Results of a study of mentally ill vagrants: The failure to recognize mental illness (Ergebnisse Einer Untersuchung Geisteskranker Landstreicher: Die Verkennung der Geisteskrankheit)

Abstract

This classic text by the German psychiatrist Karl Wilmanns stands out as exceptional in the literature describing the psychopathology of mentally ill homeless people. Wilmanns’ psychopathological descriptions are excellent, as are his observations of the disheartening failure to recognize dementia praecox in courts, prisons and workhouses, and the significant consequences of this failure for the patients. As he vividly shows, most patients manifested a wide range of severe psychiatric symptoms and signs that should have caught the attention of the courts, prison doctors, and even persons with no psychiatric knowledge. Wilmanns considers the main reason for this failure to be inadequate knowledge of psychopathology. Although dementia praecox (schizophrenia) is no longer a new concept, as it was at Wilmanns’ time, we still see people with severe psychiatric symptoms roaming the streets and failing to benefit from timely recognition and treatment of their mental disorder.

Introduction to Wilmanns’ life and work

Karl Wilmanns: Biographical aspects of an unusual academic career

Karl Wilmanns (1873–1945) was a German psychiatrist and an important figure for the Heidelberg school of psychopathology. He was born in Durango, Mexico, in 1873, as the son of a merchant family from the northern part of Germany (Leopold, 1988). He studied medicine at the universities of Berlin, Göttingen and Bonn. As was common at the time, Wilmanns served in the military several times within or parallel to his medical career.

He received his doctorate in Bonn in 1897 with a thesis on alcohol-induced excitation of the respiratory centre (Mundt et al., 2011). In 1899, Wilmanns began his psychiatric career and initially worked at state mental hospitals in Bremen and Bonn. In 1901, he moved to Heidelberg, where he became one of the last assistants to Emil Kraepelin (1856–1926), who was appointed to Heidelberg from Dorpat/Tartu in 1891 and left Heidelberg for Munich in 1903 (Rotzoll and Grüner, 2016; Steinberg and Angermeyer, 2001). Wilmanns stayed in Heidelberg and finished his habilitation thesis on the psychopathology of vagrants in 1906 and became associate professor in 1912.

During the First World War, Wilmanns quickly became one of the main figures responsible for the military hospitals in Baden – a task he fulfilled with great commitment. At the end of the war in 1918, Wilmanns swapped the daily routine of a senior military doctor for a position as full professor of psychiatry in Heidelberg, after several other colleagues had declined the position.

Rather than being remembered for his own research contributions, Wilmanns is often lauded for his organizational talent and his ability to recruit an extraordinary group of researchers, including such eminent scholars as Hans W. Gruhle (1880–1958), Wilhelm Mayer-Gross (1889–1961) and Karl Jaspers (1883–1969) (Janzarik, 1979). One of the most important works of the group is the 1932 volume on schizophrenia in the Handbuch der Geisteskrankheiten, edited by Oswald Bumke (1877–1950). The textbook dealt with central issues in psychiatric nosology (Rotzoll and Hohendorf, 2006). As a student of Kraepelin, who had first described dementia praecox during his time in Heidelberg, Wilmanns had a special connection to this topic that also takes centre stage in his habilitation thesis on mentally ill vagrants. Wilmanns habilitated alongside a neuropathologist, namely Kraepelin’s successor Franz Nissl (1860–1919). In his review of Wilmanns’ habilitation, Nissl emphasised that Wilmanns lacked the neuroanatomical publication needed as an ‘entry ticket’ into psychiatric research at the time. In other words, Wilmanns had not adapted to the ‘mainstream’ psychiatric approach of his day – something that Nissl obviously appreciated.

With this work on vagrants, Wilmanns entered a niche area of psychiatry at an early stage of his career. His habilitation is a form of participatory observation, and its descriptive accuracy reveals a basic anthropological orientation in his work. Wilmanns’ interests in psychiatry and its intersection with other disciplines came to the fore as he, together with his then assistant physician Hans Prinzhorn (1886–1933), initiated the Heidelberg art collection, which has since become world famous under the name of The Prinzhorn Collection (Mundt et al., 2011; Rotzoll and Röske, 2017).

In 1933, Wilmanns was suddenly dismissed from his position as full professor in Heidelberg by the national socialist regime, of which he was critical, ending his career prematurely. Until his dismissal, his research had been devoted to forensic and nosological topics. In his enforced retirement, only two essays were published and these brought him full circle to his early works on vagrancy, namely the essays ‘Über Morde im Prodromalstadium der Schizophrenie’ (Murders in the prodromal stages of schizophrenia) and ‘Das Vagabundentum in Deutschland’ (Vagrancy in Germany) (Wilmanns, 1940).

On Wilmanns’ 70th birthday, Gruhle praised the ‘knowledge and experience’ that had gone into Wilmanns’ 1940 essay, but that couldn’t be published in a long-awaited book ‘due to the adversity of the times’ (Gruhle, 1943). In this late essay, Wilmanns first gives a comprehensive historical overview of groups of homeless people up to the early 20th century, which leads him to argue that due to industrialisation – with its variety of job opportunities, social legislation, the rise of welfare institutions, and the expansion of the police – ‘vagrancy at the beginning of this century was a more harmless phenomenon than in earlier times’ (Wilmanns, 1940: 76). However, in Wilmanns’ own experience, different groups were still travelling the country roads around 1900, from the ‘craftsmen’ and the ‘wandering poor’, looking for work, to the ‘various types of habitual and professional beggars’ (Wilmanns, 1940: 84–86). During his years of study, Wilmanns had learnt their language, Yenish, and he used it at large gatherings of the ‘vagrants’, where he was able to make further participatory observations (Wilmanns, 1940: 96, 97). Consistent with the work in his habilitation, Wilmanns criticised the state’s harsh treatment of vagrants back then, with its focus on punitive and educational measures and absence of psychiatric expertise, as insufficient to combat ‘vagrancy’. Wilmanns showed a great deal of empathy and sympathy for the vagrants, even in retrospect in 1940. Nevertheless, in the later text he – an opponent of the national socialist regime – expressed a cautiously positive view of combating ‘vagrancy’ through the use of (forced) labour, including imprisonment in the Dachau concentration camp (Wilmanns, 1940: 106–111).

Wilmanns died in August 1945 as the Second World War came to an end. The obituaries from 1946 were the first to refer to his rejection of National Socialism, at least in an international context. An anonymous author began a short memorial text in The Lancet with the following words:

News has been received of the death of Dr. Wilmanns who was imprisoned and dismissed from the chair of psychiatry at the University of Heidelberg, by a Gauleiter’s decree based on shorthand notes taken by informers during his lectures. He had courageously warned his students against the dangers of mass hysteria and the leadership of psychopathic fanatics and criminals in politics (Orbituary, 1946).

Karl Wilmanns’ work on vagrants

The Swiss psychiatrist Max Müller (1894–1980), who cultivated an intense relationship with Wilmanns in the 1930s, reported in his memoirs that in their conversations about vagrants it was sometimes amusing to see ‘the haughty aristocrat arguing with a kind of bohemian’. According to Müller, Wilmanns considered his 1906 book On the Psychopathology of Vagrants to be his ‘main scientific achievement’ (Müller, 1982: 204, 205).

How did it come about that, as a young psychiatrist, Wilmanns chose this hitherto barely treated topic for his habilitation? Looking back in 1940, Wilmanns commented somewhat vaguely on this question: ‘With the development of psychiatry, the personality of the vagrant and beggar began to attract increased interest’ (Wilmanns, 1940: 76, 77). Wilmanns had already ‘taken a particular interest in vagrants’ as Kraepelin’s assistant in Heidelberg, where he examined the ‘biographies of 120 vagrants, . . . almost all of whom had been admitted to the Heidelberg clinic as mental patients from the Kislau workhouse’ (Wilmanns, 1940: 79). Wilmann’s first work on the subject, ‘The Psychoses of Vagrants’, was published in 1902, when Kraepelin was still in charge of the Heidelberg clinic. Kraepelin’s influence on Wilmanns’ work is unmistakable: Wilmanns refers to the concept of dementia praecox in the sense of an illness leading to mental enfeeblement or mental deficiency over the course of time and occurring in various forms: ‘The bulk of our material, and also the richest and most interesting in social and clinical terms, belongs to a group of disorders that we provisionally summarise under the term dementia precox’ (Wilmanns, 1902: 739).

Kraepelin presented the concept of dementia praecox as a group of illnesses with certain subtypes in the sixth edition of his famous textbook from 1899, differentiating dementia praecox from manic-depressive insanity (Hoff, 1994: 103). The term dementia praecox, already used by Bénédict Augustin Morel (1809–1873) (Berrios, 1996), first appeared in Kraepelin’s nosology in the fourth edition of 1893. Dementia praecox was subsumed under the category of ‘degenerative processes’, which was characterised by a poor prognosis and attributed to unknown patho-anatomical changes, and it was placed alongside catatonia and dementia paranoides. Moreover, hebephrenia, described by Ewald Hecker (1843–1909) in 1871, was categorised alongside dementia praecox (Hoff, 1994: 115, 116).

In Kraepelin’s sixth edition, dementia praecox became a generic term instead of the previously used term ‘processes of mental deficiency’, while hebephrenia, catatonia and dementia paranoides were now named as subgroups of dementia praecox (Hoff, 1994: 118). Wilmanns made the following observation in his 1902 study: ‘There is general agreement on the generally unfavourable prognosis of the insidious onset forms of dementia praecox. As far as the outcome of the acute onset forms is concerned, usually with vivid excitement and numerous hallucinations, opinions still differ widely’ (Wilmanns, 1902: 740). As time has shown, Wilmanns was right in this early assessment. It was not least the different assessment of the prognosis of dementia praecox that triggered lively debates and contributed ultimately to Eugen Bleuler’s renaming of dementia praecox as schizophrenia in 1908 (Bernet, 2013: 9–15; Bleuler, 1908).

The group studied by Wilmanns, vagrants and beggars, were mentioned only briefly in Kraepelin’s textbook: ‘Finally, according to my experience, there are probably quite a number of unrecognised Hebephrenic imbeciles among the habitual beggars and the harmless incorrigibles’ (Kraepelin, 1896: 83). However, the group was studied in an investigation on prison inmates by the psychiatrist Bonhoeffer (1868–1948) (Bonhoeffer, 1900), whose work Wilmanns commented on: ‘Bonhöffer has recently made the metropolitan beggar the subject of an in-depth psychiatric investigation. He confirmed the assumption that the majority of habitual vagrants are mentally inferior’ (Wilmanns, 1902: 729).

After the establishment of the German Empire in 1871, beggars and homeless persons could be punished for their ‘offences’ with up to 6 weeks of imprisonment, as had previously been the case in Prussia. In addition, the criminal judge could order those convicted under Section 361 of the Criminal Code of the German Empire to be ‘transferred’ to the state police after serving their sentence. The police were authorised to place the person in a workhouse for up to 2 years. This so-called corrective detention used work in hopes of facilitating the resocialisation and improvement of the offenders. Around 1900, approximately 50 workhouses were run by the aid association for the rural poor, and they were often more feared than prisons. In fact, they served far more as a deterrent than as a means of ‘correction’, resocialisation or improvement. The corrective detention of vagrants soon attracted criticism, particularly from psychiatric experts, for failing both to deter vagrancy and to achieve its educational aims (Ayass, 1993: 190–195; Hoff, 1994).

Karl Wilmanns’ classic text

In his 1906 habilitation, Wilmanns explored the relationship between dementia praecox and vagrancy, concentrating on individuals in psychiatric institutions. Of 85 male beggars and vagrants who had been admitted to the Heidelberg psychiatric hospital from the Kislau workhouse between 1890 and 1904, the 52 who suffered from dementia praecox were described in his habilitation. After an introductory chapter on the definition of dementia praecox in which he drew on Kraepelin’s views, Wilmanns described the medical histories of his subjects in great detail with the aim of making the mostly long-past onset of the illness plausible on the basis of their life stories. After two further chapters, summarising the influence of dementia praecox on the subjects’ lifestyles and criminality, Wilmanns arrived at the chapter that we here present as a classic psychiatric text, namely the chapter on ‘the failure to recognize mental illness’.

We have here emphasised Wilmanns’ relation to Kraepelin’s work and stressed his concept of dementia praecox because, when reading Wilmanns’ text, one must keep in mind that the concept of dementia praecox was new. But Wilmanns’ observations of the disheartening misjudgement of dementia praecox in vagrants by courts, prisons and workhouses, and the consequences of this failure for the patients, cannot be explained away only by the novelty of the concept. As he vividly shows in the classic text, most patients manifested a wide range of severe psychiatric symptoms and signs that should have caught the attention of the courts and prison doctors and led them to suspect an illness.

More than a hundred years have now passed, and Wilmanns’ habilitation still stands out as exceptional study. Today, the dementia praecox/schizophrenia concept is far from new, and yet we still see people with severe psychiatric symptoms roaming the streets, occasionally committing crimes and being punished, and failing to benefit from timely recognition and treatment of their mental disorder.

The text was published twice in 1906, first as his habilitation (Wilmanns, 1906a) and second as a book entitled On the Psychopathology of Vagrants (Wilmanns, 1906b). Our translation is of Wilmanns’ habilitation.