From Evolutive Paranoia,by August Wimmer (1902): Part 2

[Part 2, pp. 23–31 ^* ]

But when it comes to an arrangement of the different clinical forms of course from a common comprehensive viewpoint, then, in more recent times, the Germans have had to yield to psychiatrists in the country, where the concept of paranoia was born. It is French psychiatrists, headed by Magnan, who have provided a comprehensive and yet simple clinical basis for a natural arrangement of the paranoia forms.

Magnan’s first works on the question of paranoia date back to the beginning of the 1880s. Until then there had not been viewpoints from the French regarding these psychoses, which to any significant degree went further than to the views of Lasèque and Morel. The paranoia forms were, as a rule, described under the collective term délire de persécution, and they essentially limited themselves to delve into the symptomatology of this psychosis. In 1876 Taguet (61) described querulous paranoia (les persécutés persécuteurs). In 1871, Foville (62) had drawn special attention to the transformation of délire de persécution into délire de grandeur. It is now to the great merit of Magnan and his pupils (among them Garnier, Legrain and others) to have pointed out that in the concept of paranoia by the earlier authors a sharp distinction must be made between two forms of paranoia, which both in their symptomatology, course and aetiology showed a fundamental difference.

First Magnan (63) separates out a group of paranoid conditions which he has termed délire chronique à évolution systématique. This is a paranoia form which generally attacks individuals of mature age, who have previously been mentally healthy and who until this point had not manifested any signs of intellectual, moral or affective disturbances. The additional characteristic features of the illness are as follows: its long duration and its methodical, ever progressive course, which allows for a clear distinction of four sharply separate stages: 1. the incubation stage, characterized by the patient’s restlessness, egocentricity and the occurrence of illusions and paranoid interpretations; 2. in the persecutory stage, persecutory ideas and hallucinations occur, especially auditory, and disturbance of the general feeling of well-being; 3. the megalomanic stage is characterized by the occurrence of grandiose ideas, which quickly repress the persecutory ideas, and also the hallucinations assume a somewhat expansive character. The systematization of the paranoid ideas has now reached its acme, but often also shows an incipient decline, which becomes even more pronounced in 4. stage, the dementia stage, where the logical connection between the paranoid ideas become increasingly loose, as a progressing dementia gradually will dominate the picture. It can take decades for the various stages to develop, however, there is no question of a cessation. The progression to the terminal dementia is obligatory and, therefore, the prognosis pessima.

Magnan insists on a sharp separating out of all the paranoid conditions that do not progress through this sequence of development stages from délire chronique, and he collects them under the term les délires des dégénérés (69). According to him, what keeps these often very heterogeneous conditions together in a nosological main group is, in part, their absolute belonging with the inheritability and the psychic degeneration, in part, their mode of development, and finally their outcome. Regarding the first point, according to Magnan, the basis for these forms of paranoia is a heritable predisposition, which reveals itself through the psychic degeneracy. From childhood these paranoid individuals have shown all the signs of “déséquilibration mentale”, mental disharmony. Long before the outbreak of the illness, such abnormalities may have shown in the character – abnormal drives, obsessive thoughts, etc. – which, according to Magnan, characterize these individuals as his “stigmates psychiques” (70). Furthermore, the development of the paranoid ideas is very different from that of délire chronique. In the degenerative paranoia forms, one never finds the latter’s long incubation stage; in the degenerate individuals, the paranoid ideas occur suddenly, “d’emblée”, full-blown, without any influence of hallucinations, which by and large are infrequent in these paranoia forms. The paranoid ideas do not follow one after the other in definite periods as in délire chronique; there is no progression, no transformation of the paranoia, but it is stable, “is today as it was yesterday”. Most often the persecutory and expansive ideas exist side by side, or the délire is even more “polymorphous”, a variegated and changing mixture of expansive, persecutory, religious, hypochondriacal, etc. features. The duration of these forms of paranoia varies a lot; some cases with acute onset abate in days or weeks, others of more chronic development and more systematized persist unchanged for life, often with acute exacerbations (“bouffées”). Thus, the prognosis in these conditions is different and relatively more favourable than in délire chronique. Even though cure does not occur, termination in dementia is rare. As the first form of these degenerative forms of paranoia, Magnan (74) mentions les persécutés persécuteurs with the sub-groups les processifs, les menaçants, les hypochondriaques, les filiaux, les amoureux, and next the more systematized forms: les délires systématisés des dégénérés (75) – persecutory or expansive, combined with hallucinations and disturbance of the cenesthesia. These forms, to a deceiving degree, can resemble délire chronique, but the atypical course of development will make the differential diagnosis possible (76).

Initially, Magnan’s views were expressed in smaller periodicals and in a couple of dissertations from his department [L’Asile Sainte-Anne, Paris]. However, they did not attract much attention until Falret, in July 1886, suggested debating them in Sociéte Médico-Psychologique. This long and interesting discussion was not concluded until June 1888, giving us the opportunity to learn in more detail about the views of the French psychiatrists with respect to these psychoses.

The discussion was opened by Magnan’s disciple, P. Garnier (69), who gave a clear and concise presentation of the Magnanian theories, as has been summarized above. The next speaker was Falret (70), who by and large agreed with Magnan and Garnier, but he expressed some reservations on a couple of points in the new teachings. Concerning the main separation of the paranoia forms in the aforementioned two large groups, he unreservedly agreed with Magnan: “J’admets très volontiers … la vérité clinique de cette distinction entre les folies héréditaires et les délires chroniques, envisager les d’une manières générale.” ¹⁶ However, in his description of délire chronique, on two points he distances himself from Magnan’s categorical doctrines, for according to Falret (77), délire chronique makes its onset with a “période d’incubation” (first period); then follows the second period of the illness with auditory hallucinations, whereas the persecutory ideas increasingly take form and start to become systematized. Finally, the systematization gains momentum in the third stage – “période du délire chronique et stéréotype” – and, concurrently, hallucinations develop in the other senses – taste and smell – and the general cenesthesia. But this third period, according to Falret, can continue throughout many years and until the death of the patient without essential modification and without termination in dementia. He admits, though, that in numerous cases a transformation of the paranoia occurs to the effect that the persecuted becomes megalomanic. First of all, according to Falret (78), this transformation only happens in approximately one third of the cases, and, secondly, the original persecutory ideas and hallucinations do not become suppressed, as claimed by Magnan-Garnier. These persist unaltered alongside the megalomania, which Falret, therefore, considers as “un simple délire surajouté”. “Le tableau de l’état maladif se complète par l’addition d’un nouveau délire, qui donne un aspect extérieur différent à la maladie, mais le fond reste le même et se perpétue ainsi, pendant de longues années …”. ¹⁷ Finally, regarding Magnan’s fourth period, the dementia period, Falret opines that the decline in the patient’s intelligence, of gradual onset, cannot be considered as a “veritable démence”, but is due to either the age, apoplectic insults or similar accessory causes. Further, Falret (79) is also of the opinion that any new term for these paranoia forms is not required, but that Lasèque’s old term: délire de pérsécution should be retained.

Garnier and later Magnan gave some concession to Falret’s objections to the teachings to the effect that persecutory and expansive ideas could co-exist for a long time, and that the “dementia” is not to be taken too literally. In this instance, it was only a matter of a démence vésanique, not a démence organique, as for example in dementia paralytica. What constituted the first kind of dementia was less destructive of the intellectual functions than “la désagrégation d’un édifice délirant” (Garnier (74)).

The Magnanian theories were fully endorsed by Briand (75), Doutrebente (76), Saury (77), and Camuset (78), but were sharply and dismissively criticized by Dagonet, Delasiauve, Christian, Ball and Séglas.

Dagonet (79) asserted le délire de persecution, Lasèque, to be “un type nosologique et une véritable entité”, which, at times, is cured, but usually terminates in dementia; at other times it persists unaltered, but never follows the course of development postulated by Magnan-Garnier. On the other hand, according to Dagonet, la monomanie ambitieuse ou mégalomanie is also a nosological type and should not to be understood as a phase in a délire chronique. By and large, Dagonet appears not to have fully understood the basic idea in the Magnanian theories.

Delasiauve’s (80) objections were especially aimed against the weight that the Magnanian teachings place on inheritability as a principle of classification, but, apart from that, he could not approve of the postulated development through certain periods: the megalomania can occur before the persecutory ideas, etc.

Christian (81) is fully opposed to Magnan’s teachings: “Je critique non pas l’étiquette, mais la théorie elle-même.” He admits that a délire de persécution always has a “période d’incubation”, but a transition from one to the other stage is not necessary. The melagomanic stage is not obligatory; Christian had encountered many persécutés who had remained so all their life; certainly, in those forms that are essentially genital, megalomanic ideas never occur, at any rate only as accessory or transitory. In a few cases the ambitious stage precedes the persecutive, or alternates with this. Nor does the fourth stage, the dementia, exist. Christian has never seen a persécuté become demented, apart from the influence of age.

Ball (82) opines that a development of the paranoia through four stages cannot be doubted by anyone, but that the exaggeration starts when one tries to establish a firm rule regarding this point; if anything, these cases are rare exceptions. For these reasons, but especially out of respect, Ball will absolutely preserve the old term délire de persécution.

However, the new theories were met with the weightiest criticism from Séglas (83), who appears most clearly to have comprehended what needed to be established in this discussion. First, on the basis of clinical observation, he attempts to demolish the cornerstones of the Magnanian teachings by presenting a number of case histories that in his opinion would prove that, in patients suffering from the psychosis Magnan describes as délire de persécution, inheritability and psychic and physical stigmas can co-exist. Séglas draws attention to similar statements by a few authors, who otherwise praise the new teachings, including a thesis by Respont, in which are mentioned two cases of délire chronique in individuals with epilepsy. Rightfully, Séglas wonders about this co-incidence of a neurose dégénérative with Magnan’s délire chronique, which was supposed to be very sharply separated from the degenerative forms of insanity. On the other hand, Séglas asserts and finds his claim confirmed by cases described by Legrain (84) – that in the degenerate some cases of délire occur characterized by a slow and chronic development with all the traits of a délire systématique. In general, therefore, Séglas cannot accept délire chronique as an illness sui generis, and therefore he sees no reason to abandon the old term coined by Laséque.

First, Magnan (85) attempted, although not entirely convincingly – to show that Séglas’s case histories were not correctly reported. Magnan asserted that the inheritability does not exclude the development of a délire chronique, in that inheritability as such does not mark the individuals as “héréditaires dégénérés”; it is on the last word that the emphasis ought to be placed. Not even the presence of epilepsy is sufficient, as during such the psychic life, although in rare case, can be intact (86). By and large, in the discussions Magnan gave a number of concessions with respect to the initial strict formulation of the teachings. We have already mentioned that he quickly gave up insisting on the sharp distinction between the second and the third stage; also with respect to megalomania he had had to concede that it was not obligatory, although very common; and it did not need to consist of pronounced paranoid ideas, and that it could limit itself to a more diffuse heightening of the self-esteem. Finally, Magnan admitted, the terminal dementia was not ever absolutely necessary for the diagnosis délire chronique.

Despite these concessions to the opponents, the Magnanian theories have only found partial endorsement in the camp of the French psychiatrists. Thus, for instance Ball (87) and Séglas (88) in their lectures still defend their separate opinions, whereas Ballet (89) used the Magnanian framework as the basis for his description of the paranoia forms in “Traité de Médecine”, 1894. Finally, in a series of lectures from 1897, Magnan (90) has presented a collected and systematic exposition of his teachings on “les délires systématisés dans les diverses psychoses”.

The concept of paranoia has been given its formulation in French and German psychiatry. The literature of the other European countries has not contributed with anything original to the teachings of paranoia, but, if anything, has taken up the German or French views.

In the more recent English literature, the paranoia conditions are still described partly as monomania, partly as delusional insanity. Clouston (91), who uses the former term, distinguishes between a monomania of grandeur or pride, a monomania of unseen agency and a monomania of suspicion, as he limits himself to a purely symptomatological description. Savage (92) uses the term delusional insanity and insists these conditions be separated from mental weakness [Schwäche]; apart from that, his attempts at classification and description are also purely symptomatological. Finally, Clark (93) has taken up the Magnanian theories and describes his chronic progressive delusional insanity similarly to Magnan’s délire chronique.

The Italian authors, whose writings have not been directly accessible to me, and which I only know through Séglas’s thesis (94), seem in part to adapt the German views; they mainly use the term paranoia. Tanzi and Riva (95) appear to be especially praising the views of Krafft-Ebing. Morselli and Buccola (96) divide their pazzia sistimatizzata into primary systematic paranoia conditions, which occur as a result of developmental inhibition (Sander’s originäre paranoia), and primary systematic paranoia, which first occurs in an already fully psychically developed individual. Finally, Amadei and Tonnini (97) divide paranoia into paranoia degenerativa and paranoia psychoneurotica. The first group falls into an “original” and a “tardive” sub-group, which is further divided into simple and hallucinatory forms. Paranoia psychoneurotica is divided into a primary form, and a secondary form (the latter secondary to melancholy and mania). Further, the primary one falls into acute, curable forms, and incurable forms, in which latter a distinction is made between simple and hallucinatory forms.

In Denmark, Pontoppidan (98) has adopted the Magnanian views and describes paranoia forms that are consistent with them, under the terms typical and atypical paranoia. Friedenreich (99) also virtually adopted Magnan. He describes a paranoia major sive completa (délire chronique), an original paranoia (Sander), and finally a paranoia minor (délires systématisés des dégénérés).

II

The preceding overview of the historical development of the teachings of paranoia will have taught us how diversified views still exist among the psychiatrists, both with respect to the delimitation of paranoia from symptomatically similar psychoses and, even more, when it concerns the classification of the individual forms of paranoia into larger groups.

In this respect though, paranoia only shares the fate of the other psychoses, whose pathological-anatomical substrate is not yet sufficiently known. As long as psychiatry’s working method is still essentially clinical, consensus about the principle of psychiatric classification will be some time coming, and the classificatory attempts, therefore, will have an essential subjective character.

For the time being, one must proceed based on clinical research methods, but the aforementioned group of German authors Mendel (100), Ziehen (101), and Werner (102) [in Part 1 of this translation] were wrong to limit oneself to a purely symptomatological definition of paranoia only as being determined by “das primäre Auftreten von Wahnvorstellungen” and then under this group to collate acute, rapid transitory and chronic-stationary illness forms, whose only tie to the impartial observer would appear to be the fact that they share the symptom paranoia in common. In no other medical disciplines would one classify in this way. Everywhere, the aetiology, mode of development, whole course and outcome of the illness are used as a basis for its grouping in the classification system. Thus far, Kraepelin’s system marks a significant advance in German psychiatry. Especially with regard to the paranoia question, he is probably right when he claims that if paranoia is the one and only illness entity, it must be either acute or chronic. But now that the paranoia forms καί εξοην [in an eminent sense] are pronounced chronic illnesses, probably to be considered as the fundamental forms, and the acute psychoses, which only share in common the symptom “paranoid ideation”, therefore, most logically, they must be separated out as illness forms sui generis. In other words, if one were to support Kraepelin’s (103) description of “acute paranoia” as an “Unding” [absurdity], he has certainly gone much too far, when he reserves the term paranoia for a very small group of stationary conditions; with respect to the majority of the psychoses, which other authors describe as paranoia conditions, he virtually, for a certain course of the illness, ignores the presence of the paranoid ideas and solely gives weight to the outcome of the illness, namely the “eigenartige Schwächezustand”. Misguided by its similarity with the dementia stage in the hebephrenic and catatonic psychoses, he refers the majority of the paranoia condition to his dementia paranoides, a sub-group of his dementia praecox. Hardly any psychiatrist would deny that a large number of juvenile paranoia forms develop relatively fast into dementia, but before one can accept Kraepelin’s views it must first be shown if this dementia condition is secondary to a primary pathological process, which is identical with, although perhaps more rapidly progressing than, the one which forms the basis of the more stationary paranoia forms where the terminal dementia is longer in its coming. The occurrence of the psychosis in a juvenile and perhaps ab ovo less resistant brain would rather easily explain the relatively rapid manifestation of the dementia, and that those features the paranoid dementia shares with the hebephrenic and catatonic dementia conditions as such, and could just as easily be explained by the undeveloped brain which succumbs to these illnesses, as by an identity via the pathological-anatomical substrate of these psychoses.

Classification of the paranoia forms must be based on a clinical assessment of their aetiology, mode of manifestation, their symptomatological picture, course and outcome. Equal consideration to all these criteria must be given, if one more or less adheres to the guiding principles in other fields of medical science. Among the existing attempts at classification, it seems to us that Magnan’s system is the one that most equally gives consideration to the aforementioned various criteria. We opine, in accordance with Garnier (104), that the Magnanian main division (délire chronique – délires des dégénérés) must be considered to be “une conception, que l’observation clinique légitime, et qui ne peut être que féconde en résultats pratiques”. ¹⁸

Magnan has outlined his délire chronique so distinctly in its symptomatology, his construction giving such scientific consideration to the whole particularity of the illness’s patho-biological characteristics, that this paranoia form must certainly be called a conquest for psychiatry. Even though one must admit – as Magnan (106) does – that this psychosis is seldom encountered in its originally described “classic” form, yet its specific character is so pronounced, even in the more muted forms, that one gets the distinct impression that one is here being faced with a psychosis sui generis.

While in our opinion there is nothing to add to Magnan’s symptomatological description of délire chronique, but as far as the illness is concerned one must either acknowledge its existence or deny it, and then its position in the psychiatric system might be somewhat different from Magnan’s idea. In the Magnanian classification, this psychosis stands so isolated from the degeneracy conditions (the endogenous psychoses) that it is hard to tell if Magnan did, after all, consider his délire chronique as an exogenous form of insanity. If Krafft-Ebing (106) is wrong when he lets any paranoia occur on a pronounced degenerative basis, then Magnan (107) probably also goes too far in the other direction when to him “délire chronique et dégénérescence s’opposent l’un à l’autre en totalité. Qui dit délire chronique exclût par ce fait même la dégénérescence”. ¹⁹ What Magnan concedes to the délire chronique patients is only the predisposition (109). “Ils sont prédisposés, et si, chez eux, la prédisposition demeure longtemps enveloppée et confuse, si elle est trop faible par les doter de caractères spécifiques, elle n’en est pas moins la cause première de leur folie”. ²⁰ In that case, the only question is what is to be understood by predisposition on the one hand, and degeneracy on the other. In psychiatry the term “predisposition” is only an expression for the experience that groups of individuals, who to the same extent are exposed to the same pathogenic causes, only a minority succumb to them, and become insane; that these individuals are “predisposed” towards insanity then means that their brains are a focus minoris resistentiæ (Toulouse, 109). With the term “degeneracy” something more is already said: degeneracy is an inborn condition of psychic (and physical) debility, “la déviation du type normal anatomique et physiologique, dont les malformations, les anomalies fonctionnelles, l’émotivité morbide, l’incapacité de l’adoption au milieu et la tendance à la stérilité sont les manifestations principales” (Toulouse, 110). ²¹ Both concepts, however, are indefinite as they generally refer to a predisposition and a degeneration. But the question must certainly be asked whether any kind of disposition and degeneracy, respectively, can cause any kind of psychosis. In other words, with respect to the paranoia forms: can any kind of degeneracy condition or predisposition create the soil for paranoia, or is a particular form required in the occurrence of a paranoid condition? We believe that the latter must be assumed. First, regarding the degenerative paranoia forms: where these occur, the individual in question has, from his earliest years, manifested a particular psychic degeneracy condition, which in the following we will describe as paranoigenic degeneracy (temperament). This contains in nuce all the elements of the ensuing paranoia; its whole abnormal mode of thinking and feeling is preformed in the paranoigenic temperament. Thereby the jessant paranoia assumes quite a different character, quite another mode of development than in délire chronique. This occurs in an essentially sound brain, which is only “predisposed”, and during its progression results in first a loosening of the psychic synthesis, and later a new consolidation of this through the creation of a new ego-consciousness; here the paranoid process consists of a psychic transformation. This is not so in degenerative paranoia. In this instance, nothing new needs to be inserted into the consciousness; a simple hypertrophy of the habitual character, a luxuriation of all present psychic abnormalities – and the paranoia appears. The psycho-pathological process is then a simple evolution, with the abnormally predisposed individual’s final modus vivendi unfolding during its course of development as it does in healthy people (Sander, 111). The terminal paranoia only signifies a crystallization in an oversaturated compound. Its nature is evolution, and thus the designation of these forms of paranoia as evolutive appears to us to be more telling than the Magnanian délires des dégénérés.

Furthermore, we must assume that we are here dealing with a degeneration of a specific kind of nervous system, a congenital resistentia minoris (112). ²² But despite many and fundamental discrepancies, the délire chronique conditions manifest such great similarities with these evolutive forms of paranoia that we cannot imagine that the “predisposition”, the diminished staying power, is not first and foremost tied to the same nervous system. This means that the predisposition, the specific localized resistentia minoris, in these cases would be latent, but as Magnan (113) says, not sufficient to characterize the individual as dégénéré, yet he would refer the délire chronique conditions to the same large main group of psychotic phenomena as délires des dégénérés, the evolutive forms of paranoia, without one probably having to go as far as Toulouse (113), who is inclined to consider the predisposition as one of the symptoms of degeneration.