, 415 social signifi cance of , 38 ‘over-pathologising’ of , 403 sounds, representation of , 373 as patient’s movements , 331 Spencer, Herbert , 355, 436 positive , 331, 350, 358, 384 Spinal cord , 366 psychological mechanisms of , 382 Spinal miosis. See Argyll-Robertson pupil psychomotor , 331, 410, Spindle (‘fusiform’) cells , 23 psychosensory , 331, 332, 410 Spinoza, Baruch , 364, 366, 367, 369 quasi-neurological , 335, 360 Spirochete , 336 relation between positive and negative , 358, 384 discovery of , 336, 340, 356, 407 relation to specifi c disorders , 409 Statistical analysis/inference , 361, 424 secondary , 333, 383, 384 Stengel, Erwin , 384 sequence of appearance , 413 Stereoscopic image of the retina , 28 somatopsychic , 333, 335, 410, 413–414, 416, 417, 418 Stereotyped movements , 397 as starting point for understanding (Wernicke) , 333, Stimulation effect , 72 362, 382–383, 406 electrical, of muscle , 332 speech , 336 localization of , 126 translation issues , 451 Storch, Ernst , 346 Synapses, chemical transmission in , 354 Stroke , 346, 379, 443 Synaptic plasticity in , 371 Stupor long-term potentiation , 371 alcoholic , 295 long-term depression , 371 paralytic , 281 temporal precision of , 371 post-epileptic , 298 Syphilis , 336, 337, 339, 412 Subconscious. See Psychiatry, dynamic tradition in brain softening and , 443 Suicide , 359, 416 diverse forms of , 340, 355–356 in mania , 218 relation to progressive paralysis , 336–337, 356–357 in melancholia , 207 social factors and , 402 risk of , 336, 342, 345 spirochete as cause of , 336, 340, 356, 407 Suggestion , 90, 139 tertiary (neurosyphilis) , 340, 375, 400, 407 Sydenham’s chorea. See Motor (motility) symptoms, treatments for , 429 chorea Synchronism of sensory stimuli , 21, 22 Syllable stumbling , 173, 280 Systematization of delusions . See Delusions (general) 476 Index

T symptomatic relief , 339 T abes dorsalis , 356, 438 for syphilis , 428 relation to syphilis in Wernicke’s view , 356 Trional , 428 taboparalysis , 285 Tuberculosis (phthisis) , 337, 340, 355–356, 452 Tactile movement , 28, 33 meningitis due to , 340 Tactile organ , 34 Turning in circles , 379, 392 Tactile paralysis , 15 Twilight states Tactile hallucination , 69, 121 in Delirium tremens , 176 Taxonomy , 359 hysteric , 303 Georges Buffon and , 377 in transient psychoses , 157 as ‘natural types’ , 359, 377, 407, 436 paralytic , 283 purposes of , 407–408 pre-epileptic , 189 Telegraphy , 424 post-epileptic , 176, 297 Teleology , 370 Temporal lobe, stimulating symptoms of , 130 Tetanus , 339, 356, 444 U discovery of clostridium tetani , 339, 356 U nconscious. See Psychiatry, dynamic tradition Thalamus , 351, 376, 391 Urge to move atrophy of , 289 choreatic , 231 Theory (in science) , 332, 200 hypermetamorphic , 232 Thiamine defi ciency , 337, 357, 429 jacktatoid , 250 polyneuropathies due to , 357 psychiatric sequelae and , 340 Third Reich , 342, 359 V Thought V asomotor symptoms , 335 audible (‘thought echo’) , 335, 389 Verbigeration (‘loquacity’) , 6, 227, 251, 268, 381, compared to perception , 373 384, 397 disappearance of , 335 Vetoing a decision to act , 376 disorder , 399, 400, 417, 421 452 impairment of vetoing , 376, 379 experiments (Mach) , 354, 362 Vienna, as medical centre , 339, 350, 404 ‘laws of’ , 427 Virchow, Rudolf , 436 processing analogous to overt behaviour , 376 Visions (Visual hallucinations) , 120, 126, 377, 389, 391 role of, as agent controlling behaviour , 370 dependence on affect , 143 ‘thought withdrawal’ , 343 projection of in space , 121 ‘train of ’ , 352 Visiting rights in hospitals , 343 Threshold of perceptions , 47 Visual agnosia , 16, 347, 429, 434, 452 ‘Three-way split’ of symptoms (Wernicke) , 333, 410, Visual cortex , 331 411, 418 Visual fi eld, concentric constriction of , 47, 204 associations between domains , 415 Visual fi eld defects , 28 clinical value of , 411, 413–414 Visual memory , 15, 29 correlation structure of , 411, 415–418 association of , 21 differential diagnoses and , 418 localization of , 5, 15 dissociations between domains , 417–418 relation to hallucinations , 126 integrated to create ‘personal wholeness’ , 421 relation to perceptual images , 17, 29 sequence of recovery and , 413–414 relation to olfactory images, 16 scientifi c validity , 411, 412–413 relation to optic images , 16 strength of associations and , 414 relation to tonal images , 127 Tinbergen, Nikolaas , 370 Visual perception , 19 Tone, psychic , 205 Vitalism , 352, 434, 451 Touch Vitamin C defi ciency , 430 active , 374 Voices, hearing , 79, 117 concept , 33, 34 Voices, imperative and prohibitive , 76, 79, 143 Transitivism , 137 Treatments , 335, 339, 415, 427–429. See also Specifi c named treatments W adverse effects of , 339, 427, 428 W agner-Jauregg, Julius , 435, 436 for anxiety , 427, 428 Wahn (translation of) , 394–395 herbal medicines , 427 Ward, James , 436 in hospital, importance of , 336 Wasserman test (for syphilis) , 336, 357, 339–340 psychotherapy , 401, 428–429 Waxy fl exibility (fl exibilitas cerea ) , 336, 397, 446 Index 477

Weigert, Karl , 353, 437 natural philosophy and , 338 ‘Well-worn’ pathways, principle of , 10, 23 neuroscience, knowledge of , 353–355 Wernicke, Carl neuroscience, gaps in knowledge of , 333, 424 academic disputes and , 350, 352 not ‘distancing himself’ from patients , 344 ambivalence about ‘reformists’ , 340 openness about his own mistake , 345 anonymous acknowledgment (1894) , 337–339, 351, overinclusiveness , 426–427 352, 365 ‘Pathologie’ in Grundriss , 381–381 applying his scientifi c concepts to himself , 344 ‘person’ concept and , 369–370 approach to classifi cation , 332, 343, 362, 382, 421 professional rivals and , 350–353 approach to ‘symptoms’ , 333, 382–383, 410–419 psychosis, concept/defi nition of , 382, 396, as a ‘lone voice’ , 353 413, 451 as neurologist 336, 374–375, 384, 397 420 quantitative data and , 424 ‘associationism’ of , 352, 370, 373–374 rapport with trainees/students , 344, 345 attitude to philosophy , 369, reasoning by , 338, 361, 382, 420, 423–427 ‘causality’ vs. ‘aetiology’ , 364 rejects ‘alien’ status for patients , 344 clinical style , 333, 343–345, 382, 402, 422, 441 rejects personal authority , 422 comments on national differences , 350 search for symmetry , 425–426 comparison with Kraepelin , 421–422 signs of haste in writing of Grundriss , 349 concept of mental illness , 380–381 single case analyses by , 382 (see also Symptoms) competence as general physician , 340 specifi c diagnoses of , 408–409 competence as surgeon , 340 teaching style , 345–346 confi dentiality, concern about , 344 tension between medical training and clinical consistency of use of terms in Grundriss , 348, 422 experience , 421 Fechner and , 338 theory, importance in Grundriss , 378 fl aws in reasoning , 333, 426–427 theory of knowledge and , 366–369 hidden variables in , 361 trainees in his class , 346–347 holism and , 378, 383, 384, 401–403 validation of concepts in , 362 Hirnmythologie (‘neuromythology’) and , 380, 386 written style , 348, 422 humour in Grundriss , 350 Wernicke–Kleist–Leonhard tradition , 346 inconsistencies in Grundriss , 365, 426 Westphal, Carl Friedrich Otto , 351, 432, 436, 437 idiomatic language in Grundriss , 348–349, 350 White matter (hemispheric) , 355, 444, 446 ineptness in child psychiatry , 345 degeneration of (‘medullary’) , 448 interviewing style , 345 Willful activity, diminution of , 207 learning and memory , 371 Will (‘ das Wille’ ) , 46, 206, 335, 371 ‘local sign’ of sensory experience and , 363 defi cit of (melancholia) , 207, 383, 398 localization of function and , 370, 373–375 facilitation of (mania) , 426 meaning sometimes unclear in Grundriss , 349 loss of, in specifi c muscle areas , 397 medical concepts/terminology and , 381, 409, World Health Organization , 384 426–427 method of analysing clinical data , 378 mind/brain relationships in , 365–366 Z mixing psychological and biological language , 370, 426 Ziehen, Theodor , 338, 351, 361, 405, 408, 423, 424, 438