History of Psychiatry

http://hpy.sagepub.com Karl Ludwig Kahlbaum (1828-1899) and the emergence of psychopathological and nosological research in German psychiatry
Mario Lanczik History of Psychiatry 1992; 3; 53 DOI: 10.1177/0957154X9200300905 The online version of this article can be found at: http://hpy.sagepub.com

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History of Psychzatry, III (1992), 5353-58. Pnnted In England

Karl Ludwig Kahlbaum (1828-1899) and the emergence of psychopathological and nosological research in German psychiatry
MARIO LANCZIK*

Introduction

Since the turn of the century, two diametrically opposed theories have dominated the debate concerning the classification of the endogenous psychoses: on the one hand, Carl Wernicke, Karl Kleist and most recently Karl Leonhard have advocated a model which sees the endogenous psychoses encompassing a wide range of diseases; in contrast, Ernst Albert Zeller, Heinrich Neumann and Wilhelm Griesinger have championed the concept of a unitary psychosis. As a compromise between these two conflicting views, Kraepelin proposed that the endogenous psychoses could be divided into two groups. The Kraepelinian dichotomy has survived to the present day and forms the basis of most standard systems of classification. Kraepelins rival at the turn of the century was Wernicke, who worked at Breslau (Lanczik 1991). Unfortunately, Wernicke died in an accident in 1905, leading Leonhard to speculate that psychiatry might have taken a different course if he had survived to continue his work. Despite their rivalry, however, both Kraepelin and Wernicke recognized the debt they owed to the work of Karl Kahlbaum. Until the middle of the nineteenth century, mental disorders were classified on the basis of their clinical symptoms. In an innovative departure, Philippe Pinel attempted a classification, which took into account, not only symptomatology, but also the observed course of the illness (de Boor 1954). The work of Kahlbaum has obvious parallels with this approach.

* Address for correspondence: Dr. med. Mario Lanczik, Department of Psychiatry, School of Medicine, University ofWrzburg, Fiichsleinstr. 15, 8700 Wurzburg, Germany. The author gratefully acknowledges the assistance of Dr Allan W. Beveridge in the writing of this
,

paper.

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54
A brief biography

Originally from Driesen in Brandenburg, Kahlbaum studied medicine, natural science and mathematics in Konigsberg, Wrzburg, Leipzig and Berlin. He began work at the East Prussian provincial mental institute of Allenberg, but he was unable to pursue an academic career because, at that time, the Prussian Ministry of Culture had not yet been persuaded of the necessity of establishing a psychiatric clinic at University of Konigsberg. Disappointed by this situation, Kahlbaum moved to a private mental institute in Gorlitz, Silesia in 1866, and, the following year, became its director.
Kahlbaums psychiatric research
With the publication of his, Die Gruppirung der psychischen Krankheiten und die Einteilung der Seelenstdrungen in 1863, Kahlbaum laid the foundations for general clinical research into psychopathology and nosology in Germany. His book was influenced by French empiricism, and was a reaction to Neumanns (1859) concept of a unitary psychosis. The basis of Kahlbaums classification was his belief that a diagnosis in psychiatry - as in other branches of medicine - implied that an illness had specific aetiology, set of symptoms, course and prognosis. Pathological research should aim at uncovering the physical origin of these clinical features. His longstanding colleague, Ewald Hecker (1871a), had written that psychiatrists should not wait until the pathological basis of each syndrome had been discovered, but, instead, they should establish diagnostic categories in the light of careful clinical observation. This, in effect, is what Kahlbaum achieved. It was only after his death that Kahlbaum gained international recognition for his concept of catatonia (Kahlbaum 1874). Indeed, when he presented his work on Spannungsirresein to the 1869 meeting of the German Society of Psychiatrists and Neurologists in Innsbruck, he met with open hostility (Neisser 1924). As a result of this rejection, Kahlbaum left the description of hebephrenia, (originally named Jugendirresein) to Hecker who published his account in Virchows Archiv fiir pathologische Anatomie und Physiologie in 1871(b). The clinical description of catatonia and hebephrenia was of a progressive illness with a recognizable and consistent course; in addition, hebephrenia was said to display certain pathological features. More detail about this topic can be found in Katzensteins (1963) interesting thesis. Although Kahlbaum worked outwith German University psychiatry, his classification had a significant impact on the development of nosology in Germany (Lanczik and Elliger 1988), and his influence can be discerned in the work of Kraepelin, Wernicke, Kleist and Leonhard.

From Kahlbaum to Kraepelin

In his definition of dementia praecox,

Kraepelin adopted Kahlbaums concept of

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55 catatonia and

hebephrenia; however, he did not accept that they were discrete diagnostic categories, because he maintained that both the course of the illness
and the
outcome

varied amongst

cases

within each group. In the famous sixth

reprint of his textbook, Kraepelin described catatonia and hebephrenia as subforms of dementia praecox (incidentally, he had taken this term from the work of Benedict Morel). In addition, Kraepelin maintained that the two categories could not be clearly separated from one another. In this connection the work of Hoff (1985) is especially valuable. The belief that catatonia and hebephrenia were specific diagnostic entities was eventually discarded when Wilmanns (1907) and Lange (1922) described catatonic features in patients with manic-depressive psychosis (or more accurately mental illnesses with a favourable prognosis); in its place, the theory of psychiatric syndromes was developed. To determine the prognosis of an illness at the same time as making the diagnosis had been a long-standing ambition of physicians and psychiatrists alike. Kraepelin attempted to realize this ambition when he separated manicdepressive psychosis from dementia praecox. Even today, however, the division between the two illnesses cannot be clearly maintained, as cases of dementia praecox can recover. Eugen Bleuler (1911) and Kurt Schneider (1955) both retained the Kraepelinian dichotomy of the endogenous psychoses; but they emphasized the clinical presentation of the two conditions and discounted the prognostic implications of the diagnosis. Uncertainty continued and the dividing line between the two psychoses was repeatedly redrawn; it remains an issue
which has yet to be resolved.

The acceptance of Kraepelinian nosology by American psychiatry has led to its overwhelming influence over nearly all current classification systems. On the other hand, the French and Japanese never completely adopted Kraepelins bipartite division of the psychoses and have retained the term atypical psychoses to describe a group of illnesses that do not resemble schizophrenia or

manic-depressive psychosis.
From Kahlbaum to Wernicke, Kleist and Leonhard In contrast to Kraepelinian theory, the work of Wernicke and his followers has been much less influential. Leonhard, who died in 1988, was the last contemporary psychiatrist to retain the nosological categories of catatonia and hebephrenia (Leonhard 1979, 1986). In his writing, Leonhard refers to both Kraepelin and Wernicke. Wernicke (1906) had adopted Kahlbaums principle of categorizing mental disorders in terms of the neurological concept of function, i.e., hyper-, hypo- and parafunction. This is readily understandable, as Wernicke regarded psychoses as brain diseases; indeed, he published a classic description of sensory aphasia (Wernicke 1874). He held that mental diseases were due to interruptions in the continuity of association pathways which he called sejunctions (Wernicke 1906, Lanczik 1988). He cited mania as an example of hyperfunction, while melancholia was said to demonstrate hypofunction. According to Wernicke the

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56

precise cerebral location of any disorder in the classificatory scheme of endogenous psychoses was of little importance (Wernicke 1906, Lanczik 1988). Karl Jaspers (1922) was later to dub this materialistic perspective brain mythology. In keeping with Wernicke and Kleist (1908, 1909, 1953) who regarded schizophrenia in terms of neurological impairment, Leonhard (1936, 1948, 1986) maintained that the condition had its origins in the selective loss of cerebral function. This produced either evidence of specific mental dysfunction or symptoms of cerebral irritation, both of which lent the psychosis its characteristic clinical picture. Leonhards work echoed Wernickes scheme of classifying mental and brain diseases along lines suggested by neurology. In creating their classification Wernicke, Kleist and Leonhard concentrated on the cardinal symptoms of the disease (Teichmann 1990). This meant that they looked for symptoms which reflected a loss of function or a specific focus of cerebral irritation. Their failure to find a corresponding physical basis for psychopathological phenomena seriously weakened their theoretical position. As a consequence their work has been dismissed as merely speculation (for example, see Pauleikoff (1983)). The nosology of Wernicke, Kleist and Leonhard was flawed by its abstract notion of anatomical function; as a result it had little impact on the devising of modern classifications or operationalized diagnostic criteria. However, this appears to be unfair, as Kraepelins system has not led to any advances in biological psychiatry. In addition, it was Kleist and his colleague Neele (1949) who first proposed the subdivision of affective illness into unipolar and bipolar categories. This deserves to be more widely known, and, indeed, so do many aspects of the historical development of psychiatric nosology. For example, Leonhard (1979, 1986) delineated 35 different types of endogenous psychoses and he tried to validate them in terms of symptoms, prognosis and heredity; he outlined seven categories of catatonia and four of hebephrenia.
Conclusion
Kahlbaum introduced into German psychiatry the clinical method of determining diagnosis by considering both the course of the illness and the individual symptoms. Wernicke classified diseases according to their symptomatology, whereas Kraepelin emphasized their course and outcome. Leonhard employed Kahlbaums principles of taking into account both the symptoms and the course of the illness to produce a highly complex classification system. Kahlbaum stands at the origin of the two diverging trends in German psychiatry; the Munich and the Breslau schools of psychiatry. Leonhard was responsible for uniting these opposing theories.
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