Sei sulla pagina 1di 6

History of Psychiatry

The significance of symptom complexes in psychiatry

Alfred Hoche, R.G. Dening, T.R. Dening, T.R. Dening and G.E. Berrios
History of Psychiatry 1991; 2; 329
DOI: 10.1177/0957154X9100200710
The online version of this article can be found at:

Published by:

Additional services and information for History of Psychiatry can be found at:
Email Alerts:

Downloaded from by Daniel Martinez on November 6, 2007

1991 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

History of Psychiatry, n ( 1991 329

), 329-343. Pnnted In England

Classic Text No. 7


significance of symptom complexes

in psychiatry
Translated by R. G. DENING and T. R. DENING*
Introduction by T. R. DENING and G. E. BERRIOS


frequently-cited paper from 19121 has perhaps surprisingly never been

translated. In view of current interest in the relationships between psychiatric
symptoms and the brain, and in particular the question of localizing such
symptoms, its re-evaluation is overdue. It sounds an important cautionary note.
Alfred Erich Hoche2( 1865-1943) had been Ordinarius Professor of Psychiatry
in Freiburg for 10 years when in 1912, he delivered this paper to the annual
meeting of the German Psychiatric Union in Kiel. A parsons son, he was born in
Wildenhain, Saxony, and studied in Berlin and Heidelberg. After qualifying in
1888 he worked first for Erb in Heidelberg, moving to Freiburg in 1890 as
Assistant to the Psychiatric Clinic under Furstner. He followed Frstner to
Strasbourg in 1891, before returning, aged 37, to Freiburg as Professor. He
subsequently declined moves to Halle and Strasbourg and retired in 1933 to live
in the Black Forest.
He published on a wide range of topics. His early research interests included
neurology, neuroanatomy and the physiology of the visual pathways. Later he
published papers on a variety of clinical psychiatric topics, and a Handbook of
Legal (Forensic) Psychiatry which went to three editions. He was also a prominent
critic of psychoanalysis. After the death of his only son in 1915 and the

* Address for correspondence: T. R. Dening, MD, MRCPsych. Consultant Psychiatrist, Fulbourn

Hospital, Cambridge, CB1SEF.
A. E. Hoche, Die Bedeutung der Symptomenkomplexe in der Psychiatrie, Zeitschrift für die
Neurologie und Psychiatrie
, xii (1912), 540-551.
For biographical information see: O. Bumke, Alfred Erich Hoche, Archive für Psychiatrie und
, clxvi (1943), 339-346; and I. Fischer, Biographisches Lexikon der hervorragenden Arzte
der letzten fünfzig Jahre Volume 1 (Berlin/Vienna: Urban & Schwarzenberg, 1932), 639-640.

Downloaded from by Daniel Martinez on November 6, 2007

1991 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.


defeat of Germany in 1918, he became more solemn and gradually withdrew into
no psychiatric publications after 1928. He probably committed

Hoches reputation with posterity has undoubtedly suffered because of his
published views on euthanasia. Together with the lawyer, Karl Binding, Hoche
wrote Die Freigabe der Vernichtung lebensunwerten Lebens.4 This notorious
text advocating the ending of unnecessary lives helped fuel the euthanasia
debate, and eventually influenced Third Reich policies. However, it may
possibly be simplistic to assume that Hoche was a Nazi supporter, as he resigned
when Hitler came to power in 1933, and, furthermore, his wife was Jewish.6
The paper under consideration here, which predates any publications on
eugenics, is a contribution to three controversies which continue to persist
nowadays. The first debate concerns classification in psychiatry. The main
proponent of classification was Kraepelin, whose Lehrbuch had appeared in its
eighth edition in 1909. His legacy was the division of the functional psychoses
into dementia
and manic-depressive illness, though he later softened
this separation.vraecox
At the time of the eighth edition, Kraepelin still regarded these
concepts as disease entities comparable to medical illnesses. Inevitably, there
was a reaction against this, the most extreme expression being the psychobiology
of Adolf Meyer. Much of Hoches paper is a critique of Kraepelinian nosology.8

See G. W. Schimmelpenning, Alfred Erich Hoche, Das wissentschaftliche Werk: "Mittelmässigkeit?",

Berichte aus der Sitzungen der Joachim Jungius-Gesellschaft der Wissenschaften (Hamburg: Joachim
Jungius-Gesellschaft, 1990), 36-37. Schimmelpenning defends Hoche from recent criticism and
allegations of mediocrity (for which, see: E. Seidler, Alfred Erich Hoche (1865-1943): Versuch einer
, xciv (1986), 65-75), on the grounds of his
Standortbestimmung, Fretburger Universitatsblatter
with his contemporaries and the lasting influence of his ideas.
K. Binding & A. E. Hoche, Die Freigabe der Vernichtung lebensunwerten Lebens (Leipzig: Meiner,
cited by Schimmelpenning, op. cit., 5.
J.-E. Meyer, The fate of the mentally ill in Germany during the Third Reich, Psychologtcal
, xviii (1988), 575-581. Several recent books have discussed the wider context of social hygiene
in National Socialist Germany (see: K. Macrakis, Coming to terms with medicine and eugenics in
Germany: an essay review, Journal of the History of Medicine
, xlvi (1991), 97-109; B. Muller-Hill
Murderous Science. Elimination by scientific selection of Jews, Gypsies, and others. Germany 1933-1945.
Translated by G. R. Fraser (Oxford: Oxford University Press, 1988), and the impact of Binding and
Hoches book is discussed by P. Weindling, Health, Race, and German Politics between National
and Nazism, 1870-1945 (Cambridge: Cambridge University Press, 1989).
., 9, footnote 25.
op. cit
E. Kraepelin, Die Erscheinungsformen des Irresems, Zeitschrift fur die gesamte Neurologie und
, lxi (1920), 1-29. For an account of Kraepelins evolving thoughts, see: G. E. Berrios,
R. Hauser, The early development of Kraepelins ideas on classification: a conceptual history,
Medicine xviii (1989), 813-821.
Indeed, most of the discussion at the Kiel meeting (summarized by A. Alzheimer, Zeitschrift fur die
gesamte Neurologie und Psychiatrie: Referate ,
und Ergebnisse v (1913), 804-810) concerned Hoches attack
on Kraepelins ideas of disease entities. Alzheimers own paper supported Kraepelin, who himself
defended the utility of this concept. Siemerling, the professor in Kiel, shared Hoches scepticism, while
others suggested that the two points of view were in fact not incompatible. To what extent Kraepelin was
influenced by Hoches criticism is not clear. The important, though neglected by English-speakers,
., ref. 6) considered the question of syndromes in psychiatry. Bumkes
paper of 1920 (Kraepelin, op. cit
obituary of Hoche (
., ref. 1) suggested that Kraepelin had been influenced by Hoche, but E. Kahn
op. cit



Downloaded from by Daniel Martinez on November 6, 2007

1991 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.



strongly opposed the clear demarcation of pure forms of functional

psychosis, arguing that other concepts such as hysteria and hypochondriasis had
failed to persist as unitary entities.
The second debate concerns the cerebral localization of mental phenomena,
most strongly advocated at this time by Meynert, Luys and Wernicke and
opposed by such as Head, Goldstein, Lashley, von Monakow and the Gestalt
psychologists. Hoche also reacted against the tendency then (and now?) current

(Emil Kraepelin, American Journal of Psychiatry

, cxiii (1956), 289-294) warned against making this
assumption too readily. Besides, Kraepelin was justly famed for the constantly-evolving nature of his
thought. Kraepelins memoirs ,
Memoirs translated by C. Wooding-Deane (Berlin: Springer, 1987))




all of Hoche.

Downloaded from by Daniel Martinez on November 6, 2007

1991 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

to seek anatomical locations for psychiatric disorders. However, his reaction was
less extreme than that of the anti-localizationalists, stressing mainly the diffuse
origins of complex functions rather than totally denying their modularity.
The third, perhaps less familiar, issue is that of the specificity of mental
symptoms in relation to individual diseases. The nineteenth-century view was
that individual physical diseases gave rise to their own specific insanities, e.g.
myxoedema madness. This stance was extended by Kraepelin, in that the disease
entities of the functional psychoses gave rise to their own characteristic clinical
pictures and outcomes. In respect of organic diseases, Bonhoeffer9 reacted
against the view that symptoms (or clusters of symptoms) were specific to
diseases and instead postulated the existence of exogenous reaction-types, a
small number of stereotyped wired-in forms of behaviour which could be
triggered by any cerebral lesion, regardless of nature or localization. Hoche
similarly used the notion of symptom-complex to apply to functional illnesses
(those without known aetiology). He suggested a modular view involving small
groups of psychopathological features, e.g. elevated mood and overactivity;
delusions and hallucinations. The symptom-complexes might or
not be
pathological anatomy. Indeed,
the components of the symptom-complexes were behavioural units which
modulated personality profiles in normal subjects. 11 In this regard, Hoche
espoused a typical nineteenth century continuity model 12 of psychiatric


K. Bonhoeffer, Die symptomatischen Psychosen in Gefolge von akuten Infektionen und inneren
Erkrankungen (Leipzig: Deuticke, 1910). The contemporary relevance of Bonhoeffers work is discussed
by K-J. Neumarker, Karl Bonhoeffer (1868-1948). Leben und Werk eines deutschen Psychiaters und
Neurologen in seiner Zeit (Berlin: Springer, 1990); and K-J. Neumärker, Karl Bonhoeffer und die
Stellung der symptomatischen Psychosen - inorganische Psychosen - in Klinik und Forschung,
lx (1989), 593-602.
A modern example of this kind of approach is suggested by H. M. van Praag, G. M. Asnis,
R. S. Kahn, S. L. Brown, M. Korn, J. M. Harkavy Friedman and S. Wetzler, Monoamines and
abnormal behaviour: a multi-aminergic perspective, British Journal ,
of Psychiatry clvii (1990) 723-734.
They advocate the study of psychological dysfunctions, which lie intermediate between syndromes and
symptoms, and suggest that such dysfunctions result from disturbances in monoamine neurotransmitter

Important issues were raised by F. Kehrer, Die Stellung von Hoches "Syndromenlehre" in der
, lxxiv (1925), 427-456. Kehrer
heutigen Psychiatrie, Archiv für Psychiatrie und Nervenkrankheiten
emphasized the biological basis and preformed nature of the symptom complexes, and their influence on
normal personality as well as disease states. He also discussed problems with terminology and the
unreliability of psychiatric terms, and highlighted certain conceptual difficulties, e.g. what determines
whether symptoms are seen as being linked and forming a syndrome, and what the biological basis of the
complexes might be.
Mental symptoms may be viewed in

two ways,







clear counterpart in

normality (e.g. delusions, stupor) or as quantitative disturbances of normal function (e.g. depression).
These are respectively the discontinuity and continuity views, and are further discussed in G. E. Berrios,
Descriptive psychopathology: conceptual and historical aspects, Psychological Medicine, xiv (1984),
303-313. Another probable influence on Hoche is the work of Hughlings Jackson in the area of positive
and negative symptoms. Jackson postulated a hierarchical evolutionary model of brain function,
suggesting that negative symptoms represented activity of the disease process, while positive symptoms

Downloaded from by Daniel Martinez on November 6, 2007

1991 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.


These rather neglected views are worthy of modern consideration on two

grounds. Firstly, there is a resurgence of Kraepelinian nosology, exemplified by
the American Psychiatric Associations DSM-III-R. This adopts a symptom
checklist approach in order to generate diagnostic categories, which it is hoped
can be progressively refined by empirical research towards a nirvana of validity,
which is probably the delineation of diseases. Hoche would be highly critical of
the readoption of this strategy, and it is timely to reiterate his arguments.
Secondly, modular (as opposed to anti-localization or mass action) views of the
brain and its mind are currently back in fashion.13Hoches suggestions about
modularity are sophisticated and up-to-date. For example, he pointed out that most
of our information as to the localization of functions is from deficits after cerebral
lesions, and therefore inferences about localization of normal functions should be
made cautiously if at all. He also recognized that while some functions are likely to
be more localized or modular, e.g. speech, motor activity, others are likely to be
more extensively and diffusely sited. Such functions will not be selectively picked
off by simple lesions, nor affected in isolation. Indeed, the symptom-complex may
well be expressed as a result of a variety of insults, including local pathology,
diffuse brain disease and functional illnesses too. It is by no means impossible
that these latter may have a psychosocial precipitation.
Hoches cautious tone and his criticism of more simplistic stances, combined
have generated exaggeratedly
perhaps with his rather sombre
the resigned way in
gloomy interpretations.
example, Jaspers 4
which Hoche dismisses the symptom-complex. Hoche may have helped inspire
a pessimistic approach to classification in particular and to biological psychiatric
research in general, exemplified by the teachings of Adolf Meyer and Sir Aubrey
Lewis. Certainly, the notion of symptom-complex generated little major
empirical research, the work of Carl Schneider on schizophrenia being a notable
exception. However, given the current ascendance of modularity, this need no
longer be so,15 and this contribution by Hoche to psychiatric thinking can be
regarded with less repugnance than some of his other views.


resulted from release of normal but more primitive functions from lower centres. Hoches view is thus
redolent of Jacksons evolution of positive symptoms but without the hierarchical organization, that
is, for Hoche there is no top-to-bottom inhibition. For further analysis of this issue see G. E. Berrios,
Positive and negative signals: a conceptual history, in A. Marneros, N. Andreasen and M. T. Tsuang,
Negative Versus Positive Schizophrenia (Berlin: Springer, 1991, in press).
J. A. Fodor, The Modularity of Mind (Cambridge, Mass: MIT Press, 1983). In this regard also see J.
C. Marshall, Multiple perspectives on modularity, Cognition
, xvii (1984), 209-242; and T. Shallice,
From Neuropsychology to Mental Structure (Cambridge: Cambridge University Press, 1988).
K. Jaspers, General Psychopathology
, Seventh Edition, Translated by J. Hoenig & M. W. Hamilton
Manchester University Press, 1963), 588-589.
Conceptual issues in neuropsychiatric research have been discussed by G. E. Berrios,
T. R. Dening, Biological and quantitative issues in neuropsychiatry, Behavioural Neurology, iii (1990),
247-259. Recent examples of research requiring a modular approach include E. R. John, L. S. Prichep,
J. Fridman, P. Easton, Neurometrics: computer-assisted diagnosis of brain dysfunctions, Science
ccxxxix (1988), 162-169; and T. J. Sejnowski, C. Koch, P. S. Churchland, Computational
neuroscience, Science, ccxli (1988), 1299-1306.

Downloaded from by Daniel Martinez on November 6, 2007

1991 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.