EDITED UNDER THE PROVISIONS OF SECTION 11, CHAPTER 123, WALTER E. FERNALD, M.D. GEORGE M. KLINE, M.D. DOUGLAS A. THOM, M.D. AUGUST, 1923 PUBLICATION OF THIS DOCUMENT APPROVED BY THE COMMISSION ON ADMINISTRATION AND FINANCE *Volume VI not printed. Publication not approved by Commission on Administration and Finance FOREWORD The article presented herewith was read by Professor Wilmanns at a recent sion of the Southwestern German Psychiatric Association at Heidelberg, and was one of the most interesting contributions to the symposium on the subject of Schizophrenia. The proceedings of the meeting were published in full in Vol. 78 of the Zeitschrift für die gesamte Neurologie und Psychiatrie. We feel indebted to Dr. James V. May for the translation of this exhaustive, and at the same time impartial, review of the more recent contributions to our knowledge of dementia praecox. BOSTON, MASS., August 22, 1923. SCHIZOPHRENIA.* By Dr. KARL WILMANNS, DIRECTOR OF THE PSYCHIATRIC CLINIC, UNIVERSITY OF HEIDELBERU. Translated by Dr. James V. May, Superintendent, Boston State Hospital. GENTLEMEN: As the directors of our association have chosen schizophrenia as the subject of this year's meeting, it becomes my duty to present, in the form of a comprehensive statement, a review of the development of the Dementia Præcox or Schizophrenia theory. The history of dementia præcox is, however, the history of psychiatry during the last thirty years. I can, for that reason, show the development of our present conceptions only in the broadest outlines and must in advance ask your indulgence if I refer to many well-known facts and perhaps hardly touch upon essential problems. In resorting to this privilege I assume that the theme will be made the subject of detailed treatment by one of the other speakers. I. When Kahlbaum and Hecker, in their efforts to establish the differentiation of disease entities, proposed Katatonia and Hebephrenia as such, their work received little consideration. Even Kraepelin rejected the new doctrine at first. He did refer in a few words to Hecker's Hebephrenia in the general part of his first two editions (1883 and 1887). Kahlbaum's Katatonia, however, received no consideration at first. Even in 1887 the presentation of Katatonia as a definite disease picture was altogether rejected as an unsuccessful experiment. Katatonic conditions could appear in Melancholia Attonita, in ecstatic Wahnsinn and in Katatonic Verrücktheit, which are "in their development, course and prognosis very variable disease forms". To these, Katatonic Wahnsinn was added in the third edition. Here in Heidelberg followed the decided variations in Kraepelin's views which were expressed in the fourth edition in 1893. It is true that Verrücktheit and Wahnsinn, with their numerous varieties, covered a wide field in their presentation. Near them appeared the special disease pictures, the psychic degenerative processes, dementia præcox in its severe form, hebephrenia, katatonia, and dementia paranoides, in all of which "the unusually rapid development of a permanent state of enfeeblement is common". The fifth edition in 1896 brought further developments in the conception of dementia præcox: Wahnsinn disappeared as a special disease form, Verrücktheit became narrowly limited in favor of dementia præcox, katatonia and dementia paranoides, which were assigned by this time, with myxoedematous insanity and cretinism as deteriorating processes, to the diseases of metabolism. The suggestion already made "that many other clinical pictures. particularly certain groups of Paranoia, should be included in the deteriorative processes" had already given a hint as to the further development of Kraepelin's views. In fact, the sixth edition in 1899 with its establishment of manic-depressive insanity brought a further limitation of Verrücktheit and the elaboration of dementia praecox with its hebephrenic, katatonic and paranoid subforms, which also appeared again in the seventh edition in 1904. It looked like a concession to the views of other investigators when the last edition assigned a special place to certain paranoid forms as paraphrenia, which was included with dementia præcox in the endogenous deteriorating processes. Why our clinic did not join in this change of front is to be related. • Zeitschrift für die gesamte Neurologie und Psychiatrie, Vol. 78, Nos. 4 and 5, Sept. 23, 1922. Several footnotes and 251 references to the literature of this subject have been omitted. Only one who is familiar with the development of Kraepelin's views in the eight editions of his textbook could appreciate what a mass of work was necessary in order to lay the clinical foundation on which the later psychiater could build. Only a man with Kraepelin's zeal and optimism in research could, uninfluenced by all attacks, undaunted by errors, strive constantly towards a goal which was generally looked upon as unattainable. In fact, the result of this endless labor is probably not what Kraepelin had in mind in the beginning of his research. He did not succeed in the separation of the endogenous mental diseases into well-defined disease entities, but he was successful in the division into two groups well characterized as to form and course-manic-depressive insanity and dementia præcox. The development of the dementia præcox theory has finally led to its including the greater part of the simple mental disturbances. When Kraepelin's conception was brought forward it was a disease of adolescence which led rapidly to a permanent mental weakness. Now the cases include all ages of life from childhood to beginning senility, every known symptom-complex can leave its stamp on the disease temporarily or for a prolonged period, and its outcome ranges in limit from recovery to a severe destruction of the personality. These facts were already advanced as a hypothesis by Kraepelin in his sixth edition, in which dementia præcox was conceived not as a disease entity, but a group of outwardly similar mental disturbances. He has never since failed to attempt through new arrangements, separations and comparisons to differentiate smaller clinical entities from this main grouping. To these efforts we owe particularly the description of the presenile delusions of persecution and the hallucinatory weakmindedness of the alcoholic. They are, however, not fully recognized as independent disease pictures by other investigators and have not at any rate led to a considerable limitation of the comprehensive conception of dementia præcox. The possibility on clinical grounds of removing the disease entity dementia præcox from the group of diseases included under this name seems exhausted. That symptoms similar to those of dementia præcox and not to be differentiated from then appear in other diseases is accepted by Kraepelin and also by us. Even within the domain of gross organic brain diseases, cerebral arteriosclerosis, progresve paralysis, brain syphilis, Korsakoff's alcoholic psychosis, etc., symptom pictures may develop as an expression of cerebral processes which are not to be differentisted from certain paranoid forms of dementia præcox. When we do succeed in separating these conditions from it, it is on the basis of certain fundamental metal symptoms and above all by the accompanying characteristic physical signs. Lacking these there is no possibility of differentiating symptomatically similar diseases from dementia præcox. The hope, nevertheless, that by means of newer anatomical or serological methods we shall be placed in such a position is at present till very uncertain. In spite of all that, the separation of the endogenous mental disturbances into the groups is probably the greatest advance which has been made in clinical hiatry. Granting that the dementia præcox of Kraepelin is a group of diseases which are held together only through certain superficial similarities in their manifestations, their nucleus is one disease entity. We are forced to this conception by the results of the psychiatric investigation of families. On investigating the sympVans and the course of cases in a dementia præcox family we sometimes discover a Barprising similarity but more often an extraordinary dissimilarity. Hebephrenic, kattomic and paranoid forms, either with gradual or stormy courses, with a quick ternation in weakened states and with favorable courses, are mixed together in old ways, but demonstrate convincingly their clinical identity. Genealogical arches have prevented our following Kraepelin's efforts to separate paraphrenia the rest of dementia præcox as an independent group. II. Kraepelin always earnestly endeavored to make other scientific aids contributory pychiatry if they promised any results to the clinic. Clinical research in its zwest sense, the study of disease processes, always stood in the foreground of |