Klaus Conrad - History of Psychiatry

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DOI: 10.1177/0957154X0201305107

2002 13: 339History of PsychiatryDetlev W. Ploog

Klaus Conrad (1905-1961)

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Personalia

Klaus Conrad (1905-1961)DETLEV W. PLOOG*

* Originally published as: D. Ploog (1998). Klaus Conrad (1905-1961). In Hans Schliack andHanns Hippius (eds), Nervenrzte. Biographien (Stuttgart: Georg Thieme Verlag), 75-85.Translated from the German by permission of the publisher. This paper is published in History ofPsychiatry thanks to the great generosity of Mrs Martel Conrad and of Professor emeritus Plooghimself. The editor is very grateful to both. Address for correspondence: Prof. Dr. med. Dr.phil.h.c. Detlev Ploog, Max Planck Institute for Psychiatry, Kraepelinstrasse 2, D-80804 Munich,Germany. E-mail: [email protected]

Klaus Conrad (1905-1961) was an internationally known figure in the field ofneuropsychology and psychopathology. He applied Gestalt psychology to give abetter understanding of the aphasias, the symptomatic psychoses and incipientschizophrenia.

Klaus Conrad was born in Reichenberg in Sudetenland on 19 June 1905.His father, Otto, secretary of the Chamber of Commerce in Vienna, was aDozent (lecturer) in economics at the Technical University in Vienna andbecame an internationally known scholar through his published books. Hismother, Wilhelmine, nee Zwiauer, came from a Viennese family which wasrelated by marriage to the family of the physiologist Thomas von Brucke.Conrads fathers family, originally from Siebenbtirgen but now living inVienna, was related by marriage to the family of the surgeon ThomasBillroth. The familys friendship over several generations with the Exners, a

number of whom became well-known scientists,was

alsoan

importantelement in the environment in which Klaus Conrad grew up. Conrad was

particularly impressed by the research on bees conducted by Karl von Frisch,whom he called Uncle Karl and whom he saw during his summer vacationsin the now famous Brunnwinkel on Wolfgangsee.3 Influenced by this eminentscientist, at first Conrad wanted to become a zoologist; the subject of a long

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paper he wrote during his last year of Isecondary school was Die Sorgen den

Insekten fur ihre Nachkommenschaft(How insects take care of their

offspring). But equally fascinating tohim, if not more so, were butterfliesand the markings on their wings.Because there was no money inzoology (eine brotlose Kunst), hisavuncular friend advised him to startoff by studying medicine. In the

summer the families from Viennaspent time together in Litzlberg on

Attersee. Conrad often played musicwith them, as he did with others

throughout his life. In secondaryschool and then as a young universitystudent he was a sought-after clarinetplayer. Later, the cello captivatedhim for the rest of his life.

The formal course of Conrads life

can be outlined briefly.After gaininghisAbitur for classics at high school,he began to study medicine in

KLAUS CONRAD

Vienna in 1923 and completed his training there in 1929. It had alreadybecome clear to him after the first few semesters that he wanted to devote

himself to neurology and psychiatry. Wagner von Jauregg, Pbtzl andGerstmann were then teaching in Vienna, and Conrad worked with them asa volunteer, both as a student and then, after he had completed the statemedical examination, from 1929 to 1931. He does not appear to have had

personal contact with Sigmund Freud, although he later read Freuds majorworks intensively and, for example, held an inspiring lecture series on thepsychopathology of everyday life (Psychopathologie desAlltagslebens) .

In 1924 Conrad spent a semester in Leipzig.At that time he may alreadyhave had his first experience of the holistic approach being promulgatedthere (Ganzheitspsychologie) . Excellent caricatures of his university instructorsshow his talent for capturing the essence of his subject.A clinical semester inLondon as a volunteer in a neurosurgical department established thefoundation for his ongoing connection with theAnglo-Saxon world; later on,for example, the teachings of Henry Head and Hughlings Jackson had astrong influence on his scientific thinking.At that time the economic situation inAustria was desolate.As the result

of an advertisement about a medical position, he went to the city neuro-psychiatric hospital in Magdeburg, which was headed by Jacobi. Two papers



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written by Conrad during this period already addressed what was to becomethe main topic of his scientific work, namely, analysis of neuropsychiatricsyndromes using principles of Gestalt psychology. Starting with the idea thatall psychic activity is based on Gestalt processes, he first formulated someof the laws governing the de differentiation of the Gestalt function (Ent-di,fferen.zierung der Gestaltfwzktion) in a parietal syndrome. His love of neuro-psychology - in those days called brain pathology (Gehirnpathologie) - probablydeveloped while he was working with Otto Pbtzl.And his critical paper onPaul Schilders concept of the body image shows the Gestalt approach andConrads pleasure in questioning existing views and looking for newapproaches.

In February 1933, at very short notice, Conrad decided to go to Paris towork with Guillain at the Salpetriere and to gain a deeper understanding ofFrench neurology. Here again, as earlier in London, he had access to anotherculture, resulting later in the development of close contacts, especiallythrough his friendship with Henry Ey.A stipend from the Rockefeller Foundation, followed by one from theNotgemeinschaft der Deutschen Wissenschaft (Emergency Fund for GermanScience6), enabled the young scientist - who now had a broad training - towork in Munich from 1934 to 1938 under the direction of Ernst Rudin in

thegenealogy department

of theDeutsche Forschungsanstalt

fur

Psychiatrie(German Institute for Psychiatric Research), founded by Kraepelin. Here healmost literally threw himself into his new field of research.

The genetics of mental disorders

After only a year, the first in a series of related papers on heredity andepilepsy appeared, based on studies of 253 sets of twins. Papers thenfollowed on the progeny of individuals with epilepsy, on the question of

epileptoid psychopathyand on the genetic environment of individuals with

epilepsy and their social class. Conrad quickly became well known.At thethird annual conference of the Gesellschaft deutscher Neurologen undPsychiater in Munich in September 1937, he was the principal speaker; atthe end of his address on heredity and constitution in epileptics he made astatement about legislation on eugenics, which for listeners at that time wasvery clear and unambiguous, namely, that it must be based solely onscientific knowledge: But knowledge must never be guided by legislation,otherwise progress would be impossible (Die Erkenntnisse aber drfen sichniemals nach der Gesetzgebung richten) sonst wre ein Fortschritt unmglich).Conrads key research findings - a high concordance rate (86%) in identicaltwins with idiopathic epilepsy and a low percentage of affected individualswith children (only 6-8%) - are, as far as I know, still uncontested.

Meanwhile, under the influence of young National Socialists, the Munichresearch institute became increasingly politicized. Jewish researchers had to



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leave the institute. Conrad, who had just completed his postdoctoral dissertationin Munich and was now eligible for a university teaching position, applied fora post as senior physician at the university hospital for neuropsychiatry inMarburg on the river Lahn.

In May 1938 Ernst Kretschmer asked the young Reader to join him assenior physician at his hospital in Marburg. Two years later and shortlybefore being called up to serve as a military physician in Russia, Conradquietly completed a comprehensive monograph addressing the problem ofconstitution and character from a new angle. Kretschmers masterfuldescription of this subject had fascinated Conrad and stimulated him toconsider the constitutional types as genetically determined products of

diametrically opposed growthtendencies. The

book,which was

publishedby Springer in 1941, was entitled Der Konstitutionstypus als genetischesProblem.

The Constitutional Type as a Genetic Problem

In Conrads constitutional theory, the inherent relationship of certain bodytypes with certain basic personality structures is based on the principle of thequantitative gradation of hereditary factors and the hierarchical structure ofgenetic effects. Diametrically opposed conservative and propulsive types ofgrowth, with their associated basic psychic structures, are the result ofdifferent determining steps in the ontogenetic process of progressiveindividuation. In Conrads theory the growth tendencies are entered into asystem of coordinates, with a leptomorphic-pyknomorphic range of variationand a hyperplastic-hypoplastic range of variation. In the leptomorphic-pyknomorphic range of variation, growth tends towards length at the expenseof breadth, and breadth at the expense of length. In metromorphic typesthere is balance in growth between length and breadth - these are the classicbody proportions. The hyperplastic-hypoplastic growth tendencies are basedon too much or too little development of tissue; the more extreme typescorrespond to Kretschmers athletic and asthenic types. In the middle of this

polarity is the metroplastic type. In addition, there are dysplastic types ofgrowth of endocrine origin (e.g., eunuchoid gigantism and certain types ofobesity). Conrad calls the leptomorphic-pyknomorphic polarity primaryvariations of humans and the hyperplastic-hypoplastic polarity secondaryvariations. In this way he refers to embryonal development, in which the

primary type begins earlier and therefore has more marked effects, with thesecondary type beginning later ontogenetically and therefore having less

marked effects. The primary and secondary variations refer not only tosomatic processes, however, but also to the associated psychic differentiation.The pyknomorphic type, with its slower shifts in proportions, is closer tochildren (and the feminine body type), whereas the leptomorphic type - withits greater developmental force (Entfaltungstemperament) and more rapid



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shifts in proportions through the body shape - changes in the sense of Zellerand is closer to a pubescent individual than to a child.

The reception of Conrads theory of constitutional types was varied.Afterits initial publication in 1941 the theory attracted a great deal of attention.Jaspers discussed the excellent work (das ausgezeichnete Werk) for ten pagesin the fourth edition of hisAllgemeine Psychopathologie (1946)8 and conferredupon it the status of a radical reformation (radikale Neugestaltung) of consti-tutional theory, but in the end concluded that in spite of its brilliant naturethe whole theory will sink into oblivion without any consequences (dasGanze trotz seines geistreichell Zuges folgenlos versinken wird). Three decadeslater a leading researcher on constitution, Rainer Knuf3mann,9 recognized

thatthe

leptomorphic-pyknomorphic range of variation and the growthphases as bodily variations during ontogenesis were confirmed by empiricaldata. (For me personally, the book was a milestone on the road to abiologically-oriented psychopathology in which the causal connections playa stronger role than the meaningful psychic connections. My reading ofthe book resulted in a request for a topic for a doctoral dissertation.)Two decades later Conrad, at the request of Springer-Verlag - and related

to his comprehensive contribution to Psychiatrie der Gegenwart (CurrentPsychiatry)&dquo; on the different constitutional theories - wrote a slim secondedition of his 1941 book. In it he evaluated his early work in his ownimpartial, unassuming way: For much of what the author consideredirrefutable twenty years ago, he wrote in the Preface, doubts are now noted;the apodictic certainty no longer exists. (Zu vielem, Was demAutor vor 203ahren unbezweifelbar erschien, werden jetzt Zweifel angemerkt, die apodiktischeSicherheit besteht nicht mehr. ) But the basic ideas, the genetic-dynamicapproach to the problem of constitution, he still considered fruitful. Thesecond edition is entitled Der Konstitutionstypus. Theoretische Grundlegung undpraktische Bestimnaung (The Constitutional Type. Theoretical Foundationsand Practical Determination). It was completed in 1961 shortly before his

death.At the start of the war against the Soviet Union, Conrad was drafted to

serve at the reserve military hospital in Marburg and soon afterwardsmarched with his unit from Ukraine into the Caucasus. While there, inDecember 1942, he received orders to set up a special hospital for braininjuries in Marburg. Between 1943 and the end of the war in 1945, 808soldiers with brain injuries passed through his department, 216 of them withaphasia. Conrad examined every single patient himself. His careful docu-mentation in the medical records and with diagnostic cards (Zdhlkarten,

literally counting cards) enabled a scientific evaluation of these valuablefindings, which was begun even before the war was over. When Marburg wasoccupied by theAmerican front-line troops, the whole hospital was takenover and everyone in it became a prisoner of war, but without any changesbeing made in the internal structure of the hospital. By then I had completed



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my doctorate, and I had the good fortune to work there under Conradduring this time.

It was most impressive how patiently, systematically and at the same timeimaginatively he worked with the patients. Time after time he found newmethodological approaches to understanding the laws governing the different

aphasic disorders, the word-finding disturbances and alexia. Through hisprofessional but very personal approach, he kept the patients attention sowell that they never tired of co-operating with him, often for periods of manymonths. In other areas of his field, too, especially psychiatry-psychotherapy,masterful as he was in the examination process, he was able to win over the

patients to help him and to share the responsibility. This was the basis of his

success as a clinician. In the treatment of neuroses his efforts were centredon

the reduction of egocentricity (Ichhaftigkeit), a key concept of Fritz Knkel,whom he greatly admired. This therapy, based on a partnership, would todaybe considered a form of client-centred therapy.

In early 1946, after the oppressive final months of the war and the sadspring and summer in captivity as a PO1, his wife and four children werewith him again after a long separation following their evacuation. But, whileplaying music with friends, Conrad was suddenly taken away byAmericanofficers and put in the Zuffenhausen camp for war criminals. 12 In September,after

monthsof unsuccessful

attempts,his

bright and courageouswife

managed to get him released. The reason for his arrest and internment nevercame to light. From this period of many months without any charges or

interrogations, in a state of total uncertainty and despair, there are letters andpoems that bear witness to Conrads inner strength and human greatness.

Sonett

Von meinem Fenster seh ich ein Stiick Straj3eEin kurzes Stiick, das sich zum Dory verliert.

Auf diesem Wege Groj3 und Klein spaziert.Lustwandelnd abends zwischen Busch wzd Grase.

. Sie fiihlen nichts von jenem Ubermaj3eDer Freiheit, die sie haben, hchster Lust

Und keiner ist sich wohl des Glcks bewuJ3tSo hinzugehn - iiber eine StraJ3e.

O daj3 wir niemals es vergessen mgen)Wenn alles, was ein jeder hier ertrug,Ihm wieder ferne und verblasst genug.

DaJ3 jedes freie Gehn auf freien Wegen,Ach, daj3 in Freiheit jeder AtemzugIst Gottes immer wieder neuer Segen.



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Sonnet 13

Frommy window

I see a bit of the street .A short stretch that vanishes towards the village.On this path people large and small are walking.Promenading in the evening between bushes and grass.

They feel nothing of the plenitude ofFreedom which they have, the greatest joy

And no one seems aware of his good fortuneSo to stroll - along a street.

Oh thatwe

maynever

forget it,When everything that each of us endured hereIs again distant and dim enough.

That every unhampered walk on paths of choice,Oh, that in freedom every breathIs Gods blessing, new each time.

The tyranny of fate that he experienced in prison left its mark on thisreflective and sensitive man. Nevertheless, as if he had gone away only the

day before, he took up his work again as head of the military hospital and asa senior physician at the university hospital. In the meantime, ErnstKretschmer had gone to Tubingen in 1946, and Werner Villinger was nowhead of the university department and the hospital. For Conrad anotherfruitful period of scientific work began, and this was to be a central elementfor everything that came later.

Structural analyses of cases involving brain pathology

In 1947/48, Conrad published a total of 300 pages on these cases, in sixarticles: four in Deutsche Zeitschnft fiir Nervenheilkunde and two inArchiv fiirPsychiatrie, followed later by four additional contributions. Based on subtlecase studies of different forms of aphasia and diagrams with statistics on thelocalization of the brain damage, Conrad showed that the classical system ofbrain pathology, with its highly concentrated expression found in Lichtheimsscheme, no longer did full justice to the large amount of newly observed dataavailable. The foundation, the notion of a reflex arc that underlies theclassical concept, has become shaky and is in need of revision, he wrote (Das

Fu71dament, die Vorstellung vom Reflexbogen, das der klassischen Lehre zugrundeliegt, schwankt und ist revisionsbedrftig). This had been acknowledged inmany valuable papers, but an urgently-needed new model, which would

explain the phenomena better, was lacking. Conrad presented such a modeland referred to the great founder of the classical concept, Carl Wernicke,



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who arrived at his theory of mental illness on the basis of observations ofpeople with aphasia. In this way, as we shall see, Conrad indicated the path

he himself would take in the future.It is clearly difficult to describe, in the space available, the new, muchmore complex fundamental concept which was capable of supporting brainpathology and, in fact, psychopathology as a whole. But without such an

attempt, which should at the very least stimulate the reader to mine the veins

of gold in the original papers, the essence of Conrads way of thinking andconducting research would be lost.Two principles are the structural pillars. The first is the principle that

psychic phenomena, which appear to us as wholes or Gestalten, have a

developmentalaspect. This means that,

underlyingevery

psychic phenomenon,for example, a perception, a thought, a word, a word-finding disturbance, isa developmental process. Everything that is present has become.As a modelfor this process Conrad chose the then familiar tachistoscopic experimentsof Sander on the microgenesis (Aktualgenese) of Gestalten, whereby thedevelopment of perception goes from the stages of pre-Gestalt ( horgestalt) tothose of the final Gestalt (Endgestalt), a process which usually takes place in asplit second and is not conscious, but which, if it is disturbed, is suitable forshedding light on psychopathological ways of experiencing. Today, throughrecording of event-related potentials in the range 30-500 ms, evidence insupport of this theory is available. The term pre-Gestalt is used for thoseforms of perception that lie between the first appearance, the nucleus of an

experience, and its full formation in the final Gestalt. They are in no waylimited to visual or acoustic perceptual Gestalten, but also include movementGestalten and processes of speech production, of understanding speech, ofmemory and of thought. The question arises: is what we describe as a givenpathological phenomenon merely a consequence of a protracted micro-genetic process at different stages of the Gestalt formation?

With the introduction of principles of Gestalt theory into psychopathology,Conrad departed from the then (and to some extent probably still) prevailingpsychology of association, according to which everything psychic results fromcomplicated mechanisms of association of individual impressions or fromstimulus traces, which the cerebrum, as a mnemonic-associative apparatus,combines.Any damage in this apparatus must sever numerous connectionsand bring certain functions to a standstill, especially if the nodes ofconnection (centres) are affected. Conrad countered that it was not the lossof a function localized at a particular place but rather a change in the processof mental performance that could be disturbed from a certain location.

These changes in performance had characteristic features that were subjectto laws of Gestalt theory. To discover and describe in detail these laws bystudying different syndromes associated with brain pathology was the goal ofthe structural analyses.The second principle on which Conrads psychopathology is based is the

. 1)



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relationship between object and subject. The commonly held view of the time,based on the stimulus-response model, that a subject, with the aid of his or

her basic functions of perception, thinking, feeling and will; can understandthe objective world as a primarily independent state or - in the case ofpathology, because of an interruption of this subject-object relationship canno longer understand - was in his eyes obsolete. Instead of this model, theidea of a Gestalt-circle-like connection (gestaltkreisartige Verbundenheit) of thesubject with his or her world was introduced. The subject changes with theobjects, and the objects change with the subject; subject and object can beunderstood only in their interactive relationship. The achievements of theorganism cannot be understood without the introduction of the subject. HereConrad refers to Viktor von Weizsdckers

theoryof the Gestaltkreis.14 He also

takes from it the neurophysiologically-grounded concept of change infunction, which underlies change in performance. Originally Weizsacker wasconcerned with the hand that must feel in order to recognize objects andwith the disturbances of stereognosis the subject experiences in disorders ofthe posterior funiculus of the spinal cord, which lead to a (neurophysio-logically definable) change in function - which in turn underlies the changein performance (inability to recognize objects). Related concepts that havegained better acceptance in modern sensory physiology are expressed in thereafference principle (von Holst and Mittelstaedt), in corollary discharge(Teuber) and most recently in the complex re-entry concept of Edelman. Inthe end the modern biologically-oriented schools of the philosophy ofconsciousness are united in the new understanding of the subject-objectrelationship that Conrad developed in his case analyses of brain pathologyand later used in his research on psychoses.To understand the change in function that underlies the change in

performance, two additional concepts were necessary, which were taken from

Henry Heads studies on sensitivity and then applied to psychic processes ingeneral. These are the epicritic forms of experience, in which the given field

of experience is completely formed, and the protopathic forms of experience,in which the experiences are of the pre-Gestalt type. Their most importantfeature is the blurring of the internal structure (Binnengliederung) of what isexperienced and the emergence and dominance of the physiognomic qualities of

expression (e.g., grotesque faces in wallpaper).One has to look carefully at the individual protocols and the long series of

experiments for the different types of aphasia to grasp the force of theargumentation and to understand that the speech problems in each type of

aphasia are, on the one hand, characteristic for that type of aphasia, but that

underlying these problems arecommon rules of incorrect formation

processes or, in other words, that the mistakes of people with aphasia arestrongly predetermined. The disturbance is to be sought in the develop-mental process that leads from the preverbal existence of the thought contentto the verbal form. This developmental process has a temporal course that is



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slowed down by the change in the function of the damaged brain tissue, asConrad showed in studies of the duration of excitation and of the refraction

time in the Gestalt change.The example of a conduction aphasia will be used to illustrate thisdisturbed developmental process. This is a typical syndrome of difficulty infinding words, with literal and verbal paraphasias and a disturbance of thegrammatical structure including expressive and impressive paragrammatisms,and finally also an impaired ability to repeat words despite retainedcomprehension and a relatively good ability to read. The syndrome isdiscussed in its component parts. The paragrammatic disorder developsbecause, although the motor structures for speech are completely intact, the

microgenesisof

developing speechfrom the

preverbal stageis not

fullycompleted but gets stuck halfway through, and thus the result shows all thecharacteristics of the pre-Gestalt. The epicritic, that is, clear grammaticalstructuredness of the sentence is lost. Word finding shows the same type ofdisturbance; the paraphasic errors show all the characteristics of the absenceof epicritic detail. Because the process is slowed down, the search for a wordcan be followed through the individual developmental phases, which arequite similar to the individual phases of a microgenetic developmentalprocess. The disturbance of impressive performance corresponds to that ofthe expressive performance. The intact grasp of meaning paired with adisturbed grasp of speech sounds is a typical feature of the protopathicchange in Gestalt in the sense of physiognomization of perception. Theunderlying change in function leads to a change in the temporal processes,with the result that the time from reception of a stimulus until the meaningis grasped is lengthened. The manifestation is more pronounced withacoustic performance (which is normally tachistoscopic performance) thanwith visual performance. The conduction aphasia (which, according toGoldstein, would be better termed central aphasia) is thus the form ofaphasia in which the protopathic change in the Gestalt of speech performanceaffects both expressive and impressive performance components; it attacks ata place in the pre-verbal stage which is before the separation into expressiveand impressive components.

If one studies modern psycholinguistic models of the flow of activation inspeech production, which are based on experiments with event-relatedpotentials and other registration techniques, one is surprised by the similarityof the concepts.&dquo; There no longer appears to be any doubt that the finalGestalt, the articulated word, stands at the end of a process, the duration ofwhich can be measured. With this approach grammatical processes, too, can

be demonstrated that are not already available in the language apparatus, butmust be generated anew each time, i.e., that must go through a Gestaltprocess.

Conrad was decades ahead of his time with his developmental model.With one exception, all his papers on brain pathology (neuropsychology)



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were published in German shortly after the war and were therefore hardlynoticed internationally. The one exception of which I am aware and which is

cited occasionally, is a paper published in Brain (1954); in it, the mainquestions addressed are those of localization. The analysis of 51 cases ofmotor aphasia, 48 of which involved right-handed individuals, showed thatthe closer the injury was to the sylvian fissure the more devastating the effecton speech performance. Neither small injuries localized in Brocas areaproper nor large areas of destruction at a greater distance led to permanentspeech impairment. Once again, with this finding and the localization ofother types of aphasia, for example, the word-finding disturbance andamnestic and sensory aphasia, Conrad was ahead of his time.

For Conrad, the immense project on the structural analysis of cases ofbrain pathology, completed in barely two years, was a preliminary study forprojects he planned to do later, among them the analysis of dreams basedon Gestalt theory (in which he discussed Freuds theories extensively),studies on the symptomatic psychoses, including Korsakoffs psychosis and,especially, incipient schizophrenia.

In 1948 a new period began in the life of the Conrad family of six. Conradwas offered the newly established professorship for psychiatry and neurologyat the International University of Saarland, with a medical school located in

Homburg.In those

daysthis meant that a window to the world

openedfor

them. The Federal Republic of Germany had not yet been founded. Evenafter the currency reform in June 1948 the economic situation was stilldi~cult. With very few exceptions, contacts with scientists abroad did not yetexist. But Saarland, under French administration, was completely integratedinto the West. Because of his prewar acquaintance with French neurologyand psychiatry and thanks to his language skills, Conrad could quickly re-establish the long-prohibited connection and begin a fruitful exchange ofideas with clinicians working in neuropsychology, for example Henri H6caen

(Paris) and Oliver Zangwill (Oxford).And this in turn led to publicationsbecause of the symposia of the aphasia researchers, which he helpedestablish. Conrad was brilliant in discussion, always amiable and courteous,but very rigorous in his argumentation. I remember one of the symposia,held in an old abbey near Oxford with MacDonald Critchley as moderator,at which the official topic was the function of the parietal lobe but wherethere was also a heated discussion about visual agnosia and thus, in fact,about perceptual disorders. Such debates, some of which were continued injournals, were also extremely instructive and enlightening for youngresearchers. Today, in both spirit and style they seem to have died out.

Through trips within Europe Conrad establishednew

relationships, builtbridges between neurology and psychiatry, gave talks in 1949 at the FirstInternational Congress of Neurology and in 1950 at the First International

Congress of Psychiatry, both in Paris, at a time when the official languages atcongresses were those of the Big FourAllied Powers only, and long before



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English had become the lingua franca of science. Conrad became anhonorary member of the Paris Neurological Society. In Henry Ey, whose

work first became known to a wide audience in Germany through Fortschritteder Neurologie und Psychiatrie (then edited by Conrad, Scheid andWeitbrecht), Conrad found a friend and colleague with the same desire totrace psychiatric disorders back to an organodynamic foundation that treatsthe psychopathological not as an epiphenomenon of organic processes but as

. psychic structures that change according to a particular pattern. Currentpsychopathology, dominated today by surveyors who keep surveying the landbut never dig in it, would probably have been a horror for him.

Conrads universal spirit did not allow him to restrict himself to his

specialty.His

ongoingconcern for his time is shown

byhis articles and

talks,for example, on the psychopathology of international tensions, on develop-mental stages of mankind, on modern art, on Jugend undAlter als berindi-viduelles Problem (Youth and old age as a problem beyond the individual),and on Das Geistige und das Gehirrz (The mind and the brain). His article Derzweite Siindetifall - psychiatrische Betrachtungen zur modernen Kunst (Thesecond fall of man - psychiatric observations on modern art), whichappeared in 1953 inAnnales Universitatis Saraviensis, contains a penetratinganalysis of abstract and surrealist painting. The pointed critique of ourculture that appeared in 1961 in the Gttinger Universztdtsreden entitled Dieneurotischen Zge unserer Zeit (The neurotic aspects of our times) was a talk hewas not able to deliver because of his sudden illness. Challenging, original,sometimes polemical and critical of fashionable views, Conrad expressed histhoughts in polished language. He even avoided well-worn paths in hislectures for students, revising them regularly.

In the spring of 1958 Conrad had accepted the position he was offered inG6ttingen, succeeding Ewald as head of what was then the most modernNervenklinik, opened in 1955.As in Homburg, he covered the specialties ofneurology and psychiatry (which would later be separated). He built his first

house; chamber music at home flourished, with all four of his childrenparticipating; hospitality was written large, and his wife was an unparalleledhostess.

In the autumn of the same year Conrad was offered the position of head ofthe psychiatric department at his old hunting ground, the DeutscheForschungsanstalt fur Psychiatrie in Munich (now the Max-Planck-Institutfur Psychiatrie), and was asked to be a consultant on rebuilding the Institute.

Along with him, Richard Jung was to be appointed head of theneurophysiology department. Herr Conrad, it is reported, considers a

future biochemistry department to be the most important one; in his view theproblem of the major psychoses is a biochemical problem. (Herr Conrad hiilteine zukiinftige biochemischeAbteilung fiir die wichtigste; das Problem der groj3enPsychosen sei ein biochemisches.) In December 1960 the president of the Max-Planck-Gesellschaft (Max Planck Society),Adolf Butenandt, asked Conrad



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whether he would accept the position as head of the Institute when thehospital building had been completed, at the latest. Conrad assured him that

of course he would accept the position at that time; he had already beenmuch involved in the Munich project. But he did ask Butenandt to bear inmind that it would still be several years before the hospital building wascompleted. (And in fact it was more than five years.) None of us know, hewrote, how long we will be able to work, but we certainly know that it willnot be forever. Conrad was 55 years old at the time.A few months later he

was dead.

While he was still in Homburg, Conrad had completed what was probablyhis most influential work, Die beginnende Schizophrenie (Incipient Schizo-

phrenia).In

G6ttingenhe

began tacklingthe whole field of the

symptomaticpsychoses. He had already done a great deal of work on describing individualdisorders, e.g. chronic tactile hallucinosis, subacute panencephalitis and thediabetic psychoses; Gestalt analysis of Korsako~s psychosis has already beenmentioned. But now he tried to present a comprehensive description andrestructuring of this central group of psychopathological disorders.

The symptomatic psychoses

Conrad took advantage of the invitation to prepare the chapter Die sympto-matischen Psychosen (The symptomatic psychoses) for the handbookPsychiatrie der Gegenwart (Current Psychiatry), which was published in 1960(the second edition, 1972, also included his chapter). In it Conrad rued thefact that, in spite of important advances in the understanding of the mind,little had been added to Bonhoeffers concept of exogenous reaction types.Conrad proposed that the view of the mind as an association ofmemory linksbe replaced by a model that conceived of it as a whole (Ganzheit), as anintegrated totality which from the start appeared as a given to subjectiveexperience (Erlebera) . The method for gaining a better understanding of the

problem of the symptomatic psychoses was to study various aspects ofexperiencing: content and components, field structure and dynamics.Conrads method was again Gestalt analysis. In such a phenomenologicalperspective we do not find a perceptual function, but only the perceived, andhere the goal is to study the laws governing the perceived, which constitutethe perceptual field. Thus, Conrad describes the change in the Gestalt of theexperiential field as a process that, from the prodromal manifestations of the

psychosis to clouding of consciousness and the delusional phenomena, passesthrough characteristic states that can be described in terms of Gestalt

psychology. To this end he uses the model of the control of sleep andwakefulness (Table 1). From being wide awake to being in deep, dreamlesssleep, there is a broad physiological transition zone, the area with which weare concerned in some of the psychoses with a physical basis. The onlydifference is that instead of the physiological change in the function of sleep



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TABLE 1. The symptomatic psychoses

From Psychiatrie der Gegenwart, Vol. 2 (Berlin: Springer, 1960), 379; translated from the German bypermission of the publisher.

we have a pathological change in function resulting from a noxa. But thereare no specific noxious substances that produce specific symptoms.

Accordingly, Conrad describes the obligatory characteristics of the organicpsychoses and the different clinical syndromes in terms of Gestalt theory. Heconcludes that there is no psychotic state that cannot also be found inpsychoses with a physical basis. In fact, the current nosology of psychiatrybecame a problem for him; and from the perspective of human genetics, too,he found the sharp differentiation between schizophrenia and cyclothymia, asif they were completely different types of illness, to be highly questionable.

Finally, let us turn to the publication, also translated into Spanish andJapanese, which is of most interest to psychiatrists today.

Die beginnende Schizophrenie (Incipient Schizophrenia)

The subtitle of the book is Versuch einer Gestaltanalyse des Wahns (Attempt ata GestaltAnalysis of Delusion). Conrad saw that psychopathology after



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Jaspers was in a dilemma. Either one tried to explain psychopathologicalphenomena causally by tracing them back to an organic substrate and thus

transforming a psychopathological problem into a physiopathologicalproblem that was susceptible to medical treatment (The causal connectionsof psychic life6), or one attempted to understand the phenomenon bytracing it back to some other aspect of the psyche (Meaningful psychicconnections&dquo;) and looking for relationships to other aspects of theindividuals life history, thus transforming the psychopathological probleminto a hermeneutic problem.

Conrad proposed a third approach, the subtle description and analysis ofthe psychopathological phenomenon experienced. Here again, the method isGestalt

analysis.For

everythingthat is

experiencedhas a

Gestalt,and the

analysis of given phenomena is always the analysis of forms and config-urations.

With this in mind, Conrad studied 107 soldiers who during the war, in

1941/42, had suffered a fresh episode of schizophrenia, two-thirds of whomwere between 20 and 31 years old. The fact that all those affected were

soldiers in uniform when the psychosis broke out turned out to be anadvantage, because the effect of being uniformed was that what wasexperienced was also uniformed and this reinforced what was typical of theillness, and what was typical for the individual became less important. Theaim of the study was to identify the laws governing the phases within anindividual episode of schizophrenia and to replace the past unrelatedness ofschizophrenic symptoms and courses with a structural relationship in whicheverything that was happening can be seen in terms of uniform lawscompatible with Gestalt theory.

Conrad called the first phase Trema. It is a strange state that precedes thedelusions. With increasing affective tension (Bodenaffektivitt, to use KurtLewins term), the individuals environment gains a strange, never-before-experienced physiognomic trait. It looks coldly and hostilely at the person

experiencing it, as if at someone who has been condemned. (Es sieht kalt undfeindselig auf den Erlebenden wie auf einen, fiber den man den Stab gebrochenhat.) This trema phase can go on for a long time. It is followed by theapophany phase, the experience of abnormal awareness of meaning and thesense of being at the centre of what is happening in the world. These types of

experience, which always occur together, form the central feature ofschizophrenic experience. The cause is a severe disturbance of the ability tochange systems of reference.Although all healthy individuals are the centreof their world, they are still able to see themselves as one among others,

stand next to others or put themselves in someone elses shoes. In contrast,people with schizophrenia have in their psychosis lost the possibility ofchanging perspectives ( Uberstieg) . They are no longer able to change thesystem of reference. Therefore everything is related to them no matter wherethey direct their attention.



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Fig. 1. Diagram from Die

beginnende Schizophrenie, p. 48

Using an example of Gestalt perception,Conrad demonstrates the ability of healthy

individuals to change their system of referenceconstantly. The diagram in Fig. 1 can be seen intwo ways: if we interpret it as two squares thatintersect each other, then the small rhombus inthe middle means the area common to both ofthe large squares; but if we see two angularfigures that touch each other at their corners,then the rhombus in the middle means simplypart of the background. Analogously, thedelusional individual is unable to achieve the

shift from one system of reference to another. The first manifestation of

schizophrenic delusion occurs at the instant when changing perspectives hasbecome impossible. But it is not just the environment, the exterior space,that is affected by the apophany; the internal space is also changed by it. Eachidea (Einfalv becomes inspiration (Eingebung), ones own thoughts can beread by anyone, and so forth. The wall separating the world and me becomesporous. The more advanced the destruction process, the more the generalproperties (Wesenseigenschaften) prevail in the perceptual field, with the resultthat the perceptual connection begins to weaken. With the severing of thesituational connection, the contact to the affected individual also ceases.The apocalyptic phase begins. The field of experience is flooded with pictures,

the order in thinking is lost, voices dominate the internal field. The point ofculmination is catatonia. In the slow consolidation process the individual

goes through the phase of apophany in reverse.As on the way to catatonia, abrief paranoid phase reappears until the delusions begin to disappear.

Consolidation can go as far as to a Copernican change: the affectedindividuals are again able to achieve the crossing-over process and canrecognize that the change was not in the outside world but rather in themselves.

This would mean that the psychosis was healed. If residual symptomsremain, Conrad attributes them to the reduction in the energy potential. Inthis loss of potential - with different degrees of severity - he sees the specific(organic) schizophrenic change, the pathological change in function due to aproblem in the brain that underlies schizophrenia in the different phasesdescribed. It must be a change in function in those parts of the cerebralorganization through which the human brain is distinguished from the brainsof the highest primates, that is, those parts that are peculiar to humans. (Esmuss sich um einen Funktionswandel jenerAnteile der cerebralen Organisation

handeln, durch die sich das menschliche von den hchsten Primatengehimenunterscheidet, die also speziell dem Menschen eigentiitnlich sind.) It is worthcontinuing the search for the pathological substrate of this process.

Conrads phase model, whose far-reaching consequences for psychiatricnosology cannot be discussed here, was tested by Hambrecht and Hafner8



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on a representative sample. Their results supported Conrads assumption ofa prepsychotic phase (trema) followed regularly by a psychotic-productivephase (apophany), and they also showed that Conrads findings could beextended to include both sexes and an age range of 12-59 years. But thestrict succession of apophany and apocalypse could not be demonstrated.For methodological reasons, however, a conclusive statement on this issuecould not yet be made.One must appreciate the very close relationship between the publications

Strukturanalysen hirnpathologischer Fdlle, Die symptomatischen Psychosen andDie beginnende Schizophrenie in order to understand that they represent thedevelopment of a reformatory psychopathology that was closely related to

the classical-empirical foundations of our field, but also marked a radicalbreak with their theoretical prerequisites, namely, with the psychology of thenineteenth century. Central concepts, such as consciousness, the unconscious,recent memory and attention take on a new meaning through Gestalt analysis.Conrad was convinced that the only way to an understanding of the psychosisproblem was that of brain pathology (neuropsychology). With this view, heled phenomenological psychopathology back to a basis in science and medicine.

Unceasingly active, but at peace with himself and without haste, Conradfashioned his life and his work, both in rare accord with each other. His pathin life seemed

straightand

alwaysheaded for the

peak.But in

early1961 a

myeloma was discovered, and six weeks before his fifty-sixth birthday hedied, on 5 May 1961.

Klaus Conrad was a remarkable individual both intellectually and as a

person. For those who knew him personally, he was a shining example - as aclinician, as a researcher and as a human being. The originality of histhinking, his passion and his wide-ranging thoughts were fascinating, andthey stimulated not only his field of specialization but also related disciplinesin science and the humanities. His courageous analyses of apparentlyunshakeable teachings in psychiatry brought changes in the phenomen-ological psychopathology of his time. The question of what influences hewould have had on psychiatry if he had lived longer is unanswerable. Theonly thing that is certain is that he would have been very actively involved inits further development. For those looking for a model of how clinical workwith patients can be conducted as basic science, an in-depth study of KlausConrads work would be rewarding.

Selection of Conrads publications

The following are selected from more than one hundred.

Monographs and contributions to handbooks

1939. Erbkreis der Epilepsie. In G. Just (ed.), Handbuch der Erbbiologie desMenschen, Vol. 5 (Berlin: Springer), 932-1020.



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1941. Der Konstitutionstypus als genetisches Problem (Berlin: Springer).1951. Contribution for Germany. In G. W. Kisler (ed.), World-tension: The

Psychopathology of International Relations (New York), 87-105.1958. Die beginnende Schizophrenie. Versuch einer Gestaltanalyse des Wahns

(Stuttgart: Thieme).1958. Das vierte Zeitalter und die moderne Kunst. In H. Ehrhardt et al.

(eds), Psychiatrie und Gesellschaft (Bern/Stuttgart: Huber), 102-13.1960. Die symptomatischen Psychosen. In H. W. Gruhle, R. Jung, W.

Mayer-Gross and W. Mfller (eds), Psychiatrie der Gegenwart, Vol. II(Berlin/Gottingen/Heidelberg: Springer), 369-436; 2nd edn 1972.

1963. Der Konstitutionstypus. Theoretische Grwzdlegung und praktische

Bestimmung, 2nd rev. edn (Berlin: Springer).1967. Konstitution. In H. W. Gruhle, R. Jung, W. Mayer-Gross and W.Muller (eds), Psychiatrie der Gegenwart, Vol. I/1 (Berlin/G6ttingen/Heidelberg: Springer), 70-151.

Publications in journals1932. Versuch einer psychologischenAnalyse des Parietalsyndroms. Monats-

schriftfiir Psychiatrie und Neurologie, 84, 28-97.1933. Das K6rperschema. Eine kritische Studie und der Versuch einer

Revision.Zeitschrift fiir

diegesamte Neurologie

und

Psychiatrie, 147,346-69.

1938. Epilepsie. Vererbung und Konstitution. Zeitschrzft fiir die gesamteNeurologie und Psychiatrie, 161, 280-92.

1939. Der Begriff der Erbanlage und ihre quantitative Stufung.AllgemeineZeitschrzft fr Psychiatrie, 112, 126-37.

1947/1948. Strukturanalysen hirnpathologischer Fdlle: Part 1, Part 2 inDeutsche Zeitschrift fiir Nervenheilkunde, lS8 (1947), 344-71, 372-434;Part 3, Part 4 inArchiv fiir Psychiatrie vereinigt mit Zeitschrift fiirNeurologie, 179, 180 (1948), 502-67, 54-104; Part 5, Part 6 in

. Deutsche Zeitschrift fiir Nervenheilkunde, 158, IS9 (1948), 132-87,188-228.

1948. ber differentiale und integrale Gestaltfunktion und den Begriff derProtopathie. Der Nervenarzt, 19, 315-23.

1949. Das Problem der gest6rten Wortfindung in gestalttheoretischerBetrachtung. SchweizerArchiv fiir Neurologie und Psychiatrie, 63,141-92.

1951. Jugend undAlter als uberindividuelles Problem. Studium Generale, 4,580-7.

1952. Die Gestaltanalyse in der Psychiatrie. Studium Generale, 5, 503-14

[contains list of publications on brain pathology up to 1949].1953. ber einen Fall von Minuten-Geddchtnis. Beitrag zum Problem des

amnestischen Symptomenkomplexes. Archiv fiir Psychiatrie undZeitschrift fr Neurologie, 190, 471-502.

1953. Zur Psychopathologie des amnestischen Symptomenkomplexes. Gestalt-



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analyse einer Korsakowschen Psychose. Deutsche Zeitschrift fur Nerven-heilkunde, 170, 35-60.

1953. ber Erregungsnachdauer und Refraktdrphase im Gestaltwandelh6herer Leistungen.Analyse eines Syndroms der parieto-occipitalenbergangsregion.Archiv fiir Psychiatrie und Nervenk rank heiten, 190,196-220.

1953. Der zweite Sundenfall.Annales Universitatis Saraviensis, 1/2, 3-20.1954. New problems of aphasia. Brain, 77, 491-509.1954. Das Geistige und das Gehirn. Deutsche Universitdts-Zeitung, 5, 6 (8 and

22 March).1955. Zum Problem der chronischen taktilen Halluzinose.Archivfur Psychiatrie

und Nervenkrankheiten, 193, 601-6.1957. Das Unbewuf3te als phdnomenologisches Problem. Fortschritte der

Neurologie, - Psychiatrie, 25, 56-73.1959. Gestaltanalyse und Daseinsanalytik. Der Nervenarzt, 30, 405-10.1959. Das Problem der nosologischen Einheit in der Psychiatrie. Der

Nervenarzt, 30, 488-94.1960. Die Gestaltanalyse in der psychiatrischen Forschung. Der Nervenarzt,

31, 267-73.

TRANSLATORS NOTES

1. Then part ofAustria-Hungary, now in the Czech Republic.2. Then also part ofAustria-Hungary, now in Romania.3.A lake near Salzburg; it became well-known among scientists, especially behavioural scientists,

through von Frisch.4.A lake near Wolfgangsee.5. Six years was normal.

6. Now the Deutsche Forschungsgemeinschaft (German Research Foundation).7. Now the Max-Planck-Institut fur Psychiatrie (Max Planck Institute for Psychiatry).8. English translation: Karl Jaspers (1963). General Psychopathology (Manchester: Manchester

University Press).

9. Rainer Knumann (1978). Konstitution, Vererbung und Umwelt. CollegiumAnthropologicum,2, 154-67.10. Karl Jaspers (1946). Allgemeine Psychopathologie, 4th edn (Berlin: Springer-Verlag).11. H. W. Gruhle, R. Jung, W. Mayer-Gross and M. Mller (eds) (1960/1967). Psychiatrie der

Gegenwart. Forschung und Praxis, 3 vols (Berlin/Heidelberg/New York: Springer).12. Near Stuttgart.13. Translation, without rhymes.14. Viktor von Weizscker (1940). Der Gestaltkreis. Theorie der Einheit von Wahrnehmen und Bewegen

(Leipzig: Thieme).15. Willem J. M. Levelt (1989). Speaking: From Intention toArticulation (Cambridge, MA: MIT

Press); 5th print 1998.16. Jaspers, General Psychopathology (op. cit., Note 8), part 3.

17. Ibid., part 2.18. Martin Hambrecht and Heinz Hfner (1993). Trema,Apophnie,Apokalypse - Ist ConradsPhasenmodell empirisch begrndbar? (Trema, apophany, apocalypse - Can Conrads phasemodel be substantiated empirically?). Fortschritte der Neurologie - Psychiatrie, 61, 418-23.

Documents

Klaus Conrad - History of Psychiatry