History of Psychiatry

http://hpy.sagepub.com Carl Wernicke and the concept of 'elementary symptom'

A. Krahl and M. Schifferdecker History of Psychiatry 1998; 9; 503 DOI: 10.1177/0957154X9800903605 The online version of this article can be found at: http://hpy.sagepub.com/cgi/content/abstract/9/36/503

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History of PsychIatry,

ix

503-508. Pnnted (1998),503-

In

England

Historical vignette

Carl Wernicke and the concept of

elementary symptom
A. KRAHL* and M. SCHIFFERDECKER
Re-written by A. BEVERIDGE

Examination of contemporary medical conference papers reveal that the German clinician, Carl Wernicke, conducted a unique on-going inquiry into psychiatric nosology. Wernicke was searching for what he called the elementary symptoms of mental disorder, or, in other words, the single psychopathological feature, from which all others arose. From 1892 onwards, he postulated a variety of such elementary symptoms. Wernickes theory makes sense in terms of such categories as anxiety-psychosis and hallucinosis. His work contrasts with that of Kraepelin and also with modern diagnostic criteria. Neither Wernicke nor his followers pursued the theory of elementary symptoms, but an examination of his work sheds light on modern ideas about diagnosis.

Carl Wernickes work and his

name

psychiatrist Carl Wernicke (1848-1905) is known primarily

as a

as a

pioneering neurologist,

is remembered in such terms as Wemickes area, Wemickes aphasia, and Wernickes encephalopathy. He turned his attention to psychiatry only in 1885, when he was appointed director of the psychiatric wing of All Saints Hospital in Breslau. His new position allowed him extensive study of psychiatric patients (2), and he drew on this to develop

* Address for correspondence: Klinik und Poliklinik fur Neurologie und Psychiatrie, JosephStelzmann-Strasse 9, D- 50924 Koln, Germany.

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504

important new ideas, which he published in a textbook (9) and in the form of case histories (13). We do not have access to private letters, diaries or case notes, but we are able to examine conference proceedings from the period which reveal evidence of the development of Wernickes thinking.
From

exaggerated idea to elementary symptom1

At the triennial conference of the herein ostdeutscher Irrenrzte,2 there was not only the presentation of papers, but there was also the opportunity for the informal exchange of ideas and comparison of clinical notes. The conferences at Breslau were usually chaired by Wernicke. From 1888, the conference proceedings were published in the Allgemeine Zeitschrift fiir Psychiatrie und psychisch-gerichtliche Medizin.3 At the fifty-ninth conference, on 19 July 1892, Karl Kahlbaum from Gorlitz described his new concept of paranoia, which was based on a psychiatric report he had written. In the animated discussion which ensued, Wernicke, who appears to have been familiar with the case, took issue with Kahlbaums diagnosis of pseudoparanoia. Wernicke contended that the case was an example of an ide fixe, or, as one might usefully call it, a supervalent idea.4 He continued: Every symptom was secondary to the &dquo;supervalent idea&dquo;; this was a case ... of &dquo;logical delirium&dquo;: both affect and behaviour were simply the consequence of the idea(8). In his remarks, Wernicke argued that there was a single, fundamental symptom, and that all the other symptoms derived from it. This was the first occasion that Wernicke outlined his theory, and, in retrospect, his comments can be seen as introducing a new approach to nosology. However, it was to be another year before Wernicke actually used the term elementary symptom. Subsequent conference proceedings allow us to follow its development. The sixtieth meeting of the Verein ostdeutscher Irrenarzte took place on 26 November 1892 in Breslau, and there were thirty-two delegates. According to the proceedings: Dr Wernicke exhibits (...) 14 patients from his clinic, the first two as examples of supervalent ideas. He diagnoses the remaining 12 as cases of psychosis of motility. He reserves the details of his observations for a forthcoming publication (10). The delegates observed the fourteen patients, but no papers were read. However, at the conference at Sorau on 25 June 1893, Wernicke replied to

Eastern German League for Abnormal Psychology. General Journal of Psychiatry and Psychiatric-Legal Medicine. 4 Wernicke was employing the notion of supervalent idea/overcharged idea ( überwerthige Idee) as early as 1890, in the evaluation of a case of persecution complex. So he reported in an 1897 essay, Zur klinischen Abgrenzung des Querulantenwahnsinns (Toward a clinical definition of persecution complex), Monatsschrift für Psychiatrie und Neurologie, Bd. II, S.10.
3

Elementarsymptome.

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505

questions

about his views:

Since the question has been raised today, I would like say just a few to words about supervalent ideas and underestimation.5 There are cases where an elementary symptom is all that comprises the disorder; for example, in cases of anxiety, unhappiness, or hallucinosis, or where the entire disorder is limited to a flight of ideas; in other words, there are 6 cases where an elementary symptom dominates the entire disorder.6 There are also cases where elementary symptoms exist in combination; such cases are more frequent. So it is quite common to find supervalent ideas in cases of melancholy, which is characterized by numerous such ideas. However, the opposite condition - mania - can be characterized in terms of underestimations. By this I mean that certain ideas lose their importance. For example, ideas about discretion, honesty or decency, which the patient formed when he was younger, may now be considered as overestimations. One sees this all the time in patients with mania.

(11)
Insofar as he equated a particular symptom with a particular disorder, Wemicke was drawing on a commonly held principle of general medicine. At this stage, he was not seeking to comment on aetiology, and he remained in the German tradition of meticulous clinical description (6). Later, however, he went on to develop his complicated sejunction theory, which was based on his association theory. Here he attempted to establish a strict relationship between psychopathological symptoms and cerebral pathology (4).
From elementary symptoms to anxiety-psychosis At the sixty-sixth meeting of the herein in Breslau on 24 November 1894, Wemicke developed his ideas about the concept of anxiety-psychosis further, but he remained consistent with his earlier pronouncements:
It is a clinical necessity that we define such a group of disorders, since there are innumerable cases where a pathological fear is the dominant symptom, and where this symptom underlies all the others. The delusions that accompany the psychosis may be visual or auditory. The basic content of all such delusions is fear: the patient fears that his or her life is threatened, often in fantastic ways; or the patient fears a loss of honour, as indicated in the hostility of voices he or she hears; or the patient suffers an inferiority complex, i.e. an imagined loss of status; or, finally, the patient

... Es giebt Fälle, in welchen ein Elementarsymptom die ganze Geisteskrankheit ausmacht; es giebt ohne Zweifel Fälle, in denen die ganze Geisteskrankheit in nichts anderem als in Angst besteht, andere in denen sie nur in Hallucinationen besteht, in anderen wieder in Unglücksgefühl, wieder andere in denen die ganze Krankheit sich fast erschöpft in Ideenflucht; es giebt also Fälle, in welchen ein Elementarsymptom das ganze Krankheitsbild beherrscht.

5 Idee. unterwerthige 6 Original version:

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506
that the future is hopeless. We can describe all such delusions as delusions of anxiety, because we often observe them in the context of anxiety. One could also postulate that there was a specific type of psychosis, namely hypochondriacal psychosis, in which hypochondriacal ideas predominate ... Simple, uncomplicated cases almost always offer the best prognosis. (12)

imagines

The historical significance of the concept In contrast to Wernickes theory of the elementary symptom, Kraepelin sought to describe all the clinical aspects of a particular disorder (3). In fact, Wernickes approach only successfully accounted for two conditions: anxiety psychosis and hallucinosis. In the former, all the symptoms derived from the underlying anxiety and they grew worse as the anxiety increased. In the latter, secondary symptoms developed in response to the hallucination. Both conditions were characterized by anxiety, but in different ways. In anxietypsychosis, the symptoms were secondary to anxiety, whereas in hallucinosis, anxiety was secondary to the symptoms. As we have seen, Wernicke mentioned two other states which he sought to explain in terms of overestimations. These were unhappiness and flight of ideas. While the feeling of unhappiness in the context of depression is almost invariable, it has little aetiological significance, and Wemicke was unable to extend his argument or to establish a psychosis of unhappiness. Wernickes theory of elementary symptoms had more success in explaining flight of ideas. Mania may present primarily with flight of ideas. Nevertheless, this symptom is not confined to one discrete mental disorder, but may occur in a variety of conditions. There are three reasons why Wernickes theory of the elementary symptom met with little success. Firstly, he did not pursue his idea, preferring instead to devote time to his sejunction theory. Secondly, in keeping with the traditions of German psychiatry (6), he merely described clinical vignettes, unlike Kraepelin or Kahlbaum, who delineated syndromes or discrete disorders. Wernicke was thus unable to distinguish between the physical or psychological causes of symptoms (13). Finally, anxiety, which Wemicke placed at the centre of his clinical descriptions, is seen in nearly every mental disorder. The theory demands that all symptoms derive from one elementary symptom, but it is difficult to decide which symptom should be given priority. In practice, Wernickes system was seriously flawed and was unable to illuminate diagnosis or aetiology. Nevertheless, Wernickes hypothesis demonstrates that he was an original and independent thinker, and no comparable theory can be found in the work of Kraepelin, the French clinicians or, indeed, in any of the contemporary literature. Although he was a follower of Wernicke, Karl Leonhard ignored the concept of elementary symptoms; rather he sought to

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507

incorporate Wernickes psychopathological categories into Kraepelins binary system. Thus he renamed anxiety-psychosis, cycloid psychosis, which he believed resembled schizophrenia in its symptomatology, but also manicdepressive psychosis in the periodic course that it followed (5). However, Leonhard abandoned Wernickes original reason for proposing such
disorders.

elementary symptom today Every experienced psychiatrist has witnessed anxiety in patients. However, it is methodologically difficult to provide operational diagnostic criteria for anxiety, because it is part of normal experience and resists precise clinical description. The theory of elementary symptoms plays no role in modem discussions about nosology and aetiology, but it does have a place in modem psychopharmacology with its notion of target symptoms. Clinical psychopharmacology has been more orientated towards treating particular symptoms than diagnostic categories. The principle of treating a target symptom rests on the assumption that other symptoms are, in some sense, dependent on the original target symptom. Such theorizing has obvious parallels with Wernickes system. Even if it is impossible to determine the aetiology of anxiety-psychosis, the concept does have a bearing on current practice. Every experienced clinician has observed the coexistence of acute psychosis with high levels of anxiety. Tranquillizers are used to treat the anxiety (7), and the resultant calming effect is often accompanied by an improvement in the psychotic symptoms. Perhaps if Wernicke had been able to test his hypotheses by means of an effective psychopharmacology, the influence of his theories might have been greater.
Conclusions The proceedings of the Verein ostdeutscher Irrenarzte reveal a particularly creative phase in Carl Wernickes career at Breslau. Before he developed the sejunction theory - a doctrine which was to be crucial to his later work - he pursued the hypothesis that some mental disorders are manifest by an elementary symptom that forms the basis for all the other symptoms. His attempts to clarify the concept of anxiety-psychosis between June 1893 and November 1894 were clearly based on meticulous clinical observation. His observations stimulated a burst of creative theorizing, but unfortunately, he did not immediately commit his thoughts to writing. Tracing the evolution of Wernickes thinking is not merely of historical interest, but also provides an insight into modern diagnostic trends. Every revision of modem diagnostic manuals results in an addition to the number of mental disorders (1, 14). As a consequence, there is a desire for simplification and clarity. Wernickes crucial dictum that the clinician should identify the dominant symptom in any given mental disorder has parallels in

The

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modem practice. Each new manual tries to accommodate an ever-expanding volume of research and clinical theory. Clearly, even where diagnostic criteria are accorded equal conceptual weight, there might be practical and empirical reasons to weigh them differently in specific cases; in other words, to select certain symptoms as being more elementary. It is too early to say whether there will be efforts to simplify diagnostic manuals. Perhaps it is more likely that the manuals will continue to increase in size as they attempt to remain comprehensive, and thus become even less comprehensible. On the other hand, improvements in drug therapy can only proceed in tandem with a better understanding of what constitutes the target symptom in a particular disorder. Such improvements might lead to changes in ideas about aetiology and diagnosis. Such potential developments, presently only implicit in empirical research, would be in the tradition that Carl Wernicke established at the turn of the century.
REFERENCES

Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th edn (Washington, DC: American Psychiatric Association, 1994). 2. Karl Bonhoeffer, Die Stellung Wernickes in der modernen Psychiatrie, Berliner klinische Wochenschrift, xlii (1905), 927-8. 3. E. Kraepelin, Psychiatrie, ein kurzes Lehrbuch für Studirende und Aerzte (Leipzig: Abel, 1893). 4. Mario Lanczik and G. Keil, Carl Wernickes localization theory and its significance for the development of scientific psychiatry, History of Psychiatry, ii (1991), 171-80. 5. K. Leonhard, Aufteilung der endogenen Psychosen (Berlin: Akademie, 1986). 6. Uwe Henrik Peters, Diagnostische Bilder, Phänomene und Kriterien in der Psychiatrie - eine Gegenüberstellung, Fortschritte der Neurologie Psychiatrie, lxii (1994), 137-6. 7. U. H. Peters, Zur Psychopathologie der Angstpsychosen. In: H. Heinrich and B. Bogerts, Angstsyndrome (Stuttgart, New York: Schattauer, 1988). 8. Carl Wernicke, discussion at the 59th convention of the Verein ostdeutscher Irrenärzte, Leubus, 19 June 1892, Allgemeine Zeitschrift für Psychiatne und psychisch-genchtliche Medizin (1893),
486-9. 9. C. Wernicke, Grundriss der
10. 11. 12. 13. 14.

1. American

Psychiatrie in klinischen Vorlesungen. Teil I und II (Leipzig: Thieme, 1894,1896). Carl Wernicke, description of a case, 60th convention of the Verein , Breslau, 26 November 1892, Allgemeine Zeitschrift für Psychiatne und psychisch-gerichtliche Medizin (1895a), 206. Carl Wernicke, remarks at the 62nd meeting of the Verein, Sorau, 25 June 1893, Allgemeine Zeitschrift für Psychiatrie und psychisch-gerichtliche Medizin (1895 ), 207. b Carl Wernicke, description of a case, 66th convention of the Verein, 24 November 1894, Allgemeine Zeitschrift für Psychiatrie und psychisch-gerichtliche Medizin (1895 ), 1016-21. c C. Wernicke, Krankenvorstellungen aus der psychiatnschen Klinik in Breslau. Heft I und II (Breslau: Schlettersche Buchhandlung, 1899,1900). World Health Organization, The ICD-10 Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines (Geneva: World Health Organization, 1992).

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